Neuralgia and the diseases that resemble it

by Francis Edmund Anstie

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 anæmic 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 anæmic, 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 anæmic neuralgias is certainly something over and above its special neurotic action. No one, who has employed it much in the cases of anæmic 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 anæmia, 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 diarrhœa, 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 anæmic 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.