Chapter V: Treatment of Neuralgia (1)

I now approach what is really the most difficult portion of my task; for, although it would be easy enough to write copiously on the treatment of neuralgia, it is extremely difficult to keep a just medium between the opposite extremes of undue meagreness and of useless profusion of detail in the handling of this subject. There are also difficulties connected with the present uncertain and transitional state of opinion, even among high authorities, as to the value of particular remedies, and even of large groups of remedial agents, altogether there has been more hesitation in my mind as to this part of the present work than about any other, and the present chapter has been rewritten more than once. I mention this only to account for what there may very likely be found in it--an imperfect literary style such as too commonly marks work which has been repeatedly patched and corrected. At the same time, it should be said that my hesitation does not apply to the main principles of treatment which will be recommended below; it proceeds rather from the fear of seeming to ignore from carelessness modes of treatment which are still much used, but which I have really rejected, because, after full trial, they appeared to me valueless. Space is, after all, limited, and a complete account of all the remedies for neuralgia in vogue, in English and Continental clinics, would of itself fill a large volume.

The treatment of neuralgia may be divided into four branches: (1) Constitutional remedies; (2) narcotic-stimulant remedies; (3) local applications; (4) prophylaxis.

1. Constitutional treatment must be subdivided, as (_a_) dietetic, (_b_) anti-toxic, and (_c_) medicinal tonic.

(_a_) The importance of a greatly-improved diet for neuralgic patients is a matter which is more fully appreciated by the English school of medicine than by either the French or the German; it has, for instance, very much surprised me to notice the almost entire silence of Eulenburg on this topic. For my part, the opinions expressed three years ago[35] on this matter have only been modified in the direction of increasing certainty; I have learned by further experience that the principle is even more extensively applicable than I had supposed.

That neuralgic patients require and are greatly benefited by a nutrition considerably richer than that which is needed by healthy persons, is a fact which corresponds with what may be observed respecting the chronic neuroses in general; and it gives me much satisfaction to point out this position of neuralgia as belonging to this large class of disorders, not merely by its pathological affinities, but by its nutritive demands. In a very excellent and suggestive paper by Dr. Blandford[36] it is stated, as the result of a large experience in mental and other nervous disorders, that the greater number of chronic insane and hypochondriacal cases, as well as neuralgic patients, are remarkably benefited by what might seem at first sight almost a dangerously copious diet. Occasionally it happens that the patients discover this by the teaching of their own sensations, and the apparent excesses in eating which some epileptic and hypochondriacal persons habitually commit are looked on by many practitioners as the mere indications of a morbid _bulimia_ which represents no real want, but only the craving of a perverted sensation which ought to be interfered with and allayed rather than encouraged. It is now many years since I began to doubt the justice of this opinion; the particular instance which called my attention to it being that of epilepsy, of which disease I saw a considerable number of cases, within a short period of time, that were distinguished by the presence of enormous appetite for food; and I finally came to the conclusion that, so far from this symptom being of evil augury, and likely to lead to mischief, it is, with certain limitations, a most fortunate occurrence. It is hardly necessary to say that over-eating, such as produces dyspepsia and distention of a torpid intestine with masses of faeces, may distinctly aggravate the convulsive tendency; but the truth is that, with a little careful direction and management of the unusual appetite, these bulimic patients can in most cases be allowed to satisfy their desires without harm of this kind following; a larger portion of food really gets applied to the nutritive needs of the body, and the nervous system unmistakably benefits thereby, the tendency to atactic disorder being visibly held in check.

That which I have thus observed in the case of epilepsy, and which Dr. Blandford more particularly affirms concerning chronic mental diseases and the large number of neuroses that hover on the verge of insanity, has been most distinctly verified in my experience of the treatment of neuralgia. It is, unfortunately, by no means a frequent occurrence that the sufferer from this malady is inclined to eat largely, but the few patients of this type that I have seen were, in my judgment, distinctly the better for it. Far more common in neuralgia is a disposition of the patient to care little for food, to become nice and dainty, and in particular to develop an aversion--partly sensational and partly the result of morbid fear about indigestion--for special articles of diet. Dr. Radcliffe pointed out the special tendency of neuralgics to neglect all kinds of fat; partly from dislike, and partly because they believe it makes them "bilious;" and I have had many occasions to observe the correctness of this observation. In fact, by the time patients have become sufficiently ill with neuralgia to apply to a consulting physician, they have already, in the great majority of cases, got to reject all fatty foods, and have cut down their total nutriment to a very sufficient standard. Young ladies suffering from migraine are especially apt to mismanage themselves, to a lamentable extent, in this direction: this is natural enough, because the stomach disorder seems to them the origin of the pain, instead of being, as it is, a mere secondary consequence of the neurosis. But it is not only the sufferers from sick-headache in whom we find this tendency to insufficient eating, especially of fat; not to mention that all severe pain usually tends to disorder appetite and make it fastidious, there is nearly always some wiseacre of a friend at hand, ready to suggest that neuralgia is something very like gout, that gout is always aggravated by good living, and, _ergo_, that the patient should be "extremely cautious as to diet;" the end of which is that the poor wretch becomes a half-starved valetudinarian, but, so far from his pain getting better, it steadily becomes worse. I cannot too strongly express the benefits that I have seen accrue, in the most various kinds of neuralgic cases, from persistent efforts to remedy this state of things, and to convert the patient from a valetudinarian to a hearty eater; and I wish particularly to say that this success has always been most marked when I have from the first insisted on fat forming a considerable element of the food. Cod-liver oil is the form in which I much prefer to give it, if this be possible; there can be no mistake about the relatively greater power of this than of any other fatty matter, I believe simply from its great assimilability. But the very cases in which we most urgently desire to give fat are often those in which the patient's fantastic stomach openly revolts at the idea of the oil; we must then try other fats; and we should go on trying one thing after another--butter, plain cream, Devonshire cream, even olive or cocoanut oil (though these are the poorest things of the sort we can use)--till we get the patient well into the way of taking a considerable, if possible a decidedly large, daily allowance of fat, without provoking dyspepsia. It is surprising what can be done in this way by perseverance and tact, and it is no less striking to observe the good effects of the treatment. Nothing is more singular than to see a girl, who was a peevish, fanciful, and really very suffering migraineuse, brought to a state in which she will eat spoonful after spoonful of Devonshire cream, and at the same time lose her headaches, lose her sickness, and develop the appetite of a day-laborer; and, though such very marked instances as this are uncommon, they do sometimes occur, and a minor but still important degree of improvement is very frequent.

As for the _modus operandi_ of the fatty food, there is no certainty. Dr. Radcliffe believe it acts as a direct nutrient of the nervous centres; and I also cannot help feeling that there is some evidence in favor of this idea. But, whether this be so or not, there is another kind of action of fat that is more simple and obvious; namely, it seems to be certain that the enrichment of the diet by fat greatly assists the assimilation of food in general, and thus the patient's nutrition is altogether improved.

It is not merely, however, by increasing any one element of food that we should seek to enrich the diet of neuralgics, but rather by such a steady and persistent effort as Dr. Blandford describes, to increase the total quantity of nutriment to perhaps as much as one-third more than the patient would probably have taken in health. To those who from prejudice are incredulous of the propriety of this method, I would say, "Try it, and I venture to say your incredulity will disappear." More especially I would urge the great importance of this system in modifying the nervous status of very young, and also of aged, sufferers from neuralgia; it is the indispensable basis of a sound treatment for such patients.

This seems the proper place for such remarks as must be made upon the function of alcohol in neuralgia; for, though this agent is a true narcotic when given in large doses, it is not under that aspect that I can recommend its use in neuralgia at all. I have written so much on this subject lately, that I shall here content myself with an emphatic repetition of my protest against the use of alcoholic liquors as direct remedies for pain. They ought only to be given, in neuralgia, in such moderate doses, with the meals, as may assist primary digestion without inducing any torpor, or flushing of the face, or artificial exhilaration. I cannot too expressly reprobate the practice of encouraging neuralgics, especially women, to relieve pain and depression by the direct agency of wine or spirit; it is a system fraught with dangers of the gravest kind.

(_b_) The anti-toxic remedies include agents addressed to the modification of a special condition of the blood and tissues induced by the presence of morbid poisons, of which syphilis, malaria, and (more doubtfully) gout and rheumatism, are the representative examples.

Of syphilitic neuralgia the treatment may be summed up in a few words: Give iodide of potassium in doses rapidly increased up to a daily quantum of twenty to thirty grains. If this fails, give one-twelfth of a grain of bichloride of mercury thrice daily.

Of malarial neuralgia I can only speak from such a limited experience that I am by no means in a position to give an exhaustive account of the treatment. Quinine is, of course, the remedy that should first be tried; and, as the paroxysms are usually regular in their recurrence, I prefer to give the drug after the plan which is, I think, incontestably the best in ordinary ague--_i. e._, to administer one large dose (five to twenty grains) about an hour before the time when the attack is expected. With a few exceptions the malady, unless it had taken very deep root before we were consulted, will yield to a few doses given in this way; after the morbid sequence has been thus interrupted, it will be proper to continue the action of quinine in smaller and more frequent doses, given for three or four weeks continuously. For the comparatively rare cases in which quinine fails, the prolonged use of arsenic (Fowler's solution, five to eight minims three times a day), especially with the simultaneous employment of cod-liver oil, is to be recommended.

The part which gout may play in inducing neuralgia is, as I have already said, a far more doubtful question than the popular medical traditions assume it to be; and treatment directed to gout as a cause is an extremely uncertain affair. The direct relief of neuralgic pain by the administration of colchicum, for example, is, in my experience, a very rare occurrence, even where the gouty diathesis is unmistakably present; and, on the other hand, the depressed vitality which gouty neuralgics usually show in a marked degree, renders it very doubtful whether the relief of the pain may not be too dearly purchased at the cost of the general lowering effects of colchicum. It is probable that neuralgia occurring in gouty subjects is more safely, and equally effectually, treated upon general principles. At the same time it may be admitted that, in the subordinate function of an adjuvant to the aperients which it is sometimes advisable to give, small doses of the acetic extract of colchicum seem to possess some value.

The question of treatment addressed to a supposed rheumatic element in neuralgia will, of course, be differently judged according to the respective ideas of various practitioners as to the pathological affinities of the two diseases; and the reader already knows that I believe these affinities to be different in kind from what is generally believed. The utmost that I should concede is, that in a certain very limited number of cases the peripheral factor in neuralgia is an inflammation of the nerve-sheath, or surrounding tissues, which forms part of a chain of phenomena of local fibrous inflammations in different parts of the body. Iodide of potassium, in five or ten grain doses three times a day, is the proper treatment for such cases. I have never found alkalies do any direct good to the pain.

(_c_) The medicinal tonic variety of constitutional treatment is more especially represented by the use of iron and arsenic in cases where poverty of the blood seems to exist in a marked degree, and by the administration of certain tonics--quinine, phosphorus, strychnia, and zinc--which are supposed to exert a specially restorative influence upon the nervous tissues.

The use of quinine as an anti-malarial agent has been already referred to; its employment in non-malarial cases is of much more restricted scope and benefit. Experience has taught me to agree in general with the opinion of Valleix, that it is a very unreliable agent; the one marked exception to this being the case of ophthalmic neuralgias. What the reason may be I cannot in the least say, but it is a fact that quinine does benefit these neuralgias, in cases where there is no room for suspicion of malaria, with a frequency which is very much greater than in the treatment of the painful affections of any other nerve in the body. The quantity given should be about two grains three times a day.

The preparations of phosphorus which I have employed in the treatment of neuralgia are the phosphuretted oil, the hypophosphite of soda (five to ten grains three times a day), and pills of phosphorus (according to Dr. Radcliffe's recommendation) containing one-thirtieth of a grain, given twice or thrice daily. Either of the two last will do all that phosphorus can do, but its utility is not very extensive or reliable. I have found it to do most good in cases where there was a high degree of anaesthetic complication.

Preparations of zinc have, in my hands, done no particular good, although I have tried them in all manner of doses.

Strychnia, on the other hand, is a remedy which I have learned to prize much more highly during the last few years than previously. Its most decided efficacy has been shown in some of the visceralgiae, especially gastralgia, and (to a less extent) angina pectoris. Its internal use for these complaints is best effected by giving doses of five to ten minims of tincture of nux-vomica three times a day; but a method which I have several times employed with good effect is the subcutaneous injection of very small doses of strychnia (one-eightieth to one-fiftieth of a grain) twice daily. For the superficial neuralgias, on the other hand, I generally administer one-fortieth of a grain, with ten or fifteen minims of tincture of sesquichloride of iron, by the stomach, three times a day; this is a very powerful prophylactic remedy to prevent the recurrence of the attacks when once the sequence of them has been broken through by other means.

Of iron generally, as a remedy in anaemic cases, I have only to remark that, in order to get its full benefits, it is necessary to use large doses. I give the saccharated carbonate in twenty-grain doses twice or three times a day.

But of the sesquichloride of iron I am inclined to say something more; it has seemed to me that, besides its effects on the blood, it has a marked and direct influence upon the nervous centres, which is different from anything which one observes in the action of other preparations of iron. It is certain that the action of sesquichloride of iron, in those cases of chlorosis which are distinguished by profound nervous depression, is something quite peculiar; and the effect which it produces in the anaemic neuralgias, more especially of young women, is equally remarkable. I cannot help alluding here to the striking effects which large doses of the tincture, as recommended by Dr. Reynolds, produce in acute rheumatism; the severest pain is often checked within twenty-four hours after the commencement of this treatment. Both in this disease and in neuralgia, I employ the old-fashioned tincture: if given alone it should be used in large doses (thirty or forty minims three times a day); but an excellent combination is that, already mentioned, of ten-minim doses of this tincture with one-fortieth of a grain of strychnia. There is something in the revivifying effects of this mixture that is quite peculiar. I have very lately employed it in the case of a gentleman, aged thirty-five, who was the subject of frontal neuralgia complicated with paralysis of the internal rectus, and who was decidedly anaemic, and greatly depressed and worried in mind by the consciousness of his inability to overtake professional work which had accumulated upon him. This patient improved with great rapidity, and in the course of three weeks lost, not merely his neuralgia, but also his strabismus, almost entirely; but he then got into a condition which, though not of permanent importance, was sufficiently undesirable to make me mention it here, especially as I have seen the same thing in more than one patient besides him. It is a peculiar state of restlessness during the day and sleeplessness at night, without any positive exaltation of reflex excitability such as one used to see from strychnia in the days when mischievously large doses of that drug were very commonly given, and patients used to complain of decided twitchings and startings of the limbs. It is clearly not a strychnia effect pure and simple, nor an iron effect only; it is a _tertium quid_ compounded of the actions of both drugs.

The direct effects of arsenic in the improvement of the quality of the blood seem to me incontestable; and its use for this purpose in anaemic neuralgias is certainly something over and above its special neurotic action. No one, who has employed it much in the cases of anaemic children suffering from chorea after rheumatism, can have failed to observe its frequently striking influence upon blood-formation even long before the nervous ataxia is materially reduced. The misfortune is, however, that we possess no indications by which to judge beforehand whether we may reckon on its most favorable action in any given (non-malarious) case, with certain special exceptions. In angina pectoris it has a most direct effect, which is rarely altogether missed, and is sometimes surprising: the cases in which it succeeds best are those distinguished by anaemia, but we may well suppose, from its remarkable action upon other neuroses of the vagus, that it is something more than an action on the blood-making process which produces such powerful effects in allaying the tendency to recurrence of the paroxysms. My attention was called to its action in this disease chiefly by the remarkable case published by Philipp;[37] this was a purely neurotic angina, but one of the severest type, and the influence of arsenic was very striking. Since that time I have employed it in several cases, and, after trying various forms of administration, I conclude that nothing is better than Fowler's solution, in doses of three minims (gradually increased, if the remedy be well tolerated, up to eight or ten) three times a day. Unfortunately, there are some neurotic patients who cannot bear arsenic, the irritability of their alimentary canal is such that the drug always provokes vomiting, or diarrhoea, or both; this was the case with one of my patients, in whose case I had allowed myself to hope for the very best results from arsenical treatment. But where the patient tolerates it--and usually he tolerates it extremely well--the prolonged use of arsenic seems really to root out the anginoid tendency, or at least to confine it to the more trivial and manageable manifestations. I believe that in at least three patients, I have so completely broken down a succession of cardiac neuralgic attacks as to substitute for them a mere remnant of a tendency to "tightness at the chest" after any severe bodily exertion or mental emotion. It might be a question, in cases where the stomach does not tolerate the ordinary administration of the agent, whether it would not be worth while to try the effect of subcutaneous injection (two to four minims of Fowler), or inhalation of the smoke of arsenical cigarettes. But, in truth, it is not certain that even in this case we escape the characteristic effects of the drug upon those persons who are abnormally sensitive to it.

A remarkable instance of the beneficial influence of arsenic occurred in the case of a woman, aged forty-six, the solitary example of severe angina in a female that I have ever seen. [It is by no means uncommon, however, to see the milder forms of cardiac neuralgia in women; the remarkable statistics of Forbes, quoted in Chapter I., must certainly have been taken exclusively from cases of the severest type of the disease.] This was a hospital patient, who had always suffered much from hysteria, and from childhood had been liable to hemicranic headache; she had entered on the period of "change" at the time the attacks began, but menstruation, though irregular, still continued, and, in fact, did not cease till four years later, long after the anginal attacks had been subdued. The patient had been attacked for the first time at the end of a heavy day's washing; she dropped on the ground with the sudden agony and faintness, and thought she should "never come to life again." The paroxysms returned five times within the next month, though not always so severely as on the first occasion; but the poor woman lived in a constant state of terror. On the occasion of her second visit to me, she had a most severe attack in the waiting-room at the hospital: being called to her I found her very nearly pulseless, gasping, and with the kind of complexion which is so suggestive of approaching death. She was recovered by a large dose of ether. It was a rather uncommon feature in this case that the pain was only at and around the lower end of the sternum, except that occasionally it shot along the sixth intercostal space. The employment of Fowler's solution (in doses gradually mounting to twenty-one minims daily) for six months completely eradicated the anginal tendency; the proof that it was a real therapeutic effect was given by the result of an attempt to leave the medicine off at the end of eight weeks' treatment; the patient immediately began to suffer again. When she really left off, at the end of six months' treatment, she had had no tendency to heart-pang for more than a month, and, besides this, looked quite another creature in her improved vitality and vigor. Yet the menstrual troubles went on, and the function was not finally suppressed for a long time afterward.

I suspect, however, that the most frequent successes with arsenic will, after all, be made in the cases of more or less anaemic male patients who are attacked with the neurotic form of angina in the midst of a career (as is especially the case with some professional careers) that implies not merely incessant labor, but great anxiety of mind. The drug does little good, however, if not positive harm, in that form of angina pectoris minor which is not the result purely of these causes, but of these, or some of these, plus the morbid action of the alcoholic excess, to which the patient has fled in order to relieve mental harassment and the fatigue that comes from overwork, especially overwork at tasks that are not congenial to his natural disposition; there is usually in such cases a heightened irritability of the alimentary canal, which is almost sure to cause arsenic to disagree: the really useful treatment is quinine for the first few days, and then, when the stomach will bear it, cod-liver oil in increasing doses, up to a large daily amount given for a long time together.

On the whole, arsenic, from its singularly happy combination of powers as a blood-tonic, a special stimulant of the nervous system, and withal as a special opposer of the periodic tendency, must be regarded as one of the most powerful weapons in the physician's hands, and (although it seems to act best in the neuralgias of the vagus and of the fifth) there is a possibility of its proving the most effective remedy in almost any given case which may come before us.

2. The narcotic-stimulant treatment for neuralgia includes some of the most powerful remedies for the disease which we possess. These remedies have very different properties, but they all agree in this, that in small doses they appear restorative of nerve-function--in large doses depressors of the same.

Four very different types, at least, of narcotic-stimulant drugs are useful in neuralgia: (_a_) There is the opium type, by which pain is very directly antagonized, and, besides this, sleep is also directly favored. (_b_) There is the belladonna type, by which pain is also much relieved, though with far greater certainty in some regions than in others (_e. g._, much the most powerful effect is seen in cases of pelvic visceralgia), but sleep is by no means so certainly or directly produced as by opium. (_c_) There is the chloral type, which is almost purely hypnotic; it is represented almost solely by chloral itself, which is resembled by scarcely any other drug. (_d_) There is bromide of potassium, which stands alone for its powerful action on the cerebral vaso-motor nerves, and which is useful in neuralgia simply by its power to check psychical excitement directly (through the circulation) and indirectly (through the production of sleep).

(_a_) Opium and the remedies that resemble it are, for the treatment of neuralgia, fully represented by the hypodermic use of morphia, which is the only kind of opiate treatment that ought ever to be employed, save in very exceptional instances. The great reasons for the preference of the subcutaneous administration over the gastric are, the economy of the drug which it affects and the much smaller degree of disturbance of digestion which it causes. The hypodermic injection of morphia, if conducted on correct principles, enables us, when necessary, to repeat the dose a great number of times with but little loss of the effect, and consequently with a much smaller rate of progressive increase of the quantity required; and the absence of depressive action on digestion enables us to carry out simultaneously that plan of generous nutrition which has already been shown to be so important a part of treatment. Indeed, the case is hardly expressed with sufficient strength, when we say that hypodermic morphia is usually harmless to the digestive functions; for in a great number of instances it will be found actually to give an important stimulus both to appetite and digestion; and the patient, who without its aid could hardly be persuaded to take food at all, will not unfrequently eat a hearty meal within half an hour after the injection.

The remarkable effects of hypodermic morphia have, however, caused it to be rashly and indiscriminately used, and so much harm has been done in this way that it is necessary to be exceedingly careful in the rules which we lay down for its employment. Upon these grounds I must hope to be excused if, in order to render this work complete, I repeat a good deal of what I have already said in other places. In the first place, I shall speak of the mode of administration, and then of the dose.

As regards the mode of administration, I prefer the use of a solution of five grains of acetate of morphia to the drachm of distilled water; if the acetate be a good specimen, this will dissolve easily (and keep some time without precipitation) without the use of any other solvent. With a solution of this strength we require nothing elaborate in the form of the syringe; a simple piston arrangement does well; only it is advisable that the tube shall have a solid steel triangular point, and a lateral opening. As regards the place of injection, I must repeat the opinion[38] which I have already published, that Mr. Hunter's plan of injection at an indifferent spot is, in the great majority of instances, fully as effective as the local injection would be; nevertheless, there is one consideration which in some cases may properly induce us to adopt the latter plan. Very nervous and fanciful patients will sometimes be much more readily brought to allow the operation when it seems to go directly to the affected spot, when they would be sufficiently incredulous of the benefits of an injection performed at a distance to indulge their dislike of incurring pain by refusing to submit to it. And there is one class of cases in which it is likely that there are real physical advantages in the local injection; in instances of old-standing neuralgia with development of excessively tender "points," which are also the foci of the severest pain, it will sometimes be advisable to inject into the subcutaneous tissue at these points. There is undeniable reason for thinking that the sub-inflammatory thickening of tissues around a certain point of nerve delays the transit of the morphia into the general circulation, and enables it to act more directly and powerfully on the nerve, which it thus renders insensitive to external impressions; an important respite is thus gained, during which the nerve-centre has time to recover itself somewhat. At the same time it must be remarked that this immediate injection of a tender point is apt to be exceedingly painful, and it may be absolutely necessary to apply ether-spray before using the syringe. In early stages of neuralgia, before the formation of distinct tender points, there is no advantage whatever (except the indirect one above mentioned) in the local injection. And, on the other hand, it is often of great consequence not to run the chance of disfiguring such a part as the face, the neck, etc., when the injection can easily be done over the deltoid, or in the leg, or in some other part which even in women is habitually covered by the dress.

The dose to be employed is an exceedingly important matter, and one as to which practitioners are still very often injudicious. We ought never to commence with a larger dose than one-sixth of a grain; but very often as little as one-twelfth of a grain will give effective relief, and in not very severe cases it is well worth while to try this smaller quantity. When no larger quantity than one-sixth of a grain is employed we commonly observe no narcotic effects, _i. e._, there is no contraction of pupil, no heavy stupor, and, although the patient very often falls asleep, on waking he does not experience headache, nor is his tongue foul. I cannot too strongly express the opinion that it is advisable by all means to content ourselves with this degree of the action of hypodermic morphia, unless it fails to produce a decided impression on the pain. But in very severe cases our small doses will fail; and then, rather than allow the patient to continue having severe paroxysms unchecked, we must frankly admit the necessity of using a narcotic dose from one-quarter to one-half of a grain, according to circumstances. Whatever actual dose be employed, it is important not to repeat it with unnecessary frequency; once a day in the milder, and twice a day in the more severe cases, will be all that is advisable, save in very exceptional cases: the point being to administer it as quickly as possible after the commencement of an exacerbation. If by these means we can prevent the patient having any severe pains during a period of several days, we often give time to the affected nerve to recover itself so completely, especially with the aid of other measures to be presently mentioned, that the tendency to neuralgia is completely broken through, and we can drop the injections, either at once or by rapid diminution of the dose, and thereafter treat the case merely with tonics, and with the precautionary measures to be dwelt upon under the heading of Prophylaxis. But, if we have been driven to the use of distinctly narcotic doses, and these do not very speedily break the chain of neuralgic recurrence, it will not do to continue to rely upon hypodermic morphia; it will be best to try some of the local remedies (blistering, galvanism) with it. If this combination fails, we should then try the effect of atropine, the sulphate of which, hypodermically injected, fully represents for all useful purposes the mydriatic class of narcotics.

(_b_) The commencing hypodermic dose of atropine should be one-one hundred and twentieth grain; it is not often that so small a quantity will do any good, but it is necessary to use this agent with great precaution, as we occasionally meet with subjects in whom extremely small doses provoke most uncomfortable symptoms of atropism, as dry throat, dilated pupil, delirium, and scarlet rash. Commonly we shall find ourselves obliged to increase the dose to one-sixtieth, one-fiftieth, or one-thirtieth of a grain; and in a very few cases it may be necessary to go even as high as the one-sixteenth or one-twelfth. In my experience such instances are excessively uncommon; and I cannot but suppose that the practitioners who use the high doses frequently must inject in such a manner as to fail to get the whole dose taken up. [Absolutely inexplicable to me is the statement of the illustrious Trousseau--that hypodermic remedies are "less active" (!) than gastric remedies--except on his hypothesis.]

The most remarkable effects that I have seen from hypodermic atropia were obtained in cases of peri-uterine neuralgia, especially dysmenorrhoeal neuralgia. Speaking generally of atropine, it must undoubtedly be counted far inferior to morphia as a speedy and reliable reliever of neuralgic pain, but for all pelvic neuralgias it appears to me on the whole to surpass morphia. And besides this, in other neuralgias, where opiates altogether disagree (as with some subjects they do), it is not uncommon to find that atropia acts with exceptionally good effect. And to some extent I am inclined to confirm Mr. Hunter's opinion, that, where atropia does stop neuralgia, it does so more permanently than morphia.

There is another special use of hypodermic atropine which I have not seen mentioned by any one but myself, but which is probably very important, namely, in ophthalmic neuralgia where acute iritis, or especially glaucoma, seems coming on. I may be mistaken, but I believe that in three cases I have succeeded, by prompt injection of sulphate of atropine (one-sixtieth to one-fortieth of a grain), in saving a neuralgic eye from damage, and possibly from destruction, from impending glaucoma.

(_c_) The class of cases for which merely hypnotic remedies are of much value is limited; nevertheless, in the milder kinds of migraine and clavus, especially when they have been brought on or are kept up by mental worry or hysterical excitement, these remedies will sometimes prove very useful. In former days, before we knew chloral, I used to employ camphor for this purpose; three or four grains being administered every two hours: and in hysterical hemicrania of a not very severe type this not unfrequently produced a short sleep, from which the patient awoke free from the pain. But chloral infinitely transcends in value any agent of this kind that was known before. Perfectly valueless for the really severe neuralgias, it is of the greatest possible use as a palliative in migraine and clavus, where the great object, for the moment, is to get the patient to sleep. A single dose of twenty to thirty grains will often effect our object: it may be repeated in two hours if sleep has not been induced; it should be given as soon as the pain has at all decidedly commenced.

And here I wish to make some special remarks on the subject of "palliation," and the relation it bears to "cure." Nothing is more common than to read serious admonitions, in medical works, about the folly of trusting to remedies which only palliate for the moment but leave the root of evil untouched; and, of course, there is a certain respectable modicum of the fire of truth behind all this orthodox smoke. In the case of neuralgia, however, it is most important to understand that mere palliation, that is, stopping of the pain for the moment, may be either most useful or highly injurious, according to the way in which it is done. The unnecessary induction of narcosis for such a purpose, doubtless, is most reprehensible; but if it were possible simply to produce sleep from which the patient should awake refreshed, without any narcotic effects, then, certainly, that sort of palliation must be good. That is precisely what the judicious use of chloral does; and I may mention, as resembling though not equalling it, the action of Indian hemp, which has been particularly recommended by Dr. Reynolds. From one-fourth to one-half of a grain of good extract of cannabis, repeated in two hours if it has not produced sleep, is an excellent remedy in migraine of the young. It is very important, in this disease, that the habit of long neuralgic paroxysms should not be set up; and if the first two or three attacks are promptly stopped, by the induction of sound, non-narcotic sleep, we may get time so to modify the constitution, by tonics and general regimen and diet, as to eradicate the neuralgic disposition, or at least reduce it to a minimum. But I would decidedly express the opinion that such remedies as either opium or belladonna are mostly unsuited to this purpose. If the migraine of young persons does not yield to chloral, to cannabis, or to muriate of ammonia (in twenty or thirty grain doses), it will not be advisable to ply the patient with any remedies of the narcotic-stimulant class, but to trust to tonic regimen and the use of galvanism.

The mention of muriate of ammonia, which, for migraine and clavus and the milder forms of sciatica, not unfrequently proves useful in stopping the violence of a paroxysm and enabling the patient to get some refreshing sleep, leads me to notice that not only may a variety of the milder narcotic-stimulants be employed in this way, but the external stimulus of heat to the extremities (very hot pediluvia) greatly assists the action of any such remedies; especially if mustard-flour be added, so that a mild vapor of mustard rises with the steam and is inhaled. Perhaps the ideal medication, to arrest a bad sick-headache, is to give twenty grains of chloral, and make the patient plunge his feet in very hot mustard-and-water and breathe the steam. He can hardly fail to fall asleep for a longer or shorter time, and awake free from pain.

(_d_) The use of bromide of potassium in neuralgia is a subject of great importance, and which requires much attention and discrimination. In common with, I dare say, many others, I made extensive trial of this agent when it first began to be much talked of, but was so much disappointed with its effects in neuralgias, that at one time I quite discarded it in the treatment of those affections. Renewed experience has taught me however, that, though its use is restricted, it is extremely effective if given in appropriate cases and in the right manner. For the great majority of neuralgias it is quite useless, and, what is more, proves often so depressing as indirectly to aggravate the susceptibility of the nervous system to pain. The conditions, _sine quis non_, of its effective employment seem to be the following: The general nervous power, as shown by activity of intelligence, and capacity of muscular exertion and the effective performance of co-ordinated movements, must be fairly good, find the circulation must be of at least average vigor; the patient must not have entered on the period of tissue-degeneration. Among neuralgics who answer to this description, those who will benefit by the bromide are chiefly subjects--especially women--in whom a certain restless hyperactivity of mind and perhaps of body also, seems to be the expression of Nature's unconscious resentment of the neglect of sexual functions. That unhappy class, the young men and young women of high principle and high mental culture to whom marriage is denied by Fate till long after the natural period for it, are especial sufferers in this way and for them the bromide appears to me a remedy of almost unique power. But I wish it to be clearly understood that it is not to the sufferers from the effects of masturbation that I think the remedy specially applicable: on the contrary, it is rather to those who have kept themselves free from this vice, at the expense of a perpetual and almost fierce activity of mind and muscle. The effects of solitary vice are a trite and vulgar story; there is something far more difficult to understand and at the same time far more worth understanding in the unconscious struggles of the organism of a pure minded person with the tyranny of a powerful and unsatisfied sexual system. It is in such cases, which it heeds all the physician's tact to appreciate, that it is sometimes possible to do striking service with bromide of potassium; but it will be necessary to accompany the treatment with strict orders as to generous diet, and, very likely, with the administration of cod-liver oil.

Having decided that bromide of potassium is the proper remedy, we must use it in sufficient doses. Not even epilepsy itself requires more decidedly that bromide, to be useful, shall be given in large doses. It is right to commence with moderate ones (ten to fifteen grains), because we can never tell, beforehand, that our patient is not one of those peculiar subjects in whom that very disagreeable phenomenon--bromic acne--will follow the use of large doses. But we must not expect good results till we reach something like ninety grains daily. Let me add that it is not so far as I know, by reducing any "hyperaesthesia" of the external genitals, of which the patient is aware, that the remedy acts; I have not seen such a nexus of disease and remedy in these cases.

3. Local Measures.--The external remedies which may be applied for the treatment of neuralgia may be divided into (_a_) skin-stimulants; (_b_) paralyzers of peripheral sensory nerves; (_c_) remedies adapted to diminish local congestion; (_d_) remedies adapted to diminish arterial pulsation; (_e_) electricity; (_f_) mechanical means of protection.

(_a_) Among the skin-stimulants blisters hold the highest place as a remedy for neuralgia; indeed the assertion of Valleix, that they are the best of all remedies, is still not very wide of the truth. They are by no means universally applicable, and the degree to which their action should be carried varies materially in different forms of the disease, but they are of the greatest possible service in a large number of instances.

It is possible to view the action of blisters in neuralgia in more than one way. When applied in such a manner as to vesicate decidedly, and especially if kept open and suppurating for some time, they cause considerable pain of a different kind from that of neuralgia itself and the mental effect of this, operating as a diversion of the patient's thoughts from his original trouble, may be thought to assist in breaking the chain of nervous actions by which he is made to feel neuralgic pain. There may be something in this, but I confess that I do not believe this kind of effect goes for much in genuine neuralgia. It is rather in the pain of hypochondriasis, and the so-called spinal irritation (to be described in the second part of this work), that such an action of blisters proves useful.

Another action of blisters, which some authors hold to be perhaps the most effective portions of their agency, is that which is produced by the drain of fluid, specially when they are kept open, by which means a kind of depletion is set up, and the morbid irritation that causes the nerve pain removed. I cannot at all assent to this view. In the first place, I believe that any one who has large experience of blistering in neuralgia will ultimately come, as Valleix did, to believe that prolonged drain from a blister is rarely or never useful, and that a far better plan is that of so-called flying blisters, renewed at intervals if necessary. The most genuine successes that I have procured from blistering have certainly been got in this way. But I should go further, and say that the prolonged drain and the peculiar kind of chronic irritation produced by a suppurating blistered surface can very decidedly aggravate a neuralgia; this is more especially the case when the blister is applied immediately over the focus pain.

The view which I am strongly convinced alone explains the beneficial action of blisters is that which supposes them to act as true stimulants of nerve-function. In order that this effect shall be produced, it will be necessary that the skin-irritation be either produced at some distance from the seat of the greatest pain, or that, if applied in that spot, it shall be comparatively mild in degree. And accordingly, I have been led, in my observations to apply the blister at some distance from the focus of pain. An indifferent point, however, will not do--there must be an intelligible channel of nervous communication between the irritated portion of skin and the painful nerve. This object is accomplished by placing the blister as close as may be to the intervertebral foramen from which the painful nerve issues; the effect of this is probably a stimulation of the superficial posterior branches, which is carried inward to the central nucleus of the nerve. I must say that the results which I have derived from this plan of treatment have been far more satisfactory than those which I used to obtain when I habitually applied the vesication as near as might be to the focus of peripheral pain; and I think that this result tallies well with the idea that the essential mischief in neuralgia consists in an enfeebled vitality of the central end of the posterior root. An exceedingly interesting confirmation of this idea as to its _modus operandi_ has been afforded me by the fact that not merely neuralgic pain, but also trophic and inflammatory complications attending it, have been sensibly relieved, in several cases that I have seen, by this mode of reflex stimulation. This has been particularly the case in herpes zoster, where the process of inflammation and vesiculation has been very promptly checked by the application of a tolerably powerful blister by the side of the spine at the proper level; and I am gratified to mention that Dr. J. K. Spender, of Bath, pointed out this fact[39] at a time when he had only seen my statement that the pain could be relieved in this way. In the case of the trigeminus, the same kind of reflex stimulation is most effectively obtained by applying the blister over the branches of the cervico-occipital, at the nape of the neck; and it is remarkable what powerful effects are sometimes thus produced, even in cases that wear the most unpromising aspect. For example, in the desperate epileptiform tic of old age, I have more than once seen a complete cessation of suffering, which lasted for a very long time--so long, in fact, as to make me hope against hope that it might never return. I do not now entertain any such expectations from this remedy; still, its value is very great.

There are curious differences between the effects of blistering in trigeminal or intercostal neuralgia and in sciatica. On the whole, it would appear that blistering in the neighborhood of the spine is less frequently effective in the latter, and we sometimes, after failing with this method, obtain immediate success by two or three repetitions of the flying blister, somewhere over the trunk of the nerve, especially just outside the sciatic notch. I have one lady patient in whom this series of phenomena has several times been observed; and I have seen it occur in a particular attack, in other patients, in whom, nevertheless, on another occasion the spinal blistering has been promptly effective.

I consider blistering of the posterior branches to be an important, and usually an essential, element in the treatment of all cases of sciatica in the middle period of life which have reached some severity and lasted long enough to become complicated with decided secondary affections.

In all cases where blistering is employed it is advisable to adopt the simultaneous use of hypodermic morphia or atropine; this combination of remedies is exceedingly powerful.

Lastly, it must be said of blistering, that, on the whole, it is a remedy not well fitted to be applied to aged subjects; and in its severer forms it should never be applied to patients who are greatly prostrated in strength. For it must be borne in mind that the remedy may miss its aim of relieving the neuralgia, in which case it is necessary to remember, more accurately than many practitioners appear to do, what a very serious element of misery and prostration will be introduced into the case by the vesication itself.

I am not convinced that any of the other forms of severe skin-irritation (_e. g._, tartar-emetic inunction, or the use of veratrine-ointment to such a degree as to produce not the anaesthetic but the irritant effects) are of any particular value; if blistering failed, I should not expect to see them succeed.

A milder degree of skin-stimulation is represented by rubefacient liniments of various kinds, which may be briskly rubbed into the skin along the track of the painful nerve, without any danger of producing vesication. Among this class I continue to prefer chloroform diluted, with six or seven parts of chloroform, to any other; in the milder forms of neuralgia, especially in young persons and first attacks, it is surprising how frequently the paroxysm may be greatly relieved, if not arrested. Still, this can only be regarded as the merest palliative; and in severer cases such applications are useless. Occasionally, when chloroform-liniment has failed, a mustard plaster will do good.

The mildest degree of skin-stimulation is represented by the continuous application of moist warmth, which is best effected by the simple application of moistened spongio-piline; so far as I have observed, however, it is rather in cases of myalgia than in true neuralgia that this does good; in the latter it is probably little more than a mere protector against cold.

(_b_) A variety of agents can be employed with the object of temporarily interrupting the conductivity of the painful nerve; by this means a period of rest is obtained during which the centres--sensory and psychical--have time to regain a juster equilibrium, and the habit of pain is, _pro tanto_, broken through.

There is one agent of this class which for general purposes I do not think is worth retaining on our list of sensory paralyses--namely, cold. Cold, to be of any value, ought to be of the degree which is represented by ice allowed to melt slowly in contact with the skin; and for the majority of neuralgias this is decidedly inferior to other remedies that can be applied by painting or inunction. The one case in which ice is supremely useful is in neuralgia of the testis; here I make no doubt that it is almost, if not quite, the most useful remedy we can employ, although of course other means must be taken to modify the neuralgic temperament. It should be applied the moment an attack comes on.