Neuralgia and the diseases that resemble it

by Francis Edmund Anstie

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 fæces, 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.