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CHAPTER III.
THE PAINS OF HYPOCHONDRIASIS

There is perhaps nothing, in the whole range of practical medicine, more difficult to seize with clear comprehension, and picture to the mind with accuracy, than the group of pseudo-neuralgiæ which belong to the domain of hypochondriasis. They are among the most indefinable, and at the same time the most intractable, of nervous affections.

To understand what hypochondriac pains are, we must first be familiar with the general character of the hypochondriacal temperament, for the pains are only a subordinate and ever-varying phenomena of the general disease.

Hypochondriasis is not insanity, if by insanity we mean intellectual perversion dependent mainly or entirely on the state of the higher nervous centres. But it is closely allied to insanity in its phenomena, only that these are, as it were, manifested in a scattered form, unequally distributed over the whole central nervous system, and especially affecting the spinal sensory centres. And its radical relationship to true insanity is strongly indicated by the fact that the sufferers from hypochondriasis are nearly, if not quite, always members of families in which distinct insanity has shown itself; indeed, more often than not, of families which have been strongly tainted in this way. In the majority of instances there are psychical peculiarities of a marked kind which accompany or precede the development of the abnormal sensations which form the especial torment of hypochondriacs. Without apparent cause, they begin to evince a heightened self-feeling and an anxious concentration of their thoughts upon the state of one or more of their bodily organs. Or it may be that, before any such definite bias is given to their thoughts, they simply become less sociable and more self-centred, and are subject to fits of indefinite and inexplicable depression, or at least to great variability of spirits. But before long they begin to experience definite morbid sensations, most commonly connected with the digestive organs, and very often accompanied by positive derangement of digestion of an objective character; such as flatulence, sour eructation, spasmodic stomach-pain, etc. Along with these phenomena, or soon afterward (and not unfrequently before the patient has acquired that intensity of morbid conviction of his having some special disease which is afterward so marked a peculiarity of his mental state), he very often becomes the subject of the kind of pains which it is the special purpose of this chapter to describe.

The pains of hypochondriasis, when they assume any more definite form than that of mere dyspeptic uneasiness, present many analogies with neuralgia. They are not, usually, periodic in any regular manner, but they have the same tendency to complete intermission, and they frequently haunt some one or more definite nerves for a considerable period of time. Of all nerves that are liable to this kind of affections the vagus is undoubtedly the most susceptible; hypochondriac patients very frequently complain of pseudo-anginoid and pseudo-gastralgic pains; next in frequency are nervous pain in the region of the liver, or in the rectum or bladder. The main distinctions by which they are separable from true neuralgia are two: in the first place, the character of the pain nearly always is more of the boring or burning kind than of the acutely darting sort which is most usual in true neuralgia; and, secondly, the influence of mental attention in aggravating the pain is far more pronounced than in the latter malady; indeed, it is often possible, by merely engaging the patient in conversation on other topics, to cause the pain to disappear altogether for the time. But in hypochondriasis it is not often that we are left, for any long time, to these means of diagnosis only; the special character of the disease is that the morbid sensations shift from one place to another, in a manner that is quite unlike that of the true neuralgias. The patient who to-day complains of the most severe gastralgia, or liver-pain, will to-morrow place all his sufferings in the cardiac region, or in the rectum, or will complain of a deep fixed pain within his head; and these changes are often most rapid and frequent. Frequently there are also peculiar skin sensations, which usually approach formication in type, and these, like the pains, are apt to shift with rapidity from one part of the body to another. Later on in the disease, especially in those worst cases which approach most closely to the type of true insanity, there are often hallucinations of a peculiar and characteristic nature, such as the conviction of the patient that he has some animal inside him gnawing his vitals, that he is made of glass and in constant danger of being broken, and a variety of similar absurdities. In short, it is not the fully-developed cases of hypochondriasis that need puzzle us, these are usually distinct enough; but the earlier and less characteristic stages in which pain may be nearly the only symptom that is particularly prominent.

In hypochondriasis, as in hysteria, there is often great sensitiveness of the surface; and, as in hysteria, this sensitiveness is found to be very superficial, so that a light touch often hurts more than firm, deep pressure. As in hysteria, too, the tenderness is a phenomenon so greatly affected by the mind, that, if we can divert the patient's attention for a moment, he will let us touch him anywhere, without noticing it at all.

It is a marked peculiarity of hypochondriasis that it is far more common in men than in women; a relation which is precisely the opposite to that which rules in neuralgia. Hypochondriasis is also pre-eminently a disease of adult middle life; it is scarcely ever seen in youth, except as the result of excessive masturbation acting on a temperament hereditarily predisposed to insanity.

The results of treatment frequently assist our diagnosis in difficult cases. Almost any medicine will relieve the pains of the hypochondriac for a time, and it is generally far easier to do him good, temporarily, than it is to relieve a neuralgic patient; but, en revanche, every remedy is apt to lose its affect after a little while. The only chance of producing permanent benefit in hypochondriasis is by the judicious combination of remedies that remove symptoms (especially dyspepsia, flatulence, etc.), which mischievously engage the patient's mind, with general tonics, and, above all, which such alterations in the patient's habits of daily life as take him out of himself and compel him to interest himself in the affairs of the world around him. And, after all, our best efforts will frequently lead to nothing but disappointment.

It is notoriously the fact that hypochondriasis especially affects the rich and idle classes; but it would be a great mistake to suppose that it never attacks the poor or the hard-worked: only, in the latter instances, it apparently needs, for it development, the existence of strong family tendencies to neurotic disease, and especially to insanity. Among the numerous debilitated persons who attend the out-patient rooms of our hospitals we every now and then encounter as typical a case of hypochondriasis as could be found even among the rich and gloomy old bachelors who haunt some of our London clubs. I have one such patient under my care now, who has been a repeated visitor at the Westminster Hospital during many years: he has had pseudo-neuralgic pains nearly everywhere at different times; but his most complaint has been of pain in the groin and scrotum of the right side. The existence of what seemed, at first, like the tender points of lumbo-abdominal neuralgia, at one time led me to believe it was a case of that affection; but I was soon undeceived by finding that the tenderness did not remain constant to the same points, but shifted about. This man has professed, by turns, to derive benefit from nearly all the drugs in the Pharmacopœia; but the only remedies that have done him good, for more than a day or two at a time, have been valerian and assafœtida, with the prolonged use of cod-liver oil. He will never be really cured; and I suspect that the secret of his maladies is an inveterate habit of masturbation acting on a nervous system hereditarily predisposed to hypochondriasis.

Sometimes it happens that the starting-point of hypochondriac pains, simulating neuralgia, is a blow, or other bodily injury acting on a predisposed nervous system. Another of my patients at the Westminster Hospital was a policeman, who had received a severe kick in the groin; he suffered pains which at first seemed to wear all the characters of true neuralgia in the pudic nerve, but afterward shifted to other places and exhibited all the intractability of hypochondriasis; the patient also developed the regular appearance and the characteristic hallucinations of the latter disease. On the last occasion when I saw him, he struck me as likely to become really insane, in the melancholic form; and the probability is that the casualty which he suffered was only accidentally the starting-point of a malady which was inherent in him since birth, and would have been developed, in any case, at some period of his life.

CHAPTER IV.
THE PAINS OF LOCOMOTOR ATAXY

Considering the vast amount that has been written about this disease during the last few years, it might be thought superfluous for me to give any description of its general features. But it unfortunately happens that there is still great divergence of opinion among authorities as to the true limitation of the group of cases that can properly be ranked under this title, and, indeed, as to the propriety of employing the title at all. The phrase ataxie locomotrice progressive, as every one knows, was applied by Duchenne de Boulogne to a class of cases which really only form a subdivision of the group known under the older title of tabes dorsalis and the most advanced German pathologists maintain that the old word was better, and that Duchenne was altogether wrong in making the one symptom, ataxy of locomotion, the bases of a new phraseology;⁴⁹ more especially as his theory as to the seat of the morbid changes was undoubtedly erroneous.

In this country, however, there is as yet no disposition to give up the phrase locomotor ataxy, and it only remains to define with sufficient care the class of cases to which the word is here meant to apply. The disease is understood to depend upon a degeneration of the spinal cord, of which the following description is given by Lockhart Clarke:⁵⁰ "In true locomotor ataxy, the spinal cord is invariably altered in structure. Its membranes, however, are sometimes apparently unaffected, or affected only in a slight degree; but generally they are much congested, and I have seen them thickened posteriorly by exudations, and adherent, not only to each other, but to the posterior surface of the cord. The posterior columns, including the posterior nerve-roots, are the parts of the cord which are chiefly altered in structure. This alteration is peculiar, and consists of atrophy and degeneration of the nerve fibres to a greater or less extent, with hypertrophy of the connective tissue, which give to the columns a grayish and more transparent aspect; in this tissue are embedded a multitude of corpora amylacea. Many of the blood vessels that travel the columns are loaded or surrounded to a variable depth by oil-globules of various sizes. For the production of ataxy, it seems to be necessary that the changes extend along a certain length, from one to two inches of the cord. The posterior nerve-roots, both within and without the cord, are frequently affected by the same kind of degeneration, which sometimes extends to the surface even of the lateral columns, and occasionally along the edges of the anterior. Not unfrequently the extremity of the posterior cornua, and even deeper parts of the gray substance, are more or less damaged by areas of disintegration. The morbid process appears to travel from centre to periphery, that is, from the spinal cord to the posterior roots. In the cerebral nerves, on the contrary, the morbid change seems to travel in the opposite direction, that is, from the periphery toward the centres. From the optic nerves it has been found to extend as far as the corpora geniculata, but seldom as far as the corpora quadrigemina. With the exception of the fifth, seventh, and eighth pair, all the cerebral nerves have occasionally been found more or less altered in structure."

The symptoms which occur in cases in which the above are the morbid appearances found after death are (roughly speaking) as follows:⁵¹ "A peculiar gait, arising from want of co-ordinating power in the lower extremities, a gait precipitate and staggering, the legs starting hither and thither in a very disorderly manner, and the heels coming down with a stamp at each step."

No true paralysis in the lower extremities or elsewhere. Characteristic neuralgic pains, erratic paroxysmal in the feet and legs chiefly – pains of a boring, throbbing, shooting character, like those caused by a sharp electric shock.

More or less numbness, in the feet and legs chiefly, in all forms of sensibility, excepting that by which differences of temperature are recognized.

Frequent impairment of sight or hearing, one or both.

Frequent transitory or permanent strabismus or ptosis, one or both.

No very obvious paralysis of the bladder or lower bowel.

No necessary impairment of sexual power.

No tingling or kindred phenomenon.

No marked tremulous, convulsive, or spasmodic phenomena.

No marked impairment of muscular nutrition and irritability.

No impairment of the mental faculties.

Occasional injection of the conjunctivæ, with contraction of the pupils.

The probable limitation of the distinctive phenomenon of locomotor ataxy (the want of co-ordinating motor power) to the lower extremities.

The above description includes all the necessary facts for the recognition of the disease, except one, namely, that the use of the eyesight is always needed in order to prevent the patient from falling during progression; and is usually necessary even to enable him to stand upright without falling.

The pains of locomotor ataxy are early phenomena in most cases, and they are usually present, more or less, throughout the course of the disease.

They are often preceded by strabismus, with or without ptosis; the strabismus, is usually accompanied by amblyopia. It may happen, however, that neuralgic pains are, for a considerable time, the only noticeable phenomena; or they may be attended with a certain amount of anæsthesia.

The most frequent type of the pains is lancinating or stabbing; they are like violent neuralgias occurring successively in various nerves; shifting about from one to another. Sometimes it will happen that the pain remains fixed to one particular nerve for hours together; but it never continues long without showing the characteristic tendency to move about. Most commonly our diagnosis is soon assisted by the occurrence of a greater or less degree of ataxy. But, even before the setting in of definite atactic symptoms, the shifting character of the pains, and the development of a very noticeable amount of anæsthesia, together with the absence of anything like positive motor paralysis, will have given us the necessary clew.

The effect of treatment, or rather its want of effect, usually affords powerful assistance in distinguishing the pains of locomotor ataxy from those of true neuralgia. Even where the pain has been fixed for some hours in a single nerve, and has been stopped by some powerful remedy (such as hypodermic morphia), it will be apt speedily to recur, and frequently in some quite distant nerve.

Locomotor ataxy is a disease affecting chiefly the male sex, and occurring in the immense majority of cases between the thirty-fifth and the fiftieth year.

Not merely is it strictly limited to individuals who belong to families with neurotic tendencies, but it is itself frequently seen to occur in several members of the same family, and sometimes of the same generation. When, therefore, we meet with neuralgic pains of the shifting type above described, it is very important at once to make careful inquiries whether any members of the family have suffered from symptoms of ataxy going on to a fatal result. Otherwise, we might be the more readily deceived into the idea that the pains were merely neuralgic, because the symptoms of the disease are not unfrequently provoked by such causes as fatigue and exposure to cold or wet, which are also very ordinary exciting causes of true neuralgia.

CHAPTER V.
THE PAINS OF CEREBRAL ABSCESS

Cerebral abscesses is, fortunately, a rare disease; but the very fact of its rarity makes the resemblance of the pain it causes to that of neuralgia the more likely to lead us into serious errors. We are apt to forget the possibility of suppuration of the brain on account of its infrequence.

Pain in the head is present as an early symptom of abscess in the brain in a large proportion of cases in which there is pain at all. [Of seventy-five cases of cerebral abscess analyzed by Gull and Sutton (Reynolds's "System of Medicine," vol. ii.), pain was a symptom in thirty-nine, and most frequently an early symptom.] Many cases are recorded in which it preceded every other morbid sign by a considerable period. It is usually more or less paroxysmal, often strikingly so; in the latter case, it bears a great similarity to neuralgia. On the other hand, it sometimes takes the shape of a fixed burning sensation, much less resembling neuralgia. The situation of the pain by no means always, nor even usually, corresponds to the situation of the cerebral abscess; on the contrary, abscess in the cerebellum has often caused pain referred to the anterior part of the head, and so on. So long as the disease remains characterized only by pain, more or less, of a paroxysmal character, the diagnosis must be very uncertain; but in the great majority of cases certain more distinctive symptoms soon become superadded; either convulsions (sometimes hemiplegic), vertigo, coma, paralysis, vomiting, or a combination of some of these.

In the stage in which there is as yet no conspicuous symptom but severe pain, the diagnosis of cerebral abscess from neuralgia must rest on the following points of contrast:

The only case of cerebral abscess that I have personally seen, in which the above points of distinction would have been insufficient, was that of a boy of sixteen, in whom the only discoverable symptom, for nearly three months, was pain, very strongly resembling ordinary migraine, recurring not oftener than once in ten days or a fortnight, lasting for some hours at a time, and nearly always ending in vomiting, and disappearing after sleep. At the end of the three months, acute pain in the left ear set in, and this was followed, soon, by right hemiplegia, coma, and death. It was then discovered, although it had formerly been denied, that the boy had suffered from discharge from the left ear, following a febrile attack which had been marked by sore-throat, and followed by desquamation of the cuticle – evidently scarlet fever. In all cases of severe pain in the head, it is a golden rule to inquire most carefully as to the possible existence, present or past, of discharge from the ear, or other signs of caries of the temporal bone; and, even if no positive history of this kind be given, we should still regard with great suspicion any case in which there has been scarlet fever followed by deafness.

CHAPTER VI.
PAINS OF ALCOHOLISM

A very important class of pains, which are occasionally confounded with true neuralgias, are those which occur in certain forms of chronic alcoholism. The diagnosis of their true nature is a matter of the utmost consequence, and the failure to recognize them for what they are may have very disastrous results. It is a curious fact that this consequence of chronic alcoholic poisoning has been entirely overlooked by some of the best known writers on that affection; it has, however, been described by Mr. John Higginbottom, and also by M. Leudet.

It must be clearly understood that the pains of which we are now to speak are not among the common consequences of chronic excess in drink. The affections of sensation which most usually occur in alcoholism take the shape either of anæsthesia, or of this combined with anomalous feelings partaking more or less of the character of formication. Chronic drinking has also a tendency, in its later stages, when the nutrition of the nervous centres has been considerably impaired by the habit, to set up true neuralgia, of a formidable type, in subjects who are hereditarily predisposed to neuroses. But the affection of which I now speak may occur at any stage except the very earliest, and, though often severely painful, is essentially different both in its seat and in its general characters, from neuralgia proper.

The earliest symptoms from which the patient usually suffers in these cases are insomnia, and intense depression of spirits, which, however, is not incompatible, indeed is frequently combined, with a morbid activity and restlessness of thought. There is generally marked loss of appetite, but often there is none of the morning nausea so characteristic of the common forms of alcoholism. Nor is there, ordinarily, any special unsteadiness of the muscular system. The pains are usually first felt in the shoulder and down the spine; but as the case progresses they especially attack the wrist and ankles; and it is in these latter situations that I have found them to be most decidedly complained of. Their similarity to neuralgia consists (a) in their somewhat paroxysmal character; (b) in their frequently recurring at about the same hour of the day, most commonly toward night; and (c) in their special aggravation by bodily and mental fatigue.

Their differences from neuralgia are – (a) that they never follow the course of a recognizable single nerve; (b) that they are nearly always present in more than one limb, and usually in both halves of the body, at the same time; and (c) especially, that they are far less promptly and effectually relieved by hypodermic morphia than are the true neuralgias; indeed, opiates very frequently only slightly alleviate the pain, while they excite and agitate the patient and render sleep impossible. On the contrary, a large dose of wine or brandy will never fail to procure temporary comfort and induce sleep, at least until the patient reaches an advanced stage of the disorder, and is, in fact, on the verge of delirium tremens.

I am not quite sure that I am right in believing that there is a special physiognomy for this form of chronic alcoholism, and yet I am much inclined to believe that there is. All the patients whom I have seen suffering with it have presented a peculiar brown sallowness of face, and a general harsh dryness of the skin, which has usually lost its natural clearness, not only in the face, but even more remarkably in the hands, which are so dark-colored as to appear as if they were dirty. There is usually considerable leanness of the limbs, and, though the abdomen may be somewhat prominent, this does not seem to depend much on the presence of fat, but rather on relaxation of the abdominal muscles, and sometimes flatulent distention of the stomach and intestines. The hands are usually hot, sometimes quite startlingly so.

Some of the patients suffer, besides the pains in the limbs (which they often describe as resembling the feeling of a tight band pressing severely around the ankles or wrists), from frequent or occasional attacks of genuine hemicrania; such a combination is to me always a suspicious sign, and induces me immediately to direct my attention to the possibility of chronic alcoholic poisoning. Otherwise, the limb-pains are often spoken of as resembling rheumatism, but there is no swelling of joints, and usually no decided tenderness of the painful parts. The patient has usually a particular worn and haggard appearance, complains of intense fatigue after the most moderate muscular exertion, and is usually utterly indisposed to physical exercise even though the mind, as already said, may display a feverish activity.

So far as I have seen, the subjects of this affection are by far the most frequently women; and I am inclined to attribute this predisposition of the sex not to inherent peculiarities of female organization, but to the fact that a much larger proportion of intemperate women than of intemperate men indulge in secret excess. They never get drunk, probably, but they fly to the relief of alcohol upon every trivial occasion of bodily or mental distress; and this habit may have been going on for years before it comes to be suspected by their friends or their medical attendant. Meantime, they have been more or less looked upon, and have looked upon themselves as, "debilitated" and "neuralgic" subjects, and have come, either with or without mistaken medical advice, to consider free stimulation as the proper treatment for the very ailments which have been produced by their own unfortunate habits. I cannot avoid the expression of the misgiving, that imperfect diagnosis, and consequent erroneous prescription, have done great harm in many such cases. It has happened to me no less than three times within the last six months to be called to lady patients, all suffering from alcoholism induced by a habit of taking stimulants for the relief of so-called neuralgic pain; and in the most distressing of these the mischief had been greatly aggravated by a prescription of brandy, based on the erroneous idea that the pains were truly neuralgic. I have already protested against this kind of medication, even in cases that are truly neuralgic in character; but it is doubly mischievous where given for a state of things which actually depends on alcoholic excess.

It is undoubtedly very difficult, sometimes, to elicit the truth, even in cases where we may entertain considerable suspicion that alcoholic excesses are the real cause of the pains which the patient calls neuralgic; more especially where the patient is aware that he or she is taking an amount of alcohol which is seriously damaging to health. And it is therefore necessary to look out for every possible additional help to our diagnosis. Besides the cardinal features of the disease – the insomnia, loss of appetite, foul breath, haggard countenance, and pains encircling the limbs near the joints rather than running longitudinally down the extremities there are certain moral characteristics of the patient that often tells a significant tale. The drinker, especially if a woman, is shifty, voluble, and full of plausible theories to account for this and the other phenomenon. It will be well to try the effects of a somewhat sudden though not uncourteous remark, to the effect that the diet should be strictly unstimulating. If this be introduced with some abruptness, in the course of a conversation not apparently leading to it, the patient's manner will not unfrequently betray the truth; while, if our suspicions are groundless, we shall also probably perceive that, in the unconscious, or frankly surprised, expression of the countenance. We may sometimes derive crowning proof of the existence of alcoholic excess by cautious questions which at least reveal the fact that the patient suffers from spectral hallucinations; this is a far commoner occurrence in chronic alcoholism than is generally supposed; it needs to be inquired for with great tact, but, when established beyond doubt, and joined to insomnia and the peculiar foul breath, is of itself sufficient to establish a positive diagnosis of alcoholic poisoning.

The results of treatment, in true neuralgia and in alcoholic pains, respectively, establish an important difference between these affections. In the former malady, for instance, the hypodermic injection of morphia always produces striking palliative, and very often curative effects. In alcoholic pains this remedy either affords only trifling relief, or more commonly aggravates the malady by increasing the general nervous excitement; and the only true treatment is at once to suspend all use of stimulants, to administer quinine, and to insist upon a copious nutrition. If any hypnotic must be employed, let it be chloral, or bromide of potassium with cannabis Indica. It will be well also to put the patient upon a somewhat lengthened course of cod-liver oil. There is one special symptom from which the chronic alcoholist often suffers acutely, namely a hypersensitiveness to cold; for this I found the use of Turkish bath two or three times a week, for three or four weeks, very useful in one case that was under my care. It will be important to insist that the patient shall take the bath only after that shorter method which I have described in speaking of the prophylaxis of true neuralgia.