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A» /• ' ^ e f ■' f INAUGURAL DISSERTATION ON TIC DOULOUREUX, WHICH, IN ACCORDANCE WITH THE STATUTES, RULES, AND ORDINANCES OP THE VJVIjrBnSlTM' OF McaiMjXi COIiM^EaJE FOR THE ATTAINMENT OF THE DEGREE OF DOCTOR IN MEDICINE AND SURGERY, WAS DEFENDED IN PRESENCE OF THE PRINCIPAL, G. J. MOUNTAIN, S. S. T. P. AND THE MEDICAL FACULTY OF THE SAID UNIVERSITY. By Frederick 1S¥. Hart, OF THREE RIVERS, LOWER CANADA. Quoe medicamenta non sanant, ea ferrum sanat. Quoe ferrum non sanat, ea ignis sanat. Quoe verO ignis non sanat, ea insanabilia existimare oportet. Hippocrates Aphor. May 25th, 1835. / MONTREAIi! PRINTED BV A. BOWMAN, CANADIAN COURANT OFFICE, ST, FRAfCCIS AAVir,K STREEr. 1835. POJJ N WILLIAM ROBERTSON, M. D. PROFESSOR OF THE THEORY AND PRACTICE OF PHYSIC,, IN THE UNIVERSITY OF M'gILL COLLEGE, THIS DISSERTATION IS DEDICATED, NO LESS FOR HIS DISTINGUISHED EMINENCE AS A PHYSICIAI^ THAN FOR HIS KINDNESS TOWARDS, AND THE MANY BENEFITS DERIVED BY HIS PUPIL THE AUTHOR. 'VO J. STEPHENSON, M. D. S. C. L. Slc. PROFESSOR OF ANATOMY A]\D MIDWIFERY IN THE UNIVERSITY OF M'GILL COLLEGE. THE FOLLOWING PRODUCTION IS PRESENTED AS AN OFFERING OF RESPECT AND GRATITUDE, BY THE AUTHOR. ■I I '' THE HEAVIEST DEUT IS THAT OF (JRATTTl DF. *^ WHEN 'tis not in OUR POWER TO HE PAY IT." To BENJAMIN HART, Esquire, OF MONTREAL. RESPECTED Ai\D BELOVED PAREiXT, TO YOU I DEDICATE THIS ESSAY AS A FEEBLE RETURN FOR YOUR FOSTERING AND PATERNAL CARES, AND THE AFFECTIONATE KINDNESS EVER EXTENDED BY YOU TO TTIE AUTHOR. IH ir lit I MEDICAL INAUGURAL DISSERTATION ON JNEURALGIA, HISTORY. In describing tlic history of this disease I may re- mark that previous to the time of M. Andre, a French Surgeon of Versailles, from whom the appellation l^c Douloureux is traced in his treatise on diseases of the Urethra, published in 1756, the disease though mentioned by some was verj^ imperfectly understood and defined by terms as difficult of comprehension. Concerning the origin of the term Tic much doubt has been entertained. Sauvages has a species Tris- mus equinus ^alUce le Tic. Sic dicitur quia equi hoc aff'ectu laborantes deniihus priesepium impt- tunt et sonum Tic rejerunt* under the eighth species, Trismus Hypochondriacus, he observes, hue referri potest distortio musculorum genas oculos, ^c. maxillam macentium involuntarie et pravo usu as- sula, quiB vulgo Tic dicitur. The singular affection of horses, during which they strike their teeth together while biting at the manger, and the convulsive twitching of the muscles of the face, eyes, and lower jaw, in which some persons indulge, are therefore the roots of this expression. The term " Tic " was consequently applied to the disease and the epithet Douloureux added from the poignant pain accompanying such convulsive motion attracting as much notice as the former. The disease has also received several appellations from different authors, in the edition of Sauvages' No- sologia Methodica, 1763, it is designated by the term Trismus Dolorificus. Dr. John Fothergill un- der the appellation of " Dolor Crucians faciei^' seem- ;^»Ut iiv.o»rai*A iUai A nrli*^ Vinn nnticinntp.d him. Dro- 10 duced an excellent treatise on the subject It is not true, however as is generally stated that he is the ori- ginal discoverer of the disease, so far from being cor- rect that an operation for the relief of this disease performed long ago by Lovis is recorded * Posterior to the time of Fothergill many essays have appeared on this subject. By a very interesting view of this dis- ease and its surgical treatment, the ingenious Dr. Haighton has distinguished himself.t Dr.S.FoTHER- GiLL also produced an excellent essay on this disease under the title of " Faciei morbus crucians. Abo- lishing the unscientific language heretofore made use of, we shall adopt as the title of this disease the term Neuralgia from yof^^* a nerve, and «>^y<»s pain, so aptly denominated by Professor Chaussier, and which is generally received and made use of by most authors of the present day. In the American journals, cases are on record and mentioned by I)rs.HossACK,and Jackson. And Valentine Mott has been instrumental in reliev* ing many cases. According to Dr. Seibold, writers of all nations, ex- cepting the ItaHans, have seen cases of Neuralgia. Dr. Thilenius, a German physician saw it but twice during a most extensive practice of twenty years. Dr. Aepli, a Swiss physician saw it only once during a practice of twenty-seven years. As to the greater liability to this disease exhibited by either sex, a difference of opinion exists; the law of nervous irritability exposes females, both in England and America to a greater degree than the hardier sex. The appearance of this discLse is irregular and de- ceptive to the extreme ; seemingly every kind of tem- perament, indeed no habit of body or life appears ex- empt from its attacks. The laborious and indolent, the phlegmatic and nervous, those of rigid as well as those of lax fibre, the robust equally with the dehcate are exposed to the excruciating torments of Neuralgic affections. Fortsmann, a German writer, quoted with great fespect by Hertloupe, as also Dr. Darwin, concur that • Cooper's Surg. Dici t IVUd. Records and Rdselrches. ct It is not he is the ori- m being cor- this disease [.* Posterior ive appeared w of thisdis- igenious Dr. >r,S.FoTHER- 1 this disease ^ans. Abo- re made use ?ase the term ain, so aptly md which is )st authors of als, cases are and Jackson. tital in reliev* 1 nations, ex- r Neuralgia. it but twice ?s^enty years, once during ase exhibited ts; the law of 1 in England e hardier sex. iilar and de- kind of tem- 3 appears ex- indolent, the well as those I dehcate are ►f Neuralgic with great I, concur that and Rdseitrches. 11 the disease is laosi frequently met with between the twentieth and thirty-fifth year. The disease is seldom met with among childrenr thouervigli(> et musculorum vicinorum continua et convulsiva agi- tatione. He defines the disease by the title " Trismus Dolorificus." Dr. Mason Good, in his Physiologi- cal Nosology, remarks that Dr. Darwin very properly objects to the word Trismus, under which this genus has commonly been arranged, as no fixed spasm like that of Locked Jaw exists in this malady j Darwin also adds that in the few cases he has witnessed, there has not been any convulsion of the muscles of the face, though this may possibly occur occasionally as tho consequence of a disagreeable sensation, or to relieve it — to which Good subjoins, every other writer on this disease, besides himself has noticed the existence of some kind of nervous contraction, distortion or agita- tion from the commencement of the disease ; and in the case of Mr. Bosworth, Dr. Darwin expressly ob- serves that during the return of the pain he seems to stretch and extend his arms, and appears to have a tendency to epileptic actions clearly evincing a spas- modic diathesis. Dr Good seems to have overlooked Sauvages' definition of Trismus convulsio vel tonica vel clonica maxillse inferioris and the tremulous agita- tion of the jaws and lips together, with the temporary closure of the jaws arejwints dwelt on by many, con- sequently we see that ilr. liarwin's criticisms assisted by Mason Good, might well have been spared. The I functions of ently causing tributed. nd which by tion have by excited my nations to bo and appUca* ivages as fbl- dolorifica os mo perviglio ivulsiva agi- tle " Trismus I Physiologi- ^ery properly ih this genus I spasm hke dyj Darwin ;nessed, there 3S of the face, inally as the or to reheve »^riter on this existence of ion or agita- ease ; and in expressly ob- he seems to irs to have a icing a spas- e overlooked vel tonica lulous agita- te temporary ' many, con™ mna as&iisted pared. The j 15 following character may be less exposed to exception than many I have met with. Neuralgia is marked by acute lancinating pains not confin^ to the course of the trunk of any particular nerve, but may aftect its most minute ramifications together with distortion and convulsion of the muscles supplied by the diseased nerve. Paroxysm of short duration, occurring at ir- regular periods. DESCRIPTION. Neuralgia has been divided into Frontal, Sub Or- bital, Maxillary or Neuralgia of the lower jaw and Facial, or that of the Fortio Dura ; the first when the frontal nerves of Willis are affected, the second, when the superior MaxiUary is the seat of the afiection, the third, when the inferior Maxillary, and the fourth, when the Portio Dura is so affected. The sufferings in the first case are not complained of as confined to the upper part of the eye and forehead, but afler sometime that its effects have extended over the whole surface of the eye, conjunctively and subsequently all the corresponding sides of the face and head, the Sub Orbitary, Facial, Maxillary, Temporal, and even the Occipital nerves through the nervous connections of all those organs. The paroxysm is attended with spasmodic contrac- tion of the eyelids, as also by a flow of tears. The sub orbitary Hke the preceding is not for any time confined to the branches escaping from the foramen of the same name, but extends likewise to its nervous connections. As to the neuralgia of the facial nerve, it is a case that spreads so rapidly as to render it im- possible to distinguish it from the other species of neuralgia of the face. Like Chorea Sancti Viti it is unattended with swel- ling or any other external mark of disease. Its first symptoms are occasional, irregular twitchings of the muscles supplied by the diseased nerve ; in other inr times it begins with the violence of an electric shock, 1 !, ■ :;!i 16 again it is announced by the perception of an odour, an itchiness in the face, a kind of Aura Epileptica, the palpitation of the eyelids, a particular sense of tension in the palate and nose. By degrees the symp- toms become developed, spasmodic actions increase in frequency and acuteness, and an embarassing train of symptoms is noticed ; the pain is irregular and Tickle as to its locality and hour of accession ; sometimes it rests in a circumscribed point, at others widely diffused; it has been known to leave one side of the face and attack the other, it surpasses in atrocity the most vio- lent pains of toothache or earache; the patient is in real despair, ordinarily he can neither speak, swallow nor chew ; some persons however have the lips and tongue in constant tremulous motion, accompanied by a noise resembling that caused by manducaiion^these can both chew and speak. A strong pressure in ge- neral can be better endured on the affected parts in this form of disease than a light touch; the patient^s rest may be disturbed night after night as well as his comfort destroyed during the day; the most trifling and opposite occurrence gives rise to the spasms, which by their severity overcome the strongest resolution and force forth loud and involuntary screams of an- guish.* Washing the face, moving the hand or a handkerchief over the face, eating, drinking, speaking or coughing, sometimes the slightest motion or exertion will excite a return of the pains, taking any thing in- to the mouth hot or cold will produce the effect with aggravated violence. Sometimes it commences with a throbbing which seem to begin like the vibration of a musical cord, extending its effects to the cheeks, the nose, the eye up to the scalp on the affected side or from the corner downwards to the base of the jaw, agitating the muscles of the chin. Most frequently when the paroxysm comes on the patients whole body is convulsed, from the excessive agony, the eyes are intensely closed, mouth distorted, the cheeks quiver, the whole bodv moves backwards and forwards, and * Dr. Gardener Jones' own case, Phil. Med. Mus. New Series, Vol. I. No. II. i^ i of an odour, I Epileptica, ular sense of jes the symp- ns increase in ssing train of ir and iickle sometimes it idely diffused; the face and the most vio- patient is in )eak, swallow the Hps and companied by ucation^ these ressure in ge- cted parts in the patient's as well as his >st trifling and pasms, which est resolution ireams of an- le hand or a dng, speaking ion or exertion ; any thing in- Lhe effect with mmences with le vibration of he cheeks, the ffected side or se of the jaw, ost frequently its whole body , the eyes are cheeks quiver, forwards, and S^ew Series, Vol. I. 17 the foot of the diseased side is involuntarily moved in conformity with the flexure of the body. The face is red and swollen, sometimes livid; in other cases the blood vessels of the affected side are distended, there is little fever and the pulse is regular and slower than in health; interruption to every enjoyment and occupation of life,so admirably described by Jones' communication of his own sufferings, is only equalled by the degree of misery with which these paroxysms are attended. In general the seizure is short in proportion as the pain is exquisite, commonly it lasts for a few minutes only, seldom for fifteen minutes, and very rarely for an hour ; sometimes it subsides with a gradual, at o- ther a sudden decrease of pain, followed occasionally by a copious flow of saliva, tears, mucous from tlfe nostrils and eructations. The intervals between the paroxysms are sometimes though rarely equal. The preceding delineations are applicable to a confirmed case; involving most of the facial nerves, in many instances the operations of the disease are more confined, and give rise to a deception of the diagnosis. The first case recorded by Sau- vages was mistaken, and treated by him for Odontal- gia; this mistake has been ofi;en repeated as the obsti- nacy of the patient points to the gums, a carious tooth or the Antrum Highmorianum as the seat of the disease; with this view the gum has been divided in various directions, many teeth unnecessarily extract- ed, and useless perforations made into the cavity of the upper jaw. After lasting sometime, the disease if not arrested will involve every neighbouring nerve. In Mr. Bos- worth's case reported by Dr. Darwin, the supra-infra, orbital, and mental nerve, as also the branches of the pes anserinus, and of the superior maxillary nerve pas- sing into the cheek between the Pterygoideus Internus muscle and the upper part of the lower jaw, were all by the dexterous and repeated use of the knife suc- cessively divided; in consequence of which, this formi- dable and intricate disease was at length radically cured, and the patient perfectly restored to ease. m 18 Thec6nistitution of the patient seldom experiences any deterioration, daring the continuance of Neural- gia. CAUSES. The remote causes of Neuralgia are very obscure, in a plurality of cases no predisposing nor exciting causes can be detected; in some cases local injuries are the only assignable causes. We shall proceed to investigate its dependance on ♦he various causes enumerated : among the predispo* sing causes are ranked gout^ piles, disease of the abdo- minal viscera, derangement of periodical discharges, ^d cancerous maladies ; it is also stated that cold cli- mates predispose to the disease. As to its chief excit- ing causes, injuries of the head, suddenly suppressed evacuations, natural, artificial, and morbid, sudden transition from heat to cold or long exposure to severe cold, carious teeth, and irritation in the nerves of the teeth themselves or of those parts by which they are immediately surrounded and with which they partici- pate in action, are exciting causes of the disease. In this variety, the exact seat of pain is very diffi- cult to define, there being no black spot nor external mark to direct us to it, the tooth being often mistaken Trom the continuous sympathy excited, and sound teeth extracted in its stead ; there are instances where tooth after tooth was extracted till the whole side of the aftected jaw was divested, and without any alleviation : this is often anjidiopathic affection depen- dant on a peculiar irritability, from a cause beyond our reach, of the nerves subservient to the aching tooth, the tunics by which it is covered ; the periosteum or the fine membrane lining the interior of the alveoli.* Sir Henry Halfordt stated that diseased, bone was the cause or Neuralgia; in one of his cases there was an exostosis of the alveolar process, in another there was disease of the Antrum Highmarianum, and in tho third, the most remarkable of all, there was an im- , ■ . . . .. ■■, .. .. — I ■. ■ ■ . I ■.■■.. ■■ ■■»■ »■■■■■ ■ * Mason Good's Practice of Medicine. . ;] j t Lond. Med. Gazette, vol. I, p. 605, ( experiences se of Neural* k^cry obscure, nor exciting ocal injuries spendance on the predispo- eoftheabdo- il discharges, that cold cli- ts chief excit- ly suppressed )rbid, sudden sure to severe nerves of the hich they are they partici- disease. 1 is very diffi- t nor external »flen mistaken d, and sound stances where whole side of without any fection depen- cause beyond 5 aching tooth, periosteum or *the alveoli.* sed.bone was ses there was another there ^num, and in 3re was an im- 19 mense deposit, like frost work or petrefactions on the internal surface of the skull, which must have caused great pressure on the brain. Desault found a diseased sUte of the bony foramen, through which a branch of the third pair affected with Neuralgia passed. Cases 9re on record of diseased bone and injuries having been folbwed by this complaint ; but the difficulty of implicit reliance on such observations depends on the fact that disorders frequently exist " together " indif- ferent parts without having any kind of connection with each other, and terminate quite as independantly. Wounds of nerves, whether produced by laceration, puncture, or by the presence of foreign bodies, may be followed by this affection: such injuries,whatever be their seat or degree are followed by intense pain, whe- ther the nerve be perfectly or partially divided ; they are not necessarily accompanied by palsy of the parts to which the nerve is distributed, but when palsy does supervene, it may be temporary or permanent. According to circumstances the wounded parts sus- tain, adhesive inflammation terminating in ''Prir mitive Reunion, " occasionally th3 suppurative suc- ceeds, and sometimes the ulcerative which becoming chronic, leads to various alterations of texture ; these diversities of inflammation frequently appear to depend on thekind of Traumatic Lesion, also on accidental causes; as the influence of the atmosphere and motion of the injured part. The effects of wounds of the nerves are always modified by the constitution of the patient, and previous st?te of health or disease, as much or even more than those of any other kind of lesion. Serious accidents where they do supervene, depend on the wound only as an occasional cause ; in most instances if the person is in health and kept tranquil, a- voiding every exposure, the wound heals readily, and without accident ; as many experiments have proved. Sometimes puncture of a nerve may be followed by intense pain and even convulsions,extending to distant parts and occasionally implicating the whole system. In the case related by Dr. Jeflray the disease was produced by a wound from a piece of china imbedded ^ Hi it 20 in the substance of the cheek. Sudden irritation of the mind, also derangement of the digestive function, increased action of the blood vessels of the brain is al- so enumerated among the exciting causes. As to the proximate cause of this disease, many authors have agreed in assigning it to Arthritic matter. Dr. Hos- sack coincides partially with this opinion, thinking that in one case Mr. Apthorpes'* gout was intimately connected with x ralgia. Dr. Rush in his cnapter on gout,t expresses his o- pinion that Neuralgia is of gouty origin ; and the greater frequency of gout in the female sex, according to his ideas, is sufficient to account for their greater exposure to Neuralgia. This hypothesis is not ap- plicable to every case, at least, as the gouty diathesis cannot be detected in most instances of Neuralgia ; it may be safely pronounced inadequate to explain the mystery. Some pathologists have given out that the proxi- mate cause of this disease consists principally in some obscure affection of the brain; with which opinion, Dr. Gregory coincides,from the circumstance of his having known the disease to terminate once by Coma, and in another case to be followed by Amaurosis. Very extraordinary reasoning, I must allow : if the brain was principally m fault, it is very certain there would more frequently be observed indications of disturbed functions, than is generally noticed during Neuralgia ; in fact, during the first stages of the disease, no ins- tance is recorded of impaired function dependant on the attack, and rarely during the continuance ; nei- ther the pulse, tongue, stomach, nor intestinal canal indicate that the sensorium is affected. The treat- ment of the disease also shows the fallacy of supposing it as entirely nervous, since neither tonics nor stimu- lants have been followed by a more fortunate issue ; and most certainly if the brain were primarily affect- ed, some of the anti-phlogistic means would be of ser- vice. * Amcr. Med. and Pliilos Register, Vol. IV. No. II. page 299. + Med. Inq. and Obfiervations, Vol. II. irritation of tive function, le brain is al- s. As to the luthors have ir. Dr. Hos- ion, thinking as intimately presses his o- [gin ; and tho ex, according their greater s is not ap- mty diathesis Veuralgia ; it > explain the at the proxi- pally in some 1 opinion, Dr. of his having y Coma, and tresis. Very : if the brain I there w^ould of disturbed g Neuralgia ; ease, no ins- iependant on nuance; nei- estinal canal The treat- of supposing !S nor stimu- tunate issue; narily affect- uld be of ser- pago 299. 21 Pathology has thrown little light on the proximate cause of this disease. Cases are on record of its hav- ing continued for upwards of twenty or thirty years, without inducing any constitutional disturbance. Some cases are on record where the disease has mo- ved from one cheek to the other, by Metastasis : and others where after all attempts to cure have failed; being left to themselves, after a long time spontane- ously subsided. Dr. Parry considers as the proximate cause a Chronic Inflammation,* and thickening of the neurilemma. Increased action of the blood ves- sels of the head, inflammation of the nerve with thick- ening of its coats are confirmed to be among its causes by Martinet, who has mentioned cases, where the nerve was of a violet colour, and studded with Ecchy- moses. From close investigation, inflammation of the nerves has seldom been observed ; from the circum- stance that it has generally been confounded with the symptoms to which it gives rise ; this, no doubt de- pends on the difficulty of detecting its traces in the nerves on account of their whiteness, and the small size of their bloodvessels. Nevertheless, Pathohgical Anatomy has discovered that they have really been inflamed, also changed in structure from the inflamma- tion which has by some been considered as one of the causes of this disease ; but more likely a consequence ofit. By Pathological Anatomy alterations are some- times found in nerves, which should undoubtedly be regarded as the consequence of antecedent inflamma- tion. These may be serous infiltration of their cel- lular sheath, adhesion to the neighbouring parts; abscesses in the course of a painful nerve— softening, and purulent disorganizations, enlargement in the vi- cinity of Jiseased joints; circumscribed tumors, carti- laginous, osseous and calcareous transformations. Inflamed nerves have been observed on dissection to be reddened, tumified and infiltered with gelatinous fluia ; meir vessels uemg iiijui;i.?^, ai«A ^ -^«ir^x.--.g, -- kind of varicose dilatatio n. As to the symptoms of * Parry's Elements of Pathology. I n Hcute Neuritis, tliey have probably been confounded under tlie ijame« of convulsions and ptiins, cramos, emaciation, palsy. However, as stated by M. Be- clard, the pain of acute Neuritis is accximpanied with fever, at least local. When this disease becomes Chronic the symptoms are those of Neuralgia, which is a Chronic Inflammation of the nerves, dependant on some particular organic lesion. DIAGNOSIS. There are three diseases witb. which Neuralgia is likely to be, and has been, mistaken or confounded; and from which, by attending to the symptoms, it can easily be distinguished, viz. — Odontalgia, Rheuma- tism of the jaw and face, and Hemi-Crania. The age of the patient, condition of the teeth, and direc- tion, nature, course of the pain and in particular the convulsive twitchings will guide us in our diagnot sis : although,as before mentioned, young persons have been afiected with Neuralgia, still it is more jnchned to fasten itself on the nerves of the aged. If there be any carious loeih as from the irritation tljey may cause, may opera :t^ «a i certaa* extent on the disease, their extraction being premised, a decided opinion may be formed. In Odontalgia, the pain is obtuse or of a dull aching kind, being generally con- fined to one tooth, though somethnes a tooth in both jaws may be aching, or two in the same jaw, &c. then under these circumstances the pain will be more dif- fused; and often when produced by carious teeth in the upper jaw the pain extends through the cheeks to the eye, the gums and cheeks become greatly tumificd. The absence of swelling, shortness of paroxysms, quickness of their succession, the presence also of conviiJsions of the muscles, the darting lancinating paiii along the course of the affected nerves in Neu- ralgia, render its diagnosis comparatively easy. From rheumatism the diagnosis of this disease is inore difficult. Both may produce convul^ve motion of the mouth and cheeks; paroxisms attend both, I i 1 confounded lins, crumps, I by M. Be- accximpanied ease becomes algia, which g, dependant Neuralgia is confounded ; ptoms, it can a, liheuma- Jrania. The ti, and direc- articular the our diagno- persons have nore jncHned the irritation Hi extent on ied, a decided , the pain is merally con- ooth in both jaw, &c. then be more dif- iis teeth in the cheeks to the r tumificd. >f paroxysms, ence also of g lancinating jrves in Neu- y easy, his disease is ulsive Qiotion attend both, 53 which may becomo accumulated in frequency lor some fipace of time, leaving an interval of rest ; iKith may be excite' in its exhibi- larmlessness administer is of opin- aedicine was regard to its onii macula- he physician d quality of cautions gi- n of this ex- uired its full ist when the Bcome obser- It has then id the plants generally be ^row in the ring the pre- rudent when 5 extract, but i in the third 1 the system, s slight nau- nd often loss an not stand, up in such a its on the ge- peated every lave in very r, the patient ;chful as also ts. grs. LXX. in *. Jones ven- 3. CCC.insix le conceived, 3l the effects erfuUy, there « 25 would be a chance of effecting a real cure, a better chance than from giving a larger quantity during a long space of time. Accordingly after having exhi^ bited the medicine for about a fortnight and increa- sed the dose to six and eight pills of grs. v eacli, and having ascertained that whenever any remar- kable effect was produced it took place within fif- teen or twenty minutes after the dose was swallow- ed, resolved on a bold trial of this medicine accor- dingly, and directed eight pills to be taken as soon as the pain should come on and the same to be repeated everv twenty-five or thirty minutes, if the pain should continue and the medicine not affect the head or stomach. At this time the paroxysms of pain had become inexpressibly severe and very frequent. His directions had been carefully fol- lowed. The intervals of pain were such as to pro- long the intervals between the doses •, but in the course of six hours sixty pills were taken, making three hundred grains. After the last dose the pa- tient was quite overcome by the medicine. She be- came dizzy and faint, and was unable to sit up. — She laid upon the sofa for some time in a state of intoxication, but without suffering any very unplea- sant effects j afterwards the respite from pain and from susceptibility of pain was more perfect and longer than at any time for weeks before , but the dis- ease was not conquered, it returned the next day with considerable violence. Directions were given to repeat the medicine should the pain return, which was done, and in the course of the day forty eight pills, equal to two hundred and forty grains were swallowed. These gave entire relief and affected the head, though not so powerfully as the day before. The disease seemed now to be vanquished, and for two months the pain was not felt except in very transient twitches, which never continued for any length of time. About two months afterwards this lady walked out on an extremely cold day and the disease returned before night with con- siderable violence. The hemlock was cmploytd D Wii I 26 again, but in smaller loses at first. In three days the disease gave way, without having required very large doses of this medicine •, since hat time it has never returned, which is more than three ^The tincture of Hemlock prepared in the same pro- portion as the tiiictura digitalis purpurese has been found equally efficacious. In Dr. J«f ^f " «* P^^^' tice, in an other case of Neuralgia he began, with thirty drops at a dose to be frequently repeated, and presently increased if relief be not obtained j the dose was gradually increased to three hundred drops. It never gave reUef till the head was affec- ted and after that occurrence took place,the disease yielded in three weeks after he commenced the use of the hemlock,and since that time has not return- ed The action of narcotics on the system by repeti- tion, is diminished more than that of any other class of medicines. Each seems to have a modus operan- di peculiar to itself, and frequently alter the failure of one the administration of another wdl produce the desired effect, which shows that the operation of the same medicine in the same disease, is not tol- lowed by similar effects, from the circumstance ot thpir action becoming weakened by continued use. Doses have been given after a few days and m some cases after a few hours, as m that of Cicuta which, if administered at the commencement, would have produced death. The peculiar habit must be consulted. The narcotic, in treating this disease, must be changed till the one be found which produ- ces stupor on the nerves, and then m time the dis- ease may be cured. Datura Stramonmm has also been employed, but I believe with more efficacy m other forms of nervous disease than m this com- plaint Dr. Marcet mentions that doses from one eighth to half a gr. three times a day, have oblitera- ted this disease. AtropaBella-donna has occasional- ly been found of advantage. Cases are mentioned .Ncw-EixMund Juunial. Jackboi. on TicDolourcux. . In three ng required e that time ! than three lie same pro- reae has been ison's* prac- began, with ly repeated, ot obtained •, ree hundred id was affec- 3e,the disease imenced the as not return- em by repeti- ly other class lodus operan- er the failure will produce e operation of Lse, is not fol- rcumstance of continued use. days, and in hat of Cicuta, jement, would habit must be g this disease, I which produ- n time the dis- mium has also ore efficacy in 1 in this com- oses from one have oblitera- has occasional- are mentioned 27 where the extract in quarter grain doses three times a dav gradually increased to half a gram,have been ad- min'^tered. The pain recurred now and then,but on ^esuS he meLine ultimately went ^^^^ It has succeeded when opium and division of the nerve failed Opium has been used m some cases with success in others with no benefit whatever One case is recordedbyDr.Duncan,where it was followed Wthe desired efi^ict. Dr Gregory considers Opi- urn as the only effectual means we have. Mr. Thompson, of Whitehaven, published two cases where this medicine succeeded in doses from grs. II to IIIss. The alcohol ammoniatum is repor- ted as having been efficacious in removing this dis- lase It has'been given in doses of thirty-hve drops-, increasing a drop every dose, withsucces . Prus sic Acid has been recommended by Mi. layloi, who states that he succeeded in a shorter time than where he used the Carb-Ferri. The greatest care Lobe taken in its administration Its odour pro- duces fainting, and a drop externally will produce death He commenced with the sixteenth of a drop, gradually increasing. When these dangerous me- dicines are changed, the original dose must always ^"IrseZus acid in pills,containing a sixth of a grain with soap, is reported to have cured a case caused by an ii^ury of the Os-Frontis. This medicine will befoundof more use when combined with a sub- stance capable of diminishing the force of the circu- lation, and consequently of blunting its stimulating effect;, in which case it has been found to act more directly on the nervous energy. ^ With such a view it may be combined with Digitalis. Mercury push- ed to salivation has in some cases been found suc- cessful. Quinine. This tonic has been recom- mended by many. Cases are recorded as having been cured, by this medicine, in three grain doses. Mr Dupre published many observations repre- sentinff Sulph.auinine as a very powerful remedy m Neuralcria, as well as other aftections ol tiie nerves. II ! 28 Dr. Rabey having met with great success, from the exhibition of this medicine in Neuralgia, has published some cases in Magendie's Journal de Physiologie, April 1832. From sixteen to twenty grains may be administered during twenty-four hours. CarbFerri has proved very efficacious in this disease. In one case of Neuralgia of the extremities re- ported by Dr. Eiliotson of which we shall take a concise notice. The patient was a female, 33 year b of age, who had suffered for three months from violent pains in her leg, commencing in her great toe, running along the inside of the tibia to the ham, the* groin and along the lower part of the abdomen to the loins. It came on rapidly, excited by the slightest circumstance, was of a snooting stabbmg kind 5 she was ordered 3II. Carb. Ferri every six hours, in five days the pain was relieved, and the medicine was continued for a fortnight longer ,when the improvement not being progressive she was ordered gSS.three times a day •, three weeks subse- quently she was reported quite well. ■ When this disease is accompanied with rheumat- ic diathesis, the Tinct. Guiac : Volat : will be found serviceable in doses of a teaspoonful every two hours in a little wine. And when produced by a de* rangement of the digestive function, Emetics and Cathartics may be administered and followed by Caib. Ferri,if the latter should fail, the extract of Ci- cuta may be administered. Sir A.Coopcr applied an ointment of the sugar of lead to the face of a man, the pain by degrees abated, followed by a complete cure, a short time afterwards. In the hospital Charite (France) an ointment of the following form is used. Neuralgia Ointment. R. Lard dr. II, Opium dr. I, Ceruse §1. Local irritants have been followed by great relief, and not unfre- quently by a perfect cure. M. Andral cured a case by applying an issue directly over the seat of pain. In the course of the infra orbitar nerve, blisters atid leeches have been found serviceable, fomenta- tions and frictions with mercurial ointment have ICC6ISS, from uralgia, has Journal de n to twenty y-four hours, this disease. Lremities re- shall take a ale, 33 years aonths from in her great L to the ham, he abdomen ;ited by the ing stabbing rri every six ved, and the longer,when ive she was ^eeks subse- ath rheumat- NiW be found I every two uced byade* Emetics and I followed by extract of Ci- cr applied an Lce of a man, J a complete the hospital he following fc. R. Lard lOcal irritants id not unse- cured a case seat of pain, iierve, blisters )le, tbmenta- )intment have 29 also been applied. Electricity has been tried in some cases with wonderful effect. SURGICAL TREATMENT. The history of the operation by surgical treats ment is coeval with the first description of the dis- ease In an instance related by Sauvages, the cel- ebraied Surgeon Mareschal divided the nerve, and the patient whose sufferings had been excessive and who had not sleptfor many nights,enjoyed sweet repose the night after the operation , but withm a few days the disease *' returned." Tandem post biennium Andraas ope lapidis caustici adnasi latus inustiaquEe mercurialis ^upra escharamato^^^^ cisionis ados productoepost duodecimdies qu bus has op^ationes institute sunt statimam sublevit quae denique omnino sanata fuit cum chirurgus mitio denudatum stylo attingebat Pf «^y««^"™ **'^""^ JT lubitu excitabat cicatrice abducta ^gra sana yixit. Andre employed caustic as his great curative indi- cation, and his practice prevails in France at the present period. In an aggravated case of Dr. Haigh- ton's, reasoning on the apparent PJ^^^^.^^gy^^ ^^ disease, he was convinced that a division of the nerve would be effectual. Nor was he deceived The testimony of many surgeons is united in this point. Dr. Haighton^ besides his experience quotes Zm Sabatier's anatomical treatise. One instance from De.Haens' Ratio Medendi, another by Mr. Ritch, a Polish surgeon of high respectabihty, and a third in Paris in which the success was only tem- porary. M. Louis performed this operation with Access on a Prior of Premontres.t In addition to Dr. Haighton's authority, many excellent sur- geons admit, that where the nerves are rttectu- ally divided, a perfect suspension from misery will be obtained, at least until the reunion ot the nerves be af fected, and as that commonl yUkes •Ivied. Records and Researches, t GweUe Sttlutaite, No. 3G, 1776. 1 i 'I iii 30 place in a short time after a simple division of the nerves under certain circumstances. I shall take into consideration under this, the sur- gical treatment of the disease j those circumstances by which a re-union of the nerves is prevented, and also those by which if not prevented it will be de- layed and in some cases destroyed altogether. As some surgeons operate in such a manner as to pro- duce each of the foregoing effects, we shall now treat of divided nerves. In traumatic inflammation the two ends of the nerve,especially the superior,swell & become vascu- lar^ the surrounding cellular texture also inflames & becomes compact. The swelling and redness of the nerve extend in the end above the wound, but not in that below it : the small space between them is fill- ed with the investing cellular texture which contracts intimate adhesions with them j ultimately, the in- flammatory redness dissipatesjthe enlargement of the nerve remains, and the cicatrix unites the two thick- ened extremities. When there is much loss of substance the ends of the divided nerve continue separated in proportion to the absence of struc- ture-, when the loss of substance is inconsiderable, the two extremities become united by a cica- trix less thick than themselves, its thickness in general is proportionable, to the loss of substance j when this is considerable the separated ends of the nerve grow rounded. When a nerve is divi- ded, an oozing of organizable matter takes place, for some days, around its ends, on its surface, and in the intervening space-, the surrounding cellular tissue is penetrated by this matter and loses its permeability -, in this state the ends of the nerve are simply agglutinated together,and to the adjacent parts-, and its functions, are still suspended as they were immediately after its division. Forth- with the two ends of the nerve, which are thickened, 4i-_ : — ^^♦:.^« ^/^lliilni. fr>vtiivp nr»fl iho f^rfrnniy.ablfi matter,acquire greater consistence and become ye^y vascular -, in this state, which continues some time, vision of the r this, the sur- lircumstances levented, and it will be de- ogether. As tier as to pro- we shall now ends of the ecome vascu- so inflames &/ redness of the ind, but not in 1 them is fill- lich contracts itely, the in- •gement of the the two thick- much loss of 3rve continue ce of struc- iconsiderable, i by a cica- thickness in of substance ; ated ends of lerve is divi- takes place, [ its surface, surrounding 1 matter and ; the ends of hcr,and to the till suspended ision. Forth- ire thickened, ^ orfrnnizable 1 become ve!>y es some time, 31 the two ends of the nerve are united, by a vascular or<^anized substance, but still there is not yet a com- mSnication of nervous action between them.— In due time the cellular tissue ceases to be com- pact and vascular •, the intermediate substance gra- dually diminishes in size consistence, and redness j acquires the appearance and texture of a nerve and ultimately discharges its functions. This end is attained sooner and more perfectly vyhen the nerve has been simply divided or the excised piece small, and in a part not much subjected to motion. On the other hand when the separation has been important, re-union is never attained ; it rather takes place through the cellular texture, which does not acquire, at a certain distance from each end, the nervous structure and qualities. The time necessary to a complete recovery ot the structure and functions of a nerve has not been precisely ascertained. Some writers who scribe the fancies of their imagination, say several years. Dupuytren, Beclard, Dupuy and Roux from six to eight weeks, which I have frequently witnessed, and which must recur to every surgeon. From the results of many experiments which my space will not allow me to include, as also Irom he termination of accidental division of nerves in the restoration of their proper functions, which I am sa- tisfied cannot be performed by any other tissue, but nervous, neither by the interposition of a substance simply humid between the divided ends of anerve,nor by the remote action of the nervous system, nor by the anastomosings of nerves which, if capable ot re- establishing their functions, would constantly produce restoration in the case of a nerve completely divided with a part extirpated •, or where no extirpation has been resorted to, but merely complete division eflec- ted in a part subjected to much motion, as m the vi- cinity of a joint, occasioning, besides the primary, an accidental and variable separation,where reunion if it ever succeeds is tedious and imperfect -, aS aiSO when there is a considerable destruction of the ner- I 32 1,51' ;i! ill fflMill! I ! vous trunk by excision a great separation of its two ends remains, and its functions are forever lost. This fact is sufficient to prove that the nervous an- astomoses do nothing towards the re-establish- ment of their functions. The operation of dividing the nerve and extirpa- ting a piece of it, is the certain method of producing a radical cure. From the circumstance related, wh:re a considerable portion of the trunk of a nerve is destroyed, a great separation of its divided ends remain with the perpetual loss of function and consequently a complete barrier to the return of the complaint. M. Abernetby,however,arguing from the renewed sensibility & mobility of the ring finger on which he operated, thought that the anastomosing branches had become enlarged, and were officiating in lieu of the original trunk,by which means a com- plete cure was rendered impracticable. Had that learned surgeon removed a portion of theUlnar nerve & then been baffled in his anticipated cure,his appre- hension would have been well founded. There is some difference between the effects of a divided trunk and its branches. Nervous influence can readily be re-communicated by the preservation of the former, should the latter be effectually operated on. Moreover, as the nerve of the opposite side of the finger was derived from the radial nerve, the difficulty of solving the mystery is diminished.— To at empt a removal of a considerable portion of the frontal, infra-orbital or mental nerves, would be useless •, because the ramifications are so imme- diate and extensive as to preclude a successful en- deavour. The branches of the Pes Anserinus are in- timately connected with the Parotid gland and duct, also by some beautiful anastomoses with the other nerves of the face,so that a similar hindrance occurs here. The nerve that affords the greatest chance for effectual and final division is the Portio Dura be- lower jaw. . When the disease is in any other part of the sy»- iration of its 3 forever lost. e nervous an- re-establish- e and extirpa- I of producing itance related, trunk of a of its divided ' function and return of the Kuing from the ring finger on anastomosing /ere officiating means a com- ile. Had that heUlnar nerve 3ure,his appro- ed. There is } of a divided influence can reservation of ually operated pposite side of ial nerve, the diminished. — srable portion nerves, would ; are so imme- successful en- iserinus are in- ;land and duct, with the other idrance occurs test chance for trtio Dura be- f the .1 an 33 tern, if half an inch of the principal trunk, supplying the affected part, could be removed, there would be little dread of its return. A repetition of mci- sions, through a nerve by insulating several por- tions wilh a view of protracting a renewal of the disease, was practiced by Dr. Mott, of New- York, when operating on Dr. Jones (the sub. orbitar was the nerve operated on:) it may be remarked, as a circumstance connected with the opera- tion, that although the nerve be completely divi- ded, whether part of it be insulated or not, the chair of morbid actions will not be interrupted for several, perhaps twelve or fourteen days, even when the disease is comparatively slight. After the ope- ration the paroxysms have occurred, but day after day diminished in frequency and became less pain- ful till they disappeared altogether. Dr. Parry says that the operation of dividing the nerve, as performed by Dr. Haighton and others, did good rather by the division of the arterial branch supplying the affected divisions of the ramifications of the trigeminus nerve, than by the division of the ramification itself. He employs bleeding, both ge- neral and local, with purgatives. He also employed Opium and Calomel in one case which did rot yield easily. He mentions that he succeeded par- ticularly by local bleeding. Dr. Mitchell also states that he has cured these pains by tying the branch of the temporal artery, which goes to the parts in which they are seated. Delpech affirms that the pains are frequently the consequence of a Ganglion and thickening of the neurilemma, and in such case, excision of the part is then indispensable. OPERATION ON THE INFRA-ORBITAL NERVE. .\jx T -»-■ x: mrt of the sysi- i be detected by the course of the pain up the side of the nose, along the hollow of the orbit, and affecting E 11! I ! ;1 ! i 34 the muscles and integuments of the lower eyelid and corresponding side of the cheek. The pain ex- tends along the forepart of the upper jaw and along the canine and incisor teeth, or it may be confined to the muscles passing between the os-malae and the angle of the mouth, involving the masseter and buccinator. Pressure may be applied to the infi a- orbitar foramen, during which, the pain will be arres- ted, provided the disease depends on that nerve. A tremulous motion of the muscles of the upper lip and convulsive twitchings on one side,attend this varie- ty. The infra orbitary foramen is,in most skulls,half an inch from the lower edge of the orbit, and can be ascertained by the depression which is distinguishable in most persons. Before operating let the nose be held aside by an assistant, who also secures the pa- tients head. Introduce the Bistoury about mid-way between the nose and nasal margin of the foramen, carry it down to the bone, and pass the point close to the bone, in order to get it under the nerve. The point must then be elevated a little, tho' it must not pass through the skin from beneath. By a little rubbing motion with one finger upon the point of the knife,at the same time cutting gently with ihe knife, the nerve will be divided. As a considerable branch of the internal maxillary artery accompanies the infra-orbital nerve, its division will be made evident by a copious arterial haemor- rhage ; and a peculiar acute pain accompanies the di- vision of the nerve, in addition to the difference per- ceptible to the operator between cutting a nerve and any other soft solid ; the upper lip must now be exa- mined by a touch, if the patient acknowledge a dis- truction of sensibility, the Surgeon may withdraw his bistoury, otherwise the cutting must be repeated until from numbness, he is satisfied that the nerve is divided; but by following the directions above directed, and in a proper manner, he will find that a repetition of the cutting will not be requisite ; being certain that the nerve is thoroughly divided at the point of section, make two or three incisions through it, lower down, lower eyelid The pain ex- vv and along be confined >s-mal3e and nasseter and 1 to the infi a- will be arres- that nerve, the upper lip and this varie- »st skuUsjhalf it, and can be stinguishable t the nose be cures the pa- bout mid-way the foramen, 3 point close nerve. The lo' it must not By a little le point of the vith ihe knife, nal maxillary •ve, its division terial hscmor- ipanies the di- difference per- ig a nerve and ;t now be exa- ►wledge a dis- \f withdraw his repeated until lerve is divided; iirected, and in (petition of the ?rtain that the Dint of section, it, lower down, 35 endeavour to insulate a portion (iucludcd as it were within a parenthesis) with respect to the connnon sen- ^^ S?r A Cooper recommends (when the infra-orbital nerve is to be di''ided) the operation to be performed a quarter of an inch below the orbit. OPERATION ON THE FRONTAL NERVE. This %al distribution of a highly useful and im- portant branch of the Trigemini after it has entered the orbit through the foramen lacerum, and between the periosteum and bone, according to Meckel ; but m reality between the periosteum (to which it appears to cling) and superior rectus muscle of the eye, along with, but outside, and rather below the Troch eator, and within a few lines of the superciliary arch, divides into two branches ; tlie supra trochleator and proper frontal, which last passes through the superciliary notch or foramen, ascends on the forehead, subdivides and is lost in the muscles,and integuments of the scarp, and inosculations; the supra orbitaryforamen,inmany skulls is only a notch closed below by a ligament ; the situation of this hole or notch may be ascertained with tolerable precision, by finding the subK)rbitary foramen ; as it is about a quarter of an inch within a perpendicular line down from the latter continued up the forehead. n .^ c '^^u Pass a bistoury about three fourths of an inch within tlie orbit, immediately beneath the superficial ridc^e of the os-frontis, and divide the nerve outwards; a numbness must be felt on the forehead and eyebrow, before the knife is withdrawn; the connection between the nerve and periosteum is sufficient to impress the necessity of keeping the point of the bistoury as close as possible to the bone; and the dense periosteum affords additional resistance ; while dividing the nerve, the opthalmic artery will afford hsemorrhage for a tew minutes, but soon contracts so as to completely shut its mouth, and wlien its flow outwardly is repressed, it win piroduce so much ecchymosis as to blacken the eye to a considerable extent. 36 OPERATION ON THE MENTAL NERVK The foramen through which the termination of tho inferior maxillary branch of the fifth emerges, is situa- ted about mid-way between the alveolar process of tho jaw, and its base in a line between the cuspidatus and anterior bicuspid tooth ; the nerve may be divided by turning down the lip and introducing the bistoury about the first bicuspid tooth, with the back towards the angle of the jaw; keeping the knife close to tho bone, and by following the excavation of the jaw, the nefve will be divided by a cutting motion rather from the bone. In the aged edentulous subject from the absorption of the alveolar processes in reference, can be made to the teeth, in finding the mental foramen, it is situated generally in the same line with the supra-orbitary fo- ramen, and consequently can be easily discovered. OPERATION ON THE PORTIO DURA. The trunk of this nerve can be reached with safety, only by an incision, beginning at the very root of the mastoid process, and continued downward and for- ward along the anterior margin of the Sterno Mas- toid ; the dissection no doubt will require to be deep, but in performing it the surgeon will experience little difficulty; the lobe of the ear must be held upwards and forwards while prosecuting the dissection. In performing which, the nervus superficJalis colli will be divided where entering the lower angle of the pa- rotid. The glandular substance itself will be injured, and the arteria posterior auris cut across. A few observations on the propriety of employing caustic applications will close the subject. If the ob- ject be to destroy every prospect of a recurrence of Neuralgia; and if the patient will consent to an ex- periment, which if successful, must eventually annihi- late the nerve ; the precedents afforded by the French Surgeons will authorise the attempt. It has been ob- jected that the proximity of some of the nerves to th« L NERVK linationof tho srges, is situa- process of tho uspidatus and be divided by ; the bistoury back towards I close to tho f the jaw, the n rather from the absorption an be made to I, it is situated ra-orbitary Ib- liscovered. lO DURA. ed with safety, ry root of the ward and for- e Sterno Mas- e to be deep, :perience Httle held upwards lissection. In cJalis colli will gle of the pa- vill be injured, 3S. of employing ct. If the ob- recurrence of lent to an ex- ntually annihi«- by the French t has been ob- nervefi to the 31 bone, must necessarily involve exfoliation ; this conse- quence depends very probably on the manageinent ot the caustic, which should not be kept so long in con- tact with the bone as to endanger its continuity. After a nervO has been divided by an operation, I would advise the operator to separate the edges of the wound by means of a pair of forceps carried down to the nerve, holding the sides firmly between the tore- fmger and thumb to prevent unnecessary dilatation, merely sufficient to expose the edges of the divided nerve in such a manner as to render it possible of ap- plying the edge of a piece of caustic, pared like a drawing {lencil, to the extremity of the nerve, thus combining both expedients. The most permanent cure from this disease,has been derived by cauterization; it is in the true sense of the word, tho radical cure ; and from the circumstance of simple divided nerves uniting, and the disease return- ing after the operation with the same violence, the French Surgeons have entirely adopted the use. Many cases might be transcribed in support of cauterization ; the French journals teem with the wonders resulting from its employment as a remedy for painful nervous affections, whether produced by the action of concentrated caloric or of any caustic substance, producing an eschar; the separa- tion of which is equal to a wound with loss of sub- stance. Nerves are rarely, if ever, the exclusive sub- jects of burning or cauterization ; the nearest manner possible of confining the effects of caloric in the nerve, will be described presently, and when in this mode ; the adjacent parts will be more or less affected, for the caloric is given off* by the side of the needle, nearly, if not as much as at the point itself, though the eschar consequently will be very small when injured, in this way nearly by themselves, or imultaneou^ly with other parts, they are converted into an eschar, or the detachment of which, ihere remains between their ends a space proportionate to the extent Oi structure destroyed, and the cicatrix that closes the wound, does «ot restore the continuity of the nerves or its functions. I'll fill! < 11 n mIi |! I I " 1 38 For this reason cauterization is usually preferred in cases of Neuralgia, and most frequently determines favourable results, while simple incision is too often followed by a relapse ; experiments on the lower ani- mals prove that superficial cauterization does not des- troy the functions of the nerve, and most professional men who have seen and employed the moxa in such a manner as to produce rather a deep eschar, so that the nerve was not directly acted on, or in any manner destroyed, its function returned ; but after complete cauterization the nerves' functions are never restored. Dr. Descot gives the history of two experiments with the cautery, on a dog, in the one superficial, in the other complete cauterization was employed, with an account of the appearance of the nerve in the lat- ter, on the twelfth day after it had been injured. The animal walked on three feet, the palsy of the other being complete; the trunk of the nerve was complete- ly divided across, and a space of more than an inch existed^ between the two ends ; the upper was slightly thickened and flattened— the lower end exhibited no traces of having been cauterized, both of them ad- hered strongly to the surrounding parts to which they were intimately blended. Additionally to these, he relates a case of Maxillo-dental Neuralgia, cured by the actual cautery ; the patient, a Lady of fifty years enjoyed the " best of health'' afterwards. ■ Richerand, Delpech, and most of the leading Sur- geons in France, express their preference to the appli- cation of the moxa or cautery, v/hich they say proves more frequently successful than the knife, this should be applied directly over the apertures, from which the nerves emerge, on the forehead, cheek or chin. Ri- cherand states that in all the cases he attended, suc- cess followed the use of the moxa or cautery ; these two last remedies have been found extremely benefi- cial in painful, nervous affections, particularly the moxa ; after the application of which in painful affec- tions of the most excruciating nature, complete relief followed ; it should be applied over the point where the greatest distress exists, or when the greatest pain i» y preferred in itly determines )n is too often the lower ani- m does not des- Dst professional moxa in such a eschar, so that in any manner after complete never restored. experiments 3 superficial, in employed, with erve in the lat- 1 injured. The ;y of the other ; was complete- e than an inch ler was slightly tid exhibited no oth of them ad- s to which they lly to these, he •algia, cured by y of fifty years ds. he leading Sur- ice to the appli- they say proves nife, this should , from which the t or chin. Ri- e attended, suc- cautery ; these itremely benefi- larticularly the in painful affec- complete relief :.- i „.u^,„^ 4l%.->. pUIIll VVU^JiC; MIC greatest pain i» 39 not confined to one point, as in some nervous disease;?, but extends along the course of the nerves; it is to be applied as directed above. , , . m i The application of caloric to the body is followed by a contraction of the capillaries, and "an mcrease in the rapidity of their circulation ;" this contraction does not proceed from mere physical action, but is the result of the influence of heat on the vital properties of the vessels, and the effects of caloric are not limited to the point to which it is directly applied, but can ex- cite an action in living structures, to a considerable extent; for, it acts on the capillaries as a local tonic or stimulating astringent, and the power which this class of remedies poss ;sses of extending their influence by sympathy, along continuous surfaces or similar tex- tures, is well known. The direct effects of the moxa are seldom, if ever, confined to the skin ; if an eschar be formed, it extends to the superficial fascia, and sub- cutaneous cellular tissue ; and if the moxa be applied through the medium of a needle, the caloric may be made to propagate its influence to any depth. The moxa may be formed either by immersing Sur- geon's lint or fine linen in a filtered solution of Chlo- rate of Potass, in the proportion of one drachm to four ounces of distilled water. This burns slowly but steadily, even the blowpipe produces no sparks ; the substance must be perfectly dry, when folded should possess a proper degree of firmness, and after rolled up, the end ought to be cut to make it level for appli- cation ; the length of the moxa should be from three quarters of an inch to one inch, and the diameter may vary from one quarter to one inch ; the common mode of applying the moxa is so well known that it would be wasting time and place in describing it. When the moxa and acupuncture needle are used together, perforate a moxa of a proper size by a needle ofsuch a length as will be sufficient to reach the seat of the disease, and at the same time extend so far beyond the surface ot the skin as to keep the moxa «u^.,* ^y> irioU ^'..r^n-i u rxy af\ fnr n« to pomro the tex- ture of the skin from injury. The needle is then in- m 'm 40 trotliicod as far as the seat of the disease, by the assis- tance of a porte-aiguille, and as soon as it has been in- troduced the port-aiguille is then removed, the needle being left in the part. The moxa which had been previously perforated, should be now^ placed in a state ofcombustion, onthat end of the needle which pro- jects beyond the surface of the sldn, and allowed to T)urn round the needle by which it is thus transfixed. The heat disengaged from the moxa is commani- cated to the needle, and thence conveyed to the seat of disease. When the needle has cooled it is removed, and the wound or escha^* produced by it is scarcely observable ; and it is only from the universal success following this operation, that it so long has been and still continues preferable among the French Surgeons, together with the cautery, to division of the nerves, performed by the English Surgeons. Immediately after the operation of the moxa, ap- plied so as to produce a large slough, it is advisa- ble to wet the skin vith aqu?. ammonia, but when ap- plied with the needle as before described, no after treatment is necessary ; when eschars exist they should be covered with adhesive plaister until they separate, which may be expected in eight, ten and ercasionally twenty days afterwards. The Moxa acts more fa- vorably when the eschar is thrown off* very owly. Superficial ulcers, and excoriations may be washed once or twice a day with a solution of nitrate of silver, or sulphate of copper, and covered by adhesive plaister. FINIS. A. BOWMAN, PRINTER, MONTREAL. se, by the assis- 3 it has been in- •ved, the needle hich had been laced in a state die which pro- ind allowed to thus transfixed, a is commdni- ed to the seat of it is removed, it is scarcely dversal success ig has been and •ench Surgeons, of the nerves, * the moxa, ap- hi, it is advisa- a, but when ap- ribed, no after xist they should I they separate, nd occasionally , acts more fa- off very owly. nay be washed nitrate of silver, dhesive plaistcr. rREAL.