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Fairchild Bros. & Foster, 82 and 84 fulton st., new york. *9*»<«-«fc^?iiAH:^'»«jtoel4;tiu-r«S^*-i'-^^!^^ V A TREATISE NEURALGIA E. P. HJJRD, M, D., Mtmbtr of the Massaehuselts Medical Sociity; Member of the Climato- hgical Socitty; Member o/theSocieU de Midecine Pratique {Paris, France). One of the physicians to the Anna Jaquu Hospital, Newburyport. Mass. '4 V^' 1890. GBORGE S, DAVIS, UBTROIT, MICH. ■APS^.^-*«::§5T,g.i^St*(^'>ijW«.iftati>^V«V=i-«.a/ft.v^i*tfa;.t. '.:f J- Co| yiiirltiiit liy CIKiilidK S, 1)A\'IS ft- i DEDICATED TO DUJARDIN FJEAUMETZ, rHO HAS DONE SO MUCH TO ADVANCE TIIEHAPEUTICS, BY HIS FRIKNI), THE WRITER. ' ■Mi^i*afe-!H;ir^JW*=»Jri TABLE OF CONTENTS. CHAPTER I. PaC«. General Conilderations on Neuralgia i_i8 CHAPTER 11, Claailfication of the Neuralgias i^aj CPAPTER III. The Causes of Neuralgia 24-30 CHAPTER IV. Particular Forms of Neuralgia 31-56 CHAPTER V. Visceral Neuralgias 57-70 CHAPTER VI. Reflex and Toxic Neuralgias; Neuralgias Due to a Gen- eral M jrbid Condition 7i-8a CHAPTER VII. Diagnosis 93-91 CHAPTER VIII, Prognosis ^j 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 antemia, 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 fiom that which is endowed with motricity. pain may be looked upon as a cry of danger, as an index of a destructive process somewhere going on in the organism. IVIany iiinds of pain have lain, con- '9^- — 7 — 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, scapulo-clavicular, intercostal, and mammary regions. The motor irradiations consi.st 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 /t'c 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. THK PATHOGENY (»F NKUKAUUA. 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 '**""'«i*;">%*^=»^ftjetr»f-^'r,t^.-j»r - T I ■■*i4 — 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 .sen.sory 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. V'hen the excitability is exaggerated; this state is called hypericsthesia (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 hyperaesthesia 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 hyperjesthe- sia," and characterizes all the neuralgias, "A morbid hyperaesthesia raised to the potency of spontaneous re in R- ;s f. jr ts is [1- i- le is )• :d r- n, le of a- le id m e- id us — 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 sensibil- 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 conductibiiity, 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, he. cit. " ■ l l»i T l f « lMtl l WXy i ' awBfc»«^ If lO — trifling causes, and that thft 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 hyperasthesia 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. * Cowers, in his treatise on neuralgia, lays emphasis on the argument by which definite nerve paths (or pain, and con sequently definite nerve centres (or pain in the cerebrum are a(Brmed. Thus, tactile impressions pass up to the brain in the posterior columns. pain(ul impressions and impressions o( heat in the gray substance, as shown by experiments on animals and by clinical observations. In some Instances (as cases o( hysteria) there is conservation o( the sense o( touch and want of appreciation o( pain. Chloroform abolishes pain while oden in the ansesthesia o( chloroform sensibility to touch re- mains. Then, again, there is the electric sense and the sense of tickling, which are modalities of the sense o( 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 (or 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, underlved from and 5->iaMUi.. *^-^j"-^ ^' •■■ n — 13 — The causes of neutulgic hyperesthesia may be arranged in three orders*: 1. Intrinsic and primary modifications of the excitability of the nerve itself in some jwrt of its tract from the gray nucleus of its origin to its terminal ex- pansir)ns. 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 tht 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 proso])algia 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 Itind 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, /«•,, eit. article, Ntvralgie. Jl be he ict iX- ii- ;r- of ial T, is es ly. :al !re er- 00 In- ta- ice :fi- a ict er, — 13 — caries, or a tumor involv og a branch of the frige- minus; such lesions have bocii known to awaken neu- ralgic paroxysms inchstinguishablc from those of idiopathic prosopalgia. Illustrations of npnraljfia from reflex causes are seen in trigeminal, cervico- brachial, or intercostal neuralgias, originating in ovar- itis, or some other affection of a remote organ. Exami)les imder the third head arc seen in neuralgias due to lead poisoning, mercurial poi- soning, syphilis, or malaria. The neuralgias accom- panying anremia 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 ccmstitution 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 arc " 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 IT 5'; — 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 tr.uisformation ? 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 on, ese I is, tha e is the :e a ?es, ;ed- and ;an; 1 or uch :ral) wise essi- pro- lany cess sen- )ma- mia, nary nary le of r in- ition — '5 — 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." — (Put- nam^). % Pepper's S>8t. ol Med., vol. v., p. 1219. t A crm coined by Vanlair 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 orgeneralsensibility,— whose function iso/^^xtVi/they are set apart for pain and nothing else. It must be confessed that Vanlair gives weighty arguments in support of this view. And! ye' I cannot believe that there arc nerve centres whose sole function is the elaboration of painful sensations. In the healthy, normal sUte, 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 tliis 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 etm- scioMsness. 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 affirmingthat 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, } at y. n- If. es X- te ia s- of ys a at !ir ) a :e. int mt m- iist he res lat >n, he — 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 wi"' 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 'iii&^s^:^^^ ■^tfc.^^Sift***;;?;**: j«*iiiw.,.^^,«^ vtr-V. , . J — i8 — 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 fdaments 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. to I to en- as not fus- an- ery vith ion, ;ita- If, the I on gain ents ents ding :nce, the ilgic ;s in ichy- gesic ter- the :cen- hery, i 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 generiil 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 econrfhiy. 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. ■ wngur -irr -vuMjemfr*^ '^ '^ pyr^Hwen^ IF^.i^f^-^-'-^'^.f^,,- TJn ^i. ; , - , 1, „TW 20 — 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, 01 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. > low per- tuai we gia, less dis- lled the jive orm ther e of em; heir the vitb iral- :en- are gia& the the */\tCiliurA-i_f-w~ .-.;■ — ai — TABLEAU OF THE NEURALGIAS (FROM VANLAIR.) < < Pi u M z X H O o M (A < U H in A. Ramicu- Ur nerve*, or the neuralgias properly lo- called. I. N. Tri- facial. (Proso- palgia.) Ophthalmic Branch. Sup. max- Branch. Inferior Maxillary Branch. r fN. Supra-orbital. Prontal-palpcbro- natal. Bulbar or Ciliary, — dural. Infra-orbital . Superior-dental. Naio-palatine. Anterior auricular. Temporal. Buccal. Lingual. Inferior dental. Mental. t. Facial nerve properly so-called. The seventh pair. 3. (iervesof the Cer- vical Plexus. 4. Nerves of Brachial f N. Plexus I 5. Diaphragmitic nerves (?) 6. Dorso-intercostal ( N. Nerves. < fN. Occipital. Mastoid . Anterior cervical. Supra-clavicular. Circumflex. Supra-scapular. Ulnar. Radial. Median, Musculo-cutaneous 7. Nerves of Lumbar f N. Plexus. 8. Nerves of Sacral f N. Plexus. Dorsal, Intercostal. Mammary. Lumbar. Hypogastric. Ileo-lnguinal. Scrotalor labial. Crural. Obturator. Sciatic. Anal. Perineal. Penile. 9. Nerves of the Coccygeal Plexus (Coccygodl- nia.) ■'t«ti t<< iif i u! s ii w« iM TO <-W^» ■ competition; but it also brings with it disappointed hopes, funut, 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 fretjuency 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 among 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. TAe 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 Neuralgia in Pepper's System of American Medicine. — aj — Prnihus distasfs* predispose to neuralgia l)y the debility and an.x'mia which they occasion; tlie same may be said of unhrallhy hyji^ienic influtncei such at bad air, and insufticienl 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 anx'mia 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. KXCITING 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, gu.i-shol 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. ■j»^qwfa»g -. -3 ^„ in — 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 authors (as Vanlair) apart, under the head of pseudo-neuralgia s.X These neuralgias have a marked resemblance to ordinary neuralgias; sometimes, how- ever, they are distinguished from the latter by their *Zierassen's Cyclop., vol. xi, p. a8. t 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 traUement, 3d ed. (Bruxelles, 1882.) JS 1- ;r re le 1- >y of :d V- :ir it- ' a >le I lO- ily Ht, — 29 — 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 g/ossy 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, lac. cit. (Am. ed.), p. 175. M ^ag ^ v 9^ feja»'.Mgft ' L — 30 — 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 hyperiemia, 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. »! li h 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, deca.ed 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 ';^»M;^^.SM^(,49LU..^H£ .-^^'.■^^.^^:-^..-,^.. I! lis- — 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 on their beds and smite their heads;* 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—AV douloureux. These contvnctions may be limited to single groups of muscles, as the zygomaticse, 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 t^i 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. \ 4fcjtiWii»fcB*iM'to'«Mgtfii*>a*rt'»ti-ica**'i^ he es y. he he se rff it, it- of )ts ISS ^e ;o- or lie ed pil ird he ed in :es be lb- i ,!W > MMLJWi p W» aM N l — 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. 1 .' ='!'- _ 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 Eulenbiiry 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 Lasagne (Etudes Medicales, vol. II., p. 331), is a disease of paroxysms; a man who suffers from con- tinuous lieadaclie is not migrainous. The attaclcs do not repeat themselves at periods that can be mathemeticaliy calculated. ***** Ordinarily, the attaclcs 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, faiigue, 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 — 46 — ii A vague tentatlon of weight and twelllng of the face and a little aching of the teeth. The occipital form la the moat pain- ful, and is rarely hemlcranial; the syncipltal, 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 thev were being scalped. Sometimes, however, the integument seems to adhere to the sicull 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 fxira 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 attacit 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-htadache. There is nausea, retching, and vomiting during the attack; these symptoms pre- dominate in the stationnry period and then sometimes cut short the att&ck, 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- ■ I ■■ ■ n i iii i ii i » ,i *ft' >i r 'itii«w,'i-ii«r)n,7.riii rr^irii— Tfw— .^ — ..^^^■^, -.»>.m..uc* — 4t — tcllectual torpor with absence of Ideu, or a lub-dellrium •imilar to that of dreami, 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 io 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 eHect may be produced by full doses of some of the modern analgesics, and especially antl- pyrine, phenacetin, and caffeine. | III. CERVICO-OCCIPITAL NKURALUIA. 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. Disease^ 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- bra, 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 vertebrte 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 ^i'. »H«1*»*.J!--^^'*J-W — 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. ,^Biaiiigg»< p( ii fe i n i«aaaigiBfc' — 44 — This case seemed to me to be a fairly typical one. Antipyrine in lo 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, mto 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 bdck. 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 thf rb they enter the substance of the in- ternal intercostal muscle, and reach the inner surface, being in contact ivith the pleura; at the anterior ex- tremity of the intercostal space they pierce the mus- c'es and are distributed to the integument. Midway -^saujwur&iu!-'-' . .^^fc^itNHuaiiWjiisei«iu0v«!^iS< •?afea»H '<» >« J '» w^ * ^ i'*' '^g ^' ^'- ^^g'"* ^-^' 'J* * ^ "^'' '*'''***'''*'^^^*^'- ■jgiemiamimoiitsaisi:-- — 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 obsimate form to follow attacks of pleurisy. It may be reflex, and accompany catarrh of the digestive tube and diseases of the uterus or i ' •4 _ 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 pams m 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 TherapeuUcs. p. 74- 'ff^f.i^meamiHtf^'t li,it^,^gii^jiiMM>trm!mimSllii*J>s: n-dMm m f Fi n 9' !V Bmm»*'' IC 1- r- •n n, al >n id e) lie is- — 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. MASTODVNIA — 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 -BE_; -48- or more points over the mammary gland. Severe pain liice 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 small 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 J gr.), to be taken according to indications. VIl. LUMBO-AHDOMINAL 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 ■ i?Wi,y. — 49 — spontaneous, or provoked by walking, sudden move- ments, pressure over the nerve, etc., and remain limited to the hones, 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. CocLVDVNrA. — 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. t VIII. NEURALGIA OF THK SCIATIC NKRVE. 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, t Art. Neuralgia in Quoin's Dictionary of Medicine. 4 MM .*»TaHB^?a®®2aiiBRse»^58^B«sa«sae^^s^ssfrs^ssKte 7^Sf^^4^^iS^Mx!^S^^i!^^^t^'TT^i^ ^zi-'^v'^xm — 50 — 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 douloureux, 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; 11. 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: I, at the point of emergence of the nerve trunk; 2, in the points where a nerve filament traverses -^ !n- ial ut- to he he ra- re- vs: 2. iac ine 4. 6. i^er ;he 8. the ro- at BO- ica 3n- rve ses — SI — 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 La^cgue's view. Erb regards the anatomical changes as oimply accidental accompaniments of the disease. It is, however, true that in the experience of many practitioners, as in that of Lasegue, t the disease has not been r,o much char- acterized by lancinating, ingravesce.it 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 M ussy J looks upon sciatica as * See some very judicious remarks on this subject in Lasigue, Etudes MedicaUi, p. 310. f Las6gue, Etudes Medicates, Vol. II. Art. Sciatica. { Gueneau de Mussy Clinique Medicate, t. i., p. 306. ~Jh ! ^t aiimSSiS idii ii '-^ :i^--, i l » ^i Ji:i:,aaiid^^il-'^U'^ - — 52 — a manifestation of a rheumatic or arthritic diathesis. The great length and superficial position of the sciatic nerve renders it peculiarly liable to inlammation 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 Cyclopadia. i ■ SIS. itic om )ns, fie, ing ure ent ing vor ob- de- [ise, ird- ,, is )ch, rb's s as ices I or rts; )ain rves — 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 neuralgia.s, the pain may be looked upon as douNe; 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 pre.ssure 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, i. i, p. 502. -■■i«i«SiliS*««»JS^S^«*?.-BS^»»iu<*Sst,ia'«^^ 35»-(S.B,SKS:CS!4--.aBE^y — 54 — walk with difficulty, limpin(j:, or even are compelled to cease walking altogether. Hesides these pains, disorders of the cutaneous sensibility have been noted, and Hubert Valleroux de- scribes sensory troubles (pertaininjj 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."* Trfatmen/.—'lhG 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- Beauraetz says that in real sciatica he has generally • Reprinted from "Clinical Therapeutics. M to IU8 ie- :u- ive of lar )hy ges cin, act ase ery Re- lent to e of iliar lich ing. din- ally - 55 — found the pain to ceasi after mie or two c'i|)|)lii:ati()ns of chloride of methyl spray. (See the subject treated fully in New Medications, pid)lished by (1. S. Davis, Detroit, pajje 2S5.) The ether spray, directed over the affected nerve or nerves, jjave jf^eat relief to one of my patients in his atrocious paroxysms. Cotuj^Mo was the lirst to propose canlharides blisters, and all subsequent authorities have spoken well of them. The blisters should be of the size of the palm of the haiul, and ap|)Iied 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. Krb 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. ^sSSi»»SS>iSiBtUSa»S's««9W«4S«»i«>SWSifia><<«-i^ =i-4«-<*BtSSS«K(F'" ■Iji- 'i; _ S6 - 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 ii6). 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. /./ ler IS, :m he ge •o- •)• ps on ire )r- ii- nd ne lis io- by !n- in ed i / 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, can- asthesis* 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 canasthesis." Maudsley, Physiology and Path- ology of the Mind, page 135. ■sm m-Tm - ^' tssmiisit^^i.mi&::.ei^eii>^tii^t.^. ♦to..™— ...^"" 111 ■1l - 58- 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 natur'e; 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. Sa.;;j,c.-s; — 59 — It is needless to say that hi causes of visceralgia are the same as those which pr^'juce 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 dysmenorrhoea 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 flew 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. '>'£Slli@9aa)niisa«k)C£Siw tmsSiisu^i.iiiim^-x'Jut.i »Mu=>£^'^il.^i»iWi;<«i^^.^^^tl^^>';'.^ut^r.^4.*^i£^J^^»U!^»^^<^ ;.^*«T!***&;!^*U£!Si*v?- ^i^*^cri-.-- ri1¥w.-> — 60 — 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 admfnister • is a powerful adjuvant to the treatment. Some casts ol neuralgic dysmen- orrhoea are cured by marriagi. The diathesis should be kept in view; ansemic and chlorotic patients require iron, arsenic, strychnia, and all the elements of the haematic and tonic regi- men. Rheumatic cases demand salol, iodide of potassium, and especially guaiacum. Dewey's ammo- • Anstie, on Neuralgia, Etc.; Am. ed ; p. 72. I — 6i — niated tincture has had considerable repute in rheu- matic dysmenorrhoea. 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 S^e 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. eit., p. 60. f Clinical Therapeutics, Detroit ed., page 73. -^^!iAi«f^iiiSS:i^ii«i^>Sa,-eii&»^ii^^A*^m^iisltit^itS!gM — V.V)i*,%fe.;i^-*».t-vi,=.iiia — 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 pulsatilia 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 dysmenorrhcea. 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 gasirodynia. — 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 at ise ur :e- las ni- las sa. ni- ;tis nd of len :he ful ro- ith ;es, ere er- uf- the ith ain _ 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 digesti ale 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 e.xeption to the rule as laid down by An- stie.* Treatment.— C&usa\ 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 gastralgia 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. ii<«,t^iM^S;S«^SwwAaSk.->fifci.lV.'i-^'-?i*«*SS(»«aft*«30PSSIWlK1'J^^ ! I It , ! ;, t I lii: ^ , -:=iit-K- — irr- - 64 - speaks favorably of the lactate of iron in 3-grain (loses with equal parts of aromatic powder or extract of cinchona. In gastraljfia due to hysteria, arthritis, etc., the underlying diathesis must be treated. Gouty or lithajmic 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 i)y warmth and counter-irritants to excite deriv- ation to the joints. If the stomach be in such a hyperaesthetic 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, iec. cit. jrain tract , the y or thia, the ative )t be eriv- jndi- that irva- ' nux three ome- iteof land- en to It of line; min- _ 65 - ANGINA FKCTORIS AND THK TRUK ( AROIAl' NKU- RA I.e. I AS. 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 ani:;hni 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, prore/la: simi/is); and he adds that the predominant .sensation is one of angui-sh 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 ischajmia 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. S6e: Maladies du Coeur, 2d ed., 1883, p. 30, 3 Mil »eiw^^u;3jMsi«,«/.— Anti-neural«ic rpmew//,.«/j,— Attacks spontaneous at times, but often pro- foked by movements of the left arm, and by pressure over the painful nervts. Depends on some other (peripheral) neuralgia (brachial, dorso-intercostal), on gastric or other visceral dis- order, [s observed at all ages. Attacks long, not provoked by effort. Attention is early called to the visceral or other. afTection. 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, yVfdi'w.'M/.— Revulsives, calmatives, anti-neuralgic reme- dies, anti-dyspeptic remedies. TO,\IC I'Sf^UDU ANOINA (KRUM TOBACCO). (Generally by spasm of the coroniries.) 5)'/»/»/(PWj.— Attacks of angor, generally associated with other phenomena of a toxic kind; vertigo, gasltic and respira- tory troubles, etc. Cardiac pain accompanied by other func- tional heart symptoms, >uch as palpitations, intermittences, arythmia, lipothymia, etc. Attacks long. Paroxysms gener- ally spontaneous, rarely provoked. Prognosis. — Rapid disappearance of the symptoms by •oppression of the toxic cause. ■»irafrili> »'Mi t;jiriiiii^Wiffl9»*rfjewja«.^g.:fia!. i^)ii;^«>4e-'y:<^i=i ,^ i I — 70 — 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 anger 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 {l>) 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 ischa-mia 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. 1 ! 1 ^k. fr^T V ■ ^ ^ ^■ ^ W V^ - r^ ffW■.J;■^. ^ ^* g - 'gg H.^^J ' ■*W- ' " CHAPTER VI. REFLEX AND TOXIC NEURALGIAS. NEURALGIAS DUK TO A GENKRAL 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 iristance 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. f "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 esoentially 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. ^sar-yia'cci^i.vft.v^is^ r,v;^i*il,wrt.:;. .'*'rtj f ^^jtv^-- I " ■.! .1 1 .! ..1 — 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 Netv York Medical Record: For some years past it has been my custom to examine repeatedly anc! with care, the visual apparatus of every patient sent to me for the relief of headache and neuralgia. 1 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 forn.erly lo the clini- cal determination of modifications in the calibre of the blood- vessels of the brain. The tondittins known as "cerebral congestion," or " cerebral anismia" 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 revealfid 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 permantnt 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 rr;- rcted. \ would not be construed as denying that the blood- vesaois of the brain iiiiglit not have been abnormally dilatsd oi' peculiarly cotitracted in many of these cases at the time when their retinal vessels were examined; nor would I utter'y reject 'New y,irk yfedha/ /ournai, ianuarv, tfSi; Lectures on Nervous Disease.s, Philadi-lphi.i, i888 (F. A. Davis, Publisher); Medical RegtiUr, Philadelphia, November ig, 1887. 1'V md Dr. rof line ient lave this lent less lini- lod- ' or I ex- the s be Is of ipon rded aso- ead- with rgot, ition from maly I was iood- :d or vhen eject rvous "isttr. — 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 retina; 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 thit 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, f'ontal, and occipital neuralgias, which were relieved or cured by tenotomy of the recti mus- cles, or by suitable corrective gUi^ses. He urges the necessity of using atropine upon a patient for diag- *^'*««!4»Bl»*»*BHeBws.ttc.4Mfc.-^-»;"--, K Htie*.»A<*.-4,JHa...i ^, ii i ' i ■■' i ;:!; - ■'itt iilt ;! ;li ;: 1! - — 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 'from the stand-poiit 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." * 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: (3 Rhubarb, in coarse powder, Cardamom seeds (bruised), aS 3 i. Aquse ferventis, J viii. M. Infuse half an hour, strain, and take a wine-glassful when the stomach is oppressed. Patho'ogy is full of instances of disturbances of function owing to a morbid irritation in a distant part of the body. Thus, the irritation oi teething sometimes Lauses convulsions. * Ntiv i'ori Mtdical Rtcorii, Jan. ai, i8 of on he nd fU- st- he ny dy im ry he li- ve as ily »^» by nt, ful ion ns, — 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 ii 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 uraemic 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, -^ grain every hour for a day or two, sometimes work marvellous results. Syphilitic neuralgia is also a holopathic neuralgia, Ill -76- according to Vanlair. Rut 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- tro-intestinal 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 morhi of rheumatism yet known. Erb believes that in these rheumatic neuralgias, slight in- flammatory conditions of the neurilemma are com- monly present (hyperaemia, 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. a9>r:M'!s!!S»WCe^ «<'l£d.*i.«UUA"%AV.iAdP^k^^LUw^'J: 44 I IP '\ III li _ 78 - 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 mfer 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 DiaMic Neuralgia.— tieur&lgvd has some- times occurred in instances where it was convenient to trace the painful affection to a " glyc-enuc crasis of the blood, and whc.e an anti-diabetic regimen has alleviated or cured the pain. Worms* has made a spe- cial study of this neuralgia; these are his conclusions: (,) 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. I f !' • Vanlair, loc. cit., p. 309- i,a«aas#(»«^»l»a®!«S»r»*^'l^'^«®»*'''«*'' _ve«a<««WH»»^ IC )f ;r il- ul EIS of e- nt I las )e- [is: B^ia r a cal tias :ior ore ent (itly nia. — 79 — 4. Albuminuric Neuralgia.— '\\\tve 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 uraemic (whatever that word may mean); they are generally seated about the brow or vertex, are obstmate, 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 /r — 80 — as to deprive him of his sleep, and morphine injec- tions were for a lonK time reciuired; thty eventually wore off with return of health. Another patient whom 1 attended in the Anna Jaques Hospital for typhoid fever, had, during con- valescence, severe pains in the calves of tlie legs. It should be mentioned in this connection, that some authorities, as Vanlair, do not regard these ncu- 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 holopathU neuralgias, Van- lair classes certain mcstastatic neuralgias due to the abrupt suppression of the menses, of a htemorrhoidal 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 1 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 tht 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. V jjfi; .^j,,,^,,,^^^,^^,,,^^,,,^,^^ 8i ~ ic- ily aa »n- lat ;u- in ra- »ng an- the dal ers. ous ion had )nly the ob- :s a the arae bate, iral- :ous. Hysterical neiiralj(ia is prone to take on the hemi- cranial form, and the charaiteristic (ion hy.sUrii/iif has lonjj; attracted the attention of physicians. Hysteri- cal neiiraljijias iiave a marked pretliliction for the left side of the body. These neiiral>;ias markedly resemble the idiopa- thic, but their dependence on a diaii\esis just ilies their classification amons^ the hoiopatiiic. 8. Chlorotic and Aiuemic Neutal^ias. — Neural- gia, according to Trousseau and Pidou.x, " is an al- most constant symptom of chlorosis'" 'I'he three forms most peculiar to this morbid constitutional state are headaciie, 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, skatihg; 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- 6 MM I I'l I II I \ ) it ' 1 ' ! I '^'im — 82 — termittont hrnw-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 (luotidian type is by no i-eaii!: uncommon. It is in this kind of neuralgia that quinine in full doses is attended by the happic 1 results. 10. £rf,'0tic neuralgia (from eating spurred rye) has been witnessed in i. rtain 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. Im. al- on. ses ye) ex- ess, ia). id a i tjmoMmw r JH'jttM-vu^ijfmiMiim t m^ tumf— IMAGE EVALUATION TEST TARGET (MT-S) 1.0 I4£|28 |2.5 ■so '"^^ M^H 1^ 1^ s«,l 2.2 1.1 l.'^iia WUu lUli 1.25 1 U ,,.6 < 6" ► > ^ Photographic Sciences Corporation ^> \ V •N? lV 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 6^ CIHM/ICMH Microfiche Series» CIHM/ICIVIH Collection de microfiches. Canadian Institute for Historical MicroreproduMions / Institut Canadian de microreproductions historiques . ' i 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. lihe 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 lithsemia with true neuralgia, for the heavy character of the pain in the former instance, with scarcely any tendency to ingravescence, and its ■;aa«»6estfsw5»($sia>A«s«»i«j«s«;;i^8a«^«as»*^ _ 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 provok ng cause in dietary indiscretions. Neuralgia has been confounded with peripheral neuritis; the pathognomonic features of the latter, ac- cording to Nothnagel, are as follows: 1. 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 aifectious 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 t nd om ne. lot lot is by ind ;ral ac- the ing, :ks; I of the not eing rve- eous ia. IS in the - S5 - 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: ((/) 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; (M.:drJi».*»«^s»*^^^ =i;jct:.=-W.^.E?- — 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 s, that they are materially relieved by change of pos ure 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 tnvelalgia, i. e., a neuralgia of the medullary axis. Be- ing, therefore, /^r 5^ 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 is ten of ke- )ne are -by ex- irea ten- 1 in- ited otic dity as a Be- ural- tiere. oms, :ular ten- toms ts of lities, dor- n the - 87 - 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: /. 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 GriflSn brothers in their valuable monograph, 1844. The subject is well presrnted 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. fe'?7i^^aM^e5a«^iar;£jj&ipgg ft5ga te--^.v' — 88 — 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 hyper?emia, 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-paialytic 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 hyperjemia 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 he in- ir- on su- ns, he on >tic sx- les be in- ex- as be jrt- ms, ery een rhe eks ong ines arly ains - 89 - 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 difificulty 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 bolong 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 \ -^ptoms and stig- mata of hysteria itself. If visceral neuralgia be susp^ <.ed, the physician will, by the proper means of exploration, exclude the presence of any organic disease. .3bflK^M^«mus2^^ii#^a^^ ^ i--^«a'rfB=H-^^%~Ji?WI£^I!i« - Jlrt wiT^V ->?_•*-" '-^i^'^-^^'.M/r _ 90 — Cerrbral abscess m'x^hi 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 uel ge, id; rue ely ind Dry led im, itly ins in de- liar re- the tor :er, ion ies, the the yes the pil. co- :ain — 91 — 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. Krb, 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. 3. 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, 1. e., the trunk of a nerve and all its *Ziemssen's Cyclop., Vol. XI, p. 64. - a tli i i ttf- jOfe' -->- -.^iiro's^i^it^tgii^'^T:--^ — 02 — brao.ties. We have an example in the case of neuralgia nt the triReminus due to intra-cranial tumor. 5. It often invades little \iy little other nerved whose origin borders on that of the nerve primarily involved. 6. Pressure exercised over the region of the nerve ce.itret 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 inefBcacious.* *Vanlaif, /«r. e/<.,p.«t. of ose ret ten oni t of CHAPTER VIII. PROGNOSIS, 'I'he prognosis is more favorable where heredi- tary influence is absent than wiiere it is present. 'I'he idiopathic neiirainias are less amenable to curative means than the symi)tomatic 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. "■wii iVnTiii ftAhiU 'wTw HW'i . iui ■ ■ III I ii •triBif"ir--rt TK i ^' r. - f f r *^ < Bi» f' J i^FXa^ilu^, .t—^ ~t '1 /-^ 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 thac 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, IS a ilgic iral- ome ed a ome ; in- able neu- rule dren ider- e of "ever n to tem- rd at tasks ation >jects time, I - 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- f.'lomerate of richest animalized principles (phos- phor! ^ed 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 «an 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. >.i«atefii*aa&:a»*SM;a8»iii5isws«rf^^s:c*saivi«^b.i*i»5K:4.%tiiiWr'^ ^|-'--^,,;.---*l'VWrAV."JF'*.^J"-'^--'.i;5-**S^'.^-V ,1 - 96 - The neuropathic child siioiild 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. 'I'hose 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- *4- — 97 — lined. He should possess some liglit, 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 resthetic 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 mountain.s, with absolute freedom from brain work, shall form the principal part. 7 MM ft^«vwsafc^»*4««»S8R3^ ■r "f 1 H - 98 - 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 found f neu- : most in the ion of about should should 1 poor iture's ; open bath- before body, >ntain- r even in re- :hloral leave ;ption- apply Where ;er ale than great ■or his sies in r 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: 9 Acid arseniosi, gr. j. Ferri sulph. excic, l 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. —--J \ ? I ,i ■Ji 100 Or five minims of Fowler's solution may be asso- ciated with ten grains of bicarbonate of sodium and five of potassio-tarf ate of iron in a fluid ounce of infusion of quassia; this dose to be given after each meal. Arsenic is ene of the best anti-neuralgic reme- dies that we pjssess. According to Anstie, it is es- pecially useful in the visceral neuralgias. With arsenic, cod-iiver 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 Ihe 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.— ^euxaXgxsi 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. *i~. lOI 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 Mt ti — 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 f)f causal influences. This is Germain S^e'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 ol 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. r idio peedy, com- of the ontin- tipyrin er sub- being causal of the oblige lonths. lay be : same ;o gen- ten of; jardin- acetin, lie. lilid in o-lum- it from Citrate 1 much i where re tire, uarana — 103 — The following prescription, for which I am in- debted to the late Dr. George M. Heard, has given good results in headaches of all kinds: IJ Cit. caffein Carb. ammon ^ Sj- Elixir guaranic ^Ih M. Sig.— A leaspoonful 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 ^^^ 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 . a -asf»«»«:3w»*OTMwr»« — 104 — the attack was clearly of malarial origin, dross' neuralgic pills, in which (luinine is combined with aconite, strychnine and morphine are, 1 think, chiefly of use as a pro|)hylactic where attacks have been fre- quent. As outward applications, chloroform liniment, veratrin ointment, extract of belladonna rubbed up to a paste with water, spreatl 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 rheuinatic than when it is neuralgic. Hypnotizers claim to have accomplished wonder- ful results by putting the neuralgic sufferer into the hypnotic sleep, and a.ssuring him that the pain no longer exists. As nothing is impossible, i\ 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. Hernheim'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 lilsely to be promotive of hysteria. Germain S6e declares that to relieve pain by hypnotism and to render the patient hysterical thereby, is to cast out Satan by Berlzebub. Lim ' . ' .-.l.!-WliyUi ' ross with iefly fre- lent, I up )lied No oca- than icler- the I no and ony, h in c on ns a algi- eans nical tition teria. nd to in by — '05 — 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 hypoderniii injection of morphine. The tablet triturates of the pharmacists aie very handy for this purpose. The commencing doKe should be the sixth of a grain. If no relief is obtained, the njection may be repeated m fifteen niinut-js 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. pi i\ i.i « — 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 S^e highly commends this use of antipyrin. ■(ii ■ 1\ ' 1 TfTP aM-^ ' * ' - ' -" ' -- ' --' ' M mimm'mmti^ IS no ;ffec- For and I the Dis- Ararm r the this CllAPTEk X, APPENDIX. A more particular mentliin of the principal agents o« the antl-neuralRlc medication seems requif fil ; they will be contlder-d in ihia lupplement. I. Narcotics. Theie remedies are nerve-stupefiers. If they fail to com- bat the cause of the neuralKia. they at least attenuate the pain- ful paroxysms by an elective action on the sensory centres, whose .rethism they calm. The remedies to be considered under this head are ; Opium, belladonna, Indian-herap. hyos- cyamus, piscidia, gelsemium, and aconite. OPIUM. Opium.— While opium is not the btst analgesic for neural- fflc pains, and is certainly to be avoided as far as possible, it Is "he 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. Modt of Action.— 0\\\km. 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, dimlnlfhing reflex excitability and allaying pain. Indications and Contra-indications.— In all the ceret)ro- spinal neuralgias, opium or Its alkaloids may be indicated. Certain idiosyncrasies, however, may forbid its employ, ai where nausea and vomiting, vertigo, epigastric anguish, dys- uria. attend the therapeutic use o( 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 visceralgiat thau the cerebro-splnal neuralgias, and acts better in lymphatic than in nervous subjects. Modes of Administration and /?w«.— 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 emilastnum opii has opiuns and Burgundy pitch. In the French Codex Is a gWctntt of mot- pkia: a grains of morphia to an ounce ot glycerin. All these may be used for local effect, or the aqueous extract may be ^1 1^! Hi i i H\\ IP ( i; I- ! t I I '1 I! I J — io8 — 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, :o drops. The only alkaloid of opium deserving of mention in con- nection with the therapeutics of neuralgia, is morphine. This alkaloid may be g^ven internally in ^he 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 \f. 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 beer 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. ecoc- iyne, m be Igias, The at ion I con- This of a ; bet- Brmic ms of >ue of y and over, phine ibout atro- y the n the ecog- 1 it is mini- , now rious itered ience with was iicutn of a nar- acid. al, in Al- U the phia. n — 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 Oilman's, the formula of which I found in the Boston Medical and Surgical Journal. Q Chloroform, J ij. Glycerine. Jii. Alcohol, Jii. Spts. peppermint, i ij. Acid hydrocyanic dilute, 3 ij. Tincture capsicum, Jij. Morph. sulph., gr. viii. Syrup, iiii. 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 Oilman chlorodyne, I find in the prepara- tion devised by Parke, Davis & Co., and sold under the namt of Chloranodyne, a more eflScient 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 •hows 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 ooas grm. Tinct. capsicum ooasgrm. Hydrocyanic acid dilute 0170 grm. Alcohol socogrm. Glrcerine 4570grm. r' ri h n I > •41 it i IIO BELLADONNA. "The antl neuralgic action of belladonna," says Van- lair "is not dependent on its physiological effects, for belladonna is an excitant of the central eel s. and us stu- pefying properties do not appear till after an intense and pro- looled excitation. If we were to consider pain as a simple exaltation of the sensibility, the efficacy of be ladonna in the treatment of neuralgias would be absolutely inexplicable. * r*r But pain, not being hyperesthesia, there s nothing to prevenrbelladokna, even when it does not exert 'ts stupefying Properties, from acting against the algesic element and tri- Smohing over it. Belladonna is even superior to opium in cer- uTn respects It not only manifests an incontestable <,»^<(y«* a*t"on 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 oUier narcotics as an anti-neuralgic. arid whatever we mav think of his explanation he here seconds views before .fL-5 h« Rehier Courty, and Trousseau The kind of SeuralKias^Wch he^r^^^^^^^^ most amenable to belladonna are "£ idiopathic, and especially those affecting nerves olaced superficially. Such are the facial neuralgias, and es- SIhaIIv those of the supra-orbltal branches; the tempora SeSeias yfeld equaUy well, but neuralgias of the infra-orb.tal StrvesCmoresmbborn." * » * l"" '^l^T:.''^^^^ Affections, he would rely much on local applica ions of bella- donna The dose of the alcoholic extract and the powder of the "eaves is one-fourth of a grain twice or three times a day. Outward applications over Painful regions of the extra« rubbed up with water, or of cataplasms of ^he leaves are ^metimes of unquestioned efficacy. Trousseau counselled to mlie a oLte of the extract with a few dropsof water, and rub uSer^the painful part. He has found this treatment ol efficacy in sciatica. Vanlair prefers an ointment made by nib- bing up half a drachm to a drachm of ex.ract of belladonna in an ounce of lard, vaseline, or glycerite of starch. ^„^^,. „ r^uss,au'srrfaimen(o/Migrain,.-Hc makes a quantity of Dills of the extract of belladonna, each containing one- sUth of a gratnl one of these is given every hour (cautiously) tin the complete disappearance of the pain, or till some vertigo '" ^'^'Xtropine. the alkaloid of belladonna, has been much i! an- for itu- »ro- iple the « ; to ing tri- cer- iyne ium >ver we fore I of >nna rves I es- toral bital p.lgic ella- :r of day. ract, , are ed to Irub nt ot rub- na in intity one- )usly) srligo 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 rk g™*" '?b>et triturates being dissolved in fifteen drops of water and mjected subcu- taneously. I n 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: 9 M Sulphate of morphine, K grain. Liquor atropia, a drops. Cherry laurel water, »o drops. 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 caflft *e 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 succec.^- 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 oiyixo % 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 ex to \i grain) 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- pie that Indian hemp does good. , , .. o ^ Seguin, in the Medical Record (vol. xii, p. 774. "77), 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. ;i 112 to keep the nervous system steadily under a slight influence of cannabis (or 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: Q Oxide zinc, Ext. valerian, Ext. hyoscyamus, 'li Rr. 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 maci;latum. 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. e of s is epi- ain, ) or :iub and t at the the fre- 1 of ght, »ug- I re- I tic 3 30 the ihar- Aeg- I tain d as been lock, r the day. have — "3 — STRAMONFUM. 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 ha» 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 fiuid extract is alone pre- scribed in the United States, in the dose of a teaspoonful. CJKLSEMIUM 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. ACONITE. 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 o( the tomewhat famous neuralgic pills of the late Professor Gross, of which the formula is as follows: B Bxt. aconite, V- H- Quinite sulph., gr. ij. Acid arsenics, gr. i-ao. Strychnia, gr. t- 20. Morphia, gr. i-ao. ^ M. One pill. 8 MM •1 u .1 I 'f 1 \ m — 114 — 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 Prol, Gubler whose monographs on this medicament are of great practical utility. Gubler was one of the first to msist on the importance of this remedy in the treatment of trigemmal neu- '-tf; 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 afonitia. 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 01 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, S>eguin, Franceschini, Merck, and Laborde.* Gubler is fond of narrating an incident which occurred In ms practice. It concerned a patient on whom N61aton had prac- ticed resection "of all the branches of the trifacial (!). The pains continued to be just as atrocious and jiist as persistent as ever The patient, reduced to despair, and ready to com- mit suicide, was treated by Gubler with aconitia. Seven milli- erammes a day of Hottot's aconitia were administered m gran- ules with the most marked relief, and by perseverance m this remedy a complete cure was effected. Laborde, in the Journal dt Therapeutigue^^^\>\\%\^K^ re- ports of sixcasfsof reur-lgia mostly of the fifth pair, mall 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 houis. 'Generally t"* second granule will give relief, if the first fails to benefit. •See especially the exhaustive articles of Laborde in the Journal dt ThtrafentiqutyiSiA Tribunt Mniical*, 1881. pellus >unds) Prof, great >n the 1 neu- forms; some- and is onitia. i ji ! miii i iM i M l .t4;yJ W /t^?^j"J^J!^.Jt^.W:f^^^ ' '.V4ll. ' .51".\'" ' * ■■'"■'lyJQBfCWIK'- ■ r ser- There ent is irvico- poder- point, squent Here stress, sthetic ." and ofortn, trough wards, chloro- is Bar- :iattca. • inter- ukedly nfnl of irachial rofotm egions, e men- n hand Boston, rpose — nerves are of d inter- h bene- is by in- palm of licrania. ;, From it occa- ir thinks — "7 ('III.OKAI., Chloral has hut 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 slt-ep. The dose is from lo to 30 grains. For externa! use a liniment is prepared called the r«w- phor-chiorai Unimtnt, by rubbing gum camphor with hydrate of chloral. An oily liquid is the product, which, when rubbed over ihe 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 live grains; Seguin counsels to give 15 grain? every hour, for four doses, in migraine. Not much can be expected of this remedy, although Dr. B. W. Richardson {Braithwaile's Rft., Part 83. p. 228) spealcs 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. » # • » jhe 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. ^ guinine, gr. ii. lycerln, 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 63 years, had more than 200 crises in the twenty-four hours, and could only get relief from bis pain by taking half-drachm doses of bromide three times a day.* * Build* Thtrap.y Oct., i8;6, p. 337 doited by Vanlair). ■--gg' -^ ' ^'i ' tf 'i'^ i VW^gg ^i- k: pi ! ' — IlH — Anstie* would limit its use mainly to a class of neuralglcii. esperiluv women, in whom a certain restless hyperactivity o mTnd and perhaps o( body also, seems to be the expression of Na"u e*s unconscious resentment of the neglect of sej*"" '""^^ tions. Bromide of potassium, on the other hand, is injurious in young men exhausted by masturbation. oil. OK rKPPRRMINl— MKNTHOL. Menthol is a solid crystallizablc substance deposited from thf. oil of oepperminl. It is also found in commerce under tc name of Tapa^.ese oil of peppermint. Oil of .-PP""?'"' and menthol arc supposed to have an. dyne properties when aJpliTd externally, but probably their iherapeujlc action de pends on their rapid and complete evaporation Oil of peppe- mint has been much used as a liniment in s jperficial neurai- Jas. AsoTuUrof menthol In alcohol «nd menthol cones, have also been found of some use, especially it* migraine. COCAINE. Cocaine is an alkaloid obtained from the '"ves of ery- throxylon coca. The marked local »,"«"''"'' jfoflatrlln have been obtained from this agent, aiid which have o' '»"««: dered It so Indispensable In ophthalmic surgery, and i" minor surgical operations, have led to its employment as a topical application In neuralgias. Unfortunately Its action Is too su- J«ftclal and too translto-y. A strong «o>""on rubb'd over oainful nerves, or applied v tampons and compresses— in tic douloureux, in migraine, In Intercostal and other peripheral neuralgias— gives but momentary % .eviatlon. Hypodirmlc injections, each lni«tion^<^ons.stng of a syrlngful of the two per cent, solution o. the hydrochiorate of cocaine-have been used In neuralgia with «ome benefit In one Instance of severe cervlco brachial neuralgia. whe« I frequently resorted to these injections, the anagelsic eff«t was speedy, and lasted several hours. At the same time, some ob^ servers have recorded among the unfavorable syrnptoms attending the subcutaneous use of cocaine, nausea, and even alarming syncope. f • Anstie, " On Neuralgia." p. W; , . n- j „ .„ + Duj«rdin-BeaumetxrNew Medications, Am. Ed, p. 300- ■!ill"< »U l ll J>lW. * IA ' -',Jj l t'M P ir W " ■ )-'^r '. H 'w v." ff-g^g^' y of n of unc- ioui Irom nder miat vhen I de- pper- lural- snes, ; ery- which s ren- Tiinor apical 30 fcU- over -in tic pheral [ of a ate of t. In lere I ct was ne ob- ptoms I even — I 19 — From my own limiied rxpericnce I should say ihat if the patient be Itepi in a recumbent position, there is little danger of syncope, and that the occasional use of cocaine siibcu- tantously in neuralKla, as a substitute for morphine, is advan t.i|{eous. 111.— Nrurosthknic or Ai.tkrativk Mkdicaments. The medicines above enumerated do Rood chietiy by an action directed to ihe element pain, and their effect is more or less transient. Moreover, some of them, as opium, are objec tionable in Ihat the organism is liljelytobe in a worse condition after their use than before, lie who is obliged constantly to resort to morphine injections is almost certain to become a morphiomanlac. 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 1 may call neu- rosthenic or alterative medicaments, which are designed 10 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 anamic neuralgias than arsenic. This medicine, says Anslie "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 tendei 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 iis proving the most effect- ive remedy in almost any given case which may come beiore 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 pectons. Cohen* has administered arsenic with success to persons affected with all kinds of cerebrospinal neuralgias, fac.al, sciatic, intercostal, etc. Sciatica has been the most refractory to this remedy. Leared has found it very efficacious in gastralgia. • hurnal de Miduini de BruxtlUs, 1865. (CiWd by Vanlair). ■-■ .5*'W!'?*.iW4!U;?" 120 — !)()«• and mode of administration. — I, Fowler's solution, three dropB, KCi'dimllv inrrea^ed to eiifhl or ten, .ifter each meal. 3, Arsenlr.il pills ,'« to ..',, grain; one pill thrre time* a day. The granules of Diomorldes an|l|NI.NI. Quinine has a great reputation in the treatment of neural- gia, a reputation which is largely due to Its su' i-css In those forms of neuralgia which are of malarial origin. There is no doubt as to its utility in these latter neuralgias. The dtisc should be large, from to to 15 grains to an adult; this may be given to best advantage a few hours before the paroxysm; Stille says ■ix 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 Dupr^ with auinine after other remedies had failed, and Brodle successfully treated neuralgia of the inferior dorsal nerves by the same remedy.* 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, 11)65, (quoted by Stiiic.) t Stilli, Tktraptutks and Afatfria ytidica. ii — Ill ition, earh irn a s ure r tol. some ig lo !urttl- those is no dould ■en to ! says •ural- been Ineu- ledies if the :ribeB atgia; : face in the water form. >Hrtly spsof pala- t has f Dr. found ;ome8 r fails tn dn gnod, or Is forsnme reason Inadmlinlhlp." Mr has ((iven it chiefly In farial neiiralxiii The dos" must br lurKe; twenty grains every three hours till eighty grains are t.ikcn, or till the pain subsides. {PriutiiinHfr, Nov., 1877 p. 3ai.) IRON. It is not surprising that iron, whirh on uples surh a large place in the therapeutics <>f uiiicmiu and debility, should be regarded as a remedy of prime importance in neuralgia, a disease of anfcmia and debility; and, doubtless, as nn adjuvant to good food, exercise in the opf>n 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 anremir neuralgias. He thinks that besides its effects on the blood, it has a marked and direct influence on the nerve centres which is different (rom anything which one observes in the actiori of any other preparation of iron.* The effect which it produces in the anw«.— 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 grain? 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. 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. GUAR ANA— 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 sofbilis. Caffeine exists in guarana in the propor- tion of about s ptr 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:! '- cerebral excitation; a, complete paralysis of the sensibility; 3, tetanic sp .ms and convulsions; n, death. " These poisons, then, seem to paralyze the posterior columns of the spinal cord, and the entire system of sensory peripheral nerves, having no actior 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. t 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. i Vanlair, Loc. Cit. SafcaJt^E-l^jseisSB^s-i! o the ndon, been a. It ose of J siiti- made imous lotice plant, ropor- four : the lia, is much , then cord, rebral etanic then, 1. and ng no ection is evi- r, can- }n the guar- facial >rbital 3 gen- iirked- — 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 caiTeine, 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 w.'ter. 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 nervuus 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 {Dictionnairi de Thtraftutique, 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: B Fluid ext. ^arana, ^j. Dose, a teaspoonful p. r, n. The combination of caffeine and guarana is sometimes more efficient than either the one or the other alone: B Guarana in fine powder, 9 j. Citrate caffeine, gr, iij. ♦ Afed. Record, 1816, page 743: "Dr. H. C. Perkins, the attending ghysician, had obtained a quantity of Paulhnia from Brazil. * * * Some rilliant 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 marKed. * * * Her general health improved. For four yeais there was almost complete immunity from the pain." ^^ I M — 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-neuraloic Powder.— (Dujardin-Beaumetz.) Q Caffein, o gt. to 10 ceatifrr. White sugar, o gr. to 50 centifrr. M. One powder, p. r. n. Bamberger's Anti-neuralgic Powder, — B Sulphate of quinine, o Rr. to 50 centiKr. Citrate of caftein, o gr. 30 centigr. White sugar, 5 grammes. M. Divide in chart. No. vi. Sig.— Take four a day. Syrup of Citrate of Caffeine. — (Hannon.) Q Cit. caffeine, 4 grammes. Simple syrup, 130 grammes. M. Sig.— A teaspoonful as often as indicated. ACETANILII>-(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 b' 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 crystallizable. It is but very slightly soluble in water. Its chemical formula is CgH,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 anasthetic. Therapeutic Action. — Analgesic Effects. — Dr. Demieville, of Lausanne, was one of t)ie 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 dysmenorrhoea, and in the lightning pains ol tabes. • Rtvut Mtdical* de la Suiut Remaidt, June 15th, 1887. issii- 129 — Since thecominunication of Dr. Demieville, multiludes ot communications have appeared in the medical journals of Europe and this country on the suoject. The general verdict may be slated as favorable to the use of aceianilid as an anal- gesic withn 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, «. 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 arc given. The dose may be given in capsules, stirred in water, or in simple •■yrup, or elixir simplex. PHENACETIN. Discovered in 1887 by Kast and Huisberg, the phenacetins are three m number: Orthophenacetin. metaphenacetin a.nd par- aphenacetin. The general formula is as follows: C, oH, aNfo,. Orthophenacetin and paraphenacetin are medicinal. Phenacetin, like aniifebrine 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 of 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 7^^ 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 Irom tetanus, and recovery was attributed to the free use of 9 MM ■.i s' 5 : i- I i » > i, — 130 — the medicament. There is another advantage which this medl:ament possesses ovei 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 satisfacto-y results, and prefers it to antipyrin and acetanilid. Gaifife has used it with advantag'' in the vomiting of phthisis, also in nervous polyuria. It has thus far had no eflfect in paralysis agitans and chorea, but it markedly benefits whooping cough. Moeller, who has made much use of phenacetin in typhoid (ever, 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 me-iting of the Soci6t6 de Th6rapeutique, M. Bardet presented samples of this substance and made his report. Exalgin represents, chemically, methylacetanilide, C,H,,N.O =CeH5C,H,ONCH,. From acetanilid three methyllic derivatives are obtained; one of these is the sub- stance in question, and is designated Ortho-methylacetanllid 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 cerebrospinal 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. :h this I being in tliat le same 1 effect several results, used it lervous agitans etin in ble and it, and, . This antipy- I may e medi- tbtained of coal- s of the and in received que, M. I report, lanilide, d three the sub- :etanilid (e white n warm tered to o-spinal [>er Icilo- lessness le paral- ars, and — 13> — The physiological effects of exalgin are very similar to those of antipyrine, although the former seems to act in a more marked manner than aniipyrln 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 hour?. 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 t'me that it diminishes the quantity of sugar in the urine. ALCOHOL. Meuralgic 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. Niiro-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 fu I 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 sub:utaneou8 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 anx- mia. Nitro-glycerin seems to be an exciter of the vaso-dilator system of circulatory nerves, i. e., granting that there are vaso- dilator nerves. 'Lance/, Feb. igtb, 1887, p, 384, _.J — 132 — V. Local Treatment, etc. Electricity. f I On account of the similarity of action between the electric current and the nerve current, it early oc- cured to electro-therapeutiats so ennploy 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 nrst 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 ineflB- 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, Mo(/e of Application.— k 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 fustigalion " 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, i. e., 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 poie may be moved over the different n the ly oc- uralgic itate of radistn nne de of the :ording Since i often is now iralgia. ode of r ineflS- y may ful im- orities. ling or nt em- to be "elec- rrents. ctrode, of the ver the ices of spond- painful , moist ire not staMe, en the tators" rection nd the icessity car the tfferent — '33 — painful points of the affected nerve.* When treating tic Jou- lourfux. 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 miliiamperes, 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 af the current should be continued till the pain disappears, or till at least some mitigation is obtained. When tlif-re is a point douhurtux, the positive pole may be applied over this point (Niemeyer, B^rdet. Tripier, Apos- tol!). 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-Halslce, and the Lcclanch* battery. Among the advantages of galvanism over faradism in neuralgia, are the following: 1. It is not painful, or scarcely at all painful. 2. It exercises a decidedly sedative effect when applied ucunJum artem. 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 eleetrolysis.X 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.g 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- J Djij^din-Beaumeti, ainical Thtr,p,uih,, Am. ed. I Vanlair, loc. cil., p. aoo. i Braithwaite's Retrospect, Pan 65. page 86. p. 59. ■:' ! — 'J4 — piled them over the painful rcKlon, keeping them about on« inch apart, moving ihcm about, but not removinR them for two ninnihR. As soon as the pain ceases in a case of neu- ralKia, he makes it a rule to discontinue the application. Dr. S. J. Knoll, in l.omlon /.ancft, Dec. iSih, 1875, rcporti several very inlereslinK cases ii( sciatica cn.rtil by Ralvanism. He used eighteen cells of SlWhrers 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 /.(/«(, (2(1 part, iH7*>) we can only just allude. The same may be said of Dr. A. D Rorkwell. of New York, and Dr. Henry Lawson of St. Mary's Mospital, London. MASSACIE. — KINRSirilKKAI'V. '!i 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 f.i- as he might endeavor by gentle frictions 01 steady compressi .n over the aflectcd nerve or nerves to attenuate the pain. So.netimes 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 o( 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 os the body aflected. Deep pressure, for instance, is made with one finger or thumb I • V'anlair, Loc. cit., p. aja. t Vanlair, Loc. cit., p. m. % Cited by Vanlair. miSm )ut one cm (or )f neu- reporti ^anlsm. ; times nism In > whose ily just 3( New ondon. 'cment, t, and irc " or ! as he ■n over netimes hile on Die the in neu> edicine iresslon jassen- ly mas- jralgia. is ad- ic neu- iralgias !r<>ine.| n deep ffected. thumb — '.KS — on the nerve at the fieat of puin, which rauwes un intense pain for the moment, l)ut Is followed l)y a sort of paralvsis of the same nerve, lastinK for several hours. In neiiralKJc alTrctioris of the ulnar, pcrcu'sioti is iiKule aloiij; thin nerve from lis oriKin to its ti-rmination. ' Thf IjIows shouM be sharp and short l( the pain is a dull, heavy arhr, and of the chararlir of a slow he.ivy pressure if the pain is arute. For insi.imc, in facial ncuralKia, paralyze the trigeminus trunk to (Ut off Its sensation, then kne.nl and percuss with the finder lips." Minute dirertioiiN after this pattern are Riven in many treatises; il Is not, however, prol)al)le that m issa^e will ever have a wide field of usefulness In the treaimeni of neuralgia. Much more can be expecleil of Kymnastirs 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 dilUcult co-ordinativc movements over which it trains those centres to preside.* COUNTER-IRRITATION.— RKVULSIVKS. 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, rervico-brathial, 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 severeformsof chronic neuralgia been productive of benefit. I remember a bad case of cervico-brachlal neuralgia where pusiulation by tartar emetic ointment over the upper part of the spine caused a marked pos.ponement of the ordi- nary attacks. In sciatica, I have occisionally 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- ' An^tic, on Neuralgia, Am. ICd., p. 175. V IJ n — 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 the 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 Baunscheidt's r^veilleur de la vie, a little apparatus consisting of a bunch of pins, made to penetrate the skin by a spring; these pins were generally dippf-d in croton oil before using the instrument. Dujardin-Beaumetz* refers to the benefits so-: 'times de- rived from electro-puncture, as performed with tht condenser of Plantfe 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. I HYPNOTIC SUGGESTION. ill 1;! 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 o. reality that the pain is all gone. Bernheim has related in his book: " De la Suggestion et de set applications h la thirapeutique" 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 ol the process is involved in pro- found obscurity. ;?ii * Clinical Therapeutics, Am. Ed., p. 66 n tense s pro- 83- itinate c acid strong of the ecially ts are ins of . The I little te the croton es de- Jenser With ide to apart, ;s are bring ed by pnotic ide till nheim caftans ;raine, r by a of the tr cor- tion of lat are ugges- n pro- — 137 — NERVE STRETCHIN«S. 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: Neuraltriaof the face 14 Intestinal neuralgia 2 Neuralgias of the upper extremities 9 Neuralgias of the lower extremities 2j 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 Thtraptuticty 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 ;>ny 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 Zlemssen's Cyclopaedia, Vol. XI., 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 foc^s 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 exsectlons of the sciatic and crural nerves in obstinate neuralgias. Neurectomy of these latter nerves, however, is generally considered a dangerous and u/isatisfactory 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. i cases gh the t this is sidera- ch the of the nsory, to the might 1 some I cases re the as an ire re- ge 95- isturb- e case ch has Repair ctions, id, and ,nd re- nerve • ion in gias of itres of e than liladel- nerve e fora- 5 made stinate ver, is eration ralyses section I there — ^39 - 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 ij j. i H ,^ j,j ;gct^OT.j^W*.;.Baf^ff3g-^^wyf*Wg?' — 140 — At the hydrotherapic establis'iments there is a. variety of appliance^ 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. fei.. y of 4che lich rac- any ved :old Ing) c in ous ible ket; are iter the be- per- In >ns, )lid. •c. rse- >eu- cer- one jec- ms. lOUS lead rere the ; to the Of five — 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 bemg 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. loth, 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 theoe 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, f>R an adjunct to other treatment, in migraine, supra-orbiul 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.) M. Veratrin, o gramme 30 centig:r. Muriate of morphia , o. ij^ramme ao centiirr Glycerite of starch, 30 gr, *Dujardia-Beaumetz, Did. dt Thir. Art.; O^mic Acid 2*^. '''! r*^i- ,9"? P- '^^^ Lancet, July 95th, 1885; p. 167. Medical Record, Vol. xxvii; p. 713. ' » ' ». 1^ » 7. — 142 — Pomade de Veratrin. — (Dujardin-Beaumetz.) Veratrin, o. Kramme. oscentigr. Axunge, lo. It*' Veratria Ointment.— Veratria, 3i. Lard, Ji. M. Kor 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 c— i of tela- nus cured by this means. Baccelli employs a i per cent, so- lution of phenic acid; the injections are made over the si.»t 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! ii liluted r, and ubcu- rly in e Se- teta- It. so- i^^t of is ob- then Bcacy edica- But r who led in aedies lumph I their shows to be — 143 — Since the last edition of Anstie's worlc (October. i87i)and that of Vanlair (1882), all the so-called analgesics (antjpyrin, 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. better tin, at of the !8 but dge of i 4^- INDEX. A Page. Abbe, Dr. Robt ^j Abscess, Cerebral ^ Acetanilid (Ami(ebrin) ,02 128 in Migraine ^g Aconite ... 114 Aconitia (Aconitine) ic, 114 in Migiaine ^g Age as a Predisposing Cause js Albuminuric Neuralgia Alcohol in Neuralgia ,,, Ammonium Chlorid*' in Neuralgia ,22 Anaimic Neuralgias. g. AniBsthetics in Nt-uralgia ,,. Analgesics ■'■■ j^^ Angina Pectoris , Treatment of ^d, 69 Angio-Paralytic Migraine .^ Angio Spastic Migraine.. .^ A'-'ipyrin ".'.l".'."."'.""io2; 124 in Ovarian Neuralgia 5, Migraine ,g Sciatica ,g Injections of j^^ Anstie, ..5, 25, 35. 39, 42, 43, 51, 60, 63, 64, 100, in, V18. nq •ao, 121, 123 Appendix j^^ A""''= '.".'.100. H9 Atheroma as a Cause of Neu.algia -q Atropine '"""!!.!!!!!!! iio "1 II ill (_ _ 146 — B. P*B«- BacriUl '** Bartholow Belladonna . Bernheim Blisters in Intercostal Neuralgia 47 Sciatica " Brodle '* Bromide of Potassium '" Bromo-Pyrine and Bromo-Cafleine '03 Buzzard ^' _ „ , 109, ia6 Caffeine _ in Migraine ^o 117 Camphor-Chloral Cannabis Indica in Migraine 3" Carnochan's Operation 34 Cautery, Actual in Sciatica " Cauterizations Cervico-Occipital Neuralgia ^i Cimiclfuga Racemosa in Ovarian Neuralgia «>» Chloride of Methyl In Sciatica 5* Chloral JJJ Chloroform ■' ^ . Injections 55. 106. 116 Chlorodyne and Chlor-Anodyne 5o8 Chlorotic Neuralgias ^^J Cocaine Coccydynia ^ Cod-Liver Oil '°°' "J Cohen '"' Cold as a Cause of Neuralgia »5, ^"9 Conium Maculatum !': A ^fl Page. .. ua .. 56 , . . no , .. 136 ... 47 ... 55 ... 89 ... 117 . . . 103 ... 49 [03, 136 .. 38 ... 117 . . . Ill ... 38 ... 34 .... 55 .... 135 .... 4t . . . . 61 . . . . 54 .... 117 .... 116 106, 116 508 . . . . 81 .... 118 ... 49 ICO, 133 I30 ..15, 39 119 — M7 — Cooper on Treatment of Mastodynia .g Counter Irritation '" ,,, Co'ugno ........!...!!.'.'! lio « Croton Chloral _ ' ," D. Diagnosis g Diatheses, Treatment of 100 Diabetic Neuralgia 78 Du Bois-Reymond Dujardin-Beaumetz 46, 53, 54, 61, 115, 137. 136, 137, 139 Electricity in Neuralgia '. ,3^ l'^" :•■■:'". '7,47.51.53,55.77. 91 Ergot in Migraine -g Ergotic Neuralgia gj Erlenmcyer Ether in Neuralgia ] , ,g Etiology of Neuralgia j . ^"'"""'^ ;.'".";.';36."37, 39 E**'*'" 102, 130 Exciting Causes of Neuralgia 27, 38 Eyestrain as a Factor in Neuralgia .' 73 F. Faradization j.^ in Sciatica . - Fothergill's Pill ...!!..!..... 99 Fowler's Solution in Neuralgia ,00 G. <^a'''»n''"n 100, 133 in Gastralgia 5 . Gastralgia "...".".".". V. .63'. 63 Celsemium j in Migraine -g i I A J T' 148 — Gowen Gouty Neuralgia Gross' NeuralKic PiUi Guaiacum in Dysmenorrhoea. Guarana In Migraine Gueneau de Mussy .«, II, 71. 03 76 113 60 136 3» .104, H. Hammond his Ferruginous Tonic. Hashish Hemlcrnnia Heredity as a Cause o( Neuralgia. . Hepatalgia 5f'. S« 133 133 III 35 34 6a 35 Hesse ^ Huchard on Angina Pectorli Hydrotherapy ^ Hydrastis Canadensis Hygienic Therapeutics 9 Hypnotism '°-*' '^^ Hypnotics Hyoscyamus Hyperalgesia HyBteralgIa Hysterical Joint* Neuralgia I. Indian Hemp (see Cannabis) '" Treatment of Migraine by i" Iodide of Sodium in Angina Pectoris 70 Iodide of Potassium in Sciatica 5 Iron in Neuralgia 113 10 59 89 80 PaRC. 93 7ft 4. "3 6o 136 38 5> (i, 133 , . 133 III 3S . . 94 . . 69 35 66 "39 , , 63 98 04 136 98 iia , , 10 . . • 59 . 89 •• . 80 III . Ill . 70 . 56 . 131 ^ 149 — Page. J'"*""! '. 8.36.46, 53 Jamaica Dogwood 1 1 3 ■'«"'" .'.".'. .,"... 59. 61 K. KInealtherapy |-^ L. Laborde ,,, Lasigue on Migraine 3,^, j, Laudanum Enema in Sciatica j6 L"'«'' '.'.'.'.'.'.'.'.'.'. 119 Lcube g^ Legroux's Treatment of Sciatica 136 Liquor Sedans 5, Locomotor Ataxia go Massage ,3^ Mastodynla ,_ Maudsley ,_ ., Mcglin's Pills .'.'. ...'."."..'".'.'.'.".'.".'.'.'..'.'.■..■.' 1,3 Menthol « Methyl Chloride ^ .. ...... ...... ...... . 54 Metastatic Neuralgias ..... 80 Migraine ,, Mitchell, S. Weir .....,".,... 38 Morphine j^g Injections ,q. Myalgia ..'....'.'...... 85 Narcotics . , , 107 Neuralgia, Definition of j General Characteristics of 3 Treatment of „. 94 — ISO — Page. Neuralgia, Clinical Description of 5 Pathogeny ' Classification ^9 Causes •• ^* Idiopathic '9 Symptomatic '^ Holopathic '9. 7i Ramicular '° Particular Forms of 3^ Facial 3' Central *' Cervico-occipital *' brachial 4' Intercostal '*'* Lumbo-abdomlnal 4» Visceral 57 Reflex and Toxic 7i d frigore "^"^ Uterine and Ovarian 59. 6o. 6i Neuritis ^5. 88 Neuroses ''• *■* Neurotic Temperament *'• Neuromata ' Neurotomy and Neurectomy '37. 138 Nerve Stretching '37 In Sciatica 55 Nlemeyer "*' Nitrite of Amyl "° In Angina Pectoris 7" Migraine 39 Nltro-Glycerlne '3t in Angina Pectoris 7o Migraine ; 38 Gastralgla ^4 1, Page. . S 7 19 . 24 . 19 19 9. 71 20 31 . 31 91 41 42 44 48 57 71 77 )0, 6i $5. 88 .2. 24 24 • ■ • 89 37. 138 137 55 42 . . . 116 , . • 7<^ ■ 39 . 131 . 70 38 , , . 64 — 151 — Nothnagel . . . Nux Vomica. Page. .. 84 . . r23 Oil of reppermint in Neuralgia ns Opium Osmic Acid Osteocopic Pains 107 140 75 Paroxysm the Neuralgic, Treatment of loi Pancoast, Joseph j-g Peter, Michel ^5 ,,y Phenacetin 102, 129! 130 Phenic Acid j.^ Phosphorus j^a Phthisis in its Relation to Neuralgia 34 Piscidia Erythrina gj^ jjg Pseudo-Angina Pectoris ' gg -Neuralgia 20 Prognosis 28 93 Prophylaxis in Neuralgia g. Pulsatilla gj Putnam, J.J ag/jj' jg Q- Quinine. in Migraine. 103, 120 .... 38 Ranney. Dr. A. L., on Eye-Strain, etc 72 Revulsives '..... Rheumatic Neuralgia Richardson, Dr. M. H Romberg 135 77 139 35 Pills of in Mastodynia ^g . > - '^' ~ Page. 1 20 Salicin ' " " ^o Salol ■■■ 4g Sciatica ' [^^ ^^ ,3^ Sfee, Germain ^. on Angina Pectoris • = 30, III Seguin 35. 3^ Senkler 26 Sex as a Predisposing Cause ••••• ^^ SickHeadache ''i:"'\"- '.'. 06 Sleep in the Treatment of Neuralgia .■.'.'.".".'14, 16 Spencer, Herbert a Spring «2!» Strychnia jqj Surgical Means of Cure. . . 44 Svapiiia " *. j,^ Swedish Treatment of Neuralgia ■ ^^ Syphilitic Neuralgia T. 21 22 23 Tableau of the Neuralgias '."."'...'...'. 139 Terrillon " | ^^ Tic Douleureux " . " . . 126 Tonga 1^5 Toxic Neuralgias 99 Tonics ■ '. oft Traumatism as a Cause of Neuralgia ..■■•■■ • • • • • ^^^ Trousseau • • • • " ; , ,„ his Treatment of Migrame "" Turpentine in SciaUca. ' 41.42.47. 50. 55 Valleix 4 his Points Douloureux J vSsr::;o;v5.;8:;9:'28;76:78;"8;;9i:"o;»6.«o: 13a tii^^mMtm'a'-*^' "i"*™ Page. . I20 . 60 . 49 I, 124 . 65 5, III 5. 38 . 26 • 39 . 96 4, 16 a . . 123 . . lOI .. 44 .. 134 .. 75 82, 23 . . 139 ... 32 . . . 126 ... 75 . .. 99 . .. 28 . .. 110 ... no ... 55 50. 55 ... 4 . . 54 I30, 133 - '53 - Veratna j Viburnum Prunifolium g. Vinegar of Opium j^g Vulpian W. Watson, Dr. Eben j ^^ Worms on Diabetic Neuralgia ^s Z. Zymotic Neuralgias ^ -:^,-..™r-_,.-4ii»l %? Eligible Remedies for Neuralgia. AmonK the many remedies that are commended (or Neuralgia, we may m^nUon for internal and local application the foUowmg. wh.ch we '"^^'''^ FOR INTERNAL ADMINISTRATION. Brown-Sequard's Neuralgic Idiopathic .P»»»- Ext Hyoscyamus, 2-3 gr. Ext. Con.um ruit, 2-3 gr. Ext lenatia 1-2 gr. Ext. Stramonium seed, i-5 gr. Fx ' Od urn 1-2 gr. Ext. Aconite leaves. 1-3 gr. Exl: Belladonna 'i-6 gr. Ext. Cannabis Indica. 1-4 gr. Neuralgic Idiopat., Brown Sequard's, Half Strength. "'■ §r.n'eX*'t ""■" B.. AconU. .»..,. .-. ... Morphine sulph.. i-20 gr. Strychnme, 1-30 gr. Arsenious Acid, 1-20 gr. Neuralgic, Without Morphine, Dr. Gross'. r^r^hrll Sedative Compound.- A scientific substitute for certain copySe" prepaSs inThe market. The active constituents are poKum bromide, chloral hydrate, gelsemmm and opium. The for ""^^i?aS'?rfpa?erSedativ;Compound, Formula •; B/' which differs from thetst?.amed preparation only in the substitution of henbane for the opium in the regular formula. ,„.,„< „er PI Ext Guarana U. S. P.-Guarana contains from 4 'o 5 P" is indicated. FOR LOCAL APPLICATION. substance derived from the Japanese pian^ loothache, etc., and SS.? enclosed .o Jre.en, r.pid voUuta.uon. l^r.''pe':r'fr.Lv.'c,i";r,,;=t:^^^^ of Menthol. .,^»,t»o rr^ PARKE, DAVIS & CO., DETROIT AND NEW YORK. ilgia. leuralgia, we ig, which we N. :ti, 1-5 gr. 1-3 gr- I, 1-4 gr. Eth. t-2 gr. ite for certain nstituents are im. The for- ' which differs if henbane for )m 4 lo 5 per ny other drug. ! form, so that 1 that produced imedy in sick- erever caffeine ;amphoraceous nsis. It is em- lache, etc., and te or infusorial :eptable substi- ire it to be kept )oxe5, each one local application 3., NEW YORK. IN EXPLANATION The PhysJciaDS' Leisure Liliraiy. no rt ..l^r l!**"" """*'" " "T '^•■•""•""•'' '" ""^ l'«'l.l(ctttion of ,n«dic«l books A8 vou no d^,ub know, many of the large treatises published, which sell for four or Ave or publication o such a series, calling it The Pl.y.lrlan,. fceUure L.brarV PHYSICIANS' LEISURE LIBRARY PRICE. PAPER, 25 CT?. PER COPY, $2.50 PER SETi CLOTH, 50 CTS, PER COPY. $5,00 PER SET. Inh^erg. Inhalations and Inhalant! By Beverley Robinson, M. D. ^sSn»J?i °* Ele't'-icity in the Removal of Va?ioui Pi'ri,^ p!; ^"'^u*'''' Treatment of variou} Facial Blemishes. By Geo. Henry Fox, M. D. New Medications, in 2 Vols. By Dujardin-Beaumetr, M D '■''•B^°sl'nJSeT^Vt'Sn7ll°'D^.'^°"""- Antiieptic Midwifery. By Henry J. Garri({ues, M. D. SERIES I. On the Determination of the Necessity for Wearing Glasses. By D. B. St. John Roos M. D. The Physiological, Patholoificsl and Ther- apeutic Effects of Compressed Air. By Andrew H. Smith, M. D. *^™ nl! ur-'i' V.^ ContagiousOphthalmla. By W. F. Mittendorf, M. D. Practical Bacteriology. By Thomas E. Satterthwaile, M. D Pregnancy, Parturition, the Puerpera '*'y?i-"aii''Ff'&d§:'sf*'5"*' mT" SERIES II. Thy pjagnotitand Treatment of Htemor- By Cha». B. Kelsey, M. D. Dlteawiof the Heart, in 2 Voli. By Oujardin-Heaumeu, M. D. Translated by E. P. Hurd, M. D. The Modern Treatment of Diarrhoea and Dytentery. ^ By A. B. Palmer, M. D. Inteitinal Dieeaeeeof Children, in 2 Voitt By A. Jacobi, M. D. ^"TlnaVttcraSS'fi'.S.tftSS?'^; D. The Modern Treatment of Pleurley and *^''8;;'&"^;Garland.M.D. '»'*Tfr?iI!'n*dS*n'iy."Jtt'i!i[.D. ^"•ijYaVrffifSfeV-. l*T Translated by E. P. Hurd, M. D, SERIES III. Abdominal SurBtery By Hal C. Wyman, M. D. Dleeases of the Liver. By Dujardin-Reaumelz, M.D. Hytteria and Epilepsy. By J. Leonard Coming, 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. ""llr'Wl^i^mA Hammond, M. D. Dyspepsia. By Frank Woodbury, M. D. The Treatment of the Morphia Habit. By Erlenmeyer. The Etiologlyi Diagnosis and Therapy of By Prof. \i. von '.liemssen. TransUted by D. J. Doherty, M. D. jrrelated to romen. Nervous Syphilis. By H. C. Wood. M. D Education and^ Culture as ooi "'•'By'X.H Smith, M.D. *XirnS2nWeU;?£.M.D. Seme Major and Minor Fallacies oon oeming Syphilis. By E. L. Keyes. M. D. »'>«^^y*{Ci"m'2llli?lirbricon. SERIES IV. Practical Points. in the Management of ''•''ff;''!: P. Hurd, M.D. ""•fe^^iTe^^SSlierlee.M.D. Electricity, its application in Medicine. By Wellington Adams, M. D. ^•"te^^.'l^lBosworth.M.D. *-'«';w«'rsa'*^'S8rt&^k.M.D. Bm-iM ir*HU 6« U»u0d 0N« • month, bf/imning with jre««Ms»«r, 1»»». GEORGE S. DAVIS, Publisher, O. Boac -WTO. Detroit, ^tfloH- P ■^■^^fc • 1 uniiton, m.' D. >f PKurity and D. %.D. S!"«1:d. i IntTOli. lurd, M. D. t^ *%...-... .J ) 3t, M. D. ,'*A. M., M. D., lond, M. D. , M.D. rphia Habit, and Tliarapy of assen. toherty, M. D. Managamant of D. riee, M. D. n in Madiclna, aa, M. D. M.D. t emhe r , 1890. r. It, ^^OaUx. — -"-• ^•'" f*'.*^ T-