Entrepreneurial Small Business 4th edition by Katz Green ISBN
0078029422 9780078029424
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Small Business Strategies: Imitation with a Twist True
1. Strategy is the idea and actions that explain how a firm will make its profits.
True False
2. Small businesses typically use the strategy of innovativeness rather than imitativeness.
True False
3. The first step of the strategic planning process for small businesses is considering your customers and the benefits you want to offer them.
True False
4. There are two major classification systems that code industries: NAICS and SIC.
True False
5. The standard industrial classification system (SIC) codes have six digits.
True False
6. The new NAICS covers more industries than the SIC.
True False
7. Imitation minus one degree of similarity is the business equivalent of an innovative strategy.
True False
8. Pure innovation is an overall strategic approach in which a firm patterns itself on other firms, with the exception of one or two key areas.
True False
© 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
9. Market scale refers to the geography of the target market.
True False
10. A niche market is a narrowly defined segment of the population that is likely to share interests or concerns.
True False
11. Cost benefits include scale and scope savings.
True False
12. Generally, benefits do not influence a firm's strategy process.
True False
13. Shake-out is a type of life cycle growth stage marked by a very rapid increase in sales in a relatively short time.
True False
14. In the decline stage, sales and profits of the firms in an industry begin a falling trend.
True False
15. Funds left over after deducting the cost of goods sold are referred to as the net profit.
True False
16. Differentiation strategies target a niche segment of the market.
True False
© 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
17. The supra-strategy of a classic imitator small business start-up is single-mindedness.
True False
18. Second sourcing provides customers with greater certainty of supplies or services.
True False
19. Tactical actions are competitive responses with low resource requirements.
True False
20. Patents and trademarks are popular strategic actions for protecting a firm from competition.
True False
Multiple Choice Questions
21. _____ is the idea and actions that explain how a firm will make its profits.
A. Strategy
B. Objective
C. Mission
D. Goal
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McGraw-Hill
This document
22. Most small businesses are more _____ than _____.
A. cost-directed; profit-directed
B. imitative; innovative
C. profit-directed; cost-directed
D. innovative; imitative
23. The first step of the strategic planning process for a small business is:
A. performing a SWOT analysis.
B. reviewing and confirming the goals that define the firm.
C. mapping the prospective customers.
D. studying the dynamics and trends of the industry.
24. Which of the following is the second step of a small business' strategic planning process?
A. Reviewing and confirming the goals that define the firm
B. Knowing the magic number
C. Studying the dynamics and trends of the industry
D. Considering the customers and the benefits to offer them
25. Industry analysis is defined as the technique used to:
©
A. determine the magic number in a particular industry.
B. determine the extent to which a product is similar to another product.
C. study the dynamics and trends of an industry.
D. study the effects of low cost on an industry.
26. The fourth step of a small business' strategic planning process involves:
A. considering the customers and the benefits to offer them.
B. refining the firm's capabilities in order to maintain a competitive advantage.
C. determining the best strategic direction and strategy for the firm.
D. studying the dynamics and trends of the industry.
27. Magic number is defined as:
A. the number of employees hired by a start-up in the first year.
B. the post-tax income the entrepreneur personally seeks from the business.
C. the number of loyal customers.
D. the income a start-up is able to generate from quarterly sales.
28. Which of the following is the advantage of knowing the magic number?
A. It helps in evaluating if the proposed business can deliver the desired return.
B. It helps in retaining customers.
C. It seeks out customers who are already being serviced by another firm.
D. It helps in making incremental product improvements.
29. As a new entrepreneur, Anthony's magic number for 2013 is $42,000. If the current tax rate for his business is 30 percent, calculate the amount that Anthony's firm would need to sell for him to get his magic number.
A. $50,000
B. $50,495
C. $60,000
D. $60,854
30. _____ is the general name for the line of product or service being sold, or the firms in that line of business.
A. Industry
B. Market
C. Scope
D. Niche group
31. Which of the following are the two major classification systems that code industries?
A. NAICS and SIC
B. SCALE and SCOPE
C. SWOT and VRIO
D. OLC and SWOT
32. Standard industrial classification system (SIC) codes have _____ digits.
A. four
B. six
C. seven
D. nine
33. North American industry classification system (NAICS) codes have _____ digits.
A. three
B. six
C. eight
D. nine
© 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
34. In an imitative strategy, an entrepreneur:
A. creates a new product or service which has no competitors.
B. considers prospective customers before creating a product or service.
C. seeks to do something that is very different from what others are doing.
D. does more or less what others are already doing.
35. Which of the following is an advantage of using an imitative strategy?
A. It allows entrepreneurs to do something that is very different from what others are doing.
B. It allows business owners to buy existing technologies.
C. It allows entrepreneurs to fit their businesses to their own ideas and preferences.
D. It allows business owners to create unique settings.
36. Imitation minus one degree of similarity:
A. would be the business equivalent of cloning.
B. is equivalent to the blue ocean strategy.
C. leads to pure innovation.
D. helps in the creation of a unique setting.
37. Which of the following is true of imitation?
A. It does not involve patterning a business on existing firms.
B. It does not match the precision or completeness of copying seen in franchising.
C. It involves the creation of new products or services which have no competitors.
D. It results in the creation of previously unseen products or services.
38. An imitative business that competes locally with others in the same industry is referred to as _____.
A. incremental competition
B. niche business
C. linear competition
D. parallel competition
39. Imitation plus one degree of similarity results in:
A. patterning a business on existing firms.
B. creating previously unseen products or services.
C. creating products or services that have no competitors.
D. characterizing a business based on the returns it offers.
40. An overall strategic approach in which a firm patterns itself on other firms, with the exception of one or two key areas is referred to as _____.
A. pure innovation
B. niche strategy
C. incremental innovation
D. blue ocean strategy
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41. Amy plans to open a laundromat with a gym. She got the idea from the laundromat with a bar and game rooms, which she visits regularly. She wants to test her idea by starting out in a small space with the focus on the laundromat and a small space allocated for gym equipments. Amy's idea is an example of _____.
A. a blue ocean strategy
B. a pure innovation
C. an altruistic approach
D. an incremental innovation
42. Which of the following is true of a blue ocean strategy?
A. It results in a new product or service.
B. It is the business equivalent of cloning.
C. It involves patterning a business on existing firms.
D. It matches the precision of copying as seen in franchising.
43. A(n) _____ is the business term for the population of customers for a business owner's products or services.
A. market
B. industry
C. strategy
D. SIC
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McGraw-Hill
44. _____ refers to the size of the market, whereas _____ refers to the geographic range covered by the market.
A. Scope; scale
B. Mass; niche
C. Scale; scope
D. Niche; mass
45. A customer group that involves large portions of the population is referred to as a _____.
A. niche market
B. secondary market
C. local market
D. mass market
46. A _____ is a narrowly defined segment of the population that is likely to share interests or concerns.
A. niche market
B. mass market
C. primary market
D. parallel market
47. Which of the following is true of niche markets?
A. They are broad markets.
B. They target all the customers in the entire market.
C. They are specific and narrow.
D. They involve large portions of the population.
© 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
48. Market scope is important because:
A. it helps business owners in determining the size of the target market.
B. it helps business owners to decide where to focus their sales and advertising efforts.
C. it helps business owners in designing a product.
D. it helps business owners in calculating their magic number.
49. In the goal step of the strategic planning process, the key is to:
A. focus on the kind of customers the business wants to deal with.
B. bring together the decisions that underlie the business plan.
C. offer state-of-the-art or leading-edge technology.
D. build a brand reputation through the products or services.
50. Which of the following types of customers are likely to generate more potential customers than any other type?
A. Loyal customers
B. Local customers
C. Passionate customers
D. Corporate customers
51.
A _____ displays characteristics related to the nature of a product or service itself.
©
A. value benefit
B. cost benefit
C. scale saving
D. cause and effect diagram
52. Value benefits are important because:
A. they lead to scope savings.
B. they lead to higher prices.
C. they result in scale savings.
D. they lead to reduced costs.
53. Which of the following is an advantage of picking customer-desired benefits that a business owner's competitors do not offer?
A. They results in lower pricing.
B. They help business owners to set realistic goals.
C. They help a business owner in identifying the magic number.
D. They make the firm stand out from the competition.
54. A perceptual map is:
A. a chart that maps changes in competitors, sales and profits in an industry over time.
B. a graphic display which positions products according to their scores on important strategic dimensions.
C. a chart that indicates the changes in the magic number of a business owner.
D. a graphic display which indicates the various stages of the lifecycle of a product.
55. Which of the following is a value benefit?
A. Scale savings
B. Cost savings
C. Learning
D. Technology
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56. _____ is a value benefit that can come from the products or services that a business owner offers, or from his or her firm's reputation.
A. Brand
B. Scale savings
C. Learning
D. Scope savings
57. Which of the following types of value benefits is most likely to be offered by a product if it helps the community, a group, the environment, or the world?
A. Scope savings
B. Personalization
C. Altruism
D. Scale savings
58. Which of the following is a cost benefit?
A. Brand
B. Altruism
C. Personalization
D. Organizational practice
59. Buying in volume usually produces savings. This leads to the cost benefit of _____.
A. scope savings
B. lower costs
C. scale savings
D. learning
© 2014 by McGraw-Hill Education. This is proprietary
document
60. As a firm gets more experience, it can often work with fewer mistakes and greater efficiencies, thereby lowering costs. This leads to the cost benefit of _____.
A. personalization
B. scope savings
C. learning
D. altruism
61. Changes in competitors, sales and profits in an industry over time are referred to as:
A. industry dynamics.
B. retrenchment.
C. shake-out.
D. transformational competency.
62. The life cycle stage in which a product or service is being invented is known as the _____.
A. growth stage
B. boom
C. introduction stage
D. shake-out
63. Which of the following is true of the introduction stage of a product?
A. Sales are almost always high.
B. Most customers are unaware of the offerings.
C. Firms begin to compete on features and prices.
D. Some products turn out to be extremely popular.
© 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
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Neuralgic attacks are usually characterized, besides the pain, by a highly-interesting series of symptoms, which are in part transitory and functional, and in part due to structural changes in the tissues.4
4 See Notta, Arch. gén. de Méd., 1854; Anstie, Neuralgia and its Counterfeits.
The spasm and subsequent dilatation of blood-vessels in the affected area have already been alluded to. A disturbance of secreting organs in the neighborhood of the painful region, the lachrymal gland, the skin, the mucous membranes, the salivary glands, is of equally common occurrence, and is probably in great measure due to direct irritation of the glandular nerves, since the increased secretion is said to occur sometimes unattended by congestion.
The hair may become dry and brittle and inclined to fall out, or may lose its color rapidly, regaining it after the attack has passed.
The increased secretion of urine already alluded to attends not only renal neuralgias, but those of the fifth pair, intercostal, and other nerves. There may be unilateral furring of the tongue (Anstie).
The muscles supplied by the branches of the affected nerve or of related nerves may be the seat of spasm, or, on the other hand, may become paretic; and this is true even of the large muscles of the extremities.
Vision may be temporarily obscured or lost in the eye of the affected side in neuralgia of the fifth pair, and hearing, taste, and smell are likewise deranged, though more rarely. I am not aware that distinct hemianopsia is observed except in cases of true migraine, where it forms an important prodromal symptom.
In connection with these disorders of the special senses the occasional occurrence of typical anæsthesia of the skin of one-half of the body should be noted, which several observers have found in connection with sciatica. The writer has seen a cutaneous hyperæsthesia of one entire half of the body in a case of cervico-
occipital neuralgia of long standing. These symptoms are probably analogous to the hemianæsthesia which comes on after epileptic or other acute nervous seizures, or after concussion accidents, as has lately been observed both in this country and in Europe, and it is perhaps distantly related to the hemianæsthesia of hysteria. Local disorders of the sensibility in the neuralgic area are far more common than this, and, in fact, are usually present in some degree. The skin is at first hyperæsthetic, but becomes after a time anæsthetic; and this anæsthesia offers several interesting peculiarities. When this loss of sensibility is well marked, areas within which the anæsthesia is found are apt to be sharply defined, but they may be either of large size or so small as only to be discovered by careful searching (Hubert-Valleroux). The sensibility within these areas may be almost wanting, but in spite of this fact it can often be restored by cutaneous faradization around their margins, and the functional or neurosal origin of the anæsthesia is thus made apparent. Where the anæsthesia is due, as sometimes happens, to the neuritis with which the neuralgia is so often complicated, it is more lasting, but usually less profound and less sharply defined.
These changes may be transient, or, if a neuralgia is long continued and severe, they may pass into a series of more lasting and deeper affections of the nutrition.
The skin and subjacent tissues, including the periosteum, from being simply swelled or œdematous may become thickened and hypertrophied. The writer has known a case of supraorbital neuralgia, at first typically intermittent, to lead to a thickening of the periosteum or bone over the orbit, which even at the end of several years had not wholly disappeared.
Neuralgias of the fifth pair, which are as remarkable in their outward results as they are in their severity and their relation to other neuroses, are said to give rise to clouding and ulceration of the cornea, to iritis, and even to glaucoma.
Herpetic eruptions on the skin sometimes occur, of which herpes zoster is the most familiar instance.
Muscular atrophy is very common, especially in sciatica, and in some cases this occurs early and goes on rapidly, while in others it may be only slight and proportioned to the disease and relaxation of the muscles, even where the neuralgia has lasted for weeks or months.
Neuritis of the affected nerve is a common result or attendant of neuralgia, and may remain behind for an indefinite period after the acute pain has gone, manifesting itself by subjective and objective disorders of sensibility, by occasional eruptions on the skin, or by muscular atrophy.
It is plain that in this list of symptoms a variety of conditions have been described which would never all be met with in the same case, and which, as will be shown in the section on Pathology, are probably due to different pathological causes.
Neuralgia of the Viscera.
These neuralgias are less definitely localized by the sensations of the patient than those of the superficial nerves, and it is not definitely known what set of nerves are at fault.
They are deep-seated and are referred to the general neighborhood of the larynx, œsophagus, heart, or one of the abdominal or genital organs, as the case may be.
The pain is usually of an intense, boring character, and does not dart like the pain of superficial neuralgia, but is either constant or comes in waves, which swell steadily to a maximum and then die away, often leaving the patient in a state of profound temporary prostration.
Deep pressure often brings relief. A patient of the writer, who is subject to attacks of this kind in the right hypochondrium, will bear with her whole weight on some hard object as each paroxysm comes on, or insist that some one shall press with his fists into the painful neighborhood with such force that the skin is often found bruised and discolored.
The functions and secretions of the visceral organs are apt to be greatly disordered during a neuralgic attack, and it is often difficult or impossible to tell with certainty which of these conditions was the parent of the other Undoubtedly, either sequence may occur, but the pain excited by disorder of function, or even organic disease of any organ, is not necessarily felt in that immediate neighborhood. Thus I have known the inflammation around an appendix cæci, of which the patient shortly afterward died, to cause so intense a pain near the edge of the ribs that the passage of gall-stones or renal calculus was at first suspected.
There seems to be as much variation as to modes of onset and duration among the visceralgias as among the superficial neuralgias, but the tendency to short typical attacks of frequent recurrence seems to be greater with the former.
The visceral neuralgias are quite closely enough related to certain of the superficial neuralgias to show that they belong in the same general category The two affections are often seen in the same person, and not infrequently at the same time or in immediate succession. Thus in the case of the patient just alluded to above, the attacks of deep-seated neuralgia in the neighborhood of the right flank are at times immediately preceded by severe neuralgia of the face or head. Similarly, intercostal neuralgia may occur in immediate connection with neuralgias of the cardiac or gastric nerves.
The phenomenon of tender points is not entirely wanting in the visceralgias, though less constant and definite than in the superficial neuralgias.
The liver and the uterus especially become the seat of more or less localized tenderness, and possibly the tenderness in the ovarian region which is so common, and so often unattended by real inflammation, is, in part, of this order.
The secondary results of the visceralgias are not easy to study. Besides the disorders of secretion and function above alluded to, swelling of the liver with jaundice and paresis of the muscular walls of the hollow viscera may be mentioned as having been ascribed to neuralgia.
It is not known to what degree neuritis occurs as a cause or complication of these neuralgias, and this is a question which is greatly in need of further study.
Migraine, or Sick Headache.
This is often classified as an affection of a different order from the neuralgias, but there seem to be no real grounds for this distinction.
The superficial neuralgias themselves are probably not one, but a group of affections, with the common bond of severe and paroxysmal pain.
Neither is what is called migraine always one and the same disease.
Although in its most typical form it presents very striking characteristics, such as a marked preliminary stage, with peculiar visual and sensory auras, sometimes occupying one entire half of the body, a short and regular course and periodical return, deepseated pain without tender points, and prominent unilateral vascular disorders, yet these symptoms shade off by imperceptible degrees into those of neuralgia of the fifth pair, or more often into one or another form of unilateral neuralgic headache which stands midway between the two.
The vascular phenomena of migraine are believed by various observers, as is well known, to constitute the primary and essential pathological feature of the disease, and to be the cause of the pain. But this is a pure hypothesis, and as a matter of fact the cases are abundant in which no greater vascular changes are present than in other neuralgias of equal severity.
Migraine seems to occupy an intermediate position between the grave neuroses, especially epilepsy, and the neuralgias of neurosal origin.
The symptomatology will be described at greater length below.
GENERAL ETIOLOGY.—The causes of neuralgia may be divided into predisposing and exciting causes.
The most important of the first group are—
1. Hereditary tendencies;
2. The influences associated with the different critical periods of life;
3. The influences attached to sex;
4. The action of constitutional diseases, such as phthisis, anæmia, gout, syphilis, diabetes, nephritis, malarial poisoning, metallic poisoning.
The most important of the second group of causes are—
1. Atmospheric influences and the local action of heat and cold;
2. Injuries and irritation of nerves;
3. Irritation of related nerves (so-called reflex and sympathetic neuralgias);
4. Acute febrile diseases.
In most cases more than one cause is to blame, and each should be separately sought for.
PREDISPOSING CAUSES.—1. Hereditary Tendencies.—It is generally admitted as beyond question that neuralgias are most common in families in which other signs of the neuropathic taint are prominent. Such affections as hysteria, neurasthenia, epilepsy, asthma, chorea, dipsomania, and even gout and phthisis as it would seem, are akin to the neuralgic tendency.
The neuropathic family is thought to contain, in fact, a much larger number of members than this,5 but there is danger of exaggerating the importance of an influence of which we know as yet so little.
5 Féré, Arch. de Névrologie, 1884, Nos. 19 and 20, “La famille névropathique.”
It should be remembered, moreover, that even where an inherited taint is present its influence may be but slight as compared with that of some special exciting cause.
Some neuralgias are more closely associated with the inherited neuropathic diathesis than others. The connection is especially close in the case of migraine;6 then follow other forms of periodical headache and the visceral neuralgias. Even the superficial neuralgias7 are more or less subject to this influence. This is thought to be especially true of the facial neuralgias.
6 There is a witty French saying (quoted by Liveing), “La migraine est le mal des beaux esprits;” which might be rendered, “The disease of nervous temperaments.”
7 For tables of illustrative cases see Anstie, Neuralgia and its Counterfeits, and J. G. Kerr, Pacific Med. and Surg. Journ., May, 1885.
Reasons will be offered later for suspecting that many cases usually classed as neuralgia, and characterized by gradual onset and protracted course, are essentially cases of neuritis; and there is need of further inquiry as to how far hereditary influences are concerned in producing them, and whether such influences act by increasing the
liability of the peripheral nerves to become inflamed, or only by increasing the excitability of the sensory nervous centres.
2. Age.—Neuralgia is oftenest seen in middle life and at the epochs marked by the development and the decline of the sexual functions. The affection, when once established, may run over into advanced age, but cases beginning at this period are relatively rare and very intractable (Anstie).
Childhood is commonly said to be almost exempt from neuralgia, but, in fact, there seems no sufficient reason for withholding this term from the so-called growing pains of young children8 so long as it is accorded to the almost equally irregular neuralgias of anæmia in the adult. The same remark applies to the attacks of abdominal pain in children, which often seem to be entirely disconnected from digestive disorders.
8 Probably due to anæmia or imperfect nutrition (see Jacobi, “Anæmia of Infancy and Childhood,” Archives of Med., 1881, vol. v.).
Adolescents and children also suffer from periodical headaches, both of the migrainoid and of the neuralgic type. These are obstinate and important affections.9 Migraine especially, coming on in early life, points to a neuropathic constitution, and will be likely to recur at intervals through life, or possibly to give place to graver neuroses.
9 Blache, Revue mensuelle de l'enfance, Mar., 1883, and Keller, Arch. de Névroloqie. 1883.
3. Sex.—Women show a stronger predisposition than men to certain forms of neuralgia, as to the other neuroses, but it is generally conceded that whereas neuralgias of the fifth and occipital and of the intercostal nerves are met with oftenest among them, the brachial, crural, and sciatic neuralgias are commoner among men. This probably indicates that the neurosal element is of greater weight in the former group, the neuritic element in the latter.
4. Constitutional Diseases.—The blood-impoverishment of phthisis and anæmia, the poison of malaria, syphilis, and gout, and the obscurer forms of disordered metamorphosis of tissue, undoubtedly predispose to neuralgia and the other neuroses, as well as to neuritis and others of the direct causes of neuralgic attacks.
Anstie regards the influence of phthisis as so important as to place it fairly among the neuroses. Gout is likewise reckoned by some observers among the neuroses,10 but we tread here upon uncertain ground. Anstie does not regard gout as a common cause of neuralgia, but most writers rate it as more important, and gouty persons are certainly liable to exhibit and to transmit an impaired nervous constitution, of which neuralgia may be one of the symptoms. The neuralgias of gout are shifting, irregular in their course, and sometimes bilateral.
10 Dyce-Duckworth, Brain, vol. iii., 1880.
Syphilitic patients are liable to suffer, not only from osteocopic pains and pains due to the pressure of new growths, but also from attacks of truly neuralgic character. These may occur either in the early or the later stages of the disease. They may take the form of typical neuralgias, as sciatica or neuralgia of the supraorbital nerve (Fournier11), or they may be shifting, and liable to recur in frequent attacks of short duration, like the pains from which many persons suffer under changes of weather, anæmia, or fatigue.
11 Cited by Erb in Ziemssen's Encyclopædia
There are other obscure disorders of the nutrition, as yet vaguely defined, in connection with which neuralgia of irregular types is often found. Some of these are classed together under the name of lithæmia, and are believed to be due to imperfect oxidation of albuminoid products.12
12 See DaCosta, Am. Journ. of Med. Sciences, Oct., 1881, and W. H. Draper, New York Med. Record, Feb. 24, 1883.
Diabetes seems also to be an occasional cause of neuralgia, especially sciatica, and Berger,13 who has recently described them, says that they are characterized by limitation of the pain to single branches of the sacral nerves, by a tendency to occur at once on both sides of the body, by the prominence of vaso-motor symptoms, and, finally, by their long duration and obstinacy. There may not, at the moment, be any of the characteristic symptoms of diabetes present.
13 Neurologisches Centralblatt, 1882, cited in the Centralbl. für Nervenheilk., etc., 1882, p. 455.
Chronic nephritis also causes neuralgia, either directly or indirectly; and severe neuralgic attacks may accompany the condition, which is as yet but imperfectly known, characterized pathologically by a general arterio-fibrosis and by increased tension of the arterial system.
True rheumatism does not appear to be a predisposing cause of neuralgia.
Anæmia, both acute and chronic, is a frequent cause of neuralgia, both through the imperfect nutrition of the nervous tissues, to which it leads, and, it is thought, because the relatively greater carbonization of the blood increases the irritability of the ganglionic centres.
Even a degree of anæmia which might otherwise be unimportant becomes of significance in the case of a patient who is otherwise predisposed to neuralgia; for such persons need to have their health kept at its fullest flood by what would ordinarily seem a surplus of nourishment and care.
Under the same general heading comes the debility from acute and chronic diseases, and the enfeeblement of the nervous system from moral causes, such as anxiety, disappointment, fright, overwork and over-excitement, and especially sexual over-excitement, whether gratified or suppressed (Anstie), or, on the other hand, too great monotony of life; also from the abuse of tea, coffee, and tobacco.
Lead, arsenic, antimony, and mercury may seriously impair the nutrition of all the nervous tissues, and in that way prepare the way for neuralgia.
IMMEDIATE CAUSES.—1. Atmospheric and Thermic Influences.— Neuralgia is very common in cold and damp seasons of the year, in cold and damp localities, and in persons whose work entails frequent and sudden changes of temperature. Exposures of this sort may at once excite twinges of pain here and there over the body, and may eventually provoke severe and prolonged attacks of neuralgia.
The action of damp cold upon the body is complicated, and it exerts a depressing influence on the nervous centres in general which is not readily to be explained. One important factor, however, is the cooling of the superficial layers of the blood, which occurs the more easily when the stimulus of the chilly air is not sufficiently sharp and sudden to cause a firm contraction of the cutaneous vessels, while the moisture rapidly absorbs the heat of the blood. From this result, indirectly, various disorders of nutrition of the deeper-lying tissues or distant organs; and, among these, congestion and neuritis of the sensitive nerves.
Neuralgia often coincides with the presence or advent of storms. A noteworthy and systematic study of this relationship was carried on through many years under the direction of S. Weir Mitchell14 by a patient of his, an officer who suffered intensely from neuralgia of the stump after amputation of the leg. The attacks of pain were found to accompany falling of the barometer, yet were not necessarily proportionate to the rapidity or amount of the fall. Saturation of the air with moisture seemed to have a certain effect, but the attacks often occurred when the centre of the storm was so remote that there was no local rainfall. It was impossible to study the electrical disturbances of the air with accuracy, but a certain relationship was observed between the outbreak of the attacks and the appearance of aurora borealis.
14 Am. Journ. of Med. Sci., April, 1877, and Philada. Med. News, July 14, 1883.
This patient's neuralgic attacks were almost certainly of neuritic origin, and it is possible that the exacerbations were due to changes of blood-tension in and around the nerve-sheaths. It is also possible that they were the result of circulatory changes and disordered nutrition of the nervous centres, already in a damaged condition from the irritation to which they had been exposed.
2. Injuries and Irritation of Nerves.—Wounds and injuries of nerves15 and the irritation from the pressure of scars, new growths, and aneurisms are prolific causes of neuralgic pain, partly by direct irritation, partly by way of the neuritis which they set up. Neuralgias are likewise common during the period of the healing of wounds, as Verneuil long since pointed out. The pain may be near the wound itself or in some distant part of the body.
15 See S. Weir Mitchell, Injuries of Nerves
Neuralgia due to the pressure and irritation of tumors, new growths, or aneurisms requires a special word. The pain is apt to be intensely severe, but what is of especial importance is that the symptoms may not present anything which is really characteristic of their origin, except their long continuance; and this should always excite grave suspicion of organic disease.
These attacks of pain may be distinctly periodical; and this is true whether they are felt in the distribution of the affected nerve or of distant nerves.
Not only are direct injuries of nerves a cause of neuralgia, but sudden concussion or jar may have a like effect—whether by setting up neuritis or in some other way is not clear. Ollivier16 reports a case where a blow beneath the breast caused a neuralgia which eventually involved a large portion of the cervico-brachial plexus; and the writer has seen a like result from a blow between the shoulders.
16 Cited by Axenfeld and Huchard, p. 116.
Peripheral irritations, such as caries of the teeth (see below, under Facial Neuralgia) and affections involving other important plexuses, such as those of the uterine nerves, are a frequent cause of neuralgia, and should always be sought for. They act in part by setting up neuritis, and in part evidently in some more indirect manner, since the neuralgia which they excite may be referred to more or less distant regions, forming the so-called—
3. Reflex and Sympathetic Neuralgias.—The term reflex, as here used, is ill chosen, and the term sympathetic only covers our ignorance of the real processes involved, and which we should seek for in detail. Thus, disease of the uterus or ovaries may cause facial, mammary, intercostal, or gastric neuralgia.
Hallopeau17 suggests that some of these results may be brought about by the pressure of enlarged lymphatic glands attached to the affected organ.
17 Loc. cit., p. 766.
Another important centre of nervous irritation is the eye. Slight errors of refraction, or weakness of the muscles of fixation, especially the internal recti, are a source of frontal headaches and other nervous symptoms, and even of typical migraine,18 to a degree which is not usually appreciated. It is improbable that in the latter case the irritation acts as more than an exciting cause, but it may nevertheless be a conditio sine quâ non of the attack.
18 St. Barthol. Hosp. Repts., vol. xix.
Acute and chronic inflammations of the mucous membrane of the frontal sinuses, perhaps even of the nasal membrane, are likewise important; and although it is probable that the opinions sometimes expressed as to the significance of these causes are exaggerated, it is equally true that obstinate and, as it were, illogical persistence in their removal will sometimes be richly rewarded.
It is especially worthy of note that there need be no local sign whatever to call the attention of the patient to the presence of the peripheral irritation.
Nothnagel19 has described neuralgias which come on in the first week of typhoid, and are to be distinguished from the general hyperæsthesia of later stages. He describes an occipital neuralgia of this sort which finally disappeared under the use of a blister. Other acute diseases may have a like effect. The writer has seen a severe facial neuralgia in the first week of an insidious attack of pneumonia in a person who was not of neuralgic habit, and before the fever or inflammation had become at all severe.
19 Virch. Arch., vol. liv., 1872, p. 123.
PATHOLOGY AND DIAGNOSIS.—In surveying the clinical history of the neuralgias and the circumstances under which they occur, we have grouped together a large number of symptoms of very different character from each other, and we have now to inquire to what extent these symptoms are really united by a pathological bond.
Two opposite opinions have been held concerning the pathology of neuralgic affections. According to one opinion, every neuralgic attack, no matter how it is excited, is the manifestation of a neurosis —that is, of a functional affection of the nervous centres—to which the term neuralgia may properly be applied. This view is based on the resemblance between the different forms of neuralgia, or the apparent absence, in many cases, of any adequate irritation from without, and the fact that the persons in whom neuralgias occur usually show other signs of a neuropathic constitution.
According to the other opinion, the various forms of neuralgia are so many different affections, agreeing only in their principal symptom, and are due sometimes to congestion or anæmia of the nerves or the nerve-centres; sometimes to neuritis, the pressure of tumors, or the irritation of distant nerves; sometimes, finally, to a functional disorder of the nervous centres. The arguments in favor of this opinion are that the difference between the symptoms of the different
neuralgias as regards their mode of onset and decline, their duration, the persistence of the pain, and the degree to which the attacks are accompanied by organic changes of nutrition in the tissues and in the nerve itself, are so great as to make it appear improbable that we are dealing in every case simply with one or another modification of a single affection.
This is a valid reasoning, and it is certainly proper to exhaust the possibilities of explaining the symptoms that we find in a particular case by referring them to morbid processes which we can see or of which we can fairly infer the presence, before we invoke an influence of the nature of which we understand so little as we do that of the functional neuroses. At the same time, it must be distinctly borne in mind that the symptoms of certain neuralgias, and the relation which the neuralgias in general bear to other neuroses, can only be accounted for on the neurosal theory, and that in a given case we can never be sure that this neurosal tendency is not present and is not acting as at least a predisposing cause. It is especially important to bear this possible influence in mind in deciding upon prognosis and treatment.
We may now review briefly the signs which should lead us to diagnosticate or suspect the presence of the various special causes of neuralgic symptoms.
Neuritis is indicated by the presence of organic disorders of nutrition affecting the skin, hair, or nails, or of well-marked muscular wasting; by pain, not only occurring in paroxysms, but felt also in the intermissions between the paroxysms, or continuous sensations of prickling and numbness, even without pain; by tenderness along the course of the nerve; by anæsthesia, showing itself within the first few days of the outbreak of a neuralgia; by persistent paralysis or paresis of muscles.
Neuritis may be suspected, even if one or all of these signs are absent, in the prolonged neuralgias which follow wounds or strains of nerves or exposure to damp cold, or which occur in nerves which are in the immediate neighborhood of diseased organs; also where the
pain is relieved by compression of the nerve above the painful part, or, on the other hand, where pressure on the nerve excites a pain which runs upward along the course of the nerve.
It may also be suspected in the large class of superficial neuralgias which follow a regular and protracted course with gradual onset and decline, and where the pain is felt not only in the region of distribution of a nerve, but also along its course—that is, in the nerve-fibres (either the recurrent nerves or the nervi nervorum) which are distributed in the sheath of the main trunk or the adjoining tissues.20
20 See Cartaz, Des Névralgics envisagés au point de vue de la sensibilité récurrente, Paris, 1875.
It must be remembered that the study of neuritis, and especially of chronic neuritis, is still in its infancy, and that we are by no means in possession of its complete clinical history.21
21 See Pitres and Vaillard, Arch. de Névrologie, 1883.
The presence of congestion of the sensory nerves or nerve-centres may be inferred with some degree of probability where neuralgic attacks of relatively sudden onset and short duration occur in parts which have been exposed to heat or cold, or in connection with suppression of the menstruation, or, it is said, as a result of intermittent fever. The exacerbations of pain which take place in cases of chronic neuritis under changes of weather and after fatigue are very likely due to this cause; and the same may be true of some of the fleeting pains which occur in chlorotic and neuropathic persons who are subject to fluctuations of the circulation of vasomotor origin.
The same vaso-motor influences which cause congestion may also cause the correlative state of anæmia, which becomes thus a cause of transient and shifting though often severe attacks, which may be irregular in their distribution. General anæmia is also a predisposing cause of severe typical seizures, as has been pointed out above.
The pressure of new growths or of aneurisms is to be suspected when neuralgic attacks are unusually severe and prolonged, recur always in the same place, and occur in persons who are not predisposed to neuralgias. The pains from this cause are apt to be relatively continuous, but they may, on the other hand, be distinctly paroxysmal, and may occupy a part of the body far removed from the irritating cause.
Bilateral pains should also excite suspicion of organic disease, though they may be due to other causes, such as gout, diabetes, and metallic poisoning.
Neuralgic attacks may be supposed to be of neurosal origin when they are of sudden onset and short duration, or when they occur in persons of neuropathic constitution, and, by exclusion, when no other cause is found. These conditions are best fulfilled in the case of migraine and the visceral neuralgias. It must, however, be borne in mind that the neuropathic predisposition is sometimes well marked even in the case of the superficial neuralgias, especially the epileptiform neuralgia of the face.
GENERAL TREATMENT.—To treat neuralgia with satisfaction it is necessary to look beyond the relief of the particular attack and search out the causes by which it was provoked. As has already been remarked, these are usually multiple, and among them will be found, in the great majority of cases, some vice of nutrition or faulty manner of life.
It is safe to say that any dyscrasia occurring simultaneously with neuralgia, whether gout, phthisis, malaria, or diabetes, should receive its appropriate treatment, whatever theory we may hold as to the real connection between the two conditions.
In protracted neuralgias it is always proper to assume that neuritis may be present—i.e. to treat the nerve itself by galvanism and local applications. Local irritations, such as diseases of the eye, ear, teeth, nose, or uterus, should be sought out and removed; and attention may here be called again to the fact that a neuralgia may be due to
some local condition which does not of itself attract the patient's attention.
Patients who are subject to pain at changes of weather or on exposure should be suitably protected by clothing, and should have their cutaneous regulatory apparatus strengthened by baths and friction. The best protection, however, is incapable of entirely warding off the effect of atmospheric changes upon the nervous centres. Vaso-motor changes of neurotic origin can be, in a measure, prevented by removing the patient from the influence of irregularity of life and emotional excitement and through an improved nutrition.
If the patient has been subjected to chronic fatigue or nervous strain, not only must these be avoided, but their action should be counteracted by the requisite rest and tonic treatment.
Long hours of sleep at night may often be supplemented to advantage by rest during certain hours of the daytime. If the patient cannot take active exercise, massage is indicated, and in some cases of anæmia this may advantageously be combined with the wet pack, in the manner described by Mary Putnam Jacobi.22
22 Massage and Wet Pack in the Treatment of Anæmia
Where these measures cannot be carried out, the writer has found it of much service in these, as in a large class of debilitated conditions, to let the patient rub himself toward the end of the forenoon in a warm room with a towel wet in cold or warm water, and then lie down for an hour or so or until the next meal. If acceptable, the same operation may be repeated in the afternoon.
Neuralgic patients are apt to be underfed, and even where this is not distinctly the case, a systematic course of over-feeding,23 with nourishing and digestible food, such as milk, gruel, and eggs, given at short intervals, is often of great service if thoroughly carried out. The full benefit of this treatment cannot always be secured unless
the patient is removed from home, and, if need be, put to bed and cared for by a competent nurse.
23 See S. Weir Mitchell, Fat and Blood; and Nervous Diseases, especially of Women
A change of climate, and especially the substitution of a dry and warm for a moist and cold climate, will sometimes break up the neuralgic habit, for the time at least. In making choice of climate or locality, however, the physician should keep distinctly in view the end that he desires to gain. Thus, the debility or anæmia which is the essential condition of many neuralgias may often be relieved by surroundings which would not be thought favorable to the neuralgic tendency as such. Oftentimes the sedative influence of quiet country life is all that is required.
Of the tonic drugs, cod-liver oil, iron, arsenic, and quinine are by far the most important, and it is often well to give them simultaneously Iron may be used in large doses if well borne, for a short time at least. Quinine may be given in small doses as a tonic, or in larger doses to combat the neuralgic condition of the nervous system. This remedy has long been found to be of great value in the periodical neuralgias of the supraorbital branch of the fifth pair, but its usefulness is not limited to these cases. It may be of service in periodical neuralgias of every sort, and often even in non-periodical neuralgia.
When the attacks recur at stated intervals care should be taken to anticipate them with the quinine by about four hours, even if the patient has to be waked in the early morning for the purpose. Single doses of fifteen, twenty, or even thirty grains may check the attacks where smaller doses have failed. Such doses cannot, however, be long continued, and are not to be classed as tonic.
Of other remedies which directly influence the neuralgic condition, the following are the most important: opium, aconite, gelsemium, phosphorus, belladonna, chloride of ammonium, cannabis Indica, croton-chloral, electricity, hydropathy, massage, counter-irritation,
subcutaneous injections of water, chloroform, osmic acid, etc.; surgical operations.
Opium is usually employed only for the momentary relief of pain, but it has also been claimed that in small and repeated doses it may exert a really curative action. This should not, however, be too much counted on. Opium should never be used continuously for the simple relief of pain unless under exceptional circumstances, the danger of inducing the opium habit is so much to be dreaded. Moreover, both patient and physician are less likely to seek more permanent means of cure if this temporary remedy can always be appealed to. It is best given by subcutaneous injections of the various salts of morphine. The dose should always be small at first (gr. 1/12 and upward), unless the idiosyncrasy of the patient is already known; and there is probably no advantage in making the injections at the seat of pain or in the immediate neighborhood of the nerve supplying the affected part, except such as might attend the injection of any fluid (see below).
Belladonna (atropia), which is so often given with morphine to diminish its unpleasant effects, seems at times, even when given alone, to have an effect on neuralgia out of proportion to its anæsthetizing action, which is very slight. It is considered to be especially useful in the visceralgias.
Aconite, given, if necessary, in doses large enough and repeated often enough to cause numbness and tingling of the lips and the extremities for some days, will sometimes break up an attack, especially of trigeminal neuralgia,24 better than any other means; but its use is liable to depress the heart, and it is a dangerous remedy if not carefully watched. Some patients complain that it causes a marked sense of depression or faintness, and a feeling of coldness; and indeed its full therapeutic effect is sometimes not obtained until such symptoms as these are induced to some degree. The use of the crystallized alkaloid, aconitia, has the advantage of ensuring certainty of dose.
24 See Seguin, Arch. of Med., vol. i., 1879; vol. vi., 1881.