Of zinc, as a prophylactic tonic in cardiac neuralgia, I know but little. Truth to say, it is a nervine tonic of occasional great value, but which, on the whole, I have found so unreliable that I am somewhat prejudiced against it; and perhaps have not given it a fair trial in those milder cases of cardiac pain to which it might be suited. It does appear, however, to have some preferential action on the vagus, and might therefore be possibly more useful than I am at present inclined to think it.
The treatment of the acute neuralgic stage itself is a matter in which we are sadly limited by the exigencies of the case. Relief must be excessively rapid if we are to save life in the most threatening cases, or to deliver the patient from a most prostrating agony, which might have lasted for hours, in other instances.
The remedy which the highest authority, Dr. Walshe, seems to put first in efficacy is opium; and he directs the dose to be measured by the intensity of the pain, as much as forty to sixty drops of laudanum being given in a severe case. He says, however, that it should be given with an antispasmodic, such as brandy, or ether, or sal-volatile; and I confess that I believe the antispasmodic treatment to be by far the most important. Indeed, so marked is the success which I have found to attend the use of ether in the paroxysm, that till lately I scarcely cared to make further experiments, with drugs, for the relief of the patient at this stage. One teaspoonful of ether in two ounces of thickish mucilage should be given at once, and repeated in a short time if the patient does not rally.
In a few instances, angina seems to be provoked by the irritation of indigestible food, and when there is good reason to suspect this an emetic should be given. I strongly recommend that mustard should be used for this purpose, for the effect of a mustard-emetic is by no means merely to empty the stomach, it has a powerfully rousing influence on the heart.
Upon the subject of the inhalation of chloroform for cardiac neuralgia, I have only to say that, though I have seen it usefully employed, I should not, with my present experience, ever think of employing it myself. Every possible advantage which it could give is obtained by the internal use of ether, and many serious dangers are avoided, which would attend the use of chloroform. For it must be remembered that the only kind of chloroform inhalation which would be useful would be that in which a carefully measured small dose of a weakly impregnated atmosphere should be inhaled, and, without large experience in the administration of chloroform, the practitioner will be unable to secure this effect with certainty. And the effect of a powerfully-charged atmosphere, breathed only once or twice even, would be instantaneously fatal.
Hot epithems to the epigastrium are probably of some use, and besides this the temperature of the body should be carefully kept up by hot bottles to the feet, hot tins to the epigastrium, etc. Brandy should be freely administered during the attack, if we cannot immediately obtain either ether or a remedy now to be mentioned. I refer to the nitrite of amyl, which, at the time when the first part of this chapter was written, I had not had the opportunity of testing.
Nitrite of amyl is a highly-vaporizable fluid, which possesses the following remarkable physiological action: the inhalation even of a very small quantity is followed, after a minute or so, by a sudden acceleration of the heart's action, accompanied by intense crimson congestion of the vessels of the face and conjunctiva, and a sense of enormous fulness in the head; these phenomena are extremely fugitive, passing away completely in two or three minutes, unless the inhalation is renewed. These characteristic effects had for some years been experimentally exhibited by Dr. Fraser and others, but the practical application of amyl to the treatment of angina was first suggested, I believe, by Dr. Brunton, in the case of a patient under the treatment of Dr. Maclagon and Dr. Bennett, in the Edinburgh Royal Infirmary. The angina was in this case symptomatic, there being advanced valvular disease of the heart. Comparative examinations with the sphygmograph, during the intervals and during the paroxysms, made strikingly manifest the fact that, during the attacks, there was an increase of arterial tension which was directly proportionate to the severity of the pain and cardiac embarrassment. It was thus suggested to Dr. Brunton's mind that nitrite of amyl, by relaxing the systemic arteries, might remove the unnatural tension, and give relief to the pain; and the result confirmed this hope. Doses of five and ten drops were inhaled from a towel, with the uniform result of at once quieting the pain; it might return in a few minutes, but a second dose usually removed it entirely for many hours. Various other cases have since been reported, in which similar relief was obtained, and I had occasion to employ it myself in one instance. The gentleman whose case has been related above (see page 101), as an example of the relief obtainable by the use of ether began to suffer rather more severely from his attacks than had been the case for some time, toward the end of the year 1869. I now determined to try the amyl, and accordingly left a small bottle containing half an ounce of it in his possession, with exact instructions to the following effect: On the first symptoms of a paroxysm of angina, he was to get the bottle open, and as soon as their character was fully declared he was to put the bottle to one nostril (closing the other with the finger, and keeping the mouth shut) and take one long, powerful inspiration. The result of his first experiment was very remarkable: the first sniff produced, after an interval of a few seconds, the characteristic flushing of the face and sense of fulness of the head; the heart gave one strong beat, and then at once he passed from the state of agony to one of perfect repose and peace, and at his usual bedtime slept naturally. This experience was repeated on several occasions, and for a considerable time the patient retained such full confidence in the remedy that he discarded all use of ether, and greatly reduced his allowance of stimulants, with very marked benefit to his appetite and general health. The new remedy did not lose any of its power by repetition, but unfortunately the patient at last conceived a horror of it, which caused him to abandon its use. So distressing and alarming to him was the sense of fulness in the head produced by the amyl, that, notwithstanding his certain knowledge that he could at once cut short a paroxysm, he could not persuade himself to continue its use, and for some time past he has returned to the use of the ether and (though in less quantities than previously) of the brandy, for this purpose. And here it must be remarked that this objection, although probably needless in the case of this particular patient, may have real importance in certain circumstances. The admirable physiological researches of Dr. Brunton leave no doubt that the effect of inhalation of amyl is to relax, very suddenly, the tonic contraction of the systemic arteries, and in the case of the brain it would appear that a serious strain must be suddenly thrown upon the capillary net-work. This being the case, it appears likely that, where the atheromatous change has considerably invaded these delicate vessels, they might prove too brittle to stand the sudden distention, and a rupture and consequent cerebral hæmorrhage might ensue. This suspicion, then, that such pathological changes exist, ought to seriously affect our judgment as to the administration of amyl; and this suspicion ought to be always entertained, prima facie, in the case of patients who have much passed the age of fifty, more especially if they have gray hair and an arcus senilis, or if the sphygmograph yields a pulse-trace of the decidedly square-headed type, or if they have been long addicted to alcoholic intemperance. In such patients I should be disinclined to allow the use of amyl.
[Although I have thought fit here to give an outline of angina pectoris as a connected whole, I shall have occasion to recur to the subject again under the heads of Pathology and Treatment of Neuralgias in General.]
Gastralgia.– Neuralgia seated in the stomach itself is not to be distinguished with accuracy from neuralgic pains occupying one or other of the neighboring nervous plexuses. It must be remembered that not merely is the stomach itself copiously supplied by the pneumogastric nerves with afferent fibres, but the great solar plexus is close behind it, the cœliac plexus springs from the fore part of the latter, and these, with the coronary and superior mesenteric plexus, may all be said to be well within the region in which "gastralgic" pain is felt. It is not particularly important, however, in my opinion, to make any very exact diagnosis here, as to the site of the pain, since all these neuralgias must be considered to belong to the pneumogastric nerve, the branches supplied from which are probably the sole means by which these plexuses become the seat of neuralgia.
Abdominal pneumogastric neuralgia is an extremely distressing and occasionally a very intractable disorder. The subjects of it are almost invariably in a state of marked and evident debility, and inquiry generally elicits the fact that they have suffered at other times from neuralgia elsewhere than in its present seat. By far the most common history of previous affections of this kind is that of trigeminal neuralgia, especially of the supra-orbital branch; and it has several times occurred to me to observe the direct sequence of a gastralgia upon a unilateral browache. Anæmia is a specially frequent attendant of gastralgia, more so than of other neuralgias. Women are, by the general consent of authors, more liable to gastralgia than men.
The special mark of true neuralgic pain in the abdominal pneumogastric, as distinguished from other deep-seated pains in the epigastrium, is the remarkably direct relation of its severity to the patient's exhaustion, particularly in regard to the weakness induced by want of food. While the great majority of dyspeptic pains are increased by filling the stomach, gastralgia, on the contrary, is invariably relieved by food, often most strikingly and completely. Pressure from without, also, while it aggravates most pains dependent on local organic mischief, nearly always more or less relieves gastralgia. Equally striking is the comfort given by stimulants, especially by hot brandy-and-water; in this respect gastralgia resembles colic. There is something special in the degree of mental depression which attends gastralgic pain. In this it resembles the pains of hypochondriasis, but there is a resilience of the spirits when the pain has been relieved which is not seen in the latter affection. A very frequent complication of gastralgia is severe palpitation of the heart, but during the paroxysm itself the pulse, whether rapid or not, is commonly small, at first tense, and afterward soft, but not acquiring any considerable volume till the pain has ceased.
So severe is the pain, and so complete the mental and physical prostration in bad attacks of gastralgia, that the first aspect of the patient might suggest – indeed often has suggested – the occurrence of gastric or duodenal perforation; but, as soon as the paroxysm is over all the alarming appearances vanish, leaving only a certain amount of tenderness on deep pressure. In the more typical cases there are no signs of dyspepsia whatever, no fulness nor excessive redness of the tongue, no nausea, regurgitation of food, nor pyrosis. Occasionally the neuralgic affection is complicated with more or less gastric catarrh; but this is a much rarer occurrence, in my experience, than some writers would lead one to believe; and, moreover, where a certain amount of organic disorder of the stomach is observed, it is usually a mere secondary result of the neuralgia. The most severe example of gastralgia which I ever saw was entirely unaccompanied by dyspepsia; this patient absolutely attempted suicide to escape from his agonizing pains, which recurred with the greatest frequency and obstinacy, but were at last entirely removed by strychnia. In another patient whose very interesting case will be again alluded to under the head of Complications of Neuralgia, violent abdominal pneumogastric pain was succeeded by a severe attack of trigeminal neuralgia, accompanied by inflammation of the eye, which inflicted irreparable damage; here, too, the gastralgia was entirely uncomplicated by any other stomach-symptoms.
Cerebral Neuralgia.– We enter, here, on an extremely obscure and doubtful subject: Can there be pain in the central masses of the encephalon? There are undoubtedly a not inconsiderable number of cases of pain, neuralgic in type on the whole, in which the suffering cannot be referred to any recognizable superficial nerve. It seems deeply situated within the cranium. I have also quoted cases of Dr. Hillier's in which not merely was there deep-seated headache in children, but there was something like a characteristic general change observed in the brain-tissues after death, viz., a great moisture and softness of texture. Notwithstanding all this, I am not convinced, nor indeed much disposed to believe, that pain is ever felt in the structure of the brain; I rather believe that, in the cases where this seems to occur, the pain is either in the intracranial portion of the nerve trunks, or, far more probably, in the twigs of nerves that are distributed to the cerebral membranes. In that case they are, strictly speaking, only varieties of neuralgia of the fifth nerve, and might have been properly discussed under that heading; but it is more convenient to speak of them apart, since their phenomena present considerable differences from those of the external neuralgias of the head and face.
I have now seen several of these cases of intracranial neuralgias, and very perplexing and (at first sight) alarming they certainly are. The first of these cases came under my care in 1868. The patient was a single lady who had greatly over-tasked an intellect that was not, perhaps, originally very strong, by trying to do hack literature on conscientious principles; insisting, for instance, on knowing something about every subject she wrote upon. Her age was thirty-eight when she applied to me; menstruation was scanty but regular; and, on the whole, she could not be said to have passed an unhealthy life, although "nervous-headaches" and "sick-headaches" had occasionally beset her. This time the trouble seemed to be more serious. Ten days before applying to me, she had awaked in the morning with a feeling that something was very wrong in her head; there was not so much pain as a dull, brooding sort of weight, felt deeply within the cranium, and rather anteriorly. This had not lasted many hours when she was seized with a sensation of intense cold, amounting almost to rigors, and then before long was suddenly attacked with acute splitting pain in the same situation as the feeling of weight already mentioned had occupied. This pain, which came and went, or rather intensified and remitted, without ever completely ceasing, lasted about two hours, and then rather suddenly disappeared, leaving the patient with a deep "bruised and sore feeling in her brains." The pain recurred about the middle of the next day, lasting for several hours, and again leaving behind it the sore feeling. Day by day the paroxysms returned, and, on the day before her visit to me, the patient had, she told me, been driven frantic by her sufferings and had become actually delirious. Her appearance, when I first saw her, was wretched; the face haggard, both eyes sunken and surrounded with deep rings of dusky pigment, both conjunctivæ bloodshot, the whole face almost earthy in its pallor. At that hour (11 a. m.) the pain had not positively recommenced, but she was in momentary dread of its recurrence. She complained of giddiness, muscæ volitantes, and great feebleness of vision, and dreaded attempting to read, as the mere effort of fixing her eyes on anything intently caused flashes of fire before them. It was difficult at first to believe that there was not some serious organic brain-mischief; but on the whole I concluded that there was an absence of any genuine symptoms of such disease. At the same time, the pain was decidedly not referred to any cutaneous sensory nerve; and on the whole it appeared probable that the affection was intracranial. There remained the diagnosis of meningeal neuralgia, and to this I provisionally made up my mind. The opinion that the pain did not depend on any fixed organic disease was decisively justified by the results of treatment. One-sixth of a grain of morphia was injected on the occasion of the first visit, and this was repeated every day, and sometimes twice a day, for a fortnight; by this sole means, with rest, quietude, and light nourishing food, the patient was brought to comparative convalescence. The injections were then gradually discontinued, and she got quite well.
In a second case, which presented itself in the out-patient room at Westminster Hospital, a young man of markedly-nervous temperament, who had been somewhat given to drink, complained of similarly deep-seated intermittent pain, which he referred, however, to a point nearer the back of the head. He suffered, also, from vertigo, especially after unusually long paroxysms. Blisters to the nape of the neck, and a few subcutaneous injections of morphia, removed the pain and the vertigo completely.
A third example was that of a gentleman, aged thirty-four, who was sent over from the neighborhood of Sydney, Australia, to see me. Here, also, there was deep-seated intracranial neuralgic pain of the most severe kind, which greatly alarmed his local medical attendants; and it was only after a great many remedies had been tried that one medical man gave the opinion that the disease was "neuralgia of the membranes of the brain," and employed the hypodermic injection of morphia. This treatment at once gave great relief, though the pain had been so severe as to cause delirium on several occasions. In order to get thoroughly re-established, he was sent to England, and desired to consult me. As was expected, the voyage proved of the greatest service, as he hardly suffered at all while on the water. On arriving in England he was at first well, but in a week or two began to feel somewhat below par, and one morning, feeling an attack of pain coming on, he came to me. He was a tall and strongly-built man, with nothing peculiar in his appearance except a certain languor and heaviness of the eyes. He appeared to have lived somewhat freely and to have smoked decidedly to excess. His description of the attacks left no doubt of their neuralgic character, and in other respects they seemed quite analogous to the other cases mentioned above, except in one thing, that there seemed a good deal of evidence tending to show a bad local influence in the air of that part of Australia where he usually resided. Almost any change from that had always done him good, though nothing had done anything like so much as the voyage to England. On the occasion of his first visit to me I injected him with one-sixth grain acetate of morphia, thereby stopping the pain. I prescribed muriate of iron and minute doses of strychnia, which he took for some little time, but the pain never recurred during his stay in England and on the Continent. Unfortunately, as he was anxious to return to Australia, I permitted him to do so, after a stay in the Old World of only three or four months; but, very shortly indeed after his return to Sydney, his old complaint attacked him. This time, unhappily, the hypodermic morphia has proved merely palliative, and I have latterly heard very bad accounts from him; still, there has been nothing to throw doubt on the neuralgic character of the disease.
In reflecting upon the anatomy of the nervous branches to the dura mater, I have formed the opinion that there are two situations, one anterior and the other posterior, in which intracranial neuralgia may occur; the former at the giving off of Arnold's recurrent branch from the ophthalmic division, near the sella turcica, the other in the peripheral twigs of this same branch, distributed to the tentorium cerebelli.
Pharyngeal Neuralgia.– A rather common and extremely troublesome form of neuralgia is that which attacks the pharynx. It is very much more common in women than in men, and especially in hysterical persons. The pain commonly commences in a not very acute manner; it may be felt for some days, or even weeks, as a dull aching, coming and going pretty much in accordance with the patient's state of fatigue, or of reinvigoration after meals, etc. Some trivial circumstance, such as a slightly extra degree of exhaustion, or the influence of some depressing emotion, will then change the type to that of decided neuralgia, which may become extremely severe. Nothing is more annoying, and even distressing, than the suffering itself, besides which there are abnormal sensations in the throat which almost irresistibly compel the patient to believe that there are severe inflammation and ulceration, and that the throat is in danger of being closed up. Although the pain is usually one-sided, it sometimes affects both sides, and is felt also at the back of the pharynx. The act of swallowing being painful, there is the greater suspicion of inflammation or ulceration, but careful observation shows that a large bolus of food is swallowed with as little, if not less, pain than a small mouthful of solids or even liquids.
Pharyngeal neuralgia must, I think, be considered mainly an affection of the glosso-pharyngeal nerve; the evidence for this is found in the distribution of the pain. A slight degree of the neuralgia will only involve some one or two points in or behind the tonsil; but, when the pain is strongly developed, it will be found to radiate into the tongue, in one direction, and into the neck (following the course of the carotid) in another, besides spreading well into the region occupied by the pharyngeal plexus. One disagreeable reflex effect of severe pharyngeal neuralgia consists in involuntary movements of the muscles of deglutition, another is seen in the copious outpouring of thick mucus similar to that which collects in the pharynx and œsophagus when a foreign substance has become impacted.
Laryngeal neuralgia concentrates itself mainly in the twigs of the superior laryngeal branch of the pneumogastric which are distributed to the arytæno-epiglottidean folds, the epiglottis, and the chordæ vocales; more rarely a neuralgia is developed lower down, within the cavity of the larynx, apparently in one or more of the scanty twigs to the mucous membrane supplied by the recurrent laryngeal.
Pure neuralgias of the larynx, like those of the pharynx, are more common in women, and especially in weakly hysterical women, than in men. They are easily excited and greatly aggravated by movements of the parts, and thus it happens that, among men, by far the most numerous subjects of laryngeal neuralgia are found among clergymen, professional singers, and others whose occupation compels them to strenuous and fatiguing employment of the laryngeal muscles. It is rather a singular and striking fact, however, that the so-called "clergyman's sore-throat," which is characterized by most unpleasant sensations, and by a more or less complete loss of voice, is not, in the majority of cases, attended with any distinct laryngeal neuralgia. It seems that a predisposition to neuralgia is a necessary element in the latter affection.