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A TREATISE 
 
 NEURALGIA 
 
 
 E. P. HURB, M. D., 
 
 Member of the Massachusetts Medical Society; Member of the Climato- 
 
 logical Society; Member of the Society de Medecine Pratique 
 
 (Paris, France). One of the physicians to the Anna 
 
 Jaques Hospital, Newburyport. Mass. 
 
 ■ 
 
 It' 
 
 GEORGE S. DAVIS, 
 
 DETROIT, MICH. 
 
Ik 
 
 H1 G 
 
 Copyrighted by 
 
 GEORGE S. DAYIS. 
 
 1890. 
 
DEDICATED 
 TO DUJARDIN BEAUMETZ, 
 
 WHO HAS DONE SO MUCH TO ADVANCE THERAPEUTICS. 
 BY HIS FRIEND, 
 
 THE WRITER. 
 
TABLE OF CONTENTS. 
 
 CHAPTER I. 
 
 Page. 
 
 General Considerations on Neuralgia 1-18 
 
 CHAPTER II. 
 Classification of the Neuralgias 19-23 
 
 CPAPTER III. 
 The Causes of Neuralgia 24-30 
 
 CHAPTER IV. 
 Particular Forms of Neuralgia 31-56 
 
 CHAPTER V. 
 Visceral Neuralgias 57-7Q 
 
 CHAPTER VI. 
 
 Reflex and Toxic Neuralgias; Neuralgias Due to a Gen- 
 eral Morbid Condition 71-82 
 
 CHAPTER VII. 
 
 Diagnosis 83-92 
 
 CHAPTER VIII. 
 
 Prognosis 93 
 
 CHAPTER IX. 
 
 The Treatment of Neuralgia 94-106 
 
 CHAPTER X. 
 
 Appendix 107-143 
 
CHAPTER I. 
 
 GENERAL CONSIDERATIONS ON NEURALGIA. 
 
 Pain is a fact of consciousness, having for its 
 invariable antecedent a disturbance of a sensory nerve 
 or nerve-centre. Its seat is that part of the cerebral 
 cortex known as the sensorium; the cause is generally 
 an abnormal modification of some part of a nerve of 
 sensation. The function of sensory nerves being to 
 convey impressions to the sensorium,* when such im- 
 pressions are abnormal in kind or in intensity, the 
 phenomenon of pain may arise. One of the most com- 
 mon excitants of pain is inflammation, which causes 
 compression of the nerves of a region and disturb- 
 ance of their nutrition and function. Another cause 
 is anaemia, or want of blood, for no pain is more in- 
 tense than that which is experienced in a limb whose 
 supply of blood is cut off by an arterial embolus. 
 Tumors, foreign bodies as splinters, wounds or 
 compression of nerves, also bring about those molecular 
 changes in sensory conductors whose conscious expres- 
 sion is pain; and the same may be said of an inflamma- 
 tion confined to the sheath of the nerve itself. In fact, 
 
 * By the term sensorium, I understood with Robin, that 
 portion of the encephalon which perceives, as distinguished 
 from that which thinks, and from that which is endowed with 
 motricity. 
 
2 
 
 pain may be looked upon as a cry of danger, as an 
 index of a destructive process somewhere going on in 
 the organism. 
 
 Many kinds of pain have known pathological con- 
 ditions for their substratum; the pain is the result of 
 a phlegmon, a tumor, etc. This is not the case with 
 the kind of pain of which we are here to treat, for 
 neuralgia belongs to a class of nervous diseases 
 known as neuroses — i. e., which are functional or dyna- 
 mic, not dependent on any gross anatomical lesion. 
 
 Neuralgia is a neurosis whose essential symptom 
 consists in a lancinating pain, paroxysmal in character, 
 described as boring, burning, stabbing, localized in 
 particular nerve-trunks or their terminal branches; 
 apyretic, without redness, without tension or apparent 
 swelling; generally accompanied by secondary phe- 
 nomena of a motor, vaso-motor, secretory, or trophic 
 nature.* 
 
 Spring thinks that in order that the word neural- 
 gia should be applicable to any particular case, there 
 should exist two conditions: i, the pain should be 
 paroxysmal in character; 2, there should be no peri- 
 pheral or central lesions present. f 
 
 Gowers would restrict the name neuralgia to the 
 idiopathic class, and would exclude all forms (among 
 
 * The throbs of pain sometimes coincide with the arterial 
 pulsations (Gowers.) 
 
 f Dujardin-Beaumetz, " Clinical Therapeutics," American 
 ed., p. 51. 
 
— 3 — 
 which he thinks sciatica generally belongs) which are 
 the result of neuritis. 
 
 General Characteristics. — A general feature of 
 neuralgic cases is the existence of anaemia and debil- 
 ity. Anstie insists on this condition of anaemia, or 
 vital depression, as an invariable factor in neuralgia. 
 The patient has been fatigued from overwork, physi- 
 cal or mental, or has gone through an exhausting ill- 
 ness. Prolonged suppurations, haemorrhages, exces- 
 sive venery, in fact debilitating influences of all kinds, 
 may bring about the neuralgic diathesis. 
 
 One of the most severe and obstinate cases of 
 gastralgia that I ever witnessed was in a young woman 
 who, while nursing a robust infant, carried on the 
 work of a large family while living on a meagre and 
 quite insufficient diet. 
 
 Another characteristic is that exhaustion, from 
 any cause, brings on an attack of pain. The victim 
 of hemicrania, for instance, will have an attack after 
 the fatigue of too long a walk, or a night's watching. 
 
 Another common feature of the neuralgias is the 
 intermittence of the pain. The symptoms are par- 
 oxysmal in character: this is owing to the law of 
 nervous exhaustion, for nervous actions are not con- 
 tinuous, but interrupted by periods of repose, due to 
 exhaustion of the excitability, even when the excite- 
 ment is persistent.* 
 
 *Jaccoud, Pathologie Interne. Vol. i, p. 485. 
 
In consequence of a fancied resemblance between 
 the phenomena of neuralgic paroxysms and those of 
 genuine intermittent, Van Swieten applies the name 
 oifebris topica to the former, and declares neuralgia 
 to be only another manifestation of ague; with this 
 view other ancient authorities coincide.* It is not an 
 uncommon thing for a paroxysm of neuralgic pain to 
 pass off after an hour or two of severity, leaving a 
 state of perfect quiescence; oftener however, it must 
 be confessed, a deep, contusive, fixed or diffuse pain 
 remains till the next attack, which may come on in a 
 few hours, or not till the sleep of the night is over. 
 The resemblance to an access of intermittent fever, it 
 must be confessed, is superficial and slight, but the 
 paroxysmal character is none the less a fact. 
 
 Another event common to all the neuralgias is 
 the occurrence of certain tender spots ( points doul- 
 oureaux) which are always found in neuralgias of a 
 certain persistence and duration. These are called 
 Valleix's painful points. These painful spots are gen- 
 erally situated at the point where a nerve trunk 
 emerges from a bony foramen, or pierces the fascia of 
 a muscle to be distributed to the skin. These spots 
 are sometimes the centres of radiation of spontaneous 
 pain; pressure upon them provokes very severe pain 
 which may intensify the neuralgic attack. 
 
 Lastly, another peculiarity of neuralgias is their 
 
 * Rowland On Neuralgia. 1837. 
 
generally unilateral character. This is so much em- 
 phasized by Anstie, that it forms a part of his defini- 
 tion.* 
 
 Clinical Description. — As a type of our descrip- 
 tion, we will take a case of facial neuralgia, known 
 also as neuralgia of the fifth, or trigeminus. The pa- 
 tient may have been well up to the time of the attack; 
 or, as is oftener the case, may have been depressed 
 from cold, insomnia, overwork. Suddenly, or after 
 certain premonitions, as nausea, chilliness, a sense of 
 weight about the head, and a vague feeling of gen- 
 eral discomfort — a circumscribed pain makes its ap- 
 pearance in some point of the face, or in one of its 
 cavities. This pain, at first dull and contusive, soon 
 becomes more intense, darts up and down one of the 
 main trunks, and affects simultaneously numerous 
 branches. The attack may consist of a continuous 
 ache, or of a succession of violent twinges, with com- 
 parative ease in the intervals. In the height of the 
 paroxysm, the pain seems to shoot into every nerve 
 twig of the affected side, with predominance of aching 
 in one particular spot where it first started. A pecu- 
 liarity of the pain is that it manifests itself in a series 
 of shocks more or less near together, though each 
 series is separated by an appreciable interval; the 
 sum of these series constitutes the attack. The 
 
 * Anstie, Neuralgia and the Diseases that Resemble It, 
 New York, D. Appleton & Co., 1883. 
 
duration of the paroxysm is from a quarter of an 
 hour to an hour and a half; in one inveterate case, I 
 have known the paroxysms to last all day, with only 
 brief intervals between. The pain is increased and 
 even awakened by a touch of the hand, while it is 
 often the case that gentle rubbing, or even firm press- 
 ure over the affected part, produces alleviation.* 
 
 With the pain, there is frequently spasmodic 
 twitching of the neighboring muscles, and sometimes 
 rigid spasm. The existence of tetany in true neu- 
 ralgia is denied by Vanlair, but it has been noted by 
 other writers, and the writer saw a remarkable instance 
 of contracture of the elevator muscles of the shoulder 
 in a severe case of cervico-brachial neuralgia, f 
 
 Secondary phenomena of a vaso-motor kind, as 
 flushing of the affected region, copious lachrymation 
 from the neighboring eye, or running from the nostril 
 on that side, are frequent accompaniments of the 
 attack. 
 
 Pressure over Valleix's points is generally ex- 
 ceedingly painful; these, in trigeminal neuralgia, are :g| 
 at the supra-orbital and infra-orbital and mental 
 foramina. Good observers, however, have failed to 
 recognize these painful points in facial neuralgia. 
 
 * A short pressure is followed by exaggeration of the pain, 
 a prolonged pressure, by diminution (Romberg). The con- 
 tinuous pressure interrupts conductibility. 
 
 f Medical Record, 1 876, page 744. 
 
The tactile sensibility of the skin is almost al- 
 ways diminished after a time in the neighborhood of 
 the affected nerve. (Buzzard.) 
 
 The pain is very apt to radiate from the affected 
 region to the nerves (sensory and motor) of neighbor- 
 ing regions. Thus, in trigeminal neuralgia, we may 
 have pains in the posterior cervical region and the 
 occiput, scapuloclavicular, intercostal, and mammary 
 regions. The motor irradiations consist in the clonic 
 contractions (more rarely tonic) already alluded to; 
 the muscles innervated by the facial nerve are con- 
 vulsed. When facial neuralgia assumes this violent 
 form, it is called tic douleureux. The convulsive shocks 
 sometimes extend to the symmetrical muscles of the 
 other side of the face, and even to the muscles of the 
 trunk and limbs. 
 
 The attack of pain may pass off gradually, a 
 dull aching and a soreness remaining for some time, 
 or it may end suddenly, the patient passing, as by 
 magic, from intense suffering to complete repose. 
 The latter mode of termination is especially likely to 
 follow a judicious anti-neuralgia treatment. 
 
 THE PATHOGENY OF NEURALGIA. 
 
 We know very little about the material alterations 
 which attend neuralgia. We distinguish three phases 
 in the operation of sensory nerves: 
 
 i. When the conduction is normal. Here the 
 nerve conducts to the cerebrum impressions natural 
 
— 8 - 
 
 in quantity and quality; the resulting sensations are 
 pleasurable or indifferent. Such normal conduction 
 is a necessary condition of that correspondence be- 
 tween the organism and its environment which enables 
 the former to adjust itself to changes outside of itself. 
 A stimulus (heat, cold, a touch, some chemical or 
 mechanical irritant, etc.), produces a certain effect of 
 a chemical, molecular kind, on the terminal filaments 
 or trunk of a sensory nerve — this molecular change is 
 propagated as a wave of motion to the cord and sen- 
 sorium, where it produces the appropriate sensori- 
 motor responses; there is a definite ratio between the 
 stimulus and the effects engendered. 
 
 2. When the excitability is exaggerated; this 
 state is called hyperesthesia (excessive sensibility). 
 The functional activity of the nerve is exalted 
 from intensity of the excitation. When this hyper- 
 sensibility reaches a certain degree it becomes pain, 
 but this lasts no longer, or but little longer, than the 
 excitation which has given rise to it. Instances of 
 this functional hyperesthesia are seen in all inflamma- 
 tions attended with pain. 
 
 3. When the conduction is abnormal; the 
 resulting sensations are the consequence of a morbid 
 irritability of the nerves and nerve centres. This form 
 has been called by Jaccoud "spontaneous hyperesthe- 
 sia," and characterizes all the neuralgias, "A morbid 
 hyperesthesia raised to the potency of spontaneous 
 
— 9 — 
 pain constitutes neuralgia." *The word spontaneous, as 
 here used, " does not imply the absence of any cause 
 capable of accounting for the anomalous state of the 
 nerve; it indicates simply that this anomalous state is 
 not linked to the exercise of the function of sensibiK 
 ity, as is the case with a pain occurring in connection 
 with the inflammation of a part." 
 
 It is difficult to find illustrations which can 
 make plain the difference between these several 
 modes of conductibility, and the consequent state of 
 consciousness. 
 
 If we place a number of marbles in a row, an 
 impulse at the proximal end of the line will be trans- 
 mitted to the distal end with a quality and intensity 
 corresponding to the force communicated to the first 
 marble of the series. We may suppose the molecules 
 of a sensory nerve to be so arranged that an agitation 
 at the peripheral end is similarly transmitted. Im- 
 pacts beyond a certain intensity might produce at the 
 central end a shock which would so disturb the sen- 
 sorial centers as to give rise to the phenomenon of 
 pain; and yet there would be a definite correspond- 
 ence between these central molecular disturbances 
 and the amounts of peripheral irritations. If we could 
 imagine that each marble of that row was composed 
 of something akin to dynamite; that there were irreg- 
 ular, fitful explosions all along the line from the most 
 
 * Jaccoud, loc. cit. 
 
IO — 
 
 trifling causes, and that the quantity and intensity of 
 the disturbance at the distal end bore no propor- 
 tion to the force which started the disturbance, we 
 might have, perhaps, a faint notion of the condition 
 of the perturbed sensory nerves in a case of neuralgia. 
 There certainly is no objection to the hypothesis — 
 which alone explains the facts — that the protoplasmic 
 molecules of certain portions of the sensory apparatus 
 in neuralgic patients are in a state of peculiarly un- 
 stable equilibrium, at the least provocation falling to 
 a lower plane and liberating force, which is propagated 
 as a motor- wave to the central end; that such nerves 
 are by this very instability and explosiveness ill-fitted 
 for their ordinary functions of conductors of sensory 
 impressions, while always predisposed to be the seats 
 of violent attacks of spontaneous pain. 
 
 Writers have objected to the word hyperesthesia 
 as used in connection with the pain of neuralgia, and 
 Vanlair has substituted the word hyperalgesia. If the 
 former term may be supposed to mean exalted function, 
 it is manifestly inappropriate; if exalted irritability, it is 
 perfectly proper. It does not require a wide familiarity 
 with various kinds of pain to convince one that where 
 there is pain, there is increased excitability of a cer- 
 tain nerve or nerves; nor is it difficult, from personal 
 experience, to recall instances where this hyperesthe- 
 sia, by the very fact of intensification, has run into 
 pain, as in the sensory hyperesthesia attending an 
 
— II — 
 
 ophthalmia.* The pains from palpable organic causes 
 imperceptibly shade into those properly regarded as 
 neuralgic, and there is no absolute line of demarca- 
 tion at the origin. All kinds of pain have for their 
 direct antecedent, excessive molecular transformation, 
 and all are markedly influenced by anaesthetics, by 
 quiet, absence or removal of stimuli; in fact, some 
 pains of an undoubted neuralgic character get well 
 as soon as all periphereal excitations are removed. 
 
 * Gowers, in his treatise on neuralgia, lays emphasis on 
 the argument by which definite nerve paths for pain, and con- 
 sequently definite nerve centres for pain in the cerebrum are 
 affirmed. Thus, tactile impressions pass up to the brain in the 
 posterior columns, painful impressions and impressions of heat 
 in the gray substance, as shown by experiments on animals 
 and by clinical observations. In some instances (as cases of 
 hysteria) there is conservation of the sense of touch and want 
 of appreciation of pain. Chloroform abolishes pain while 
 often in the anaesthesia of chloroform sensibility to touch re- 
 mains. Then, again, there is the electric sense and the sense 
 of tickling, which are modalities of the sense of touch, and 
 which under some circumstances are abolished, while other 
 forms of sensibility persist. Brown- Sequard has done much 
 toward the demonstration if not mystification of this subject; 
 among those who insist on definite specialization of nerve fibres 
 and centres for the various modalities of sensation, we may 
 mention Herzen, Magnus Blix, Donaldson, and Goldscheider. 
 
 It cannot, however, be said that there is yet anything 
 like agreement among physiologists respecting this vexed ques- 
 tion, and we find Vulpian maintaining to the last as the result of 
 his experimentation the doctrine of " indifferent conductibility." 
 
 That pain is not something special, underived from and 
 
12 
 
 The causes of neuralgic hyperesthesia may be 
 arranged in three orders*: 
 
 i. Intrinsic and primary modifications of the 
 excitability of the nerve itself in some part of its tract 
 from the gray nucleus of its origin to its terminal ex- 
 pansions. 
 
 2. Extrinsic lesions, which act directly, or indi- 
 rectly by reflex action. 
 
 3. Constitutional states which modify the ner- 
 vous excitability, generally by the intermediation of 
 an alteration of the blood. 
 
 The first group contains the primary, or essential 
 neuralgias; the other two groups, the secondary, 
 called sympathetic or symptomatic neuralgias. 
 
 An example of primary idiopathic neuralgia is 
 seen in face-ache (prosopalgia) from cold. Examples 
 of neuralgia due to extrinsic lesions acting directly, 
 are seen in attacks of prosopalgia starting in dental 
 
 separate from ordinary sensibility, is seen in the fact that there 
 is no particular exciting agent productive of pain; the exagger- 
 ation of any kind of special sensibility may produce it; — too 
 strong a light by affecting injuriously the retina, sounds too in- 
 tense by violent agitation of the auditory nerve, thermic excita- 
 tions carried to the extreme, intense cold, sufficient to produce 
 disorganization of the tissues (Mathias Duval). Duval's defi- 
 nition of pain is a fairly good one: " Pain is constituted by a 
 modality in the functionment of the centres, due to the fact 
 that impressioning agents act in a violent, exaggerated manner, 
 and inflict a perturbation on the organs of sensibility." 
 * Vide Jaccoud, loc, cit. article, Nevralgie. 
 
— 13 — 
 caries, or a tumor involving a branch of the trige- 
 minus; such lesions have been known to awaken neu- 
 ralgic paroxysms indistinguishable from those of 
 idiopathic prosopalgia. Illustrations of neuralgia 
 from reflex causes are seen in trigeminal, cervico- 
 brachial, or intercostal neuralgias, originating in ovar- 
 itis, or some other affection of a remote organ. 
 
 Examples under the third head are seen in 
 neuralgias due to lead poisoning, mercurial poi- 
 soning, syphilis, or malaria. The neuralgias accom- 
 panying anaemia and chlorosis are also generally 
 classed under this head, being due to blood deprave- 
 ment. 
 
 Is it possible, from the knowledge which physiol- 
 ogy gives us of the constitution of nerves, to come 
 any nearer to an understanding of the phenomena 
 which take place in neuralgia? 
 
 The conductibility of nerves is a property inher- 
 ent in the axis cylinder, which is the central core of 
 the nerve, and is composed of protoplasm. The ulti- 
 mate peripheral termination of sensory nerves is the 
 naked cylinder. On these protoplasmic filaments, 
 which in many parts of the body terminate in sundry 
 appliances (Paccinian corpuscles) which are " multi- 
 pliers of disturbance," and have the function of con- 
 centrating on the nerve ends the action of external 
 agents, come a multitude of impressions from the 
 outer world, from the tissues in which these nerves 
 ramify, and from the circulating blood. What is the 
 
— 14 — 
 
 kind of change which is produced when an impression, 
 as of contact, of heat, or of cold, is made on these 
 sensory filaments? The only tenable supposition is, 
 that a wave of molecular disturbance — akin to tha 
 modification in a telegraph wire when a message is 
 sent — is instantly propagated the whole length of the 
 nerve to its central nucleus. In the normal state a 
 nerve apparatus which is the seat of such changes, 
 not inaptly called "isomeric transformations," speed- 
 ily reintegrates itself from the circulating blood, and 
 the disturbance does not exceed the healthy mean; 
 there is no pain. How is it, when from natural or 
 acquired instability of the nerves, there is too much 
 molecular transformation ? 
 
 Herbert Spencer remarks that " the (peripheral) 
 afferent nerves of individuals who, though otherwise 
 healthy, have lax tissues, are often unduly impressi- 
 ble." Other causes besides " lax tissues " may pro- 
 duce this excess of impressibility. It may accompany 
 vaso-motor weakness and congestion, for local excess 
 of the blood is attended with local exaltation of sen- 
 sibility. We have to note, also, the seemingly anoma- 
 lous fact that local deficiency of blood, as in anaemia, 
 renders the nerves abnormally impressible. Ordinary 
 excitants are capable of producing an extraordinary 
 amount of molecular change. Cold, which is one of 
 the normal excitants, may, by its prolongation or in- 
 tensity, bring about that excessive transformation 
 
— i5 — 
 which finds expression in a neuralgic paroxysm.* A 
 mental shock, a physical injury, even a decayed tooth, 
 may start a disturbance in certain nerve branches 
 which, not being repressed by the higher nervous en- 
 ergies — co-ordination being weakened or broken — soon 
 amounts to a riot in the organism; the central sensory 
 centres are fatigued, overcome, charged with the pro- 
 ducts of disintegration, and brought to that state of 
 molecular disorder which constitutes algesia } \ and 
 whose conscious expression is pain. 
 
 * The modus operandi of cold may be thus explained. "It 
 exerts a depressing influence on the nervous centres in general. 
 The superficial layers of the blood are cooled; this occurs the 
 more easily when the stimulus of chilly air is not sufficiently 
 sharp and sudden to cause a firm contraction of the cutaneous 
 vessels, while the moisture rapidly absorbs the heat of the 
 blood. From this result indirectly various disorders of nut- 
 rition of the deeper-lying tissues or distant organs, and among 
 these, congestion and neuritis of the sensory nerves. 1 ' — (Put- 
 nam:}:). 
 
 X Pepper's Syst. of Med., vol. v., p. 1219. 
 
 f A term coined by Yanlair to denote the state of the 
 central nerve cells whose manifestation is pain. According to 
 this writer, there are special groups of cells — not cells of special 
 sensation or general sensibility, — whose function is algesia ; they 
 are set apart for pain and nothing else. It must be confessed 
 that Vanlair gives weighty arguments in support of this view. 
 And yet I cannot believe that there are nerve centres whose 
 sole function is the elaboration of painful sensations. In the 
 healthy, normal state, these cells would have no office, and 
 might be expected to atrophy. More reasonable is the doctrine 
 
— i6 — 
 
 But it will not do to lose sight of the fact that 
 neuralgia may begin centrally as well as peripherally, 
 in a lowered state of nutrition, and in resulting dyn- 
 amic perturbation of the central gray nucleus itself. 
 The pain would be, as it were, projected on the nerves 
 whose nucleus is diseased. Such neuralgias are ex- 
 ceptions. 
 
 The above conception — instability of the ultimate 
 nerve elements, broken coordination, brings neuralgia 
 into harmony with the other neuroses, epilepsy, hys- 
 teria, chorea, etc. 
 
 The intermittency of pain is a consequence of 
 the intermittent character of nerve action. " If," says 
 Herbert Spencer, " a nervous disturbance travels as a 
 wave of molecular change; if this wave is such that 
 the molecules of nerve substance fall from one of their 
 
 that pain is only a modification of common sensibility and is a 
 property of protoplasm under certain conditions of disturbance. 
 Pain is the suffering of the living element wherever that element 
 exists. And yet there must be superadded a factor without 
 which our conception of pain is incomplete; that factor is con- 
 sciousness. 
 
 It is not known just where consciousness is located — 
 probably its zone occupies the entire cortex cerebri; but just 
 there where the nerves of common sensibility terminate in the 
 conscious zone, is the seat of pain. 
 
 We do not know enough about the material correlatives 
 of conscious states in general to warrant us in affirming that 
 pain is not a property of cortical cells whose ordinary function, 
 under normal conditions of nutrition and stimulation, is the 
 elaboration of sensations, pleasurable and indifferent, 
 
— 17 — 
 
 isomeric states to the other; then, having fallen, in 
 passing on and increasing the shock, they remain in- 
 capable of doing anything more until they have re- 
 sumed their previous isomeric state." 
 
 But how may we account for the peculiar charac- 
 ter of neuralgic pains ? The pain of a neuralgic par- 
 oxysm is something different from that of abscess in an 
 otherwise healthy individual, or the pain of pleurisy. 
 The pain of neuralgia may be decomposed into a per- 
 manent pain, and, at certain moments, aggravations of 
 this pain, of the nature of spontaneous recrudescences. 
 Moreover, the neuralgic suffering is attended with 
 painful irradiations into neighboring nerves of the 
 same branch, and subsequently into other nerve trunks 
 and their branches. 
 
 The explanation must be sought in the constitu- 
 tional state of the subject whose neuro-mechanism is 
 in the peculiar condition of instability and impressi- 
 bility before alluded to, — responding to irritants in a 
 fitful, disorderly, and excessive manner; then, for a 
 brief time becoming exhausted till sufficient material 
 has been assimilated for another series of discharges. 
 The phenomenon of diffusion and irradiation is ac- 
 counted for by the intensity and quantity of the mole- 
 cular motion liberated — waves from one set of nerves 
 being reflected upon other sets of nerves. According 
 to this view, the phenomenon is one of peripheral trans- 
 fer—of simple overflow. Erb, however, has another 
 explanation. In these cases of irradiation, we have to 
 do with a transfer of the excitation from the central 
 
— 18 — 
 
 cells to other cells also central, but corresponding to 
 other nerve branches, and the sensation is referred to 
 the periphery of the latter in virtue of the law of eccen- 
 tricity. But it would seem that this explanation, as 
 well as that before given of peripheral transfer, is not 
 so applicable to painful irradiations as to simple diffus- 
 ion of pain. Perhaps the explanation given by Van- 
 lair may be deemed the most satisfactory. Every 
 nerve of sensation exchanges recurrent filaments with 
 the neighboring branches. In an algesic condition, 
 the recurrent filaments may be spared, if the excita- 
 tion does not exceed a certain degree of intensity. If, 
 however, the excitation becomes too vehement, the 
 cells of the recurrent system of nerves will take on 
 in their turn the algesic state, to become quiet again 
 when the hyper-excitation shall have ceased. 
 
 A similar use is made of these recurrent filaments 
 in explaining the points douloureaux. These filaments 
 lose themselves suddenly in the tissues surrounding 
 the nerves in the vicinity of a foramen of emergence, 
 subcutaneous tissue, periosteum, neurilemma. If the 
 recurrent filaments become the seat of a neuralgic 
 process, the least pressure exercised on the tissues in 
 question, or even the normal tension of the parenchy- 
 mata or of the blood, will always affect, in an algesic 
 sense, a part of the fibres which form this sort of ter- 
 minal tuft. The impression will be transmitted to the 
 central cells, and these, by virtue of the law of eccen- 
 tricity, will refer the painful sensation to the periphery, 
 to the very point irritated. 
 
CHAPTER II. 
 
 CLASSIFICATION OF THE NEURALGIAS.* 
 
 The first general division comprehends two great 
 classes; idiopathic and symptomatic neuralgia. 
 
 Idiopathic or essential neuralgia develops spon- 
 taneously, or under the influence of an excitating 
 cause, but independently of any general morbid state, 
 actual or pre-existent or known organic cause. 
 
 Symptomatic neuralgia is dependent on the ex- 
 istence of a known organic cause, or general morbid 
 state. 
 
 Idiopathic neuralgias, from the point of view of 
 their cause, are not susceptible of any division. 
 Symptomatic neuralgias naturally fall under two cate- 
 gories; in the first are placed neuralgias due to the 
 general state (holopathic neuralgias); in the second, 
 those which depend on a localized morbid state. 
 
 The general morbid state may be: i, inherent in 
 the organism (inherited or acquired) or 2, the result 
 of some poison introduced into the economy. 
 
 As instances of neuralgias dependent on a gen- 
 eral morbid state apart from ordinary chemical poi- 
 sons, we have gouty, hysterical, syphilitic, diphther- 
 
 * I have closely followed Vanlair's classification in this 
 chapter. Many of these divisions are destined to be aban- 
 doned as wider knowledge is gained of the organic causes of 
 pain. 
 
itic, chlorotic, diabetic neuralgias, those which follow 
 fevers and other acute diseases, and such as super- 
 vene in consequence of the suppression of an habitual 
 discharge. 
 
 As examples of neuralgia caused by a poison, we 
 have lead (or painters') colic, alcoholic neuralgia, 
 neuralgia from abuse of tobacco, or from mercury. 
 
 The localized morbid state may be more or less 
 distant from the seat of pain. Sometimes the dis- 
 tance is considerable; here the neuralgia is called 
 sympathetic, or reflex. Lesions directly affecting the 
 nerve itself, or the tissue surrounding it, do not give 
 rise to true neuralgia, but to simple neuralgiform 
 pains, ox pseudo-neuralgia. 
 
 From the point of view of their seat, whether 
 they be idiopathic or symptomatic, neuralgias are of 
 two kinds: i, neuralgias of the cerebro-spinal system; 
 2, neuralgias of the ganglionic system. 
 
 The pain may occupy the nerve trunks or their 
 peripheral extremities (muscles and teguments) or the 
 nerve centres. 
 
 Hence "we might make another division with 
 three clases, ramicular neuralgias, or common neural- 
 gias, muscular and tegumentary neuralgias, and cen- 
 tral neuralgias. The tegumentary neuralgias are 
 cutaneous or mucous, and the central neuralgias 
 affect the cerebro-spinal axis, or the ganglia of the 
 sympathetic. The visceral neuralgias belong to the 
 latter. 
 
21 
 
 TABLEAU OF THE NEURALGIAS (FROM VANLAIR.) 
 
 A. Ramicu- 
 
 i. N. Tri- 
 facial. 
 (Proso- 
 palgia.) 
 
 fN. 
 Ophthalmic j 
 Branch. ■{ 
 
 I 
 
 Supra-orbital. 
 Frontal-palpebro- 
 nasal . 
 
 Bulbar or Ciliary, 
 — dural. 
 
 lar nerves, 
 
 or the 
 neuralgias 
 properly so- 
 called. 
 
 
 Sup. max- I N. 
 Branch. < 
 
 Inferior fN. 
 Maxillary | 
 Branch. J 
 
 1 
 
 Infra-orbital . 
 Superior-dental. 
 Naso-palatine . 
 
 Anterior auricular. 
 
 Temporal. 
 
 Buccal. 
 
 Lingual. 
 
 Inferior dental. 
 
 Mental. 
 
 
 a. Facial nerve properly so 
 
 -called. The seventh 
 
 
 pair. 
 
 
 
 3. Nerves of the Cer- fN. 
 vical Plexus. 1 
 
 Occipital. 
 Mastoid . 
 
 Anterior cervical. 
 Supra-clavicular. 
 
 - 
 
 4. Nerves of Brachial f N. 
 
 Plexus 
 
 1 
 
 1 
 I 
 
 5. Diaphragmitic 
 
 nerves (?) 
 
 Circumflex. 
 
 Supra-scapular. 
 
 Ulnar. 
 
 Radial. 
 
 Median. 
 
 Musculo-cutaneous 
 
 
 6. Dorso-intercostal ( N. 
 Nerves. •< 
 
 Dorsal. 
 Intercostal. 
 Mammary . 
 
 
 7. Nerves of Lumbar fN. 
 Plexus. 
 
 i 
 
 Lumbar. 
 
 Hypogastric. 
 
 Ileo-inguinal. 
 
 Scrotal or labial. 
 
 Crural. 
 
 Obturator. 
 
 
 8. Nerves of Sacral f N. 
 Plexus. J 
 
 I 
 
 Sciatic. 
 Anal. 
 Perineal. 
 Penile. 
 
 
 9. Nerves of the Coccygeal Plexus (Coccygodi- 
 nia.) 
 
22 
 
 TABLEAU OF THE NEURALGIAS (CONTINUED.) 
 
 B. Muscular nerves, or myalgia. 
 
 C. Cutaneous nerves, or dermalgia. 
 
 D. Cemral nerve, jfe-bralgia. 
 
 "Z'tc 
 
 Nerves of the Pharynx. 
 Nerves of the CEsophagus. 
 Nerves of the Larynx. 
 Neroes of the Lungs. 
 Nerves of the Heart. 
 Nerves of the Stomach. 
 Nerves of the Intestines. 
 
 | v j Nerves of the Liver. 
 
 c> ' Nerves of the Spleen. 
 
 ^ ° I Nerves of the Kidneys. 
 
 "- 1 I Nerves of the Bladder. 
 
 ! Nerves of the Uterus. 
 Nerves of the Ovaries. 
 
 j Nerves of the Testicle. 
 
 I Nerves of the Vagina. 
 
— 2 3 — 
 
 TABLEAU OF THE NEURALGIAS, CONTINUED. 
 SECOND CLASS SYMPTOMATIC NEURALGIAS. 
 
 si' g. 2£ 
 
 II till 
 
 td 
 
 SLS 
 
 "J g?K Si fti 
 
 ■•o a 
 
 (UT3 
 
 2* &I8S s 
 
 o - S«o3 ** 
 
 a *o • o'^B o 
 
 2 2 o S-S b. 
 
 °S. oW 
 
CHAPTER III. 
 
 THE CAUSES OF NEURALGIA. 
 
 First among the predisposing causes is heredity. 
 Since Morel and Moreau laid the foundations of the 
 doctrine of hereditary neuroses, all authorities have 
 recognized the influence of the neuropathic predispo- 
 sition in the genesis of neuralgia. The neuralgic sub- 
 ject will be often found to have inherited in the direct 
 family line the particular weakness of nerve organiza- 
 tion which finds expression in the paroxysmal attacks 
 from which he suffers. 
 
 Nothing, moreover, has been more clearly demon- 
 strated than the fact of the interchangeability of the 
 various neuroses. The victim of neuralgia may have 
 had an hysterical or an epileptic mother, or an insane 
 father or grandfather; the neuropathic tendency was 
 transmitted, and circumstances have determined what 
 neurosis should manifest itself. 
 
 It would appear, also, that the neurotic tempera- 
 ment is largely akin to the phthisical. Many writers 
 (and especially Anstie) have shown the interchangea- 
 bility of various functional nervous diseases with pul- 
 monary consumption. The neuropathic patient has 
 had a phthisical parent; the child, after suffering for 
 a series of years from some nervous malady — epilepsy, 
 hysteria, neuralgia— ultimately dies of phthises. An- 
 
— 25 — 
 stie's tables bring this fact clearly to view; I have 
 myself seen frequent confirmation of it.* 
 
 As for age, the extremes of life have a relative 
 immunity from neuralgia. Out of 296 cases, Valleix 
 met with but 5 cases of neuralgia in subjects between 
 seventy and eighty years, while there were but 2 cases 
 in children nnder ten years. The maximum of cases 
 (68) was between twenty and thirty. 
 
 There are, however, more cases in advanced life 
 than statistics appear to show, the number of aged 
 persons in any community being relatively limited as 
 contrasted with that of adults. Anstie affirms that 
 the period of declining life is preeminently the time 
 for severe and intractable neuralgias. Neuralgia in 
 the aged is associated with degenerative changes in 
 the arteries, and general mal-nutrition. 
 
 The middle period of life is the period of toil and 
 care. Men are absorbed in the pursuit of business 
 and in the support of their families; the rich and the 
 idle are immersed in dissipation, which, no less surely 
 than exhaustive toil, saps the vitality; with women, 
 this is the term of child-bearing, the rearing of fami 
 lies, and household drudgery. Middle age brings 
 with it high resolves, great undertakings, and fierce 
 
 *See in this connection Chapter III. in Anstie's book on 
 Neuralgia; also Maudsley "On the Pathology of the Mind," 
 p. 87 et seq,\ Blandford, "Lectures on Insanity," chapter on 
 Causation. 
 
— 26 — 
 
 competition; but it also brings with it disappointed 
 hopes, ennui, and weariness — all the moral and physi- 
 cal conditions of nerve-tire and nerve-ache. 
 
 Sex does not appear to have an important predis- 
 posing influence on the frequency of neuralgia in gen- 
 eral. According to Putnam,* if women show a 
 stronger predisposition than men to certain forms of 
 neuralgia, as to the other neuroses, it is generally 
 conceded that, whereas neuralgias of the fifth and 
 occipital and of the intercostal nerves are met with 
 oftenest amoug them, the brachial, crural and sciatic 
 neuralgias more commonly occur among men. This, 
 he thinks, indicates that the neurosal element is of 
 greater weight in the former group, the neuritic ele- 
 ment in the latter. 
 
 The sexual periods of life have a recognized influ- 
 ence in the production of neuralgia. The physiologi- 
 cal processes connected with the development of the 
 reproductive organs in the male, with ovulation and 
 menstruation, gestation and puerperality, and the 
 menopause in the female, are attended with the ex- 
 penditure of enormous nutritive and nervous energy, 
 and predispose to neuralgic affections. The prema- 
 ture, excessive, or unnatural exercise of these organs 
 and functions depresses the organism and favors the 
 development of the neuropathic diathesis. 
 
 * Article A T euralgia in Pepper's System of American 
 Medicine. 
 
— 27 — 
 
 Previous diseases* predispose to neuralgia by the 
 debility and anaemia which they occasion; the same 
 may be said of unhealthy hygienic influences such as 
 bad air, and insufficient food. Cold and damp weather 
 has an influence; neuralgias are more prevalent in 
 this country in the fall and spring months. General 
 disturbances of nutrition, and especially those included 
 under the names anaemia and chlorosis, and all cache- 
 tic, states, such as cancer, tuberculosis, scurvy, dia- 
 betes, may be regarded as important conditions in the 
 etiology of this disease. 
 
 EXCITING CAUSES. 
 
 It is not always possible to find for idiopathic 
 neuralgia any exciting cause. Yet generally a minute 
 inquiry will bring out the fact that there had been 
 previous exposure to cold and wet, excessive muscular 
 exertion, inordinate sensorial fatigue, or some moral 
 shock, as the immediate antecedent. Wounds of sen- 
 sory nerves, contusions, gun-shot wounds, punctures, 
 and other injuries, have caused most obstinate and 
 distressing neuralgias. Even comparatively slight in- 
 juries to small sensory nerves, as by venesection, a 
 subcutaneous injection, have resulted in neuralgiform 
 pains or attacks of genuine neuralgia. Erb supposes 
 all these injuries to act "either by occasioning inflam- 
 
 *I have seen very obstinate neuralgias follow typhoid 
 fever. One very severe case of gastralgia that came under my 
 observation was the sequel of an exhausting accouchement. 
 
— 28 — 
 
 matory changes (neuritis), or by forming tumors on 
 the nerves (traumatic neuromata, amongst which the 
 neuromata following amputation are the most fre- 
 quent causes of severe neuralgia), or lastly, purely 
 mechanically, by pressure and laceration in conse- 
 quence of the retention of foreign bodies in the 
 wound." * 
 
 • Dr. S. Weir Mitchell, in his book " On Injuries 
 of the Nerves," has narrated many remarkable in- 
 stances of neuralgia starting from gun-shot or other 
 wounds of the nerves, and cases are on record where 
 a fall on a member has developed neuralgia of the 
 sensory nerves of the limb.f 
 
 Many of these cases do not seem to be true neu- 
 ralgias, in fact, all traumatic neuralgias are classed by 
 some authoTs (as Vanlair) apart, under the head of 
 pseudo-neuralgias. \ These neuralgias have a marked 
 resemblance to ordinary neuralgias; sometimes, how- 
 ever, they are distinguished from the latter by their 
 
 *Ziemssen's Cyclop., vol. xi, p. 28. 
 
 f One of the most intractable neuralgias I have ever wit- 
 nessed involved the brachial plexus, and was brought on by a 
 fall on the shoulder in a runaway accident. Considerable 
 atrophy of the muscles of the corresponding limb followed. I 
 have seen, in very sensitive persons, neuralgia succeed a hypo- 
 dermic injection, paroxysmal pain appearing at intervals daily 
 for several days. 
 
 % Vanlair, Les Nevralgies, leurs formes et leur traitement, 
 2d ed. (Bruxelles, 1882.) 
 
— 2 9 — 
 
 extraordinary violence and obstinacy. Sometimes the 
 pain is of a burning character, at others, lancinating 
 (stabs or darts); it may remain localized to the 
 region, or may be of a spreading character. Trophic 
 disturbances sooner or later follow, which affect par- 
 ticularly the skin; the red, thin, and shiny skin known 
 as glossy skin, is one of the effects of traumatic neu- 
 ralgias of the extremities. 
 
 Closely resembling traumatism in its action on 
 nerves, are those diseases of the periosteum and bones 
 which by mechanically irritating and disordering 
 nerves in the neighborhood, occasion neuralgia. The 
 fifth nerve is especially liable to such lesions, having 
 to pass through a long narrow bony canal, any 
 periosteal thickening of which cannot but seriously 
 affect its structural and functional integrity. Syphi- 
 litic ostitis and periostitis have been reckoned 
 among the causes; it is doubtful whether these can 
 cause true neuralgia. Syphilis may produce neu- 
 ralgia by depressing the general health and tone — this 
 disease is, however, much more likely to cause motor 
 affections (as paralysis), than sensory. * 
 
 That cold, and especially damp cold, is an im- 
 portant factor in the production of neuralgia, no one 
 with much experience in the various forms of this 
 neurosis will dispute. In fact, persons predisposed to 
 neuralgic affections are almost certain to suffer either 
 
 *Anstie, he. eit. (Am. ed.), p. 175. 
 
— 3° — 
 a renewal or an aggravation of their complaints after 
 being chilled. 
 
 A special chapter will be devoted to the reflex 
 and sympathetic neuralgias which are due to organic 
 causes more or less distant from the seat of pain, and 
 to the toxic neuralgias which result from mal-nutrition 
 of the sensory nerve system by chronic poisoning. 
 
 Among other causes of neuralgia, must be men- 
 tioned the fatty and atheromatous changes in the 
 tissues and arteries consequent on old age, overwork 
 of body and mind,* and diseases of the central ner- 
 vous system, as hyperemia, inflammation, and tumors 
 of the brain and spinal cord. 
 
 * Many severe cases of facial neuralgia are caused by eye- 
 strain, as by reading too long, and before too bright a light. 
 
CHAPTER IV. 
 
 PARTICULAR FORMS OF NEURALGIA. 
 
 I. FACIAL NEURALGIA. 
 
 This disease has been called prosopalgia, neu- 
 ralgia of the fifth, trigeminal neuralgia, and tic doulou- 
 reux. It is one of the most frequent of neuralgias; 
 this is explained by the relations of its branches to 
 various important organs, the disturbances of which 
 may extend to the nerves supplying them, and by the 
 fact that the face is more exposed than other parts of 
 the body to cold and injurious influences. 
 
 This affection is generally unilateral. As the 
 fifth nerve divides on emerging from the cranium into 
 three nerve trunks, the ophthalmic, the superior 
 maxillary and the inferior maxillary, any one of these 
 branches may be the seat of the neuralgia. Com- 
 monly, however, it occupies the entire trifacial nerve. 
 As causes, the following have been enumerated: 
 " Cold, decayed teeth, contusions and wounds of the 
 face, compression of the nerves by foreign bodies, 
 neuromata, tumors of the petrous bone, aneurisms of 
 the internal carotid, tumor of the pons, fungus of the 
 dura mater." All the predisposing and exciting 
 causes before enumerated may be factors in the 
 genesis of this neuralgia. Diseases of the nasal and 
 
— 32 — 
 frontal sinuses, and fatigue of the eyes, shock and 
 mental emotion, have been occasional causes. 
 
 The paroxysm may come on suddenly or gradu- 
 ally. It generally begins with a sensation of heat or 
 cold over the affected parts with occasional violent 
 strokes of darting pain, which become more and 
 more frequent till the attack is at its height. 
 
 Probably no more atrocious suffering is known. 
 " During the attack, the patients utter loud outcries, 
 toss about ontheirbeds and smite theirheads;*the mus- 
 cles of the affected side of the face are often the seat 
 of rapid contraction, — convulsive shocks, which have 
 gived to this disease one of the names by which it is 
 known — tic douloureux. These contractions may be 
 limited to single groups of muscles, as the zygomatics, 
 or the frontal part of the occipito-frontalis. The face 
 becomes turgescent; there is often photophobia, 
 lachrymation, buzzings in the ears; then the par- 
 oxysmal shocks diminish in frequency and intensity, 
 and all becomes calm; the storm has passed, to be re- 
 newed again under the same form in a time not far 
 distant. 
 
 According to the branches affected, certain phe- 
 nomena present themselves: photophobia, injection of 
 the eyes, lachrymation, transient amaurosis in neural- 
 gia of the ophthalmic, odontalgia, pituitary secretion 
 
 * " In neuralgias about the head, the patient will often be 
 seen to cringe and recede before the plunges of pain as though, 
 he were receiving blows." Buzzard. 
 
— 33 — 
 in neuralgia of the superior maxillary, painful deglu- 
 tition and mastication, exaggerated salivary secretion 
 in neuralgia of the inferior maxillary nerve."* 
 
 Valleix's painful points are: i, supra-orbital, over 
 supra-orbital foramen; 2, palpebral; 3, nasal (internal 
 and superior part of nose;) 4, ocular; 5, infra-orbital 
 (infra-orbital foramen); 6, molar; 7, superior dental; 
 8, superior labial; 9, palatine; 10, temporal; 11, tem- 
 poro-maxillary; 13, mental (mental foramen): 14, 
 lingual: 15, inferior labial. 
 
 Putnam (loc. at., 1232) makes three varieties of 
 facial neuralgia: 1, ordinary facial neuralgia, analo- 
 gous to the neuralgias of the other superficial nerves; 
 2, intermittent supra-orbital neuralgia, sometimes 
 called brow-ague, though by no means always of 
 malarial origin; 3, epileptiform neuralgia (tic doulou- 
 reux). The first, or ordinary facial neuralgia, is 
 painful and obstinate, though not so serious as tic 
 douloureux. It is often due to decayed teeth, and 
 diseases of the gums or of the alveolar process. The 
 second, or intermittent form, has one variety which 
 bears a certain relationship to migraine, occurs in dis- 
 tinctly neuropathic individuals and families, and in 
 attacks of about the same duration and periodicitv of 
 occurrence. Another variety is characterized by a 
 daily seizure which occurs with absolute regularity, 
 coming on usually about nine in the morning, and 
 
 * Vide " Clinical Therapeutics,'" p. 76 (foot note). 
 
 3 MM 
 
— 34 — 
 increasing in severity for an hour or so, then persist- 
 ing unchanged till midday or later, when it gradually 
 diminishes, finally disappearing in the course of the 
 afternoon. As a rule, Putnam says, is is brought on 
 by catarrh of the frontal sinuses, often following an 
 acute attack of coryza. This form is greatly con- 
 trolled by quinine (15, 20 to 25, and even 30 grains) 
 four hours before the attack. The epileptiform vari- 
 ety (tic douloureux) is characterized by the sudden- 
 ness of its onset, and the severity of its paroxysmal 
 pain. The path pursued by the darts of pain is gen- 
 erally in the direction of the nerve-tracks. According 
 to Putnam's view above given, the name tic doulour- 
 eux is only applicable to the disease when it appears 
 in its more painful character. 
 
 Treatment. — Only the surgical treatment will be 
 here mentioned. The medicinal treatment will be dis- 
 cussed in the chapter devoted to general therapeutics. 
 
 In 185 1 Dr. J. M. Carnochan operated in the first 
 case for complete resection of the second branch of 
 the fifth pair from the foramen rotundum to the infra- 
 orbital foramen — with the removal of Meckel's gan- 
 glion — w ith complete success. Simple subcutaneous 
 section of the infra-orbital nerve in the cheek had 
 been often done before that time, but with no very 
 encouraging results; in fact, the relief coming from 
 the operation was very temporary. 
 
 The operation is a bold one, and involves trephin- 
 ing the antrum. 
 
— 35 — 
 Dr. Robert Abbe, of New York, has lately pub- 
 lished in the New York Medical Journal reports of a 
 series of cases in which he has performed Carnochan's 
 operation with brilliant success.* 
 
 II. MIGRAINE, ITS PATHOLOGY AND TREATMENT. f 
 
 According to Anstie, migraine (hemicrania) is a 
 variety of neuralgia of the ophthalmic division of the 
 fifth nerve. He remarks that the attacks of migraine 
 often interchange with neuralgia seizures; that they 
 often begin with pain distinctly located in the supra- 
 orbital nerve, as the result of exposure to cold or 
 other of the causes of ordinary neuralgia. This view 
 is favored by Senkler in " Pepper's System of Medi- 
 cine." 
 
 Romberg regarded migraine as a neuralgia of the 
 cerebrum, but Hesse observes that the symptoms of 
 this neurosis are equally compatible with its location 
 in the branches of the fifth distributed to the meninges 
 and bones of the cranium. 
 
 There is, however, much to be said in defence of 
 the view that migraine is primarily a neurosis of the 
 sympathetic nerve. According to Du Bois-Reymond, 
 the phenomena of migraine are best explained by the 
 
 * Vide New York Medical Journal, Aug. 3d, 1889. 
 
 f In this section, as in one or two other instances {vide 
 angina pectoris), the writer has availed himself of articles of his 
 own which have appeared in the Boston Medical and Surgical 
 Journal and Medical Age. 
 
- 36 - 
 supposition that there is abnormal excitation of the 
 sympathetic on the affected side, and he emphasizes 
 in this connection the retraction of the temporal artery, 
 the pallor of the countenance, the dilatation of the 
 pupil; all of which are due to tonic contraction of the 
 vascular and oculo-pupillary muscles. 
 
 But, as Jaccoud remarks, the constancy of these 
 phenomena has not been established, and Moellendorff 
 afterwards maintained a directly contrary view, to wit, 
 that the symptoms of hemicrania depend on the unilat- 
 eral relaxation of the vessels of the head, from want of 
 energy of the vaso-motor nerves. Eulenburg* adopts 
 an intermediate theory, affirming that a certain class 
 of cases is undoubtedly vaso-motor in its origin. He 
 describes two types of migraine: the sympathetico- 
 tonic or angio-spastic, and the angio-paralytic or 
 neuro-paralytic forms. In the one, the face is pale 
 and sunken; in the other, it is hot, turgid and flushed 
 during the height of the attack. In the one, the pupil 
 is dilated and the temporal artery appears as a hard 
 cord; in the other, the pupil is contracted, and the 
 temporal artery is swollen and throbs with increased 
 force. In the one, the eyes are pale and sunken; in 
 the other, they are suffused and prominent. 
 
 Jaccoud reconciles the pathological differences 
 above mentioned by assuming that tnere cannot be 
 two vascular conditions so contradictory, as the sub- 
 
 *Ziemssen's Cyclop. Art. Hemicrania. 
 
— 37 — 
 stratum of migraine. If, he says, clinicians have wit- 
 nessed opposite phenomena, it is simply because they 
 observed at different periods; in other words, the 
 paroxysm of migraine is constituted by an abnormal 
 excitation of the sympathetic followed by a paralysis 
 by exhaustion, which marks the decline and the ter- 
 mination of the paroxysm. The contraction of the 
 vessels during the onset and the active period of the 
 attack explains why the pain is exaggerated at each 
 pulsation of the artery; as for the origin of this pain, 
 it may be attributed to the vascular cramp itself, which 
 compresses the nerve filaments contained in the un- 
 striped muscles.* 
 
 Hemicrania is a disease from which no station or 
 condition of life is exempt. Rich and poor, the man 
 of ease and the fashionable lady, the mill-operative 
 and the kitchen drudge, are alike subject to migraine. 
 Among the factors in its production, hereditary pre- 
 dispostion is the most potent. The disease follows 
 the female line, being usually inherited from the 
 mother only, and by the daughters only (Eulenburg). 
 When there is a strong hereditary tendency, girls of 
 quite a young age may be attacked by migraine, 
 Eulenburg has known girls of four or five years to be 
 sufferers. 
 
 In half the women affected with migraine, the at- 
 tacks occur at the menstrual period or immediately 
 
 * Jaccoud: Path. Interne, t. i, p. 478. 
 
- 38 - 
 
 after. In other cases, the attacks are due to mental 
 excitement, after attendance at a party, at a theatre, 
 etc. Sometimes the attack is provoked by reading 
 and study; some persons have hemicrania from read- 
 ing by artificial light. The attacks sometimes appear 
 to originate in indigestion. 
 
 It is in this form of neuralgia that the recently 
 discovered analgesics, antipyrin, acetanilide, phena- 
 cetin, exalgin, seem to do the most good. Here the 
 triumph of guarana and caffein is often seen. 
 When the attack can be traced to the stomach, ipecac- 
 uanha in one-fourth grain doses every hour has been 
 commended, also rhubarb and soda, or some of the 
 effervescing aperients. 
 
 In the angio-spastic variety, nitrite of amyl in- 
 halations, and nitro-glycerin by mouth, have been 
 beneficial. In the angio-paralytic form, ergot has 
 been found useful. 
 
 Senkler speaks favorably of bromide of lithium, 
 fifteen grains every hour for two or three doses. The 
 effervescent bromide of caffein, or bromo-pyrin, is a 
 good preparation. Seguin's favorite treatment is 
 cannabis indica, one-fourth grain doses of the alco- 
 holic extract three times a day, to be continued for 
 weeks and even months. Aconitia (one two-hun- 
 dredth grain) and gelsemium have been praised; the 
 former is, perhaps, one of the most certain remedies 
 in the angio-spastic variety. Malarious forms are 
 speedily benefited by large doses of quinine. Always, 
 
— 39 — 
 as prophylactic treatment, arsenic and cod-liver oil 
 are indicated. 
 
 Anstie and Eulenburg think well of galvanism 
 to the head and sympathetic. Firm pressure on the 
 head and compression of the carotids sometimes give 
 relief; the same may be said of sinapisms to the nape 
 of the neck, and the application of a hot-water bag to 
 the back of the head. 
 
 After all, resort must sometimes be had to hypo- 
 dermic morphia in the atrocious suffering of mi- 
 graine. 
 
 Migraine, says Lasegue (Etudes Medicales, vol. II., p. 
 331), is a disease of paroxysms; a man who suffers from con- 
 tinuous headache is not migrainous. The attacks do not repeat 
 themselves at periods that can be mathemetically calculated. 
 * * * * * Ordinarily, the attacks do not recur 
 oftener than once a week. On the other hand, he who has 
 only one or two attacks a year, cannot be said to be a victim of 
 true migraine. * * * . 
 
 The duration of the attack also obeys positive laws. Any 
 attack of cephalalgia which lasts less than six hours and more 
 than forty-eight hours, cannot properly be called migraine. 
 Typical migraine appears in the morning. Afier certain pro- 
 dromes; physical and mental atony with diminution of appetite, 
 pallor, fatigue, the headache begins with a diffused sensation 
 of cranial tension, sometimes by a pain in one spot, which 
 spreads over the cranium and face of the affected side, never 
 limiting itself to a nerve tract. 
 
 Topographically, migraine is hemicranial, occipital, syn- 
 cipital, or diffuse; in the first case it has its maximum of inten- 
 sity in the orbit, in the infra-orbital and temporal regions, 
 never fixing itself below the infra-orbital line; at the most there 
 
— 4© — 
 
 is a vague sensation of weight and swelling of the face and a 
 little aching of the teeth. The occipital form is the most pain- 
 ful, and is rarely hemicranial; the syncipital, never. 
 
 Migraine is exceptionally diffuse at first; starting from 
 one or more points, it spreads with rapidity to the entire cran- 
 ial surface, without having everywhere an equal intensity. Pa- 
 tients affirm that the skin seems to be detached, as though they 
 were being scalped. Sometimes, however, the integument 
 seems to adhere to the skull by a violent retraction; the patients 
 complain of being tortured by a leaden cap, or by an iron band. 
 Intolerable as the pain is, it is rather contunding than lancina- 
 ting, and seems to the patient rather extra than intra cranial. 
 
 In proportion as the paroxysm advances towards its 
 acme, the sufferings become ordinarily more confused, proba- 
 bly by reason of the general malaise which becomes more pro- 
 nounced; sometimes, however, the pains change their place, 
 redoubling their intensity. This sudden migration of the pain 
 during the attack is a remarkable fact which differentiates mi- 
 graine from the ordinary neuralgias; sometimes, for instance, 
 the pain suddenly shifts from the left to the right side, or vice 
 versa. 
 
 To the pericranial sufferings are soon conjoined certain 
 ailments connected with the stomach which have given to mi- 
 graine one of its names, sick-headache. There is nausea, 
 retching, and vomiting during the attack; these symptoms pre- 
 dominate in the stationary period and then sometimes cut short 
 the attack, though at the onset vomiting does not relieve. 
 
 It may be affirmed that no attack of headache not accom- 
 panied by gastric complications is true migraine. 
 
 In the third period the violent pain is decreased, and the 
 nausea much less pronounced. The head becomes heavy; it 
 seems at times as if it were enormously swollen; the pain 
 through the eyes is more pronounced, though vision may be 
 unaffected. The first manifestations of a cerebral kind are in- 
 
— 41 — 
 tellectual torpor with absence of ideas, or a sub-delirium 
 similar to that of dreams, though the patient can still control 
 himself. The necessity of sleep is now felt, and the patient . 
 gladly yields to it; a delicious slumber closes the attack; the 
 patient wakes with a feeling of prostration, though free from 
 pain; he is not himself again until he has taken food. 
 
 If the attack, when left to itself and pursuing its course 
 in silence and darkness — the favorite environment of the mi- 
 grainous — accomplishes thus its regular evolution, it may be 
 suddenly interrupted by adventitious modifying circumstances. 
 Many a sufferer from migraine has experienced sudden deliv- 
 erance from his attack under the influence of a strong emotion, 
 a fright, or a piece of unexpected good news. 
 
 [It may be added that the same effect may be produced by 
 full doses of some of the modern analgesics, and especially anti- 
 pyrine, phenacetin, and caffeine.] 
 
 III. CERVICO-OCCIPITAL NEURALGIA. 
 
 This is an uncommon form of neuralgia, affecting 
 the sensory nerves of the occipital region, neck and 
 nape of the neck; the pain is located in the first four 
 cervical nerves. 
 
 The causes do not differ from those which pro- 
 duce facial neuralgia. According to the observations 
 of Valleix, this form of neuralgia is most generally 
 due to prolonged exposure to cold, as sitting in a 
 draught. Neuritis and congestion of the neurilemma 
 are suggested as probable causes. Diseases of the 
 vertebrae also appear to induce this form of neuralgia, 
 by pressing on the veins as they pass out of the verte- 
 bral canal, and swollen lymphatic glands deep in the 
 
— 42 — 
 
 neck by pressing on the cervical plexus and occipitalis 
 major (Niemeyer). 
 
 There are painful points over the first two verte- 
 brae, at the point of exit of the great occipital nerve 
 from the complexus, over the mastoid process, near 
 the parietal protuberance, and in the auricle. 
 
 As the tendency of this neuralgia is to spread to 
 the lower part of the face, it sometimes becomes, as 
 Valleix observes, indistinguishable from neuralgias of 
 the third division of the trigeminus. 
 
 In the treatment of this affection, neurotomy has 
 been tried, but with only partial success. Anstie has 
 derived marked benefit from blistering. 
 
 IV. CERVICO-BRACHIAL NEURALGIA. 
 
 By cervico- brachial neuralgia is meant neuralgia 
 having its seat in the four lower cervical vertebrae and 
 in the first dorsal (the brachial plexus). These are 
 neuralgias of the shoulder, arm, forearm, and hand, 
 and they are often very severe and obstinate. 
 
 The causes are oftener extrinsic (from material 
 lesion) than in any other form of neuralgia. Injuries 
 of the brachial plexus by cutting instruments, gun- 
 shot wounds, contusions, neuromata, swollen lym- 
 phatic glands, or aneurismal tumors in the axilla, peri- 
 ostitis, tubercle or cancer of the vertebrae causing 
 pressure on the nerves at their foramen of emergence, 
 have been enumerated as perceptible causes. Attacks 
 of this neuralgia have been referred to immoderate 
 
— 43 — 
 exercise of the muscles of the forearm and hand, as in 
 playing on the piano, in sewing, and in knitting. 
 
 The pain is paroxysmal, of regular or irregular 
 type, and is characterized by lancinations in various 
 directions, which make themselves felt especially in 
 the terminal expansion of the nerves. The most 
 common seat of cervico-brachial neuralgia, according 
 to Anstie, is the ulnar nerve, though the pain, when 
 intense, always spreads to the other sensory nerves of 
 the brachial plexus. In a very obstinate case to 
 which I have before referred, the principal focus of 
 the pain was the shoulder. 
 
 In another case, of which I have notes, the neu- 
 ralgia was brought on by a contusion (a fall from a 
 carriage). For thirteen years, this patient (an elderly 
 lady) was a sufferer from neuralgia, affecting chiefly 
 the ulnar nerve, the inner part of the forearm and 
 little and ring fingers being chiefly affected. During 
 the severe paroxysms of pain (which were frequent) 
 the fingers were contractured in a semi-flexed condi- 
 tion. The forearm and hand were permanently 
 swollen and somewhat livid, the outer fingers were 
 often numb and cold. Prickly sensations were com- 
 mon. During the painful crises, all the sensory 
 nerves of the fingers seemed affected; the pain being 
 principally in the terminal extremities of the nerves. 
 During the intervals of the attacks, there was always 
 an aching pain along the ulnar side of the forearm. In 
 damp, chilly weather, the attacks were generally worse. 
 
— 44 — 
 
 This case seemed to me to be a fairly typical 
 one. Antipyrine in 10 grain doses, arsenic, iron, cod- 
 liver oil, and opiates were all tried in this case. Anti- 
 pyrine gave much relief the last two years of this pa- 
 tient's life, and frequently stayed the paroxysms, but 
 morphine was often necessary. A proprietary pre- 
 paration of opium called svapnia in \ grain doses was 
 resorted to with benefit at times, and seemed to have 
 less baneful after-effects than morphine. 
 
 In cervico-brachial neuralgia, neurectomy of the 
 affected nerve has sometimes been followed by a per- 
 manent cure. 
 
 V. INTERCOSTAL NEURALGIA. 
 
 Intercostal neuralgia is neuralgia affecting the 
 sensory branches of the dorsal nerves. These nerves 
 — twelve in number — divide after their emergence 
 from the intervertebral foramen, into an anterior and 
 a posterior branch; the anterior cords are the inter- 
 costal nerves, the posterior branches are distributed 
 to the muscles and skin of the back. 
 
 The intercostal nerves run along in the inter- 
 costal space, at first resting on the external intercostal 
 muscles, then lying between the muscles; beyond the 
 middle of the rib they enter the substance of the in- 
 ternal intercostal muscle, and reach the inner surface, 
 being in contact with the pleura; at the anterior ex- 
 tremity of the intercostal space they pierce the mus- 
 cles and are distributed to the integument. Midway 
 
— 45 — 
 between the vertebral column and sternum, each 
 intercostal nerve gives off a lateral cutaneous branch, 
 which pierces the external intercostal muscle and 
 divides into twigs for the supply of the skin of the side 
 of the thorax. The six lower intercostal nerves con- 
 stitute the anterior cutaneous nerves of the abdomen. 
 
 The points douloureux are three in number: 
 one posterior, by the side of the spinous processes, 
 over the point of emergence of the nerves; one 
 median, over the point where the lateral cutaneous 
 branch perforates the muscles; an anterior, situated a 
 little outside the sternum, or at the epigastrium, ex- 
 ternally to the median line at the origin of the ante- 
 rior perforating branch. These circumscribed spots 
 are generally very sensitive to touch or pressure. 
 
 Intercostal neuralgia is generally unilateral and 
 seated on the left side. It is more common in 
 females than in males, and generally affects several 
 of the intercostal nerves at the same time. 
 
 The causes are multiple: impression of cold; 
 contusion of the thorax; neuritis; neuroma; lesion 
 of neighboring organs, as the lungs, pleura, and ver- 
 tebral column; congestion and dilatation of the intra- 
 vertebral venous plexuses or intercostal veins. Inter- 
 costal neuralgia is a very frequent, though not con- 
 stant, accompaniment of herpes zoster, and has been 
 known in a very obstinate form to follow attacks of 
 pleurisy. It may be reflex, and accompany catarrh of 
 the digestive tube and diseases of the uterus or 
 
- 46 - 
 
 ovaries. It is observed in hysteria, chlorosis, anaemia, 
 malaria, lead poisoning, syphilis, and rheumatism. 
 Michel Peter defines the pain of pneumonia as a 
 pleuritic pain, and regards the latter as an intercostal 
 neuralgia.* 
 
 Dujardin-Beaumetz regards the pains in the side 
 observed in phthisical patients at the apex of the 
 lungs as neuritis from inflammation of the lungs and 
 pleura. In tuberculous neuritis it is the first, second, 
 and. sometimes third intercostal spaces that are the 
 seat of the pain. In anaemic neuralgias it is the 
 fourth, fifth, and sometimes sixth intercostal spaces 
 on the left side, and the pain is most severe on a level 
 with the fourth dorsal vertebra. 
 
 Continuous pain is the predominant symptomatic 
 element, presenting itself under the form of a con- 
 strictive tension half girdling the thorax and exagger- 
 ated by movements, especially those of respiration 
 (Jaccoud). Along with this dull continuous pain, 
 there are shootings along the course of the intercostal 
 nerves. Real paroxysmal accessions are less common 
 than in other forms of neuralgia, yet they now and 
 then occur. 
 
 Double intercostal neuralgia (which is very rare) 
 would, according to Jaccoud, lead one to suspect the 
 existence of an intra-thoracic tumor, or a chronic dis- 
 ease of the spinal cord or its membranes. 
 
 * Clinical Therapeutics, p. 74. 
 
— 47 — 
 
 Intercostal neuralgia is liable to be confounded 
 with pleurodynia or rheumatism of the thoracic mus- 
 cles. In the latter affection the pain is more diffused 
 than in intercostal neuralgia, is seated in certain mus- 
 cles, is aggravated by certain movements, and gets 
 well in a few days; moreover, there is absence of the 
 painful points. 
 
 With regard to the treatment, the general prin- 
 ciples laid down in a subsequent chapter are here ap- 
 plicable. All authorities speak favorably of counter 
 irritation to the skin; Valleix and Erb especially com- 
 mend flying blisters, applied in succession over the 
 painful points. Erlenmeyer recommends repeated 
 cauterization of the skin with nitrate of silver. Fara- 
 dization with the metallic brush has seemed some- 
 times to do good. In one bad case that came under 
 my observation, firm pressure over the painful foci 
 with the bare hand gave great relief during the at- 
 tacks. Chloroform and menthol liniments and the 
 local application of cocaine solutions confer but little 
 benefit. Hypodermic injections of chloroform or 
 antipyrine may be tried; these failing, the resort, as 
 usual, must be to morphine, by mouth or subcutane- 
 ously. 
 
 VI. MASTODYNIA IRRITABLE BREAST. 
 
 Women about the period of puberty or from then 
 to the thirtieth year, often, without any perceptible 
 cause, become sensitive to the slightest touch at one 
 
- 4 8 - 
 
 or more points over the mammary gland. Severe 
 pain like tic douloureux, occasionally shoots out to- 
 ward the shoulder, axilla, or hip. 
 
 The disease sometimes develops in connection 
 with pregnancy or lactation. Now and then smalt 
 neuromata or painful tumors of the nerves of the 
 mammary glands appear to be the starting points of 
 the neuralgia; these consist of connective tissue, not 
 of glandular substance. 
 
 Mastodynia is sometimes very obstinate. Cooper 
 recommends a belladonna plaster; Romberg, pills of 
 ext. conii, ext. papaver (aa gr. ij), ext. stramonii (£ to 
 i gr.), to be taken according to indications. 
 
 VII. LUMBO-ABDOMINAL NEURALGIA. 
 
 Neuralgia of the lumbar plexus is generally situ- 
 ated on the left side. Its causes are various: impres- 
 sion of cold, contusion, alteration or compression of 
 nerves by bony tumors or other tumors in the vicinity. 
 It may be provoked by a mordid state of the genital 
 organs, testicle, uterus, and its annexes, and co-exist 
 with neuralgia of the neck of the womb. It may oc- 
 cupy all the branches of the plexus, or several of them, 
 or each of the following branches: i. The abdominal 
 branches which furnish the ilio-scrotal nerve; 2. The 
 internal inguinal branches; 3. The external branch 
 which furnishes the scrotal or labial nerves. 
 
 The pain, as in all other neuralgias, is permanent^ 
 dull, or contusive, or is paroxysmal. The attacks are 
 
— 49 — 
 spontaneous, or provoked by walking, sudden move- 
 ments, pressure over the nerve, etc., and remain 
 limited to the bones, the flank, and the inferior part 
 of the hypogastrium, or are propagated to the groin 
 or the testicle, or labia majora, according as the scrotal, 
 testicular, labial branch, etc, is affected. Irritable 
 testicle, according to Sir Astley Cooper, is ileo-scrotal 
 neuralgia.* 
 
 The treatment does not differ essentially from 
 that of dorso-intercostal neuralgia. 
 
 Coccydynia. — This is neuralgic pain having its 
 seat in the region of the coccyx. Women are more 
 subject to it than men. It is felt particularly in sitting 
 and during defecation. Buzzard regards it as neural- 
 gia of the coccygeal plexus. The treatment consists 
 either in subcutaneous division of the muscles and 
 fibrous structures attached to the coccyx, or in extirpa- 
 tion of the coccyx. f 
 
 VIII. NEURALGIA OF THE SCIATIC NERVE. 
 
 Neuralgia may attack any of the sensory branches 
 of the sacral plexus, and the term sciatica is often 
 used to designate neuralgia of that plexus. Want of 
 space obliges me to restrict the signification of the 
 word (in accordance with its common acceptation) 
 to neuralgia of the great sciatic nerve. 
 
 * Reprinted from Clinical Therapeutics, note 3, p. 73, 
 f Art, Neuralgia in Quain's Dictionary of Medicine \ 
 
 4 MM 
 
— 5° — 
 
 Cotugno, an Italian physician, more than a cen- 
 tury and a quarter ago, gave the first magisterial 
 description of sciatica; his pathology has been out- 
 grown, for he attributed the disease, in great part, to 
 dropsy of the nerve sheath, and compression of the 
 nerve substance. 
 
 Valleix at a later day, relegated sciatica to the 
 rank of functional neuroses under the name oifemoro- 
 popliteal neuralgia. 
 
 The search for points dou/oureux, as usual, pre- 
 occupies Valleix. His painful points are as follows: 
 i. A lumbar point immediately above the sacrum; 2. 
 A sacro-iliac point on a level with the sacro-iliac 
 articulation, in front of the posterior superior spine 
 of the ilium; 3. Iliac, over the crest of the ilium; 4. 
 Gluteal, at the top of the great sciatic notch; 5. 
 Trochanteric, upper border of the great trochanter; 6. 
 Femoral points superior, middle, and inferior, over 
 the origin of the principal nerves given off from the 
 sciatic; 7. Popliteal, over the popliteal space; 8. 
 Patellar, over the patella; 9. Peroneo-tibial, over the 
 upper articulation of the tibia and fibula; 10. Pero- 
 neal, about the neck of the fibula; it. Malleolar, at 
 the posterior and inferior part of the external malleo- 
 lus; 12. Dorsum of the foot and plantar region. 
 
 In other words, according to Valleix, sciatica 
 obeys the law according to which the pains are con- 
 centrated: 1, at the point of emergence of the nerve 
 trunk; 2, in the points where a nerve filament traverses 
 
— 5i — 
 the muscle to approach the skin to which it is dis- 
 tributed; 3, in the points where the terminal branches 
 lose themselves in the teguments.* Lasegue has 
 pointed out that Valleix, in calling attention to pain 
 and especially paroxysmal pain, as the principal dis- 
 tinguishing element, and overlooking the fact of a 
 morbid organic process with its periods, its acuteness, 
 and its chronicity, has given a picture which is little 
 in accordance with clinical facts as they ordinarily 
 present themselves to the practitioner. He regards 
 sciatica as an organic disease, due to neuritis, or some 
 degenerative alteration of the nerve. 
 
 It cannot however, be said that the relatively few 
 post-mortem examinations that have been made of 
 sciatic patients have revealed that constancy of morbid 
 changes which would bear out Lasegue's view. Erb 
 regards the anatomical changes as simply accidental 
 accompaniments of the disease. It is, however, true 
 that in the experience of many practitioners, as in that 
 of Lasegue, \ the disease has not been so much char- 
 acterized by lancinating, ingravescent pangs, as by a 
 constant dull pain aggravated by pressure and motion 
 seated in some part of the nerve trunk. 
 
 Causes. — Anstie regards senility as a predisposing 
 cause, and Gueneau de MussyJ looks upon sciatica as 
 
 *See some very judicious remarks on this subject in 
 Lasegue, Etudes Medicates, p. 310. 
 
 f Lasegue, Etudes Medicales, Vol. II. Art. Sciatica. 
 % Gueneau de Mussy Clinique Medicale, t. i., p. 306. 
 
— 52 — 
 a manifestation of a rheumatic or arthritic diathesis. 
 The great length and superficial position of the sciatic 
 nerve renders it peculiarly liable to inflammation from 
 cold and to injuries.* 
 
 Among the accidental causes are exposure to cold, 
 and especially damp cold, wounds, contusions, 
 neuritis, fractures, the presence of abdominal, pelvic, 
 stercoral tumors, pressure of the fcetal head during 
 accouchment, etc. Erb regards mechanical pressure 
 by sitting on hard, uncomfortable seats as a frequent 
 cause. 
 
 Excessive walking and occupations requiring 
 prolonged standing certainly sometimes seem to favor 
 if not directly cause sciatica, and I have seen one ob- 
 stinate case accompany diabetes as a part of the de- 
 cadence and mal-nutrition resulting from that disease. 
 
 The disease is oftener seen in robust and hard- 
 working men than in delicate nervous persons, is 
 more frequent in middle life than at any" other epoch, 
 and in males than in females. According to Erb's 
 observations, the proportion of males to females is as 
 4 to i. 
 
 Symptoms. — The disease generally announces 
 itself by a feeling of numbness, tingling, cold or 
 heat in the entire limb, or in certain limited parts; 
 then, after a variable time, there is an outbreak of pain 
 which may occupy different branches of the nerves 
 
 * Erb in Ziemssen's Cyclopaedia. 
 
— 53 — 
 (genito-crural, cutaneous femoral branches of the 
 lesser sciatic, articular branches of the great sciatic 
 and peroneal, internal saphenous, short saphenous or 
 posterial tibial, or terminal plantar nerves). As in 
 the other neuralgias, the pain may be looked upon as 
 double; there is a continuous element, a deep, contu- 
 sive pain, and a paroxysmal element, manifesting 
 itself by ascending, descending, or irregular lancina- 
 tions*. 
 
 " Under the influence of walking, muscular exer- 
 tion, heat, or without any known cause, lancinating 
 pangs, are experienced radiating along the course of 
 the nerve; the patient can often mark out with his 
 finger the track of the painful nerve. These pains 
 are exasperated by pressure and by movement. The 
 patient instinctively seeks repose and avoids all mus- 
 cular contractions, lying on the opposite side from the 
 pain. In some cases the patients feel in the bones 
 and joints a sort of a deep and piercing pain, which, 
 according to Jaccoud, indicates an intra-vertebral 
 origin of the neuralgia. When there are, moreover, 
 alterations of sensibility, consisting in formications, 
 tingling, aching sensations in the back, the neuralgia 
 has for its origin a lesion of the cord or meninges 
 acting on the posterior columns. 
 
 Apart from the attack some patients suffer little 
 and are able to work. Others become incapacitated, 
 
 * Jaccoud, Path. Interne, t. I, p. 502. 
 
— 54 — 
 walk with difficulty, limping, or even are compelled to 
 cease walking altogether. 
 
 Besides these pains, disorders of the cutaneous 
 sensibility have been noted, and Hubert Valleroux de- 
 scribes sensory troubles (pertaining to tactile sensibil- 
 ity, sensibility to temperature, etc.), especially occu- 
 pying the posterior region of the thigh, or four or five 
 fingers' breadth below the popliteal space; atrophy of 
 the affected member has been noted; a slow, muscular 
 atrophy in the pure neuralgias, a more early atrophy 
 in the neurites. Some writers have observed changes 
 in the temperature and in the color of the skin, 
 erythema, furunculi, patches of herpes along the tract 
 of the nerve. 
 
 Sciatica has a very irregular march. It may cease 
 spontaneously and periodically; its duration is very 
 variable, from several days or weeks to years. Re- 
 lapses are frequent."* 
 
 Treatment. — The general principles of treatment 
 applicable to the other neuralgias are applicable to 
 sciatica. 
 
 Of the new methods of treatment, the chloride of 
 methyl spray is perhaps the most noted. A peculiar 
 apparatus is needed to carry out this treatment, which 
 is attended with congelation, smarting and burning, 
 but afterwards with marvellous relief. Dujardin- 
 Beaumetz says that in real sciatica he has generally 
 
 Reprinted from "Clinical Therapeutics." 
 
- 55 — 
 found the pain to cease after one or two applications 
 of chloride of methyl spray. (See the subject treated 
 fully in New Medications, published by G. S. Davis, 
 Detroit, page 285.) 
 
 The ether spray, directed over the affected nerve 
 or nerves, gave great relief to one of my patients in 
 his atrocious paroxysms. 
 
 Cotugno was the first to propose cantharides 
 blisters, and all subsequent authorities have spoken 
 well of them. The blisters should be of the size of 
 the palm of the hand, and applied at intervals of two 
 or three days over the painful regions. Anstie recom- 
 mends blistering to the sacrum — the blisters may be 
 dressed with some simple ointment and healed, then 
 put on again. 
 
 The actual cautery has been recommended by 
 Valleix, Jobert, and others — light, superficial, " trans- 
 current " cauterization being employed. 
 
 Faradization by the electric brush has had its 
 advocates. Erb has seen brilliant cures from galvan- 
 ism of the affected nerve — the anode being placed 
 upon the sciatic foramen, or sacrum, and the cathode 
 upon the specially painful parts. 
 
 Among specific remedies, oil of turpentine has 
 been extolled; oil of turpentine, 3 j, honey, |j; a 
 tablespoonful twice daily. 
 
 Neurotomy and nerve-stretching have not given 
 very satisfactory results; neurotomy is not to be rec- 
 ommended except when the pain is confined to a 
 small branch. 
 
-56 - 
 
 But almost always the resort must be had, sooner 
 or later, to chloroform injections, antipyrin injections, 
 or to narcotics. The deep injection of chloroform 
 into the substance of the gluteal muscle over the 
 nerve, is Bartholow's method; (see Appendix, page 
 116). Antipyrin may also be used to advantage hypo- 
 dermically (see also Appendix, article "Antipyrin"). 
 Opium may be used in the form of enema; 30 drops 
 of laudanum to 2 ounces of thin starch, the injection 
 to be retained. Generally the narcotic will be more 
 speedy and effectual if employed in the form of mor- 
 phine injections subcutaneously administered (for di- 
 rections, see Appendix, article " Opium "). Hammond 
 gives instances where the hypodermic of morphine 
 was given every day for three or four months. This 
 treatment would be quite certain to make a morphio- 
 maniac of the patient. 
 
 Doubtless, in the congestive attacks produced by 
 cold, revulsion by irritant liniments (menthol, turpen- 
 tine, etc.) and vesicants do the most good, while in 
 the purely rheumatic form benefit may be expected 
 from a prolonged course of iodide of potassium. 
 
CHAPTER V. 
 
 VISCERAL NEURALGIAS. 
 
 The internal organs are mainly supplied with 
 nerves from the great sympathetic. Although the 
 ganglionic nerves are sensory as well as motor, yet 
 the sensibility of the sympathetic system differs in 
 many respects from that of the cerebro-spinal system. 
 In the normal functionment of organs innervated by 
 the sympathetic, there is little sensibility and never 
 pain. We are not, for instance, in health cognizant 
 of the state of our digestive tube during digestion; 
 the changes which the food is undergoing do not 
 enter as an element into our consciousness, unless, it 
 may be, in contributing to a massive, vague, indefin- 
 able sensation of bien-etre, called by Maudsley, cosn- 
 cesthesis* In pathological states, however, the sen- 
 sory elements of the sympathetic declare their exist- 
 ence by vague impressions of discomfort, if not by 
 actual pain. Pain of a severe kind is experienced in 
 gastric cancer as well as in gastralgia, in enteritis, etc., 
 and the uterus, which in the normal state is insensi- 
 tive, in various morbid conditions may be the seat of 
 severe pain. 
 
 * "The general feeling of well being which results from 
 a healthy condition of all the organs of the body * * * is 
 known as the ccencesthesis ." Maudsley, Physiology and Path- 
 ology of the Mind, page 135. 
 
-5« - 
 
 In neuralgia of the viscera, the pain is deep 
 seated, sometimes a dull, heavy ache, sometimes of a 
 boring character, rarely lancinating. " It does not 
 dart, like the pain of superficial neuralgia, but is 
 either constant or comes in waves which steadily 
 swell to a maximum and then die away, often leaving 
 the patient in a state of profound temporary prostra- 
 tion " (Putnam).* 
 
 The pain is generally diffused, and there are no 
 definite points douloureux although the organ may be 
 tender to touch. In severe attacks there are painful 
 irradiations, as in the superficial neuralgias. Pressure 
 generally relieves the pain, it never provokes an at- 
 tack. 
 
 General disorders like those that attend the neu- 
 ralgias of the cerebro-spinal system accompany the 
 visceral neuralgias, in virtue of the law that one part 
 cannot suffer without entailing suffering on the whole. 
 Besides the loss of appetite and the decadence in the 
 nutritive functions with consequent emaciation, there 
 are reflex disturbances which are often of a serious 
 nature; witness the nausea, vomiting, indigestion, con- 
 stipation, which attend uterine or ovarian neuralgia. 
 The functions of the organ which is the seat of the 
 neuralgia are also more or less disturbed or interrup- 
 ted; thus, in gastralgia, digestion is suspended, and 
 food, if taken, provokes vomiting. 
 
 * Pepper's Syst. American Medicine, Vol. v, page 1215. 
 
— 59 — 
 
 It is needless to say that the causes of visceralgia 
 are the same as those which produce neuralgias of the 
 cerebro-spinal system, and that neuralgias of the 
 sympathetic are often interchangeable with the super- 
 ficial neuralgias which occur in states of anaemia and 
 prostration, in persons of a neuralgic habit, etc. 
 
 Uterine and Ovarian Neuralgia. — It is now gen- 
 erally conceded that the uterus is sometimes the seat 
 of a suffering which is essentially neuralgic. There 
 is, for instance, a form of dysmenorrhea called, by 
 common consent, neuralgic. The pain is independ- 
 ent of all organic disease; it is not due to any ob- 
 struction to menstruation, but attends the monthly 
 function on account of an exaggerated irritability of 
 the ovaries. The pain manifests itself before or after 
 the beginning of menstruation, and may cease when 
 the flow becomes established, or may continue through 
 the period.* 
 
 In some patients the whole period is one of in- 
 tense suffering; commencing 'with sharp, darting, 
 lancinating pain in the uterus and vagina, and extend- 
 ing down the thighs. There is often severe reflex 
 pain in one or both breasts. 
 
 Hysteralgia is sometimes coincident with neural- 
 gic affections of the cerebro-spinal nerves, sometimes 
 it takes the place of the latter; it is apt to occur in 
 persons of the neuralgic disposition. 
 
 *Jenks, Diseases of Menstruation, Detroit, 1887. 
 
— 6o — 
 
 Anstie speaks of a class of cases, which, I believe, 
 are sufficiently common in the experience of physi- 
 cians, where the affection " appears to be a severe 
 ovarian neuralgia, attended with a vaso-motor par- 
 alysis which causes great engorgement of the ovary 
 and consequent difficulty of ovulation."* He also 
 believes that peri-uterine neuralgia is often due to 
 peripheral irritation, arising from such sources as the 
 following: Ascarides in the rectum; profuse and 
 irritable leucorrhoea; calculus in the kidney and 
 ureter; prolapsus uteri; tumors in the uterus or its 
 appendages; ulcer of the cervix; large masses of 
 scybalous faeces in the rectum, etc. 
 
 Treatment. — In the endeavor to alleviate uterine 
 neuralgia, the general principles of treatment to be 
 hereafter set forth are applicable. A fortifying regi- 
 men is to be insisted upon, of which exercise in the 
 open air is an essential part. All delicate females are 
 the better for judicious gymnastic training. Hydro- 
 therapy properly administered is a powerful adjuvant 
 to the treatment. Some cases of neuralgic dysmen- 
 orrhea are cured by marriage. 
 
 The diathesis should be kept in view; anaemic 
 and chlorotic patients require iron, arsenic, strychnia, 
 and all the elements of the haematic and tonic regi- 
 men. Rheumatic cases demand salcl, iodide of 
 potassium, and especially guaiacum. Dewey's ammo- 
 
 * Anstie, on Neuralgia, Etc.; Am. ed ; p. 72. 
 
— 6i — 
 
 niated tincture has had considerable repute in rheu- 
 matic dysmenorrhea. 
 
 Jenks* speaks favorably of electricity; a mild 
 galvanic current down the spinal column for ten min- 
 utes, and a strong current through the pelvis; the 
 whole sitting not to exceed twenty-five minutes. 
 
 Among the external remedial agencies, revulsive 
 applications to the os and cervix with the Paquelin 
 cautery, or the acid nitrate of mercury have the en- 
 dorsement of Dujardin-Beaumetz.f 
 
 Narcotics will often be required where simpler 
 remedies fail to relieve the pain, and here supposi- 
 tories of opium, morphine, belladonna, will render 
 good service. Jenks gives several formulae in his 
 useful little book on the Disorders of Menstruation, 
 which belongs to the series of 1887. The morphine 
 suppository of the U. S. Ph. has proved useful in my 
 practice. Lavements of thin starch and laudanum 
 have also promptly relieved the pain. 
 
 Of late, antipyrin, by mouth, hypodermic injec- 
 tion, or lavement, has been attended with excellent 
 results. Germain See especially recommends the ad- 
 ministration by lavement. The following formula 
 may be employed : Antipyrin, 3 i; starch, § ij. M. 
 For one injection, which should be retained. 
 
 Jenks speaks well of cimicifuga racemosa, begun 
 
 * Loc. cit., p. 60. 
 
 f Clinical Therapeutics, Detroit ed., page 73. 
 
— 62 — 
 
 two or three days before the flow, and continued at 
 brief intervals through the entire period. The dose 
 would be half a fluid drachm to a drachm every four 
 or six hours. The tincture of Pulsatilla in three- 
 drop doses every two hours while the pain lasts has 
 been highly recommended. 
 
 The fluid extract of black haw (viburnum pruni- 
 folium) in teaspoonful doses every four hours has 
 achieved good results in neuralgic dysmenorrhea. 
 The liquor sedans of P., D. & Co. has viburnum pruni- 
 folium along with Jamaica dogwood and hydrastis 
 Canadensis. 
 
 Neuralgias of the bladder, urethra, testicle, and 
 spermatic cord, have been observed. A neuralgia of 
 the liver, under the name of hepatalgia, has also been 
 described. A more common form is neuralgia of the 
 stomach, known as: — 
 
 Gastralgia, or gastrodynia. — This is a very painful 
 affection, met with in persons of a delicate, neuro- 
 pathic temperament. It is often associated with 
 anaemia, sometimes with hysteria. In other cases, 
 arthritis is the underlying element. One very severe 
 case which came under my observation attended over- 
 work and lactation in a patient who had been a suf- 
 ferer from neuralgia. 
 
 It is probable that gastralgia is a neuralgia of the 
 pneumogastric nerve, as the stomach is supplied with 
 sensory as well as motor fibres from that nerve. 
 
 The special characteristics of true neuralgic pain 
 
- 63 — 
 
 in the abdominal pneumogastric nerve, are: (i) It 
 comes on in states of exhaustion; (2) unlike dyspep- 
 tic pains, it is relieved by food; (3) it is also relieved 
 by stimulants, as brandy and water, thus resembling 
 colic; (4) it is diminished by pressure, which aggra- 
 vates most pains dependent on local organic mischief 
 (Anstie). " The most severe example of gastralgia 
 which I have ever seen," says Anstie, "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." 
 
 Although gastralgia is not dependent on dyspep- 
 sia, it is sometimes provoked by food, even of a bland 
 and digestible character, just as neuralgic attacks of 
 the peripheral nerves are frequently provoked by 
 ordinary stimuli. One marked instance of this kind 
 has come under my observation, which was in this 
 sense an exception to the rule as laid down by An- 
 stie.* 
 
 Treatment. — Causal indications, as far as possi- 
 ble, must be attended to; anaemia and chlorosis de- 
 mand the appropriate remedial agents. Leubef 
 
 * Mrs. A. , living in Beck street, Newburyport, for weeks 
 a sufferer from typical gastralgic attacks, which at certain 
 times were brought on by anything whatever introduced into 
 the stomach, and were not relieved by free vomiting. 
 
 f Ziemssen's Cyclop., vol. vii., p. 306. 
 
- 6 4 - 
 
 speaks favorably of the lactate of iron in 3-grain 
 doses with equal parts of aromatic powder or extract 
 of cinchona. 
 
 In gastralgia due to hysteria, arthritis, etc., the 
 underlying diathesis must be treated. Gouty or 
 lithsemic patients require alkalies (Vichy water, lithia, 
 potas. carbonate), colchicum, saline laxatives, the 
 proper dietary regimen, and possibly a derivative 
 treatment. Garrod recommends that the attempt be 
 made by warmth and counter-irritants to excite deriv- 
 ation to the joints. 
 
 If the stomach be in such a hypersesthetic condi- 
 tion that food excites the pain, it is still better that 
 food be taken; there is nothing gained by a starva- 
 tion treatment. 
 
 As special remedies, Anstie speaks highly of nux 
 vomica; ten drops of the tincture to be taken three 
 times a day. The hyperaesthetic stomach is some- 
 times benefited by full doses of bismuth, or oxalate of 
 cerium. Hypodermics of morphine may be demand- 
 ed. Leube especially recommends galvanism: ten to 
 fifty elements, the anode upou the painful point of 
 the epigastrium, the cathode on the left axillary line; 
 the application to be kept up from five to ten min- 
 utes.* 
 
 * Leube, loc. cit. 
 
- 65 - 
 
 ANGINA PECTORIS AND THE TRUE CARDIAC NEU- 
 RALGIAS. 
 
 There is a form of cardiac pain which is always of 
 bad prognosis, because indicative of organic and gen- 
 erally incurable lesion. It was first correctly described 
 by Rougnon, and nearly simultaneously by Heberden, 
 in 1768; it was afterwards called Heberden's disease, 
 though Heberden gave it the name of angina pectoris, 
 the word angina being indicative of the peculiar an- 
 guish accompanying the attack. Seneca, who appears 
 to have been a sufferer from angina pectoris, speaks 
 in one of his letters of the suddenness of its invasion, 
 which he compares to the impetuousness of a tempest 
 (brevis impetus, procellce, simi/is); and he adds that the 
 predominant sensation is one of anguish as of impend- 
 ing death. 
 
 This kind of cardiodynia has its seat in the ter- 
 minal cardiac filaments of the pneumogastric nerve, 
 and is due to ischasmia of the heart muscle. The 
 old theory was that angina pectoris is a primary or 
 symptomatic neurosis of the cardiac plexus. This is 
 denied by the best recent authorities, who compare 
 the pain to that attending gangrene from occlusion of 
 an artery. 
 
 " Let us suppose," says Germain See,* " that the 
 myocardium receives less than its normal quantity of 
 
 * G. See: Maladies du Coeur, 2d ed., 1883, P- 30. 
 
 5 MM 
 
— 66 — 
 
 blood; the terminal extremities of the vagus will re- 
 ceive less also. Now oligemia of a sensory nerve 
 manifests itself by pain. This oligaemia also accounts 
 for the peculiar distress, the anger." 
 
 Huchard. in a recent work on arterio-sclerosis 
 and the arterial cardiopathies!, which is the most 
 complete by far that has yet appeared, sums up the 
 numerous anatomatical and other theories, and gives 
 weighty reasons for the view, which he holds in com- 
 mon with Balfour, Kreysig, Tiedemann, Potain, Parry, 
 Liegois, See, and others, that true angina pectoris is 
 always dependent on lesions (sclerosis, thrombosis, 
 atheroma, sometimes, however, spasm) of the coronary 
 arteries, with ischaemia of the myocardium. The or- 
 dinary lesion is arterio-sclerosis, which is sometimes of 
 toxic origin (diathetic, alcoholic, nicotinic), sometimes 
 a senile degeneration. 
 
 There is an angina pectoris which ends almost 
 always in sudden death; there are other kinds of car- 
 diodynia, quite as distressing, which almost invariably 
 terminate in recovery. The latter are functional and 
 nervous. Huchard ranges the latter under the head 
 of false angina pectoris (pseudo angina); they con- 
 stitute the true neuralgias of the heart. 
 
 Huchard divides the peculiarly neuralgic forms 
 into three classes: the neurotic, the reflex and the 
 
 f Huchard: Maladies du Cceur et des Vaisseaux, etc., 
 Paris, 1889. 
 
- 6 7 - 
 
 toxic. He formerly added a fourth the diathetic; 
 but, he is now conviced that this, as a separate class, 
 has no raison d'etre. 
 
 (i.) The neurotic is that painful condition of 
 the cardiac innervation which has its origin in the 
 state of the nervous system accompanying hysteria, 
 neurasthenia, hypochondria, exophthalmic goitre, 
 spinal irritation, neuro-arthritism, and (according to 
 some authors) epilepsy. 
 
 (2) The reflex form, of peripheral or visceral 
 origin, takes its point of departure in some distant 
 irritation, as of the stomach, uterus, etc., which is re- 
 flected on the cardiac plexus. Huchard, under this 
 head, gives instances of reflex pseudo-angina accom- 
 panying intercostal neuralgia, painful peripheral ex- 
 citation of the nerves of the extremities, neuromata, 
 and neuralgia of the left arm. 
 
 (3) The toxic form, is perhaps, oftener caused 
 by tobacco than by any other agent, and this (the 
 nicotinic) is given as the typical, toxic species, though 
 cases have been referred to tea, coffee and alcohol. 
 There is a functional cardiodynia from tobacco-smok- 
 ing relatively benign, resulting from spasm of the 
 coronary arteries; this Huchard calls spasmo-nicotinic 
 angina. There is another kind, also due to abuse of 
 tobacco, which is dependent on arterio-sclerosis; he 
 calls it sclero -nicotinic angina. 
 
 The following table from Huchard, gives the 
 principle distinctive features of the true and spurious 
 anginae: 
 
— 68 — 
 
 TRUE, ARTERIAL ANGINA PECTORIS. 
 
 Anatomical Cause. — Aortitis, with obliteration of the coro- 
 nary arteries. Sclerosis, with constriction or obliteration of 
 the coronaries. An arterial affection. 
 
 Symptoms. — Pains almost always paroxysmal, not per- 
 manent, provoked by walking, emotional excitement, effort. 
 Rarely periodical and nocturnal attacks. Cardiac pain isolated 
 from other neurotic symptoms. Agonizing pain, with sensa- 
 tion of compression as a vise. Pains of short duration, ceasing 
 with repose. Sub-sternal seat of the pain, generally over the 
 aorta. 
 
 Attitude of the Patient. — Silence, arrest of all movements, 
 the pain ceasing with absolute rest. No painful points, but 
 the latter may be present when true angina is complicated with 
 cardiac and phrenic neuritis by propagation of the peri-arteritis 
 to the plexuses of nerves in the vicinity. Often sub-sternal 
 anguish without pain. 
 
 Prognosis. — True angina pectoris is almost always fatal. 
 
 Treatment. — Arterial medication. Revulsives of no ac- 
 count. 
 
 FALSE, NEURALGIC ANGINA. 
 
 Anatomical Causes. — Aortitis with neuritis of the cardiac 
 plexus. Hyperaemia oi the cardiac plexus. Neuralgia of the 
 cardiac plexus. A neuralgic or neuritic affection. Often (as 
 in hysteria) a vasomotor neurosis. 
 
 Symptoms. — Pains less frankly paroxysmal, often peri- 
 odical, coming on at the same hour (hysterical, neurasthenic, 
 pseudo-angina); not provoked by effort, bat often caused by 
 cold. Attacks frequently periodical, recurring at fixed hours, 
 and nocturnal. Cardiac pain associated with other neurotic 
 symptoms. Pain less agonizing, with sensation of distention 
 of the heart. Pains of long duration, not ceasing by repose. 
 Seat of the pain often frankly cardiac. 
 
-69 - 
 
 Attitude of the Patient. — Incessant agitation. Continu- 
 ance of walking; rest brings no diminution of the pain. Exist- 
 ence of points painful to pressure, especially along the tract of 
 the phrenic nerves (neuritis of the cardiac plexus and of the 
 diaphragmatic nerve). Anguish less pronounced, always asso- 
 ciated with the pain. Pseudo angina is never fatal, except in 
 cases where the cardiac neuritis is associated with coronary 
 sclerosis. 
 
 Treatment. — Anti-neuralgic remedies. Revulsives often 
 beneficial. 
 
 REFLEX, NEURALGIC, PSEUDO-ANGINA PECTORIS. 
 
 A nervous affection. 
 
 Symptoms. — Attacks spontaneous at times, but often pro- 
 yoked by movements of the left arm, and by pressure over the 
 painful nerves. Depends on some other (peripheral) neuralgia 
 (brachial, dorso-intercostal), on gastric or other visceral dis- 
 order. Is observed at all ages. Attacks long, not provoked 
 by effort. Attention is early called to the visceral or other, 
 affection. Pain precordial, with feeling of distention; little 
 irradiation to arm and neck. In gastric pseudo-angina, signs 
 of dilatation of the stomach often accompany it. Prognosis be- 
 nign, never terminates in death. 
 
 Treatment. — Revulsives, calmatives, anti-neuralgic reme- 
 dies, anti-dyspeptic remedies. 
 
 TOXIC PSEUDO ANGINA (FROM TOBACCO). 
 
 (Generally by spasm of the coronaries.) 
 
 Symptoms. — Attacks of angor, generally associated with 
 other phenomena of a toxic kind; vertigo, gastric and respira- 
 tory troubles, etc. Cardiac pain accompanied by other func- 
 tional heart symptoms, such as palpitations, intermittences, 
 arythmia, lipothymia, etc. Attacks long. Paroxysms gener- 
 ally spontaneous, rarely provoked. 
 
 Prognosis. — Rapid disappearance of the symptoms by 
 suppression of the toxic cause. 
 
— 7© — 
 
 Huchard gives an exemplification of the difficulty 
 under which the clinical observer must sometimes 
 labor in diagnosticating the affection. " In gout he 
 may have thoracic angor under three conditions: (a) 
 it is either a true angina, arising from an arterial 
 lesion (arterio-sclerosis, atheroma of the coronary 
 arteries, lesions of the aorta, etc.) to which gouty per- 
 sons are always predisposed; or {b) gastric troubles, 
 frequent in gouty patients, may provoke attacks of 
 false angina pectoris which may terminate in recovery; 
 or (c) the angina pectoris may be a neuralgic attack, 
 such as gouty neurasthenic invalids are prone to." 
 
 In true angina pectoris, the leading indication is 
 to remedy the cardiac ischsemia which causes the 
 pain. This indication can be only partially met by 
 the so-called vaso-motor dilators, — nitrite of amyl 
 (two or three drops to be inhaled from the open 
 palm); nitro-glycerin (frequent drop doses of the 
 centesimal solution); and iodide of sodium, which, ac- 
 cording to Huchard, should be given in ten-grain 
 doses three or four times a day for a long time. 
 Hypodermics of morphia seems to favor the capillary 
 circulation, as well as allay nervous irritation, and will 
 be often demanded in severe paroxysms. 
 
 In the pseudo forms, the general anti-neuralgic 
 and revulsive treatment will be called for, due atten- 
 tion being given to the cause, whether peripheral, 
 visceral, or toxic. 
 
CHAPTER VI. 
 
 REFLEX AND TOXIC NEURALGIAS. 
 
 NEURALGIAS DUE TO A GENERAL MORBID CONDITION. 
 
 Reflex neuralgias are caused by a lesion more or 
 less distant from the seat of pain. The irritation is 
 transferred or reflected from one set of nerves to the 
 terminal filaments of another through the medium of 
 the cerebro-spinal or sympathetic system. The sympa- 
 thetic nerve is ordinarily the seat, and the primary 
 cause of the pain generally resides in some one of the 
 viscera, although the painful reflex may start in a 
 cerebro-spinal nerve branch; an instance of this is 
 seen in the severe eye-ache or brow-ache which some- 
 times attends a carious tooth that may itself be pain- 
 less. Lisfranc *once obtained the cure of a sciatica by 
 the extirpation of a painless vaginal polypus. Other 
 examples of reflex neuralgias are found in the hepa- 
 talgia accompanying gastritis, gastralgia caused by 
 taenia, cystalgia due to an affection of the kidneys. f 
 
 *Vanlair, Loc. cit. 
 
 \ "When no local pain is felt, we must assume that the 
 centre to which the apparent impressions directly come is not 
 thus excitable to painful activity, or even so as to influence 
 consciousness, but that it is in connection with another centre 
 which by natural or acquired susceptibility is disposed to ex- 
 cessive action," "(Gowers' Neuralgia, Its Etiology, Diagnosis, 
 and Treatment," p. 27.) The above is essentially Vanlair's 
 explanation of reflex neuralgias, where the pain seems to spare 
 the sensory centres of the region in which the cause exists, to 
 be reflected on some distant centre. 
 
— 72 — 
 Eye-strain is a fruitful cause of headache and 
 neuralgia. This has been made very clear by Dr. 
 Ambrose L. Ranney, in an article in a late number of 
 the New York Medical Record: 
 
 For some years past it has been my custom to examine 
 repeatedly and with care, the visual apparatus of every patient 
 sent to me for the relief of headache and neuralgia, I have 
 already published, from time to time, many cases where this 
 line of research has been followed by marked and permanent 
 benefit.* 
 
 I deem it worthy of remark, in this connection, that less 
 importance is being attached to day than formerly to the clini- 
 cal determination of modifications in the calibre of the blood- 
 vessels of the brain. 
 
 The conditions known as "cerebral congestion," or 
 " cerebral anaemia" of certain authors who have written ex- 
 tensively upon headache and neuralgia, are very often the 
 results of underlying factors. 
 
 Their existence (as has been claimed) may sometimes be 
 revealed by the ophthalmoscopic examination of the vessels of 
 the retina and confirmed by the effects of nitrite of amyl upon 
 the patient; but when so, they are probably to be regarded 
 rather as an evidence of a functional derangement of the vaso- 
 motor system of nerves, than as permanent factors in head- 
 aches or neuralgias. 
 
 I have known many patients who have followed, with 
 negative results, a prolonged course of treatment (by ergot, 
 bromides, amyl, etc.), which was based upon the examination 
 of the retinal vessels, and I have often seen them recover from 
 their headaches and neuralgias without drugs when an anomaly 
 of the refraction or of the muscular adjustment of the eyes was 
 corrected. 
 
 I would not be construed as denying that the blood- 
 vessels of the brain might not have been abnormally dilated or 
 peculiarly contracted in many of these cases at the time when 
 their retinal vessels were examined; nor would I utterly reject 
 
 * New York Medical Journal, January, 1888; Lectures oq Nervous 
 Diseases, Philadelphia, 1888 (F. A. Davis, Publisher); Medical Register, 
 Philadelphia, November 19, 1887. 
 
— 73 — 
 
 the hypothesis that the retina sometimes affords us a valuable 
 means of determining by our sense of sight the condition of 
 the cerebral vessels in any given individual. 
 
 What I do mean to assert is this: That changes in the 
 cerebral circulation (as is often observed in the case of a blush 
 upon the cheek) may be caused by subtle nervous influences 
 that ergot, bromides, nitrite of amyl, or other drugs will not 
 arrest; that a classification of headaches or neuralgias which is 
 based upon so variable a sign is unscientific; and that any line 
 of medication which is directed toward this condition alone is 
 very liable to be unsatisfactory, both to the physician and his 
 patient, sooner or later. 
 
 To illustrate this point I will mention a remarkable ex- 
 perience of my own that impressed me strongly at the time. 
 
 Some ten years ago, when almost in despair from con- 
 tinuous and intractable headache, and doubtful of my ability to 
 long endure it, two oculists of equal prominence and ability 
 were asked by me to examine my retinae by means of the 
 ophthalmoscope. 
 
 One diagnosed my condition as " typical nicotine poison- 
 ing of the retina;" the other discovered what seemed to him to 
 be conclusive evidences of " congestion of the brain," and that 
 nothing but prolonged rest from work, in his opinion, could 
 relieve. Neither suggested the detection of any "lateral " re- 
 fractive error, or the use of glasses. My sight was apparently 
 perfect and unusually acute. 
 
 Subsequently the instillation of atropine into my eyes 
 (which was used at my earnest solicitation) and the correction 
 by proper convex glasses of a hypermetropia of 3.00 diopters 
 (not previously suspected) restored me to health and comfort 
 as if by magic. A complete and immediate cessation of all 
 pain for over nine months followed the correction of my 
 refractive error; and for many years I have been almost en- 
 tirely free from pain, in spite of continuous eye-work at my 
 desk and elsewhere." 
 
 Dr. Ranney reports fifty cases of headaches — 
 supra-orbital, frontal, and occipital neuralgias, which 
 were relieved or cured by tenotomy of the recti mus- 
 cles, or by suitable corrective glasses. He urges the 
 necessity of using atropine upon a patient for diag- 
 
— 74 — 
 
 nostic purposes when an error of refraction or of 
 accommodation is suspected. 
 
 " Personally," he adds, " I do not regard an examination 
 as complete without it. It solves the common question of the 
 presence of latent' hyperopia — a very common defect, and 
 possibly a very serious one (irom the stand-point of the neu- 
 rologist) if allowed to go unrecognized. It reveals the exist- 
 ence of a previous ciliary spasm. It often arrests headache 
 as if by a magic touch, and solves the nervous origin of many 
 other similar symptoms.' 1 * 
 
 These reflex neuralgias are familiar to everybody 
 who has known headache from indigestion or from 
 constipation. The disturbances of the alimentary 
 canal are reflected upon sensory branches of the 
 fifth nerve; here relief can only be obtained by rem- 
 edies which correct the disorders of the digestive 
 tube. I know persons whose "bilious headaches" (as 
 they are called in the older terminology) are speedily 
 remedied by an emetic of ipecac or a calomel purge; 
 others can only keep free from these headaches by 
 rigid dieting and some mild stomachic and aperient, 
 like the infusion of rhubarb and cardamoms: 
 
 (5 Rhubarb, in coarse powder, 
 
 Cardamom seeds (bruised), aa 3 i, 
 Aquae ferventis, § viii. 
 M. Infuse half an hour, strain, and take a wine-glassful 
 when the stomach is oppressed. 
 
 Pathology is full of instances of disturbances of function 
 owing to a morbid irritation in a distant part of the body. 
 Thus, the irritation of teething sometimes causes convulsions, 
 
 New York Medical Record, Jan. 2?, 
 
— 75 — 
 
 and a prolapsed uterus has been known to cause melancholia. 
 Maudsley thus explains this reflex transmission: "A molecu- 
 lar change in the interior of a nerve being set up by the pri- 
 mary irritation * * * is carried to any part with which it 
 is in connection by continuity of nerve structure; when the 
 molecular agitation reaches a motor centre it is reflex move- 
 ment or reflex paralysis; when it reaches a sensory centre it is 
 reflex or sympathetic sensation; when it reaches the supreme 
 ideational centres it may occasion reflex disorder of thought, 
 feeling, and will." 
 
 Toxic Neuralgias. — A good instance of neuralgia 
 of toxic origin is the hemicrania which sometimes 
 attends renal insufficiency and ursemic poisoning. This 
 kind of neuralgia has, however, been classed by some 
 authorities among the holopathic, which are due to a 
 general morbid state. (See Vanlair's table). Lead colic 
 is an obstinate neuralgia of the abdominal walls from 
 lead poisoning. The pain ordinarily starts from the 
 umbilicus and radiates through the entire abdominal 
 muscles. It presents at times atrocious paroxysms; is 
 ordinarily accompanied by nausea, vomiting, and con- 
 stipation. The treatment is by calmatives, purga- 
 tives, and iodide of potassium; the latter favors the 
 elimination of lead from the system. 
 
 The osteocopic pains of syphilis have been 
 classed among the toxic neuralgias. Here the spe- 
 cific treatment alone will do good; small doses of cal- 
 omel, -fa grain every hour for a day or two, sometimes 
 work marvellous results. 
 
 Syphilitic neuralgia is also a holopathic neuralgia, 
 
_ 7 6 - 
 
 according to Vanlair. But syphilis is attended with 
 palpable lesions which cause pain, and the existence of 
 true neuralgia from syphilis has been disputed. 
 
 Some cases of neuralgia from mercurial saliva- 
 tion have been noticed. Anstie narrates one of a 
 young girl, who not only lost every tooth in her head 
 and suffered extensive exfoliation from the maxillae, 
 but after the process was over suffered frightfully 
 from neuralgic pains in her arms and legs. This pa- 
 tient got better under tonics and cod liver oil, but 
 was never fully restored. In neuralgia from abuse of 
 mercury, it is found that iodide of potassium in as 
 large doses as can be borne, and continued for months, 
 gives the most relief. 
 
 Neuralgias from alcohol, tobacco, arsenic, and 
 ergot, have also been noted; these agents operate not 
 so much by their irritant properties as by bringing 
 about a condition of malnutrition and dyscrasia. 
 
 Under the head of toxic neuralgias might also be 
 ranged many neuralgias which, like the neuralgias of 
 syphilis and Bright's disease, are due to some morbid 
 material in the blood depressing innervation and dis- 
 turbing nutrition; they are also neuralgias due to a 
 general morbid state. Thus writers have spoken of: 
 
 i. Gouty Neuralgia. Gouty neuralgia has a 
 predilection for the viscera, especially for the gas- 
 trointestinal canal (Vanlair), and for the sciatic 
 nerve. These neuralgias sometimes take the place of 
 the regular gouty paroxysm (having thus a metastatic 
 
— 77 — 
 character); they disappear under the influence of an 
 arthritic attack (gout in the great toe), or even of 
 a cutaneous eruption; they coincide with the uric 
 acid diathesis; the exciting cause is often exposure to 
 cold, even an unusual dampness in the atmosphere. 
 These neuralgias are benefited by calmatives, by 
 derivation to the usual seats of election of the gout, 
 by alkalies, by colchicum, by drastic purgatives, and, in 
 short, by the general treatment of gout. 
 
 2. Rheumatic Neuralgia. It has been customary 
 to regard those painful attacks which are consequent 
 on " catching cold " (as when a person is exposed to 
 cold and wet, and has severe pains in the muscles of 
 the neck, in the shoulders or back, in the tract of the 
 sciatic nerve), as rheumatic neuralgia. Undoubtedly 
 face-ache and migraine are often excited by sitting in 
 a draught. There is much obscurity with regard to 
 the pathogeny of neuralgia a frigore, as well as of 
 rheumatic neuralgia generally; nor is even the partic- 
 ular materies morbi of rheumatism yet known. Erb 
 believes that in these rheumatic neuralgias, slight in- 
 flammatory conditions of the neurilemma are com- 
 monly present (hyperemia, swelling, exudations, etc.) 
 Eulenburg states that neuralgia caused by cold, more 
 frequently attacks the sciatic nerve than any other, and 
 thinks that the tendency to sciatica is characteristic of 
 the relation of rheumatism to the sensory nerves.* 
 
 Cited by Anstie. 
 
- 7 8 - 
 
 To justify one in calling any particular neuralgic 
 attack rheumatic, he would have to show a history of 
 previous rheumatism; it would not be enough to infer 
 a rheumatic origin from the fact that the attack fol- 
 lowed exposure to cold and wet. It is doubtful 
 whether rheumatism or the rheumatic diathesis has 
 any very frequent causal connection with any form of 
 neuralgia. 
 
 3. Diabetic Neuralgia. — Neuralgia has some- 
 times occurred in instances where it was convenient 
 to trace the painful affection to a " glycaemic crasis " 
 of the blood, and where an anti-diabetic regimen has 
 alleviated or cured the pain. Worms* has made a spe- 
 cial study of this neuralgia; these are his conclusions: 
 
 (1). There exists a special form of neuralgia 
 proper to diabetes, which presents for its character a 
 disposition to be seated in the two symmetrical 
 branches of a same nerve; 
 
 (2) Thus far, this symmetrical neuralgia has 
 been chiefly observed in sciatica, and in the inferior 
 dental nerve; 
 
 (3) Diabetic neuralgia appears to be much more 
 painful than the other neuralgias; 
 
 (4) It does not yield to the ordinary treatment 
 of neuralgias (quinine, morphine, bromides, etc.); 
 
 (5) It is aggravated or mitigated coincidently 
 with the aggravation or attenuation of the glycaemia. 
 
 * Vanlair, loc. cit., p. 309. 
 
— 79 — 
 
 4. Albuminuric Neuralgia. — There is probably 
 no disease that more profoundly modifies and vitiates 
 the blood than Bright's disease in its advanced stages. 
 Irritation and degeneration of the nervous centres is 
 certain to follow; hence the stupor, the convulsions, 
 the obstinate headaches, the amaurosis of chronic 
 parenchymatous or interstitial nephritis. The head- 
 aches of albuminuria are ursemic (whatever that word 
 may mean); they are generally seated about the brow 
 or vertex, are obstinate, lasting in some cases five or 
 six weeks without much mitigation; are exasperated 
 by heat and light, and resist all ordinary therapeutic 
 means, though they sometimes yield to a thorough 
 depurative treatment. 
 
 5. Zymotic Neuralgias. — Obstinate neuralgia 
 sometimes follows the acute infectious diseases, and 
 as a result of the general blood poisoning and nerve 
 degeneration. Patients convalescing from diphtheria, 
 typhus, yellow fever, cholera, the eruptive fevers, etc., 
 besides being predisposed to the ordinary neuralgias, 
 are often afflicted with severe pains of a very peculiar 
 and puzzling nature. Such was the case of a young 
 man, a private patient whom I last year attended 
 during an attack of typhoid fever. The disease ran 
 a severe course, and convalescence only came on about 
 the thirtieth day of the fever, and was slow and 
 tedious. This patient complained of pains, some- 
 times acute and shooting, sometimes dull and contin- 
 ued, in the soles of his feet. These pains were such 
 
— 80 — 
 
 as to deprive him of his sleep, and morphine injec- 
 tions were for a long time required; they eventually 
 wore off with return of health. 
 
 Another patient whom I attended in the Anna 
 Jaques Hospital for typhoid fever, had, during con- 
 valescence, severe pains in the calves of the legs. 
 
 It should be mentioned in this connection, that 
 some authorities, as Vanlair, do not regard these neu- 
 ralgias as so much due to the presence of bacteria in 
 the blood or poisonous ptomaines, as to the degenera- 
 tive lesions of the nervous system brought on by long 
 exhausting illness. 
 
 6. Under the head of holopathic neuralgias, Van- 
 lair classes certain mestastatic neuralgias due to the 
 abrupt suppression of the menses, of a haemorrhoidal 
 flux, of chronic pulmonary catarrh, or of old ulcers. 
 He might have added, the retrocession of a cutaneous 
 eruption. I myself once witnessed the supervention 
 of a severe hemicrania in a woman on whom I had 
 operated by ligature for bleeding piles; it was only 
 after some months of rather frugal dieting, and the 
 plentiful use of Carlsbad salts, that this patient ob- 
 tained exception from headaches. Barras cites a 
 similar case, where obstinate gastralgia followed the 
 suppression of hamorrhoids. 
 
 7. Hysterical Neuralgias belong to the same 
 category of neuralgias due to a general morbid state. 
 Hysteria is responsible for a great variety of neural- 
 gic affections, ramicular, visceral, and cutaneous. 
 
— 81 — 
 
 Hysterical neuralgia is prone to take on the hemi- 
 cranial form, and the characteristic clou hysterique has 
 long attracted the attention of physicians. Hysteri- 
 cal neuralgias have a marked prediliction for the left 
 side of the body. 
 
 These neuralgias markedly resemble the idiopa- 
 thic, but their dependence on a diathesis justifies their 
 classification among the holopathic. 
 
 8. Chlorotic and Antzmic Neuralgias. — Neural- 
 gia, according to Trousseau and Pidoux, " is an al- 
 most constant symptom of chlorosis - " 
 
 The three forms most peculiar to this morbid 
 constitutional state are headache, gastralgia, and mus- 
 cular aching; the latter resembles the sensation of 
 fatigue rather than muscular rheumatism. 
 
 It is in these cases that a tonic, fortifying regi- 
 men (exercise in the open air, boating, horse-back 
 riding, skating; full diet consisting of meat, eggs and 
 fats), with iron, arsenic, and manganese, sometimes 
 works wonders. Attention to the excretions is im- 
 portant; iron does not work well if the bowels are 
 constipated; warm baths to promote the cutaneous 
 functions followed, as the patient can bear it, by cold 
 water treatment, may be important adjuvants to a 
 successful medication. 
 
 9. Malaria is frequently a cause of neuralgia, es- 
 pecially in regions where fever and ague prevail. The 
 nerves most commonly affected are the supra-orbital 
 branches of the fifth. A distinct feature of this in- 
 
— 82 
 
 termittent brow-ache is a periodicity of the attacks 
 which are separated by intervals of complete calm. 
 The type is tertian, double tertian or quartan, al- 
 though the quotidian type is by no means uncommon. 
 It is in this kind of neuralgia that quinine in full doses 
 is attended by the happiest results. 
 
 10. Ergotic neuralgia (from eating spurred rye) 
 has been witnessed in certain parts of France. The ex- 
 tremities (hands or feet) are affected with numbness, 
 tingling, darting pains (acrodynia or cheiropodalgia). 
 It is doublful if this affection can properly be called a 
 true neuralgia. 
 
CHAPTER VII. 
 
 DIAGNOSIS. 
 
 The distinguishing features of idiopathic neural- 
 gic pains are: i. Their frankly intermittent or remit- 
 tent character; 2. The suddenness of their onset 
 (Anstie gives as an example the sudden and violent 
 neuralgic pain of the eyebrow which some persons ex- 
 perience from swallowing a bit of ice); 3. The limita- 
 tion of the pain to a definite nerve trunk or the area 
 occupied by its terminal branches, and its generally 
 unilateral character; 4. The points douloureux which 
 occur in various parts of the tract of the nerves; 5. 
 The various motor, vaso-motor and trophic disturb- 
 ances which accompany the painful phenomena, and 
 which pertain principally to the area of distribution 
 or immediate vicinity of the nerve or nerves affected; 
 6. The absence of fever or other marked constitutional 
 disturbance and the signs of local inflammation; 7. 
 Finally, the characteristic common to all neuralgias, 
 that fatigue and every other depressing influence 
 directly predispose to an attack and aggravate it 
 when already existing (Anstie). 
 
 With these diagnostic characteristics in mind, one 
 will hardly confound an ordinary headache from in- 
 digestion or lithaemia with true neuralgia, for the 
 heavy character of the pain in the former instance, 
 with scarcely any tendency to ingravescence, and its 
 
— 84 - 
 
 usually bilateral situation, the nausea, languor and 
 coated tongue, which ordinarily accompany it from 
 the first, sufficiently distinguish it from migraine. 
 Moreover, these attacks of gastric headache are not 
 periodical, but arise from some error in diet, and not 
 infrequently from catarrh of the stomach. It is 
 hardly necessary to qualify the foregoing remark by 
 the statement that true migraine does sometimes find 
 its provoking cause in dietary indiscretions. 
 
 Neuralgia has been confounded with peripheral 
 neuritis; the pathognomonic features of the latter, ac- 
 cording to Nothnagel, are as follows: 
 
 i. The spontaneity and continuousness of the 
 pain. Paroxysmal exacerbations are not wanting, 
 but they are more rare than in neuralgia. 
 
 2. The peculiarly cyclical course of the attacks; 
 the pains come on, and disappear, gradually. 
 
 3. The constant awakening or exasperation of 
 the pain under the influence of pressure. 
 
 4. The cessation, after a certain time, of the 
 pains both spontaneous and provoked. (This is not 
 properly a pathognomonic sign of neuritis, seeing 
 that it is met with in other affectious of the nerve- 
 cords.) 
 
 5. The centripetal direction of the spontaneous 
 or provoked pain. 
 
 6. The precocity of the cutaneous anaesthesia. 
 
 7. The appearance of trophic disturbances in 
 the domain of the nerve; notably, alterations of the 
 
- 8 5 - 
 
 cutaneous tegument and its dependencies (thickening 
 of the skin, herpes, lesions of the hairs, nails, etc.). 
 Rapid muscular atrophy would have almost the same 
 significance. 
 
 To these signs (of varying value) Vanlair would 
 add the following: 
 
 (a) The more circumscribed and direct limitation 
 of the pain — neuritis limits itself, ordinarily, to a 
 definite nerve, and rarely gives rise to irradiations 
 into the extremities of the nerves; (£),the fixedness of 
 the seat; (c), the absence of multiple painful points; (d,) 
 the exaggerated excitability of the diseased nerve — 
 in idiopathic neuralgia the nerves lose their electric 
 sensibility; (e), the constant appearance of troubles of 
 motility (when the affected nerve is a mixed nerve); 
 (/), the possibility, in some cases, of feeling the swelling 
 and induration of the nerve, sometimes even of per- 
 ceiving a reddish streak visible at the surface of the 
 skin; (g), the very constant presence of a traumatic 
 cause, of the local action of intense cold, etc.; (/t), the 
 ordinary absence of relapses, while relapse is the rule 
 in neuralgias; (/), the fever, when it exists.* 
 
 Myalgia (muscular rheumatism) is the pain of 
 over-fatigued muscles — of muscles obliged to work 
 when imperfectly nourished. A familiar example is 
 the stiff neck, or lumbago resulting from exposure to 
 cold, an accident especially likely to occur when the 
 
 * Vanlair, loc. cit., p. gS. 
 
— 86 — 
 
 individual is enfeebled by work and is perspiring; 
 pleurodynia, or pain in the intercostal muscles, is 
 another example of myalgia, and this affection is often 
 mistaken for pleurisy by the laity. 
 
 Bearing in mind the distinguishing features of 
 neuralgic pains (before given), there can be little like- 
 lihood of confounding neuralgia with myalgia. One 
 characteristic of myalgic pains is, that they are 
 materially relieved by change of posture and rest — by 
 keeping the affected muscles in a position of full ex- 
 tension. The pains can be easily referred to the area 
 of certain muscular groups; and if there are any ten- 
 der points, these are over the tendinous origins and in- 
 sertions of the muscles. Myalgic pains are aggravated 
 by movements, and occur in persons of no neurotic 
 tendency as often as in the neuralgic; while heredity 
 has no marked influence in their genesis. 
 
 Spinal Irritation may be looked upon as a 
 mye/a/gia, i. e., a neuralgia of the medullary axis. Be- 
 ing, therefore, per se a member of the group of neural- 
 gias, its diagnostic features need brief statement here. 
 These consist in the connection of certain symptoms, 
 or groups of symptoms, with tenderness in particular 
 regions of the spine. Thus, when the region of ten- 
 derness is in the cervical region, there are symptoms 
 such as headache, nausea, vomiting, face-ache, fits of 
 insensibility, cough, pains in the upper extremities, 
 etc. When the tenderness is in the cervical and dor- 
 sal region, there may be, in addition, pains in the 
 
- 8 7 - 
 
 sides and in the stomach, pyrosis, palpitation, and 
 oppression. 
 
 When the dorsal region is the seat of the spinal 
 tenderness, there will be pain in the stomach and sides, 
 cough, oppression, fits of syncope, hiccough, eructa- 
 tions. With tenderness in the dorsal and lumbar re- 
 gions, in addition to the symptoms of the foregoing 
 group, there will be pains in the abdomen, loins, hips? 
 lower extremities, and dysuria and ischuria. With 
 tenderness in the lumbar region principally, pains in 
 the lower part of the abdomen, testes or lower extremi- 
 ties, dysuria, ischuria, disposition to paralysis of the 
 lower extremities.* 
 
 Pseudo-Neuralgias — The pseudo-neuralgias, as 
 has been elsewhere said, owe their existence to some 
 lesion in the region where the pain is located: i. e. 
 they come on after a wound injuring a nerve or 
 nerves, or they are consequent on some tumor, as a 
 neuroma or a malignant growth, a congestion or 
 some obscure diathetic condition. The intense pain 
 
 * This disease was first identified by T. P. Teale in 1829, 
 "On Neuralgic Affections Dependent on Irritation of the Spinal 
 Marrow," 1829; also by the Griffin brothers in their valuable 
 monograph, 1844. The subject is well presented by Hammond 
 "On Spinal Irritation," Leisure Library Series, 1886. The 
 treatment is by restoratives and rest, nerve sedatives and an- 
 algesics; blisters over the painful points are highly spoken of. 
 See further, Radcliffe's article in Reynold's System of Medi- 
 cine. 
 
that accompanies an ophthalmia or ulceration of the 
 cornea belongs to this category. The pains of con- 
 gestion in general, whether the nerve trunks par- 
 ticipate in the hyperaemia, or are simply pressed upon 
 or stretched are of this nature. The pains of pneu- 
 monia and pleurisy, of hepatitis, of cystitis, of metritis, 
 etc., where not due to actual neuritis, belong to the 
 same category. There is a rare painful affection 
 called by S. Weir Mitchell and Lannois "angio-paralytic 
 neuralgia of the extremities " occupying the lower ex- 
 tremities, the soles of the feet especially, sometimes 
 unilateral, sometimes bilateral, which should also be 
 classed under this head. 
 
 The pain wich attends gangrene is another in- 
 stance of the kind. 
 
 The reverse of hyperemia or fluxion, namely ex- 
 treme anaemia, causes pain quite as excruciating as 
 any neuralgic suffering, and no better example can be 
 given than the pain following embolism of an import- 
 ant artery. 
 
 Wounds of nerves (by swords, knives, fire-arms, 
 etc.) cause painful neurites which are sometimes very 
 intractable. The symptoms of neuritis have been 
 given above and need not here be repeated. The 
 ordinary traumatic neuralgias appear several weeks 
 after the lesion. They may get well, or persist long 
 after the cicatrization of the wound. They sometimes 
 so resemble the essential neuralgias as to be nearly 
 if not quite indistinguishable from them. The pains 
 
- 8 9 - 
 
 are of the same lancinating character, and there are 
 the tender points; in many cases there is an intoler- 
 able burning sensation (causalgia), which is patho- 
 gnomonic of nerve injury. 
 
 The trophic and motor troubles attending trau- 
 matic neuralgias are more severe and persistent than 
 those attending essential neuralgia (hypertrophy, 
 atrophy, motor paralyses). The epidermis is prone to 
 atrophy, giving the appearance known as " glossy 
 skin." 
 
 It is not necessary to dwell on the pains of cancer 
 which can offer no difficulty in diagnosis. 
 
 With regard to the little painful tumor called 
 neuroma, it often follows amputation of a limb, the 
 section of a nerve, and it is attended with pain of a 
 very intense and persistent kind. There is generally 
 anaesthesia in the domain of the affected nerve, and 
 the patient complains of numbness. Nothing but ex- 
 cision of the morbid growth does much good. 
 
 Those painful affections of the joints first de. 
 scribed by Brodie, and known as hysterical arthro- 
 pathies belong to the category of pseudo-neuralgias. 
 Here the diagnosis, as in the true hysterical neural- 
 gias, must be based on considerations drawn from the 
 presence of the pathognomonic symptoms and stig- 
 mata of hysteria itself. 
 
 If visceral neuralgia be suspected, the physician 
 will, by the proper means of exploration, exclude the 
 presence of any organic disease. 
 
— 9° — 
 
 Cerebral abscess might be confounded with neu- 
 ralgia of the head. The former is sometimes a sequel 
 of caries of the internal ear and purulent discharge, 
 the result of scarlet fever, measles, etc., in childhood; 
 may follow a blow on the head. There are no true 
 "points douleureux" and the pain does not completely 
 intermit; the pain is fixed, tenacious, profound and 
 circumscribed; there are no well localized secretory 
 or vaso-motor phenomena; the pain is usually attended 
 by severe psychical and motor disturbances (delirium, 
 coma, convulsions, hemiplegia) which are sufficiently 
 characteristic of central disease. 
 
 It might be easy to mistake the lightning pains 
 of locomotor ataxia for those of true neuralgia, but in 
 the spinal disease there are symptoms denoting de- 
 generation of the posterior root-zones; the peculiar 
 staggering gait, the numbness in the feet, the fre- 
 quent impairment of sight, the suppression of the 
 tendon reflexes, etc. The early signs of locomotor 
 ataxia, especially insisted upon by Dr. Marx Karger, 
 are, besides the presence of a cord like sensation 
 around the waist, numbness of the lower extremities, 
 retardation of the rate conduction of sensations, the 
 difficulty or inability of balancing the body when the 
 feet are placed parallel or close together and the eyes 
 are shut (Romberg's symptom), the absence of the 
 patellar-reflex, and the want of reaction of the pupil. 
 
 As genuine neuralgia may be the result of alco- 
 holism and mercurial poisoning, so there are certain 
 
— 9 I — 
 
 pseudo-neuralgias due to these poisons distinguish- 
 able, according to Erb, by their persistence, their 
 localization in symmetrical parts of the extremities, 
 especially in the vicinity of joints. Erb, while ad- 
 mitting that syphilis may produce true neuralgia, 
 regards the osteocopic pains of syphilis as true 
 organic pains, the result of morbid deposit about 
 nerves, and distinguishable from neuralgic pains by 
 their seat, their symmetrical position, and their noc- 
 turnal exacerbations.* 
 
 The limits of this treatise will not allow me to 
 enter upon the vexed question of the diagnosis of 
 neuralgias of central from those of peripheral origin, 
 a matter concerning which we have still few fixed 
 rules for our guidance. 
 
 As for the diagnosis of those neuralgiform pains 
 which depend on an appreciable lesion of the en- 
 cephalon or cord, the following characteristics (given 
 by Vanlair) will aid in distinguishing them from 
 idiopathic neuralgias: 
 
 i. They present an exceptional obstinacy. 
 
 2. The pain is sometimes continuous, sometimes inter- 
 mittent. In the latter case, it often manifests itself as a light- 
 ning irradiation which does not follow the anatomical tract of 
 any nerve. 
 
 3. It presents generally, when it is continous, a great 
 fixedness. 
 
 4. These pains, unlike ordinary neuralgias, occupy a 
 nerve in its totality, i. e. t the trunk of a nerve and all its 
 
 *Ziemssen's Cyclop., Vol. XI, p. 64. 
 
— 9 2 — 
 
 branches. We have an example in the case of neuralgia of 
 the trigeminus due to intra-cranial tumor. 
 
 5. It often invades little by little other nerves whose 
 origin borders on that of the nerve primarily involved. 
 
 6. Pressure exercised over the region of the nerve centres 
 corresponding to the point of emergence of the nerves, often 
 produces a very severe pain extending to all the ramifications 
 of the nerve. 
 
 7. Local means, i.e., all those applied over the tract of 
 the nerve, are inefficacious.* 
 
 * Vanlair, loc. cit., p. 92. 
 
CHAPTER VIII. 
 
 PROGNOSIS. 
 
 The prognosis is more favorable where heredi- 
 tary influence is absent than where it is present. 
 
 The idiopathic neuralgias are less amenable to 
 curative means than the symptomatic or constitu- 
 tional; the latter, whether chlorotic, syphilitic, malar- 
 ial, diabetic, or gouty, get well or improve as the con- 
 stitutional state improves, on which they depend. 
 
 The toxic neuralgias will be likely to undergo 
 attenuation and disappear when the toxic agent which 
 causes them ceases to act or is eliminated. 
 
 Neuralgias accompanying grave cachectic states, 
 from whatever cause, are relatively obstinate. None 
 are more intractable than those of the decline of life 
 and of old age, and neuralgias of central origin are 
 more difficult of treatment than those of peripheral 
 origin. 
 
 It can hardly be said that sex influences the 
 prognosis. 
 
 Neuralgias of long standing with frequently re- 
 peated attacks are among the least curable. 
 
 Hysterical neuralgia is apt to be very obstinate. 
 
 Neuralgias of early life are relatively benign. 
 
 According to Gowers, neuralgias of the fifth 
 nerve are more intractable than all others. 
 
CHAPTER IX. 
 
 THE TREATMENT OF NEURALGIA. 
 
 PROPHYLACTIC TREATMENT. 
 
 Idiopathic neuralgia, like other neuroses, is a 
 hereditary disease. The ancestors of the neuralgic 
 subject — one, or more of them — were either neural- 
 gic, or were sufferers from hysteria, epilepsy, or some 
 other neurosis; or, the parent may have impaired a 
 naturally good constitution by intemperance or some 
 other vice, and so entailed on the offspring that in- 
 stability of nerve-organization which, under suitable 
 provocation, finds expression in some form of neu- 
 ralgia. 
 
 There are, of course, exceptions to the rule 
 that neuralgia is a hereditary disease ; children 
 born healthy have had their constitutions under- 
 mined by insufficient diet, by some one or more of 
 the diseases peculiar to children (as scarlet fever 
 or diphtheria), or even by precocious addiction to 
 some vice. 
 
 Children who have inherited the neuralgic tem- 
 perament should not be allowed to study too hard at 
 school, and should not be subjected to physical tasks 
 of an arduous and exhausting nature. Moderation 
 in all things should be the rule. Such subjects 
 are unfitted to bear a strain. At the same time, 
 
- 95 — 
 they should be required to be much in the open air, to 
 indulge in invigorating sports, to perform gymnastic 
 exercises of certain kinds which can be borne with- 
 out too much fatigue, to practice rowing, horse-back 
 riding, and swimming. The cold bath or cold 
 douche in the morning is a good auxiliary. All these 
 hygienic measures improve the circulation and develop 
 a strong muscular and nervous organization. Hydro- 
 therapy especially toughens the integument and 
 prevents the frequent occurrence of debilitating 
 rheums. 
 
 To these means should be added a full, generous 
 diet of meat, eggs, fish, milk, cereals, vegetables, and 
 fruits. Very many cases of neuralgia have been 
 traced to a meager and insufficient dietary. When 
 we remember that neuralgia is essentially a disease 
 of malnutrition, and that nerve substance is a con- 
 glomerate of richest animalized principles (phos- 
 phorized oleo-albumen), we see that we must place in 
 the foremost rank of remedial agencies those means 
 which improve or restore the nutritive functions. 
 
 Some of the worst forms of migraine, prosopal- 
 gia, etc., that I have ever seen were among the poor 
 and ill-fed. For delicate, half-starved children, brought 
 up in slums and crowded tenement houses, there can 
 be but little hope; out of these breeding places of dis- 
 ease, come the multitude of the hysterical, the neural- 
 gic, the nervously shattered, who float about between 
 the hospital and the alms-house. 
 
- 9 6 - 
 
 The neuropathic child should be taught the neces- 
 sity of plenty of sleep. Too much emphasis cannot 
 be placed on this requirement. Eight, even ten hours 
 sleep a day is not too much. Those predisposed to 
 neuralgia should be compelled to go to bed early — 
 between the hours of nine and ten every night, and 
 all evening excitements should be forbidden. Among 
 the latter should be mentioned the reading of dime 
 novels. 
 
 As everything that favors the precocious devel- 
 opment of the passions is bad, the evil influence of 
 corrupt companions is to be deprecated and avoided 
 by every possible means. It is, however, a matter of 
 great difficulty for the parent or guardian always to 
 avert such influences, for the cousin or class-mate of 
 the moral and " goody " sort is often the one who in 
 secret instils the poison and corrupts the nature of 
 the child. 
 
 Doubtless the evils of masturbation, as practiced 
 by children, have not been too highly painted. The 
 neuropathic child cannot be too early, too earnestly, 
 or too faithfully warned against the pernicious effects 
 of this vice. 
 
 PROPHYLAXIS IN THE ADULT. 
 
 The adult, who, by faulty organization, by de- 
 bilitating influences, by previous attacks of neuralgia, 
 is predisposed to this neurosis, demands essentially 
 the same prophylactic hygiene as has been above out- 
 
— 97 — 
 lined. He should possess some light, healthy em- 
 ployment, and avoid occupations that involve arduous 
 toil and great anxiety. Good, nutritious food at 
 regular seasons should be eaten, and alcoholic and 
 other stimulants eschewed; the neuralgic should also 
 religiously refrain from smoking. These patients are 
 prone to seek excitement, and often suffer a break- 
 down in consequence. One patient with whom I was 
 acquainted, used invariably to experience a return of 
 her megrim after going to an evening party or a ball. 
 Such persons are uncommonly vivacious under ex- 
 citement, and endure well the strain for the time 
 being. They are, however, capable of using up in 
 one evening's dissipation all their reserves, and of 
 bringing their nerve-centres into a state of unnatural 
 erethism that weeks of rest may not calm. 
 
 The condition of these sufferers is often deplor- 
 able. Of fine literary and aesthetic tastes, they can- 
 not long enjoy reading, artistic pursuits, etc., without 
 paying the penalty in an attack of severe orbital or 
 supra-orbital neuralgia. One of my acquaintances 
 cannot read an hour consecutively without twinges of 
 pain. through his temples, which oblige him to desist, 
 He regards himself as shut out from the best enjoy- 
 ment of life; is gloomy and suicidal. Persons of this 
 temperament need an especially fortifying regimen; 
 of which life on the sea (yachting), in the woods, 
 among the mountains, with absolute freedom from 
 brain work, shall form the principal part. 
 
- 9 8 - 
 
 Some writers (as Vanlair and Anstie), have found 
 excessive religiousness a factor in the genesis of neu- 
 ralgia; but doubtless an ardent espousal of the most 
 gloomy theological beliefs is less harmful than the 
 indulgence of depressing vices, or the cultivation of 
 voluptuous appetites. 
 
 The same remarks that have been made about 
 sleep, are applicable to the adult neurotic, who should 
 have regular habits of sleep, and whose sleep should 
 be long and sound. If he happens to be a poor 
 sleeper, he should endeavor to woo tired Nature's 
 sweet restorer, by taking much exercise in the open 
 air, and especially diverting exercises, by cold bath- 
 ing in the morning, and the warm bath just before 
 going to bed, with vigorous shampooing of the body, 
 along with the sipping of a cup of hot water contain- 
 ing some mild cordial, as spirits of lavender, or even 
 a little Fluid Beef; this is far better than re- 
 sorting to any of the ordinary hypnotics, as chloral 
 and sulphonal, which are sure, in the end, to leave 
 the nervous tonus damaged. It is only exception- 
 ally that I would allow a neuropathic patient to apply 
 to any of the so-called hypnotics for relief. Where 
 a small dose of whisky, or a glass of bitter ale 
 will produce refreshing sleep, this is safer than 
 chloral or a narcotic. Sometimes it makes a great 
 difference what the victim of insomnia eats for his 
 supper, and there are all sorts of idiosyncrasies in 
 regard to this. Some persons will sleep better with 
 
— 99 — 
 a full, some with an empty stomach. To some pa- 
 tients your best prescription is a supper of hominy 
 and milk; to others, a light lunch, or cup of beef-tea 
 on going to bed; a full dose malt extract. 
 
 Above all things, the neuralgic invalid should 
 have a mind at ease, for anxiety, care, worry, over- 
 mastering passions, are the greatest foe to healthful 
 sleep. 
 
 As adjuvants to a cure, there are certain tonic 
 medicines which deserve mention here : Quinine, 
 strychnine, iron, arsenic, and a very moderate 
 amount of some of the fermented liquors, wine and 
 beer. To the anaemic, iron and arsenic are especially 
 useful; a good combination is the iron, arsenic and 
 strychnia pill, furnished by a number of our pharma- 
 cists. 
 
 Fothergill's pill is a good stomachic tonic. Its 
 formula is as follows: 
 
 5 Acid arseniosi, gr. j. 
 
 Ferri sulph. excic, 3 ss. 
 
 Pulv. capsici, 3 j. 
 
 Pil. aloes et myrrh, q. s. 
 M. Ft. pil. No. LX. 
 Sig. One pill three times a day. 
 
 A pill of dried sulphate of iron, aloes and myrrh, 
 i grain each, sometimes works well in chlorosis ac- 
 companied with constipation. The same may be said 
 of the well known sulphate of iron, sulphate of qui- 
 nine, and sulphate of magnesia mixture. 
 
Or five minims of Fowler's solution may be asso- 
 ciated with ten grains of bicarbonate of sodium and 
 five of potassio-tartrate of iron in a fluid ounce of 
 infusion of quassia; this dose to be given after each 
 meal. 
 
 Arsenic is one of the best anti-neuralgic reme- 
 dies that we possess. According to Anstie, it is es- 
 pecially useful in the visceral neuralgias. With 
 arsenic, cod-liver oil may often be conjoined to ad- 
 vantage. More satisfactory results will be obtained 
 from the pure oil, when it can be borne, than from 
 any of the emulsions, of all of which, according to 
 my experience, patients soon tire. Too much care 
 cannot be taken that the oil shall be perfectly sweet 
 and fresh. 
 
 A course of electric treatment (galvanism pre- 
 ferably to Faradism), sometimes works well; both by 
 calming the erethism of the nerve centres, and pro- 
 moting the nutrition of the latter. The electrical 
 treatment of neuralgia will claim especial considera- 
 tion in another chapter. 
 
 Treatment of Diatheses which lead to Neural- 
 gia. — Neuralgia is sometimes under the dominance 
 of a diathesis, such as gout, chlorosis, rheumatism, 
 hysteria, diabetes. The treatment which is devoted 
 to the diathesis is the proper treatment of the neu- 
 ralgia. 
 
 Neuralgia of Toxic Origin. — Neuralgia may be 
 dependent on a poison in the blood; lead, mercury. 
 
arsenic, alcohol, malaria. Here the leading indica- 
 tions are : i, To suppress, then antidote, then pro- 
 mote elimination of the poison; 2, as far as possible 
 to protect the organism from the effects of the toxic 
 agent, and palliate symptoms as they may arise. It 
 is evident that when the proper antidote can be ad- 
 ministered, this is the remedy par excellence for the 
 neuralgia. In malarial neuralgia, for instance, qui- 
 nine in large doses is indicated. In alcoholic neu- 
 ralgia, suppression of all alcoholic stimulants should 
 be strictly enjoined. In nicotinic neuralgia, tobacco 
 should be abstained from. In colica pictonum, the 
 proper treatment of lead poisoning will also cure the 
 neuralgia. 
 
 Reflex Neuralgias. — These neuralgias are due to 
 a localized morbid state (of the uterus, kidneys' etc.) 
 and the successful treatment of the suffering organ 
 will cure the neuralgia. 
 
 Surgical means of cure. — Neurotomy, neurectomy 
 and nerve stretching have all been practised for the 
 cure of intractable neuralgia. Nerve stretching has 
 been principally applied to sciatica, and neurectomy 
 (which has given some brilliant results), to the treat- 
 ment of prosopalgia. 
 
 Treatment of Neuralgic Paroxysms. — When you 
 are in the presence of an attack of neuralgia, the first 
 thing, of course, to do is to relieve the pain. It is 
 desirable, if possible, to obtain analgesia without re- 
 sorting to morphine. In many of the neuralgias, such 
 
102 
 
 as migraine, and those of central origin, whether idio- 
 pathic or symptomatic, antipyrin often gives speedy, 
 marked relief, fifteen grains being followed by com- 
 plete disappearance of the pain. A repetition of the 
 same dose in the course of a few hours, and a contin- 
 uance of this treatment for several days, the antipyrin 
 being given often enough to keep the pain under sub- 
 jection, may be all that is required, the patient being 
 as far as possible removed from the reach of causal 
 influences. This is Germain See's treatment of the 
 headaches of students, headaches which often oblige 
 matriculants to suspend study for weeks or months. 
 Acetanilid, in half the dose of antipyrin, may be 
 attended with an equally good result, and the same 
 may be said oi phenacetin, which is coming into gen- 
 eral favor. Lately exalgin has been well spoken of; 
 it has been praised as an anti-neuralgic by Dujardin- 
 Beaumetz and Bardet. 
 
 I must express my own partiality for phenacetin, 
 which I have found hypnotic as well as analgesic. 
 
 I have also seen good results from acetanilid in 
 neuralgic headaches. In cervico-brachial, dorso-lum- 
 bar, and sciatic neuralgia, I have seen no benefit from 
 any of these new remedies except phenacetin. Citrate 
 of caffeine and guarana are remedies from which much 
 good may be expected in hemicrania, and always where 
 the pain seems to be the consequence of nerve tire. 
 The dose of caffeine is three or four grains, of guarana 
 twenty grains. 
 
— 103 — 
 
 The following prescription, for which I am ' in- 
 debted to the late Dr. George M. Beard, has given 
 good results in headaches of all kinds: 
 
 ^ Cit. caffein 
 
 Carb. ammon aa 3j. 
 
 Elixir guaranae f § j. 
 
 M. Sig. — A teaspoonful every hour till the pain is relieved. 
 
 Some of my patients, delicate, migrainous patients, 
 keep a bottle of citrate of caffeine constantly on their 
 toilet tables; a frequent resort to it keeps them free 
 from headaches. I have never seen any harm result 
 from the continuous use of this drug. 
 
 Bromo-pyrin and Bromo-caffeine are two pro- 
 prietary medicines whose efficacy depends on the an- 
 tipyrin and caffeine which they contain. 
 
 Aconitine, in pills of j^-q grain, one pill every five 
 hours till the supervention of the physiological effects, 
 or till the pain disappears, sometimes has a charming 
 effect in migraine and tic douloureux. 
 
 In face-ache, especially when due to a decayed 
 tooth, the tincture of gelsemium in five-drop doses, 
 every two hours, is often followed by speedy subsid- 
 ence of the pain. I have always found gelsemium in 
 this dose to be a perfectly safe remedy. 
 
 Some practitioners have great faith in a full dose 
 of quinine (fifteen grains) in neuralgias of the peri- 
 pheral nerves, whether due to malaria or some other 
 cause. I cannot say that I have ever found this alka- 
 loid beneficial in neuralgic paroxysms, except where 
 
— 104 — 
 
 the attack was clearly of malarial origin. Gross' 
 neuralgic pills, in which quinine is combined with 
 aconite, strychnine and morphine are, I think, chiefly 
 of use as a prophylactic where attacks have been fre- 
 quent. 
 
 As outward applications, chloroform liniment, 
 veratrin ointment, extract of belladonna rubbed up 
 to a paste with water, spread on cloth and applied 
 over the seat of pain, have had their advocates. No 
 external means can be relied on. Anodyne embroca- 
 tions are more useful when the pain is rheumatic than 
 when it is neuralgic. 
 
 Hypnotizers claim to have accomplished wonder- 
 ful results by putting the neuralgic sufferer into the 
 hypnotic sleep, and assuring him that the pain no 
 longer exists. As nothing is impossible, a priori, and 
 all things are to be believed on sufficient testimony, 
 we have now adequate warrant for a certain faith in 
 hypnotism as a means of cure. Bernheim's book on 
 "Suggestion as a Therapeutic Agency" contains a 
 number of instances of severe neuralgic and neuralgi- 
 form pains cured by hypnotic suggestion.* 
 
 It will often happen that none of the above means 
 
 * It cannot but be admitted, however, and good clinical 
 authorities are coming to see this, that the frequent repetition 
 of hypnotic practices is likely to be promotive of hysteria. 
 Germain See declares that to relieve pain by hypnotism and to 
 render the patient hysterical thereby, is to cast out Satan by 
 Beelzebub. 
 
— io5 — 
 are applicable to the case in hand, or, if tried, they 
 have resulted in failure. There is nothing to do then, 
 but to resort to a hypodermic injection of morphine. 
 The tablet triturates of the pharmacists are very 
 handy for this purpose. The commencing dose should 
 be the sixth of a grain. If no relief is obtained, the 
 njection may be repeated in fifteen minutes or half 
 an hour. In bad cases of tic douloureux, migraine, 
 visceralgia, I have often had to repeat these injections 
 every half hour until a grain, a grain and a half, and 
 even two grains have been administered. Severe pain 
 creates great tolerance of morphine. I have seen a 
 delicate neurotic girl in a paroxysm of cervico-brachial 
 neuralgia bear with impunity a quantity of morphine 
 introduced subcutaneously that would have killed a 
 strong, well man. There is not the same tolerance of 
 atropine, and it will not do to push the injections of 
 this alkaloid. If, for the first injection, one of the 
 morphine and atropine tablets be used, in the subse- 
 quent injections the atropine should be omitted. The 
 dryness of the mouth and throat that follows a full 
 dose of atropine gives the patient great annoyance 
 and discomfort. 
 
 For ordinary hypodermic use I employ a solution 
 of morphine, consisting of four grains of sulphate of 
 morphine to a fluidounce of cherry-laurel water. Of 
 this, a hypodermic syringeful may be injected with 
 safety to an adult. The cherry-laurel water keeps the 
 solution from spoiling. 
 
— 106 — 
 
 Inject into a fleshy part of the arm; there is no 
 advantage in injecting over the seat of the pain. 
 
 Deep injections of chloroform sometimes as effec- 
 tually relieve the pain as morphine injections. For 
 sciatica, take up a syringeful of pure chloroform and 
 inject it the depth of the syringe-needle into the 
 gluteal muscles. 
 
 Antipyrin may also be used hypodermically. Dis- 
 solve eight grains in a hypodermic-syringeful of warm 
 water, and inject the whole into a fleshy part of the 
 arm or thigh. Germain See highly commends this 
 use of antipyrin. 
 
CHAPTER X. 
 
 APPENDIX. 
 
 A more particular mention of the principal agents of the 
 anti-neuralgic medication seems required; they will be considered 
 in this supplement. 
 
 I. Narcotics. 
 
 These remedies are nerve-stupefiers. If they fail to com- 
 bat the cause of the neuralgia, they at least attenuate the pain- 
 ful paroxysms by an elective action on the sensory centres, 
 whose erethism they calm. The remedies to be considered 
 under this head are : Opium, belladonna, Indian-hemp, hyos- 
 cyamus, piscidia, gelsemium, and aconite. 
 
 OPIUM. 
 
 Opium. — While opium is not the best analgesic for neural- 
 gic pains, and is certainly to be avoided as far as possible, it is 
 the most powerful antagonist of pain that we possess, and after 
 all other remedies have failed, the physician is obliged to fall 
 back on this incomparable anodyne. 
 
 Mode of Action. — Opium is a true protoplasmic poison. 
 In proper doses, it suspends those molecular changes on which 
 life depends. It acts on the cortical cells of the cerebrum as a 
 stupefier, diminishing reflex excitability and allaying pain. 
 
 Indications and Contra-indications. — In all the cerebro- 
 spinal neuralgias, opium or its alkaloids may be indicated. 
 Certain idiosyncrasies, however, may forbid its employ, as 
 where nausea and vomiting, vertigo, epigastric anguish, dys- 
 uria, attend the therapeutic use of any opiate. Some patients 
 are so prostrated by opiates that they will suffer almost any 
 degree of pain rather than resort to them. 
 
 According to Vanlair, opium is better adapted to the 
 treatment of the visceralgias thau the cerebro-spinal neuralgias, 
 and acts better in lymphatic than in nervous subjects. 
 
 Modes of Administration and Doses. — Opium may be 
 employed externally in the form of liniments, ointments, and 
 plasters. The linimentum opii contains equal parts of lauda- 
 num and opodeldoch. The emplastrium opii has opium and 
 Burgundy pitch. In the French Codex is a glycerite of mor- 
 phia: 2 grains of morphia to an ounce ot glycerin. All these 
 may be used for local effect, or the aqueous extract may be 
 
— 108 — 
 
 rubbed up with water and applied in compresses. The decoc- 
 tion of poppies has sometimes been used as a local anodyne. 
 It must be confessed, however, that no great benefit can be 
 obtained from these external applications. 
 
 Crude opium is seldom given internally for neuralgias, 
 and the same may be said of the fluid preparations. The 
 vinegar of opium (English black drops) has a certain reputation 
 in gastralgia; dose, 10 drops. 
 
 The only alkaloid of opium deserving of mention in con- 
 nection with the therapeutics of neuralgia, is morphine. This 
 alkaloid may be given internally in the dose of a quarter of a 
 grain, every hour or two, until the pain is relieved. The bet- 
 ter method of administration, however, is the hypodermic 
 method. One-fourth grain of morph. sulph., or ten minims of 
 Magendie's solution may be injected into the cellular tissue of 
 a fleshy part of the arm ; the effect will be far more speedy and 
 lasting than when the alkaloid is given by mouth. Moreover, 
 only about half the ordinary dose is needed when the morphine 
 is injected, a quarter of a grain thus introduced having about 
 the same effect as halt a grain taken by the mouth. 
 
 Morphine may advantageously be combined with atro- 
 pine for hypodermic use, as in the tablet triturates sold by the 
 apothecaries. 
 
 There is no need at the present day of insisting on the 
 advantages of hypodermic medication; all practitioners recog- 
 nize the superiority of this method over every other when it is 
 a question of obtaining the maximum of effect with the mini- 
 mum dose. 
 
 Nor is it necessary to speak of the endermic method, now 
 superseded by the hypodermic. 
 
 Chlorodyne — Chloranodyne . — How to obviate the injurious 
 after-effects of morphine when this alkaloid is administered 
 for pain, has long been the study of physicians. Experience 
 has taught many a practitioner that the combination with 
 aromatic stimulants, as peppermint, lavender, cajaput, was 
 often useful; many claimed that they had found in capsicum 
 and ginger the desideratum; some wanted the advantage of a 
 union of the opiate with alcohol, chloroform, or various nar- 
 cotics and sedatives, such as belladonna and hydrocyanic acid. 
 When I was an interne of the Montreal General Hospital, in 
 1864, Collis Browne's chlorodyne was much in vogue. Al- 
 though its composition was uuknown, no one doubted that the 
 active anodyne ingredient of this preparation was morphia. 
 
— 109 — 
 
 In my subsequent private practice I was much in the custom of 
 resorting to this chlorodyne (notwithstanding its high cost) 
 when obliged to give morphia to patients who were in the 
 habit of experiencing unpleasant results from the drug when 
 given alone. I found it, however, an uncertain preparation, 
 apt to spoil by precipitation of the molasses, which was the 
 vehicle of the active ingredients; and about seven years ago I 
 abandoned the Collis Browne Chlorodyne for Gilman's, the 
 formula of which I found in the Boston Medical and Surgical 
 Journal: 
 
 IJ Chloroform, 3 ij. 
 
 Glycerine, |ii. 
 
 Alcohol, ?ii. 
 
 Spts. peppermint, 3 ij, 
 
 Acid hydrocyanic dilute, 3 ij. 
 
 Tincture capsicum, 3 ij. 
 
 Morph. sulph., gr. viii. 
 
 Syrup, 5 iii- 
 M. 
 
 The dose of this preparation for an adult is one teaspoon- 
 ful, which contains one-eighth grain morphia, 
 
 The above combination is a good one, the ingredients 
 being all held in solution, and the taste being far less un- 
 pleasant than the nasty, tarry-looking compound generally sold 
 under the name of chlorodyne. 
 
 Despite the fact that I have long used, and almost daily 
 in my practice, the Gilman chlorodyne, I find in the prepara- 
 tion devised by Parke, Davis & Co., and sold under the name 
 of Chloranodyne, a more efficient and elegant combination. I 
 do not hesitate to say that nothing as yet made is quite so sat- 
 isfactory. The dose is about the same as the old Collis 
 Browne article, while the action is more certain. The small- 
 ness of the dose (15 to 20 drops) is an advantage over the Gil- 
 man chlorodyne, which must be given in drachm doses and is 
 about equally expensive. 
 
 The formula of Parke, Davis & Co.'s chlor-anodyne 
 shows each gramme to contain the following ingredients in the 
 quantities indicated: 
 
 B Morphia muriate oo£o grm. 
 
 Tinct. Cannab. Ind 0800 grm. 
 
 Chloroform 1350 grm. 
 
 Oil of peppermint 0025 grm. 
 
 Tinct. capsicum 0025 grm. 
 
 Hydrocyanic acid dilute 0170 grm. 
 
 Alcohol 30C0 grm. 
 
 Glycerine 4570 grm. 
 
— no — 
 BELLADONNA. 
 
 "The and neuralgic action of belladonna," says Van- 
 lair, "is not dependent on its physiological effects, for 
 belladonna is an excitant of the central cells, and its stu- 
 pefying properties do not appear till after an intense and pro- 
 longed excitation. If we were to consider pain as a simple 
 exaltation of the sensibility, the efficacy of belladonna in the 
 treatment of neuralgias would be absolutely inexplicable. * 
 * * But pain, not being hyperesthesia, there is nothing to 
 prevent belladonna, even when it does not exert its stupefying 
 properties, from acting against the algesic element and tri- 
 umphing over it. Belladonna is even superior to opium in cer- 
 tain respects. It not only manifests an incontestable anodyne 
 action, but it also exerts anti-neuralgic properties which opium 
 does not possess to the same degree." 
 
 Vanlair thus expresses his preference for belladonna over 
 the other narcotics as an anti-neuralgic, and whatever we 
 may think of his explanation he here seconds views before 
 uttered by Behier, Courty, and Trousseau The kind of 
 neuralgias which he thinks most amenable to belladonna 
 are "the idiopathic, and especially those affecting nerves 
 placed superficially. Such are the facial neuralgias, and es- 
 pecially those of the supra-orbital branches; the temporal 
 neuralgias yield equally well, but neuralgias of the infra-orbital 
 nerves are more stubborn." * * * In the above neuralgic 
 affections, he would rely much on local applications of bella- 
 donna. The dose of the alcoholic extract and the powder of 
 the leaves is one-fourth of a grain twice or three times a day. 
 Outward applications over painful regions of the extract, 
 rubbed up with water, or of cataplasms of the leaves, are 
 sometimes of unquestioned efficacy. Trousseau counselled to 
 make a paste of the extract with a few drops of water, and rub 
 it over the painful part. He has found this treatment ol 
 efficacy in sciatica. Vanlair prefers an ointment made by rub- 
 bing up half a drachm to a drachm of extract of belladonna in 
 an ounce of lard, vaseline, or glycerite of starch. 
 
 Trousseau's Treatment of Migraine. — He makes a quantity 
 of pills of the extract of belladonna, each containing one- 
 sixth of a grain ; one of these is given every hour (cautiously) 
 till the complete disappearance of the pain, or till some vertigo 
 is felt. 
 
 Atropine, the alkaloid of belladonna, has been much 
 
— Ill — 
 
 given in neuralgia.* The dose would be one-hundredth of a 
 grain, which should not be repeated more than three times in 
 the twenty-four hours. Atropine is preferably given by the 
 hypodermic method; one of the j-foy grain tablet triturates 
 being dissolved in fifteen drops of water and injected subcu- 
 taneously. In obstinate idiopathic cerebro-spinal neuralgias it 
 will not do to rely on this alone; the atropine works more 
 speedily and effectually if combined with morphine. Thus: 
 
 fy Sulphate of morphine, % grain. 
 
 Liquor atropia, 2 drops. 
 
 Cherry laurel water, 20 drops. 
 M. For one hypodermic injection. 
 
 Or the tablet triturates may be employed. Each contains 
 one-fourth grain of morphia, and one-hundredth of atropia. 
 
 It is hardly necessary to add that belladonna is not in 
 quite the same repute in which it was held some years ago. 
 before the antithermic analgesics and caffeine were introduced 
 into therapeutics. The dose both of belladonna and of its 
 alkaloid required for the complete relief of pain can hardly be 
 regarded as a perfectly safe dose; at any rate this powerful drug 
 demands skilled and experienced management for its success- 
 ful employ. 
 
 CANNABIS INDICA— (HASHISH— INDIAN HEMP.) 
 
 Indian hemp, much inferior to opium as an analgesic, 
 has been found serviceable in some cases of migraine. Ring- 
 er declares that no single drug has been found so useful in this 
 common neuralgic affection. It should be given for weeks 
 and even months in doses of ^ to x / 2 grain twice a day. 
 
 Greene, an English practitioner, was one of the first to 
 make of hashish a sort of specific against migraine. He gave 
 of the alcoholic extract of Indian hemp from 0.02 to 0.03 
 (/4 to % g ram ) before each meal; after several weeks he in- 
 creased the dose somewhat, and continued the treatment for 
 three months. It is especially in the migraine of young peo- 
 ple that Indian hemp does good. 
 
 Seguin, in the Medical Record (vol. xii, p. 774, 1877), 
 recommends the same treatment, and insists that the doses 
 shall be given with the greatest regularity. The principle is 
 
 ♦According to Anstie, atropine is particularly useful in glaucomatous 
 neuralgia, and in neuralgia of the pelvis. , 
 
to keep the nervous system steadily under a slight influence of 
 cannabis for a long period of time. He says that cannabis is 
 nearly as efficacious in migraine as the bromides are in epi- 
 lepsy. Male patients can generally begin with half a grain, 
 and it is well to give them three-quarters of a grain in two or 
 three weeks. 
 
 Lothrop, in a paper read before the Buffalo Medical Club 
 {Medical Record, vol. xix, p. 99), advocates Greene's and 
 Seguin's method. It is stated as a matter of course, that at 
 first no appreciable effect is observed, and that not until the 
 use of the remedy is persevered in for many weeks will the 
 patient find a decided diminution in the severity and fre- 
 quency of the attacks Lothrop gives a fourth of a grain of 
 the alcoholic extract before each meal for the first fortnight, 
 then a third of a grain for the second fortnight, to be aug- 
 mented to half a grain at the end of four weeks. Corrigan re- 
 ports favorable results from tincture of Indian hemp in tic 
 douloureux; he employs the tincture in the dose of 8 to 30 
 drops. 
 
 HYOSCYAMUS. 
 
 This narcotic agent is little employed in neuralgia, the 
 analgesic effects obtained from safe doses of the various phar- 
 maceutical preparations of henbane being too feeble. Meg- 
 lin's pills, which have considerable repute in neuralgia contain 
 extract of hyoscyamus. The composition is as follows: 
 
 IJ Oxide zinc, 
 Ext. valerian, 
 Ext. hyoscyamus, aa gr. j. 
 
 For one pill. To be given three times a day. 
 
 Hyoscyamus leaves, bruised and steeped and applied as 
 a cataplasm to the skin in superficial neuralgias, have been 
 vaunted by Trousseau and Pidoux. 
 
 CONIUM MACULATUM. 
 
 The same remarks are applicable to conium or hemlock. 
 The succus conii, however, anciently had a reputation for the 
 cure of tic douloureux, in the dose of 30 drops three times a day. 
 The conium plaster, and cataplasms of hemlock leaves have 
 been recommended for outward application. 
 
— n3 — 
 
 STRAMONrUM. 
 
 The leaves of stramonium have been similarly used as an 
 application to painful parts. A good way is to mix a quantity 
 of the dried and pulverized leaves with the ingredients of an 
 ordinary poultice. 
 
 PISCIDIA F.RYTHRINA. 
 
 This plant is known under the name of Jamaica Dogwood. 
 Introduced into medicine as a hypnotic and narcotic, it has- 
 been found to possess analgesic properties similar to gelsemium. 
 It is especially in rebellious facial neuralgias that it has been 
 prescribed. 
 
 Preparation and doses. — The fluid extract is alone pre- 
 scribed in the United States, in the dose of a teaspoonful. 
 
 GELSEMIUM SEMPERVIRENS. 
 
 This plant, known as the yellow jasmine, has real analgesic 
 properties, and has been especially useful in facial neuralgias 
 and in hemicrania. Perhaps its efficacy is more marked in 
 dental neuralgia than in any other form of pain. Gelsemium 
 is a direct paralyzerof the sensory conductors in the cord. 
 
 A severe case of cervico brachial neuralgia which came 
 under my observatioa in 1876-1877 was markedly benefited by 
 this drug. On numerous occasions I saw violent paroxysms 
 yield to five drop doses of a saturated tincture. This patient 
 (a young lady of highly neuropathic organization) was kept in 
 comparative comfort for more than a year by the gelsemium. 
 
 The dose is from 2 to 10 drops of a saturated tincture, or 
 of the fluid extract, which may be cautiously repeated every 
 hour or two till abatement of the pain is produced. 
 
 We do not believe that aconite in the form of tincture or 
 extract,* is of much service in neuralgia, but there is no doubt 
 as to the utility of its active principle aconitia. 
 
 * The extract of aconite is, however, a principal ingredient of the 
 somewhat famous neuralgic pills of the late Professor Gross, of which the 
 formula is as follows: 
 
 3 Ext. aconite, qr. y±. 
 Quiniae sulph., gr. ij. 
 Acid arsenios, gr. 1-20. 
 Strychnia, gr. 1-20. 
 Morphia, gr. 1-20. 
 M. One pill. 
 
 8 MM 
 
— H4 — 
 
 Aconitia (which exists in the root of the aconitum napellus 
 in the proportion of about one drachm to twenty-six pounds) 
 has been made the subject of special study by the late Prof. 
 Gubler. whose monographs on this medicament are of great 
 practical utility. Gubler was one of the first to insist on the 
 importance of this remedy in the treatment of trigeminal neu- 
 ralgia. 
 
 ?"-L~, Aconitia is found in commerce under two distinct forms; 
 the amorphous and the crystallized. The latter, which is some- 
 what stronger and more reliable, is the best known, and is 
 generally prescribed under the name of Duquesnel's aconitia. 
 
 Not to dwell on the toxic effects of this powerful alkaloid, 
 which is only safe in very minute doses, we may sum up its 
 therapeutical actions by the observation that it seems to have 
 a special selective influence on the extremities of nerves of 
 sensation, which it paralyzes. This elective affinity is especi- 
 ally manifest in the case of the fifth pair of nerves. 
 
 The beneficial effects of this medicament in neuralgia, in 
 facial neuralgias in particular, have been attested by a multitude 
 of observers, among whom we may mention Oulmont, Seguin, 
 Franceschini, Merck, and Laborde.* 
 
 Gubler is fond of narrating an incident which occurred in his 
 practice. It concerned a patient on whom Nelaton had prac- 
 ticed resection "of all the branches of the tri-facial " (!). The 
 pains continued to be just as atrocious and just as persistent 
 as ever. The patient, reduced to despair, and ready to com- 
 mit suicide, was treated by Gubler with aconitia. Seven milli- 
 grammes a day of Hottot's aconitia were administered in gran- 
 ules with the most marked relief, and by perseverance in this 
 remedy a complete cure was effected. 
 
 Laborde, in the Journal de Therapeutique, publishes re- 
 ports of six cases of neuralgia mostly of the fifth pair, in all 
 of which marked benefit was received from aconitia; in some 
 the benefit was permanent. In all these cases the medicine 
 was given by mouth. He makes use of the granules of Du- 
 quesnel, containing one-fourth of a milligramme. One gran- 
 ule is a sufficient commencing dose, and he advises that the 
 dose should not be repeated under four hours. Generally the 
 second granule will give relief, if the first fails to benefit. 
 
 *See especially the exhaustive articles of Laborde in the Journal de 
 Thtrapeutique, and Tribune Medicale, 1881. 
 
— u5 — 
 
 A safe and efficient way, which we have often tried, is the 
 following, which is in accordance with the directions laid down 
 by Dujardin Beaumetz: Duquesnel's aconitia is ordered — the 
 one-fourth of a milligramme granules. Of these the patient is 
 ordered to take one granule every three hours, till eight have 
 been taken during the twenty-four hours. It is seldom that 
 there is any occasion to go any further. Generally the second 
 or third dose causes complete disappearance of the pain. Given 
 in this way, we do not exceed two milligrammes a day. If this 
 dose not not relieve, it is vain to push the remedy further. 
 Sometimes after the second or third granule, a little tingling of 
 the tongue and pricking of the skin of the face, with constric- 
 tion of the mouth are experienced. Patients sometimes com- 
 plain that their head feels " hoop-bound " for a time. 
 
 There is no doubt about the superlative excellence of this 
 medicament in all so-called congestive neuralgias, and we have 
 notes of obstinate cases of sciatica which have proved amen- 
 able to treatment by aconitia. It is one of the remedies that 
 should be first tried in severe sciatica and lumbago aftigore. 
 
 Even in the case of symptomatic facial neuralgias, as 
 well as protopathic, the pain is often alleviated by aconitia, as 
 Laborde has shown.* 
 
 II. Anaesthetics. 
 
 The only anaethsetics that will be here mentioned are 
 chloroform, ether, nitrite of amyl, chloral, cocaine, bromide 
 of potassium, and menthol. 
 
 These remedies abolish sensibility, but their action is 
 fugacious, and temporary, therefore they are only to be resorted 
 to as palliatives, and as adjuvants to the other analgesics. 
 
 * From an article by the author in the Medical Record, July 14, 1883. 
 The following formulae are taken from the Formulaire Pratique, by Du- 
 jardin-Beaumetz: 
 
 IJ Liquor Aconitice (Turnbull), 
 
 Amorphous aconitina, 1 gramme (15 grains). 
 Alcohol, 8 grammes ( 3 ii). 
 
 M. For frictions over the face in prosopalgia. 
 
 ^ Sulphate quinine, o gr. 20 centigrammes, 
 
 Crystalized nitrate of aconitia, o— % milligramme, 
 Ext. cinchona q. s. for one pill. 
 
 Take one to three of these pills in the 24 hou * s 
 
— n6 — 
 
 Chloroform, Ether. — Anaesthetics sometimes render ser- 
 vice in alleviating the violence of neuralgic paroxysms. There 
 are cases where every remedy seems to fail; the patient is 
 racked with an atrocious migraine, tic-douleureux, or cervico- 
 brachial neuralgia. Morphine has been given hypoder- 
 mically up to the point of danger, or very near to this point, 
 and still the persistent, boring pain continues, with frequent 
 stabs and darts, and the poor patient can get no rest. Here 
 the free inhalation of ether will for a time attenuate the distress. 
 The effects are generally fugitive ; nevertheless, the anaesthetic 
 may be "the last straw that breaks the camel's back," and 
 the paroxysm may yield to a few whiffs of ether or chloroform. 
 
 Of the two, chloroform is the most prompt and thorough 
 in its action, producing less nausea and vomiting afterwards, 
 but ether is generally preferred, being safer. 
 
 Lately, deep, parenchymatous injections of pure chloro- 
 form (20 to 30 drops), have been recommended (Roberts Bar- 
 tholuw, Ernest Besnier, Dujardin-Beaumetz, etc.), in sciatica. 
 The needle should be plunged deeply into the muscular inter- 
 stices. These injections are painful, but frequently markedly 
 efficacious I have injected the amount of a teaspoonfnl of 
 pure chloroform into the deltoid in a case of cervico-brachial 
 neuralgia; the result was satisfactory. * * * Chloroform 
 has been also used locally as a liniment, over painful regions, 
 and with good results. 
 
 One of the uses of sulphuric ether may be here men- 
 tioned. If sprayed over a painful region — a common hand 
 atomizer, such as is made by Codman & Shurtleff, Boston, 
 which throws a continuous spray, being used for the purpose — 
 an intense refrigeration is produced, which benumbs the nerves 
 and for a time allays the pain. These pulverizations are of 
 considerable use in dermalgia, in occipital, temporal, and inter- 
 costal neuralgia, and I have known them to be used with bene- 
 fit in sciatica, 
 
 NITRITE OF AMYL. 
 
 Nitrite of amyl has been used with some success by in- 
 halation (three or four drops on a handkerchief or the palm of 
 the hand) in facial and intercostal neuralgias and in hemicrania. 
 Most authorities, however, place very little reliance on it. From 
 the vaso-motor paralysis and the congestions which it occa- 
 sions, it is likely to do more harm than good. Vanlair thinks 
 it of remarkable efficiency in sympathetic headaches. 
 
CHLORAL. 
 
 Chloral has but feeble analgesic properties. It is never 
 given in neuralgias of any kind except as an adjuvant to mor- 
 phine, to calm reflex excitability and produce sleep. The 
 dose is from 10 to 30 grains. 
 
 For external use a liniment is prepared cared the cam- 
 phor-chloral liniment, by rubbing gum camphor with hydrate of 
 chloral. An oily liquid is the product, which, when rubbed 
 over the seat of pain in pleurodynia, cervico-bracbial neural- 
 gia, lumbago, etc., causes first some smarting and redness, then 
 considerable local anaesthesia. 
 
 CROTON-CHLORAL. 
 
 This substance seems to possess analgesic properties 
 superior to thore of chloral. Per contra, it is not so good a 
 hypnotic. It has given good results in facial neuralgia and 
 in migraine. The dose is five grains; Seguin counsels to 
 give 15 grains every hour, for four doses, in migraine. 
 
 Not much can be expected of this remedy, although Dr. 
 B. W. Richardson (Braithwaites Ret., Part 83. p. 22S) speaks 
 highly of its employment. He says: " Looking upon neural- 
 gia as a form of vascular spasm in tracts of nerves (?), we have 
 a clear idea of the reason why antispasmodics are so useful in 
 some forms of this disease. * * The 
 
 alcohol in port wine has for this reason obtained its reputation 
 for the relief of tic. In croton-chloral combined with quinine 
 we have an instant remedy more effective than alcohol. * * 
 The formula is: 
 
 Croton-chloral, gr. ii. 
 
 8uinine, gr. ii. 
 lycerin, as much as suffices to make a pill. 
 
 The pill to be taken when the attack threatens, and to be re- 
 peated every two hours till relief is obtained." 
 
 BROMIDE OF POTASSIUM. 
 
 Peter relates a case of cure by bromide of potassium of 
 an epileptiform neuralgia of the face; the patient, aged 62 
 years, had more than 200 crises in the twenty-four hours, 
 and could only get relief from his pain by taking half-drachm 
 doses of bromide three times a daw* 
 
 Bull de Therap., Oct., 1876, p. 337 (cited by Vanlair). 
 
— n8 — 
 
 Anstie* would limit its use mainly to a class of neuralgics, 
 especially women, in whom a certain restless hyperactivity of 
 mind, and perhaps of body also, seems to be the expression of 
 Nature's unconscious resentment of the neglect of sexual func- 
 tions. Bromide of potassium, on the other hand, is injurious 
 in young men exhausted by masturbation. 
 
 OIL OF PEPPERMINT — MENTHOL. 
 
 Menthol is a solid crystallizable substance deposited from 
 the oil of peppermint. It is also found in commerce under 
 the name of Japanese oil of peppermint. Oil of peppermint 
 and menthol are supposed to have anodyne properties when 
 applied externally, but probably their therapeutic action de- 
 pends on their rapid and complete evaporation. Oil of pepper- 
 mint has been much used as a liniment in superficial neural- 
 gias. A solution of menthol in alcohol, and menthol cones, 
 have also been found of some use, especially in migraine. 
 
 COCAINE. 
 
 Cocaine is an alkaloid obtained from the leaves of ery- 
 throxylon coca. The marked local anaesthetic effects which 
 have been obtained from this agent, and which have of late ren : 
 dered it so indispensable in ophthalmic surgery, and in minor 
 surgical operations, have led to its employment as a topical 
 application in neuralgias. Unfortunately its action is too su- 
 perficial and too transitory. A strong solution rubbed over 
 painfu 1 nerves, or applied on tampons and compresses — in tic 
 douloureux, in migraine, in intercostal and other peripheral 
 neuralgias — gives but momentary alleviation. 
 
 Hypodermic injections, each injection consisting of a 
 syringful of the two per cent, solution of the hydrochlorate of 
 cocaine — have been used in neuralgia, with some benefit. In 
 one instance of severe cervico brachial neuralgia, where I 
 frequently resorted to these injections, the anagelsic effect was 
 speedy, and lasted several hours. At the same time, some ob- 
 servers have recorded among the unfavorable symptoms 
 attending the subcutaneous use of cocaine, nausea, and even 
 alarming syncope. f 
 
 * Anstie, " On Neuralgia," p. 241. 
 
 + Dujardin-Beaumetz, New Medications, Am. Ed., p. 300. 
 
— II 9 — 
 
 From my own limited experience I should say that if the 
 patient be kept in a recumbent position, there is little danger 
 of syncope, and that the occasional use of cocaine subcu- 
 taneously in neuralgia, as a substitute for morphine, is advan- 
 tageous. 
 
 III.— Neurosthenic or Alterative Medicaments. 
 
 The medicines above enumerated do good chiefly by an 
 action directed to the element pain, and their effect is more or 
 less transient. Moreover, some of them, as opium,' are objec- 
 tionable in that the organism is likely to be in a worse condition 
 after their use than before. He who is obliged constantly to 
 resort to morphine injections is almost certain to become a 
 morphiomaniac. Nor can it be said that the constant use of 
 belladonna, cannabis, or any other narcotic is unattended with 
 injury to the organism. 
 
 Perhaps the same objection is not (at least to the same 
 extent) applicable to a class of medicines which I may call neu- 
 rosthenic or alterative medicaments, which are designed to 
 strengthen the nerve element. Of this class I shall notice only 
 the principal : Arsenic, quinine, salicin, iron, phosphorus, 
 chloride of ammonium, strychnia, and cod-liver oil. 
 
 ARSENIC. 
 
 Perhaps no remedy is more prized at the present day in 
 anaemic neuralgias than arsenic. This medicine, says Anstie, 
 "from its singularly happy combination of powers as a blood 
 tonic, a special stimulant of the nervous system, and withal, as 
 a special opposer of the periodic tender. cy, must be regarded as 
 one of the most powerful weapons in the physician's hands, 
 and although it seems to act best in the neuralgias of the vagus 
 and the fifth, there is a possibility of its proving the most effect- 
 ive remedy in almost any given case which may come betore 
 us." Anstie has seen especially good results from arsenic in 
 the paroxysms of angina pectoris; from his description it would 
 appear that he refers to those purely neurotic forms of cardiac 
 pain called by Huchard false angina pectoris. 
 
 Cohen* has administered arsenic with success to persons 
 affected with all kinds of cerebro-spinal neuralgias, facial, 
 sciatic, intercostal, etc. Sciatica has been the most refractory to 
 this remedy. Leared has found it very efficacious in gastralgia. 
 
 * Journal de Medicini de Bruxelies, 1865. (Cited by Vanlair). 
 
120 
 
 Doses and mode of administration. — I, Fowler's solution, 
 three drops, gradually increased to eight or ten, after each 
 meal. 2, Arsenical pills -^ to -^j- grain; one pill three times a 
 day. The granules of Dioscorides and the Asiatic pills are 
 ancient preparations. Fowler's solution can generally be tol- 
 erated if any arsenical preparation can be taken, but in some 
 patients arsenic in every form is contra-indicated, owing to 
 gastro-intestinal irritability. 
 
 QUININE. 
 
 Quinine has a great reputation in the treatment of neural- 
 gia, a reputation which is largely due to its success in those 
 forms of neuralgia which are of malarial origin. There is no 
 doubt as to its utility in these latter neuralgias. The dose should 
 be large, from 10 to 15 grains to an adult; this may be given to 
 best advantage a few hours before the paroxysm; Stille says 
 six to eight hours. 
 
 Numerous examples of the efficacy of quinine in neural- 
 gia of the ulna, sciatic, crural, and other nerves have been 
 given by Dr. Hanfield Jones.* A case of femoro popliteal neu- 
 ralgia was cured by Dupre with quinine after other remedies 
 had failed, and Brodie successfully treated neuralgia of the 
 inferior dorsal nerves by the same remedy. f Anstie ascribes 
 to it a special value in the treatment of ophthalmic neuralgia; 
 Vanlair finds it indicated particularly in neuralgias of the face 
 and neck, and regards the existence of marked periodicity in the 
 paroxysms as a leading indication for quinine. 
 
 It is better to give quinine in substance in a little water 
 and made soluble by a drop of a mineral acid, than in pill form. 
 If administered in an infusion of coffee, its bitterness is partly 
 disguised. Graves reccommends the addition of a few drops of 
 chloroform to the mixture, which is thus rendered more pala- 
 table. 
 
 SALICIN. 
 
 Salicin is a glycoside obtained from willow bark. It has 
 been used in neuralgia chiefly on the recommendation of Dr. 
 Maclagan " The cases," he says, "in which I have found 
 salicin to be of most service are those in which the pain comes 
 on in periodic exacerbations, and in which quinine either fails 
 
 * Lancet, June, 1865, (quoted by Stille.) 
 
 t Stille, Therapeutics and Materia Medica. 
 
to do good, oris for some reason inadmissible." He has given 
 it chiefly in facial neuralgia The dos^ must be large; twenty 
 grains every three hours till eighty grains are taken, or till the 
 pain subsides. {Practitioner, Nov., 1877, p. 321.) 
 
 IRON. 
 
 It is not surprising that iron, which occupies such 
 a large place in the therapeutics of anaemia and debility, should 
 be regarded as a remedy of prime importance in neuralgia, a 
 disease of anaemia and debility; and, doubtless, as an adjuvant 
 to good food, exercise in the open air, and other fortifying 
 measures, iron may render important service in the treatment 
 of neuralgia. 
 
 Anstie speaks highly of the tincture of sesquichloride of 
 iron in the anaemic neuralgias. He thinks that besides its 
 effects on the blood, it has a marked and direct influence on 
 the nerve centres which is different from anything which one 
 observes in the action of any other preparation of iron.* The 
 effect which it produces in the anaemic neuralgias, more es- 
 pecially of young women, is something quite peculiar. He 
 recommends the combination with strychnine, ten minims 
 of the tincture of the chloride with one-fortieth of a grain of 
 strychnine, and alludes to a severe case of frontal neuralgia 
 that was markedly benefitted by this combination. (The dose 
 is an exceedingly unpleasant one to take, and the tincture of 
 iron doubtless has a deleterious action on the teeth). 
 
 Another favorite iron preparation is the saccharated car- 
 bonate, of which the dose is a scruple three times a day. 
 
 Hutchinson affirms that he has cured several cases of 
 temporo-facial neuralgia by the sub-carbonate in large doses. 
 A teaspoonful may be given of this red iron powder stirred 
 into a little water, three times a day, The phosphate and 
 pyrophosphate (especially the latter) are eligible preparations. 
 In chlorotic patients with delicate stomachs the ammonio-cit- 
 rate will sometimes suit better than any other form of iron. 
 
 Among the useful non-official preparations is the dixit of 
 phosphate of iron, quinia and strychnia; dose, a teaspoonful 
 three times a day; the elixir of lactophosphate of iron; the fol- 
 lowing formula of Dr. W. A. Hammond is a powerful tonic 
 combination: 
 
 1 Anstie on Neuralgia, Am. Ed., p. 229. 
 
122 
 
 3 Pyrophosphate of iron. 3 i, 
 
 Quinine sulph., 3 ss, 
 
 Strychnine, gr. j. 
 
 Acid phosphoric dilute, 
 
 Syrup of ginger, aa 1 ij. 
 M. Dose, a teaspoonful three times a day. 
 
 CHLORIDE OF AMMONIUM. 
 
 Dr. Eben Watson has represented this drug to be an effic- 
 ient remedy for neuralgia of the fifth pair of nerves, and he 
 refers to two cases in which the pain ceased within a few min- 
 utes after it had been given.* Anstie also speaks favorably of 
 its use in migraine. 
 
 The dose is 20 grains dissolved in a large quantity of 
 water. Muriate of ammonia is a very disagreeable medicine 
 to take. The addition of a little licorice renders it somewhat 
 more palatable. 
 
 STRYCHNINE. 
 
 If nux vomica or strychnia has any efficacy in neuralgias, 
 it is by improving the circulation of the blood and the tone and 
 nutrition of the nerves on which it acts. It is principally in the 
 facial neuralgias and in gastralgia that it proves beneficial. 
 Anstie speaks of the utility of strychnia in "cardiac neuralgia," 
 though he gives the precedence to arsenic. 
 
 The dose of strychnia would be from -fa to -fa grain, ad- 
 ministered in pill form. The liquor strychnia may be given in 
 doses of from 5 to 10 drops. 
 
 Of nux vomica, one grain of the powder, one-fourth grain 
 of the extract, or five drops of the tincture may be given for a 
 dose. 
 
 PHOSPHORUS. 
 
 The use of this drug is altogether empirical. It has been 
 given in the pill form, each pill containing -^ grain. The 
 phosphorated oil is not a very eligible preparation, though it may 
 be administered in capsules, each capsule representing one-six- 
 tieth of a grain, to be taken after meals. Phosphide of zinc is 
 an excellent form for the administration of phosphorus; pills 
 y| grain; dose, one pill after each meal. Thompson in Eng- 
 land, and W. A, Hammond in this country are the principal 
 advocates of the phosphorus treatment of neuralgia. 
 
 * Stille, Therapeutics and Materia Med., Vol. II, p. 839. 
 
— 123 — 
 
 COD LIVER OIL. 
 
 There is no question as to the value of fatty foods in neu- 
 ralgia, although patients are often averse to them, and many 
 with delicate stomachs are unable to tolerate or digest crude 
 fats in any form. The neuralgic, as a rule, are lean and anae- 
 mic. The appetite is poor and assimilation is imperfect. The 
 pains from which they suffer are often the outcry of starved 
 nerves for more blood and better blood. If we would do these 
 patients good, we must do something besides alleviating the 
 pain for the time being. They must be built up by generous 
 diet of which flesh and fats form a considerable proportion. 
 As nerve substance is composed chiefly of albumen and fat, we 
 see the importance of an abundant supply of these materials in 
 the food. 
 
 But what can be done in cases where the appetite is absent 
 — where the stomach loathes the kind of food that is needed ? 
 As far as possible, all the resources of hygienic therapeutics 
 must be called into exercise; pure air, out door exercise, moun- 
 tain climbing, horseback riding, rowing, walking, gymnastics. 
 Or if the patient be bedridden, massage and electricity may be 
 tried, with feeding according to the Weir- Mitchell method. Such 
 fats as can be asr imilated must be taken: sweet cream, salad 
 oil, above all, cod-liver oil. In addition to the ordinary fare, a 
 cup of beef peptonoids between meals, and in 'the night time. 
 If cod liver oil in its purity cannot be borne, possibly some of 
 the emulsions may suit, especially that with malt extract. 
 
 "It is" says Anstie "surprising what can be done in 
 in this way by perseverance and tact. * * * * Nothing 
 is more singular than too see a girl who was a peevish, fanci- 
 ful and really very suffering migraineuse brought to a state in 
 which she will eat spoonful after spoonful of Devonshire 
 ci earn, and at the same time lose her headaches, lose her 
 sickness and develop the appetite of a day laborer." 
 
 IV. Modifiers of the Nervous System. Analgesics — 
 
 Antipyrin. 
 
 Of all the analgesic medicines which have ever been pre- 
 scribed for the neuralgic affections, antipyrin seems to have 
 been the most uniformly successful, as well as the most harm- 
 less. Not even opium or morphine can be excepted, for opium 
 does not more speedily relieve pain than antipyrin in cases 
 
— 124 — 
 
 for which the latter is adapted, nor are the effects more per- 
 manent; besides at what cost is the analgesia of opium some- 
 times obtained. 
 
 History. — Antipyrin was discovered in 1885 by Knorr, 
 of Erlangen, Germany. It is one of the products of the destruc- 
 tive distillation of coal tar. Antipyrin is a derivative of oxy- 
 menthl quinizine, which is obtained by the reaction of aceta- 
 cetic ether on phenylhydrazine; if to this oxymethyl quinizine 
 there is introduced a new methylic group, methylated oxy- 
 methyl quinizine is obtained, to which Felehne gave the name 
 of antipyrin. It is a grayish white powder, slightly bitter to 
 the taste, and quite soluble in water. The chemical formula 
 of antipyrin is C 20 H 10 N 2 O2. 
 
 The manufacture of antipyrin has unfortunately fallen 
 into the hands of a monopoly, which has patented the name in 
 all civilized countries; hence the price of this drug has been 
 relatively high. It is not, however, maintained, that the pro- 
 cess of its manufacture is in any sense a secret. 
 
 Physiological Action. — While antipyrin in large doses is 
 speedily fatal to animals, producing convulsions both clonic 
 and tonic, and paraplegia or general paralysis, in smaller, 
 medium doses its action is characterized by diminution of the 
 sensory perception, and reflex excitability.* 
 
 G. See, and Chouppe have demonstrated that antipyrin 
 lessens the excito- motor properties of the cord, and that it is 
 also a sedative to the cerebrum. This physiological action 
 gives hints as to the modus operandi of its therapeutic action in 
 cases characterized by sensory hyper-excitability. 
 
 We are not here concerned with antipyrin in its relation 
 to fever, and those marked anti-thermic effects which make it 
 perhaps our best antipyretic. 
 
 Therapeutic Eviploy. — After antipyrin had been for more 
 than a year employed in fevers, it was found to be of prime 
 utility in combating the element pain. Nor is it strange that 
 a remedy which lowers fever-heat by depressing the activity of 
 the heat centres, should do good in other conditions dependent 
 on abnormal nervous activity. It was found to be of benefit 
 in acute rheumatism, by alleviating the pains in the joints. 
 Professor Germain See was one of the first to point out the 
 analgesic properties of antipyrin in all other affections where 
 pain is a predominant symptom. He reported a first series of 
 
 *Dujardin-Beaumetz, Dictionnaire de TherapeutiQue. 
 
— 125 — 
 
 observations, fourteen in number, relative to pains of the 
 head ; of these, four were cases of facial neuralgia; six were 
 obstinate cases of migraine; four were the headaches of grow- 
 ing children. In all, antipyrin caused the pains rapidly to 
 cease. 
 
 A second series of observations pertained to eighteen 
 cases of neuralgia or neuritis, and of muscular pains; to five 
 cases of sciatica; to several cases of painful zona, of lumbago, 
 etc. In all these, antipyrin proved efficacious. 
 
 Wolff has found antipyrin promptly beneficial in mus- 
 cular rheumatism and pleurodynia; Ungar speaks favorably of 
 its effects in hemicrania, and in those headaches which accom- 
 pany ophthalmias; while Lepine and Germain See have found 
 severe cases of the douleurs fulgurantes of tabes dorsalis 
 amenable to the same remedy Professor See has also had 
 good results from antipyrin in angina pectoris. 
 
 Otalgia (earache) has been treated with success by anti- 
 pyrine (Gomprez), and lumbago, whatever be its origin, ac- 
 cording to Germain See, gets well immediately after two sub- 
 cutaneous injections of five grains of antipyrin, with forty-five 
 grains taken internally. 
 
 In visceral pains (hepatic, nephritic, gastro-intestinal 
 colic, uterine colic). Germain See has never known antipy- 
 rin to fail. His treatment is a hypodermic injection of fifteen 
 grains, aided by fifteen grain doses by mouth four times a day 
 for eight days. In painful dyspepsias, he associates antipyrin 
 with bicarbonate of soda, eight grains of each, three times a 
 day at meal times. In painful menstruation he gives a lave- 
 ment containing fifteen grains of antipyrin. 
 
 Mode of Administration and Doses. — Antipyrin, being 
 soluble, is readily administered in water, or in alcohol and 
 water. Simple elixir is a good excipient. The dose is from 
 ten to twenty grains. Ten or fifteen grains may be given every 
 hour or two till six doses have been given. Antipyrin may be 
 safely administered in hypodermic injections. Seven or eight 
 grains are dissolved in one or two cubic centimitres of water, 
 and the whole injected under the skin. A little smarting fol- 
 lows the injection, which soon passes off. 
 
 Antipyrin sometimes causes a scarlatiniform rash, 
 which, however, is never serious. Now and then a little 
 nausea or vertigo attends its medicinal use, but it never causes 
 the depression and cyanosis which frequently attend the use of 
 acetanilid. 
 
126 
 
 TONGA. 
 
 TT^r! Tonga is a new remedy for neuralgia, introduced to the 
 profession by Sidney Ringer and William Murrell. of London, 
 in 1880, and obtained from the Fiji Islands. It has long been 
 used by the South Sea Islanders for all cases of neuralgia. It 
 is employed in the form of an alcoholic extract, in the dose of 
 a teaspoonful every few hours. Its effects seem to be very sim- 
 ilar to those of guarana. A good preparation of tonga is made 
 by Parke, Davis & Co. 
 
 GUARANA — CAFFEINE. 
 
 Guarana, and its alkaloid, caffeine, are somewhat famous 
 anti-neuralgic remedies. Guarana was first brought into notice 
 about twenty years ago. It is the product of a Brazilian plant, 
 the Paullinia sotbilis. Caffeine exists in guarana in the propor- 
 tion of about 5 per cent. The discovery of caffeine in four 
 plants belonging to separate natural families, namely: the 
 coffee and tea plants, the Paraguay tea, and the Paullinia, is 
 an interesting result of recent chemical investigations.* 
 
 Physiological Action. — Guarana and its alkaloid act much 
 like tea, coffee, and cocoa, causing at first excitation, then 
 diminution of the functions of the cerebrum and spinal cord. 
 Beaumetz sums up the principal effects as follows:f 1, cerebral 
 excitation; 2, complete paralysis of the sensibility; 3, tetanic 
 spasms and convulsions; 4, death. " These poisons, then, 
 seem to paralyze the posterior columns of the spinal cord, and 
 the entire system of sensory peripheral nerves, having no 
 action on the anterior columns and motor nerves." 
 
 These are the principal points of interest in connection 
 with the anti-neuralgic uses of guarana and caffeine. It is evi- 
 dent that the analgesic action, which is the one sought for, can- 
 not be dependent on the paralyzing action of the drug on the 
 sensory nerves and centres, which follows large doses. 
 
 Therapeutic Uses. — It is especially in migraine that guar- 
 ana or its alkaloid have proved beneficial. Nevertheless, facial 
 neuralgia has proved amenable to its use, and the supra-orbital 
 and infra-orbital headaches.:}: Common sick- headache, so gen- 
 erally referred to gastro hepatic derangement, is often marked- 
 
 * Wood & Bache, U. S. Dispensatory. 
 t.Dujardin-Beaumetz, Dictionaire de Therapeutique. 
 % Vanlair, Loc. Cit. 
 
— 127 — 
 
 ly relieved by guarana, and I have witnessed one case of cer- 
 vico-brachial neuralgia, which for more than three years was 
 kept in abeyance by this drug.* 
 
 Doses. — The dose of guarana is fifteen to thirty grains; 
 that of caffeine, three to six grains. The former may be taken 
 well stirred in a little warm water, as a wineglassful. The 
 caffeine, which is generally given in the form of a citrate (the 
 citrate is, however, merely a mechanical combination of caf- 
 fein and citric acid, and not a true salt) may be taken in a 
 spoonful of syrup, simple elixir, or water. The dose may be 
 repeated in an hour or two if no result is derived from the first 
 dose. 
 
 "I know," says Dujardin-Beaumetz, "a physician who 
 infallibly cuts short his attacks of migraine by the use of one 
 or two grammes of guarana." This has been a frequent ex- 
 perience. I personally know many (mostly delicate females) 
 who were formally martyrs to nervous headaches, and who 
 have for years been made comfortable by an occasional scruple 
 dose of guarana, taken in time to ward off an impending par- 
 oxysm. 
 
 Dujardin-Beaumetz {Dictionnaire de Therapeutique, art. 
 Guarana) gives the following directions for the administration 
 of guarana: " If the attacks of migraine are frequent (several 
 a month), take every morning two grammes of guarana, half 
 an hour before breakfast, 
 
 " At the onset of an attack, or, better still, as soon as the 
 precursory symptoms show themselves, take seven and one- 
 half grains in a little sweetened water; wait a quarter of an 
 hour, if the migraine is not gone, repeat the dose." 
 
 Formulae: 
 
 R Fluid ext. guarana, 5j. 
 Dose, a teaspoonful p. r. n. 
 
 The combination of caffeine and guarana is sometimes 
 more efficient than either the one or the other alone: 
 
 R Guarana in fine powder, 3j. 
 Citrate caffeine, gr. iij. 
 
 * Med. Record, 1876, page 743: "Dr. H. C. Perkins, the attending 
 physician, had obtained a quantity of Paullinia from Brazil. * * * Some 
 brilliant cures were wrought, and every form of neuralgia seemed to be 
 
 controlled by the Paullinia powders. In the case of Miss R , the good 
 
 effects were especially mar iced. * * * Her general health improved. 
 For four years there was almost complete immunity from the pain." 
 
128 
 
 Make one powder. To take in a little water when pre- 
 cursory symptoms first appear. This dose will sometimes 
 interrupt an attack that is in progress. 
 
 Anti-neuralgic Powder. — (Dujardin-Beaumetz.) 
 
 B Caffein, o gr. to 10 centigr. 
 
 White sugar, o gr. to 50 centigr. 
 M. One powder, p. r. n. 
 
 Bamberger's Anti-neuralgic Powder. — 
 
 B Sulphate of quinine, o gr. to 50 centigr. 
 
 Citrate of caffein, o gr. 50 centigr. 
 
 White sugar, 5 grammes. 
 M. Divide in chart, No. vi. Sig. — Take four a day. 
 
 Syrup of Citrate of Caffeine. — (Hannon.) 
 
 B Cit. caffeine, 4 grammes. 
 
 Simple syrup, 120 grammes. 
 M. Sig.— A teaspoonful as often as indicated. 
 
 ACETANILID^(ANTIFEBRIN). 
 
 The introduction of acetanilid into therapeutics is due to 
 Cohn and Hepp, in 1886, who first made known its antithermic 
 properties, and called it antifebrin. Acetanilid is obtained 
 by the action of glacial acetic acid on anilin. It is a substance 
 of a beautiful pearly white color, of slightly pungent, not dis- 
 agreeable, taste. Very crystaliizable. It is but very slightly 
 soluble in water. Its chemical formula is C 8 H 9 NO. 
 
 Physiological Effects. — There is nothing in the physiologi- 
 cal effects of this drug especially suggestive of the analgesic 
 action which medicinal doses exercise in many forms of pain. 
 It is true that large toxic doses are attended with abolition of 
 sensibility, but it has not been shown that moderate doses are 
 anaesthetic. 
 
 Therapeutic Action. — Analgesic Effects. — Dr. Demieville, 
 of Lausanne, was one of the first to call attention to acetanil- 
 id as a nervous medicament.* He administered it with bene- 
 fit in sciatica, lumbago, neuralgia, in headaches of various 
 kinds, in pains of obscure origin, in dysmenorrhcea, and in the 
 lightning pains of tabes. 
 
 * Revue Medicate de la Suisse Remaide, June 15th, 1887. 
 
— 129 — 
 
 Since the communication of Dr. Demieville, multitudes of 
 communications have appeared in the medical journals of 
 Europe and this country on the subject. The general verdict 
 may be stated as favorable to the use of acetanilid as an anal- 
 gesic wtihin a limtied range. It is especially in hemicrania 
 that it seems to do good. Some practitioners even seem to 
 think it equal to antipyrin as an analgesic. The dose is about 
 one half that of antipyrin, i. e., ten grains, to be repeated 
 three or four times a day. As acetanilid sometimes causes 
 alarming cyanosis, even in medicinal doses, many practitioners 
 are shy of it. A safe way of administration would be to give 
 five grains every two hours till four or five doses are given. 
 The dose may be given in capsules, stirred in water, or in 
 simple syrup, or elixir simplex. 
 
 PHENACETIN. 
 
 Discovered in 1887 by Kast and Huisberg, thephenacetins 
 are three in number: Orthophenacetin. metaphenacetin, and par- 
 aphenacetin. The general formula is as follows: C 10 H 13 N.O 2 . 
 
 Orthophenacetin and paraphenacetin are medicinal. 
 
 Phenacetin, like antifebrine and antipyrine, is both anti- 
 pyretic and analgesic; especially the latter. 
 
 As an analgesic, it has given good results in nervous 
 headaches, m graine, neuralgia cf the trigeminus, sciatica, and 
 the lightning pains of locomotor ataxia. A dose of ten grains 
 ordinarily suffices to allay pain; if this is not sufficient, an- 
 other dose of five or ten grains may be with safety adminis- 
 tered. Its hypnotic properties are also considerable. 
 
 Experiments made by Dujardin-Beaumetz in Cochin 
 Hospital the past year have shown that the phenacetins pos- 
 sess great medicinal value, are but little toxic, and have all 
 the properties of antipyrin, while being superior to the latter. 
 He administers it in the dose of i l / z grains morning and even- 
 ing, it being a matter of indifference whether ortho- or para- 
 phenacetin be chosen. 
 
 Phenacetin is but slightly soluble ; may be given in cap- 
 sules or tablets, each containing seven grains. There need be 
 no fear of any toxic action; Beaumetz has administered to ani- 
 mals as much as three grammes per kilogramme of the weight 
 of the animal without causing death. Enormous doses, 
 amounting in all to nearly two ounces, were given in the 
 course of a little more than a fortnight to a patient suffering 
 from tetanus, and recovery was attributed to the free use of 
 
 9 MM 
 
— 13° — 
 
 the medicament. There is another advantage which this 
 medi:ament possesses over antipyrin and acetanilid, in being 
 perfectly tolerated by the stomach. Its price is less than that 
 of antipyrin, at the same time, it is more powerful in the same 
 dose; in fact, one gramme of phenacetin produces an effect 
 fully equal to that of two grammes of antipyrin. 
 
 Prof. Lepine has now employed phenacetin for several 
 months as a " nervine medicament," with satisfactory results, 
 and prefers it to antipyrin and acetanilid. Gaiffe has used it 
 with advantage in the vomiting of phthisis, also in nervous 
 polyuria. It has thus far had no effect in paralysis agitans 
 and chorea, but it markedly benefits whooping cough. 
 
 Mceller, who has made much use of phenacetin in 
 typhoid fever, states that it does not produce a durable and 
 constant apyrexia; patients soon get accustomed to it, and, 
 moreover, it has no effect on the course of the disease. This 
 clinical authority prefers antipyrin and antifebrin as antipy- 
 retics, but finds phenacetin far superior as an analgesic. I may 
 add that this has been my own experience. 
 
 Exalgin. 
 
 Still another compound of apparently considerable medi- 
 cinal value (if we may trust the statements) has been obtained 
 from one of the products of the destructive distillation of coal- 
 tar. It has been experimented with by several members of the 
 Academy of Medicine, who have reported favorably; and in 
 consequence of its marked analgesic properties it has received 
 the name exalgin. 
 
 At a late meeting of the Societe de Therapeutique, M. 
 Bardet presented samples of this substance and made his report. 
 
 Exalgin represents, chemically, methylacetanilide, 
 C 9 H 1X N.0 = C 6 H 5 C 2 H 3 ONCH 3 . From acetanilid three 
 methyllic derivatives are obtained; one of these is the sub- 
 stance in question, and is designated Ortho-methylacetanilid 
 It presents itself in the form of fine needles or large white 
 tablets, is little soluble in cold water, more soluble in warm 
 water, and very soluble in spirit and water. Administered to 
 animals this substance acts energetically on the cerebro-spinal 
 axis and speedily kills in the dose of 40 centigrammes per kilo- 
 gramme of the weight of the animal. It causes restlessness 
 and trembling, and the respiratory muscles soon become paral- 
 yzed. In a less dose all sensibility to pain disappears, and 
 the temperature of the body diminishes gradually. 
 
— I3 1 — 
 
 The physiological effects of exalgin are very similar to 
 those of antipyrine, although the former seems to act in a 
 more marked manner than antipyrin on the sensibility, and 
 less energetically on the heat centres. 
 
 The analgesic effects of exalgin are obtained by a full 
 dose of seven grains; in some instances it may be necessary 
 to repeat this dose in a few hours. The relief from pain is 
 more prompt and more lasting than when antipyrin is given; 
 this is emphatically the case in all forms of neuralgia, especi- 
 ally in the visceral neuralgias. So far, no symptoms of gastric 
 or intestinal irritation have been noted when exalgin has been 
 given for its medicinal effects; its use has never been attended 
 by cutaneous eruptions or by cyanosis. 
 
 Exalgin is eliminated by the urine, the excretion of 
 which it seems to lessen in diabetic polyuria, at the same time 
 that it diminishes the quantity of sugar in the urine. 
 
 Neuralgic patients are often benefited by various alco- 
 holic preparations in moderate, tonic doses, as an adjuvant to 
 food and exercise. Wine, ale, and porter are the preferable 
 forms; a small glass of Bass' English ale or Dublin porter 
 promotes appetite and general invigoration. Alcohol is not 
 to be used in neuralgia for its narcotic effect as a remedy for 
 pain. 
 
 NITRO-GLYCERIN. 
 
 Nitro-glycerin has been recommended in some forms of 
 neuralgia accompanied with pallor, a weak pulse, small, rigid 
 radial artery, etc. Single drop doses of a one per cent, solu- 
 tion (glonoin) are given in cases of small pulse, but with a 
 full pulse, the full effects cannot be produced with less than 
 two-drop doses (Trussewitsch). When, on the other hand, 
 headache and neuralgia occur in patients with chronic conges- 
 tion of the subcutaneous veins of the face nitro-glycerin is to be 
 avoided.* The condition in which it does the most good is 
 one of failing circulation with atheromatous arteries and anae- 
 mia. 
 
 Nitro-glycerin seems to be an exciter of the vaso-dilator 
 system of circulatory nerves, *. e. , granting that there are vaso- 
 dilator nerves. 
 
 * Lancet, Feb. 19th, 1887, p. 384. 
 
— i3 2 — 
 
 V. Local Treatment, etc. Electricity. 
 
 On account of the similarity of action between the 
 electric current and the nerve current, it early oc- 
 cured to electro-therapeutists so employ electricity in neuralgic 
 complaints, with the intent of modifying the molecular state of 
 the nerves and restoring the physiological function. Faradism 
 was at first almost the only mode put in use, and Duchenne de 
 Boulogne was one of the first to make thorough trials of the 
 interrupted current in the treatment of neuralgia. According 
 to his reports, remarkable success attended these trials. Since 
 that epoch, Faradization has given uncertain results and often 
 complete disappointment in neuralgic affections, and is now 
 seldom resorted to in the treatment of any form of neuralgia. 
 
 Faradization is believed to act as a particular mode of 
 revulsion (Vanlair). Feeble Faradic currents are utterly ineffi- 
 cacious in neuralgia. In order, says Vanlair, that they may 
 manifest their curative active, they must provoke painful im- 
 pressions. This has been the experience of other authorities. 
 
 Mode of Application. — A Kidder, Mcintosh, Fleming or 
 Hall battery may be used, and a pretty strong current em- 
 ployed with frequent interruptions; the painful region to be 
 electrized by the metallic brush. This is the method of "elec- 
 tric fustigation " employed by Duchenne and Tripier. 
 
 Becquerel recommended very strong and rapid currents. 
 He advised the extra current and a wet sponge for electrode, 
 and directed to apply the positive pole over the part of the 
 nerve nearest the nerve centre, and the negative pole over the 
 divisions of the nerve; to be passed to and fro. Seances of 
 five minutes' duration. 
 
 Vanlair prefers the "dry excitator," which, correspond- 
 ing to the negative pole, should be placed over the painful 
 region, the other electrode, which may terminate in a moist 
 sponge, is placed a little distance off The electrodes are not 
 moved back and forth over the skin, *. <?., the current is stabile, 
 and not labile. Seances of five to ten minutes. When the 
 sedative action of the current is desired, the " moist excitators" 
 are employed, the current is given a centrifugal direction 
 (positive pole central, negative pole peripheral), and the 
 seances are somewhat longer. 
 
 Galvanism. — All authorities are agreed as to the necessity 
 of using mild currents. The negative pole is applied near the 
 nerve centre, the positive pole may be moved over the different 
 
— *33 — 
 
 painful points of the affected nerve.* When treating tic dou- 
 loureux, the current should be very mild, and should not ex- 
 ceed three or four milliamperes.f In the case of sciatica, 
 stronger currents are required, twenty mtliiamperes, and even 
 more. The sittings should be short, though according to 
 Apostoli, the duration of the seance cannot be fixed in advance, 
 and the passage of the current should be continued till the pain 
 disappears, or till at least some mitigation is obtained. 
 
 When there is a paint douloureux, the positive pole may 
 be applied over this point (Xiemeyer, Bardet, Tripier, Apos- 
 toli). Static electricity is little employed in neuralgia, though 
 recommended by Arthuis. 
 
 With regard to the choice of batteries when galvanism is 
 indicated, those principally in use are the Daniell battery, the 
 Gaiffe, the Bunsen, the Siemens-Halske, and the Leclanche 
 battery. 
 
 Among the advantages of galvanism over faradism in 
 neuralgia, are the following: 
 
 i. It is not painful, or scarcely at all painful. 
 
 2. It exercises a decidedly sedative effect when applied 
 secundum arte?n. A notable depression of the sensibility and 
 motility of the nerve follows. 
 
 3. It has the property of acting on the nutrition of the 
 tissues in energizing the exchange of materials. This is the 
 catalytic effect of the current, called electrolysis. % 
 
 According to Eulenburg, sciatica, of all the neuralgias, is 
 that which most readily yields to the constant current, while 
 intercostal neuralgia, (so amenable, according to this authority 
 to faradism) resists the action of the galvanic current. 
 
 Migraine, according to Dr. Joseph Stead, § is almost 
 always benefited by the constant current. He cites cases 
 where a five minutes application of a galvanic current pro- 
 duced most gratifying results. The battery used was that of 
 Weiss. He employed about eight cells with very small 
 sponges (about as large as would fill the end of a thimble) 
 soaked in warm water, and fixed to those small conical elec- 
 trodes which are used for the localization of the current in 
 paralysis of the interossei and lumbricales muscles. He ap- 
 
 *Dujardin-Beaumetz, Clinical Therapeutics, Am. ed., p. 59. 
 
 t lb. loc. cit. 
 
 + Vanlair, loc. cit., p. 200. 
 
 § Braithwaite's Retrospect. Part 65. page 86. 
 
— 134 — 
 
 plied them over the painful region, keeping them about one 
 inch apart, moving them about, but not removing them for 
 two months. As soon as the pain ceases in a case of neu- 
 ralgia, he makes it a rule to discontinue the application. 
 
 Dr. S. J. Knott, in London Lancet, Dec. 18th, 1875, reports 
 several very interesting cases of sciatica cured by galvanism. 
 He used eighteen cells of Stfchrers battery; seances three times 
 a week. 
 
 Another writer who has made much use of galvanism in 
 the treatment of neuralgia is Dr. J. Russell Reynolds, to whose 
 valuable articles in the Lancet (2d part, 1S70) we can only just 
 allude. The same may be said of Dr. A. D. Rockwell, of New 
 York, and Dr. Henry Lawson of St. Mary's Hospital, London. 
 
 MASSAGE. — KINESITHERAPY. 
 
 Kinesitherapy is the treatment of diseases by movement, 
 and includes gymnastic exercises, Swedish movement, and 
 massage. 
 
 One would never resort to the "movement cure" or 
 massage during a neuralgic paroxysm, except so far as he 
 might endeavor by gentle frictions or steady compression over 
 the affected nerve or nerves to attenuate the pain. Sometimes 
 such manipulations are attended with signal benefit, while on 
 other occasions all pressure and movement aggravate the 
 suffering. 
 
 Valleix has noticed that pressure diminishes certain neu- 
 ralgic pains, and the authors of the Compendium of Medicine 
 speak of facial neuralgias calmed by methodical compression 
 over the trunk of the nerve.* In a recent publication, Gassen- 
 baur relates two cases of rebellious neuralgia treated by mas- 
 sage, f The one was a sciatic, the other a crural neuralgia. 
 From his own researches, Faye concludes that massage is ad- 
 vantageous in acute and well circumscribed idiopathic neu- 
 ralgia, and notably in sciatica, facial neuralgia, and neuralgias 
 of the perineal region. It has but a feeble action in migraine. % 
 
 The Swedish treatment of neuralgia consists in deep 
 kneading of the entire limb or portion of the body affected. 
 Deep pressure, for instance, is made with one finger or thumb 
 
 * Van lair, Loc. cit., p. 222. 
 t Vanlair, Loc. cit., p. 222. 
 % Cited by Vanlair. 
 
— 135 — 
 
 on the nerve at the seat of pain, which causes an intense pain 
 for the moment, but is followed by a sort of paralysis of the 
 same nerve, lasting for several hours. In neuralgic affections 
 of the ulnar, percussion is made along this nerve from its 
 origin to its termination. "The blows should be sharp and 
 short if the pain is a dull, heavy ache, and of the character of 
 a slow heavy pressure if the pain is acute. For instance, in 
 facial neuralgia, paralyze the trigeminus trunk to cut off its 
 sensation, then knead and percuss with the finger tips." 
 
 Minute directions after this pattern are given in many 
 treatises; it is not, however, probable that massage will ever 
 have a wide field of usefulness in the treatment of neuralgia. 
 Much more can be expected of gymnastics in the prophylaxis 
 of neuralgia, for the exercises included under this head have a 
 directly fortifying effect on the general muscular system, on 
 the nerves and nerve centres. Besides, as Anstie points out, 
 gymnastics not only improve the circulation and general 
 nutrition, including the nutrition of the nervous centres, they 
 also give the nervous centres an education by the variety of 
 difficult co-ordinative movements over which it trains those 
 centres to preside.* 
 
 COUNTER-IRRITATION. — REVULSIVES. 
 
 In my judgement, counter-irritants (as mustard, turpen- 
 tine, acetic acid, oil of cajeiput) have not a very important place 
 in the therapeutics of neuralgia. I have never seen a severe 
 case of intercostal, cervico-brachial, sciatic or other pure neu- 
 ralgia much relieved by a mustard plaster or a turpentine 
 stupe, I believe that it is in rheumatoid pains and in myalgia 
 that these applications principally do good. Severe revulsion 
 by vesicants, the actual cautery, the thermo-cautery, has, how- 
 ever, in many severe forms of chronic neuralgia been productive 
 of benefit. 
 
 I remember a bad case of cervico-brachial neuralgia 
 where pustulation by tartar emetic ointment over the upper 
 part of the spine caused a marked postponement of the ordi- 
 nary attacks. In sciatica, I have occasionally seen good from 
 blisters applied along the nerve, over the seat of pain. 
 
 Latterly, the chloride of methyl spray has proved the 
 most efficacious means of treating sciatica. A peculiar appara- 
 
 Anstie, on Neuralgia, Am. Ed., p. 275. 
 
— 136 — 
 
 tus is required for these pulverizations, which produce intense 
 cold, followed by marked revulsion. A description of this pro- 
 cess will be found in New Medications, Am. Ed., page 283. 
 
 Cauterizations have been employed in very obstinate 
 cases. Legroux was in the habit of employing sulphuric acid 
 in the treatment of sciatica; with a stick soaked in the strong 
 acid, he marked out on the painful member ihe branches of the 
 sciatic nerve. At the present day, the hot iron, and especially 
 the Paquelin cautery are used; with this cautery, points are 
 made all along the nerve. Acupuncture is another means of 
 revulsion, now, however, pretty much gone out of vogue. The 
 same may be said of Baunscheid? s rdveilleur de la vie, a little 
 apparatus consisting of a bunch of pins, made to penetrate the 
 skin by a spring; these pins were generally dipped in croton 
 oil before using the instrument. 
 
 Dujardin-Beaumelz* refers to the benefits sometimes de- 
 rived from electro-puncture, as performed with the condenser 
 of Plant6 appropriated by Trouve to medical practice. With 
 a wire heated to a red heat by electricity, points are made to 
 the depth of a half a centimetre, and some little distance apart, 
 over the tract of the affected nerve. The punctures are 
 followed by considerable inflammation, but they often bring 
 the greatest relief to the patient. 
 
 HYPNOTIC SUGGESTION. 
 
 Of late many remarkable cures have been claimed by 
 hypnotic suggestion. The subject is thrown into the hypnotic 
 or mesmeric sleep, and the suggestion is repeatedly made till 
 it proves to be a reality that the pain is all gone. Bernbeim 
 has related in his book: " De la Suggestion et de ses applications 
 a la the'rapeutique" facts of this kind. The pain of migraine, 
 sciatica, pleurodynia, etc., has been caused to disappear by a 
 profound impression made on the sensory nerve centres of the 
 subject. It would appear that under hypnotism the higher cor- 
 tical centres are dormant, and that in a certain proportion of 
 cases, the functional activity of sensori-motor ganglia that are 
 in a state of morbid irritation may be suspended by sugges- 
 tion. But the modus operandi of the process is involved in pro- 
 found obscurity. 
 
 Clinical Therapeutics, Am. Ed., p. 66. 
 
— 137 — 
 
 NERVE STRETCHING. 
 
 Nussbaum was the first to practice nerve stretching: 
 Billroth about the same epoch (in 1872) performed this opera- 
 tion. It has since been performed in England, Germany, 
 France, and America. From Chauvit's article (" On Nerve 
 Stretching," Arch. Gen. de Med., 1881, p. 701-710) we ascertain 
 that in 188 1 nerve stretching has been employed in fifty-two 
 cases of neuralgia, as follows: 
 
 Neuralgia of the face 14 
 
 Intestinal neuralgia 2 
 
 Neuralgias of the upper extremities 9 
 
 Neuralgias of the lower extremities 27 
 
 In these fifty-two cases of neuralgia there were thirty 
 complete cures, twelve cases where there was marked amelior- 
 ation, and ten failures.* 
 
 According to Dujardin-Beaumetz, the benefits obtained 
 in some instances from nerve stretching may be thus explained: 
 It is probable that "the stretched nerves have a reactive in- 
 fluence on the sensory spinal centres which favorably modifies 
 the molecular state of the cells; this view receives support from 
 the fact that very powerful tractions do the most good." The 
 elongation does not act by causing a solution of continuity in 
 the nerve fibres. In fact, according to the observations of 
 Davalt, the sensibility returns at the end of twenty-four hours, 
 which would not be possible were there a rupture of the nerve 
 filaments. 
 
 In one of Cox's cases the ulnar nerve was stretched for a 
 traumatic neuralgia; the operation resulted in a cure. Both 
 supra-orbital and infra-orbital nerves have been stretched for 
 obstinate pain located in their tracts, and other branches of 
 the fifth nerve have been stretched, with variable results. Sci- 
 atica has been sometimes benefited by the operation. 
 
 The nerve is cut down upon in the most exposed place, 
 lifted out with the forefinger and pulled upon with a force of 
 forty to fifty pounds. 
 
 NEUROTOMY. 
 
 Neurotomy was performed for the first time by Marichal, 
 more than a century ago, for neuralgia, and has since been 
 repeated in a multitude of instances. 
 
 * Clinical Therapeutics, Am. Ed. (Detroit), p. 63. 
 
- 138- 
 
 It cannot be denied that marked relief has in many cases 
 been obtained by simple section of painful nerves, though the 
 results are generally temporary and disappointing. That this is 
 likely to be the case is apparent from the following considera- 
 tions: i. It may be difficult, if not impossible, to reach the 
 suffering nerve when it is situated deeply. 2. The seat of the 
 pain may really be central and not peripheral. The sensory, 
 cortical, ganglia may be affected, and the pain referred to the 
 peripheral branch; in this event section of the nerve might 
 fail in any way to modify the encephalic centre, although some 
 brilliant results have been recorded from neurectomy in cases 
 where the neuralgia was of purely centric origin. Here the 
 strong peripheric stimulus of the operation has acted as an 
 energetic nervous alterant. Instances of this kind are re- 
 corded by Erb in Ziemssen's Cyclopaedia, Vol. XL, page 95. 
 3. Another objection to nerve section is the trophic disturb- 
 ances which are likely to follow; this is especially the case 
 when a mixed nerve has been severed. 
 
 On account of the partial and fleeting success which has 
 attended neurotomy, the favorite operation is now: 
 
 NEURECTOMY. 
 
 Here a portion is exsected from the painful nerve. Repair 
 eventually takes place, and the nerve resumes its functions, 
 but respite from pain for a considerable time is obtained, and 
 during the period of formation of new nerve tissue and re- 
 establishment of conduction by union of the divided nerve 
 ends, it is hoped that restoration of the normal condition in 
 the diseased focus may be established. 
 
 Neurectomy is hardly practicable except in neuralgias of 
 the trigeminus, and not more than about two centimetres of 
 the diseased nerve ought to be excised. 
 
 Neurectomy of the fifth nerve was performed more than 
 fifty years ago by the late Dr. Joseph Pancoast, of Philadel- 
 phia, who was the first to reach the interior maxillary nerve 
 by sawing through the condyle, and to cut it close to the fora- 
 men ovale. Dr. W. H. Pancoast, son of the former, has made 
 several exsections of the sciatic and crural nerves in obstinate 
 neuralgias. Neurectomy of these latter nerves, however, is 
 generally considered a dangerous and unsatisfactory operation 
 as they are mixed nerves, and both trophic and motor paralyses 
 are sure to follow the operation. Hooker practiced exsection 
 of the popliteal in one desperate case; for three months there 
 was absence of all pain. 
 
— 139 — 
 
 Dr. Maurice H. Richardson, of the Massachusetts Gen- 
 eral Hospital, has practiced exsection of the inferior dental 
 nerve with brilliant results. This nerve is comparatively easy 
 of access. In 1876 the first operation for avulsion and de- 
 struction of the whole nerve was performed, and this operation 
 has been several times repeated since then. The buccal nerve 
 has been in several instances divided where it comes out over the 
 buccinator, and the superior maxillary nerve has been exsected 
 in the floor of the orbit. Dujardin-Beaumetz alludes to a case 
 occurring under his care in St. Antoine Hospital.* The pa- 
 tient 11 as a sufferer from tic douloureux. All medical means 
 had been unavailing. It was an infra-orbital neuralgia. 
 Beaumetz advised resection of the upper maxillary nerve; the 
 operation was performed by Terrillon. The nerve was sought 
 at its point of emergence from the foramen, and followed into 
 the floor of the orbit; the terminal portion of the nerve to the 
 extent of three centimetres was excised. Two years had 
 elapsed at the time of the writing; the pain had never returned. 
 
 But the operation is seldom so successful, and, as Beau- 
 metz remarks, many instances are on record where branches 
 of the trifacial have been resected for painful affections, and 
 with the utmost skill and thoroughness, with no result but 
 aggravation of pain to the patient and mortification to the sur- 
 geon. This, as before said, is especially apt to be the case 
 where the pain is central; and it must be remembered, too, 
 that much of the neuralgia that one ordinarily sees is consti- 
 tutional or dyscrasic, i.e., due to morbid alterations of the 
 blood; it is not to be expected that such neuralgias would be 
 materially benefited by any operation on the nerves. 
 
 HYDROTHERAPY. 
 
 Doubtless the external action of cold water in the form of 
 douches, jets, the shower bath, the cold plunge, sea bathing, 
 is of prime utility in toughening the integument and strength- 
 ening the peripheral nerves of neuralgic persons. Fleury has 
 applied with success the cold douche to recent trifacial, inter- 
 costal, and sciatic neuralgias. He has seen the pain disappear 
 after two or three treatments. Intercostal neuralgia is the most 
 amenable to the cold douche. He records that the first applica- 
 tions are likely to exasperate the pains, b.it perseverance brings 
 its reward. 
 
 * Clinical Therapeutics, Detroit ed., page 62. 
 
— 140 — 
 
 At the hydrotherapy establishments there is a variety of 
 appliances for cold water treatment {douche en jet mobile, douche 
 en lame, douche en pluic, douche en cercle, etc.), all of which 
 must be dispensed with in private and ordinary hospital prac- 
 tice. It has not even been proved that the wet pack is of any 
 utility in the neuralgias of the trunk or viscera. 
 
 It would appear that the principal benefit to be derived 
 from hydrotherapy is of a prophylactic kind, and that the cold 
 douche is principally of use (like cold bathing and sea bathing) 
 in strengthening weak organisms. 
 
 Nevertheless, some authorities (notably Baruch) speak in 
 unqualified terms of the benefits of hydropathy in various 
 forms of neuralgia. Baruch has found it especially serviceable 
 in sciatica. The patient is wrapped in a dry woolen blanket; 
 pieces of old woolen blanket two and four feet, doubled, are 
 wrung out of hot water by means of a wringer. These, after 
 liftfng the blanket, are applied to the affected limb over the 
 region of the nerve, and are rapidly changed till the parts be- 
 come thoroughly congested and the patient is bathed in per- 
 spiration. This treatment is kept up about half an hour. In 
 chronic cases the general tonic treatment by cold ablutions, 
 douches, and plunges is indicated. 
 
 OSMIC ACID. 
 
 Osmic acid is a tetroxide of osmium. It is colorless, solid, 
 crystallizable in long, brilliant, flexible prisms, melts at 40 C. 
 and volatilized at 100 C. It exhales a very pungent horse- 
 radish odor, and its vapors are very irritant. 
 
 This substance was first introduced into the therapeu- 
 tics of neuralgia by Eulenberg, who treated with success cer- 
 tain neuralgias by hypodermic injections of osmic acid, a one 
 per cent, solution in distilled water. He found that the injec- 
 tions of the above strength caused no unpleasant symptoms. 
 He selected twelve cases of neuralgia in different cutaneous 
 nerve districts of the upper and lower extremities of the head 
 and body; most of these were fresh and not unusually severe 
 cases. The treatment extended over one to six weeks; the 
 number of injections in individual cases was from three to 
 fourteen. The amount injected was a half a gramme of the 
 solution; the injection was made into the diseased part. Of 
 twelve cases three were cured, four more or less relieved; five 
 were not benefited. 
 
— 141 — 
 
 More recently, Shapiro, of St. Petersburg, has reported 
 success with the subcutaneous use of osmic acid in facial neu- 
 ralgia. The commencing dose was five drops. He had not 
 observed any evil local effects from these injections. He re- 
 marks that the most important action of the drug is to cause 
 inflammation of the terminal nerve branches, its narcotic effect 
 being of a secondary nature only. 
 
 Dr. G. W. Jacoby, of New York, claims to have treated 
 eighteen cases, mostly of sciatica, by these injections, eight of 
 which were cured, and some others benefited. 
 
 Dr. Merces {Lancet, Jan. ioth, 1885) reports having tried 
 osmic acid in eighteen cases of sciatica. The patient's ages 
 varied from eighteen to sixty-five. In twelve cases, he suc- 
 ceeded in giving absolute relief for a period of three weeks, 
 when he lost sight of them. In six he gave temporary relief. 
 The injections were as many as twelve in one case. He says 
 that although he gave these patients no permanent relief, they 
 obtained more comfort from the osmic acid than from even 
 hypodermic injections of morphine. He used a one per cent, 
 solution, injecting from three to five minims deeply over the 
 sciatic nerve. At the seat of the puncture the patient com- 
 plained of a numb feeling, which, however, was transient. In 
 some cases the effect was marvellous, the patient being able 
 after a short time to stand on the affected leg, a feat which 
 he had been unable to do before for years. He thinks the 
 effects are "undoubtedly local," but does not believe that it 
 exerts its action by setting up an inflammation, but rather 
 by a narcotic effect.* 
 
 VERATRIA. 
 
 There is some testimony in favor of veratria ointment, 
 as an adjunct to other treatment, in migraine, supra-orbital and 
 intercostal and other neuralgias. Anstie has seen it do much 
 good in mammary neuralgia. 
 
 The following preparations are in vogue: 
 
 Pommade Contre Neuralgies. — (Bertrand.) 
 
 Veratrin, o gramme 30 centigr. 
 Muriate of morphia, o. gramme 20 centigr. 
 Glycerite of starch, 30 gr, 
 M. 
 
 *Dujardin-Beaumetz, Diet, de The'r. Art.; Osmic Acid. 
 Bull, de The'r. t. Cx, p. 188: Lancet, July 25th, 1885; p. 167. 
 Medical Record, Vol. xxvii; p. 713. 
 
— 142 — 
 Pomade de Veratrin. — (Dujardin-Beaumetz.) 
 
 Veratrin, o. gramme. 05 centigr. 
 Axunge, 10. 
 M. 
 
 Veratria Ointment. — 
 
 Veratria, 3i. 
 Lard, fi. 
 
 M. For ordinary use in neuralgia this ointment should be diluted 
 with as much, or twice as much, lard. 
 
 PHENIC ACID IN HYPODERMIC INJECTIONS. 
 
 Recently Baccelli (Semaine Medical, 1888, p. 422, and 
 1890, p. xxiv.) has lauded the use of phenic acid in subcu- 
 taneous injections in neuralgias in general, and particularly in 
 sciatic, supra-orbital, and intercostal neuralgias. In the Se- 
 maine Medical for February 6, 1890, he reports a case of teta- 
 nus cured by this means. Baccelli employs a 1 per cent, so- 
 lution of phenic acid; the injections are made over the seat of 
 pain. The injections are repeated every hour till relief is ob- 
 tained; at first one-sixth grain of the active substance, then 
 two-sixths, by injection. According to this writer, the efficacy 
 of phenic acid is due to the sedative action which this medica- 
 ment exerts on the excitability of the nervous centres. But 
 little pain or smarting follows these injections. 
 
 CONCLUSION. 
 
 The medical student and the junior practitioner who 
 know little of neuralgias except what they have learned in 
 books, may imagine from the above formidable list of remedies 
 that with such a therapeutic arsenal they may easily triumph 
 over every form of pain. Alas! how soon will they find their 
 mistake! This very abundance of therapeutic resources shows 
 the intractableness of the painful neuroses. It were to be 
 wished that we had fewer medicaments, and better. 
 
 At the same time, the medical profession is far better 
 able to cope with diseases, whose principal element is pain, at 
 the present day than ever before in the past. Think of the 
 physician of former times, with no analgesic medicines but 
 crude opium and other narcotics; without any knowledge of 
 the surgical means! 
 
— 143 — 
 
 Since the last edition of Anstie's work (October, 1871) and 
 that of Vanlair (1882), all the so-called analgesics (antipyrin, 
 exalgin, acetanilid, etc.), have been discovered; cocaine has 
 come into general use as a local anaesthetic; several new and 
 valuable hypnotics (paraldehyd, sulphonal, chloralamid, etc.) 
 have been introduced; hypnotic suggestion has been brought 
 into prominence, and has won some triumphs in the realm of 
 obstinate neuralgias, and Hygienic therapeutics, which includes 
 massage, gymnastics, the Swedish movement cure, hydrother- 
 apy, aerotherapy, climatotherapy, dietetics, etc., have under- 
 gone considerable development. 
 
 Yet, despite progress in neurology, in pathology, in 
 therapeutics, the physician must still often find himself power- 
 less before a stubborn case — powerless to contend against the 
 forces of heredity, powerless to right an organism that has 
 always been wrongly constituted. 
 
 It is to be lamented that we have not more precise indica- 
 tions as to the uses of most of the drugs mentioned above, 
 whose employment must be still largely empirical. Nor can it 
 yet be said that we have for the various forms of neuralgia cer- 
 tain specifics on which we can depend, so that one may affirm 
 that in this kind of pain phenacetin is especially applicable, in 
 that acetanilid, etc. The physician will often be compelled to 
 feel his way along by the help of somewhat vague lights, and 
 no text-book or treatise can do more than give him hints which 
 he may tentatively apply to each particular case. 
 
INDEX. 
 
 A. Page. 
 
 Abbe, Dr. Robt 35 
 
 Abscess, Cerebral 90 
 
 Acetanilid (Antifebrin) 102, 128 
 
 in Migraine 38 
 
 Aconite 114 
 
 Aconitia (Aconitine) 103, 114 
 
 in Migiaine 38 
 
 Age as a Predisposing Cause 25 
 
 Albuminuric Neuralgia 79 
 
 Alcohol in Neuralgia 131 
 
 Ammonium Chloride in Neuralgia 122 
 
 Anaemic Neuralgias 81 
 
 Anaesthetics in Neuralgia 115 
 
 Analgesics 123 
 
 Angina Pectoris 65 
 
 Treatment of 68, 69 
 
 Angio-Paraly tic Migraine 36 
 
 Angio Spastic Migraine 36 
 
 Antipyrin 102, 124 
 
 in Ovarian Neuralgia 61 
 
 Migraine 38 
 
 Sciatica 56 
 
 Injections of 106 
 
 Anstic.5, 25, 35, 39, 42, 43, 51, 60, 63, 64, 100, in, 118, 119 
 
 120, I2i, 123 
 
 Appendix 107 
 
 Arsenic 100, 119 
 
 Atheroma as a Cause of Neuralgia. 30 
 
 Atropine no 
 
— 146 — 
 
 B. Page. 
 
 Baccilli 142 
 
 Bartholow 56 
 
 Belladonna no 
 
 Bernheim 136 
 
 Blisters in Intercostal Neuralgia 47 
 
 Sciatica 55 
 
 Brodie 89 
 
 Bromide of Potassium 117 
 
 Bromo-Pyrine and Bromo-Caffeine. 103 
 
 Buzzard 49 
 
 C. 
 
 Caffeine 102, 126 
 
 in Migraine 38 
 
 Camphor-Chloral 117 
 
 Cannabis Indica ill 
 
 in Migraine 38 
 
 Carnochan's Operation 34 
 
 Cautery, Actual in Sciatica 55 
 
 Cauterizations 135 
 
 Cervico-Occipital Neuralgia 41 
 
 Cimicifuga Racemosa in Ovarian Neuralgia 61 
 
 Chloride of Methyl in Sciatica 54 
 
 Chloral 117 
 
 Chloroform 116 
 
 Injections 55, 106, 116 
 
 Chlorodyne and Chlor- Anodyne 508 
 
 Chlorotic Neuralgias 81 
 
 Cocaine 118 
 
 Coccydynia 49 
 
 Cod-Liver Oil 100, 123 
 
 Cohen 120 
 
 Cold as a Cause of Neuralgia 15, 29 
 
 Conium Maculatum 112 
 
— 147 — 
 
 Page. 
 
 Cooper on Treatment of Mastodynia 48 
 
 Counter Irritation 135 
 
 Cotugno 50, 55 
 
 Croton Chloral 117 
 
 D. 
 
 Diagnosis 83 
 
 Diatheses, Treatment of 100 
 
 Diabetic Neuralgia , 78 
 
 Du Bois-Reymond 35 
 
 Dujardin-Beaumetz 46, 53, 54, 61, 115, 127, 136, 137, 139 
 
 E. 
 
 Electricity in Neuralgia 132 
 
 Erb 17,47,51.52,55,77. 91 
 
 Ergot in Migraine 38 
 
 Ergotic Neuralgia 82 
 
 Erlenmeyer 47 
 
 Ether in Neuralgia 116 
 
 Etiology of Neuralgia 24 
 
 Eulenburg 36, 37, 39 
 
 Exalgin 102, 130 
 
 Exciting Causes of Neuralgia 27, 28 
 
 Eye-strain as a Factor in Neuralgia 72 
 
 F. 
 
 Faradization 132 
 
 in Sciatica 54 
 
 Fothergill's Pill 99 
 
 Fowler's Solution in Neuralgia 100 
 
 G. 
 
 Galvanism 100, 132 
 
 in Gastralgia ... 64 
 
 Gastralgia 62, 63 
 
 Gelsemium 103 
 
 in Migraine 38 
 
— 148 — 
 
 Page. 
 
 Gowers 2, 11, 71, 93 
 
 Gouty Neuralgia 76 
 
 Gross' Neuralgic Pills 104, 113 
 
 Guaiacum in Dysmenorrhcea 60 
 
 Guarana 1 26 
 
 in Migraine 38 
 
 Gueneau de Mussy 51 
 
 H. 
 
 Hammond 56, 122 
 
 his Ferruginous Tonic 122 
 
 Hashish 111 
 
 Hemicrania 35 
 
 Heredity as a Cause of Neuralgia 24 
 
 Hepatalgia 62 
 
 Hesse 35 
 
 Huchard on Angina Pectoris 66 
 
 Hydrotherapy 139 
 
 Hydrastis Canadensis 62 
 
 Hygienic Therapeutics 98 
 
 Hypnotism 104, 136 
 
 Hypnotics 98 
 
 Hyoscyamus 112 
 
 Hyperalgesia to 
 
 Hysteralgia 59 
 
 Hysterical Joints 89 
 
 Neuralgia 80 
 
 I. 
 
 Indian Hemp (see Cannabis) in 
 
 Treatment of Migraine by in 
 
 Iodide of Sodium in Angina Pectoris 70 
 
 Iodide of Potassium in Sciatica 56 
 
 Iron in Neuralgia 121 
 
_ 149 — 
 
 Page. 
 
 J. 
 
 Jaccoud 8, 36, 46, 53 
 
 Jamaica Dogwood U3 
 
 Jenks 59. 6l 
 
 K. 
 
 Kinesitherapy 134 
 
 L. 
 
 Laborde 1 1 5 
 
 Lasegue on Migraine 39» 5 1 
 
 Laudanum Enema in Sciatica 56 
 
 Leared 119 
 
 Leube 64 
 
 Legroux's Treatment of Sciatica 136 
 
 Liquor Sedans 62 
 
 Locomotor Ataxia 90 
 
 M. 
 
 Massage 134 
 
 Mastodynia 47 
 
 Maudsley 57, 75 
 
 Meglin's Pills 112 
 
 Menthol 118 
 
 Methyl Chloride 54 
 
 Metastatic Neuralgias 80 
 
 Migraine 35 
 
 Mitchell, S. Weir 28 
 
 Morphine 108 
 
 Injections 105 
 
 Myalgia 85 
 
 N. 
 
 Narcotics 107 
 
 Neuralgia, Definition of .2 
 
 General Characteristics of 3 
 
 Treatment of 94 
 
— is© — 
 
 Page. 
 
 Neuralgia, Clinical Description of 5 
 
 Pathogeny 7 
 
 Classification 19 
 
 Causes ; 24 
 
 Idiopathic 19 
 
 Symptomatic 19 
 
 Holopathic 19, 71 
 
 Ramicular 20 
 
 Particular Forms of 31 
 
 Facial 31 
 
 Central 91 
 
 Cervico-occipital 41 
 
 brachial .... 42 
 
 Intercostal , 44 
 
 Lumbo-abdominal 48 
 
 Visceral 57 
 
 Reflex and Toxic 71 
 
 h frigore 77 
 
 Uterine and Ovarian 59, 60, 61 
 
 Neuritis 85, 88 
 
 Neuroses 2, 24 
 
 Neurotic Temperament 24 
 
 Neuromata 89 
 
 Neurotomy and Neurectomy 137. 138 
 
 Nerve Stretching 137 
 
 in Sciatica 55 
 
 Niemeyer 42 
 
 Nitrite of Amyl 116 
 
 in Angina Pectoris 70 
 
 Migraine 39 
 
 Nitro-Glycerine 131 
 
 in Angina Pectoris 70 
 
 Migraine \ 38 
 
 Gastralgia 64 
 
— i5i — 
 
 Page. 
 
 Nothnagel 84 
 
 Nux Vomica 122 
 
 O. 
 
 Oil of Peppermint in Neuralgia 118 
 
 Opium 107 
 
 Osmic Acid . 140 
 
 Osteocopic Pains 75 
 
 P. 
 
 Paroxysm the Neuralgic, Treatment of 101 
 
 Pancoast, Joseph 138 
 
 Peter, Michel 46, 117 
 
 Phenacetin 102, 129, 130 
 
 Phenic Acid 142 
 
 Phosphorus 122 
 
 Phthisis in its Relation to Neuralgia 24 
 
 Piscidia Erythrina 62, 113 
 
 Pseudo-Angina Pectoris 66 
 
 -Neuralgia 20, 28 
 
 Prognosis 93 
 
 Prophylaxis in Neuralgia 94 
 
 Pulsatilla 62 
 
 Putnam, J. J 26, 33, 58 
 
 Q - 
 
 Quinine 103, 120 
 
 in Migraine 38 
 
 R. 
 
 Ranney, Dr. A. L., on Eye-Strain, etc 72 
 
 Revulsives 135 
 
 Rheumatic Neuralgia 77 
 
 Richardson, Dr. M. H 139 
 
 Romberg 35 
 
 Pills of in Mastodynia 48 
 
— 152 — 
 
 Page. 
 S. 
 
 Salicin 120 
 
 Salol ., 60 
 
 Sciatica 49 
 
 See, Germain 102, 106, 124 
 
 on Angina Pectoris 65 
 
 Seguin 38, in 
 
 Senkler . 35, 38 
 
 Sex as a Predisposing Cause 26 
 
 Sick Headache 39 
 
 Sleep in the Treatment of Neuralgia 96 
 
 Spencer, Herbert 14, 16 
 
 Spring 2 
 
 Strychnia 122 
 
 Surgical Means of Cure 101 
 
 Svapnia 44 
 
 Swedish Treatment of Neuralgia 134 
 
 Syphilitic Neuralgia 75 
 
 T. 
 
 Tableau of the Neuralgias 21, 22, 23 
 
 Terrillon 139 
 
 Tic Douleureux 32 
 
 Tonga 126 
 
 Toxic Neuralgias 75 
 
 Tonics 99 
 
 Traumatism as a Cause of Neuralgia 28 
 
 Trousseau no 
 
 his Treatment of Migraine no 
 
 Turpentine in Sciataca 55 
 
 V. 
 
 Valleix 41, 42, 47, 50, 55 
 
 his Points Douloureux 4 
 
 Valleroux 54 
 
 Vanlair 10, 15, 18, 19, 28, 76, 78, 85, 91, no, 116, 120, 132 
 
— i53 — 
 
 Page. 
 
 Veratria 141 
 
 Viburnum Prunifolium 62 
 
 Vinegar of Opium 108 
 
 Vulpian 11 
 
 W. 
 
 Watson, Dr. Eben 122 
 
 Worms on Diabetic Neuralgia 78 
 
 Z. 
 
 Zymotic Neuralgias 79 
 
Eligible Remedies for Neuralgia. 
 
 Among the many remedies that are commended for Neuralgia, we 
 may mention for internal and local application the following, which we 
 supply: 
 
 FOR INTERNAL ADMINISTRATION. 
 
 Brown-Sequard's Neuralgic Idiopathic Pills— 
 
 Ext. Hyoscyamus, 2-3 gr. Ext. Conium fruit, 2-3 gr. 
 Ext. Ignatia, 1-2 gr. Ext. Stramonium seed, 1-5 gr. 
 
 Ext. Opium, 1-2 gr. Ext. Aconite leaves, 1-3 gr. 
 
 Ext. Belladonna, 1-6 gr. Ext. Cannabis Indica, 1-4 gr. 
 
 Neuralgic Idiopat., Brown-Sequard's, Half Strength. 
 Dr. Gross' Neuralgic Pills- 
 Quinine sulph., 2 gr. Ext. Aconite leaves, t-2 gr. 
 Morphine sulph., 1-20 gr. Strychnine, 1-30 gr. 
 Arsenious Acid, 1-20 gr. 
 Neuralgic, Without Morphine, Dr. Gross'. 
 Cerebral Sedative Compound. — A scientific substitute for certain 
 copyrighted preparations in the market. The active constituents are 
 potassium bromide, chloral hydrate, gelsemium and opium. The for- 
 mula is published on each bottle. 
 
 We also prepare a Sedative Compound, Formula " B," which differs 
 from the last named preparation only in the substitution of henbane for 
 the opium in the regular formula. 
 
 Fl. Ext. Guarana, U. S. P.— Guarana contains from 4 to 5 per 
 cent, of caffeine, a larger proportion than is found in any other drug. 
 Moreover, the caffeine exists in this drug in a very soluble form, so that 
 its action is very prompt, and the effect is greater than that produced 
 by an equivalent quantity of the pure alkaloid. As a remedy in sick- 
 headache guarana has no rival. It may be employed wherever caffeine 
 is indicated. 
 
 FOR LOCAL APPLICATION. 
 
 Menthol, Genuine Japanese, in Crystals. — A camphoraceous 
 substance derived from the Japanese plant, Mentha arvensis. It is em- 
 ployed for the relief of neuralgic pains, headache, toothache, etc., and 
 is said to be valuable as an antiseptic inhalation in acute or infusorial 
 catarrh. It is an agreeable medicine, and makes an acceptable substi- 
 tute for the ordinary smelling falts. Its properties require it to be kept 
 tightly enclosed to prevent rapid volatilization. 
 
 Menthol Pencils. — Put up in neat turned wood boxes, each one 
 containing a pencil. These pencils greatly facilitate the local application 
 of Menthol. 
 
 PARKE, DAVIS & CO., 
 
 DETROIT AND NEW YORK. 
 
IN EXPLANATION 
 
 OF 
 
 The Physicians' Leisure Library. 
 
 We have made a new departure in the publication of medical books. As you 
 no doubt know, many of the large treatises published, which sell for four or five or 
 more dollars, contain much irrelevant matter of no practical value to the physi- 
 cian, and their high price makes it often impossible for the average practitioner to 
 purchase anything like a complete library. 
 
 Believing that short practical treatises, prepared by well known authors, con- 
 taining the gist of what they had to say regarding the treatment of diseases com- 
 monly met with, and of which they had made a special study, sold at a small price, 
 would be welcomed by the majority of the profession, we have arranged for the 
 publication of such a series, calling it Tlie Physicians' Leisure Library. 
 
 This series has met with the approval and appreciation of the medical profes- 
 sion, and we shall continue to issue in it books by eminent authors of this country 
 and Europe, covering the best modern treatment of prevalent diseases. 
 
 The series will certainly afford practitioners and students an opportunity 
 never before presented for obtaining a working library of books by the best authors 
 at a price which places them within the reach of all. The books are amply illus- 
 trated, and issued in attractive form. 
 
 They may be had bound, either in durable paper covers at 25 Cts. per copy, 
 or in cloth at 50 Cts. per copy. Complete series of 12 books in sets as announced, 
 at $2.50, in paper, or cloth at $5.00, postage prepaid. See complete list. 
 
 PHYSICIANS' LEISURE LIBRARY 
 
 PRICE: PAPER, 25 CTS. PER COPY, $2,50 PER SETj CLOTH, 50 CTS, PER COPY, 
 $5.00 PER SET. 
 
 SERIES I. 
 
 Inhalers. Inhalations and Inhalants. 
 By Beverley Robinson, M. D. 
 
 The Use of Electricity in the Removal of 
 Superfluous Hair and the Treatment of 
 Various Facial Blemishes. 
 By Geo. Henry Fox, M. D. 
 New Medications, in 2 Vols. 
 
 By Dujardin-Beaumetz, M. D. 
 
 The Modern Treatment of Ear Diseases. 
 By Samuel Sexton, M. D. 
 
 The Modern Treatment of Eczema. 
 By Henry G. Piffard, M. D. 
 
 Antiseptic Midwifery. 
 
 By Henry J. Garrigues, M. D. 
 
 On the Determination of the Necessity for 
 Wearing Glasses. 
 
 By D. B. St. John Roosa, M. D. 
 
 The Physiological, Pathological and Ther- 
 apeutic Effects of Compressed Air. 
 By Andrew H. Smith, M. D. 
 
 GranularLidsand ContagiousOphthalmia. 
 By W. F. Mittendorf , M. D. 
 
 Practical Bacteriology. 
 
 By Thomas E. Satterthwaite, M . D 
 
 Pregnancy, Parturition, the Puerpera 
 State and their Complications. 
 By Paul F. Munde, M. D. 
 
SERIES II. 
 
 The Diagnosisand Treatmentof Haemor- 
 rhoids. 
 
 By Chas. B. Kelsey, M. D. 
 
 Diseases of the Heart, in 2 Vols= 
 By Dujardin-Beaumetz, M. D. 
 Translated by E. P. Hurd, M. D. 
 
 The Modern Treatment of Diarrhoea and 
 Dysentery. 
 
 By A. B. Palmer, M. D. 
 Intestinal Diseases of Children, in 2 Vols. 
 By A. Jacobi, M. D. 
 
 The Modern Treatment of Headaches. 
 By Allan McLane Hamilton, M. D, 
 
 The Modern Treatment of Pleurisy and 
 Pneumonia. 
 
 By G. M. Garland, M. D. 
 
 Diseases of the Male Urethra. 
 By Fessenden N. Otis, M. D. 
 
 The Disorders of Menstruation. 
 By Edward W. Jenks, M. D. 
 
 The Infectious Diseases. In2vols. 
 
 By Karl Liebermeister. 
 Translated by E. P. Hurd, M. D. 
 
 SERIES III. 
 
 Abdominal Surgery 
 
 By Hal C. Wyman, M. D. 
 
 Diseases of the Liver. 
 
 By Dujardin-Beaumetz, M.D. 
 
 Hysteria and Epilepsy. 
 
 By J. Leonard Corning, M. D. 
 
 Diseases of the Kidney. 
 
 By Dujardin-Beaumetz, M. D. 
 
 The Theory and Practice of the Ophthal- 
 moscope. 
 
 By J. Herbert Claiborne, Jr., M. D. 
 
 Modern Treatment of Bright's Disease. 
 By Alfred L. Loomis, M. D. 
 
 Clinical Lectures on Certain Diseases of 
 Nervous System. 
 
 By Prof. J. M. Charcot, M. D. 
 
 The Radical Cure of Hernia. 
 
 By Henry O. Marcy, A. M., M. D., 
 L. L. D. 
 
 Spinal Irritation. 
 
 By William A Hammond, M. D. 
 Dyspepsia. 
 
 By Frank Woodbury, M. D. 
 The Treatment of the Morphia Habit, 
 
 By Erlenmeyer. 
 The Etiologly, Diagnosis and Therapy of 
 Tuberculosis. 
 
 By Prof. H. von Ziemssen. 
 
 Translated by D. J. Doherty, M. D. 
 
 SERIES ITT. 
 
 Nervous Syphilis. 
 
 By H. C. Wood, M. D. 
 
 Education and Culture as correlated to 
 the Health and Diseases of Women. 
 By A. J. C. Skene, M. D. 
 
 Diabetes. 
 
 By A. H. Smith, M. D. 
 
 A Treatise on Fractures. 
 
 By Armand Despres, M. D. 
 
 Some Major and Minor Fallacies con- 
 cerning Syphilis. 
 
 By E. L. Keyes, M. D. 
 
 Hypodermic Medication. 
 
 By Bourneville and Bricon. 
 
 Practical Points in the Management of 
 Diseases of Children 
 By I. N. Love, M. D. 
 
 Neuralgia. 
 
 By E. P. Hurd, M. D. 
 
 Rheumatism and Gout. 
 
 By F. Le Roy Satterlee, M. D. 
 
 Electricity, its application in Medicine. 
 By Wellington Adams, M. D. 
 
 Taking Cold. 
 
 By F. H. Bosworth, M. D. 
 
 Auscultation and Percussion. 
 
 y Frederick C. Shattuck, M. D. 
 Series IV will be issued one a month, beginning with November, 1889. 
 
 GEORGE S. DAVIS, Publisher, 
 
 O. Bo=c -i'T'O. Detroit, liv^iclL. 
 

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