Neuralgia and the Diseases that Resemble it

(6) Impurity of the atmosphere in which they habitually or daily reside must be carefully shunned for young children, especially for the nervous. The kind of dull and diffused headache which children often complain of, after study for some time in a close, ill-ventilated school-room, is very likely (if the bad influence be continued for a number of years) to develop itself, at puberty, into a regular migraine. Purity of air in the school-room must therefore be scrupulously provided for; and the same thing must be attended to as regards the sleeping rooms.

Of the climatic influences we may speak in a few words. Besides the avoidance of distinctly malarial districts, and also of places where, although there is no distinct ague, there is a prevalence of neuralgic or even of so-called "rheumatic" complaints, it is necessary very carefully to shun damp soils, and places where there is a great deal of harsh and cold wind. Mere lowness of average temperature is not in itself a strong predisposer to neuralgia, at any rate if guarded against by abundant food and the use of such clothes as will prevent children from ever feeling chilly and depressed. But damp and harsh winds are actively bad; and when joined to habitual or frequent lowness of temperature, they constitute very unfavorable surroundings for the nervous systems of delicate children.

(b) We come now to the prophylaxis which is to be adopted in the intervals of the paroxysms when neuralgia has been actually set up. This consists essentially in three things: (1) Physiological rest, as perfect as possible, of the affected parts; (2) protection from cold; (3) protection from sunlight; (4) avoidance of injurious mental emotions.

(1) The maintenance of physiological rest, to the greatest extent that is possible, is an absolute necessity, if we would shield a nerve, which has lately been attacked with neuralgia, from fresh paroxysms. The most evident illustrations of this fact are afforded by those neuralgic affections in which it is most difficult to adopt this precaution. Thus the greatest embarrassment from this cause is met with in the case of sciatica; a mild case is often converted into one of great severity and intractability because the patient, in the early stages, either cannot or will not maintain the recumbent posture. So, too, though in less marked degree, the cure of cervico-brachial neuralgia is often greatly impeded by the difficulty of maintaining complete rest of the limb. Again, in neuralgia affecting the third division of the fifth, the movements of mastication and of speech are a terrible hinderance to the progress of recovery; and it often becomes necessary, in severe cases, to prescribe absolute silence, and even to feed the patient exclusively with such liquid or semi-liquid food as shall require no efforts of chewing.

(2) Preservation from external cold is highly important. When a nerve of the arm, or leg, or trunk, is affected, warm flannel under-clothing ought immediately to be adopted. The patient who has been suffering from cervico-occipital neuralgia should for some time, in anything but quite summer weather, never go out without wearing a warm comforter round the neck. The sufferer from facial neuralgia should for some time after the cessation of actual attacks never face wind without wearing a thick veil.

(3) Exposure to bright light must be scrupulously avoided by sufferers from ophthalmic neuralgia. The affection known as "snow-blindness" is really a neuralgia, with vaso-motor complications, produced by the glare of light reflected from snow; and one of the severest attacks of neuralgia which I personally ever experienced was provoked in this way. Even the comparatively slighter, but for an Englishman unusual, glare of sunlight which one meets with during the first days of a Continental holiday, in wandering about towns made up of clean white stone or whitewashed houses, is enough to provoke an attack, unless the eyes are carefully guarded with colored glasses.

(4) It is scarcely necessary, after what has been already said, to insist upon the absolute necessity of mental quietude, as far as this can be obtained. This precaution is more or less important in all neuralgic affections; but in migraine and in other trigeminal neuralgias it is almost of more consequence than any other prophylactic measure; and in angina pectoris it is so essential that adoption or neglect of it may easily turn the scale between life and death. All forms of abdominal visceral neuralgia, also, are greatly affected by emotion, and passion or strong excitement of any kind must be scrupulously shunned if the neuralgic habit is to be broken through. Unfortunately, it too often happens that the mental surroundings of the patient cannot be so changed as to enable us to carry out this kind of prophylaxis effectually; and neuralgic cases of this class are among the severest trials of the physician's tact and skill, and too frequently defy his efforts.

(c) The precautionary measures which are to be adopted, after the neuralgic habit has apparently been fairly broken through, in order to prevent the patient from sliding again into the old vicious groove, can hardly be defined with exactness though their general character will be readily gathered from the picture of the clinical history and pathology of the disease which has been exhibited at large in this work. They mainly consist in the avoidance of severe, and especially of unequal, strains upon bodily or mental powers; and in redoubled carefulness in these respects at those natural crises in the life of the organism which have been shown to exercise so important an influence upon the neuralgic tendency. To a certain extent, also, but with much precaution, we may attempt to modify the peripheral sensibility by what is commonly called a hardening regimen. Thus, with great care, and proceeding in a very gradual manner, we may by degrees accustom the patient to a larger amount of exposure to free air, and even at last to rough weather, so that in the end he may become less sensitive to some of the commonest immediately exciting causes of neuralgia. If one were to construct an advancing scale of such measures, one might arrange them something like this: First, in-door gymnastics, and gentle horse-exercise for out-door work, in fine weather only; then horse-exercise alternated with pedestrianism, sea-bathing in warm weather; and, finally, we should try to reach a stage at which the patient can well endure a ten or fifteen miles' walk or ride every day, and be comparatively careless about the weather. In reaching this latter stage I have seen some patients helped, in an extraordinary degree, by the frequent use of the Turkish bath, followed by douche. Upon this latter subject I beg to offer some remarks, which are the result of pretty careful and extensive study of the effects of the Turkish bath in a variety of chronic nervous diseases. I believe it to be a very great mistake to suppose that, either in rheumatism or in true neuralgia, the process of the bath should be prolonged to such an extent as is commonly done. Instead of the usual slow heating process, gradually carried to a point at which excessive sweating occurs, I believe that the really scientific is the following: The patient should as quickly as possible get into the hottest atmosphere he intends to expose himself to, which should never be more than about 170° Fahr. He should stay in this place just long enough to get thoroughly hot, and, with the assistance of a glass or so of water drunk, throw himself into a free but gentle perspiration. He should then be rapidly shampooed, exposed to the spinal douche for two or three minutes, and then pass to the cooling-room. Let him beware of too long dawdling in the latter place, and let him avoid smoking there. It is a positively dangerous thing to cool one's self quite down to the normal heat, still more so to induce the slightest chilliness; the body should be still in a universal glow when one issues into the street. Over and over again I have proved upon myself that it is the beneficial method, whereas the prolonged use of the bath, the production of very copious sweating, and above all a lengthened cooling process, most seriously exhaust the nervous energy.

There are certain special considerations as to the habits of life that require a word or two. I need say nothing more to enforce the views already put forward as to the necessity of copious supplies of food. I need only refer to what I have already said about the decidedly mischievous tendency of anything like habitual excess in the use of alcohol, merely adding a special caution against such indulgence during, and particularly toward, the end of the period of sexual activity. There is one more topic upon which something must be said, namely, the extent to which sexual intercourse should be allowed. Speaking of neuralgia generally (excluding neuralgic affections of the sexual organs themselves), it may decidedly be said that the regular and moderate exercise of the function, during the natural period of sexual life, is beneficial; but that excess is always dangerous, and that the continuance of sexual intercourse, after the powers naturally begin to wane, is extremely pernicious in its tendency to revive latent tendencies to neuralgia. As regards neuralgias of the sexual organs, it is very difficult to speak positively; and yet I believe that (once the neuralgic habit broken through by other means) it is very desirable that the patient should live according to the laws of normal physiological life.

NOTE IADDITIONAL FACTS BEARING ON THE QUESTION OF NEUROTIC INHERITANCE

The following cases must be now added to those recorded in my list of private patients whose family history has been ascertained with reliable accuracy.

Case I. is that of a gentleman, aged forty-seven, the subject of lumbo-abdominal neuralgia: no history of nervous disease in the family; his mother, however, was of a "nervous" temperament.

Case II. – A gentleman, aged sixty-four, suffering from angina. His family nervous history is fearful. On the father's side it is not possible to get a clear account. But on the maternal side there has been a strong tendency to insanity and suicide; and in the patient's own generation one brother committed suicide from insanity, and one sister is still alive, insane. An interesting fact is, that the mother's family have shown an extraordinary proclivity to erysipelas.

Case III. – The young gentleman, whose single but extremely severe attack of angina is previously described, comes of a family in whom the tendency to neuralgia is undoubtedly very strongly inherited. His father is frequently and very severely migraineux, and in early life suffered cardiac symptoms not unlike his son's. A brother was also liable to attacks of true migraine between puberty and the age of twenty-one.

Case IV. – On the other hand, a case of angina which I saw in the country, last year, occurred in a gentleman, aged fifty, whose family presented no traceable neurotic history. But the damage inflicted upon his nervous system by various external influences was quite extraordinary. In some way or other he got some attacks of migraine at the age of fifteen or sixteen; for these he was treated with bleeding, and with a most savage antiphlogisticism generally. From that time he never got free of the neuralgic tendency. He used to have not only facial, but intercostal neuralgia; for this last he was repeatedly bled, under the idea that it was pleurisy. Added to all this he habitually did an immense deal of brain-work in his study, and for years had performed clerical duties of the most exacting and exhausting character. It is not much wonder that these combined circumstances had sufficed to generate the neurotic temperament.

NOTE IITHE INHIBITION THEORIES OF HANDFIELD JONES AND JACCOUD

In the present transitional state of opinion concerning the mode in which the phenomena are produced that are popularly known under the name of "reflex paralysis," I cannot pass without notice the doctrines of these two observers. The reader will have perceived that, as regards the secondary paralytic symptoms observed in neuralgias, I explain the phenomena mainly on the theory of a process which is central, and not peripheral, in origin. And, even where, as in some few instances, it seems possible that the starting-point was an organic affection of some viscus, we must always consider the possibility that the link between this and the neuralgia and paralyses was a neuritis migrans travelling inward to the sensory centre, and from that passing over to motor centres and thus producing paralysis; or that, without the intervention of any truly inflammatory process, the continual impressions streaming in upon the cord from the original seat of organic disease may damage the nutrition of the sensory nerve-root, producing a partial atrophy, and that this process may extend to the motor root.

It remains, however, to inquire whether the influence of powerful peripheral agencies may not, in a purely "functional" manner, disable the nerve-centres for a time, causing paralysis with or without neuralgia. The main supporters of such a doctrine are Dr. Handfield Jones46 and M. Jaccoud.47

Dr. Handfield Jones expressly rejects the theory of Brown-Sequard, as to spasm of the vessels in the nerve-centres, and we need not repeat his arguments on that head, because it seems to be generally felt that the vascular spasm theory will not account for the facts. Jones believes that the state produced in the nerve-centre by the peripheral influence is one of paresis from shock-depression, and that from the sensory centre this state can communicate itself to motor and vaso-motor centres, though commissural fibres. He does not believe in the existence of a special inhibitory portion of the nervous system: he believes that an impression may prove stimulating when it is mild, or paralyzing when it is strong; and that any afferent nerve may convey either the one influence or the other to the centres and thus produce secondary stimulus or secondary paralyses in various efferent nerves. Jones has the distinguished merit of being one of the first authors distinctly to perceive that pain must rank on the same level with paralysis: hence he sees nothing unintelligible in the communication of paralysis to a motor centre from a sensory centre that was in the state which the mind interprets as pain.

The theorie d'epuisement of Jaccoud (Erschopfungs-theoric) also denies the possibility of Brown-Sequard's idea of prolonged spasm of the vessels of the centres. It imagines that powerful peripheral excitements exhaust the irritability of the nerve, and through that of the centres, and induce a state of unimpressibility – analogous to that which exists in a nerve or nerve-centre, which is included in the circuit of a constant current. The nervous force is wasted, and, until an opportunity of repose is afforded to the centre, the faculty of impressibility cannot again revive.

I must say that of these two theories I decidedly incline to that of Handfield Jones (though I imagine that in reality the cases are extremely rare, if there be any, in which the change in the centres is really only functional and non-organic), I prefer the idea of paralyzing shock to that of exhaustion from over-excitement, from a consideration of the nature of that form of peripheral influence which has been specially mentioned by authors as competent to produce this sort of "reflex" affections, namely, intense and persistent cold. It seems to me a mere abuse of words to speak of this as an agent that could exhaust the nerve by over-stimulation; it must surely exhaust it in a much more direct manner than this, namely by the direct physical agency of withdrawing heat from the nerve, and spoiling its physical texture, pro tanto. If such an effect as that which must thus be produced on the nerve, and through it on the centre, is to be looked on as a case of over-stimulated function, then, it seems to me, there is no meaning in language, and no possibility of attaining to clear ideas on the subject of nervous influence.

NOTE IIIARSENICAL TREATMENT OF VISCERALGIÆ

Since writing the above chapter on the Treatment of Neuralgia, I have had two fresh and very striking examples, in private practice, of the power of arsenic to break the morbid chain of nervous actions in angina pectoris.

The first example was that of a medical man, aged seventy-five, in whom a neuralgia, originally malarial in origin, and of some years' duration, had fixed itself for some time in the fifth and sixth left intercostal spaces, and of late had become complicated with anginoid attacks of an unmistakable character, though not of the highest degree of severity. The case certainly seemed very unpromising, looking at the patient's age and the consequent high probability that there was much arterial degeneration. However, the use of Fowler's solution (five minims three times a day) was commenced and steadily pushed. The anginoid attacks rapidly diminished in frequency and at the end of ten days' time were entirely gone, and after one month of treatment he still had no return of them, although they had previously been of daily occurrence. It is a curious fact, whether a mere coincidence or not I cannot say, that, some few days after the anginoid attacks ceased, he began to experience somewhat severe pains, rheumatic in feeling, but unattended with heat or swelling, in the elbows, wrists, and fingers, symmetrically. This has nearly disappeared, but he is still free from angina. There is no discoverable heart-lesion in this patient.

The other case was that of a fine old man of sixty-four, who, but for some few slight attacks of gout, a few small calculi, and a troublesome prostatic affection, had always enjoyed remarkably good health, until about five months ago, when he began to notice tightness across the chest, etc., when he walked uphill. About a fortnight before he came to me, he was seized with very violent and alarming paroxysms of pain across the chest and running down both arms, extreme intermittence of pulse, and a sense of impending dissolution. The attack had recurred daily, at the same hour (6 p. m.), ever since; besides which there was an abiding sense of uneasiness in the cardiac region, and a consciousness that the least excitement or exertion would bring on the paroxysm. I put the patient on five minims of Fowler, three times a day, with directions to take ether when the paroxysms came. At the end of the first week there was already much improvement, the paroxysms having been both less frequent and less severe. At the end of a fortnight's treatment he reported that there had been nothing like a paroxysm for the last eight days, although there was still a good deal of uneasiness from time to time. The hour at which the attack was expected passed by absolutely without a trace of angina. It remains to be seen how long this improvement will last, but the altered state of things, and particularly the suddenness of the change, cannot be overlooked, and has very much struck the patient himself. It is now six weeks since he had any paroxysm.

It becomes more and more apparent that arsenic is generally applicable to neuroses of the vagus. In asthma, I have long held it to be the most powerful prophylactic tonic that we possess. It is also an excellent remedy in gastralgia; although I have rather dwelt (in the text of this work) on the action of strychnia in this disease, I would not omit my testimony to arsenic. Dr. Leared has related some exceedingly interesting cases bearing on this point. (See British Medical Journal, November 23 and 30, 1867.)

NOTE IVINFLUENCE OF GALVANISM ON CUTANEOUS PIGMENT

Dr. Reynolds pointed out to me the exceedingly curious fact, which I have several times verified, that the constant current, in relieving facial neuralgia, not unfrequently disperses, almost instantaneously, the brown skin-pigment that has collected in the painful region; e. g., near the orbit.

NOTE VTHE ACTUAL CAUTERY

A remedy for inveterate neuralgia which of late years I had almost discarded – the actual cautery – has quite recently yielded me very good palliative results in two cases. Its omission from the text of the chapter on Treatment was an accident due to the effect of habit in making one, half unconsciously, reckon this remedy as a "counter-irritant." The longer I practise, however, the more decidedly I am convinced that the actual cautery, if properly applied, does not act as an irritant at all; and this fact was sufficiently in my mind, when writing of irritant remedies, to make me omit the cautery from that section. I should have inserted it under the heading of remedies that interrupt the conductivity of nerves, and thus give the centres temporary rest. The only useful way to apply it is, to make an iron white hot, and very lightly brush the skin over so as to make an eschar not followed by suppuration. The galvano-cautery (Stohrer's Bunsen) is the best for the purpose, but I have made the flat-iron cautery serve very well.

PART II.

DISEASES THAT RESEMBLE NEURALGIA

CHAPTER I.

MYALGIA

Of all the diseases which superficially resemble neuralgia, none are so likely to be confounded with it, on a cursory glance, as myalgia. More careful inquiry, however, furnishes, in nearly all cases, ample means for distinguishing between the two affections.

Myalgia is an exceedingly painful affection, and it is also much more common than was formerly supposed. It is to Dr. Inman that we undoubtedly owe the demonstration of the frequent occurrence of this malady, and the facility with which it may be mistaken for other, and sometimes much more serious, diseases, with very disastrous results. At the same time, I must express the opinion that this ingenious author has decidedly exaggerated the importance of this local disease at the expense of an unjust depreciation of the frequency and significance of other painful disorders which have their origin within the nervous system.

Myalgia proper includes all those affections which are severally known as "muscular rheumatism" (for the muscles generally), and "lumbago," "pleurodynia," etc. (according to locality). It is essentially pain produced in a muscle obliged to work when its structure is imperfectly nourished or impaired by disease.

The clinical history of the different varieties of myalgia absolutely requires this key for its interpretation; otherwise, the appearance of the sufferers from different kinds of myalgia is so widely dissimilar that we should be exceedingly likely to miss the important features of treatment, which must be applied to them all in common. Nothing, for instance, can be more strikingly unlike than the appearance of the pallid, stunted, under-nourishment cobbler who complains of epigastric myalgia, and that of the ruddy and muscular navvy who suffers from acute lumbago, or the similarly plethoric-looking country commercial traveller, who has been driving in his gig against wind and rain, and complains of violent aching pains in one or both shoulders; yet one and all of these individuals are suffering from precisely the same cause of pain, viz., a temporarily crippled muscle or set of muscles which has been compelled to work against the grain. Why this state of things should invariably be interpreted as sensation in the form of acute pain never absent, but severely aggravated by every movement of the affected part, is a matter beyond our powers of explanation, we must accept it as an ultimate fact for the present.

There is scarcely any need to describe the pain of myalgia, since almost every one has suffered either from lumbago, or from a stiff neck produced by cold. The pain is essentially the same in all cases; it is an aching actually felt either in or toward the tendinous insertions of the affected muscles, and sharply renewed by every attempted contraction of those muscles. The variations in the character and severity of the pains are really entirely due to the greater or the less opportunity for physiological rest which the muscle can obtain. Thus the most obstinate and the most severe, kind of myalgic pain is undoubtedly that of pleurodynia – pain in the intercostal muscles and their fibrous aponeuroses – a fact which depends on the incessant movements which these muscles are compelled to perform in the act of respiration. And next to this in severity and obstinacy are myalgias of the great muscles which are incessantly engaged in maintaining, by their accurately opposed contraction, the erect position of the spinal column and of the head. This rate of proportional frequency and severity, however, must be taken as strictly relative; i. e., it is correct upon the supposition that the different sets of muscles were equally worked and that the state of nutrition was equal in the different parents. It is otherwise when the conditions are reversed. Thus, the unfortunate cobbler or tailor, who sits for long hours in one cramped and bent posture, is continuously exerting his recti abdominales (probably suffering from an under-nutrition common to all his tissues) to a degree perfectly abnormal, and out of all proportion to the functional work he is getting out of any other part of his muscular system. The consequence is, that he comes to us complaining of acute epigastric, and sometimes pubic, pain, rising to agony when he assumes his ordinary sitting posture, and only reduced to any thing moderate by the most complete extension of the whole trunk in the supine posture.