Читать книгу Neuralgia and the Diseases that Resemble it - Anstie Francis Edmund - Страница 2

Although it is, in a general way, unadvisable to introduce abstract discussions into a treatise which should be strictly practical, it is almost impossible to avoid some few general reflections on the physiological import of Pain, as a preliminary to the discussion of the maladies which form the subject of this volume. This whole group of disorders is linked together by the fact that pain is their most prominent feature; and, with regard to most of them, the relief of the pain is the one thing required of the physician. It seems, therefore, very important that we should ascertain, at least approximately, in what the immediate state consists, which consciousness interprets as pain. It is not necessary to enter at this stage into any inquiry as to the pathological causes of the phenomenon; what we know of these, and it is unfortunately too little, will be discussed in detail under the headings of the several affections which I shall have to describe.

The question before us now is this: What is that functional state of the nerves which consciousness interprets as pain? Is it, or is it not, an exaltation of the ordinary function of sensation?

The latter question is generally answered affirmatively, without much thought, by those to whom it casually occurs; but indeed there is plenty of prescriptive authority for so dealing with it. Pain has been described by some of the most distinguished writers on nervous diseases as a hyperæsthesia. Yet there is really little difficulty in convincing ourselves, if we institute a thorough inquiry into the matter, that pain is certainly not a hyperæsthesia, or excess of ordinary sensory function, but something which, if not the exact opposite of this, is very nearly so.

The leading fallacy in the common view is the confusion which is perpetually being made between function and action. Now, the function of individual nerves is very nearly a constant quantity, at least, it varies only within narrow limits; while the action of the same nerves may be almost any thing. The function of the nerve is that kind of work for which it is fit when its molecular structure is healthy; it is the series of dynamic reactions which are necessarily produced in nerve-tissue by the external influences which surround and impinge upon it in the conditions of ordinary existence. The action of nerves, under the pressure of extraordinary influences, may include all manner of vagaries which really have nothing in common with the effects of ordinary functional stimulation; which are, in fact, nothing but perturbation. No one can suppose, for instance, that the explosive disturbances of nerve-force which give rise to the convulsions of tetanus are any mere exaggerated degree of the orderly and symmetrical action by which the healthy nerve responds to the stimulus of volition ordering a given set of muscles to contract; they are something quite different in kind. And so it is with the sensory nerves. The functions of these conductors, in health, is to convey to the perceptive centres the sensations, varying only within a most limited range, which correspond to a state of well-being of the organs, and which excite only those reflex actions that are necessary to life. Thus the large surface of sensitive nerve terminals which is represented by the collective peripheral branches of the fifth cranial conveys to the medulla oblongata an impression, derived from the temperature and movement of the surrounding air, when the latter is neither too hot nor too cold, which imparts to the brain a perception of comfortable sensations, and excites in return the reflex action of breathing, which is necessary to life. But the impression produced on this same peripheral expanse of nerve-branches by prolonged exposure to cold wind may, and often does, convey to the centres sensations which are quite different and provokes reflex movements which are altogether abnormal. Pain is the product in one direction; sneezing, perhaps, in the other. It seems absurd to say that sneezing is any part of the function of those motor nerves whose action regulates the performance of expiration. And it appears to me not less absurd to say that pain is the function of the sensitive fibres of the trigeminus. But the best way, perhaps, to illustrate the looseness and incorrectness of applying the term "hyperæsthesia" (implying exalted function) to the state of sensitive nerves when suffering pain, is to examine the condition of distinctive perception in the very same parts to which the painful nerves are distributed. It will invariably be found, as we shall have occasion to see more fully proved hereafter, that, in parts which are acutely painful, a marked bluntness of the tactile perceptions can be detected. The tactile perceptions are, no doubt, conveyed by an independent set of fibres from those which convey the sense of pain.1 Yet it is surely impossible to believe the effect of the same influence, in functional power can be different – much more than it can be exactly opposite – in the two cases.

If pain be not a heightening of ordinary sensation, then we seem to be shut up to the idea that it is a perversion owing to a molecular change of some part of the machinery of sensation which frustrates function. For it is to be observed that, while the sensations conveyed by the healthy nerve are correct in the indications which they afford to the percipient brain, the indications given by pain are vague and untrustworthy, and often seriously misleading. Not to speak of the nerves of special sense, or of the fibres which convey the sensations of muscular movement, even the nerves of common sensation do carry to the internal perception, in health, a distinct impression of the well-being of the organs to which they are distributed. Mr. Bain2 has well pointed out the positive character of this feeling, which is so often incorrectly referred to as if it were a mere negation of feeling. It is a sensation of equable and diffused comfort, if I may be allowed to use the expression, which streams in from all parts of the organism; and there is no possibility of comparing it, in any scale of less or more, with the sensation of pain; for the latter commonly conveys no correct information as to the organ from which it proceeds, or appears to proceed. Especially is this the case in the neuralgias, for more commonly than not the apparent seat of the pain is widely removed from the actual seat of the mischief which causes it.

If we inquire a little further into the circumstances under which various kinds of pain occur, we gain some fresh suggestions. Among the neuralgias, those are the most acutely agonizing which occur under circumstances of impaired nutrition incident to the period of bodily decay, and strong reasons will be hereafter adduced for the belief that there is especial impairment of the nutrition of the central end of the painful nerves. To find a parallel to the severity of this kind of pains we must turn to the case of organic tumors, which, from their position, structure, and mode of growth, necessarily exercise continuous and severe pressure on the branches or the trunk of a nerve; or to the class of pains which attend severe cramp, or tonic contraction of muscles. Now, it can scarcely be doubted that in the latter instance there is an abnormally rapid and violent destruction of tissue going on; at the very least there is an extraordinarily violent and irregular manifestation of motor force. In any case the patent fact here is dynamic perturbation of a severe kind; and, in the instance of organic tumors exercising steady and continuously increasing pressure on nerves, one can scarcely doubt that a similar perturbation, less intense but more enduring, is necessarily set up. That which can be done in the way of producing severe pain by these severe affections of the peripheral portions of nerves, or of tissues lying outside them, we might a priori expect would be effected by slighter but continuous changes in the nutrition of the more important portion of the nerve itself – its central gray nucleus. One would say that a pathological process which continuously and progressively lowered the standard of nutrition here must interfere from hour to hour, certainly from day to day, with that regular and equable distribution of force which is the essence of unimpeded function.

Take, again, the case of the very severe pain which frequently attends inflammation of the pleura and of the peritoneum. Whatever theory of the causation of these pains we may adopt, it is certain that one most important element in their production and maintenance is the continual movement and friction of the affected parts. But there is little doubt that the moving muscles are involved in the inflammatory process, as Dr. Inman has correctly observed. It would seem plain that under these circumstances – an inflamed muscular structure forced to perform its ordinary contractions as well as it can – there must be powerful dynamic perturbation going on.

If perturbation of nerve-function – a disturbance quite different from mere exaltation of the normal development of nerve-force – be the essence of pain, how comes it that pains of the severest type may be produced by changes in structures which are usually described, for practical purposes, as lying outside the nervous system? We must, in the first place, remark that the externality of any bodily tissue to the nervous system is more apparent than real. Microscopic researches are constantly revealing nerve-fibres, in ever-increasing profusion, which penetrate to parts seemingly the least vitalized in the organism. But, in any case, the nerves are certainly the ultimate channel of communication between the suffering part and the sentient centre. It seems, therefore, the inevitable conclusion that a dynamic perturbation going on in the non-nervous tissue is continued along the nerves themselves: and that the severity of the pain perceived by the conscious centres is proportionate to the tumultuousness, the want of coordination, and the waste with which force is being evolved in the cramped muscle, or whatever structure it may be, in which the pain takes its source.

Not to pursue these topics further, we may sum up the considerations which have now been adduced, in the following general propositions, which will tend to simplify the examination of the various painful disorders which we are about to discuss:

1. Pain is not a true hyperæsthesia; on the contrary, it involves a lowering of true function.

2. Pain is due to a perturbation of nerve-force, originating in dynamic disturbance either within or without the nervous system.

3. The susceptibility to this perturbation is great in proportion to the physical imperfection of the nervous tissue, until this imperfection reaches to the extent of cutting off nervous communications (paralysis).