ON THE NATURE, SEAT, AND RELATIONS OF NEURALGIA

C. Handheld Jones
1859 The Lancet  
258 Thus, I have found the womb drawn up by bands, uniting its s fundus to the anterior walls of the abdomen. Huguier has E found latero-nexions of the womb to be caused by pelvic adhe-( sions; and if, as Dr. Oldham has correctly observed, dysmenor-Thcea induces retroversion, it is sometimes owing to peri-uterine 1 inflammation, and subsequent adhesions. Struck by the frequency of adhesions when the womb is in a state of flexion, 1 Virchow has even supposed that the uterus was bent upon itself
more » ... y the bands originating in peritonitis; but I rather look upon i them, with Scanzoni, as complications determined by the prolonged flexion of the womb. In some cases, false membranes ' so bind down the womb as to render permanent its flexion, and fmy attempt to correct it dangerous. It is said that partial atrophy of the womb has been likewise caused by the pressure of vuluminous false membranes. In like manner, if part of an ovarian tumour becomes inflamed, it often brings on local peritonitis in the corresponding portion of the peritoneum, thus producing those adhesions so difficult to detect, and which have so frequently prevented the removal of ovarian tumours after the operation of gastrotomy. Cancer of the womb is generally associated with pelvi-peritonitis, by which it becomes more or less immovably fixed. Again, there is no more frequent cause of sterility than pelviperitonitis. This has been long well known to the profession, and in a paper which I had the honour to read before the Westminster Society, I explained how peritonitis caused sterility sometimes by thickening the serous covering of the ovaries, and so embedding them in false membranes, that it became difficult, or impossible, for the ripe follicle to burst, and let fall the germ. Sterility, however, still more frequently depends on the occlusion of the distal ends of the oviducts, or on their permanent adhesion to some portion of the pelvis, so that the germ cannot be conveyed to the womb. In this way many women become sterile who are not so reputed, because they have had one or more children previous to an attack of pelviperitonitis. Sometimes the womb is so tightly bound down by adhesions, that its development after impregnation is prevented, and abortion ensues as often as conception takes place. This imperfect sketch must not be concluded without pointing out some of the instances in which the conservative agency of local peritonitis is apparent. Should any of the pelvic viscera become inflamed, the adjoining peritoneum thickens, becomes inflamed, and throws off plastic exudations, to prevent the fatal effusion of urine or feces into the peritoneal cavity. We may certainly admire the conservative efforts of nature, when we find false membranes forming a semi-cartilaginous cyst around a diseased portion of intestine, so as to receive the faecal matter which would be fatal if effused into the peritoneum. The conservative tendency of peritonitis which accompanies cancer of the womb or other pelvic viscera, is equally obvious, although less successful. In one form of hæmatocele, blood collects in the pelvic portion of the peritoneal cavity, in which case plastic lymph is thrown up, so as to circumscribe the blood, and cut it off from the rest of the serous cavity; this pathological labour being indicated by intense abdominal pain, nausea, or vomiting. Treatment.-I am afraid that our larger knowledge of the diseases peculiar to women has not in every instance led to their better treatment. However wrong were our predecessors in giving the name of inflammation of the bowels" to so many different diseases, still the name led to the enforcing of perfect repose, of low diet, warm poultices, and leeches-treatment which I still believe is the most appropriate, notwithstanding the disrepute into which venesection has fallen, and the spreading of the dangerous doctrine that a stimulant system constitutes the best means of treating fevers and inflammations. In pelvi-peritonitis, I have no hesitation in applying leeches, and in giving calomel and opium, according to the patient's strength, which is much more likely to be undermined by the repeated relapses of a tedious complaint than by energetic treatment in the beginning. According to Scanzoni and my friend Dr. Aran, leeches are more effectual, in peri-uterine phlegmon, if they are applied to the neck of the womb. I have no experience of the plan, but I am inclined to think that in many cases the advantage to be derived from the direct application of leeches would not be proportioned to the pain and inconvenience entailed by the prolonged application of the speculum. Mercurial and belladonna ointment should be freely smeared over the abdominal walls, and warm poultices fre. quently applied. Mild purgatives will be advantageous. Large blisters may be successively applied to the abdomen during the :nteromenstrual period, but they should not be kept open. These measures, first used to check inflammation, may be afterwards more or less extensively employed to promote the ab sorption of adventitious products; for I have several times seen accumulations of false membranes, sufficient to modify considerably the sound on percussion, disappear by degrees, the abdomen resuming its proper sonoreity. I have not found bleeding and leeching, previous to a menstrual period, to prevent the relapse of peritonitis; and I prefer to seek to obviate this by enjoining perfect rest, and the continued application of warm poultices or spongio-piline, sprinkled with from thirty to forty drops of laudanum. It is easy to understand that it might be necessary to open into the vagina the collection of pus, no matter whether originating in pelvi-peritonitis or periuterine phlegmon; but I have not had occasion to do so, and I think it better to trust to nature for the due performance of this little operation, if it be required. -This is the treatment which I have generally found successful. Some practitioners recommend opium, in half-grain doses, every hour; and Dr. Beau's mode of treating general peritonitis might be effectual. Dr. Beau gives eight grains of sul. phate of quinine every eight hours. After four or five doses, deafness and singing in the ears come on, the action of the heart is lowered, and then the symptoms of peritonitis are said to abate. I need scarcely add, that in the anæmic stage of the disease combinations of steel and bark should be given, and that the nervous symptoms will tax the ingenuity of the medical ad viser. York-street, Portman-square, Aug. 1859. ON THE prevalent opinion respecting the nature of neuralgia seems to be that its existence implies an excited or over-active condition of the sensory nerves. Romberg uses neuralgia and hyperæsthesia as convertible terms, and states-" In hyperæsthesia we find that not only the irritation is increased, but that also the irritability of the nerves of sensation generally is ex alted both during the paroxysms as well as in the intervals," It is very evident that we can have no knowledge from actual observation of the state of the affected nerve or nerves during the neuralgic attack. We must form our conclusions as best we may from consideration of the attendant circumstances, the juvantia, and the relation of the disorder to others. For the moment let us put aside all cases of neuralgia which may be regarded as depending on a local irritation of any kind-either direct, as a splinter imbedded in a nervous trunk; or remote, as a worm in the bowels; or on demonstrable poison generated in the system, or received into it-e. g., that of gout or lead. There remain then all those cases in which the disorder is dependent upon no ascertainable cause, except it be malaria, a draught of cold air, exposure to damp, overwork of mind or body, or some cause of exhaustion. These form a group which may be distinguished as Non-organic Neuralgia. Now, in these the existing debility or prostration is at least very often ' almost as marked a symptom as the pain. It is also more ; abiding and unvarying, and the conviction becomes wrought in & m i d d o t ; the mind of the observer, that it is the fundamental state upon which the pain is, as it were, engrafted-the appropriate soil, without which the seed would not grow. It is proved by experience that, unless this debility and prostration can be removed, and replaced by healthy vigour, no real progress can be made in the cure of neuralgia. The task is like that assigned 7 to Sisyphus, the patient's and doctor's hope is worn out by ever-recurring relapses. The debility seems in a special man-e ner to affect the nervous system. The brain is languid and dull, and inapt for mental labour; sometimes it, function acltually fails, and wandering or delirium occurs. Stimuli are beneficial, often very markedly so, though their effect is tem-
doi:10.1016/s0140-6736(02)21460-9 fatcat:5ebyusyrwvf63cxtuxzpocvd2a