By combining all these methods of treatment the writer has sometimes been able to cut short a severe attack of neuralgia in its early stage. The advantage of his plan is best seen in acute neuralgia of a large nerve like the sciatic, and it may be carried out as follows:—A hypodermic syringe of at least 3o mins. capacity is needed, and the dose of Morphia (say A gr.) in solution is diluted with the syringeful of water; the course of the nerve being marked out on the skin, the stopper of a bottle containing concen trated Carbolic Acid is applied to the spot about to be punctured. The needle is plunged deeply into the tissues at right angles to the surface, the aim being to puncture the sheath of the nerve and inject about 5 mins. of the solution into the nerve substance; 5 or 6 punctures are to be thus made between the trochanter and the heel along the course of the nerve in the thigh and its main branch in the leg; some of these insertions can hardly fail to strike the sheath. The action of the carbolic acid renders the puncture almost painless, whilst its caustic or vesicant action affords marked counter-irritant results afterwards. By this simple method all the advantages obtained by the narcotic are combined with acupuncture, aquapuncture, counter-irritation and parenchymatous or hypodermic injection. This plan is not suitable for the treatment of facial neuralgia except under special modifications.
If the pain returns the operation may be repeated after a few days' interval, and the sleeping hour is, for obvious reasons, the best time for the injections. By employing morphia in this way the risks of the opium habit are decidedly less than when the drug is given by the mouth or by one dose injected under the skin; should the result prove to be but temporary or palliative, the morphia should not be continued after a few trials, but other measures should be resorted to.
Unfortunately treatment must be mainly symptomatic and empirical; the drug (narcotics being excluded) which relieves smart neuralgic pain in one patient may have little or no effect in another case.
Cocaine is preferred to morphia by Gowers and others, who maintain that the drug not only relieves pain, but that it arrests the local trans mission of impulses which cause pain. Unfortunately, the danger of establishing the cocaine habit is a very real one, and the drug should only be given by the hypodermic route and never by the mouth for the relief of neuralgia.
Next in value to narcotics come the host of new analgesics—Antipyrine, Phenacetin, Aspirin, Salicylates, Caffeine, &c., which possess some power of relieving pain without acting on the cerebrum, as narcotics do. The list of these drugs continues to increase, as new ones are created from day to day in the laboratory, and the reader will find all the most important and reliable members of the group mentioned upon p. 551, in the article
on Megrim, the relief of migrainous pain being carried out on the same principles as in neuralgia.
Butyl Chloral hydrate is believed to exercise a selective analgesic action over the different branches of the fifth nerve. It often entirely fails except in very mild attacks, and it is of no use in the grave so-called epileptiform type of tic douloureux. Nevertheless, it is a useful and safe routine at the commencement of supra-orbital neuralgia, and in mild cases of involvement of the twigs supplying the alveoli in the lower jaw; the drug, moreover, possesses some hypnotic power. It may be combined with the following remedy: Gelsemium has been vaunted as a specific in neuralgia of the dental branches of the fifth nerve; like almost every other antincuralgic remedy, it sometimes acts most satisfactorily, whilst at other times it fails to produce the slightest result. A good combination will be found in a pill containing gelsemium and butyl chloral, to which Cannabis Indica is added : Ext. Gelscenii Alcoholici gr. ss.
Butyl Chloral Hydr. gr. iv.
Ext. Cannabis Indicce gr. Misce.
Ft. pit. Mitte xii. Sternal i. tertiis horis.
Gelsemium may be pushed in maxillary neuralgia till ptosis becomes evident and some giddiness is experienced; the writer has witnessed its absolute failure in a case where the patient had taken an overdose which caused alarming symptoms of poisoning—staggering gait, double vision, &c. The drug is worthless in all forms of visceral neuralgia. The Indian Hemp in the above recipe appears to exert a very desirable analgesic action in those cases where the pain is slight and almost continuous, but as in the use of opiates the danger of a drug habit must be always kept in sight.
Atropine or Belladonna internally has been often found successful, especially when combined with other remedies. Thus in visceral neural gias when prescribed with Codeine or Heroin ( gr.) it is a valuable routine. Trousseau treated facial and other neuralgias by administering gr. Ext. Belladonna every hour till giddiness was produced, after which the intervals between the doses were gradually lessened. Atropine is a valuable addition to morphine whenever this narcotic is urgently demanded for the relief of neuralgic pain by the hypodermic method. and r min. of the B.P. solution may be added to the morphia when the deep parenchy matous method already described has been decided upon; a hypodermic dose of Hyoscine Hydrobromide gr.) relieves pain and sends the patient to sleep.