There are certain special considerations as to the habits of life that require a word or two. I need say nothing more to enforce the views already put forward as to the necessity of copious supplies of food. I need only refer to what I have already said about the decidedly mischievous tendency of anything like habitual excess in the use of alcohol, merely adding a special caution against such indulgence during, and particularly toward, the end of the period of sexual activity. There is one more topic upon which something must be said, namely, the extent to which sexual intercourse should be allowed. Speaking of neuralgia generally (excluding neuralgic affections of the sexual organs themselves), it may decidedly be said that the regular and moderate exercise of the function, during the natural period of sexual life, is beneficial; but that excess is always dangerous, and that the continuance of sexual intercourse, after the powers naturally begin to wane, is extremely pernicious in its tendency to revive latent tendencies to neuralgia. As regards neuralgias of the sexual organs, it is very difficult to speak positively; and yet I believe that (once the neuralgic habit broken through by other means) it is very desirable that the patient should live according to the laws of normal physiological life.
NOTE I
ADDITIONAL FACTS BEARING ON THE QUESTION OF NEUROTIC INHERITANCE
The following cases must be now added to those recorded in my list of private patients whose family history has been ascertained with reliable accuracy.
Case I. is that of a gentleman, aged forty-seven, the subject of lumbo-abdominal neuralgia: no history of nervous disease in the family; his mother, however, was of a "nervous" temperament.
Case II. – A gentleman, aged sixty-four, suffering from angina. His family nervous history is fearful. On the father's side it is not possible to get a clear account. But on the maternal side there has been a strong tendency to insanity and suicide; and in the patient's own generation one brother committed suicide from insanity, and one sister is still alive, insane. An interesting fact is, that the mother's family have shown an extraordinary proclivity to erysipelas.
Case III. – The young gentleman, whose single but extremely severe attack of angina is previously described, comes of a family in whom the tendency to neuralgia is undoubtedly very strongly inherited. His father is frequently and very severely migraineux, and in early life suffered cardiac symptoms not unlike his son's. A brother was also liable to attacks of true migraine between puberty and the age of twenty-one.
Case IV. – On the other hand, a case of angina which I saw in the country, last year, occurred in a gentleman, aged fifty, whose family presented no traceable neurotic history. But the damage inflicted upon his nervous system by various external influences was quite extraordinary. In some way or other he got some attacks of migraine at the age of fifteen or sixteen; for these he was treated with bleeding, and with a most savage antiphlogisticism generally. From that time he never got free of the neuralgic tendency. He used to have not only facial, but intercostal neuralgia; for this last he was repeatedly bled, under the idea that it was pleurisy. Added to all this he habitually did an immense deal of brain-work in his study, and for years had performed clerical duties of the most exacting and exhausting character. It is not much wonder that these combined circumstances had sufficed to generate the neurotic temperament.
NOTE II
THE INHIBITION THEORIES OF HANDFIELD JONES AND JACCOUD
In the present transitional state of opinion concerning the mode in which the phenomena are produced that are popularly known under the name of "reflex paralysis," I cannot pass without notice the doctrines of these two observers. The reader will have perceived that, as regards the secondary paralytic symptoms observed in neuralgias, I explain the phenomena mainly on the theory of a process which is central, and not peripheral, in origin. And, even where, as in some few instances, it seems possible that the starting-point was an organic affection of some viscus, we must always consider the possibility that the link between this and the neuralgia and paralyses was a neuritis migrans travelling inward to the sensory centre, and from that passing over to motor centres and thus producing paralysis; or that, without the intervention of any truly inflammatory process, the continual impressions streaming in upon the cord from the original seat of organic disease may damage the nutrition of the sensory nerve-root, producing a partial atrophy, and that this process may extend to the motor root.
It remains, however, to inquire whether the influence of powerful peripheral agencies may not, in a purely "functional" manner, disable the nerve-centres for a time, causing paralysis with or without neuralgia. The main supporters of such a doctrine are Dr. Handfield Jones46 and M. Jaccoud.47
Dr. Handfield Jones expressly rejects the theory of Brown-Sequard, as to spasm of the vessels in the nerve-centres, and we need not repeat his arguments on that head, because it seems to be generally felt that the vascular spasm theory will not account for the facts. Jones believes that the state produced in the nerve-centre by the peripheral influence is one of paresis from shock-depression, and that from the sensory centre this state can communicate itself to motor and vaso-motor centres, though commissural fibres. He does not believe in the existence of a special inhibitory portion of the nervous system: he believes that an impression may prove stimulating when it is mild, or paralyzing when it is strong; and that any afferent nerve may convey either the one influence or the other to the centres and thus produce secondary stimulus or secondary paralyses in various efferent nerves. Jones has the distinguished merit of being one of the first authors distinctly to perceive that pain must rank on the same level with paralysis: hence he sees nothing unintelligible in the communication of paralysis to a motor centre from a sensory centre that was in the state which the mind interprets as pain.
The theorie d'epuisement of Jaccoud (Erschopfungs-theoric) also denies the possibility of Brown-Sequard's idea of prolonged spasm of the vessels of the centres. It imagines that powerful peripheral excitements exhaust the irritability of the nerve, and through that of the centres, and induce a state of unimpressibility – analogous to that which exists in a nerve or nerve-centre, which is included in the circuit of a constant current. The nervous force is wasted, and, until an opportunity of repose is afforded to the centre, the faculty of impressibility cannot again revive.
I must say that of these two theories I decidedly incline to that of Handfield Jones (though I imagine that in reality the cases are extremely rare, if there be any, in which the change in the centres is really only functional and non-organic), I prefer the idea of paralyzing shock to that of exhaustion from over-excitement, from a consideration of the nature of that form of peripheral influence which has been specially mentioned by authors as competent to produce this sort of "reflex" affections, namely, intense and persistent cold. It seems to me a mere abuse of words to speak of this as an agent that could exhaust the nerve by over-stimulation; it must surely exhaust it in a much more direct manner than this, namely by the direct physical agency of withdrawing heat from the nerve, and spoiling its physical texture, pro tanto. If such an effect as that which must thus be produced on the nerve, and through it on the centre, is to be looked on as a case of over-stimulated function, then, it seems to me, there is no meaning in language, and no possibility of attaining to clear ideas on the subject of nervous influence.
NOTE III
ARSENICAL TREATMENT OF VISCERALGIÆ
Since writing the above chapter on the Treatment of Neuralgia, I have had two fresh and very striking examples, in private practice, of the power of arsenic to break the morbid chain of nervous actions in angina pectoris.
The first example was that of a medical man, aged seventy-five, in whom a neuralgia, originally malarial in origin, and of some years' duration, had fixed itself for some time in the fifth and sixth left intercostal spaces, and of late had become complicated with anginoid attacks of an unmistakable character, though not of the highest degree of severity. The case certainly seemed very unpromising, looking at the patient's age and the consequent high probability that there was much arterial degeneration. However, the use of Fowler's solution (five minims three times a day) was commenced and steadily pushed. The anginoid attacks rapidly diminished in frequency and at the end of ten days' time were entirely gone, and after one month of treatment he still had no return of them, although they had previously been of daily occurrence. It is a curious fact, whether a mere coincidence or not I cannot say, that, some few days after the anginoid attacks ceased, he began to experience somewhat severe pains, rheumatic in feeling, but unattended with heat or swelling, in the elbows, wrists, and fingers, symmetrically. This has nearly disappeared, but he is still free from angina. There is no discoverable heart-lesion in this patient.
The other case was that of a fine old man of sixty-four, who, but for some few slight attacks of gout, a few small calculi, and a troublesome prostatic affection, had always enjoyed remarkably good health, until about five months ago, when he began to notice tightness across the chest, etc., when he walked uphill. About a fortnight before he came to me, he was seized with very violent and alarming paroxysms of pain across the chest and running down both arms, extreme intermittence of pulse, and a sense of impending dissolution. The attack had recurred daily, at the same hour (6 p. m.), ever since; besides which there was an abiding sense of uneasiness in the cardiac region, and a consciousness that the least excitement or exertion would bring on the paroxysm. I put the patient on five minims of Fowler, three times a day, with directions to take ether when the paroxysms came. At the end of the first week there was already much improvement, the paroxysms having been both less frequent and less severe. At the end of a fortnight's treatment he reported that there had been nothing like a paroxysm for the last eight days, although there was still a good deal of uneasiness from time to time. The hour at which the attack was expected passed by absolutely without a trace of angina. It remains to be seen how long this improvement will last, but the altered state of things, and particularly the suddenness of the change, cannot be overlooked, and has very much struck the patient himself. It is now six weeks since he had any paroxysm.
It becomes more and more apparent that arsenic is generally applicable to neuroses of the vagus. In asthma, I have long held it to be the most powerful prophylactic tonic that we possess. It is also an excellent remedy in gastralgia; although I have rather dwelt (in the text of this work) on the action of strychnia in this disease, I would not omit my testimony to arsenic. Dr. Leared has related some exceedingly interesting cases bearing on this point. (See British Medical Journal, November 23 and 30, 1867.)
NOTE IV
INFLUENCE OF GALVANISM ON CUTANEOUS PIGMENT
Dr. Reynolds pointed out to me the exceedingly curious fact, which I have several times verified, that the constant current, in relieving facial neuralgia, not unfrequently disperses, almost instantaneously, the brown skin-pigment that has collected in the painful region; e. g., near the orbit.
NOTE V
THE ACTUAL CAUTERY
A remedy for inveterate neuralgia which of late years I had almost discarded – the actual cautery – has quite recently yielded me very good palliative results in two cases. Its omission from the text of the chapter on Treatment was an accident due to the effect of habit in making one, half unconsciously, reckon this remedy as a "counter-irritant." The longer I practise, however, the more decidedly I am convinced that the actual cautery, if properly applied, does not act as an irritant at all; and this fact was sufficiently in my mind, when writing of irritant remedies, to make me omit the cautery from that section. I should have inserted it under the heading of remedies that interrupt the conductivity of nerves, and thus give the centres temporary rest. The only useful way to apply it is, to make an iron white hot, and very lightly brush the skin over so as to make an eschar not followed by suppuration. The galvano-cautery (Stohrer's Bunsen) is the best for the purpose, but I have made the flat-iron cautery serve very well.
PART II.
DISEASES THAT RESEMBLE NEURALGIA
CHAPTER I.
MYALGIA
Of all the diseases which superficially resemble neuralgia, none are so likely to be confounded with it, on a cursory glance, as myalgia. More careful inquiry, however, furnishes, in nearly all cases, ample means for distinguishing between the two affections.
Myalgia is an exceedingly painful affection, and it is also much more common than was formerly supposed. It is to Dr. Inman that we undoubtedly owe the demonstration of the frequent occurrence of this malady, and the facility with which it may be mistaken for other, and sometimes much more serious, diseases, with very disastrous results. At the same time, I must express the opinion that this ingenious author has decidedly exaggerated the importance of this local disease at the expense of an unjust depreciation of the frequency and significance of other painful disorders which have their origin within the nervous system.
Myalgia proper includes all those affections which are severally known as "muscular rheumatism" (for the muscles generally), and "lumbago," "pleurodynia," etc. (according to locality). It is essentially pain produced in a muscle obliged to work when its structure is imperfectly nourished or impaired by disease.
The clinical history of the different varieties of myalgia absolutely requires this key for its interpretation; otherwise, the appearance of the sufferers from different kinds of myalgia is so widely dissimilar that we should be exceedingly likely to miss the important features of treatment, which must be applied to them all in common. Nothing, for instance, can be more strikingly unlike than the appearance of the pallid, stunted, under-nourishment cobbler who complains of epigastric myalgia, and that of the ruddy and muscular navvy who suffers from acute lumbago, or the similarly plethoric-looking country commercial traveller, who has been driving in his gig against wind and rain, and complains of violent aching pains in one or both shoulders; yet one and all of these individuals are suffering from precisely the same cause of pain, viz., a temporarily crippled muscle or set of muscles which has been compelled to work against the grain. Why this state of things should invariably be interpreted as sensation in the form of acute pain never absent, but severely aggravated by every movement of the affected part, is a matter beyond our powers of explanation, we must accept it as an ultimate fact for the present.
There is scarcely any need to describe the pain of myalgia, since almost every one has suffered either from lumbago, or from a stiff neck produced by cold. The pain is essentially the same in all cases; it is an aching actually felt either in or toward the tendinous insertions of the affected muscles, and sharply renewed by every attempted contraction of those muscles. The variations in the character and severity of the pains are really entirely due to the greater or the less opportunity for physiological rest which the muscle can obtain. Thus the most obstinate and the most severe, kind of myalgic pain is undoubtedly that of pleurodynia – pain in the intercostal muscles and their fibrous aponeuroses – a fact which depends on the incessant movements which these muscles are compelled to perform in the act of respiration. And next to this in severity and obstinacy are myalgias of the great muscles which are incessantly engaged in maintaining, by their accurately opposed contraction, the erect position of the spinal column and of the head. This rate of proportional frequency and severity, however, must be taken as strictly relative; i. e., it is correct upon the supposition that the different sets of muscles were equally worked and that the state of nutrition was equal in the different parents. It is otherwise when the conditions are reversed. Thus, the unfortunate cobbler or tailor, who sits for long hours in one cramped and bent posture, is continuously exerting his recti abdominales (probably suffering from an under-nutrition common to all his tissues) to a degree perfectly abnormal, and out of all proportion to the functional work he is getting out of any other part of his muscular system. The consequence is, that he comes to us complaining of acute epigastric, and sometimes pubic, pain, rising to agony when he assumes his ordinary sitting posture, and only reduced to any thing moderate by the most complete extension of the whole trunk in the supine posture.
There is no need to dilate at greater length upon the varieties in the symptoms of myalgia, according as it affects one or another part of the body. We must consider, briefly the different kinds of cause that produce it. The immediate source of the pain being, as we have seen, the sense of embarrassment in a muscle obliged to contract when unfit for the work, we have to ask what are the remoter causes that can produce this special unfitness for the work of contraction. They are three: (a) Overlabor pure and simple (i. e., in proportion to the existing bulk and quality of the muscle); (b) cold, and especially damp cold, producing a semi-paralyzing effect on the vaso-motor nerves, and causing congestion and sometimes a little effusion among the fibres or within the sheath of the muscle; (c) fatty degeneration of muscle which is exposed to inevitable and incessant work. Either of these conditions may so disable the muscle that its unavoidable contractions will set up the myalgic state.
Undoubtedly however there is something further, in the shape of a natural predisposition not yet understood, which makes some patients so much more liable to suffer myalgic pain as a consequence of this sort of influences than other persons are. I am in no condition to decide what the nature of this predisposition is; I feel sure it is heightened by an inherited or acquired gouty taint, but I have seen it in people whom there is no reason to suspect of gouty tendencies. It appears to have no connection with true rheumatism.
Still after all that can be said, myalgia remains a disease chiefly of local origin, and depending for nine-tenths of its causation upon a derangement between the balance of work and nutrition in the muscle.
As regards the diagnosis of myalgia from neuralgia, which is a very important matter, the following are the main points that we should recollect:
The treatment of myalgia is not only satisfactory in itself, but often affords, in its results, a very desirable confirmation of diagnosis.
For a very large number of cases, all that is required is (a) to put and keep the affected muscle in a position of full extension, which is only to be changed at somewhat rare intervals; (b) to cover the skin all over and round it with spongio-piline, so as to maintain a perpetual vapor-bath; (c) on the subsidence of the acutest pain and tenderness, to complete the treatment by one or two Turkish baths, to be taken in the manner that I have recommended by speaking of the prophylaxis of neuralgia.
When treatment such as this cures a pain which was greatly aggravated by muscular movement, we may be sure that pain was myalgic and not neuralgic.
The pain, however, is not unfrequently rebellious to such simple remedies as these, more especially when (as in pleurodynia) we are not able to enforce complete physiological rest of the part. When this is the case, we shall find the internal use of twenty and thirty grain doses of muriate of ammonia by far the most effective remedy. In the first very acute stage of a severe case it may be advisable to inject morphia hypodermically; but this is seldom necessary. The muriate-of-ammonia treatment may be usefully accompanied by prolonged gentle frictions, three or four times a day, with a weak chloroform liniment.
When there is visibly a very great deficiency in the general nutrition, we shall often fail to obtain a cure until we have remedied this defect; and accordingly, in the majority of cases of half-starved and overworked needle-women, cobblers, tailors, and the like, who present themselves in the out-patient room, I accompany the above-named treatment with the steady administration of cod-liver oil for three or four weeks or more.
There is one remedy for this pain which I have myself seen used in only a few cases, but which I believe promises exceedingly well for the treatment of obstinate myalgia; viz., acupuncture. I have not even mentioned it as a remedy for neuralgia, for I believe it to be totally useless in true cases of that disease, whether applied in the simple form or in that of galvano-puncture. I think very differently of its use in myalgia; and I venture to believe that it is entirely to cases of this disease that the exceedingly interesting observations of Mr. T. P. Teale, in a recent number of the Lancet, apply. Where (after the usual remedies for myalgia have been applied) we are unable to get rid of a deep-seated and fixed muscular pain, I believe it to be excellent practice to plunge two or three long needles deeply into the muscle near its tendinous attachment.