Neuralgia and the diseases that resemble it

by Francis Edmund Anstie

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 anæsthetic 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 visceralgiæ, 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 anæmic 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.