The Brooklyn Medical Journal. Vol. II. No. 2. Aug., 1888

by Various

This question is no mere quibble about words or definitions, but it is one of the utmost practical importance in its relation to treatment. According as we settle in our minds whether a given case of pain is an exaggeration or a lessening of the ordinary physiological condition, our treatment will logically be either narcotic or stimulant.

Leaving for the present the question as to the nature of pain, let us examine some of the modes in which it expresses itself; and as far as practicable I will limit myself to the various pains about the head, for all the varieties are there manifested.

The first point which strikes every observing man is the difference of individuals in their susceptibility to pain. It is not merely or even mainly a question of the amount of courage of the patient in bearing pain, but it is far more a question of inherited or acquired sensitiveness. The same amount of injury, as nearly as we can judge, in two differently organized individuals will produce extremely differing degrees of pain. In general it may be stated that the unduly susceptible individual has either inherited a weak nervous constitution as regards pain, or else that some depressing agency has lowered his power of resistance. When I speak of a weak nervous constitution as regards pain, I do not mean that it need be a generally weak physique. Perhaps a more happy word would be unstable. You remember the physicists talk of bodies being in stable equilibrium when after a disturbance they tend to return to their bottom, or centre of gravity; while unstable equilibrium is that state where a little shove off the centre, results in a big tumble. Now, the people who are markedly susceptible to pain, who have recurrences of it, may be said to have a nervous system in a state of unstable equilibrium. In other respects these same individuals may be splendid types of muscular or mental development.

The same condition holds good with pain’s first cousin, muscular spasm. The analogue to the sensory crisis of attacks of neuralgia is seen in the muscular convulsions of attacks of epilepsy. And yet some of the greatest men of the world’s history in mental vigor have been epileptics, notably Napoleon Buonaparte and Julius Cæsar. Although at first we may not be able to see any outward manifestation of such attacks of pain as I have spoken of, if they recur sufficiently often they are sure to leave their traces behind.

If we prosecute our inquiries in the other direction, to find what has predisposed our patient to recurrences of pain, we find in a large number of cases that his immediate progenitors have suffered from similar or allied manifestations. By allied manifestations I mean such other nervous diseases as epilepsy or chorea (St. Vitus’ dance), or insanity. Moreover, there is one predisposing cause that I believe to have quite peculiar efficacy, and that is the tendency to phthisis. Again and again I have verified the truth that where a member of a tubercular family escapes consumption, he is extraordinarily liable to develop one of the graver neuroses, preferably recurrent attacks of pain.

Now, the first point we may consider settled, as to the mode in which pain expresses itself is in an inherited susceptibility, a lessened power of resistance, and this can only reside in the central nervous system.

But, as we have already said, the lessened power of resistance may be acquired, it need not be inherited.

Without stopping to dwell very long on this part of our subject, it will suffice to enumerate one or two of the principal efficient agents. And the first and far the most important of these is malnutrition of the nerve tissues, whether accompanied by the signs of anæmia and general constitutional malnutrition or not, the main cause being our civilization, with its excessive nervous wear and tear, no less in the educational period than in the intense competition of mature life. No more striking verification of this fact is needed than the results obtained in the relief of pain by physiological rest, by systematic feeding, especially of certain kinds of food, particularly fatty food. It is the general rule that in these cases there is either an indisposition to take sufficient food, or else that certain necessary ingredients are omitted owing to the patient’s repugnance.

In the familiar example of sick-headache, or migraine, the patient invariably ascribes his condition to a disordered stomach, and scrupulously avoids such foods as eggs and milk and fat, which he will tell you always make him bilious. It is the hardest thing in the world to convince him that he has put the cart before the horse, and that the real fact is that the nervous trouble, the neurosis of the ophthalmic division of the fifth, is the cause and not the effect of the gastric disturbance. I am convinced that much of the suffering in the dental branches of the fifth nerve can similarly be traced to the nervous malnutrition of insufficient food, and, in addition, the local condition of the teeth is pathologically influenced by their not getting their proper physiological stimulus in the quantity or character of the food to be chewed.

Of all the means at our command in combating the neuralgic condition, the regulating and increase in the quantity of rest and of the food supply should stand first. These facts have been known and recognized for a long time; but it is due to an American, Dr. Weir Mitchell, of Philadelphia, to have intelligently systematized their use. The principles of his treatment of nervous prostration, spinal irritation, and allied disorders, in which pain is often a prominent symptom, consists in a system of rest and forced feeding by which a larger quantity of nutriment is gotten into the system, and the waste eliminated by means of artificial exercise, by massage. It is evident that in this process the increased food absorbed into the blood goes indifferently to nourish all the tissues; but inasmuch as the muscles are not the seat of the trouble, if left alone unexercised, they would become diseased under the very stuffing process. That is where the kneading and shampooing, and movements supplied from without, are so valuable; the muscles get their healthy action without drawing on the forces of the enfeebled nervous system to set the process going. And so the nervous system has a chance to lie idle and grow fat. Similar remarkable results have been obtained in another disease whose hereditary relations to pain I have spoken of, namely consumption, by a process of forced feeding. The recent results obtained, more especially in France, by stuffing phthisical subjects, have constituted by far the greatest advance in the treatment of this disease in recent years. But in these cases the massage is entirely inapplicable because the waste of tissue is already too great. The lessons taught by the treatment of these two classes of diseases are invaluable in combating the more inveterate forms of pain.