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 {1223}
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]
[Footnote 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.
[Footnote 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 {1224} 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.
[Footnote 24: See Seguin, _Arch. of Med._, vol. i., 1879; vol. vi.,
1881.]
{1225} The susceptibility of different persons to this drug is so
different that the dose should first be as small as 1/400 gr., but
this may be repeated every three hours, and gradually increased to
1/100 gr., or until its physiological effects are felt. Patients must
sometimes be kept under its influence for weeks together.[25] It is,
however, a remarkable fact that occasionally a few full doses will
secure an immunity from pain for a long period. Although most useful
in facial neuralgias, the writer has known it to be effective in
brachial and mammillary neuralgia. Aconitia can now be had in granules
of 1/400 gr., or can be given in alcoholic solution.
[Footnote 25: See Seguin, _Arch. of Med._, vol. vi., 1881.]
Gelsemium is also occasionally very useful in facial and even in
intercostal neuralgia, and is said to be of special service in the
neuralgia due to carious teeth. The commencing dose of the fluid
extract is five minims, which may be gradually increased to twenty, or
until a slight degree of muscular prostration, ptosis, or dilatation
of the pupil is induced.
The use of phosphorus has been revived of late years, chiefly through
the efforts of J. Ashburton Thompson, and it is at least occasionally
of service. Success is said to be best obtained by full doses (about
1/20 gr. every three or four hours, up to 1/5 or 1/4 gr. daily for
some days), watch being kept for signs of gastric irritation. The best
preparation is an alcoholic solution (Thompson's), such as the
following:
Rx. Phosphorus, gr. j;
Abs. alcohol, fluidrachm vi.
Dissolve with heat.
Glycerin, fluidounce iss;
Alcohol, fluidrachm ij;
Spts. peppermint, minim v.
One teaspoonful represents gr. 1/20.
Electricity, if properly used, is capable of temporarily, and even
radically, relieving the neuralgic state. The forms most often
employed are faradic and galvanic electricity, though frictional
electricity has also been coming into use of late, mainly as a
substitute for faradism. The galvanic current is by far the most
efficacious of all. This probably acts mainly by directly inducing
better nutritive and better functional conditions in the nerves and
nerve-centres, but the fact that it is often of use in cases of
undoubted neuritis seems to indicate that it may also influence the
grosser structural changes in the affected parts, if such are present.
It is impossible to explain its action more exactly, and the teachings
of physiological experiments do not lend us much aid.
It is probably not of much consequence which pole is used in the
neighborhood of the affected nerve. It should be remembered that the
peripheral nerve-trunks are so deeply buried that the electrodes
cannot be directly applied to them, as they are to the exposed nerve
of a frog in the laboratory, and, further, that instead of being
isolated they are surrounded with tissues of good conducting power,
into which the current must rapidly flow off. For these reasons the
nerve near which either electrode is applied is virtually exposed to
the action of both poles in almost equal degree; and although it is
more customary to use the positive pole in the neighborhood of parts
which are considered to be in a state of irritation, yet clinical
experience has not justified the conversion of this custom into a
rule. Neither is the direction of the current of material consequence.
{1226} It is, however, very important in acute cases to take care that
the current-strength should not be rapidly changed; and for this
reason the electrode should be drawn slowly to a distance from the
nerve before it is removed, or left in situ while the current is
gradually diminished by a suitable rheostat. As a rule, the former
method is the more practicable.
In the treatment of acute cases moderate currents and short
applications, frequently repeated, are the best. On the other hand, in
cases of long standing, especially cases of sciatica, strong currents
are sometimes more effective, and even interruptions and reversals of
the current may be in place.
The choice of a battery is not a matter of indifference. Any
stationary battery of high interior resistance will answer the
purpose, but most of the portable (zinc-carbon) batteries in common
use are objectionable,[26] for the reason that their interior
resistance is so low in proportion to that of the body that it may
almost be counted out as a factor in determining the strength of the
current. The latter is liable to rise, therefore, quite suddenly as
the resistance of the body—_i.e._ the vascularity of the skin—becomes
modified. This objection is obviated if a large, constant resistance
(water or graphite rheostat) is attached to the battery and kept
always in the main circuit.
[Footnote 26: _Archives of Medicine_, April, 1884.]
Faradism probably owes its efficiency to the indirect effects of
stimulation of the sensitive nerves of the skin. This may be produced
either by the wire brush, which causes a sharp irritation and
reddening, and is to be compared with the counter-irritants, or by the
milder application of a moist or dry electrode or the hand of the
operator. The latter procedure may be compared to the superficial
manipulation which is sometimes so grateful, especially in nervous
headaches.
The value of electricity as a general tonic should be remembered in
this connection.
Hydropathy.—Douches and baths of various kinds have doubtless proved
of much value in the treatment of neuralgia. The majority of them,
however, are difficult of application for the general practitioner,
and we confine ourselves to mentioning the tonic and soothing action
of the wet pack and of the prolonged warm bath, which should be
followed by sponging with cool water, and used under every possible
precaution against exposure.
Long-continued local applications of gentle heat (bags of sand or
salt, or hot water) are often temporarily grateful, and in the
treatment of chronic cases the daily application of hot water or
ice-bags to the spine is said to have a good effect. In acute and
subacute neuritis, and in those forms of neuralgia in which neuritis
plays a large part, such as sciatica, the persistent application of
ice-bags along the course of the affected nerve, even for days
together, is sometimes of great service. Even where we cannot be sure
that neuritis is present, long-continued applications of ice may be of
use, but alternations of cold and heat, on the other hand, are usually
to be carefully avoided. This treatment is safer in chronic than in
acute cases, though it may be useful in either.
Counter-irritation.—A spray of ether may be substituted for ice when
only a temporary chilling is desired, for its counter-irritant effect.
This {1227} has even been used on the face, the eye being protected by
some suitable covering, and a good deal of benefit is to be hoped for
both from this and from the similar use of chloride of methyl.
Debove[27] has found the chloride of methyl, used in this manner,
singularly effective in the treatment of sciatica. A considerable and
long-continued counter-irritation is thus made over a large surface
and without great pain. The neuralgia is said to be greatly relieved
and a rapid cure sometimes affected.
[Footnote 27: _Bulletin générale de Thérap._, cited in the _Boston
Med. and Surg. Journ._, vol. cxii. p. 210.]
Counter-irritation is also practised by making applications of
cutaneous irritants, such as blisters, mustard, turpentine,
chloroform, or of the actual cautery carried in light superficial
stripes over the skin, and repeated if necessary at short intervals.
As a rule, the counter-irritation is more effective the larger the
surface which is covered.
The use of the cautery and of blisters is in place in almost every
form of neuralgia where the temporary disfigurement is of no
consequence.
Of other cutaneous applications, aconite and chloroform liniments,
menthol in substance or in alcoholic solution (drachm j or drachm ij
to fluidounce j), aconite and veratrine ointments, are the most
useful. A strong aconitine ointment, made with Duquesnet's aconitia
and lard (drachm j to ounce j), has been recommended by Webber[28] to
be used in portions of the size of half a split pea, but, though
effective, it needs to be employed with great caution.
[Footnote 28: _Nervous Diseases_, Boston, 1885.]
These applications act in part as irritants, by keeping up a play of
sensitive impressions in virtue of the lodgment which they effect in
the skin, but also, no doubt, by reducing the sensitiveness of the
cutaneous nerve-fibres, and thus removing one source of excitation of
the diseased nervous centres. The remarkable temporary benefit
sometimes obtained from the instillation of cocaine into the eye in
cases of neuralgia of the ophthalmic division of the fifth nerve bears
testimony in favor of this explanation.
Surgical operations for neuralgia are of three kinds—section
(neurotomy), removal of a piece of nerve (neurectomy), and
nerve-stretching. The two former operations are of course rarely
practised, except upon the purely-sensitive fifth pair of nerves, the
latter upon mixed nerves also.
Neurectomy is now almost always substituted for simple neurotomy, and
sometimes still more effective means are taken to prevent the reunion
of the nerve, such as doubling over the cut end, destroying the nerve
throughout the length of the bony canal in which it lies, and even
plugging the canal with cement.[29]
[Footnote 29: Heustis (_Med. News_, Dec. 8, 1883) found that the
infraorbital nerve could be readily drilled out with a piece of piano
wire.]
The inconvenience following nerve-section is as nothing compared to
the pain of a severe and intractable neuralgia. It has rarely happened
that the disease has been increased by the operation, and under proper
antiseptic precautions the surgical risks are not great. There is some
chance of permanent cure, and a much greater chance of securing an
immunity from pain for a long period.
It is important to remember that when the neuralgia occupies the
distribution of several branches of the fifth nerve, an operation on
the one primarily or most severely affected may relieve the pain in
all. On the {1228} other hand, the converse may be true,[30] inasmuch
as the same district is supplied by recurrent fibres from several
different sources. Before any operation is decided on it should be
remembered that even in apparently desperate cases of trigeminal
neuralgia the persistent and thorough use of tonic and other remedies
may in the end be crowned with success, perhaps at the moment when it
is least expected.
[Footnote 30: Cartaz, _Des névralgies envisagés au point de vue de la
sensibilité récurrente_.]
During the past few years the operation of nerve-section has been to
some degree superseded by that of nerve-stretching, as being less
serious in its immediate (though not necessarily in its remote)
consequences, and sometimes more efficacious. Hildebrandt, indeed,
raises the question whether the traction which is apt to be exerted
when a nerve is cut is not an important element in bringing about the
result. On the other hand, cases are reported where neuralgia which
had not been relieved by stretching was cured by resection.[31]
[Footnote 31: Nocht, _Ueber die Gefolge der Nerven-dehnung_.]
The best showing for the operation is in the treatment of sciatica,
but most of the other superficial nerves, including the intercostals,
have been successfully treated in the same manner.
On the other hand, this treatment is not without its dangers. Apart
from the risks of the operation itself, cases have been reported in
which the spinal cord has been injured, so that chronic myelitis has
been set up, and a greater or less degree of paralysis—rarely
permanent, it is true—may be induced by the direct injury to the
nerve.
This means of treatment is therefore certainly to be thought of in
serious and obstinate cases, but not lightly decided on.
A substitute operation for sciatica is the so-called bloodless
stretching, in which, the patient having been etherized, the thigh is
forcibly flexed on the pelvis, and then the leg extended on the thigh
and the foot on the leg (dorsal flexion), and held for a short time in
this position. A very material degree of stretching of the sciatic
nerve is doubtless possible in this way, and a number of cures have
been thus effected. But, though less dangerous than the stretching of
the exposed nerve, this operation is not a trifling one.
In one case of sciatica the writer has seen a neuritis of some
severity lighted up by this operation, perhaps because the disease was
in too active a state, although it had lasted some months. The
operation is probably most indicated in chronic cases.
The anatomical effects of nerve-stretching are manifold. Nerve-fibres
are usually destroyed in greater or smaller number, and the conducting
power of the nerve correspondingly impaired. Small blood-vessels are
broken and the circulation and nutrition of the nerve-trunks altered,
and it is probable that adhesions in and around the nerve-sheaths,
where such exist, are severed. The nerve-fibres ramifying in the
inflamed sheaths of the large trunks may also be ruptured, and it may
be that the displacement of the fluid contents of the nerve brings
about better nutritive conditions.[32] It is also probable that the
operation either directly or indirectly affects the nutrition of the
nerve-centres,[33] and although this is not without its dangers, the
chances are in favor of a beneficial result.
[Footnote 32: See “Die Rückenmarks-dehnung,” Hegar, _Samml. klin.
Vorträge_, 239.]
[Footnote 33: Hegar, _loc. cit._]
{1229} Another means of directly acting on neuralgic nerves is by
subcutaneous injections of water, chloroform, ether, osmic acid,
nitrate of silver, and other substances. The deep injection of water
over the affected nerve is attended with but little danger, and is
occasionally successful. The similar use of chloroform, in doses of 15
to 30 minims, is much more often effective, but sometimes causes great
pain, and even abscess. It has been mainly used in sciatica, also in
other neuralgias, even those of the fifth pair. In this case the
injection is best made through the buccal mucous membrane. This
treatment is not without danger of causing collapse, or even death,
probably due to the wounding of a small vein. In one case of sciatica
treated by the writer the chloroform probably entered the nerve itself
to some extent, as the injection was followed by very severe pain
lasting for several hours, and eventually by some degree of muscular
wasting. The neuralgic pain, which had continued obstinately for a
long period, was, however, cured, and had not returned at the end of
some days, when the patient was lost sight of.
Osmic acid has been used recently in the same way, and the reports
show about an equal number of successes and failures. The dose is
about 8 minims of a 1 per cent. solution, and the injection may be
repeated at intervals of a few days. It has been used successfully in
various parts of the body, including the face and the fingers. The
injection causes no great pain, but occasionally, though rarely,
excites abscess.
Under the general heading of massage a number of manipulations may be
grouped which are of value in the treatment of neuralgia, even of
long-standing cases of sciatica and the like.[34] When, as often
happens in the case of sciatica, the nerve is the seat of congestion
and exudation, strong and deep kneading along its course, with
vigorous stroking upward in the direction of the lymph-vessels, is the
important part of the treatment. Besides this, however, the prolonged
and gentle manipulation of the painful region may greatly relieve the
patient for a time, apparently by acting on the sensitive nerves and
exerting a sort of inhibitory action, in which it is not at all
impossible that an influence upon the attention analogous to that of
Braidism plays a part.
[Footnote 34: See Reibmayr, _Die Massage, etc._, Wien, 1883.]