NERVES, Gunshot Injuries of.
See under Neuromata, where the operations of nerve transplantation, nerve anastomosis or nerve transference are enumerated.
NETTLE-RASH—see under Erythema. NEURALGIA.
Probably no such condition as a purely functional neuralgia can exist, and the tendency to regard the majority of cases formerly labelled as neuralgia in the light of a neuritis is a growing one; nevertheless, a group of neuralgias remain which present symptoms different from those typical of neuritis.
In neuralgia of the fifth nerve it has been long demonstrated that a point of irritation situated anywhere in the sensory path without revealing its location by pain or even tenderness may excite severe paroxysms of pain along distant branches of the nerve. Thus a diseased tooth in the upper jaw which does not ache may cause severe reflected pain in the lower maxillary region, in the supra-orbital branches, the eye, nose, temple or lips. Hence in every case of neuralgic pain the first duty of the physician is to make a diligent search for any point of irritation in the course of the numerous branches of the affected nerve, and upon the discovery of such a focus, measures should be employed for its removal, after which the neuralgia may be expected to disappear.
Each tooth is carefully examined, the condition of the gums investigated, and the ear, the frontal and nasal sinuses explored; the sight must be tested for errors of refraction and the globe submitted to examination in order to exclude glaucoma, iritis, foreign bodies, &c.
In neuralgic pain in other regions the presence of such foci must be sought for, otherwise severe pain in the testicle may be treated as a neuralgia of the nerves supplying this organ when the mischief may be due to a stone in the ureter; or a case of liver disease, aortic or heart affection be treated as one of brachial neuralgia. The detection of tender points may be taken as strong evidence of the functional nature of the pain, and the presence of anesthesia and muscular wasting are suggestive of inflammatory condition of the nerve.
After the elimination of every possible source of local irritation a con siderable group of cases remain, to which the title of idiopathic neuralgia may be applied. The first step in the management of such cases should
be an investigation into the possible constitutional causes. Anzemia is the most important of these, and especially that form of secondary amemia which arises from exhausting diseases like diabetes, and continuous suppurations, from prolonged lactation, frequently recurring pregnancies, severe mental strain and long-continued anxiety and emotional dis turbances. There is a clearly defined group of toxic causes as the poisons of lead, alcohol, arsenic, copper and mercury, and the organic toxins produced in influenza, malaria, gout, rheumatism, Bright's disease and the eruptive fevers. The cases in which trauma and exposure to cold figure as causal agents are probably examples of neuritis.
Any such causes having been discovered, the indications for treatment become clear, and the causal elements, together with every other departure from the healthy standard, should be met by suitable eliminatory treat ment. Improved hygiene, open-air life, overfeeding by a diet rich in fats and easily digested proteids, should he instituted, the digestive functions being aided by peptonised foods and gastric tonics when needed, or by massage and Weir Mitchell treatment in eases where anorexia and wasting are present. The hours of rest should be prolonged and those of mental work or close application shortened. The physician should see that sleep be encouraged by natural means, and when insomnia exists simple hypnotics should be administered, narcotics being avoided when possible.
Such rational treatment in no way interferes with the various methods by which pain is to be relieved. It cannot be too strongly stated that though the temporary relief of suffering should play an important part in the treatment of the various neuralgic conditions, it should not be regarded as the chief or sole principle upon which the physician should approach the management of a case of severe neuralgia, though it is true that he may find in some cases no other indication for treatment..