Francis Edmund Anstie

“ Diagnosis.—The diagnosis of angina pectoris, in those severe forms with which the popular idea of the disease is chiefly connected, can hardly be a matter of much difficulty. When we see an elderly man lying in a state of deathly collapse, which has suddenly come on, with cold sweats and nearly extinguished pulse, gasping for breath, and complaining of intolerable pain in the chest and arm, and a sense of oppression more dreadful, even, than the pain, we can hardly doubt that the case is angina in its worst form. ”

“ And certainly it is infinitely more probable that paralysis or spasm of a muscular viscus should occur as a reflex consequence of neuralgia occurring in a nerve whose central nucleus was closely connected with the motor centre of the organ, than that mere paralysis of the viscus should convey a reflex impression to sensitive nerves which should express itself in the form of acute pain. It must be confessed that the matter hangs in doubt; but the evidence is, on the whole, very strong for the belief that central nervous mischief is the most important element in angina. ”

“ But the lessons which our psychologists are rapidly learning, as to the evil effects on the brain of an education that promotes self-consciousness, are sorely needed to be applied to the pathology of nervous diseases generally, and of neuralgia among the rest. Common sense and common humanity, when united with the physician's knowledge, cry out against the system under which religious parents and teachers subject the feeble and highly mobile nervous systems of the young to the tremendous strain of spiritual self-questioning upon the most momentous topics. ”

“ Indeed, it is not known that any organic change of the heart or great vessels, even of the slightest kind, is necessary to the production of angina; on the contrary, there is every reason to think that mere fatigue and depression may bring on the attacks in persons of a strongly nervous temperament. For my own part, I am inclined to believe, however that there really always is disease somewhere in the cardiac centre of the spinal cord, though that disease may consist in no more than a disposition to minute interstitial atrophy. ”

“ I would be clearly understood not to suppose for a moment, either that this sort of cause is usually at work in the production of neuralgia in the young, or that of itself it is sufficient to produce the disease; but I would say, for certain, that on children of nervous families such influences act with disastrous energy; and, moreover, that where we see signs, in a neuralgic young person, of that general form of bad health which is connected with precocious puberty, we may be nearly certain that such influences have actually been at work. ”

“ At present, it is interesting to remark on the general freedom of the busy middle period of life from first attacks of neuralgia. A person who has had neuralgia previously may, and very likely will, during this epoch, be subject to recurrence of the old affection under stress of exhaustion of any kind. But it is very rare, in my experience, for busy house-mothers or fathers of families to get first attacks of neuralgia during this period of life. It is not the way in which a still vigorous man's nervous system breaks down, if it breaks down at all. ”

“ It is with the age of puberty that self-consciousness begins to be a feature in the mind of the young, and its appearance marks the entrance of a dangerous element into the character. It is an inevitable stage in mental growth, and, if wisely dealt with, is ultimately productive, not of evil, but of good; but it is more perilous to some children than to others, and it is especially fraught with danger to those whose nervous centres are, by inheritance, weak and unstable in whole or in parts. ”

“ The question of administering remedies with the direct intention of procuring sleep, for patients suffering from spinal irritation, often becomes an important and a very difficult one. It is, for the most part, highly objectionable to commence the use of such remedies; and yet sleeplessness is a very distressing symptom with many patients, and is, of course in itself exhausting and deleterious. For as long as we possibly can, we should content ourselves with efforts to produce sleep by the timely administration of nourishment. ”

“ As regards the working of the intellect, it is easier to speak in a free and unembarrassed manner than respecting the other matters. There can be no doubt that, of intellectual work, that sort which exhausts and harasses the nervous system is the forced, the premature, and the unreal kind; and this it is which predisposes, among other nervous maladies, to neuralgia. It is more difficult to speak the truth about emotional influences generally, and especially about those which are concerned with the highest spiritual matters ”

“ The bad peripheral influence of constant fatigue of the eyes in study may so completely modify a young man's constitution as to make a wreck of him in a very few years, changing him from the state of habitual and conscious health to that of chronic neurosis of one sort or another. And, though it is doubtless on persons with congenital tendencies to nervous diseases that such a combination of bad influences produces its most serious effects, yet there unquestionably are a few persons in whom they appear to entirely generate the neurotic constitution. ”

“ In the stir and tumult which pervade the organism, and especially in the enormous diversion of its nutritive and formative energy to the evolution of the generative organs and the correlative sexual instincts, the delicate apparatus of the nervous system is apt to be overwhelmed, or left behind, in the race of development. Under these circumstances, the tendency to neuralgic affections rapidly increases. It will, however, be seen later that there is a great preponderance of particular varieties of the disease during this time. ”

“ As in hysteria, too, the tenderness is a phenomenon so greatly affected by the mind, that, if we can divert the patient's attention for a moment, he will let us touch him anywhere, without noticing it at all.
It is a marked peculiarity of hypochondriasis that it is far more common in men than in women; a relation which is precisely the opposite to that which rules in neuralgia. Hypochondriasis is also pre-eminently a disease of adult middle life; it is scarcely ever seen in youth, except as the result of excessive masturbation acting on a temperament hereditarily predisposed to insanity. ”

“ It would be a hundred times better that a boy, or even a girl, should study the frank and outspoken descriptions to be found in Shakespeare or Fielding, with all their occasional coarseness, than that they should enervate their minds with the sickly trash that is most current and most popular at the present day, in theatre and circulating library. ”

“ 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. ”

“ 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. ”

“ Yet there is really little difficulty in convincing ourselves, if we institute a thorough inquiry into the matter, that pain is certainly not a hyperæsthesia, or excess of ordinary sensory function, but something which, if not the exact opposite of this, is very nearly so.
The leading fallacy in the common view is the confusion which is perpetually being made between function and action. Now, the function of individual nerves is very nearly a constant quantity, at least, it varies only within narrow limits; while the action of the same nerves may be almost any thing. ”

“ It should be born in mind that, if we are summoned to a patient's assistance, and have no previous history to guide us, our diagnosis, to be useful, must be rapid; and it is always better to err on the side of angina than in other directions, and to employ remedies boldly in that sense, if there be any reasonable ground for believing the case to be of that nature. A more mature and careful diagnosis may be made when the patient has recovered from the severe symptoms of the paroxysm. ”

“ It must be clearly understood that the pains of which we are now to speak are not among the common consequences of chronic excess in drink. The affections of sensation which most usually occur in alcoholism take the shape either of anæsthesia, or of this combined with anomalous feelings partaking more or less of the character of formication. Chronic drinking has also a tendency, in its later stages, when the nutrition of the nervous centres has been considerably impaired by the habit, to set up true neuralgia, of a formidable type, in subjects who are hereditarily predisposed to neuroses. ”

“ But the impression produced on this same peripheral expanse of nerve-branches by prolonged exposure to cold wind may, and often does, convey to the centres sensations which are quite different and provokes reflex movements which are altogether abnormal. Pain is the product in one direction; sneezing, perhaps, in the other. It seems absurd to say that sneezing is any part of the function of those motor nerves whose action regulates the performance of expiration. And it appears to me not less absurd to say that pain is the function of the sensitive fibres of the trigeminus. ”

“ I do not know that the poisonous action of any other metallic poison than mercury has been distinctly shown to produce neuralgic pains of superficial nerves. The action of lead is well known to produce colic, a disease which will be specially dwelt on elsewhere. And undoubtedly a certain amount of aching pain sometimes attends certain stages of lead-palsy of the extensor muscles of the forearm. But I know of no facts pointing to a true saturnine neuralgia. And the chronic poisonous effects of arsenic on the nervous system seem to produce sensory paralysis, rather than pain. ”

“ The chronic rheumatism does also, occasionally, affect the sheath of the nerve in such a manner as to produce a deposit which sets up neuralgic pain, must also be admitted, although I believe the number of such cases to be preposterously over-estimated by careless observers. It has several times happened that a patient has come under my care with so-called "rheumatic affection of the nerves" of the thigh and leg, and that on examination one has found all the symptoms and clinical history of a neurosis, but not the slightest valid argument for a diagnosis of the rheumatic diathesis. ”

“ Let us now pass quite to the other extreme, and consider a class of momenta which take a decided part in producing many neuralgiæ, but which are altogether accidental and factitious, and cannot be included among the necessary hostile conditions of life. To push the contrast to the utmost, let us inquire first, what amount of influence in the production of neuralgia can be given by such a purely "functional" influence as educational misdirection of intellect and emotion? ”

“ But in hypochondriasis it is not often that we are left, for any long time, to these means of diagnosis only; the special character of the disease is that the morbid sensations shift from one place to another, in a manner that is quite unlike that of the true neuralgias. The patient who to-day complains of the most severe gastralgia, or liver-pain, will to-morrow place all his sufferings in the cardiac region, or in the rectum, or will complain of a deep fixed pain within his head; and these changes are often most rapid and frequent. ”

“ Its most striking teaching is the fact that the acutest agonies of neuralgia can be felt in a nerve, the central end of which is reduced to such a pitch of degeneration that conduction between centre and periphery must very shortly have entirely ceased had the patient lived. And hardly less important is its illustration of the fact that permanent injury to the ganglion of the posterior root of a spinal nerve impairs the vitality of the posterior root itself—a fact which has been independently made out by the physiological researches of Bernard and of Augustus Waller. ”

“ Lead-poisoning, again, only produces so highly special a form of neuralgia (if colic be neuralgia at all) that it need not detain us here. The influence of malaria is, for the most part, an utter mystery to us, but by so much as we can see it appears plain that one of the most important features in the disease is a powerful disturbance of the spinal vaso-motor centres. But the most interesting consideration that we have to deal with is the question of the supposed relations of the rheumatic and the gouty diatheses, and the syphilitic dyscrasia, to the neuralgic tendency. ”

“ It cannot, indeed, be left out of sight as a cause of disorders of the mind itself, nor are there many who would deny that such diseases as cerebral softening are, in a considerable number of cases, the premature ending to a life that has been broken down by harassing work and anxiety. But what is far less appreciated is the tendency of certain unfortunate mental surroundings and modes of mental life to produce a generally neurotic condition, which may express itself in a variety of functional disorders, among which not the least common is neuralgia. ”

“ In fact, by the time patients have become sufficiently ill with neuralgia to apply to a consulting physician, they have already, in the great majority of cases, got to reject all fatty foods, and have cut down their total nutriment to a very sufficient standard. Young ladies suffering from migraine are especially apt to mismanage themselves, to a lamentable extent, in this direction: this is natural enough, because the stomach disorder seems to them the origin of the pain, instead of being, as it is, a mere secondary consequence of the neurosis. ”

“ But, an even more serious and difficult matter than the regulation of the amount of intellectual work to be done is, the question how we are to deal with the unfolding emotional instincts of [183] the boy or girl who has reached the age of puberty. It is useless to ignore this side of the mental life; it will assert itself either for good or for evil. ”