CHAPTER V.

TREATMENT OF NEURALGIA.

I now approach what is really the most difficult portion of my task; for, although it would be easy enough to write copiously on the treatment of neuralgia, it is extremely difficult to keep a just medium between the opposite extremes of undue meagreness and of useless profusion of detail in the handling of this subject. There are also difficulties connected with the present uncertain and transitional state of opinion, even among high authorities, as to the value of particular remedies, and even of large groups of remedial agents, altogether there has been more hesitation in my mind as to this part of the present work than about any other, and the present chapter has been rewritten more than once. I mention this only to account for what there may very likely be found in it--an imperfect literary style such as too commonly marks work which has been repeatedly patched and corrected. At the same time, it should be said that my hesitation does not apply to the main principles of treatment which will be recommended below; it proceeds rather from the fear of seeming to ignore from carelessness modes of treatment which are still much used, but which I have really rejected, because, after full trial, they appeared to me valueless. Space is, after all, limited, and a complete account of all the remedies for neuralgia in vogue, in English and Continental clinics, would of itself fill a large volume.

The treatment of neuralgia may be divided into four branches: (1) Constitutional remedies; (2) narcotic-stimulant remedies; (3) local applications; (4) prophylaxis.

1. Constitutional treatment must be subdivided, as (_a_) dietetic, (_b_) anti-toxic, and (_c_) medicinal tonic.

(_a_) The importance of a greatly-improved diet for neuralgic patients is a matter which is more fully appreciated by the English school of medicine than by either the French or the German; it has, for instance, very much surprised me to notice the almost entire silence of Eulenburg on this topic. For my part, the opinions expressed three years ago[35] on this matter have only been modified in the direction of increasing certainty; I have learned by further experience that the principle is even more extensively applicable than I had supposed.

That neuralgic patients require and are greatly benefited by a nutrition considerably richer than that which is needed by healthy persons, is a fact which corresponds with what may be observed respecting the chronic neuroses in general; and it gives me much satisfaction to point out this position of neuralgia as belonging to this large class of disorders, not merely by its pathological affinities, but by its nutritive demands. In a very excellent and suggestive paper by Dr. Blandford[36] it is stated, as the result of a large experience in mental and other nervous disorders, that the greater number of chronic insane and hypochondriacal cases, as well as neuralgic patients, are remarkably benefited by what might seem at first sight almost a dangerously copious diet. Occasionally it happens that the patients discover this by the teaching of their own sensations, and the apparent excesses in eating which some epileptic and hypochondriacal persons habitually commit are looked on by many practitioners as the mere indications of a morbid _bulimia_ which represents no real want, but only the craving of a perverted sensation which ought to be interfered with and allayed rather than encouraged. It is now many years since I began to doubt the justice of this opinion; the particular instance which called my attention to it being that of epilepsy, of which disease I saw a considerable number of cases, within a short period of time, that were distinguished by the presence of enormous appetite for food; and I finally came to the conclusion that, so far from this symptom being of evil augury, and likely to lead to mischief, it is, with certain limitations, a most fortunate occurrence. It is hardly necessary to say that over-eating, such as produces dyspepsia and distention of a torpid intestine with masses of fæces, may distinctly aggravate the convulsive tendency; but the truth is that, with a little careful direction and management of the unusual appetite, these bulimic patients can in most cases be allowed to satisfy their desires without harm of this kind following; a larger portion of food really gets applied to the nutritive needs of the body, and the nervous system unmistakably benefits thereby, the tendency to atactic disorder being visibly held in check.

That which I have thus observed in the case of epilepsy, and which Dr. Blandford more particularly affirms concerning chronic mental diseases and the large number of neuroses that hover on the verge of insanity, has been most distinctly verified in my experience of the treatment of neuralgia. It is, unfortunately, by no means a frequent occurrence that the sufferer from this malady is inclined to eat largely, but the few patients of this type that I have seen were, in my judgment, distinctly the better for it. Far more common in neuralgia is a disposition of the patient to care little for food, to become nice and dainty, and in particular to develop an aversion--partly sensational and partly the result of morbid fear about indigestion--for special articles of diet. Dr. Radcliffe pointed out the special tendency of neuralgics to neglect all kinds of fat; partly from dislike, and partly because they believe it makes them "bilious;" and I have had many occasions to observe the correctness of this observation. In fact, by the time patients have become sufficiently ill with neuralgia to apply to a consulting physician, they have already, in the great majority of cases, got to reject all fatty foods, and have cut down their total nutriment to a very sufficient standard. Young ladies suffering from migraine are especially apt to mismanage themselves, to a lamentable extent, in this direction: this is natural enough, because the stomach disorder seems to them the origin of the pain, instead of being, as it is, a mere secondary consequence of the neurosis. But it is not only the sufferers from sick-headache in whom we find this tendency to insufficient eating, especially of fat; not to mention that all severe pain usually tends to disorder appetite and make it fastidious, there is nearly always some wiseacre of a friend at hand, ready to suggest that neuralgia is something very like gout, that gout is always aggravated by good living, and, _ergo_, that the patient should be "extremely cautious as to diet;" the end of which is that the poor wretch becomes a half-starved valetudinarian, but, so far from his pain getting better, it steadily becomes worse. I cannot too strongly express the benefits that I have seen accrue, in the most various kinds of neuralgic cases, from persistent efforts to remedy this state of things, and to convert the patient from a valetudinarian to a hearty eater; and I wish particularly to say that this success has always been most marked when I have from the first insisted on fat forming a considerable element of the food. Cod-liver oil is the form in which I much prefer to give it, if this be possible; there can be no mistake about the relatively greater power of this than of any other fatty matter, I believe simply from its great assimilability. But the very cases in which we most urgently desire to give fat are often those in which the patient's fantastic stomach openly revolts at the idea of the oil; we must then try other fats; and we should go on trying one thing after another--butter, plain cream, Devonshire cream, even olive or cocoanut oil (though these are the poorest things of the sort we can use)--till we get the patient well into the way of taking a considerable, if possible a decidedly large, daily allowance of fat, without provoking dyspepsia. It is surprising what can be done in this way by perseverance and tact, and it is no less striking to observe the good effects of the treatment. Nothing is more singular than to see a girl, who was a peevish, fanciful, and really very suffering migraineuse, brought to a state in which she will eat spoonful after spoonful of Devonshire cream, and at the same time lose her headaches, lose her sickness, and develop the appetite of a day-laborer; and, though such very marked instances as this are uncommon, they do sometimes occur, and a minor but still important degree of improvement is very frequent.

As for the _modus operandi_ of the fatty food, there is no certainty. Dr. Radcliffe believe it acts as a direct nutrient of the nervous centres; and I also cannot help feeling that there is some evidence in favor of this idea. But, whether this be so or not, there is another kind of action of fat that is more simple and obvious; namely, it seems to be certain that the enrichment of the diet by fat greatly assists the assimilation of food in general, and thus the patient's nutrition is altogether improved.

It is not merely, however, by increasing any one element of food that we should seek to enrich the diet of neuralgics, but rather by such a steady and persistent effort as Dr. Blandford describes, to increase the total quantity of nutriment to perhaps as much as one-third more than the patient would probably have taken in health. To those who from prejudice are incredulous of the propriety of this method, I would say, "Try it, and I venture to say your incredulity will disappear." More especially I would urge the great importance of this system in modifying the nervous status of very young, and also of aged, sufferers from neuralgia; it is the indispensable basis of a sound treatment for such patients.

This seems the proper place for such remarks as must be made upon the function of alcohol in neuralgia; for, though this agent is a true narcotic when given in large doses, it is not under that aspect that I can recommend its use in neuralgia at all. I have written so much on this subject lately, that I shall here content myself with an emphatic repetition of my protest against the use of alcoholic liquors as direct remedies for pain. They ought only to be given, in neuralgia, in such moderate doses, with the meals, as may assist primary digestion without inducing any torpor, or flushing of the face, or artificial exhilaration. I cannot too expressly reprobate the practice of encouraging neuralgics, especially women, to relieve pain and depression by the direct agency of wine or spirit; it is a system fraught with dangers of the gravest kind.

(_b_) The anti-toxic remedies include agents addressed to the modification of a special condition of the blood and tissues induced by the presence of morbid poisons, of which syphilis, malaria, and (more doubtfully) gout and rheumatism, are the representative examples.

Of syphilitic neuralgia the treatment may be summed up in a few words: Give iodide of potassium in doses rapidly increased up to a daily quantum of twenty to thirty grains. If this fails, give one-twelfth of a grain of bichloride of mercury thrice daily.

Of malarial neuralgia I can only speak from such a limited experience that I am by no means in a position to give an exhaustive account of the treatment. Quinine is, of course, the remedy that should first be tried; and, as the paroxysms are usually regular in their recurrence, I prefer to give the drug after the plan which is, I think, incontestably the best in ordinary ague--_i. e._, to administer one large dose (five to twenty grains) about an hour before the time when the attack is expected. With a few exceptions the malady, unless it had taken very deep root before we were consulted, will yield to a few doses given in this way; after the morbid sequence has been thus interrupted, it will be proper to continue the action of quinine in smaller and more frequent doses, given for three or four weeks continuously. For the comparatively rare cases in which quinine fails, the prolonged use of arsenic (Fowler's solution, five to eight minims three times a day), especially with the simultaneous employment of cod-liver oil, is to be recommended.

The part which gout may play in inducing neuralgia is, as I have already said, a far more doubtful question than the popular medical traditions assume it to be; and treatment directed to gout as a cause is an extremely uncertain affair. The direct relief of neuralgic pain by the administration of colchicum, for example, is, in my experience, a very rare occurrence, even where the gouty diathesis is unmistakably present; and, on the other hand, the depressed vitality which gouty neuralgics usually show in a marked degree, renders it very doubtful whether the relief of the pain may not be too dearly purchased at the cost of the general lowering effects of colchicum. It is probable that neuralgia occurring in gouty subjects is more safely, and equally effectually, treated upon general principles. At the same time it may be admitted that, in the subordinate function of an adjuvant to the aperients which it is sometimes advisable to give, small doses of the acetic extract of colchicum seem to possess some value.

The question of treatment addressed to a supposed rheumatic element in neuralgia will, of course, be differently judged according to the respective ideas of various practitioners as to the pathological affinities of the two diseases; and the reader already knows that I believe these affinities to be different in kind from what is generally believed. The utmost that I should concede is, that in a certain very limited number of cases the peripheral factor in neuralgia is an inflammation of the nerve-sheath, or surrounding tissues, which forms part of a chain of phenomena of local fibrous inflammations in different parts of the body. Iodide of potassium, in five or ten grain doses three times a day, is the proper treatment for such cases. I have never found alkalies do any direct good to the pain.

(_c_) The medicinal tonic variety of constitutional treatment is more especially represented by the use of iron and arsenic in cases where poverty of the blood seems to exist in a marked degree, and by the administration of certain tonics--quinine, phosphorus, strychnia, and zinc--which are supposed to exert a specially restorative influence upon the nervous tissues.

The use of quinine as an anti-malarial agent has been already referred to; its employment in non-malarial cases is of much more restricted scope and benefit. Experience has taught me to agree in general with the opinion of Valleix, that it is a very unreliable agent; the one marked exception to this being the case of ophthalmic neuralgias. What the reason may be I cannot in the least say, but it is a fact that quinine does benefit these neuralgias, in cases where there is no room for suspicion of malaria, with a frequency which is very much greater than in the treatment of the painful affections of any other nerve in the body. The quantity given should be about two grains three times a day.

The preparations of phosphorus which I have employed in the treatment of neuralgia are the phosphuretted oil, the hypophosphite of soda (five to ten grains three times a day), and pills of phosphorus (according to Dr. Radcliffe's recommendation) containing one-thirtieth of a grain, given twice or thrice daily. Either of the two last will do all that phosphorus can do, but its utility is not very extensive or reliable. I have found it to do most good in cases where there was a high degree of anæsthetic complication.

Preparations of zinc have, in my hands, done no particular good, although I have tried them in all manner of doses.

Strychnia, on the other hand, is a remedy which I have learned to prize much more highly during the last few years than previously. Its most decided efficacy has been shown in some of the visceralgiæ, especially gastralgia, and (to a less extent) angina pectoris. Its internal use for these complaints is best effected by giving doses of five to ten minims of tincture of nux-vomica three times a day; but a method which I have several times employed with good effect is the subcutaneous injection of very small doses of strychnia (one-eightieth to one-fiftieth of a grain) twice daily. For the superficial neuralgias, on the other hand, I generally administer one-fortieth of a grain, with ten or fifteen minims of tincture of sesquichloride of iron, by the stomach, three times a day; this is a very powerful prophylactic remedy to prevent the recurrence of the attacks when once the sequence of them has been broken through by other means.

Of iron generally, as a remedy in anæmic cases, I have only to remark that, in order to get its full benefits, it is necessary to use large doses. I give the saccharated carbonate in twenty-grain doses twice or three times a day.

But of the sesquichloride of iron I am inclined to say something more; it has seemed to me that, besides its effects on the blood, it has a marked and direct influence upon the nervous centres, which is different from anything which one observes in the action of other preparations of iron. It is certain that the action of sesquichloride of iron, in those cases of chlorosis which are distinguished by profound nervous depression, is something quite peculiar; and the effect which it produces in the anæmic neuralgias, more especially of young women, is equally remarkable. I cannot help alluding here to the striking effects which large doses of the tincture, as recommended by Dr. Reynolds, produce in acute rheumatism; the severest pain is often checked within twenty-four hours after the commencement of this treatment. Both in this disease and in neuralgia, I employ the old-fashioned tincture: if given alone it should be used in large doses (thirty or forty minims three times a day); but an excellent combination is that, already mentioned, of ten-minim doses of this tincture with one-fortieth of a grain of strychnia. There is something in the revivifying effects of this mixture that is quite peculiar. I have very lately employed it in the case of a gentleman, aged thirty-five, who was the subject of frontal neuralgia complicated with paralysis of the internal rectus, and who was decidedly anæmic, and greatly depressed and worried in mind by the consciousness of his inability to overtake professional work which had accumulated upon him. This patient improved with great rapidity, and in the course of three weeks lost, not merely his neuralgia, but also his strabismus, almost entirely; but he then got into a condition which, though not of permanent importance, was sufficiently undesirable to make me mention it here, especially as I have seen the same thing in more than one patient besides him. It is a peculiar state of restlessness during the day and sleeplessness at night, without any positive exaltation of reflex excitability such as one used to see from strychnia in the days when mischievously large doses of that drug were very commonly given, and patients used to complain of decided twitchings and startings of the limbs. It is clearly not a strychnia effect pure and simple, nor an iron effect only; it is a _tertium quid_ compounded of the actions of both drugs.

The direct effects of arsenic in the improvement of the quality of the blood seem to me incontestable; and its use for this purpose in anæmic neuralgias is certainly something over and above its special neurotic action. No one, who has employed it much in the cases of anæmic children suffering from chorea after rheumatism, can have failed to observe its frequently striking influence upon blood-formation even long before the nervous ataxia is materially reduced. The misfortune is, however, that we possess no indications by which to judge beforehand whether we may reckon on its most favorable action in any given (non-malarious) case, with certain special exceptions. In angina pectoris it has a most direct effect, which is rarely altogether missed, and is sometimes surprising: the cases in which it succeeds best are those distinguished by anæmia, but we may well suppose, from its remarkable action upon other neuroses of the vagus, that it is something more than an action on the blood-making process which produces such powerful effects in allaying the tendency to recurrence of the paroxysms. My attention was called to its action in this disease chiefly by the remarkable case published by Philipp;[37] this was a purely neurotic angina, but one of the severest type, and the influence of arsenic was very striking. Since that time I have employed it in several cases, and, after trying various forms of administration, I conclude that nothing is better than Fowler's solution, in doses of three minims (gradually increased, if the remedy be well tolerated, up to eight or ten) three times a day. Unfortunately, there are some neurotic patients who cannot bear arsenic, the irritability of their alimentary canal is such that the drug always provokes vomiting, or diarrhoea, or both; this was the case with one of my patients, in whose case I had allowed myself to hope for the very best results from arsenical treatment. But where the patient tolerates it--and usually he tolerates it extremely well--the prolonged use of arsenic seems really to root out the anginoid tendency, or at least to confine it to the more trivial and manageable manifestations. I believe that in at least three patients, I have so completely broken down a succession of cardiac neuralgic attacks as to substitute for them a mere remnant of a tendency to "tightness at the chest" after any severe bodily exertion or mental emotion. It might be a question, in cases where the stomach does not tolerate the ordinary administration of the agent, whether it would not be worth while to try the effect of subcutaneous injection (two to four minims of Fowler), or inhalation of the smoke of arsenical cigarettes. But, in truth, it is not certain that even in this case we escape the characteristic effects of the drug upon those persons who are abnormally sensitive to it.

A remarkable instance of the beneficial influence of arsenic occurred in the case of a woman, aged forty-six, the solitary example of severe angina in a female that I have ever seen. [It is by no means uncommon, however, to see the milder forms of cardiac neuralgia in women; the remarkable statistics of Forbes, quoted in Chapter I., must certainly have been taken exclusively from cases of the severest type of the disease.] This was a hospital patient, who had always suffered much from hysteria, and from childhood had been liable to hemicranic headache; she had entered on the period of "change" at the time the attacks began, but menstruation, though irregular, still continued, and, in fact, did not cease till four years later, long after the anginal attacks had been subdued. The patient had been attacked for the first time at the end of a heavy day's washing; she dropped on the ground with the sudden agony and faintness, and thought she should "never come to life again." The paroxysms returned five times within the next month, though not always so severely as on the first occasion; but the poor woman lived in a constant state of terror. On the occasion of her second visit to me, she had a most severe attack in the waiting-room at the hospital: being called to her I found her very nearly pulseless, gasping, and with the kind of complexion which is so suggestive of approaching death. She was recovered by a large dose of ether. It was a rather uncommon feature in this case that the pain was only at and around the lower end of the sternum, except that occasionally it shot along the sixth intercostal space. The employment of Fowler's solution (in doses gradually mounting to twenty-one minims daily) for six months completely eradicated the anginal tendency; the proof that it was a real therapeutic effect was given by the result of an attempt to leave the medicine off at the end of eight weeks' treatment; the patient immediately began to suffer again. When she really left off, at the end of six months' treatment, she had had no tendency to heart-pang for more than a month, and, besides this, looked quite another creature in her improved vitality and vigor. Yet the menstrual troubles went on, and the function was not finally suppressed for a long time afterward.

I suspect, however, that the most frequent successes with arsenic will, after all, be made in the cases of more or less anæmic male patients who are attacked with the neurotic form of angina in the midst of a career (as is especially the case with some professional careers) that implies not merely incessant labor, but great anxiety of mind. The drug does little good, however, if not positive harm, in that form of angina pectoris minor which is not the result purely of these causes, but of these, or some of these, plus the morbid action of the alcoholic excess, to which the patient has fled in order to relieve mental harassment and the fatigue that comes from overwork, especially overwork at tasks that are not congenial to his natural disposition; there is usually in such cases a heightened irritability of the alimentary canal, which is almost sure to cause arsenic to disagree: the really useful treatment is quinine for the first few days, and then, when the stomach will bear it, cod-liver oil in increasing doses, up to a large daily amount given for a long time together.

On the whole, arsenic, 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 tendency, 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 of the fifth) there is a possibility of its proving the most effective remedy in almost any given case which may come before us.

2. The narcotic-stimulant treatment for neuralgia includes some of the most powerful remedies for the disease which we possess. These remedies have very different properties, but they all agree in this, that in small doses they appear restorative of nerve-function--in large doses depressors of the same.

Four very different types, at least, of narcotic-stimulant drugs are useful in neuralgia: (_a_) There is the opium type, by which pain is very directly antagonized, and, besides this, sleep is also directly favored. (_b_) There is the belladonna type, by which pain is also much relieved, though with far greater certainty in some regions than in others (_e. g._, much the most powerful effect is seen in cases of pelvic visceralgia), but sleep is by no means so certainly or directly produced as by opium. (_c_) There is the chloral type, which is almost purely hypnotic; it is represented almost solely by chloral itself, which is resembled by scarcely any other drug. (_d_) There is bromide of potassium, which stands alone for its powerful action on the cerebral vaso-motor nerves, and which is useful in neuralgia simply by its power to check psychical excitement directly (through the circulation) and indirectly (through the production of sleep).

(_a_) Opium and the remedies that resemble it are, for the treatment of neuralgia, fully represented by the hypodermic use of morphia, which is the only kind of opiate treatment that ought ever to be employed, save in very exceptional instances. The great reasons for the preference of the subcutaneous administration over the gastric are, the economy of the drug which it affects and the much smaller degree of disturbance of digestion which it causes. The hypodermic injection of morphia, if conducted on correct principles, enables us, when necessary, to repeat the dose a great number of times with but little loss of the effect, and consequently with a much smaller rate of progressive increase of the quantity required; and the absence of depressive action on digestion enables us to carry out simultaneously that plan of generous nutrition which has already been shown to be so important a part of treatment. Indeed, the case is hardly expressed with sufficient strength, when we say that hypodermic morphia is usually harmless to the digestive functions; for in a great number of instances it will be found actually to give an important stimulus both to appetite and digestion; and the patient, who without its aid could hardly be persuaded to take food at all, will not unfrequently eat a hearty meal within half an hour after the injection.

The remarkable effects of hypodermic morphia have, however, caused it to be rashly and indiscriminately used, and so much harm has been done in this way that it is necessary to be exceedingly careful in the rules which we lay down for its employment. Upon these grounds I must hope to be excused if, in order to render this work complete, I repeat a good deal of what I have already said in other places. In the first place, I shall speak of the mode of administration, and then of the dose.

As regards the mode of administration, I prefer the use of a solution of five grains of acetate of morphia to the drachm of distilled water; if the acetate be a good specimen, this will dissolve easily (and keep some time without precipitation) without the use of any other solvent. With a solution of this strength we require nothing elaborate in the form of the syringe; a simple piston arrangement does well; only it is advisable that the tube shall have a solid steel triangular point, and a lateral opening. As regards the place of injection, I must repeat the opinion[38] which I have already published, that Mr. Hunter's plan of injection at an indifferent spot is, in the great majority of instances, fully as effective as the local injection would be; nevertheless, there is one consideration which in some cases may properly induce us to adopt the latter plan. Very nervous and fanciful patients will sometimes be much more readily brought to allow the operation when it seems to go directly to the affected spot, when they would be sufficiently incredulous of the benefits of an injection performed at a distance to indulge their dislike of incurring pain by refusing to submit to it. And there is one class of cases in which it is likely that there are real physical advantages in the local injection; in instances of old-standing neuralgia with development of excessively tender "points," which are also the foci of the severest pain, it will sometimes be advisable to inject into the subcutaneous tissue at these points. There is undeniable reason for thinking that the sub-inflammatory thickening of tissues around a certain point of nerve delays the transit of the morphia into the general circulation, and enables it to act more directly and powerfully on the nerve, which it thus renders insensitive to external impressions; an important respite is thus gained, during which the nerve-centre has time to recover itself somewhat. At the same time it must be remarked that this immediate injection of a tender point is apt to be exceedingly painful, and it may be absolutely necessary to apply ether-spray before using the syringe. In early stages of neuralgia, before the formation of distinct tender points, there is no advantage whatever (except the indirect one above mentioned) in the local injection. And, on the other hand, it is often of great consequence not to run the chance of disfiguring such a part as the face, the neck, etc., when the injection can easily be done over the deltoid, or in the leg, or in some other part which even in women is habitually covered by the dress.

The dose to be employed is an exceedingly important matter, and one as to which practitioners are still very often injudicious. We ought never to commence with a larger dose than one-sixth of a grain; but very often as little as one-twelfth of a grain will give effective relief, and in not very severe cases it is well worth while to try this smaller quantity. When no larger quantity than one-sixth of a grain is employed we commonly observe no narcotic effects, _i. e._, there is no contraction of pupil, no heavy stupor, and, although the patient very often falls asleep, on waking he does not experience headache, nor is his tongue foul. I cannot too strongly express the opinion that it is advisable by all means to content ourselves with this degree of the action of hypodermic morphia, unless it fails to produce a decided impression on the pain. But in very severe cases our small doses will fail; and then, rather than allow the patient to continue having severe paroxysms unchecked, we must frankly admit the necessity of using a narcotic dose from one-quarter to one-half of a grain, according to circumstances. Whatever actual dose be employed, it is important not to repeat it with unnecessary frequency; once a day in the milder, and twice a day in the more severe cases, will be all that is advisable, save in very exceptional cases: the point being to administer it as quickly as possible after the commencement of an exacerbation. If by these means we can prevent the patient having any severe pains during a period of several days, we often give time to the affected nerve to recover itself so completely, especially with the aid of other measures to be presently mentioned, that the tendency to neuralgia is completely broken through, and we can drop the injections, either at once or by rapid diminution of the dose, and thereafter treat the case merely with tonics, and with the precautionary measures to be dwelt upon under the heading of Prophylaxis. But, if we have been driven to the use of distinctly narcotic doses, and these do not very speedily break the chain of neuralgic recurrence, it will not do to continue to rely upon hypodermic morphia; it will be best to try some of the local remedies (blistering, galvanism) with it. If this combination fails, we should then try the effect of atropine, the sulphate of which, hypodermically injected, fully represents for all useful purposes the mydriatic class of narcotics.

(_b_) The commencing hypodermic dose of atropine should be one-one hundred and twentieth grain; it is not often that so small a quantity will do any good, but it is necessary to use this agent with great precaution, as we occasionally meet with subjects in whom extremely small doses provoke most uncomfortable symptoms of atropism, as dry throat, dilated pupil, delirium, and scarlet rash. Commonly we shall find ourselves obliged to increase the dose to one-sixtieth, one-fiftieth, or one-thirtieth of a grain; and in a very few cases it may be necessary to go even as high as the one-sixteenth or one-twelfth. In my experience such instances are excessively uncommon; and I cannot but suppose that the practitioners who use the high doses frequently must inject in such a manner as to fail to get the whole dose taken up. [Absolutely inexplicable to me is the statement of the illustrious Trousseau--that hypodermic remedies are "less active" (!) than gastric remedies--except on his hypothesis.]

The most remarkable effects that I have seen from hypodermic atropia were obtained in cases of peri-uterine neuralgia, especially dysmenorrhoeal neuralgia. Speaking generally of atropine, it must undoubtedly be counted far inferior to morphia as a speedy and reliable reliever of neuralgic pain, but for all pelvic neuralgias it appears to me on the whole to surpass morphia. And besides this, in other neuralgias, where opiates altogether disagree (as with some subjects they do), it is not uncommon to find that atropia acts with exceptionally good effect. And to some extent I am inclined to confirm Mr. Hunter's opinion, that, where atropia does stop neuralgia, it does so more permanently than morphia.

There is another special use of hypodermic atropine which I have not seen mentioned by any one but myself, but which is probably very important, namely, in ophthalmic neuralgia where acute iritis, or especially glaucoma, seems coming on. I may be mistaken, but I believe that in three cases I have succeeded, by prompt injection of sulphate of atropine (one-sixtieth to one-fortieth of a grain), in saving a neuralgic eye from damage, and possibly from destruction, from impending glaucoma.

(_c_) The class of cases for which merely hypnotic remedies are of much value is limited; nevertheless, in the milder kinds of migraine and clavus, especially when they have been brought on or are kept up by mental worry or hysterical excitement, these remedies will sometimes prove very useful. In former days, before we knew chloral, I used to employ camphor for this purpose; three or four grains being administered every two hours: and in hysterical hemicrania of a not very severe type this not unfrequently produced a short sleep, from which the patient awoke free from the pain. But chloral infinitely transcends in value any agent of this kind that was known before. Perfectly valueless for the really severe neuralgias, it is of the greatest possible use as a palliative in migraine and clavus, where the great object, for the moment, is to get the patient to sleep. A single dose of twenty to thirty grains will often effect our object: it may be repeated in two hours if sleep has not been induced; it should be given as soon as the pain has at all decidedly commenced.

And here I wish to make some special remarks on the subject of "palliation," and the relation it bears to "cure." Nothing is more common than to read serious admonitions, in medical works, about the folly of trusting to remedies which only palliate for the moment but leave the root of evil untouched; and, of course, there is a certain respectable modicum of the fire of truth behind all this orthodox smoke. In the case of neuralgia, however, it is most important to understand that mere palliation, that is, stopping of the pain for the moment, may be either most useful or highly injurious, according to the way in which it is done. The unnecessary induction of narcosis for such a purpose, doubtless, is most reprehensible; but if it were possible simply to produce sleep from which the patient should awake refreshed, without any narcotic effects, then, certainly, that sort of palliation must be good. That is precisely what the judicious use of chloral does; and I may mention, as resembling though not equalling it, the action of Indian hemp, which has been particularly recommended by Dr. Reynolds. From one-fourth to one-half of a grain of good extract of cannabis, repeated in two hours if it has not produced sleep, is an excellent remedy in migraine of the young. It is very important, in this disease, that the habit of long neuralgic paroxysms should not be set up; and if the first two or three attacks are promptly stopped, by the induction of sound, non-narcotic sleep, we may get time so to modify the constitution, by tonics and general regimen and diet, as to eradicate the neuralgic disposition, or at least reduce it to a minimum. But I would decidedly express the opinion that such remedies as either opium or belladonna are mostly unsuited to this purpose. If the migraine of young persons does not yield to chloral, to cannabis, or to muriate of ammonia (in twenty or thirty grain doses), it will not be advisable to ply the patient with any remedies of the narcotic-stimulant class, but to trust to tonic regimen and the use of galvanism.

The mention of muriate of ammonia, which, for migraine and clavus and the milder forms of sciatica, not unfrequently proves useful in stopping the violence of a paroxysm and enabling the patient to get some refreshing sleep, leads me to notice that not only may a variety of the milder narcotic-stimulants be employed in this way, but the external stimulus of heat to the extremities (very hot pediluvia) greatly assists the action of any such remedies; especially if mustard-flour be added, so that a mild vapor of mustard rises with the steam and is inhaled. Perhaps the ideal medication, to arrest a bad sick-headache, is to give twenty grains of chloral, and make the patient plunge his feet in very hot mustard-and-water and breathe the steam. He can hardly fail to fall asleep for a longer or shorter time, and awake free from pain.

(_d_) The use of bromide of potassium in neuralgia is a subject of great importance, and which requires much attention and discrimination. In common with, I dare say, many others, I made extensive trial of this agent when it first began to be much talked of, but was so much disappointed with its effects in neuralgias, that at one time I quite discarded it in the treatment of those affections. Renewed experience has taught me however, that, though its use is restricted, it is extremely effective if given in appropriate cases and in the right manner. For the great majority of neuralgias it is quite useless, and, what is more, proves often so depressing as indirectly to aggravate the susceptibility of the nervous system to pain. The conditions, _sine quis non_, of its effective employment seem to be the following: The general nervous power, as shown by activity of intelligence, and capacity of muscular exertion and the effective performance of co-ordinated movements, must be fairly good, find the circulation must be of at least average vigor; the patient must not have entered on the period of tissue-degeneration. Among neuralgics who answer to this description, those who will benefit by the bromide are chiefly subjects--especially women--in whom a certain restless hyperactivity of mind and perhaps of body also, seems to be the expression of Nature's unconscious resentment of the neglect of sexual functions. That unhappy class, the young men and young women of high principle and high mental culture to whom marriage is denied by Fate till long after the natural period for it, are especial sufferers in this way and for them the bromide appears to me a remedy of almost unique power. But I wish it to be clearly understood that it is not to the sufferers from the effects of masturbation that I think the remedy specially applicable: on the contrary, it is rather to those who have kept themselves free from this vice, at the expense of a perpetual and almost fierce activity of mind and muscle. The effects of solitary vice are a trite and vulgar story; there is something far more difficult to understand and at the same time far more worth understanding in the unconscious struggles of the organism of a pure minded person with the tyranny of a powerful and unsatisfied sexual system. It is in such cases, which it heeds all the physician's tact to appreciate, that it is sometimes possible to do striking service with bromide of potassium; but it will be necessary to accompany the treatment with strict orders as to generous diet, and, very likely, with the administration of cod-liver oil.

Having decided that bromide of potassium is the proper remedy, we must use it in sufficient doses. Not even epilepsy itself requires more decidedly that bromide, to be useful, shall be given in large doses. It is right to commence with moderate ones (ten to fifteen grains), because we can never tell, beforehand, that our patient is not one of those peculiar subjects in whom that very disagreeable phenomenon--bromic acne--will follow the use of large doses. But we must not expect good results till we reach something like ninety grains daily. Let me add that it is not so far as I know, by reducing any "hyperæsthesia" of the external genitals, of which the patient is aware, that the remedy acts; I have not seen such a nexus of disease and remedy in these cases.

3. Local Measures.--The external remedies which may be applied for the treatment of neuralgia may be divided into (_a_) skin-stimulants; (_b_) paralyzers of peripheral sensory nerves; (_c_) remedies adapted to diminish local congestion; (_d_) remedies adapted to diminish arterial pulsation; (_e_) electricity; (_f_) mechanical means of protection.

(_a_) Among the skin-stimulants blisters hold the highest place as a remedy for neuralgia; indeed the assertion of Valleix, that they are the best of all remedies, is still not very wide of the truth. They are by no means universally applicable, and the degree to which their action should be carried varies materially in different forms of the disease, but they are of the greatest possible service in a large number of instances.

It is possible to view the action of blisters in neuralgia in more than one way. When applied in such a manner as to vesicate decidedly, and especially if kept open and suppurating for some time, they cause considerable pain of a different kind from that of neuralgia itself and the mental effect of this, operating as a diversion of the patient's thoughts from his original trouble, may be thought to assist in breaking the chain of nervous actions by which he is made to feel neuralgic pain. There may be something in this, but I confess that I do not believe this kind of effect goes for much in genuine neuralgia. It is rather in the pain of hypochondriasis, and the so-called spinal irritation (to be described in the second part of this work), that such an action of blisters proves useful.

Another action of blisters, which some authors hold to be perhaps the most effective portions of their agency, is that which is produced by the drain of fluid, specially when they are kept open, by which means a kind of depletion is set up, and the morbid irritation that causes the nerve pain removed. I cannot at all assent to this view. In the first place, I believe that any one who has large experience of blistering in neuralgia will ultimately come, as Valleix did, to believe that prolonged drain from a blister is rarely or never useful, and that a far better plan is that of so-called flying blisters, renewed at intervals if necessary. The most genuine successes that I have procured from blistering have certainly been got in this way. But I should go further, and say that the prolonged drain and the peculiar kind of chronic irritation produced by a suppurating blistered surface can very decidedly aggravate a neuralgia; this is more especially the case when the blister is applied immediately over the focus pain.

The view which I am strongly convinced alone explains the beneficial action of blisters is that which supposes them to act as true stimulants of nerve-function. In order that this effect shall be produced, it will be necessary that the skin-irritation be either produced at some distance from the seat of the greatest pain, or that, if applied in that spot, it shall be comparatively mild in degree. And accordingly, I have been led, in my observations to apply the blister at some distance from the focus of pain. An indifferent point, however, will not do--there must be an intelligible channel of nervous communication between the irritated portion of skin and the painful nerve. This object is accomplished by placing the blister as close as may be to the intervertebral foramen from which the painful nerve issues; the effect of this is probably a stimulation of the superficial posterior branches, which is carried inward to the central nucleus of the nerve. I must say that the results which I have derived from this plan of treatment have been far more satisfactory than those which I used to obtain when I habitually applied the vesication as near as might be to the focus of peripheral pain; and I think that this result tallies well with the idea that the essential mischief in neuralgia consists in an enfeebled vitality of the central end of the posterior root. An exceedingly interesting confirmation of this idea as to its _modus operandi_ has been afforded me by the fact that not merely neuralgic pain, but also trophic and inflammatory complications attending it, have been sensibly relieved, in several cases that I have seen, by this mode of reflex stimulation. This has been particularly the case in herpes zoster, where the process of inflammation and vesiculation has been very promptly checked by the application of a tolerably powerful blister by the side of the spine at the proper level; and I am gratified to mention that Dr. J. K. Spender, of Bath, pointed out this fact[39] at a time when he had only seen my statement that the pain could be relieved in this way. In the case of the trigeminus, the same kind of reflex stimulation is most effectively obtained by applying the blister over the branches of the cervico-occipital, at the nape of the neck; and it is remarkable what powerful effects are sometimes thus produced, even in cases that wear the most unpromising aspect. For example, in the desperate epileptiform tic of old age, I have more than once seen a complete cessation of suffering, which lasted for a very long time--so long, in fact, as to make me hope against hope that it might never return. I do not now entertain any such expectations from this remedy; still, its value is very great.

There are curious differences between the effects of blistering in trigeminal or intercostal neuralgia and in sciatica. On the whole, it would appear that blistering in the neighborhood of the spine is less frequently effective in the latter, and we sometimes, after failing with this method, obtain immediate success by two or three repetitions of the flying blister, somewhere over the trunk of the nerve, especially just outside the sciatic notch. I have one lady patient in whom this series of phenomena has several times been observed; and I have seen it occur in a particular attack, in other patients, in whom, nevertheless, on another occasion the spinal blistering has been promptly effective.

I consider blistering of the posterior branches to be an important, and usually an essential, element in the treatment of all cases of sciatica in the middle period of life which have reached some severity and lasted long enough to become complicated with decided secondary affections.

In all cases where blistering is employed it is advisable to adopt the simultaneous use of hypodermic morphia or atropine; this combination of remedies is exceedingly powerful.

Lastly, it must be said of blistering, that, on the whole, it is a remedy not well fitted to be applied to aged subjects; and in its severer forms it should never be applied to patients who are greatly prostrated in strength. For it must be borne in mind that the remedy may miss its aim of relieving the neuralgia, in which case it is necessary to remember, more accurately than many practitioners appear to do, what a very serious element of misery and prostration will be introduced into the case by the vesication itself.

I am not convinced that any of the other forms of severe skin-irritation (_e. g._, tartar-emetic inunction, or the use of veratrine-ointment to such a degree as to produce not the anæsthetic but the irritant effects) are of any particular value; if blistering failed, I should not expect to see them succeed.

A milder degree of skin-stimulation is represented by rubefacient liniments of various kinds, which may be briskly rubbed into the skin along the track of the painful nerve, without any danger of producing vesication. Among this class I continue to prefer chloroform diluted, with six or seven parts of chloroform, to any other; in the milder forms of neuralgia, especially in young persons and first attacks, it is surprising how frequently the paroxysm may be greatly relieved, if not arrested. Still, this can only be regarded as the merest palliative; and in severer cases such applications are useless. Occasionally, when chloroform-liniment has failed, a mustard plaster will do good.

The mildest degree of skin-stimulation is represented by the continuous application of moist warmth, which is best effected by the simple application of moistened spongio-piline; so far as I have observed, however, it is rather in cases of myalgia than in true neuralgia that this does good; in the latter it is probably little more than a mere protector against cold.

(_b_) A variety of agents can be employed with the object of temporarily interrupting the conductivity of the painful nerve; by this means a period of rest is obtained during which the centres--sensory and psychical--have time to regain a juster equilibrium, and the habit of pain is, _pro tanto_, broken through.

There is one agent of this class which for general purposes I do not think is worth retaining on our list of sensory paralyses--namely, cold. Cold, to be of any value, ought to be of the degree which is represented by ice allowed to melt slowly in contact with the skin; and for the majority of neuralgias this is decidedly inferior to other remedies that can be applied by painting or inunction. The one case in which ice is supremely useful is in neuralgia of the testis; here I make no doubt that it is almost, if not quite, the most useful remedy we can employ, although of course other means must be taken to modify the neuralgic temperament. It should be applied the moment an attack comes on.

Far more useful, in neuralgias generally, is the external application of aconite or of veratrine. Aconite may be employed in the milder or the stronger form; in the former case, we simply paint the ordinary tincture on the skin over the painful nerves (avoiding any cracks or sores); in the latter, we rub in an ointment containing one grain of the best hydrate of aconitine to the drachm of lard, about twice a day, and to such an extent as to maintain complete numbness of the parts continuously, for two, three, or four days. I do not believe that this will ever, by itself, cure a true neuralgia of any considerable severity; but I have more than once known its intervention, at a crisis in treatment when it seemed that other remedies might fail, produce a striking change in the progress even of a very bad case.

A milder, but still very useful form of the same kind of action, is produced by veratrine-ointment. I would recommend, however, as a rule, that it be employed, at any rate at first, of weaker strength than that recommended in the Pharmacopoeia, for with some persons it is easy to pass the anæsthetic, and to enter on the irritant, action of veratrine upon the skin. This leads me to give a caution that should properly have come earlier, when I was speaking of skin-stimulants. In aged subjects, especially, we rather frequently meet, in neuralgia, with a specially irritable state of the skin, even although there may be at the same time some loss of common and tactile sensation; and the practitioner must be warned against the danger of producing an amount of skin-irritation which will fearfully annoy his patient. I speak feelingly, having by such an indiscretion lost the richest patient who ever favored my consulting-room with his presence!

The inunction of mild veratrine-ointment is extremely useful, as an adjunct to other treatment, in migraine and supra-orbital neuralgias of suckling women, and of chlorotic girls. I have also seen it do much good in mammary neuralgia.

The last division of the subject of paralyzing agents in the treatment of neuralgia includes the surgical operations for division or resection of a painful nerve. Upon this question there is much difficulty in speaking decidedly. I admit at once, of course, that surgical interference is evidently indicated when, along with decided and intractable neuralgic pain, there is plain evidence either of the existence of a neuromatous tumor, or the presence of a foreign body impacted, or a tight cicatrix pressing upon a nerve. I admit, also, though with much greater qualifications, that carious teeth may need to be extracted before we can cure a neuralgia; but even here I should put in the decided caveat that we must consider whether the system is in a state to bear the shock, and that in any case we probably ought to mitigate the effects of the operation by performing it under chloroform. And I need hardly tell any one, who is familiar, either practically or from reading, with the subject, that thousands of carious teeth have been extracted from the mouths of neuralgic patients, not only without benefit, but with the effect of distinctly aggravating the disease. And I am yet more doubtful as to the advisability of such surgical procedures as the division or the resection of a piece of the painful nerve. Theoretically, as the reader will understand from the strong opinion I have given as to the mainly central origin of neuralgias, I never could anticipate that such a procedure would be more than temporarily successful; on the contrary, the mischief in the central end of the nerve remaining, I should suppose that the trying process of the reunion of the nerve (which always takes place) would be almost certainly attended with a revival of the neuralgia, too probably in an aggravated form. The only two cases of excision of a piece of the nerve, that I have ever seen, completely answered to this anticipation. In common fairness, however, I must admit that there is a large amount of evidence on the other side. Neuralgias of the trigeminus are pretty nearly the only cases in which the proposal of neurotomy or neurectomy ought to be entertained; in mixed nerves the inconvenience of the muscular paralyses that would follow would be usually too serious to allow of our incurring them. But resection of painful branches of the trigeminus has been performed in a great number of instances, more especially by German surgeons, with results that merit our attention; the cases recorded by Nussbaum, Wagner, Bruns, and Podratzki, may be especially referred to. On the other hand, with the exception of simple division of the nerve, which can be subcutaneously performed, and is a trivial proceeding (but has very short-lived effects), these operations are by no means without danger, especially when they are pushed to such a length as the opening of bony canals, and the resection of considerable portions of bone in order to get sufficiently far toward the centre, and fatal results have in more than one case followed. Above all, we can never too seriously reflect on the most interesting case of Niemeyer's reported by Wiesner,[40] in which the most formidable operations of this kind have been performed, in an apparently desperate case of epileptiform facial tic, and in which, after all, the application of the constant current painlessly effected an infinitely greater amount of good than had been done by all those severe and painful surgical manipulations. I think it is impossible, after this, not to conclude that neurectomy ought never to be even thought of except as a last resort, in cases of extreme severity, after other measures had been patiently tried and had decisively failed.

(_c_) Of remedies that are intended to relieve local congestion, I must speak with very doubtful approbation. Leeches or scarifications are, I think, very seldom of value. The only remedy that has sometimes seemed to do good is local compression, and, after all, it is quite as likely that this acts by anæsthetizing the nerve as by reducing congestion.

(_d_) Remedies that interfere mechanically with arterial pulsation are of considerable value where they can be effectively applied. I have already pointed out the specially aggravating effect of the momentarily-repeated shocks of arterial pulsation upon neuralgic pain. Where, then, it is possible, effectively to control an artery pretty near to the point where it divides into the branches that lie close to the painful part of the nerve, it is always worth while to try the experiment. But such a measure as the compression of the carotid in trigeminal neuralgia is of very doubtful propriety; I suspect the consequent anæmiation of the brain more than does away with any benefit that might be mechanically produced. And any attempt to interfere with the general arterial circulation by cardiac depressants is not to be permitted for an instant.

(_e_) We enter now upon a most important subject, the treatment of neuralgia by electricity. It is necessary to exercise much caution in speaking upon this topic, and, as I shall have to express somewhat decided opinions, I may be excused for referring to the circumstances under which I have arrived at my present stand-point upon this question. I can hardly be accused of having, with any very rash haste, espoused the cause of medical electricity in the therapeutics of pain, as any one will see who cares to turn to my article on Neuralgia[41] written only three years ago. At that time I had already been studying the subject for a considerable period, but was so convinced of the multitude of opportunities for fallacy that beset the student of electro-therapeutics, that I was unwilling to state more than the minimum of what I hoped and believed might be affected by this mode of treatment. Since that time I have become more fully acquainted with the researches of foreign observers, and, with the help of their indications, have been able to apply myself more fruitfully to my personal inquiries into the matter. The result is, that I am now able to speak with far greater assurance of the positive value of electricity as a remedy for neuralgic pain. I shall make bold to say that nothing but the general ignorance of the facts can account for the extraordinary supineness of the mass of English practitioners with regard to this question.

In the first place, I have arrived at a decided conviction that Faradic electricity is of little or no value in true neuralgias, and that the cases which are apparently much benefited by it will invariably be found, on more careful investigation, to belong to some other category.

On the effect of frictional electricity I have had such very small experience that I cannot venture to speak with any confidence, and the accounts that I have heard from others whose experience is much larger have not led me to attribute much importance to this agent. If I am to judge at all, I should say it merely acts as a skin-stimulant, and is, in that capacity, inferior to many other simpler and more facile applications.

Very different is the verdict of experience as regards the effects of the constant current; here the results which I have obtained have been so remarkable that even now I should distrust their accuracy, were it not that they are in accord with the general result which (among minor discrepancies) may be gathered, we may fairly say, from all the more important researches that have lately been carried out in Germany. The constant current, as I now estimate it, is a remedy for neuralgia unapproached in power by any other, save only blistering and hypodermic morphia, and even the latter is often surpassed by it in permanence of affect; while it is also applicable in not a few cases where blistering would be useless or worse.

The English medical profession has not as yet adequately appreciated the necessity for great care in the choice of apparatus and the mode of application of electricity. It is all-important, however, and especially in the case of applying galvanism for the relief of pain. The first quality that must be absolutely required in a battery, that is to be used for this purpose, is that it shall deliver its current with as little as possible variation of tension, in fact that it shall be constant, and not merely continuous; a vast majority of all the various galvanic apparatus that have been used have been merely the latter, and have consequently been almost valueless for the relief of pain. Such are Pulvermacher's chains, the voltaic piles made with elements of metallic gauze, Cruickshank's battery, and many others that have been used. A sufficiently constant current may be obtained from either of the following apparatuses, (1) Daniell's battery, (2) Bunsen's, (3) Smee's. For hospital use, the Daniell battery (in Muirhead's modification, or with the form of cells introduced by Siemens-Halske) is perhaps the most desirable; but for private practice it is worth while to sacrifice something of the superior constancy which we gain in the Daniell battery for the sake of comparative portability. All purposes which we aim at in the electric treatment of neuralgia may be sufficiently obtained by the use either of the Bunsen battery (zinc-carbon, excited by dilute sulphuric acid), as modified by Stohrer, or by the Smee battery (zinc and platinized silver, excited by dilute sulphuric acid), as in the highly convenient apparatus devised by Mr. Foveaux, of Weiss & Son's. It must be remarked that, for the purpose of treating neuralgia, we shall never need to employ more than fifteen, or at the utmost twenty, cells of either of these batteries. Both the Stohrer's Bunsen and the modified Smee of Weiss are made so that the elements are not immersed in the exciting fluid until the moment when the battery is going to be used; a simple mechanism at once throws the battery into or out of gear. In this way, destruction of the elements is minimized; and either of these two batteries may be used for from three to six months without any renewal, supposing the average work done to be one or two daily seances. If the battery is worked harder, it will require more frequent revivification. I strongly recommend London practitioners to deliver themselves from all care and trouble about the repair of their batteries, by making an agreement with the manufacturers to inspect and set them in order at stated intervals. The country practitioner, on the other hand, will do well to familiarize himself with the process of renewing the acid, of cleaning the plates, of amalgamating the zinc, etc.; in fact, to make himself independent of the manufacturer in every thing short of an actual renewal of the elements, when that becomes necessary. For all further details respecting the above-named, and other batteries, I must refer the reader to systematic works on medical electricity.[42] I must now pass on to the various modes of application, and the cautions to be observed.

It is, in the first place, necessary to say, that all the best observers coincide in the statement that the use of a current intense enough to produce actual pain or severe discomfort is never to be thought of in the treatment of true neuralgias; such practice will infallibly do harm. Only such a current is to be employed as produces merely a slight tingling, and (on prolonged application) a slight burning sensation, with a little reddening of the skin at the negative electrode. This being the case, it is perhaps not unnatural for those who have not had practical experience, to suspect that an application which causes so little palpable perturbation is devoid of any positive influence at all. Such skepticism will certainly not survive any tolerably lengthened observation of the actual facts; but, as some persons may be deterred by this _prima-facie_ view of the case from making any fair trial of the current, it may be worth while, here, to allude to the unmistakable physical effects which similarly painless constant currents are repeatedly observed to produce in cases of motor-paralysis attended with a wasted condition of muscles. Those who have had experience of the treatment of such cases know that it is a by no means infrequent thing to see both muscles and nerves aroused from a state of complete torpidity, and brought into a condition in which the Faradic current, quite powerless before, is again able to excite powerful contractions, while, at the same time, the bulk of the muscles has increased most sensibly. These, surely, are sufficient indications of a positive action of the painless constant current; and such facts have now been recorded, in multitudes, by most competent observers.

The next maxim of first-rate importance is that the applications of the current should be made at regular intervals, and at least once daily; in most instances, this is enough, but occasionally it will be found useful to operate twice in the day. The matter of regularity is, I find, of great consequence, and it will not do to intermit the galvanism immediately on the occurrence of a break in the neuralgic attacks: it should be continued for some days longer.

The length of sittings is a point as to which there is considerable difference of opinion between various authorities; but my own experience coincides with that of Eulenburg, that from five to ten, or, at the utmost, fifteen minutes, is almost the range of time.

Closely connected with the question of the length of sittings, is that of the continuity with which the current is to be applied. I have seen the best results, on the whole, from passing a weak current, without any breaks, for about five minutes. But, where there are several foci of intense pain, it will often be advisable to apply the current to each of these, successively, for three or four minutes.

The places to which the electrodes should be applied vary much according to the nature of the case.

Benedikt's rule, that the application of electricity, to be useful, must be made to the seat of the disease, is undoubtedly true; but it is capable of being applied in a somewhat different manner from that which he recommends in particular cases, the difference being due to the view of the pathology of neuralgia which is taken in this work. That view is, that the essential _locus morbi_ is always in the posterior nerve-root (and usually in that portion of the root which is within the substance of the cord), and that the peripheral source of irritation, if any, is only of secondary--though sometimes of considerable--importance. Hence the main object, in electrization, would seem to be to direct the influence of the current upon the posterior nerve-root. This may, however, be done in different ways, according to the situations in which we place the electrodes, and the direction in which we send the current.

There are, as yet, very considerable differences of opinion among electro-therapeutists as to the principles which should govern us, both in the localization of the effect and the direction of the current. Benedikt, for example, recommends that the current should be directed toward the supposed seat of the mischief. Thus, if we suppose a neuralgia to depend on morbid action within the spinal cord, then we may galvanize the spine, taking care to make the current come out through any vertebra over which we detect tenderness. If we suppose the seat of the disease to be in the nerve-root in the mere ordinary sense of the word, then we apply the positive pole to the vertebra opposite the highest nerve-origin that can be concerned, and we stroke the negative pole down by the side of the spinous processes, some forty times in succession. The proportion of cases of idiopathic neuralgia in which this treatment succeeds is, according to Benedikt, very large. In other cases, he sends the current from the cord to the apparent seat of pain.

On the other hand, Althaus[43] tells us that, whether the application be central or peripheral, it is the positive pole, alone, which should be applied to the part which we intend to affect: and that the application of the negative pole in this situation is rather likely to do harm than good, as proving too exciting. Eulenburg, also, says that in general the positive pole should be applied to the seat of the disease, the negative on an indifferent spot, or on the peripheral distribution of the nerve.

It is, however, very doubtful to me whether, in the majority of cases, the direction of the current makes any considerable difference in its effects, provided only that the stream is fairly directed so as to include the _locus morbi_ in the circuit, and care is taken to apply it with sufficient persistence and with not too great intensity. Upon this point I am glad to be able to cite the authority of Dr. Reynolds, whose experience is very large. This author, while admitting that in theory the "direct" and the "inverse" currents would seem likely to have different effects, declares that in practice this does not prove to be the case, either in the instance of pain of nerve or of spasm of muscle. Dr. Buzzard, also, in relating a very striking case (which I had the advantage of personally observing) before the Clinical Society, particularly mentioned that the direct and the inverse currents had a precisely similar effect in relieving the pain. The patient suffered from severe and probably incurable cervico-brachial neuralgia; the poles were placed, respectively, on the nape of the neck and in the hand of the affected limb, and whether the positive was on the nape and the negative in the hand, or _vice versa_, the effect was the same. Very striking remission of the pain was always produced, and the immunity from suffering sometimes lasted for a considerable time, while no other plan of treatment seemed to have more than the most momentary effect.

My own experience tells the same story very decidedly, for I have on very many occasions obtained great benefit, both by the direct and by the inverse currents, in the same patient. I shall here relate a few instances:

CASE I.--A married woman, aged forty-eight, whose menstrual periods had ceased quietly some six years previously. She was, on the whole, a healthy person, but had suffered from migraine in her youth, and came of a neurotic family. She was attacked with severe cervico-brachial neuralgia, which resisted all treatment for nearly three months, and, on her then trying a month's change of air and absence from medication, became worse than ever. The constant current was applied, from ten (and afterwards fifteen) cells of Weiss's battery, daily for twenty-four days, the pain vanished finally at the end of thirteen days, and the accompanying anæsthesia and partial paralysis disappeared before the treatment was concluded. In this case the negative pole was applied by the side of the three lower cervical vertebræ, and the positive was applied, successively, to three or four different parts of the most intense peripheral pain.

CASE II.--A young lady, aged twenty-four, suffered from neuralgia in the leg. Galvanization (twenty cells Daniell), from the anterior tibial region to the spine was found invariably to cut short the pain. I now reversed the current; the effect was the same. After ten sittings I suspended the treatment, as there had been no attack for three days; but a week later the neuralgia returned in full fury. I resumed galvanization from periphery to spine; after twelve more sittings the attacks had become rare and slight. I continued treatment for eight days longer, during the whole of which time there was no pain. It had not recurred when I saw her fifteen months afterward.

CASE III.--H. G., a footman, aged twenty-three, applied to me at Westminster Hospital, with neuralgia of the first and second divisions of the right trigeminus, of six weeks' standing. The right eye was bloodshot and streaming with tears, the skin of the right side of the nose and right cheek was anæsthetic, the right levator palpebræ was partially paralyzed. Hypodermic injections of morphia proved only very temporarily beneficial. After a fortnight's treatment with this and with flying blisters to the nape of the neck and the mastoid process, I commenced the use of the constant current daily (ten cells, Weiss). The first application (positive on nape, negative on infra-orbital foramen) stopped the pain, and procured fourteen hours' immunity. On the next day I reversed the current; the pain stopped after three minutes' galvanization; it did not recur for four days, during which time, however, I continued the daily use of the direct current. On the sixth day of treatment the patient came to me with a somewhat severe paroxysm, almost limited to the ophthalmic division; it was accompanied by spasmodic twitchings of the eyelid, and copious effusion of altered Meibomian secretion, looking like pus. Galvanization from supra-orbital foramen to nape stopped the pain in five minutes. The next day the patient presented himself, quite free from pain, which had not returned; the conjunctiva was clear, and there was no visible Meibomian secretion. Inverse galvanization was continued for ten days; but no recurrence of the pain took place. The cure was permanent three months later.

On the contrary, we sometimes see complete failure of the current to affect any good whatever; and in these cases the reversal of the current has not, so far, appeared to me to make any particular change in the result. Such was the case with a patient whose history I detailed (along with that of Case I.) to the Clinical Society. She was an ill-fed and overworked unmarried needle woman, aged thirty; the neuralgia was a most violent double occipital pain, with foci, on each side, where the great occipital nerves become superficial. The current was passed daily, for some days, from one focus to another (necessarily passing through the nerve-roots and the spinal cord), and the positions of the conductors were occasionally reversed; this not succeeding, the current was applied altogether to the spine, the negative pole being placed on the highest cervical vertebræ, but no good effect was produced after a treatment, altogether, of sixteen days.

Notwithstanding these, and a good many similar facts that could be adduced, I should hesitate to go so far as to say that there is never any importance in the direction of the current. In old-standing cases, where there are well-marked _points douloureux_ that are exceedingly sensitive, I have found that the application of the positive pole, successively, on the most tender points, the negative being placed on the spine opposite the point of origin of the nerve, has had a more beneficial effect than any other mode of application.

There are very considerable differences, both as to the best manner of galvanization, and also as to the chances of doing good with it, in the case of neuralgias of different nerves; and, on the whole, I find Eulenburg's conclusions on this matter very just. He indicates sciatica as the affection which is by far the most curable by the constant current; he says that many cases are cured in from three to five sittings, while others require as many weeks, or even months of treatment; and that a total absence of benefit is only seen in rare cases dependent on central causes, or on diseases which are irremovable (like malignant pelvic tumors). On the other hand, he reports that intercostal neuralgia has never been materially benefited by galvanization in his hands. With regard to ordinary trigeminal neuralgias, he speaks strongly of the current as a palliative, but very doubtfully of its power to cure, in genuine and severe cases. In cervico-brachial neuralgia he speaks of it as dividing with hypodermic morphia the whole field of useful treatment, in the majority of cases. In cervico-occipital neuralgia he says it rarely does much good. I shall return to Eulenburg's estimate of its utility in migraine, presently. Let me here say that I am inclined to indorse everything in the above-detailed statements, excepting that I should place a considerably higher estimate on the curative powers of the current in ordinary trigeminal neuralgias. The remedy, like every other, will doubtless fail in a considerable number of those very bad cases which occur in the degenerative period of life; but if anyone desires to see the proof of the power it sometimes exerts, even in extreme cases, he should study the two most remarkable cases treated by Prof. Niemeyer, of Tubingen, and reported by Dr. Wiesner.[44] The patients were respectively aged sixty-four and seventy-four, and the duration of the neuralgia had been respectively five and twenty-nine years; in both the pain was of the severest type, and in both the success was most striking. In one of them every possible variety of medication, and several distinct surgical operations for excision of portions of the affected nerve, had been quite vainly tried. The cases are altogether among the most interesting facts in therapeutics that have ever been recorded. Dr. Russell Reynolds has also told me of a case under his own care, in which a lady, who had been the victim, for twenty years, of an extremely severe neuralgia of the ophthalmic division of the fifth, which attacked her daily, and had caused great injury to her general health and nutrition, was not merely benefited, but the affection absolutely removed, at any rate for a long period, by a single application of the current. I have personally seen no such remarkable cases as these but I have had some extremely severe cases under my care in which the effect of the current was to arrest the pain in a few applications, and procure a remission for several days, or even weeks. And I have had several slighter cases which were as much cured, to all appearance, as any disease can be, by any remedy.

As a general rule, neuralgia of the limbs requires to be treated with a more powerful current than neuralgia of the face (twenty cells instead of ten). In the latter case, indeed, it is necessary to be exceedingly cautious (commencing with five cells), since a current of high power has been known to produce most serious effects upon the deeper-seated organs; the retina has been permanently paralyzed, by too strong a current applied on the face, and still graver dangers attend the incautious use of galvanization of the brain or of the sympathetic, of which we have now to speak.

Galvanization of the brain is a remedy chiefly employed in true migraine, and is certainly very effective in that disease. I have not found it useful to apply the current in the long axis of the cranium, but transmitted from one mastoid process to the other it has proved most useful; and I am glad to find that my experience on this point coincides with that of Eulenburg. But the use of this remedy is highly perilous in careless hands. In working with either Daniell's or Weiss's battery, it is necessary to use at first only three or four cells, and to increase the number only with the greatest caution. The sittings should never last more than half a minute; but the slightest giddiness should make us stop even sooner. On the other hand, the applications ought to be made daily, and usually twice a day. Ten cells (Daniell or Weiss) is the utmost that will ever be required, few patients will bear so much; and, apart from the possibility of more serious mischief, there is nothing which annoys and frightens patients more seriously than the sudden and intense vertigo which over-galvanization of the brain may induce.

Even more ticklish than the galvanization of the cerebral mass is galvanization of the sympathetic. I am not going to raise here the vexed question in physiological electricity as to the possibility of a galvanization the effects of which shall be accurately limited to the sympathetic. The fact is unquestionable, that very powerful and peculiar effects, utterly unprocurable in any other way, can be produced by placing one pole on the superior cervical ganglion (just behind and below the angle of the jaw) and the other on the manubrium sterni. This is a mode of galvanization which has been highly praised, more especially by Remak, and after him by Benedikt, but it has yielded rather disappointing results in neuralgia in my hands. Either I have not observed any distinct effect at all, or, if a current even a very little too strong were applied, I have repeatedly seen most uncomfortable, and sometimes very alarming, symptoms. I shall not easily forget a patient who applied at the Westminster Hospital, suffering from a severe form of facial neuralgia, and who was persuaded to come to my house and have his sympathetic galvanized. I used only twenty cells of Daniell, but the current had not been applied more than a few seconds when the patient fell on the floor, and remained in a state of half swoon for a considerable time. I allude to this and other less dangerous accidents that I have seen follow galvanization of the sympathetic, not with the view to prove that the method is useless in trigeminal neuralgia--I should certainly hesitate to say that, considering the large amount of respectable evidence in its favor--but I think that it is a procedure requiring the utmost caution, and meantime I have not personally found it nearly so useful as the methods already described.

There are sundry special applications of galvanism to particular forms of neuralgia which require a few words of notice. Of electrical treatment in regular angina pectoris I have had no experience; and in the one case of intercostal neuralgia, complicated with quasi-anginal attacks, in which I applied the constant current to the spine and the cardiac region, in the direction of the affected intercostal nerve, no effect was produced. I shall, however, mention the experience of Eulenburg, as he is a sober and dispassionate writer on the effects of electric treatment in general. He says he believes that in the proper use of the constant current we shall discover the chief, possibly the only direct, remedy for angina; and he describes the apparently favorable results he has already obtained in three or four cases. The current was from thirty cells; the positive pole was placed on the sternum (broad electrode), the negative on the lower cervical vertebræ. The alternative method which Eulenburg suggests, but has not, so far, put in practice, is direct galvanization of the sympathetic and vagus in the neck.

The application of the constant current in neuralgic affections of the larynx and pharynx is of most indisputable service; the experience of Tobold[45] upon this point is fully borne out by my own, as far as it goes. In many cases it will be sufficient to place the positive pole (from fifteen cells Weiss) on the pomum Adami, and the negative on the nape of the neck, and to keep up a continuous current for five or ten minutes daily; but in some cases the direct application of the current to the pharynx or larynx may be required; in such, a modification of Dr. Morell Kackenzie's laryngeal conductor will be found useful. [I shall have occasion, in Part II., to notice the superior action of Faradization in mere hysteric throat-pain, as distinguished from true neuralgia.]

Neuralgia of the testicle can be best treated, if galvanism be thought necessary, by immersing the whole scrotum in a basin of salt and water, in which the positive pole is placed: the negative pole is to be placed on the upper lumbar vertebræ; the current should be from fifteen cells Weiss, and the application should last continuously for ten minutes. In neuralgia of the urethra, I should be inclined to adopt a plan, mentioned to me by Dr. Buzzard, of attaching one conductor to an ordinary silver catheter introduced into the urethra, and placing the other pole upon the perinæum.

Neuralgia of the neck of the bladder I have found to be materially relieved by the constant current from twenty cells passed through from pubis to perinæum; the sittings being rather long. I have also, on one occasion, tried the introduction of a proper _porte-electricite_, insulated, except at the tip; but the result was not superior to that obtained in the other way.

As a general rule, it may be said that electricity, like other local measures which tend to concentrate the patient's attention on the parts, is only to be applied to the genital organs as a last resort. This is, of course, especially true in the neuralgias of these organs in women.

In concluding what will doubtless seem to some English readers an over-long and over-favorable estimate of the employment of galvanism in neuralgias, I must carefully guard myself against the supposition that I consider it a remedy to be applied in all cases, or likely to meet with uniform success, even in the forms of the disease to which it is most appropriate. It is a weapon which I seldom employ in the first instance, for many reasons; the principal of which is the costliness of the proceeding to the patient. Either the physician must personally administer the remedy, daily, often for a considerable period, or he must make the patient provide himself with an expensive battery; and in the latter case there is, after all, the unsatisfactory consideration that the application (even after the most careful directions have been given) will perhaps be unskilfully and inefficiently made. On the other hand, it is not desirable to delay the employment of galvanism too long, if other remedies have been fairly tried; and the practitioner will do well to remember the distinctions above laid down as to the varieties of neuralgia in which it is specially likely to prove decidedly and quickly beneficial. More especially in sciatica it would really, with our present knowledge, be a decided neglect of duty were we to allow the disease to run any considerable length without giving the constant current a thorough trial. [I can only briefly refer, here, to the novel mode of galvanization introduced by Dr. Radcliffe, and based upon his ingenious theory, according to which the true effects of the voltaic current upon nerve are the result of the charge of free electricity which it sets up, and not of the current directly. The reader will find the whole argument elaborately worked out in Dr. Radcliffe's recent work on "The Dynamics of Nerve and Muscle," Macmillan & Co., 1871. It will be enough to say, here, that the object to be attained, according to this view, is to replace the neuralgic nerve in its healthy physiological state, by charging it with free positive electricity. The manner in which this is done is as follows: In a case, _e. g._, of cervico-brachial neuralgia, we place the positive pole as near as may be to the central origin of the affected nerve; the negative pole is held in the hand of the same side, which is immersed in a basin of warm salt and water. In this same basin is another electrode, the wire from which is put in communication with the earth--most conveniently by putting it in contact with a gas-pipe. The patient, and the battery, ought properly to be insulated. The result of this arrangement is, that the free negative electricity is carried off by the earth-wire, and the limb remains charged with free positive electricity. I have had no sufficient experience of this method to give any opinion of its merits, but the inventor thinks it decidedly superior to the ordinary modes of applying the constant current.]

(_f_) The last kind of local remedies for neuralgia of which we have to speak are those by which we seek to mitigate the paroxysm by thoroughly excluding the air from the site of apparent pain. These are chiefly of value in those cases where a distinct inflammation (herpetic or erysipelatoid), or an unusual degree of sensitiveness on pressure, etc., has become developed around the superficial branches of the neuralgic nerve. Very much the best agent of this kind with which I am acquainted is the flexible collodion; in neuralgic herpes and erysipelas the effect of this application, conjoined with the hypodermic injection of morphia (preferably in the immediate neighborhood), is of the greatest possible service in mitigating the pain. In herpes it has this further special advantage, that it prevents the occurrence of sores after the vesicles fall, an accident which otherwise will sometimes happen, and which very much increases the severity and intractability of the consecutive neuralgic pain.

4. Lastly, we have to speak of prophylactic measures, which really ought never to be thought of as a separate matter, but always as an essential and most important part of the treatment of neuralgia. The prophylaxis of neuralgia is divisible into (_a_) measures for preventing the development of the neuralgic habit in those who may be supposed to have a predisposition to it; (_b_) measures between the paroxysms; (_c_) measures to be adopted after the attacks have ceased.

(_a_) The measures that should be taken to avert neuralgia, in those who may be reasonably assumed to be predisposed to it, have scarcely received any consideration at the hands of systematic writers; yet this is a most important subject. The persons in question are children who belong to families known to be infected with tendencies to neurotic diseases, or persons whose daily occupations submit them to peculiarly strong predisposing influences of an external kind. The hostile influences that should be avoided, or at any rate compensated, are of several kinds: (1) Psychical; (2) defects of nutrition; (3) mismanagement of the muscular system; (4) sexual irregularities; (5) over-fatigue of the special senses, and insufficiency of sleep, especially the latter; (6) unhealthy atmosphere and climate.

(1) The psychical influences which must be especially avoided, if we would avert the formation of the neuralgic habit, form a large and somewhat indefinite group, which it is doubtless difficult to deal with satisfactorily. The matter is, however, highly important, and the attempt must be made. And there are, at any rate, some leading principles that I feel justified in laying down with confidence.

We shall best commence the inquiry by directing our attention once more to the fact, so often insisted upon in this work, that the large majority of neuralgic patients carry in them the seeds of their malady from their birth. It has been amply proved that every child born of a family that has shown strong tendencies to insanity, epilepsy, paralysis, etc., etc., ought to be looked on as a neurotic subject, and as a potential sufferer from neuralgia. It has been shown that such children will be exposed, even under favoring external circumstances, to the danger of neuralgia at certain important stages of their physiological history. The earliest of these critical periods is marked by the occurrence of puberty; and it is not till this time that psychical influences, as such, come to have any serious bearing on the formation of the neuralgic habit. Mischief may, indeed, be done to the brain and the general nervous system, by injudicious mental training, at a far earlier period; but this mischief, serious or even fatal as it may be, usually takes some other form than that of neuralgia. It will be necessary, here, to reflect a little upon certain features of the childish mind, in order that we may rightly estimate the kind of influence which puberty exerts upon it.

A very young child is selfish, in the purely animal sense; it is greedily acquisitive, and its selfishness is unchecked by any sense of shame. With later childhood there comes a sense of right and wrong, and a sensitiveness to shame, which check this tendency; still it is the exception rather than the rule to find any great capacity of self-abnegation in young school-boys. But a moderately healthy-minded child, up to the age of puberty, is only acquisitively selfish; he is not self-centered in the sense of dwelling upon his own mental state, and reflecting upon the nature of his motives and feelings. It is with the age of puberty that self-consciousness begins to be a feature in the mind of the young, and its appearance marks the entrance of a dangerous element into the character. It is an inevitable stage in mental growth, and, if wisely dealt with, is ultimately productive, not of evil, but of good; but it is more perilous to some children than to others, and it is especially fraught with danger to those whose nervous centres are, by inheritance, weak and unstable in whole or in parts. The mental antidote to its possible evil effects is to be found in a vigorous (but not excessive) training of the mind in studies which shall be as far as possible external, and the discouragement of all tendencies to introspection. I would venture to express the decided opinion that the common idea, that close study injures the young, is only true in a modified sense. It is, however, unquestionably the fact, that hasty and imperfect cram-work does very seriously impair the stability of the brain and the nervous system in young people; there is a spurious excitement about this kind of learning (especially when it is mainly competitive, and directed to the gaining of prizes and medals) which must be injurious. But I think it is quite ridiculous to suppose that, in this country, the actual amount of intellectual labor undergone by boys and girls at school is sufficient to do harm, were it only regular and systematic, and carried out in a conscientious manner; on the contrary, though I think that the total daily period occupied in study ought not to exceed some six or seven hours, I believe that the insisting on strenuous diligence during school hours, and the maintenance of a high standard as to the quality of the work exacted, is all on the side of nervous health. But, an even more serious and difficult matter than the regulation of the amount of intellectual work to be done is, the question how we are to deal with the unfolding emotional instincts of the boy or girl who has reached the age of puberty. It is useless to ignore this side of the mental life; it will assert itself either for good or for evil. At the risk of seeming to meddle with matters that belong to the school-master rather than to the physician, I would urge very strongly that a portion of the training be deliberately directed to a serious study of one or other of the fine arts--to that one, whether poetry, painting, sculpture, or music, to which the boy or the girl instinctively leans. I am aware that there is a prejudice among parents that the study of the fine arts renders young people idle and indifferent to other branches of education and other duties of life. I believe that this only applies to the miserably inefficient way of teaching these subjects which prevails at present in all but a few English schools; and that, in truth, a thorough knowledge of the principles of either music or painting, and a real study of the best masters, would be sure to prevent the development of that lazy, conceited manner, and that neglect of other duties, which no doubt unfavorably distinguish a good many of the young ladies and gentlemen who dabble a little in music, or painting, or versification. We want the German rather than the English type of training, we want the acquirement of sound knowledge of the principles of music (at any rate) to be made so common that the accidental possession of two pennyworth of superficial accomplishment in that line shall not enable young ladies and gentlemen to give themselves airs in society. The truth is, that the young people who make music or painting an excuse for idleness respecting other matters are invariably imposters even in that which is their own supposed _forte_. On the other hand, the serious study of art, a certain definite portion of time being set apart for it, and thoroughness being insisted upon, is, I believe, an admirable vent for the emotional effervescence of commencing sexual life; and I no less firmly believe that the things that are usually substituted for it are intensely pernicious. I have already, in the chapter on Pathology, remarked on the mischief which is often done by the anxiety of religious parents to make their children (usually somewhere about this perilous time of puberty) experience the emotional struggle which is believed to end in a change of heart and principles. I need, therefore, only now repeat the expression of my intense conviction that the results of this process, as seen by the physician to occur within that mental region where the emotions and the organic nervous system come into closest relations, are simply disastrous. It is not my business to suggest the proper alternative to a mode of spiritual training which I think deleterious; I can only intimate, in the most general way, my belief that a calm and systematic training in the simplest principles of duty and religion is greatly more suitable to the immature mind and brain of youth than any strong emotional excitement on such topics. But if ill-regulated spiritual emotion of a religious kind be a dangerous thing for young persons in the most serious crisis of bodily development, far more decidedly pernicious is the spurious excitement of feeling which is directed to lower and often most unworthy objects. The increasing precocity of boys and girls, in their familiarity with the most objectionable aspects of passion and intrigue, is steadily fed, in the present day, by a system that allows them, too often, unlimited access to light literature which (as is strikingly the case with many novels of our day) is at once devoid of true literary and artistic merit and at the same time replete with sensational incident of a vulgarly exciting kind. The same degrading tendency is very distinctly to be noted in the character of the dramatic and other public exhibitions which are most popular at the present day; the main characteristics being, bad art, and thinly-veiled sensuality, all the more pernicious for being veiled at all. It would be a hundred times better that a boy, or even a girl, should study the frank and outspoken descriptions to be found in Shakespeare or Fielding, with all their occasional coarseness, than that they should enervate their minds with the sickly trash that is most current and most popular at the present day, in theatre and circulating library.

(2) The defects of nutrition that assist the development of the neuralgic tendency are often the consequence of a system which, it is to be hoped, is to a large extent becoming effete, but which, nevertheless, survives in sufficient vigor and extent to demand express reprobation. It was till lately the general, and it is still a too common practice, to keep children and young persons on a very insufficient allowance of the most important elements of food; the state of things in this respect, both in public and private schools, in the first half of the present century, is a lasting reproach to the medical practitioners of those days, who scarcely lifted a finger to amend it, even when they did not expressly approve it, under the influence of absurd theories about the dangers of excessive "grossness of blood." It is indeed amazing that, with the palpable fact staring them in the face, of the rapid and incessant additions to tissues which are being made by children and young people, medical men should have failed to perceive the necessity for supplies of food practically unlimited except by the capacity of digestion. Yet this seems hardly ever to have been thought of, and the unfortunate results seem scarcely to have been noticed, except when they led to emaciation or consumptive disease. But the effects were perhaps even more disastrous where, with a maintenance of a fair amount of muscular nutrition, there was only a little dyspepsia, and perhaps some slight tendency to nervousness, to show that anything was wrong. The children who were born of strong and healthy parents, may have suffered comparatively little from this regimen as regards their nervous system, but those who were born of neurotic ancestors undoubtedly suffered extensively. The crisis of puberty was, in such ill-nourished children, too frequently the signal for an explosion of epilepsy, chorea, or neuralgia; and too often the mischief was yet further increased by a most injudicious medical treatment, including a deterioration rather than an improvement in the already insufficient dietary system. At the present day, however, we may fairly hope that common sense is prevailing, so as to put an end to this mischief as regards the children of the upper and middle classes. Unfortunately, with the poor a similar ill-nourishment of the young is too often inevitable, and the consequences are constantly to be traced in enfeeblement of the nervous system, of which neuralgia is a pretty common result.

It cannot be too frequently repeated that for those children, more especially those who come of nervous families, any considerable error in this direction has a fatal tendency to awaken the disposition to nervous disease. At every step of the infancy, childhood, and youth of such persons, the most generous allowance of the more nutritive elements of food is of the first importance. At the same time I am entirely opposed to the practice of giving stimulants to any considerable extent, or indeed to any extent, save in exceptional instances. Good meat, bread, milk, butter, fruit, and vegetables, are really the efficacious means of fortifying the nervous system against the impending dangers. With hospital out-patients, for whom we cannot command such diet, our best course, whenever they show signs of deficient nutrition, will be the steady administration of cod-liver oil for a long period.

(3) The true and proper training of the muscular system is among the most important means of antagonizing the tendency to the development of the neuralgic habit. It is a great mistake to suppose that over-training in athletics of any kind is of use; but the systematic employment of means which tend to make the muscular system hardy and efficient is of very great benefit. The parents of children who may be supposed by inheritance to possess a tendency to neuralgia would do well to study such a methodical series of directions as those which are given by Mr. Maclaren, in his excellent work on physical training. I suspect that the benefit of judicious gymnastics is wrought in two ways: first, by its improving circulation and general nutrition, including the nutrition of the nervous centres; and, secondly, that it gives the nervous centres an education, so to speak, by the variety of difficult co-ordinative movements over which it trains those centres to preside. But unquestionably the matter is a science, not a mere rude art, and requires to be studied as such.

(4) Of unspeakable importance to the object of averting the formation of the neuralgic habit is the prevention of sexual irregularities in the young. Under this heading is included a large and various group of influences; of these the first that requires notice is the prevention of precocious sexual stimulation, whether by talk or by acts, which may precipitate the occurrence of puberty at an unnaturally early age. I know very well how difficult it is to devise any scheme which really would effectively control and antagonize the worst mischief of schools; but it is at least a duty to say here, that no experienced physician can doubt that such a scheme must be found, if we are ever to hope for a healthier race of children and of young men and women, and if we are to break down one of the most potent of the influences that go to the production and maintenance of the neurotic disposition. I would be clearly understood not to suppose for a moment, either that this sort of cause is usually at work in the production of neuralgia in the young, or that of itself it is sufficient to produce the disease; but I would say, for certain, that on children of nervous families such influences act with disastrous energy; and, moreover, that where we see signs, in a neuralgic young person, of that general form of bad health which is connected with precocious puberty, we may be nearly certain that such influences have actually been at work. At all cost, and by all conceivable means, all children, but most especially the delicate and nervous ones, ought to be shielded from the risk of this occurring.

Another form of sexual irregularity which can be counted as a contributor to the formation of the neuralgic habit is menstrual irregularity, especially at the commencement of sexual life. By far the most mischievous in this way is menorrhagia of the young. I have seen exceedingly severe and intractable neuralgia set up by it. As regards the influence of simple amenorrhoea, I am by no means clear: it seems pretty nearly as likely that the deficient excretion (when not dependent on mechanical cause) is a mere sign of the general weakness which also predisposes to the neuralgia, as that the neuralgia is in any way the direct consequence of the amenorrhoea.

Leucorrhoea, especially when profuse and long-continued, is a much more indisputable factor in many neuralgias. It is a point of real importance to put an end promptly to such a discharge, if it exists, and the usual remedies--cold bathing, mild astringent injections, etc.--should be at once prescribed.

Dysmenorrhoea, a painful menstruation, when not dependent on a purely mechanical cause, affords a strong example of neuralgia connected with sexual difficulty; but there is every reason to think that the neuralgia is the primary and not the secondary affection. The only effective prophylaxis, therefore, is the adoption of such general measures as will raise the whole tone of nervous health. It often happens that marriage completely cures the tendency to these attacks.

(5) Insufficiency and irregularity as to the allowance of sleep are potent influences in developing neuralgia in those who are hereditarily predisposed. It is needless to say a single word to prove the imperative need of the young for periodical and prolonged repose from the conscious actions of the nervous system. Full ten hours of sleep in the twenty-four, for boys and girls who are at or near the period of puberty, is an absolute necessity if we would prevent any existing irritability of the nervous system from developing into the fully-formed neurotic temperament. Indeed, I believe that, for all young people (but especially girls) up to the age of twenty-five, this allowance is not the least beyond what is necessary: only the need is most pressing at, and just before, the development of the sexual organs. Of course a much larger allowance of sleep is necessary in actual infancy: from seven to twelve we may be content if we get nine hours clear sleep; but during the two or three years preceding puberty we should insist upon ten hours, at any rate for children who possess the nervous temperament.

(6) Impurity of the atmosphere in which they habitually or daily reside must be carefully shunned for young children, especially for the nervous. The kind of dull and diffused headache which children often complain of, after study for some time in a close, ill-ventilated school-room, is very likely (if the bad influence be continued for a number of years) to develop itself, at puberty, into a regular migraine. Purity of air in the school-room must therefore be scrupulously provided for; and the same thing must be attended to as regards the sleeping rooms.

Of the climatic influences we may speak in a few words. Besides the avoidance of distinctly malarial districts, and also of places where, although there is no distinct ague, there is a prevalence of neuralgic or even of so-called "rheumatic" complaints, it is necessary very carefully to shun damp soils, and places where there is a great deal of harsh and cold wind. Mere lowness of average temperature is not in itself a strong predisposer to neuralgia, at any rate if guarded against by abundant food and the use of such clothes as will prevent children from ever feeling chilly and depressed. But damp and harsh winds are actively bad; and when joined to habitual or frequent lowness of temperature, they constitute very unfavorable surroundings for the nervous systems of delicate children.

(_b_) We come now to the prophylaxis which is to be adopted in the intervals of the paroxysms when neuralgia has been actually set up. This consists essentially in three things: (1) Physiological rest, as perfect as possible, of the affected parts; (2) protection from cold; (3) protection from sunlight; (4) avoidance of injurious mental emotions.

(1) The maintenance of physiological rest, to the greatest extent that is possible, is an absolute necessity, if we would shield a nerve, which has lately been attacked with neuralgia, from fresh paroxysms. The most evident illustrations of this fact are afforded by those neuralgic affections in which it is most difficult to adopt this precaution. Thus the greatest embarrassment from this cause is met with in the case of sciatica; a mild case is often converted into one of great severity and intractability because the patient, in the early stages, either cannot or will not maintain the recumbent posture. So, too, though in less marked degree, the cure of cervico-brachial neuralgia is often greatly impeded by the difficulty of maintaining complete rest of the limb. Again, in neuralgia affecting the third division of the fifth, the movements of mastication and of speech are a terrible hinderance to the progress of recovery; and it often becomes necessary, in severe cases, to prescribe absolute silence, and even to feed the patient exclusively with such liquid or semi-liquid food as shall require no efforts of chewing.

(2) Preservation from external cold is highly important. When a nerve of the arm, or leg, or trunk, is affected, warm flannel under-clothing ought immediately to be adopted. The patient who has been suffering from cervico-occipital neuralgia should for some time, in anything but quite summer weather, never go out without wearing a warm comforter round the neck. The sufferer from facial neuralgia should for some time after the cessation of actual attacks never face wind without wearing a thick veil.

(3) Exposure to bright light must be scrupulously avoided by sufferers from ophthalmic neuralgia. The affection known as "snow-blindness" is really a neuralgia, with vaso-motor complications, produced by the glare of light reflected from snow; and one of the severest attacks of neuralgia which I personally ever experienced was provoked in this way. Even the comparatively slighter, but for an Englishman unusual, glare of sunlight which one meets with during the first days of a Continental holiday, in wandering about towns made up of clean white stone or whitewashed houses, is enough to provoke an attack, unless the eyes are carefully guarded with colored glasses.

(4) It is scarcely necessary, after what has been already said, to insist upon the absolute necessity of mental quietude, as far as this can be obtained. This precaution is more or less important in all neuralgic affections; but in migraine and in other trigeminal neuralgias it is almost of more consequence than any other prophylactic measure; and in angina pectoris it is so essential that adoption or neglect of it may easily turn the scale between life and death. All forms of abdominal visceral neuralgia, also, are greatly affected by emotion, and passion or strong excitement of any kind must be scrupulously shunned if the neuralgic habit is to be broken through. Unfortunately, it too often happens that the mental surroundings of the patient cannot be so changed as to enable us to carry out this kind of prophylaxis effectually; and neuralgic cases of this class are among the severest trials of the physician's tact and skill, and too frequently defy his efforts.

(_c_) The precautionary measures which are to be adopted, after the neuralgic habit has apparently been fairly broken through, in order to prevent the patient from sliding again into the old vicious groove, can hardly be defined with exactness though their general character will be readily gathered from the picture of the clinical history and pathology of the disease which has been exhibited at large in this work. They mainly consist in the avoidance of severe, and especially of unequal, strains upon bodily or mental powers; and in redoubled carefulness in these respects at those natural crises in the life of the organism which have been shown to exercise so important an influence upon the neuralgic tendency. To a certain extent, also, but with much precaution, we may attempt to modify the peripheral sensibility by what is commonly called a hardening regimen. Thus, with great care, and proceeding in a very gradual manner, we may by degrees accustom the patient to a larger amount of exposure to free air, and even at last to rough weather, so that in the end he may become less sensitive to some of the commonest immediately exciting causes of neuralgia. If one were to construct an advancing scale of such measures, one might arrange them something like this: First, in-door gymnastics, and gentle horse-exercise for out-door work, in fine weather only; then horse-exercise alternated with pedestrianism, sea-bathing in warm weather; and, finally, we should try to reach a stage at which the patient can well endure a ten or fifteen miles' walk or ride every day, and be comparatively careless about the weather. In reaching this latter stage I have seen some patients helped, in an extraordinary degree, by the frequent use of the Turkish bath, followed by douche. Upon this latter subject I beg to offer some remarks, which are the result of pretty careful and extensive study of the effects of the Turkish bath in a variety of chronic nervous diseases. I believe it to be a very great mistake to suppose that, either in rheumatism or in true neuralgia, the process of the bath should be prolonged to such an extent as is commonly done. Instead of the usual slow heating process, gradually carried to a point at which excessive sweating occurs, I believe that the really scientific is the following: The patient should as quickly as possible get into the hottest atmosphere he intends to expose himself to, which should never be more than about 170° Fahr. He should stay in this place just long enough to get thoroughly hot, and, with the assistance of a glass or so of water drunk, throw himself into a free but gentle perspiration. He should then be rapidly shampooed, exposed to the spinal douche for two or three minutes, and then pass to the cooling-room. Let him beware of too long dawdling in the latter place, and let him avoid smoking there. It is a positively dangerous thing to cool one's self quite down to the normal heat, still more so to induce the slightest chilliness; the body should be still in a universal glow when one issues into the street. Over and over again I have proved upon myself that it is the beneficial method, whereas the prolonged use of the bath, the production of very copious sweating, and above all a lengthened cooling process, most seriously exhaust the nervous energy.

There are certain special considerations as to the habits of life that require a word or two. I need say nothing more to enforce the views already put forward as to the necessity of copious supplies of food. I need only refer to what I have already said about the decidedly mischievous tendency of anything like habitual excess in the use of alcohol, merely adding a special caution against such indulgence during, and particularly toward, the end of the period of sexual activity. There is one more topic upon which something must be said, namely, the extent to which sexual intercourse should be allowed. Speaking of neuralgia generally (excluding neuralgic affections of the sexual organs themselves), it may decidedly be said that the regular and moderate exercise of the function, during the natural period of sexual life, is beneficial; but that excess is always dangerous, and that the continuance of sexual intercourse, after the powers naturally begin to wane, is extremely pernicious in its tendency to revive latent tendencies to neuralgia. As regards neuralgias of the sexual organs, it is very difficult to speak positively; and yet I believe that (once the neuralgic habit broken through by other means) it is very desirable that the patient should live according to the laws of normal physiological life.

NOTE I.

ADDITIONAL FACTS BEARING ON THE QUESTION OF NEUROTIC INHERITANCE.

The following cases must be now added to those recorded in my list of private patients whose family history has been ascertained with reliable accuracy.

CASE I. is that of a gentleman, aged forty-seven, the subject of lumbo-abdominal neuralgia: no history of nervous disease in the family; his mother, however, was of a "nervous" temperament.

CASE II.--A gentleman, aged sixty-four, suffering from angina. His family nervous history is fearful. On the father's side it is not possible to get a clear account. But on the maternal side there has been a strong tendency to insanity and suicide; and in the patient's own generation one brother committed suicide from insanity, and one sister is still alive, insane. An interesting fact is, that the mother's family have shown an extraordinary proclivity to erysipelas.

CASE III.--The young gentleman, whose single but extremely severe attack of angina is previously described, comes of a family in whom the tendency to neuralgia is undoubtedly very strongly inherited. His father is frequently and very severely _migraineux_, and in early life suffered cardiac symptoms not unlike his son's. A brother was also liable to attacks of true migraine between puberty and the age of twenty-one.

CASE IV.--On the other hand, a case of angina which I saw in the country, last year, occurred in a gentleman, aged fifty, whose family presented no traceable neurotic history. But the damage inflicted upon his nervous system by various external influences was quite extraordinary. In some way or other he got some attacks of migraine at the age of fifteen or sixteen; for these he was treated with bleeding, and with a most savage antiphlogisticism generally. From that time he never got free of the neuralgic tendency. He used to have not only facial, but intercostal neuralgia; for this last he was repeatedly bled, under the idea that it was pleurisy. Added to all this he habitually did an immense deal of brain-work in his study, and for years had performed clerical duties of the most exacting and exhausting character. It is not much wonder that these combined circumstances had sufficed to generate the neurotic temperament.

NOTE II.

THE INHIBITION THEORIES OF HANDFIELD JONES AND JACCOUD.

In the present transitional state of opinion concerning the mode in which the phenomena are produced that are popularly known under the name of "reflex paralysis," I cannot pass without notice the doctrines of these two observers. The reader will have perceived that, as regards the secondary paralytic symptoms observed in neuralgias, I explain the phenomena mainly on the theory of a process which is central, and not peripheral, in origin. And, even where, as in some few instances, it seems possible that the starting-point was an organic affection of some viscus, we must always consider the possibility that the link between this and the neuralgia and paralyses was a neuritis migrans travelling inward to the sensory centre, and from that passing over to motor centres and thus producing paralysis; or that, without the intervention of any truly inflammatory process, the continual impressions streaming in upon the cord from the original seat of organic disease may damage the nutrition of the sensory nerve-root, producing a partial atrophy, and that this process may extend to the motor root.

It remains, however, to inquire whether the influence of powerful peripheral agencies may not, in a purely "functional" manner, disable the nerve-centres for a time, causing paralysis with or without neuralgia. The main supporters of such a doctrine are Dr. Handfield Jones[46] and M. Jaccoud.[47]

Dr. Handfield Jones expressly rejects the theory of Brown-Sequard, as to spasm of the vessels in the nerve-centres, and we need not repeat his arguments on that head, because it seems to be generally felt that the vascular spasm theory will not account for the facts. Jones believes that the state produced in the nerve-centre by the peripheral influence is one of paresis from shock-depression, and that from the sensory centre this state can communicate itself to motor and vaso-motor centres, though commissural fibres. He does not believe in the existence of a special inhibitory portion of the nervous system: he believes that an impression may prove stimulating when it is mild, or paralyzing when it is strong; and that any afferent nerve may convey either the one influence or the other to the centres and thus produce secondary stimulus or secondary paralyses in various efferent nerves. Jones has the distinguished merit of being one of the first authors distinctly to perceive that pain must rank on the same level with paralysis: hence he sees nothing unintelligible in the communication of paralysis to a motor centre from a sensory centre that was in the state which the mind interprets as pain.

The _theorie d'epuisement_ of Jaccoud (Erschopfungs-theoric) also denies the possibility of Brown-Sequard's idea of prolonged spasm of the vessels of the centres. It imagines that powerful peripheral excitements exhaust the irritability of the nerve, and through that of the centres, and induce a state of unimpressibility--analogous to that which exists in a nerve or nerve-centre, which is included in the circuit of a constant current. The nervous force is wasted, and, until an opportunity of repose is afforded to the centre, the faculty of impressibility cannot again revive.

I must say that of these two theories I decidedly incline to that of Handfield Jones (though I imagine that in reality the cases are extremely rare, if there be any, in which the change in the centres is really only functional and non-organic), I prefer the idea of paralyzing shock to that of exhaustion from over-excitement, from a consideration of the nature of that form of peripheral influence which has been specially mentioned by authors as competent to produce this sort of "reflex" affections, namely, intense and persistent cold. It seems to me a mere abuse of words to speak of this as an agent that could exhaust the nerve by over-stimulation; it must surely exhaust it in a much more direct manner than this, namely by the direct physical agency of withdrawing heat from the nerve, and spoiling its physical texture, _pro tanto_. If such an effect as that which must thus be produced on the nerve, and through it on the centre, is to be looked on as a case of over-stimulated function, then, it seems to me, there is no meaning in language, and no possibility of attaining to clear ideas on the subject of nervous influence.

NOTE III.

ARSENICAL TREATMENT OF VISCERALGIÆ.

Since writing the above chapter on the Treatment of Neuralgia, I have had two fresh and very striking examples, in private practice, of the power of arsenic to break the morbid chain of nervous actions in angina pectoris.

The first example was that of a medical man, aged seventy-five, in whom a neuralgia, originally malarial in origin, and of some years' duration, had fixed itself for some time in the fifth and sixth left intercostal spaces, and of late had become complicated with anginoid attacks of an unmistakable character, though not of the highest degree of severity. The case certainly seemed very unpromising, looking at the patient's age and the consequent high probability that there was much arterial degeneration. However, the use of Fowler's solution (five minims three times a day) was commenced and steadily pushed. The anginoid attacks rapidly diminished in frequency and at the end of ten days' time were entirely gone, and after one month of treatment he still had no return of them, although they had previously been of daily occurrence. It is a curious fact, whether a mere coincidence or not I cannot say, that, some few days after the anginoid attacks ceased, he began to experience somewhat severe pains, rheumatic in feeling, but unattended with heat or swelling, in the elbows, wrists, and fingers, symmetrically. This has nearly disappeared, but he is still free from angina. There is no discoverable heart-lesion in this patient.

The other case was that of a fine old man of sixty-four, who, but for some few slight attacks of gout, a few small calculi, and a troublesome prostatic affection, had always enjoyed remarkably good health, until about five months ago, when he began to notice tightness across the chest, etc., when he walked uphill. About a fortnight before he came to me, he was seized with very violent and alarming paroxysms of pain across the chest and running down both arms, extreme intermittence of pulse, and a sense of impending dissolution. The attack had recurred daily, at the same hour (6 P. M.), ever since; besides which there was an abiding sense of uneasiness in the cardiac region, and a consciousness that the least excitement or exertion would bring on the paroxysm. I put the patient on five minims of Fowler, three times a day, with directions to take ether when the paroxysms came. At the end of the first week there was already much improvement, the paroxysms having been both less frequent and less severe. At the end of a fortnight's treatment he reported that there had been nothing like a paroxysm for the last eight days, although there was still a good deal of uneasiness from time to time. The hour at which the attack was expected passed by absolutely without a trace of angina. It remains to be seen how long this improvement will last, but the altered state of things, and particularly the suddenness of the change, cannot be overlooked, and has very much struck the patient himself. It is now six weeks since he had any paroxysm.

It becomes more and more apparent that arsenic is generally applicable to neuroses of the vagus. In asthma, I have long held it to be the most powerful prophylactic tonic that we possess. It is also an excellent remedy in gastralgia; although I have rather dwelt (in the text of this work) on the action of strychnia in this disease, I would not omit my testimony to arsenic. Dr. Leared has related some exceedingly interesting cases bearing on this point. (See _British Medical Journal_, November 23 and 30, 1867.)

NOTE IV.

INFLUENCE OF GALVANISM ON CUTANEOUS PIGMENT.

Dr. Reynolds pointed out to me the exceedingly curious fact, which I have several times verified, that the constant current, in relieving facial neuralgia, not unfrequently disperses, almost instantaneously, the brown skin-pigment that has collected in the painful region; _e. g._, near the orbit.

NOTE V.

THE ACTUAL CAUTERY.

A remedy for inveterate neuralgia which of late years I had almost discarded--the actual cautery--has quite recently yielded me very good palliative results in two cases. Its omission from the text of the chapter on Treatment was an accident due to the effect of habit in making one, half unconsciously, reckon this remedy as a "counter-irritant." The longer I practise, however, the more decidedly I am convinced that the actual cautery, if properly applied, does not act as an irritant at all; and this fact was sufficiently in my mind, when writing of irritant remedies, to make me omit the cautery from that section. I should have inserted it under the heading of remedies that interrupt the conductivity of nerves, and thus give the centres temporary rest. The only useful way to apply it is, to make an iron white hot, and very lightly brush the skin over so as to make an eschar not followed by suppuration. The galvano-cautery (Stohrer's Bunsen) is the best for the purpose, but I have made the flat-iron cautery serve very well.

FOOTNOTES:

[35] Art. "Neuralgia" ("Reynolds's System of Medicine," vol. ii. 1868.)

[36] Practitioner, vol. iv., 1870.

[37] Berlin. klin. Wochensch., 1865.

[38] In a paper on the "Hypodermic Use of Remedies," in the _Practitioner_ of July, 1868, I gave the reasons for this opinion in full; and I see no reason to alter any thing I then said.

[39] Practitioner, vol. iv.

[40] Berlin. klin. Wochensch., 17, 1868.

[41] "System of Medicine," vol. ii.

[42] The English reader may consult Althaus ("A Treatise on Medical Electricity," second edition, Longmans), or Meyer ("Medical Electricity," translated by Hammond: Trubner & Co.)

[43] "A Treatise on Medical Electricity," second edition, Longmans.

[44] _Op. cit._

[45] Berlin. klin. Wochensch., 22, 1865.

[46] _Op. cit._

[47] "Les Paraplegies et l'Ataxie du Mouvement." Par S. Jaccoud. Paris, 1864.