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 graindoses 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 necessaryto 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 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 atertium quidcompounded 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 longbefore 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 aidcould 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 injectionof 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, fullyrepresents 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 dysmenorrhœal 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 thepatient 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 stimulusof 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 toaccompany 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 "hyperæsthesia" 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 believethat 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 itsmodus operandihas 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 thenape 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 anæsthetic 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 surprisinghow 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.
Far more useful, in neuralgias generally, is the external application of aconite or of veratrine. Aconite may be employed in the milder or the stronger form; in the former case, we simply paint the ordinary tincture on the skin over the painful nerves (avoiding any cracks or sores); in the latter, we rub in an ointment containing one grain of the best hydrate of aconitine to the drachm of lard, about twice a day, and to such an extent as to maintain complete numbness of the parts continuously, for two, three, or four days. I do not believe that this will ever, by itself, cure a true neuralgia of any considerable severity; but I have more than once known its intervention, at a crisis in treatment when it seemed that other remedies might fail, produce a striking change in the progress even of a very bad case.
A milder, but still very useful form of the same kind of action, is produced by veratrine-ointment. I would recommend, however, as a rule, that it be employed, at any rate at first, of weaker strength than that recommended in the Pharmacopœia, for with some persons it is easy to pass the anæsthetic, and to enter on the irritant, action of veratrine uponthe skin. This leads me to give a caution that should properly have come earlier, when I was speaking of skin-stimulants. In aged subjects, especially, we rather frequently meet, in neuralgia, with a specially irritable state of the skin, even although there may be at the same time some loss of common and tactile sensation; and the practitioner must be warned against the danger of producing an amount of skin-irritation which will fearfully annoy his patient. I speak feelingly, having by such an indiscretion lost the richest patient who ever favored my consulting-room with his presence!
The inunction of mild veratrine-ointment is extremely useful, as an adjunct to other treatment, in migraine and supra-orbital neuralgias of suckling women, and of chlorotic girls. I have also seen it do much good in mammary neuralgia.
The last division of the subject of paralyzing agents in the treatment of neuralgia includes the surgical operations for division or resection of a painful nerve. Upon this question there is much difficulty in speaking decidedly. I admit at once, of course, that surgical interference is evidently indicated when, along with decided and intractable neuralgic pain, there is plain evidence either of the existence of a neuromatous tumor, or the presence of a foreign body impacted, or a tight cicatrix pressing upon a nerve. I admit, also, though with much greater qualifications, that carious teeth may need to be extracted before we can cure a neuralgia; but even here I should put in the decided caveat that we must consider whether the system is in a state to bear the shock, and that in any case we probably ought to mitigate the effects of the operation by performing it under chloroform. And I need hardly tell any one, who is familiar, either practically or from reading, with the subject, that thousands of carious teeth have been extracted from the mouths of neuralgic patients, not only without benefit, but with the effect of distinctly aggravating the disease. And I am yet more doubtful as to the advisability of such surgical procedures as the division or the resection of a piece of the painful nerve. Theoretically, as the reader will understand from the strong opinion I have given as to the mainly central origin of neuralgias, I never could anticipate that such a procedure would be more than temporarily successful; on the contrary, the mischief in the central end of the nerve remaining, I should suppose that the trying process of the reunion of the nerve (which always takes place) would be almost certainly attended with a revival of the neuralgia, too probably in an aggravated form. The only two cases of excision of a piece of the nerve, that I have ever seen, completely answered to this anticipation. In common fairness, however, I must admit that there is a large amount of evidence on the other side. Neuralgias of the trigeminus are pretty nearly the only cases in which the proposal of neurotomyor neurectomy ought to be entertained; in mixed nerves the inconvenience of the muscular paralyses that would follow would be usually too serious to allow of our incurring them. But resection of painful branches of the trigeminus has been performed in a great number of instances, more especially by German surgeons, with results that merit our attention; the cases recorded by Nussbaum, Wagner, Bruns, and Podratzki, may be especially referred to. On the other hand, with the exception of simple division of the nerve, which can be subcutaneously performed, and is a trivial proceeding (but has very short-lived effects), these operations are by no means without danger, especially when they are pushed to such a length as the opening of bony canals, and the resection of considerable portions of bone in order to get sufficiently far toward the centre, and fatal results have in more than one case followed. Above all, we can never too seriously reflect on the most interesting case of Niemeyer's reported by Wiesner,[40]in which the most formidable operations of this kind have been performed, in an apparently desperate case of epileptiform facial tic, and in which, after all, the application of the constant current painlessly effected an infinitely greater amount of good than had been done by all those severe and painful surgical manipulations. I think it is impossible, after this, not to conclude that neurectomy ought never to be even thought of except as a last resort, in cases of extreme severity, after other measures had been patiently tried and had decisively failed.
(c) Of remedies that are intended to relieve local congestion, I must speak with very doubtful approbation. Leeches or scarifications are, I think, very seldom of value. The only remedy that has sometimes seemed to do good is local compression, and, after all, it is quite as likely that this acts by anæsthetizing the nerve as by reducing congestion.
(d) Remedies that interfere mechanically with arterial pulsation are of considerable value where they can be effectively applied. I have already pointed out the specially aggravating effect of the momentarily-repeated shocks of arterial pulsation upon neuralgic pain. Where, then, it is possible, effectively to control an artery pretty near to the point where it divides into the branches that lie close to the painful part of the nerve, it is always worth while to try the experiment. But such a measure as the compression of the carotid in trigeminal neuralgia is of very doubtful propriety; I suspect the consequent anæmiation of the brain more than does away with any benefit that might be mechanically produced. And any attempt to interfere with the general arterial circulation by cardiac depressants is not to be permitted for an instant.
(e) We enter now upon a most important subject, the treatment of neuralgia by electricity. It is necessary to exercise much caution in speaking upon this topic, and, as I shall have to express somewhat decided opinions, I may be excused for referring to the circumstances under which I have arrived at my present stand-point upon this question. I can hardly be accused of having, with any very rash haste, espoused the cause of medical electricity in the therapeutics of pain, as any one will see who cares to turn to my article on Neuralgia[41]written only three years ago. At that time I had already been studying the subject for a considerable period, but was so convinced of the multitude of opportunities for fallacy that beset the student of electro-therapeutics, that I was unwilling to state more than the minimum of what I hoped and believed might be affected by this mode of treatment. Since that time I have become more fully acquainted with the researches of foreign observers, and, with the help of their indications, have been able to apply myself more fruitfully to my personal inquiries into the matter. The result is, that I am now able to speak with far greater assurance of the positive value of electricity as a remedy for neuralgic pain. I shall make bold to say that nothing but the general ignorance of the facts can account for the extraordinary supineness of the mass of English practitioners with regard to this question.
In the first place, I have arrived at a decided conviction that Faradic electricity is of little or no value in true neuralgias, and that the cases which are apparently much benefited by it will invariably be found, on more careful investigation, to belong to some other category.
On the effect of frictional electricity I have had such very small experience that I cannot venture to speak with any confidence, and the accounts that I have heard from others whose experience is much larger have not led me to attribute much importance to this agent. If I am to judge at all, I should say it merely acts as a skin-stimulant, and is, in that capacity, inferior to many other simpler and more facile applications.
Very different is the verdict of experience as regards the effects of the constant current; here the results which I have obtained have been so remarkable that even now I should distrust their accuracy, were it not that they are in accord with the general result which (among minor discrepancies) may be gathered, we may fairly say, from all the more important researches that have lately been carried out in Germany. The constant current, as I now estimate it, is a remedy for neuralgia unapproached in power by any other, save only blistering and hypodermic morphia, and even the latter is often surpassedby it in permanence of affect; while it is also applicable in not a few cases where blistering would be useless or worse.
The English medical profession has not as yet adequately appreciated the necessity for great care in the choice of apparatus and the mode of application of electricity. It is all-important, however, and especially in the case of applying galvanism for the relief of pain. The first quality that must be absolutely required in a battery, that is to be used for this purpose, is that it shall deliver its current with as little as possible variation of tension, in fact that it shall be constant, and not merely continuous; a vast majority of all the various galvanic apparatus that have been used have been merely the latter, and have consequently been almost valueless for the relief of pain. Such are Pulvermacher's chains, the voltaic piles made with elements of metallic gauze, Cruickshank's battery, and many others that have been used. A sufficiently constant current may be obtained from either of the following apparatuses, (1) Daniell's battery, (2) Bunsen's, (3) Smee's. For hospital use, the Daniell battery (in Muirhead's modification, or with the form of cells introduced by Siemens-Halske) is perhaps the most desirable; but for private practice it is worth while to sacrifice something of the superior constancy which we gain in the Daniell battery for the sake of comparative portability. All purposes which we aim at in the electric treatment of neuralgia may be sufficiently obtained by the use either of the Bunsen battery (zinc-carbon, excited by dilute sulphuric acid), as modified by Stohrer, or by the Smee battery (zinc and platinized silver, excited by dilute sulphuric acid), as in the highly convenient apparatus devised by Mr. Foveaux, of Weiss & Son's. It must be remarked that, for the purpose of treating neuralgia, we shall never need to employ more than fifteen, or at the utmost twenty, cells of either of these batteries. Both the Stohrer's Bunsen and the modified Smee of Weiss are made so that the elements are not immersed in the exciting fluid until the moment when the battery is going to be used; a simple mechanism at once throws the battery into or out of gear. In this way, destruction of the elements is minimized; and either of these two batteries may be used for from three to six months without any renewal, supposing the average work done to be one or two daily seances. If the battery is worked harder, it will require more frequent revivification. I strongly recommend London practitioners to deliver themselves from all care and trouble about the repair of their batteries, by making an agreement with the manufacturers to inspect and set them in order at stated intervals. The country practitioner, on the other hand, will do well to familiarize himself with the process of renewing the acid, of cleaning the plates, of amalgamating thezinc, etc.; in fact, to make himself independent of the manufacturer in every thing short of an actual renewal of the elements, when that becomes necessary. For all further details respecting the above-named, and other batteries, I must refer the reader to systematic works on medical electricity.[42]I must now pass on to the various modes of application, and the cautions to be observed.
It is, in the first place, necessary to say, that all the best observers coincide in the statement that the use of a current intense enough to produce actual pain or severe discomfort is never to be thought of in the treatment of true neuralgias; such practice will infallibly do harm. Only such a current is to be employed as produces merely a slight tingling, and (on prolonged application) a slight burning sensation, with a little reddening of the skin at the negative electrode. This being the case, it is perhaps not unnatural for those who have not had practical experience, to suspect that an application which causes so little palpable perturbation is devoid of any positive influence at all. Such skepticism will certainly not survive any tolerably lengthened observation of the actual facts; but, as some persons may be deterred by thisprima-facieview of the case from making any fair trial of the current, it may be worth while, here, to allude to the unmistakable physical effects which similarly painless constant currents are repeatedly observed to produce in cases of motor-paralysis attended with a wasted condition of muscles. Those who have had experience of the treatment of such cases know that it is a by no means infrequent thing to see both muscles and nerves aroused from a state of complete torpidity, and brought into a condition in which the Faradic current, quite powerless before, is again able to excite powerful contractions, while, at the same time, the bulk of the muscles has increased most sensibly. These, surely, are sufficient indications of a positive action of the painless constant current; and such facts have now been recorded, in multitudes, by most competent observers.
The next maxim of first-rate importance is that the applications of the current should be made at regular intervals, and at least once daily; in most instances, this is enough, but occasionally it will be found useful to operate twice in the day. The matter of regularity is, I find, of great consequence, and it will not do to intermit the galvanism immediately on the occurrence of a break in the neuralgic attacks: it should be continued for some days longer.
The length of sittings is a point as to which there is considerable difference of opinion between various authorities; butmy own experience coincides with that of Eulenburg, that from five to ten, or, at the utmost, fifteen minutes, is almost the range of time.
Closely connected with the question of the length of sittings, is that of the continuity with which the current is to be applied. I have seen the best results, on the whole, from passing a weak current, without any breaks, for about five minutes. But, where there are several foci of intense pain, it will often be advisable to apply the current to each of these, successively, for three or four minutes.
The places to which the electrodes should be applied vary much according to the nature of the case.
Benedikt's rule, that the application of electricity, to be useful, must be made to the seat of the disease, is undoubtedly true; but it is capable of being applied in a somewhat different manner from that which he recommends in particular cases, the difference being due to the view of the pathology of neuralgia which is taken in this work. That view is, that the essentiallocus morbiis always in the posterior nerve-root (and usually in that portion of the root which is within the substance of the cord), and that the peripheral source of irritation, if any, is only of secondary—though sometimes of considerable—importance. Hence the main object, in electrization, would seem to be to direct the influence of the current upon the posterior nerve-root. This may, however, be done in different ways, according to the situations in which we place the electrodes, and the direction in which we send the current.
There are, as yet, very considerable differences of opinion among electro-therapeutists as to the principles which should govern us, both in the localization of the effect and the direction of the current. Benedikt, for example, recommends that the current should be directed toward the supposed seat of the mischief. Thus, if we suppose a neuralgia to depend on morbid action within the spinal cord, then we may galvanize the spine, taking care to make the current come out through any vertebra over which we detect tenderness. If we suppose the seat of the disease to be in the nerve-root in the mere ordinary sense of the word, then we apply the positive pole to the vertebra opposite the highest nerve-origin that can be concerned, and we stroke the negative pole down by the side of the spinous processes, some forty times in succession. The proportion of cases of idiopathic neuralgia in which this treatment succeeds is, according to Benedikt, very large. In other cases, he sends the current from the cord to the apparent seat of pain.
On the other hand, Althaus[43]tells us that, whether theapplication be central or peripheral, it is the positive pole, alone, which should be applied to the part which we intend to affect: and that the application of the negative pole in this situation is rather likely to do harm than good, as proving too exciting. Eulenburg, also, says that in general the positive pole should be applied to the seat of the disease, the negative on an indifferent spot, or on the peripheral distribution of the nerve.
It is, however, very doubtful to me whether, in the majority of cases, the direction of the current makes any considerable difference in its effects, provided only that the stream is fairly directed so as to include thelocus morbiin the circuit, and care is taken to apply it with sufficient persistence and with not too great intensity. Upon this point I am glad to be able to cite the authority of Dr. Reynolds, whose experience is very large. This author, while admitting that in theory the "direct" and the "inverse" currents would seem likely to have different effects, declares that in practice this does not prove to be the case, either in the instance of pain of nerve or of spasm of muscle. Dr. Buzzard, also, in relating a very striking case (which I had the advantage of personally observing) before the Clinical Society, particularly mentioned that the direct and the inverse currents had a precisely similar effect in relieving the pain. The patient suffered from severe and probably incurable cervico-brachial neuralgia; the poles were placed, respectively, on the nape of the neck and in the hand of the affected limb, and whether the positive was on the nape and the negative in the hand, orvice versa, the effect was the same. Very striking remission of the pain was always produced, and the immunity from suffering sometimes lasted for a considerable time, while no other plan of treatment seemed to have more than the most momentary effect.
My own experience tells the same story very decidedly, for I have on very many occasions obtained great benefit, both by the direct and by the inverse currents, in the same patient. I shall here relate a few instances:
Case I.—A married woman, aged forty-eight, whose menstrual periods had ceased quietly some six years previously. She was, on the whole, a healthy person, but had suffered from migraine in her youth, and came of a neurotic family. She was attacked with severe cervico-brachial neuralgia, which resisted all treatment for nearly three months, and, on her then trying a month's change of air and absence from medication, became worse than ever. The constant current was applied, from ten (and afterwards fifteen) cells of Weiss's battery, daily for twenty-four days, the pain vanished finally at the end of thirteen days, and the accompanying anæsthesia and partial paralysis disappeared before the treatment was concluded. In this case the negative pole was applied by the side of the three lower cervical vertebræ, and the positive wasapplied, successively, to three or four different parts of the most intense peripheral pain.
Case II.—A young lady, aged twenty-four, suffered from neuralgia in the leg. Galvanization (twenty cells Daniell), from the anterior tibial region to the spine was found invariably to cut short the pain. I now reversed the current; the effect was the same. After ten sittings I suspended the treatment, as there had been no attack for three days; but a week later the neuralgia returned in full fury. I resumed galvanization from periphery to spine; after twelve more sittings the attacks had become rare and slight. I continued treatment for eight days longer, during the whole of which time there was no pain. It had not recurred when I saw her fifteen months afterward.
Case III.—H. G., a footman, aged twenty-three, applied to me at Westminster Hospital, with neuralgia of the first and second divisions of the right trigeminus, of six weeks' standing. The right eye was bloodshot and streaming with tears, the skin of the right side of the nose and right cheek was anæsthetic, the right levator palpebræ was partially paralyzed. Hypodermic injections of morphia proved only very temporarily beneficial. After a fortnight's treatment with this and with flying blisters to the nape of the neck and the mastoid process, I commenced the use of the constant current daily (ten cells, Weiss). The first application (positive on nape, negative on infra-orbital foramen) stopped the pain, and procured fourteen hours' immunity. On the next day I reversed the current; the pain stopped after three minutes' galvanization; it did not recur for four days, during which time, however, I continued the daily use of the direct current. On the sixth day of treatment the patient came to me with a somewhat severe paroxysm, almost limited to the ophthalmic division; it was accompanied by spasmodic twitchings of the eyelid, and copious effusion of altered Meibomian secretion, looking like pus. Galvanization from supra-orbital foramen to nape stopped the pain in five minutes. The next day the patient presented himself, quite free from pain, which had not returned; the conjunctiva was clear, and there was no visible Meibomian secretion. Inverse galvanization was continued for ten days; but no recurrence of the pain took place. The cure was permanent three months later.
On the contrary, we sometimes see complete failure of the current to affect any good whatever; and in these cases the reversal of the current has not, so far, appeared to me to make any particular change in the result. Such was the case with a patient whose history I detailed (along with that of Case I.) to the Clinical Society. She was an ill-fed and overworked unmarried needle woman, aged thirty; the neuralgia was a most violent double occipital pain, with foci, on each side,where the great occipital nerves become superficial. The current was passed daily, for some days, from one focus to another (necessarily passing through the nerve-roots and the spinal cord), and the positions of the conductors were occasionally reversed; this not succeeding, the current was applied altogether to the spine, the negative pole being placed on the highest cervical vertebræ, but no good effect was produced after a treatment, altogether, of sixteen days.
Notwithstanding these, and a good many similar facts that could be adduced, I should hesitate to go so far as to say that there is never any importance in the direction of the current. In old-standing cases, where there are well-markedpoints douloureuxthat are exceedingly sensitive, I have found that the application of the positive pole, successively, on the most tender points, the negative being placed on the spine opposite the point of origin of the nerve, has had a more beneficial effect than any other mode of application.
There are very considerable differences, both as to the best manner of galvanization, and also as to the chances of doing good with it, in the case of neuralgias of different nerves; and, on the whole, I find Eulenburg's conclusions on this matter very just. He indicates sciatica as the affection which is by far the most curable by the constant current; he says that many cases are cured in from three to five sittings, while others require as many weeks, or even months of treatment; and that a total absence of benefit is only seen in rare cases dependent on central causes, or on diseases which are irremovable (like malignant pelvic tumors). On the other hand, he reports that intercostal neuralgia has never been materially benefited by galvanization in his hands. With regard to ordinary trigeminal neuralgias, he speaks strongly of the current as a palliative, but very doubtfully of its power to cure, in genuine and severe cases. In cervico-brachial neuralgia he speaks of it as dividing with hypodermic morphia the whole field of useful treatment, in the majority of cases. In cervico-occipital neuralgia he says it rarely does much good. I shall return to Eulenburg's estimate of its utility in migraine, presently. Let me here say that I am inclined to indorse everything in the above-detailed statements, excepting that I should place a considerably higher estimate on the curative powers of the current in ordinary trigeminal neuralgias. The remedy, like every other, will doubtless fail in a considerable number of those very bad cases which occur in the degenerative period of life; but if anyone desires to see the proof of the power it sometimes exerts, even in extreme cases, he should study the two most remarkable cases treated by Prof. Niemeyer, of Tubingen, and reported by Dr. Wiesner.[44]The patientswere respectively aged sixty-four and seventy-four, and the duration of the neuralgia had been respectively five and twenty-nine years; in both the pain was of the severest type, and in both the success was most striking. In one of them every possible variety of medication, and several distinct surgical operations for excision of portions of the affected nerve, had been quite vainly tried. The cases are altogether among the most interesting facts in therapeutics that have ever been recorded. Dr. Russell Reynolds has also told me of a case under his own care, in which a lady, who had been the victim, for twenty years, of an extremely severe neuralgia of the ophthalmic division of the fifth, which attacked her daily, and had caused great injury to her general health and nutrition, was not merely benefited, but the affection absolutely removed, at any rate for a long period, by a single application of the current. I have personally seen no such remarkable cases as these but I have had some extremely severe cases under my care in which the effect of the current was to arrest the pain in a few applications, and procure a remission for several days, or even weeks. And I have had several slighter cases which were as much cured, to all appearance, as any disease can be, by any remedy.
As a general rule, neuralgia of the limbs requires to be treated with a more powerful current than neuralgia of the face (twenty cells instead of ten). In the latter case, indeed, it is necessary to be exceedingly cautious (commencing with five cells), since a current of high power has been known to produce most serious effects upon the deeper-seated organs; the retina has been permanently paralyzed, by too strong a current applied on the face, and still graver dangers attend the incautious use of galvanization of the brain or of the sympathetic, of which we have now to speak.
Galvanization of the brain is a remedy chiefly employed in true migraine, and is certainly very effective in that disease. I have not found it useful to apply the current in the long axis of the cranium, but transmitted from one mastoid process to the other it has proved most useful; and I am glad to find that my experience on this point coincides with that of Eulenburg. But the use of this remedy is highly perilous in careless hands. In working with either Daniell's or Weiss's battery, it is necessary to use at first only three or four cells, and to increase the number only with the greatest caution. The sittings should never last more than half a minute; but the slightest giddiness should make us stop even sooner. On the other hand, the applications ought to be made daily, and usually twice a day. Ten cells (Daniell or Weiss) is the utmost that will ever be required, few patients will bear so much; and, apart from the possibility of more serious mischief, there is nothing which annoys and frightens patients more seriouslythan the sudden and intense vertigo which over-galvanization of the brain may induce.
Even more ticklish than the galvanization of the cerebral mass is galvanization of the sympathetic. I am not going to raise here the vexed question in physiological electricity as to the possibility of a galvanization the effects of which shall be accurately limited to the sympathetic. The fact is unquestionable, that very powerful and peculiar effects, utterly unprocurable in any other way, can be produced by placing one pole on the superior cervical ganglion (just behind and below the angle of the jaw) and the other on the manubrium sterni. This is a mode of galvanization which has been highly praised, more especially by Remak, and after him by Benedikt, but it has yielded rather disappointing results in neuralgia in my hands. Either I have not observed any distinct effect at all, or, if a current even a very little too strong were applied, I have repeatedly seen most uncomfortable, and sometimes very alarming, symptoms. I shall not easily forget a patient who applied at the Westminster Hospital, suffering from a severe form of facial neuralgia, and who was persuaded to come to my house and have his sympathetic galvanized. I used only twenty cells of Daniell, but the current had not been applied more than a few seconds when the patient fell on the floor, and remained in a state of half swoon for a considerable time. I allude to this and other less dangerous accidents that I have seen follow galvanization of the sympathetic, not with the view to prove that the method is useless in trigeminal neuralgia—I should certainly hesitate to say that, considering the large amount of respectable evidence in its favor—but I think that it is a procedure requiring the utmost caution, and meantime I have not personally found it nearly so useful as the methods already described.
There are sundry special applications of galvanism to particular forms of neuralgia which require a few words of notice. Of electrical treatment in regular angina pectoris I have had no experience; and in the one case of intercostal neuralgia, complicated with quasi-anginal attacks, in which I applied the constant current to the spine and the cardiac region, in the direction of the affected intercostal nerve, no effect was produced. I shall, however, mention the experience of Eulenburg, as he is a sober and dispassionate writer on the effects of electric treatment in general. He says he believes that in the proper use of the constant current we shall discover the chief, possibly the only direct, remedy for angina; and he describes the apparently favorable results he has already obtained in three or four cases. The current was from thirty cells; the positive pole was placed on the sternum (broad electrode), the negative on the lower cervical vertebræ. The alternative method which Eulenburg suggests, but has not, so far, put inpractice, is direct galvanization of the sympathetic and vagus in the neck.
The application of the constant current in neuralgic affections of the larynx and pharynx is of most indisputable service; the experience of Tobold[45]upon this point is fully borne out by my own, as far as it goes. In many cases it will be sufficient to place the positive pole (from fifteen cells Weiss) on the pomum Adami, and the negative on the nape of the neck, and to keep up a continuous current for five or ten minutes daily; but in some cases the direct application of the current to the pharynx or larynx may be required; in such, a modification of Dr. Morell Kackenzie's laryngeal conductor will be found useful. [I shall have occasion, in Part II., to notice the superior action of Faradization in mere hysteric throat-pain, as distinguished from true neuralgia.]