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NEURALGIA
ITS
HISTORY, NATURE, AND TREATMENT.
           BY

CHARLES W. PARSONS, M.D.,
      OF PROVIDENCE, RHODE ISLAND.
THE DISSERTATION
TO WHICH THE
FISKE FUND PRIZE WAS AWARDED
Published by Request of the Rhode Island Medical Society,
       PHILADELPHIA:
T. K. AND P. G. COLLINS, PRINTERS.
            1854. 
k 
PEIZE ESSAY.
HISTORY, NATURE, AND TREATMENT
NEURALGIA. 
 
NEURALGIA,
ITS
HISTORY, NATURE, AND  TREATMENT.
            BY

CHARLES W. PARSONS, M.D.,
      OF PROVIDENCE, RHODE ISLAND.
         THE DISSERTATION
              10 WHICH THE

FISKE FUND PRIZE WAS AWARDED.

               VeT'lOST


    Published by Request of the Rhode Island Medical Society.
        PHILADELPHIA:
T. K. AND P. G. COLLINS, PRINTERS.
             1854. 
dicarSocTett  h.H  ?t° pFlsk.e/und> Ta* the annual meeting of the Rhode Island Me-
fiftvrl.iw7'*heI,duat P«>^ence, June 7, 1854, announced that the premium of
fifty dollars offered by them in 1853, for the best dissertation on Neuralgia  taKUtorv

Zfmolto?  °ftreatmmt> had been ™arded t0 th* author of the dissertation bearing
" What is writ is writ,
 Would it were worthier!"
Joseph Mauran, M. D., ")
Sylvanus Clapp, M. D., I Trustees.
            u, M. D.,   J
                                     Joseph Mauran, M. D.,
                                     Sylvanus Clai
»_„  .        „                      Ariel Ballou,
Aug. Arnold, Secretary. 
NEURALGIA.
    The writer cannot suppose that a detailed description of the symptoms or
 varieties of locality of neuralgia  is expected in this Essay.   It is believed
 that the objects for which this generous foundation was established, and is
 now administered, will be  best consulted by brevity, and a strictly practical
 aim in the choice of topics'.   We  shall, therefore, confine ourselves to the fol-
 lowing subjects:—

      I.  The General Topography  of Neuralgia.
    II.  Its Causes.
    III.  Its " Nature," or Pathology.
    IV.  Its Treatment.

   I.  By general topography we mean an  account of the  kinds of nerves, or
 divisions of the nervous system  in which neuralgia exists; and  also some
 general statements as to the situations iu the course of any nerves, which are
 its ordinary seats and centres of radiation.  We do not mean to include a list
 of all the individual nerves that are sometimes attacked.
   Neuralgia is best known as  occurring in the cerebro-spinal nerves.  Does
 it ever attack those of  the  ganglionic or  sympathetic system ?  Experiment
 has proved  that mechanical irritation of these nerves does not elicit signs of
 pain  till after a  time,  when congestion or vascular excitement is  produced,
 and then acute  pain is caused by such  irritation.1  We might expect then
 that other irritating causes, such as poisons circulating in  the blood, or some
 derangement of different functions, might produce an analogous sensitiveness
 in the nerves of the sympathetic system.  And such is the fact.   The analogy
 of many painful  visceral affections  to external neuralgia is as complete as the
 nature  of the case admits; though the sensations cannot be  described so de-
 finitely, because the nervous fibres have not so direct and continuous a relation

  1 Brachet,  Eecherches  Experimentales  sur les fonctions du Systeme Nerveux
Ganglionaire.  Paris, 1837.
       2 
6
with the sensorium as the cerebro-spinal nerves have.  These affections, gas-
tralgia, nephralgia, Sec, are not  necessarily or  usually  connected with any
change of structure.   In angina pectoris, one of this class, ossification of the
coronary arteries, fatty degeneration of the  heart, and  other organic altera-
tions  have been found, but by no means uniformly; they are not, so far as we
now know, essential  parts of the disease.   The attacks  of  these " visceral
neuralgiae" are generally marked by little constitutional  disturbance, in pro-
portion to their severity.  They are paroxysmal, and often the fits arise without
any obvious exciting  cause.   Though very obstinate, they sometimes subside
suddenly, we know not why, and their long continuance does not always seri-
ously affect the general health,  except by the mere amount of suffering.  They
occasionally alternate  with external neuralgia.  If  the attacks of those which
occupy glandular  organs sometimes end in a  sudden flow of  secretion, the
same is common also  in the analogous affection of  the fifth pair.1  It is true
that there is  generally some functional derangement accompanying the pain,
and, of course,  the distinct character of  these  internal neuralgia),  as  pure
nerve-pains, is not so  perfectly  marked, nor so  uncomplicated, as in  pains of
the superficial nerves.
  How far the acquired sensitiveness of ganglionic nerves depends  on their
connections with the cerebro-spinal system, is a question properly of physiology,
which  we will waive.
  Among cerebro-spinal nerves, the  most superficial ones  are said to be  the
most  common  seats of well-marked neuralgia.  But to this  there are many
exceptions.   Nerves which  plunge into the thickness of dense organs have
their  branches closely interwoven with the  tissues around, so that  the sen-
sorium  can  only distinguish a  diffused  pain.   Such affections as neuralgia of
bone and of the testis (when the spermatic cord is not involved), are called
neuralgic, because pain is  altogether out  of proportion  to the slight and in-
constant anatomical changes. But in the superficial nerves, pain can be tracked
along  the nervous trunks, so that a patient can study their  anatomy on his
own person.   Facial, dorso-intercostal, and  sciatic neuralgia  are  believed to
be the most common  forms.
  But certain points  appear to be the peculiar and favourite rallying  points,
or foci, of this disease.  This part of its history  has been particularly investi-
gated by Valleix,2 and his observations are among  the most interesting addi-
tions  recently made to our knowledge of this affection.   The " focal points"
of external neuralgia are generally in the following situations:—
  1.  The place of  emergence of a nervous trunk, as at the supra-orbital and
infra-orbital foramina, the crural arch and ischiatic notch, &c.
  2.  The points where a nervous branch comes  out  through  the  muscles, to
ramify in  the integuments.   For example, where the posterior branch of the
second cervical appears behind  the mastoid process, or where those of the lower
spinal  nerves become  superficial.
  3.  The points where the terminal branches of a nerve expand in the integu-
ments, as at the anterior extremity of the intercostal nerves.
  4.  The points where the nervous trunks become superficial during their
course, as where the ulnar nerve passes the inner condyle.
   These points are peculiarly liable to suffer  in neuralgia;  they are, almost

  1 The secretions may be apparently perverted during the fits.   A patient of Maccul-
loch suffered from neuralgia in different superficial nerves, and at last from nephralgia,
accompanied by diabetes mellitus.  This "was strictly paroxysmal,  or the morbid
secretion of sugar commenced with the fit, and entirely disappeared in the  interval."
  2 Traite des Nevralgies, &c.   Paris, 1841. 
7
without  exception, sensitive on pressure in the intervals between the attacks,
but much more so during the attacks;  at these places  there  is, in  nearly all
cases, a constant dull pain,  or bruised, tense, or numb feeling; and from these
points the lancinating pains diffuse themselves, either by spreading  along the
nerve in a continuous line, or leaping over to other spots. Pressure sometimes
merely increases the dull pain in these points, sometimes causes twinges along
the nerves.  The extent of surface over which this tenderness exists is very
small, often less than a square inch.  The tenderness may be  absent at one
examination, and be found on a subsequent one;  it would appear sometimes
to intermit.   These  facts  explain, wholly or in part, the various opinions of
observers as to the effects of pressure.  I have many times examined the points
above mentioned as focal points, in facial and sciatic neuralgia,  and  have only
once failed  to  ascertain that the patients had painful sensations there in the
intervals of acute paroxysms, and  that  pain was produced by  pressing these
spots.   Valleix mentions but  one exceptional case—a sciatica, which had ex-
isted only twenty-four or thirty-six hours, and was very  slight.
   Neuralgia commonly occurs  in the nerves which, in health, are con-
ductors of sensation.   Is  it confined to these, or do some motor nerves ever
become morbidly sensitive in  this affection ?  The inquiry is interesting, be-
cause many cases of tic douloureux occupy the side of the  face, and  follow
nearly or exactly the course of the branches of the facial nerve  or portio-dura,
a motor nerve.  They are often believed to be seated in this nerve.  Some are
accompanied by spasmodic motions of the cheek, which  gave rise  to the name
tic, and these are thought to show that the motor functions of this  nerve are
implicated.   To  suppose that the  same nerve-fibres are at once sending  an
impression of pain toward the brain, and also a motor impulse from  the  brain
to the muscles, would be in contradiction to all received notions of physiology.
In one case—and perhaps many such have occurred—a competent surgeon con-
sidered a neuralgic affection to be  seated in  this nerve, the  pains  spreading
over the cheek from the stylo-mastoid foramen, where this nerve emerges from
the cranium.   He divided this nerve near its place of  exit, with the effect of
paralyzing the  muscles of that side of the face, with no mitigation of the pain.
As to the inference drawn  from  muscular spasm accompanying the pain,  it
has been shown by contemporary observers, that real involuntary spasmodic
movements are rare in  tic douloureux.1  After all, their existence is explained
by the anatomical  facts, which will be  found, we  believe, to account for  all
these phenomena.
   Communicating fibres from the inferior maxillary nerve2 join the facial near
its point of emergence, behind the jaw, so  that the latter contains threads
whose origin and endowments are  the  same as those of the trifacial or fifth
nerve.   In some dissections, this branch from the fifth nerve has been found as
large as the whole portia dura of the seventh.   It has been shown by experi-
ment that, when the fifth  nerve is divided within the  cranium,  the seventh
loses all traces of sensibility.
   Nor is this all.   The posterior branch of the second cervical nerve sends  a
division to the back part of the scalp, passing almost  exactly over that  point
already named, where  the  facial nerve  issues from  the cranium.   In  many
cases, the seventh pair was believed to be affected because the  pains started
from near the mastoid process.   But in many of them it will be  found that

  1 Rowland and Valleix.   They occurred in four out of fourteen cases  observed by
Valleix, and in sixteen out of fifty-five, whose history he collected.
  2 From  the ascending branch of the anterior auricular. 
8
the starting-point is intermediate between the mastoid process and spine, exactly
where  this cervical branch comes out from the muscles to become superficial.
Indeed, the same thing is mentioned by authors who did not interpret it as 1
would do.  Halliday, in  his Treatise before me, gives a case of " neuralgia of
the facial nerve;" it is stated that the pains "set out from the ocoiput, a little
above the nucha,  between that and the mastoid process."  There bad been a
softish swelling in the same spot. It is believed these anatomical circumstances
may explain most, if not all the alleged instances of neuralgia of the facial
nerve.
   II. A consideration of the causes of disease is, in a practical point of view,
one of the  most important parts of  its history.  It is too common to pay ex-
clusive attention to  the structural changes, the visible effects of morbific agents,
and to classify disease on such principles alone—an error which cannot fail to
have its influence on treatment.
   Of the local causes of neuralgia, the most frequent undoubtedly is exposure
to cold and wet.  These attacks, in my own observation, are most frequent in
the earlier  months of spring.   A residence in cold,  damp situations  and cli-
mates is a  predisposing cause.   Bellingeri analyzed the history of forty cases,
and found thirty-four of them attributable, as  he believed, to exposure of this
kind.  A  cold, dry, and  piercing wind,  or sitting in a current of air, sitting
long in wet clothing, are the exciting causes most often  and distinctly recog-
nized.   Indeed, any agent which deranges the circulation of the  surface for a
long time,  so that a proper reaction is not established, is capable  of inducing
attacks.
   The forms of neuralgia most often produced in this way are, I believe, facial
and sciatic.  The branches of the trifacial or fifth nerve are distributed over a
large extent, many of them are quite near the surface, and the part they supply,
the face, is habitually most exposed to changes  of temperature.   The  sciatic
nerve is deeply covered,  but its fibrous envelop is of denser  structure than the
neurilemma of other nerves, more allied to the textures usually invaded  by
rheumatism; and we find, accordingly, that  it  is very liable to  an  affection
completely analogous to rheumatism in its nature and causes.  Sciatica pre-
vails in cold, wet seasons, in stormy and changeable weather, and in low and
damp places; also,  according to European observers, in sailors  and fishermen.
The severest and most  intractable cases I have seen were  in Irish labourers,
who had been employed in wet and underground work, and wore their clothing
wet for hours.
   Exposure  to  heat has sometimes produced neuralgic attacks, as in the face
of a cook who had  to stand over a hot fire a  great deal.  In connection with
this may be mentioned a case I  have lately seen in a man whose  face is often
exposed to the vapours  of hydrochloric acid.   He  says that  many of those
working in the same business have eruptions  on the face, which  he  has not.
His neuralgia has lasted six years, and occupies the terminal branches of  the
superior maxillary  nerve.
   Direct mechanical injuries are not among the most common causes.   Bell-
ingeri analyzed forty cases, and found but two of them from injury.  Halliday
relates twenty-seven, and only two of these came  from injury.   In several
cases proceeding from this cause, the disease has continued for months or even
years after the accident; and the origin of the symptoms has  been shown by
their immediate subsidence upon making an incision over the part.  One case
in a girl of fifteen, began after a severe blow on the right  temple, continued
 rather mild for the first two months, then ceased for two or  three months, and
 came on again in severe neuralgic fits.   No  immediate cause for this recur- 
9
rence could be  ascertained, except that the catamenia had failed  to appear.
Relief was twice obtained by covering the cicatrix with lunar caustic.   This
point was so tender at times, that the slightest touch produced acute suffering,
which at one time was followed by general convulsions.   The catamenia were
regularly established about thirteen months after the original injury, and the
neuralgia rapidly improved after that time.
   Venesection  is known to have often produced neuralgia, both in the arm
and leg.   A puncture of  the  superior maxillary nerve at the  infra-orbitary
foramen, made for the purpose of applying galvanism, has caused it. In some
cases of neuralgia from puncture, it has been proved that the nerve was pierced
or partially divided, and a complete division at the wounded part, or about it,
has sometimes  given relief.  But it is not certain that a nerve is touched in
all these cases.  The analogy of other causes, such as cutaneous  eruptions,
leads me to doubt whether any inflammation or great disturbance in the cir-
culation around a number of the most minute terminal fibres may not  serve
as an excitant, and whether, therefore, we need always suppose the wound to
have reached a nervous  trunk.   Dr. Rowland mentions a  person who had
neuralgia i'rom leech-bites, applied to a bubo.
   Neuralgia seldom begins immediately after the  wound, or rather, as soon as
the pain caused at the time has subsided.   Such  a fact is not unknown.   One
man had a severe laceration on the thigh, leaving some filaments of the  sciatic
nerve hanging  loose.  Shooting pains, with spasmodic twitchings, came on in
about four hours, and were  followed by numbness, &c.   All these symptoms
were passed in nine days.   The disease rarely presented so acute a form.   In
general,  neuralgia  following external injuries, begins after  cicatrization, or
even some months later.  With a view to prognosis and  treatment, it is very
important to distinguish between those cases in which the symptoms come on
within a few hours after the injury, and those in which they manifest  them-
selves after the wound has healed.  , In the former, we  have  more reason to
think a wounded nerve  has  occasioned the pains, and we may suspect a partial
division of the nerve.  An operation is much more  likely to give relief in
these cases.  " It is  always to be feared," says Mayo, " when the nervous
symptoms have been slow in  coming (and, therefore, have been present for
many days), that they are dependent not more upon the injured  point  of the
nerve than on an irritation involving its whole length."   Some of those which
immediately follow a  wound may be presumed to  be inflammatory; as in the
above-mentioned case which followed laceration.
   It is important to bear in mind that an injury which had not been suspected
of having involved any particular nerve, and perhaps  had  occurred so long
before as to have been forgotten, may still  cause  acute nervous pains.   For
example, Dr. Rowland mentions a girl, aged sixteen, who had paroxysms of
darting pain in the left temple and side of the head;  and upon inquiry  it was
found that several years previously she had received a severe  cut over the
right parietal bone, which was long in healing, and this spot had been tender
ever since.  A large uneven cicatrix was discovered, when the hair had been
removed, and a blister over this part, relieved the pain for several weeks.  The
pains may be much more distant from the seat of injury, and  even  tenderness
of the cicatrix  may be wanting as a guide to their true source.
   Pressure upon nerves is a more common  local'cause.   It may be made by
some foreign body,  a tumour, an enlarged or displaced organ, a  curved  spine,
stercoral concretions, the passage of  the fcetal head, the pressure of crutches
against the armpit,  &c.   In a  neuralgia of the spermatic cord, pain was ex-
cited  by flatus  passing through the caecum.  Dr. W. E. Coale, of Boston,
<t 
10
witnessed a case of neuralgia, relieved on the appearance of a deciduous tooth,
which had remained in the upper jaw till the peixm reached mature age.
■   Pressure by bone is a well-recognized cause.  Sir Henry Ilalford may be
thought to generalize from his observations a  little too broadly; but  as  he
gives facts for his authority,  we will not make this topic a bone of ('(intention.
He thinks that " the disease  (tic douloureux) is connected with some  preter-
natural  growth  of bone, or  a deposition of  bone in  a  part  of the  animal
economy, where it is not usually found  in a sound and healthy coudition, or
with a diseased bone."  He gives four cases, all of them interesting, and three
of them pertinent here.   A lady, aged forty, suffered  severely from tic dou-
loureux; it was observed that the attacks were frequently preceded by uneasi-
ness in one tooth, which exhibited, however, no signs of unsoundness.  The
tooth being extracted, a large exostosis was observed at its root;  and the lady
never suffered more than slight attacks afterward, and those very seldom.   In
another, recovery took place after the completion of an exfoliation from the
antrum maxillare.  In a third, there was exfoliation of the alveolar processes,
and relief occurred only after an apoplectic seizure.  This may have depended
on  disease within the cranium, as  in the case of Dr.  Pemberton,  related
in the same connection by Halford, but which we may do  best  to consider
under another head.
   Tumours may form in the nerves,  and become the radiating centres  of neu-
ralgic pain.   Though  not  among the most common causes of neuralgia, still,
tumours of nerves form an important part  of our subject, and  we  will give
a condensed sketch of the leading facts respecting them.
   The only known cause of them is a wound or similar  irritation of the nerve,
at the point where they appear.   Hence, they are divided  into two varieties,
the traumatic and idiopathic neuroma.  They are generally  ovoidal, their long
axis parallel to the nerve, movable, not adherent to the skin.  The majority
of cases where but a single  tumour occurs, are believed to be of traumatic
origin;  but under some unknown predisposing influence, many tumours, even
hundreds, may exist in one person.   The symptoms of neuroma, when seated
in superficial nerves, correspond very well with those  of neuralgia—constant
sensations of tingling, &c, with exacerbations of acute, shooting pain,  excited
by atmospheric changes, disordered digestion, &c, as well as external pressure.
The pain is by no means proportioned to the  size of the tumour.  It  is more
moderate at first, perhaps no more  than a tenderness, with many ill-defined
sensations along the course of the nerve.  Traumatic  neuroma is, of course,
most common on nerves near the surface.  In cases where a great many exist
in the same person, they have been found in  the  nerves both  of the  sympa-
thetic and cerebro-spinal systems.
   The structure of these tumours is pretty uniform.   They are probably never
cancerous, and never act like malignant disease.  Those coming  from  injury
are generally solid, but either variety may be encysted.   The solid  tumour
begins in the neurilemma, or cellular sheath of the nerve, or else in one of the
finer sheaths enveloping particular fibres of the nerve; the nervous  threads
may generally be traced through it, by careful management; those which are
not involved  in it are  generally pushed one side, or some of them are  spread
and flattened out on all sides, according to the exact situation where the growth
commences.   The neurilemma  by its compression gives the ovoid shape. The
section of a solid neuroma shows it  to be fibro-cellular and homogeneous;  it'
cuts smooth.   Those  in tho shape  of a oyst contain  some kind of liquid.
Rokitansky believes they serve as bursas mucosae.
   A bulbous enlargement of this shape and  structure forms  on the nerves 
11
after amputation, usually without occasioning pain.  But some of the worst
known instances of neuralgia have followed amputation, so that patients have
more than once submitted  to reamputation, for the chance of relief.  "The
adhesion of  the end of the nerve to the cicatrix of the stump;  its irritation
by osseous spiculae springing from the extremity of the  sawn bone; the in-
cluding of a nervous filament in  a ligature; the occurrence of a conical stump,
such are a few among the many circumstances which have been  stated as the
occasional causes  of these terribly painful  tumours."1
  Carious teeth are believed to  be a  very frequent cause of tic douloureux.
From my own observation, I should  not  expect  much good from extracting
teeth, unless the  pains occupied  the very nerve whose branches pass  to a dis-
eased tooth.  Brodie says, in his lectures in the London Medical Gazette, that
he never knew a  case where genuine  tic douloureux was relieved by the  ex-
traction of a carious tooth; and a very experienced dentist informed  him that
he had arrived at the same result.   Still,  it cannot be denied  that neuralgia,
even at a distance from the face, is sometimes caused by carious  teeth.   Bell
met with a case "in a gentleman, who had for  some time suffered from a neu-
ralgic affection  of the right arm; the paroxysms  were  subsequently  observed
to commence with pain in the second  molar tooth, and to be excited whenever
it was pressed  or otherwise irritated.  Upon  the removal of the tooth, the
pain disappeared."  A pain running  up the  left arm  to the shoulder, chest,
and cardiac region, has been immediately cured by extracting a carious molar.
   Neuralgia has  sometimes been produced by stretching  of  nerves, without
any laceration or wound, as where a heavy weight has  been suddenly brought
into such a  position as to be supported  by one  arm.   Sir  Everard Home re-
ported in the Philosophical Transactions, for 1801, the case of a gentleman,
who  received a  violent sprain  of the thumb by the  weight  of his body
being thrown upon it, in saving himself when he was nearly thrown  off of his
horse.   The attacks of pain extended up  the arm; and the case, proved very
obstinate.   A nerve was divided without  obtaining a cure.
   Various irritations and eruptions of the skin  are sometimes curiously associ-
ated with pains in the neighbouring nerves.  The congestion, or peculiar state
of  circulation in  the minute vessels, which immediately precedes the appear-
ance  of  eruptions, is more commonly marked by  itching and diffused burning
heat, but sometimes  assumes a properly neuralgic character, particularly in
herpes zoster, also sometimes in eczema and impetigo.   These pains may last
through the eruptive period, aggravated by everything that heats the surface.
The most obstinate pains, I believe,  that  are connected with herpes,  are those
which follow its  disappearance,  and which are noticed by Dr. Bright in his
lectures as  particularly refractory to  treatment.   A recent writer, Marriott,
mentions that he has observed many  cases, which all subsided spontaneously
after some weeks or months.
   Carbuncle may cause neuralgia, in near or distant nerves, as shown  by a case
which was long under my own care.   The carbuncle was a large and bad one,
seated over the left scapula.  Its appearance was  preceded  by severe pleuro-
dynia on the same side;  at the height of the suppuration there  were paroxysms
of  pain in the subscapular nerve; and at that  period the followiug symptoms
first appeared.   Pain and numbness were felt down the left ulnar nerve, par-
ticularly at  the point where it passes  beneath the inner condyle,  and from the
inner side of the wrist down the little finger, and half the next.   The pleuro-

  1 This quotation, as well as most of the  account of neuroma, is from an excellent
monograph, "On the Pathology, Diagnosis, and Treatment of Neuroma."  By Robert
W.  Smith, M. D., &c.  Dublin, 1849. 
12
 dynia was very distressing, was always relieved  by soothing  applications  to
 the carbuncle, and never so severe after that was freely opened.  It disappeared
 long before healing was effected, but the pain in the arm continued.  The spot
 was quite slow in healing, being exposed to  continual fretting  by the motions
 of the scapula;  and while it  continued open, the  pains  down the  arm were
 constantly increased by anything that irritated the little ulcer, and relieved by
 soothing applications.  After complete cicatrization, for a month  or  two if not
 longer, pressure on the scar would cause painful  and  strange thrilling sensa-
 tions  down the ulnar nerve.  A second, comparatively small boil, on  the corre-
 sponding  point  on  the right side, caused much  slighter and very transient
 suffering of the same kind, at the same points of the right ulnar nerve.
   Inflammation of mucous membranes has been  known to excite neuralgia in
 those nerves which supply the inflamed membranes.   This has been observed
 in influenza particularly.  I have just had a case  under treatment,  where the
 fits of pain shooting over the whole scalp and temple, recur about three o'clock
 every morning, with  a good deal of regularity, and last till late in  the forenoon,
 when they seem to be relieved by a copious discharge from the  pituitary mem-
 brane.  The pains were confined to the region of  the frontal sinus—a severe
 headache, till the influenza had lasted about five days.  There are some curious
 notices in authors of similar pains, caused by larvae of insects lodged  in the
 frontal sinus.
  Neuralgia may have its origin in the nervous centres.  It would be obviously
 out of place to give an account of all  the  affections of the brain  or spinal
 cord in which  it may arise as  a symptom.   Softening of the brain is more
 often  indicated in its earlier stages by spasmodic contractions of the muscles,
 particularly rigid spasm, and by prickings or numbness;  sometimes these are
 preceded or accompanied by shooting pains in the limbs.  I do not know that
 these  pains ever follow exactly the track of a nerve.   Like symptoms are apt
 to be  among the earlier indications of softening of the spinal cord.
  Neuralgia is thought to be  sometimes a  symptom of cerebral congestion.
 Interesting  cases are related by Dr. Copland, in his Dictionary.  One, in a
 gentleman aged about fifty, was treated by him as  depending ou  an  active de-
 termination of blood to the head, and disappeared.  In about  two years  it
 returned, and was followed by apoplexy and  death.   A  lady about the same
 age was relieved by  cupping  on the back of the neck, but the pains soon re-
turned, when carbonate of iron was prescribed by another attendant; after
this " she immediately became maniacally delirious, afterwards hemiplegic,
and she soon afterwards died."   An autopsy showed intense  congestion and
 signs of previous inflammation.
  Similar statements will be found in the writings of Dr. Armstrong.  He
regarded congestion, or disturbed  action in  the vessels of the brain, as the
most common cause of  tic douloureux and of periodical headache.
  In the London Journal of Medicine, August, 1850,  is a case of pains which
 were unaccompanied by any signs of inflammation,  and considered and treated
 as neuralgic; situated in a limited spot near upper and inner margin of right
 ilium.  An unnatural fretfulness was the only proper cerebral symptom.   The
 liver was enlarged, so as to be  felt below the ribs, and this was thought to
 explain the neuralgia.  These symptoms began in  the autumn, the pain sud-
 denly subsided about the middle of the following April, and two weeks after
 an attack of apoplexy occurred, which was fatal  in five days.   Autopsy re-
 vealed extensive softening of left  side of  cerebrum, with effusion  of  blood.
 The cessation of pain was probably owing to the progress of the disease  in the
 brain. 
13
   Sir Anthony Carlisle mentions that a lady was relieved of infra-orbital neu-
ralgia, by three bleedings within a week of one another.  First, sixteen ounces
were taken;  three days later, twelve ounces; three days later, sixteen ounces
again.   She  was entirely free from pain, and never had any return of it.  She
died two years after this, of apoplexy.   These facts should  not be  forgotten
in estimating the gravity of this disease, and in determining whether  to give
tonics.
   In the case of Dr.  Pemberton, there was disease of the bones within the
cranium—an unusual  thickness of the os frontis  above its sinuses,  and near
its junction with the  parietal bones;  and in the falx, near the crista galli,
there was "a small osseous substance about three-eighths of an inch in length,
rather less in  breadth, and  about a line  in thickness."   After amputation,
performed for neuralgia in  the leg, the posterior surface of the spinal cavity
has been found studded with cartilaginous and bony deposits.
   It would be interesting to obtain a series of facts, to  show how frequently
neuralgic pains are connected with a tendency to serious disease in the nervous
centres, and  how far  they may be premonitions of such disease.  In persons
approaching  that age  when apoplectic and paralytic affections may be feared,
obstinate sciatica, not  traceable to any obvious  external cause, should always
call our attention to the state of the brain.  Facial  neuralgia, too, has some-
times passed into severe periodical ache in the inside of the cranium, followed
by cerebral symptoms.   Before leaving this subject, we will quote  the sug-
gestive remarks of Copland, from whom we have already given cases in point.
After  referring  to the external physical causes, cold and  wet,  &c.  he says:
"When  neuralgia  cannot be  imputed  to any of these  causes, when it is oc-
casioned by  less  manifest causes, when there is  reason to suspect that organic
lesion  exists  within either the cranium or spine—protracted disease may be
expected, and the  supervention of another malady, generally resulting from
the progressive increase of the primary lesion, and of still more fatal tendency,
may be anticipated although at a more or less remote period. In a very large
majority of these cases, neuralgia terminates in some related malady,  in a con-
vulsive, epileptic, apoplectic, or paralytic seizure.  From either of these the
patient may  recover partially, rarely completely, and be again  attacked, but
he seldom experiences the neuralgic  affection, or at least in the  same form or
degree of severity.   Of  the  several  maladies  into  which  neuralgia  passes,
palsy,  generally in the form of hemiplegia, sometimes in that of  paraplegia,
when the lower extremities have been  the seat of the affection, has been that
most frequently brought under my own observation.  Next  to this, apoplectic,
or apoplectic joined with  convulsive seizures, have  been noticed."  In cases I
have witnessed, where neuralgia was followed by palsy, I have  not seen any
relief ensue,  except so far as the sensorium was blunted for the time against
the perception of pain.
   The following remarks of Simon, one of the ablest recent writers on patho-
logy, are too interesting to be  overlooked.  He gives no specific facts to con-
firm them : " It is in these diseases of subordinate centres—chiefly of tertiary
centres—that neuralgia  so commonly arises;  for  by this term, when  it is
properly used, we denote the  subjective experience of  pain in a part where
there is no equivalent  objective disease; and in most  of such cases, the disease
is  not in the nerve-tubules, but amid the gray nerve matter of the secondary or
tertiary centre"—i. e.  the cerebellum, optic thalamus, corpus striatum (second-
ary), or gray matter of the spinal cord, or sensitive ganglia (tertiary).
   As this essay is intended  to have  a practical  character, we will not go
deeply into the  vexed  question of spinal irritation  as a cause  of neuralgia.
i, 
14
Certain cases of this disease  in  the face, and  more  particularly in the inter-
costal  nerves  and  abdomen, are  connected with tenderness  alongside  the
spine—often confined to  the surface over  those  intervertebral  foramina
which transmit nerves to the  parts affected  by pain.  This tenderness  is ex-
hibited  on pressure, or on applying  heat or cold, as for instance by a hot
sponge or the cold hand passed down the back;  and also after some motions
of the limbs or body.  Pressure  here will sometimes excite the painful or
other peculiar sensations iu distant parts.  There is often  a little oedema about
the tender spots; and it is said the skin is  at times  more easily irritated  by
such applications as tartarized antimony than the surrounding parts.  Lastly,
many such complaints are relieved, or perhaps permanently cured, by leeching
or counter-irritation over the  neighbourhood where tenderness exists.
   These facts  have been  ascribed to a state  called "spinal irritation," of
which only a very vague idea can be formed.  It has been considered a very
moderate sort of inflammation—proved to exist by the tenderness on pressure,
and by the very prompt good effects of leeching, blistering, &c.   As to this
theory, it  is enough to say that no pressure  can, as a glance at the anatomy
of the parts will show, be transmitted from our fingers on the outside  to the
spinal marrow itself.  And the effects of  treatment  are  by no means so con-
stant as to make a fair ground for pathological inferences.   They show,  we
think, that there is  a state—temporary congestion it may be—of these parts
of the spinal cord, which causes or keeps  up the neuralgic,  and other distant
affections. But the relief is both very uncertain, and sometimes so surprisingly
prompt as to show that some  other condition than inflammation has existed.
   The tenderness itself has often a neuralgic character.   It is in many cases
excited by a slight brush or change of temperature more than by firm pressure.
Pinch up a fold of the skin over the  intervertebral  foramen,  and in many of
these cases the  local sensitiveness will be evinced, and, what" is more, the dis-
tant neuralgia will be waked  up.  This result is not constant, it is true, but
neither  are  any of  the phenomena of spinal irritation.   We  have seen (p.
418) that tenderness on pressure usually occurs, iu neuralgia, at those  points
where  the nerve issues, either from  bony foramina, or through  the mass of
muscles, to come nearer the surface.   All the facts of tenderness, &c. prove,
then, is, that the posterior branches of the spinal nerves in question are affected
together with the anterior, and that very probably the ganglia contained in
the cord itself are the media  of communication between them.  It should  be
added, to  illustrate  the  inconstancy of all these  facts, that  many of these
patients have numerous tender points in different regions, a general sensitive-
ness—that the  same spinal tenderness may be found without any neuralgia, or
any of the other complaints which modern  theorists have traced to the same
source—and, conversely, that just such symptoms, apparently owing to some
peculiar state—call it irritation if you please—of the spinal marrow, are found
without any of  the spinal tenderness.  A man was in my office yesterday, with
quite a variety  of visceral neuralgia, which, according to his story, take turns
with a chronic eruption on his skin ; there was a fine assortment of the remote
effects of spinal irritation, but no  flinching when I examined  his back.   The
case was no remarkable one.
   Let  us  try to shun hypothesis,  and state what  is most important in this
connection:—
   1. Pains  in the course of the anterior branches of spinal nerves, and also
spasmodic and  various nervous  affections, sometimes coexist  with pain and
tenderness in the corresponding posterior branohes; and the tenderness  is fre-
quently, as we  might expect, at that point where the posterior branch  issues
from beneath the muscles, to become more superficial. 
15
  2. In addition to this, there is sometimes disorder in some  internal organ,
which is probably primary, the spinal cord serving  as the medium through
which irritant impressions from this organ are conveyed to the nerves affected.
  3. Some persons have, with spinal tenderness and neuralgia, a good deal of
suffering in bending, stooping, or even holding so hard  as to make the liga-
mentous stays of the vertebrae tense.  I have  seen such cases proceeding from
a strain, as in trying to hold  a runaway horse;  and some of them appear to
be rheumatic, the  ligamentous  and adjoining white textures being probably
involved.1
  4. In determining whether a painful affection, say within the abdomen, be
inflammatory or not, we may sometimes infer its neuralgic character from the
presence of this neuralgic state of the posterior spinal branches.
  Beside functional derangements, particularly of the uterus, many  organic
lesions may produce spinal irritation—as tubercular deposition in its early
stages, and wounds of nerves.
  As to neuralgia from disorder of the digestive organs,  I can say little from
my own observation.  Sir Charles Bell has given some five cases of tic doulou-
reux successfully treated  by croton-oil, and was disposed to infer  that they
depended on  derangement or overloading of these organs, which he easily  ex-
plained by the connections between the trifaoial and sympathetic nerves. Many
English physicians of  the schools of Hamilton and Abernethy, attach much
importance to the  treatment by purgatives. It is certain that neuralgic attacks
may be excited, in persons subject to them, by indigestible food in the stomach
or bowels, and by the passage of cathartic medicines.  From the teeth to the
rectum, every part of the alimentary canal may make its disturbances felt in
this  manner.    In a case of stricture of the oesophagus, every attempt  at
swallowing excited acute pain  in the little finger.    Pain in  the lower limbs
has been known to come on violently after dinner, and be relieved on vomiting
up some ice-cream;  also to be immediately removed by swallowing an alkali,
by removing fecal accumulations, and by replacing a protruded hemorrhoidal
tumour.   Many persons of sedentary habits have their tic douloureux usually
aggravated by allowing the bowels to become confined, and severe attacks re-
lieved by free evacuation.   I have  known one who avoided sweetmeats of all
kinds, from having observed that they excited  paroxysms of  facial neuralgia.
Possibly, this person had carious teeth, which produced the pains.2
   The mention of nervous pains in the lower limbs from hemorrhoids naturally
reminds us of like cases caused by distension of the bladder and the passage of
calculi.  I have seen  the same after lithotomy.   The patient, a man of 70,
suffered within less than  a week after the operation, from a painful swelling
of the thigh and leg, resembling phlegmasia alba dolens, which subsided  in
five or six days.   For  a few months after the subsidence of this, he was dis-
tressed by fits of lancinating pain down the long saphenous nerve.
   Rheumatism  undoubtedly depends on  a material cause circulating in the
blood, probably lactic  acid evolved in the transformations of the tissues.   It
invades all the  membranous forms of areolar tissue,  from the fibrous textures
about the joints to the serous membranes.   The sheaths of nerves belong  to
this class of  tissues, and  may be the seat of rheumatism.  Were I  to take
my own observation as the only guide, I should be surprised that  any doubt
of this existed among  practical observers, particularly  as  regards sciatica.
This and other  forms of neuralgia are common among those who are much

  1  See Wood's Practice, vol. ii.; art. Spinal Irritation.
  2  For interesting  cases in point, see Edin. Med. and Surg. Journal, April, 1850.
(Communication by Dr. Stark.) 
16
exposed to wet and cold and atmospheric changes.   Symptoms characteristic
of neuralgia not unfrequently supervene in the course of acute rheumatism,
toward its close.   The analogous affection of temporary paralysis of particular
parts, as the  hand, without any signs of cerebral  affection, has  also been
observed in the same circumstances.  The  painful sensations common in per-
sons subject to  rheumatism, at times when they are comparatively well, are
sometimes indefinite in  their seat,  but in  some cases follow the well-known
course of some  nerve.   Rheumatism attacking the  neurilemma, in an acute
form, is known  by the unusually  severe pain, gnawing and piercing sensa-
tions, and by its haunting a particular seat, at the same time having  marked
remissions.  I am  glad to see that the frequent occurrence of rheumatism in
this seat is recognized in the latest excellent work  on  this  subject, that by
Fuller of London.   The following  is the commencement of his chapter, "On
Sciatica, and other forms of Neuralgic  Rheumatism."  " When  rheumatism
attacks  the nerves or their fibrous  envelops, it causes pain which follows the
course of the nervous trunks, and extends along their several branches.   The
pain is bounded by such narrow limits, and can be traced so clearly following
the track of the larger nerves, that it cannot be mistaken for pain affecting
any of the other structures."
  Some of the  most intelligent clinical observers  of our day have  pointed
out affections of the spinal cord  and of the nerves, depending on the gouty
diathesis.   Dr.  Graves has adduced cases tending to show that " gouty in-
flammation of the nerves and their  neurilemma may  in process of time extend
to the spinal marrow and its investments, and  give  rise  to the derangements
of the latter, terminating in ramollissement and structural degeneration."  In
the Edinburgh  Medical and Surgical Journal, Jan. 1854, Dr. Begbie gives
numerous illustrations of the many  forms of gout, among which, besides neph-
ralgia, he mentions three cases of neuralgia in the lower limbs.   One, a case
of sciatica,-was treated with colchicum and neutral  salts, and complete relief
was  quickly obtained on two occasions.   Another  case, also a sciatica, was
of a  more asthenic character, the gouty diathesis " more  suspected than
proved or acknowledged," and yielded to quinia combined with colchicum.
  For myself, I have only suspected this connection of  neuralgia with gout;
in some cases from finding no other ascertainable cause of  neuralgic pains;
from  the hereditary tendency to gout or gravel in a patient's family, and from
the good effects of colchicum.   The neuralgiae I have seen under  these  cir-
cumstances were facial (accompanied by inflammation  of  the articulation of
the lower jaw on  the  same  side), and visceral pains somewhat resembling
colic.                               '
  Syphilis has  been pronounced a cause of neuralgia, on account of the occa-
sional cures by mercury.  There are few operations  of medicine more reliable
than  the good effects of iodide of  potassium  in syphilitic headache;  and  in
some cases which were relieved by this  medicine, I have been  unable, on
careful  examination, to detect even any  commencement  of puffy swelling.
Were they neuralgic, or are we to  assume that  there was some brooding in-
flammation of periosteum or bone?   From their lancinating character, and
their radiating from a well-known centre of neuralgic pains, near the parietal
protuberance, I am disposed to consider them of this nature, in a case lately
under my treatment.
  The metallic poisons, lead and mercury, by their  slow absorption into the
blood, produce  affections  of a neuralgic stamp.  The  " lead-arthralgia"  of
Tanquerel is a disease remittent, subject to severe paroxysms, the pain  being
little  dependent on motion of the part, and not increased, but oftener  dimi-
\ 
17
nished by pressure.  The scalpel shows no correspondent anatomical lesion
in the limb, or the nervous centres; lead has been found in the  muscles of
the limb.   The diagnostic marks between this and  " common neuralgia,"
named by Tanquerel, do  not characterize a distinct  disease.   His observa-
tions include 1,217 cases  of lead colic, 755 of " arthralgia," 127 of paralysis,
72 of encephalopathy.   Lead-colic is probably a compound of muscular para-
lysis and neuralgia, having its seat in the bowels; so that by far  the larger
number of the cases,  where lead  poisons the nervous system, partake of  a
neuralgic  character.
  Malaria is a well-ascertained cause.   Neuralgia prevails in marshy districts
and damp climates, and particularly in  some of the haunts of fever and ague.
A condition resembling the  cold  stage of intermittents  has been noticed at
the beginning of the neuralgic  paroxysm, marked  by a similar character of
the pulse, and  a sensation of cold, either  local or general, followed  by local
heat.  Neuralgia is often  periodical, as  regularly so as fever and ague, and
with the same  intervals.   The same persons have often had ague and neural-
gia alternately; and in particular, many who  have  suffered  first from  severe
intermittent fever have afterwards had neuralgia.  Bark and its preparations,
and sometimes arsenic, have  rapidly cured these periodical cases.
  The following is quoted from  Macculloch, in his Essay on Marsh Fever and
Neuralgia (London, 1828):—
   " In  this  case, the situation was so  decidedly  subject to malaria, that
scarcely an individual, out of many different families which had resided in it,
had escaped intermittent at some period of their stay.   In one  season,  and in
one family consisting  of  twelve or fourteen persons, the  following were  the
effects on as many individuals:  one  tertian, one double quotidian headache,
one diseased spleen; in one individual, aged only eighteen, a temporary hemi-
plegia, with obscure quotidian, and symptoms  of diseased spleen; a  regular
neuralgia of the face, of  double tertian type.   In a following distant season,
and in some of the same  persons, there occurred palsy of the face, with im-
perfect speech—an attack lasting beyond a week, and  replaced by quotidian
neuralgia (tic); a double  tertian, common intermittent, terminating in a quo-
tidian or  double  tertian  neuralgia; a quotidian with neuralgia in the shin-
bone; the same patient having had, in a preceding  season, a common tertian
so obscurely marked that he was  ordered to Italy  for a consumption (a con-
sumption  which was cured by two ounces of bark  and a change of place to
ten miles  distance);  and,  in  a following one, having been  attacked again with
a double tertian, of which one fit was attended by neuralgia of the skin,  and
the other  by a headache."
  It  is well to mention  that the disease is not always of malarious origin
when distinctly periodical.   Many  cases, even coming  from a  permanent
organic cause, recur  regularly, with the same intervals  as the common forms
of intermittent fever.
  Lastly, whatever vitiates  the blood,  by withholding  healthy nourishment,
or interfering with healthy assimilation, may be the source of this  painful
disease.  Anaemia  itself is a most frequent cause of nervous disturbances, both
of movement and sensation.   They have  been  observed in  limbs  after liga-
ture  of  the main artery, in women blanched by flooding,  and in the anaemia
of Bright's disease, and chlorosis.   Many of these phenomena have been best
investigated by Dr. Marshall Hall, to whose Essay  on  the Effects of the Loss
of Blood,  I may refer.
  But the constitution of  the blood,  and healthy state of the nervous system,
may  be impaired by  unhealthy modes of living as well as by actual disease. 
18
The debility caused by neglect, voluntary or forced, of the great rules of
living, is a most common influeuce predisposing to neuralgia.   Our bodies
cannot be kept  sound without  enough suitable food and oxygen, with exer-
cise to quicken the reception of these elements into the system, and to distri-
bute them in due proportion through our organs.  The  habit of sewing too
closely, and  the use of such articles of diet  as  give a  temporary unnatural
stimulus in the place of substantial nutriment—tea and coffee in particular—
are the hygienic  errors most needing to be noted.

   III. The  subject of  this essay (as at first  announced) requires  something
to be said of the " nature" of neuralgia.   Our knowledge on this question  is
so slight and unsatisfactory that we shall devote very little  space  to  it.   In
the majority of cases, where dissection has been had, no  morbid changes have
been found in the nerves.   When  found, they have been various,  and not
always in  the part where  the symptoms appeared.  The  knowledge  derived
from the symptoms and course  of the disease is  almost equally negative; we
learn what neuralgia is not, and some of the laws it observes; but  do not
know what it commonly is.   In truth, while we do  not know the nature of
the processes by which healthy sensation is effected, how can we understand
the mechanism of diseased sensation ?
   1.  Some rare  examples of  neuralgia depend on inflammation of the nerve.
We  related  a case  at page 421, which shows this by its history.   In other
instances, the nerves  have presented redness, serous effusion  among  their
filaments, bloody infiltration, enlargement, hardening,  softening, or finally
purulent effusion, indicating  that inflammation had existed, sometimes acute
and at other times chronic.  A  remarkable instance of the acute kind  is men-
tioned by Gendrin.   In this case, and the one just before alluded to, numb-
ness in the parts below the inflamed part was a prominent symptom.   We
shall presently  see that  Fuller mentions as signs  of effusion in  sciatica,
" a dull, aching, benumbing  pain  in  the limb,  causing it to feel swollen."
Simon says : " It is practically of great importance, as a point  conducive to
accurate diagnosis, to notice whether the neuralgic affection  be or be not accom-
panied by anaesthesia (or numbness.)  Attention to this point will often enable
us to give confident prognosis as to the issue of a particular case  by deter-
mining whether  the symptoms are such as to imply destructive  disease in the
nervous apparatus of the part.  Neuralgia  of long duration can hardly exist
separately from anaesthesia, as a result of such disease."   Other more obvious
signs of  inflammatory neuralgia are  tenderness on  pressure over the whole
course of  the nerve, felt  enlargement of the  nerve sometimes observed, and
the greater fixedness and constancy of the pains.
   But the inflammatory character of this affection  is seldom shown, either by
its symptoms, the  effects  of treatment, or post-mortem  examination.   For
discussions of this whole subject, we may refer to the able essays of Drs.  Oli-
ver W. Holmes1 and Richard Rowland.2
   2.  In  some forms  of neuralgia,  we may convince ourselves that it arises
from a morbid state of the blood, in particular from a poison circulating in it,
which we may believe  from analogy—perhaps in the case of lead  it  will be
proved by analysis—comes into direct relation with the  nerve-substance or
neurilemma.
   3.  We find neuralgia in certain instances a manifestation  of disease in the
nervous centres; and we may  feel  that  we know something- of its  nature,
1 Boylston Prize Essay.   Boston, 1838.
2 A Treatise on Neuralgia.  London, 1838. 
19
 when we connect it with those laws of the nervous system by which affections
 of the nerve near its origin are referred to points along its course.
   4. Those cases in which disturbances of one organ excite pain in a remote
 part, through the means of nervous  connections, are illustrations  of what is
 called sympathy.   But this term  only serves as a convenient name, like the
 x or y of the algebraist, to represent an unknown thing; and though we may
 study its phenomena, assort them under different  heads, and  generalize our
 statements into laws, we are still ignorant of its nature.   Interesting methodi-
 cal accounts of the phenomena of morbid  sympathy may  be found in the
 recent works of Henle and Simon on General Pathology.

   IV.  Treatment of Xeuralgia.—We have dwelt at length on the conditions
 under which neuralgia arises, because they afford the most important hints
 for treatment.  Many of them admit of being removed or lightened.   It is
 true that the removal of the  apparent  causes  may not  cure the disease, yet
 even here this knowledge is useful,  because the continued operation of the
 causes may be stopped,  and also  because powerful nervines have a great con-
 trol over those cases in  which the pains persist after the condition that first
 excited them has ceased.  But there are generally several causes or influences
 that keep up the disease, and a physician's  tact will be best shown in detect-
 ing and disentangling them.  Thus there  is  often  a  general  state, such  as
 anaemia or the rheumatic diathesis, making a person liable to nervous pains,
 and some local exposure or  accident determines the place where this consti-
 tutional cause shall take effect.   If  our management  be  not  founded  on a
 comprehensive understanding of the case,  its success will be at best very un-
 certain.
   Let us  develop these ideas a little  in  detail.   Exposure to cold  and wet
 must be  avoided.  A person living in a damp and chilly situation, or obliged
 to work  in the  water,  can hardly expect a cure, unless he can  change his
 business,  and go to a dry and comfortable dwelling, or hospital.   This ap-
 plies  most strongly  to sciatica, yet not  exclusively.   The best  writer on
 neuralgia of the face,  Halliday, urges the same measures, an omission  of'
 which may, he says, compromise the good effect of any other treatment.  The
 patient should be taken  also  from a situation exposed  to marsh miasmata.
 Non-conducting substances should be worn over the affected part, if possible.
 Flannel  and  silk are  useful, and in  sciatica, buckskin drawers.   Flannel
 covered with oiled silk is worn by some, attached  to a  sort of visor, to pre-
 vent, if not  to cure, attacks of facial neuralgia.   The usefulness of many
 plasters depends upon their protecting  the surface against changes  of  tem-
 perature.
   The existence  of rheumatism, gout,  and the various poisons in the blood
 should all occur to the mind as possible causes.  We cannot give in full the
 symptoms or  treatment of either of these diseases, yet the  following  sen-
 tences of  Fuller are apposite enough  to be quoted.  They are written with a
 special reference to sciatica: " If the patient  is thin, pale, sallow, and ex-
 tremely sensitive  to atmospheric vicissitudes;  if he has experienced pain or
 threatenings of pain,  in  other parts of  the  body; if, at  some former period
 he has suffered from rheumatism affecting the joints; and, above all if his
 present attack is the result  of exposure to  cold and damp, the  disease under
 which he is  labouring  is rheumatic, and is to be relieved by vapour-baths
guaiacuin, alkalies,  and  similar  remedies.   On the  other  hand, is he stout
florid, and a free liver, taking little exercise and sleeping much;  is he plagued
with heartburn, acid eructations,  and  occasional lowness of spirits • or has he 
20
  previously suffered from gout, his malady is certainly of gouty origin, and is
  to be cured by colchicum, alkalies, and alteratives.   Again, is he cachectic,
  and out of health; has his throat been ulcerated, or his skin disfigured  by
  blotches or eruptions;  has he  taken  mercury, or  experienced  pain  in  his
  bones, the mischief is probably due to a syphilitic taint, and is to be cured by
  sarsaparilla, with iodide of potassium."
    In the pains from syphilis, benefit is ako derived from nitric  or nitromu-
  riatic acid washes.
    When an individual, once strong, has  become weak  and  pallid, without a
  rheumatic  diathesis, and we recognize  anemia as a  source  of the neuralgia,
  we have a case for the use of  iron.  The strength and size of  pulse, appear-
  ance of red blood in the complexion, and presence or absence of  other symp-
  toms that are known to  be  often produced by general anemia, are  to  be
  inquired into.  Iron is inappropriate, not  only in  full-blooded  persons, but
  also in those who are predisposed to inflammation or irritation of the stomach
  and bowels.   Its best effects are seen in cases where no local cause is known.
  Its effects on the action of the  bowels are  different in different persons.   In
  moderate doses it is apt to constipate,  and  require some cathartic joined with
  it.   But only a small part of the large doses of  the  carbonate of iron is ab-
  sorbed.   When a drachm or more is given, most of  it passes off in an insolu-
  ble form, the sulphuret, and by its mechanical irritation in  some  persons it
  promotes peristaltic movement.   The  large doses" therefore, cannot be more
  useful than moderate ones, by their increased power  of furnishing iron to the
  blood.  Several authors who recommend the carbonate, empirically, insist  on
  the greater efficacy of large doses; and perhaps this is owing to  a revulsive
  action on the bowels.  Thirty grains three  times a day are often given;  some
  failures are attributed to this small dose!   It is  said that half an  ounce  every
  four hours can be well  borne, producing no inconvenience unless some feeling
  of weight  in  the stomach, as  long as  the bowels  are kept  freely open.   In
  employing  the carbonate, I have  usually given not more  than   five to ten
  grains at a dose, combined commonly with powdered  rhubarb and an aromatic
'  (cinnamon).
   After endeavouring to give  some indications for the use of iron in what we
  may call the rational treatment, we must glance at  its empirical  use.   Like
  most other drugs, it has been used too  indiscriminately in neuralgia.   The
  subcarbonate of iron was first distinctly brought  forward, as a cure for neural-
  gia,  by B. Hutchinson (London, 1822).  He reported twenty-seven cases, all
  but two or three  of which were cured, under a course in which  this was the
  leading  remedy.   In  those few, it  gave more relief than anything  else.
  Though it has been less uniformly useful in the  hands of others, still, it has
  kept its place as one of the most valuable remedies.
   Sir B. Brodie says of the use of iron :  "  We have  never known any benefit
  to accrue from increasing  the  dose of  the  carbonate beyond a drachm thrice
 daily."  He insists on the occasional administration of a purgative to prevent
  accumulation in the colon.
   Whatever the nature of spinal irritation, there is reason to believe it means
 something, and that this something keeps  up neuralgic and other nervous
 complaints.   We must dwell a little  on remedies  applied over  the spine.
 Simple rubbing and shampooing, even the pressure of a warm hand over the
 seat  of tenderness, and  anodyne liniments, give great relief.   As a palliative,
 the  following is excellent: one part of solid  camphor  and chloroform, each,
 mixed with two parts of olive oil, making a liniment.   The belladonna plaster
 is of more permanent  benefit.  These harmless measures ought  to be tried,
 unless symptoms are very severe, before leeching and blistering. 
21
   After the name of spinal irritation came into vogue in England, the use of
 leeches and counter-irritation over the tender vertebrae became very common,
 almost a national peculiarity, which has followed the Anglo-Saxon destiny to
 this side of the Atlantic.   The little book of Teale, written  to  enforce this
 doctrine, has gained a reputation in both countries;  the  edition before me
 being printed at Concord.  It recounts twenty-one cases of external neuralgia,
 angina  pectoris, and other nervous  affections,  accompanied  by  some spinal
 tenderness, and relieved  almost constantly by  leeches and blisters over the
 spine.   His cases  show that  these affections  may be very  much mitigated by
 such appliances, and some of an acute character even cured.   But the long-
 standing cases were treated by so many different means at the same time, that
 it is hard to judge how much the local measures aided in  a permanent cure,
 where such was obtained.  A great many of these affections occur in weakly
 persons, who  cannot  well  bear repeated  loss of blood,  which increases  the
 general irritability.  For myself, I have seen permanent good come from local
 depletion only when the cases were very recent.   Persons  who have suffered
 long may, however, be relieved  of suffering, and, on this account, leeching
 and cupping  may be, on the whole, beneficial in some  circumstances.   The
 harsher  external  applications, according to the  best observers, have  often
 failed;  I have seen them followed  by an  increase of spasmodic  disturbance,
 not, that I now remember, of neuralgic suffering.
   Sir Benjamin Brodie, in his able lectures  on  local  nervous affections, has
 raised his commanding voice against the indiscriminate use of these applica-
 tions, particularly in young and nervous females, in whom we commonly find
 the symptoms in question.  He believes that many are made invalids for life!
 by the repeated losses of blood, each of which may have given relief at  the
 time.   He condemns in  the same way the practice of enforcing a recumbent
 posture, and establishing a discharge over the  spine, whether by tartarized
 antimony,  caustics, or setons.  Good diet, air and exercise, agreeable occupa-
 tion of the mind, cheerful feelings, with some  tonic medicines, are, he says,
 the best remedies.   He  also advises the use of belladonna plasters, which I
 have already spoken of.
   From my own limited observation, I am convinced of the truth of Brodie's
 statement,  and that  many patients  are kept  invalids  under treatment for
 " spinal complaint,"  who  would be  able to lead a comparatively active and
 happy life.   Have we not all seen such cases ?   Granting  that the condition
 of  a portion of the spinal cord is one of congestion, or too great fulness of
 blood, is it not a  result and indication of weakness?  The phenomena of
 blushing, a result  of moral weakness, have  been  very happily employed to
 illustrate this kind of congestion, which springs from physical weakness, or
 from moral and physical combined.   To cure it, says an  excellent reviewer of
 Brodie, " we should not leech and blister, or enjoin rest, but we should ex-
 pose abundantly to fresh  air, insist on regular and plentiful exercise, with
 sufficient intervals of perfect rest, feed with  a most generous  and nutritious
 diet, and with but little apprehension, in the  majority of cases, of failing in
effecting a cure."1
  Those who consider neuralgia to be very often a result of deranged digest-
ion,  will insist  much  on  the  management of the digestive organs.  I have
already  mentioned some  cures  reported by Bell, &c.  When  an  overloaded
state of the primae viae is suspected, emetics and cathartics may be useful.
I have read of remarkable cases where purgatives given for some  days, with

               1 British and Foreign  Medical Review, July, 1841.
       3 
00
no good effect for awhile, have at last brought  away accumulated matters,
and given immediate relief.   Iu sciatica, they are  often successful.   The ab-
domen should therefore be examined, in  any case where constipated habits,
with any fetor of breath and loaded tongue, set  our suspicions on this track.
The following is an outline  of treatment which has been very useful in my
hands, especially in some cases of dorso-intercostal neuralgia of the left  side,
where the complexion  was  muddy, and  tongue  coated.   A blue pill  every
fifth day, followed by a saline cathartic;  extractum taraxaci in pills—say six
a day; anodyne applications outside;  bitter  tonics after  pain  was removed,
and a plain, nutritious diet through the whole period.  One case was remark-
able for having been aggravated by abstinence from meat or other hearty food,
and for the prompt disappearance of symptoms under this treatment.
  Dr.  Hunt, who gives the  most  rational advice  as to management  of the
stomach and bowels, ascribes many cases to atony in these viscera, and recom-
mends arsenic after evacuants, to be continued until pain is relieved, and then
some tonic to take its place.    He combines the arsenic with camphor, or some
sedative;  or, in case of acid stomach, with bicarbonate of soda, giving  small
doses  of liquor arsenicalis (four minims three times a day at first, increased
to ten.')1
  I have nothing interesting to add as to the treatment of other constitutional
causes of neuralgia, and will  next speak of indications drawn from local causes.
Several cases have already been mentioned, where neuralgia  was relieved  or
cured by treatment applied to old scars, &c.  A complete  removal of the cica-
trix by the knife  has done this most effectually; and when the  scar is tender,
pressure on  it exciting the lancinating pains, and the situation  admits, this is
the best remedy.   In other  situations, as on the  scalp, a crucial incision  or
cauterization may be substituted.   A line of cautery carried round the  cica-
trix will sometimes give temporary relief, and may be advantageously prac-
tised at the  same  time  that the cicatrix itself is converted into a slough.   This
treatment has often succeeded.
  " In neuralgia  depending on cutaneous eruptions," says Rowland, "relief
may often be effected by touching the vesicle or pustule  with  lunar caustic.
In herpes  zoster,  for  instance, I  have removed  the severe  neuralgic  pains
almost instantly by this means.   Sometimes  in these cases, one or two vesi-
cles are pointed out as the chief source of the suffering;  but, in general, it is
better to apply the caustic to the whole of each group, or to cover them with
a strong solution of this substance."
  Neuroma on superficial nerves is said to have sometimes disappeared  spon-
taneously; and, in some recent cases  of an inflammatory nature, arising from
injury, leeches are stated (by Frank of Turin) to have succeeded in dispers-
ing it.  But it usually presents itself to observation as a chronic disease,
curable only by operation.   The safest and most eligible mode  is to cut away
both the tumour and piece of nerve to which it is  attached.  The tumour is
usually too closely implicated with  the nerve-fibres to be dissected out.  In
one instance, where a large  tumor  was dissected out from the axilla, death
ensued, and there was no evident cause for death  shown on post-mortem
examination except inflammation of a nerve.9
  Neuralgia after amputation is one of the most discouraging  varieties.   It
has returned after three successive amputations of the same  limb, and after
the sciatic nerve had been exposed and an inch and a half of its length cut

              1 Braithwaite's Retrospect, p. 10.
              2 For further directions, consult Mayo's Pathology. 
23
 out.  It has been  cured in one instance by acupuncture, and  in  one bv
 quinia.                                                                 J
    Indications for treatment may be derived from  the  type of the  disease
 which may be  inflammatory or periodical.   Neuritis may be known bV its
 acute course, by  tenderness, perhaps  swelling over  the nerve, and numbness
 and thrilling sensations, with little intermission; sometimes by spasms in the
 muscles, and the presence  of some fever.   General bleeding is  seldom re-
 quired.   Dr.  Rowland mentions having procured relief by it  in a  case of
 sciatica.  Leeches, anodyne fomentations, and poultices, were used with  best
 results m the cases best recorded (those of Martinet).  Immersion in warm
 water and  irrigation with it as practised in a Boston hospital, have both had
 very kindly effects.   Dr. Holt, in  commenting on  some cases which  he  con-
 siders inflammatory, says:  " Cold applications in  these cases are commonly
 agreeable and beneficial, as a means of relief.  The application of ice, or cloths
 wet in cold water, is often a very valuable auxiliary in this form of the disease 1
    Ihe writer on rheumatism,  Fuller,  from  whom  we have already drawn
 quite freely, recommends means particularly to meet the condition of effusion
 within the sheath of the (sciatic) nerve.   The signs of this effusion he thus
 enumerates: " When a patient who is suffering from sciatica complains of a
 dull, aching, benumbing pain in the limb, causing  it to feel swollen; when
 this sense of numbness  and increased bulk has succeeded to pain of  greater
 intensity, accompanied by cramps and startings of the limb; and  more espe-
 cially when, in  addition to  these symptoms, there is more or less inability to
 move the limb, inability arising from  loss of power, and not as a result of ex-
 cessive pain," &c.  In these circumstances, he recommends that measures be
 taken for the specific  purposes of checking  further effusion, promoting  the
 absorption  of that which exists,  or mechanically  evacuating it.   For these
 purposes he uses cupping and leeching, if the effusion is supposed to be recent.
 In cases of longer standing, he uses long and narrow blisters along the track
 of the nerve, dressed with mercurial ointment, or sprinkled, if necessary, with
 powder  of pure morphia, also mercury internally.  In somewhat obstinate
 cases, when inflammation has gone by, and only its result, effusion, exists, he
 recommends acupuncturation, to mechanically evacuate the fluid.   " Six or
 eight pairs  of needles, specially adapted for the purpose, are carefully inserted
 into the  thigh, along the course of the sciatic nerve, the object being to punc-
 ture the  neurilemma, and thus to allow of the escape of the fluid."   This
 operation he has seen give complete relief in three cases, and in one the relief
 was permanent.   He thinks failure may have been owing to the operation
 being tried when there was   no effusion, or when inflammation was not sub-
 dued, or to the fluid not being reached.
   Acupuncture  has  been used without  this definite indication.   Cloquet re-
 ported many successes from  it, the needles being left in for some  minutes   or
 even hours.   Drs. Renton and Elliotson, in England, also used acupunctura-
 tion extensively, with benefit, in  sciatica.  The former left them  in only five
 or ten minutes, inserting sometimes ten along  the thigh and le«*.  He effected
 many immediate cures in old obstinate cases.    He inserted the needles with a
 slight rotating motion, and " without pain."*   The effects of acupuncturation
 employed empirically, have been, on the  whole, quite uncertain.
   When neuralgia is  periodical, following any of the common types of in-
termittent fever, whether  caused  or  not by miasmata, it is usually  cured for
some months, if not permanently, by preparations of bark.
1 Bost. Med. and Surg. Journ. May, 1845.       2 Lond. Med. Gaz July, 1841. 
24
   Even where the attack is not exactly regular, but tends to return about tho
same part of the day, there is no one medicine more to be relied upon, in the
neuralgia so common in females  of weak  constitution  and sedentary habits.
Many patients form a habit of using  quinia  on the return of a paroxysm of
tic douloureux, cutting it off speedily, and relieving them for several months,
or even a year or more.  Some physicians  employ grain doses  three  or  more
times in a day.  Some, who have gained a good deal of local reputation, and
self-confidence in the  treatment  of facial  neuralgia, administer ten or fifteen
grains at a dose.  I have known the small doses to succeed immediately after
the large had repeatedly failed.
   Brodie says that very large doses may be needed.  He had to raise the dose,
in one instance, up  to  half a  drachm daily, of  something  called  quinia.  It
is used in as large quantities as that in France.  Brodie speaks with perfect
confidence  of succeeding  by  the  use of  cinchona or quinia, combined,  if
needful, with
   Arsenic.   This and the  carbonate of iron are both considered particularly
useful in  periodical neuralgia.  Having no extensive experience in its use, I
will  once more quote Dr. Hunt: " Arsenic operates most favourably on  per-
sons who are of lax fibre, accompanied by a languid state of the circulation, and
whose secretions are rather profuse than otherwise;  the urine pale and  plen-
tiful, and more especially on those whose skin is cold and moist.   In persons
of this  description, whilst  arsenic, to an extent far beyond  other medicines,
relieves the neuralgic pain, it improves the general health, and gives firmness
and  vigour  to the  constitution.   When the  urine is  of a  deep  colour and
scantily secreted, or when it  deposits the lithate  of  ammonia,  the tongue
loaded, especially if the tip or edges of if are red, arsenic almost invariably
disagrees, and aggravates  the  pain.  But as  this morbid state of the system
frequently depends on  or is complicated with disorder of some important viscus,
arsenic will often agree, and relieve the neuralgic pain, after the visceral dis-
order has been removed by appropriate remedies."1
   Our distinguished countryman,  Dr. Gross, has found Fowler's solution less
serviceable than the arsenious acid in substance—less effective in  curing the
disease, and more likely to nauseate.
   In some intermittent cases, M. Cazenave applied ligatures or tourniquets to
the limbs, with very happy effects.  One patient had excessive pains in the
head, returning  periodically, and  baffling all  treatment.  Ligatures were ap-
plied to each limb a few hours before the  expected attack, moderately tight.
The  pains were lessened the first day, still less the next, and  did not appear
at all on the third day.  He advises that the  application be continued  after
the disappearance of the neuralgia, for five or six days.
   But supposing that we  have no obvious indications for  treatment, drawn
from causes  of disease to  be counteracted, or from the peculiar features and
type of the  case in  hand.  We have  still many resources,  and some light—
alas! too little—to guide  us in their use.  It will be necessary to name  a
good many medicines that  have gained the best reputation in this painful dis-
ease.  They are undoubtedly used too much at random; and what  we need is,
less to have new medicines, than to learn how to use what we have.  Let me
once more enjoy the luxury of transferring to my humble pages the counsels
of one of the most  judicious, observing, and enlightened physicians, Brodie.
He is addressing students.
   " Nor can I think well," says he, " of this  modern fashion of resorting on
1 Prov. Med. Journ. April, 1844. 
25
all  occasions to novel methods of treatment.  I advise you, if you wish to
succeed in your profession, and to be useful to society, to pursue a  different
course.   Make yourselves masters of the old remedies.   Learn how to handle
them, and what good they will  do, and, as a general rule, have recourse to
them in the first instance.   If the old remedies fail, and you are at a loss as
to what you should do, then, and not till then, have recourse to the new ones."
   In estimating the value  of any medication for  this  disease, we  must re-
member that intervals of ease, extending over a period  sometimes of several
months, may give us a hope that  the disease is finally  cured, but the pains
may afterwards return.   Many modes  of  treatment  are successful  only up
to this point, and in the  most exquisite forms of neuralgia it is a blessed boon
to obtain even this respite.
   The medicines which have done most service by their employment internally,
might be arranged, not very strictly,  however, under the general heads of se-
dative  or narcotic  medicines, tonics, and medicines whose operation is not
understood—unclassifiable, alterative medicines.
   As mere palliatives, sedatives are useful by cutting off the paroxysm, giving
relief to pain,  and  lessening  the  power of that unhappy habit which makes
future paroxysms more likely to ensue.  In  this respect, the anaesthetic va-
pours appear to me to be more useful than  any other  substances.   Believing
that chloroform is unsafe in the  best hands, I always prefer  sulphuric ether,
though  much less convenient and elegant.  It need not be inhaled long enough
to make one  insensible; the power of perceiving pain being  lost before con-
sciousness of identity of perception of surrounding persons and objects.  In
forms of  neuralgia depending on mere  nervousness and  irritability, the pains
will not always return as the effects of  ether disappear, and inhalation, there-
fore, does not require to be continued  long.  Many interesting facts of  this
kind are related by English physicians.
   These substances are all more  applicable to neuralgia excited by irritation
reflected from a distant organ, or some temporary exposure, than to those cases
where some local mechanical cause affects the nerve itself.
   With a curative object, the best effects from sedative  medicines are got by
giving some of the vegetable narcotics, in full and frequent doses, until the
pain is  quelled, then continuing them with larger intervals for a while, and
finally substituting a  tonic.  Among these narcotics, it is difficult to say which
has the  greatest weight  of testimony in its favour.  Leaving out aconite, as
being a substance of very peculiar properties, we find  different practitioners
preferring belladonna or conium—less generally, stramonium or hyoscyamus,
or the preparations of opium.
   I have collated the testimony of many authors whose communications ap-
pear in  the journals, as well as the systematic writers on  neuralgia; but as the
same principles govern  the  administration of all  these remedies, I  will not
attempt to give the various  facts on which different practical men found their
preference for this or  that medicine.   Belladonna, employed on the principles
just named, has, I think, the strongest testimonials in its behalf.   The fol-
lowing  mode of employment has succeeded very well with  M. Trousseau: A
quarter of a grain of the extract is given, in pill, every hour,  until some diz-
ziness or effect on vision is  produced, by which time  the pains are  quieted.
Then the medicine is continued with longer intervals.   This course  must be
resumed, if the pains recur.   After they have disappeared, a tonic  is used;
usually quinia or iron.   This  plan succeeds best in facial neuralgia.   Accord-
ing to all who have used it, belladonna must be  continued until some slight
effect is perceived in the  throat or state of vision, or vertigo.   In full-blooded 
26
persons, it may be combined with ipecac, as recommended  by Golding Bird
for neuralgic dysmenorrhcea;  or, in those who are pale and feeble, with iron
or zinc.
   Conium is preferred by many.   Mr. Lawrence  says it is the only one of
these narcotics on which we can have any reliance for checking the paroxysms.
" I have seen in several cases,  where it has  been given largely and at short
intervals—and it must be given in such doses as to produce some of its pecu-
liar effects on the nervous system—that it has put a stop to the paroxysms,
and  for such a length of time that I have thought it had cured the disease;
but in some instances, where persons have remained well for  several months,
and even in one case for more  than a year, the pains have again showed them-
selves; but the agony has been considerably controlled by it."   He  does  not
mention what has been the result of following up this temporary cure with a
tonic course.
   Such has been the experience with  all these  narcotics.   To  state who  has
succeeded best with one, and who with another, would be hardly a profitable
use of our remaining space.  It is necessary, and often difficult to procure the
substances pure and strong, especially the extracts.   We must also seek care-
fully for any circumstances that may aggravate or keep up the irritation,  and
attend to  the state of the bowels, and several secretions.
   Opium  and its preparations, are considered to be better suited  to internal
than external pains.   Morphia and its salts are most employed.   Their  use
may be profitably confined, I think, to cases that recur at night, or early morn-
ing,  when an evening  anodyne may be  extremely useful.   The acetate of
morphia is stated, however, to have produced some cures, in the hands of Dr.
Bard'sley and others.   But the more common opinion is,  that it tends to in-
crease nervous irritability and costiveness, more  than the other narcotics, with-
out having  so much  control over neuralgic pain.   For  immediate relief to
agonizing paroxysms, it is every way inferior to sulphuric ether, used by in-
halation.
   Aconite.—The internal administration of aconite has often disappointed
physicians, yet when  used in full doses, and continued for some time,  perma-
nent relief has often been derived from it.   Dr. Fleming has called particular
attention  to its power of  depressing nervous and vascular action, and to its
use in neuralgia.  " He gives a table of forty cases;  ten of these have been
published by others, and they are all permanent cures.   Of the thirty cases
which fell under his own  care, there were seventeen permanent cures, and in
thirteen the relief was only temporary.  In some of  these, the  medicine  was
used internally, in others  externally, sometimes both."  Aconite is considered
an antiphlogistic, not well adapted for feeble persons.  Dr. Fleming suggests
that its internal use is most likely to be beneficial, when neuralgia depends on
inflammation in any  part of  the nerve (a condition  quite unusual), or on
sympathetic irritation; its external use, when  the disease  arises from local
functional irritation.   The strong tincture which he recommends has occasioned
several deaths, by its accidentally being swallowed in an  overdose.  He uses
five minims three times a day, increasing cautiously.  The article we get here
is apt to be quite weak.   On the whole, the results of aconite used internally,
as I find them reported, do not seem  to me  so favourable as  those  of bella-
donna, while it is much less safe and manageable.
   I have  obtained good effects from the following combination of aconite with
tonics.  R.—Iron by hydrogen 3'j; tinct. aconit. rad. (sat.) 3j; M. ft.  pil. lx.
   Give one  pill after each meal, until the neuralgic pain ceases, and then sub-
stitute the following tonic pills.  R.—Quin. sulph., iron by hydrogen,  aa,  5j j
M. ft.  pil. lx. 
27
   All these narcotics, including aconite,, have been known to cure obstinate
cases, when given by accident in excessive  quantities.   I have collected from
different sources a number of cures, said to be permanent, gained by means of
narcotism produced suddenly by large doses of belladonna, opium, and aconite.
The same  thing  has happened with strychnia.   A  lady who  had  suffered
severely for years, from facial and cervical  neuralgia, took by mistake, a tea-
spoonful of the strongest  tincture of aconite root, which  had been  prepared
for use by friction.   The immediate effects were most distressing and danger-
ous, her life being saved only by the prompt employment of stimulants. After
her recovery she continued wholly free from the neuralgia for more than a year,
after which time it returned, in a milder form.
   One Dr.  Chabert,  of  New York, proposes to only poison his  patients with
prussic acid, not quite dead, and then bring  them to.  He succeeded in one
instance, if we may  believe him (not only in bringing the  man to, but  in
curing the neuralgia.) • These results are curious, whether practically valuable
or not.
   Nux vomica and strychnia are medicines of great utility in the neuralgia of
feeble persons. The former was long ago recommended by Linnaeus as a cure
for gastralgia.  The cases it is believed  to be best fitted for are those occurring
in pallid, lymphatic persons, not those subject to derangement of the motor
functions.   Rowland thinks strychnia most valuable in intermittent neuralgia.
It acts as a tonic, particularly promoting the digestion of food.  It can never
be administered without anxiety, and should be closely watched.  I have known
myself of but one instance  of  its having poisonous effects, when given for
neuralgia.   But whether from a cumulative property, or from varying suscep-
tibilities of the system, it will sometimes break out unexpectedly, as in the
case I alluded to.  The first  spasmodic  symptoms were violent  trismus, with
a sense of  suffocation, &c. The patient was  saved, and  the gastralgia she had
been long suffering from,  was almost perfectly cured.  I suspected its  employ-
ment in homoeopathic practice, from tetanoid symptoms connected with  some
mysterious pills,  in  one young lady, whose  disease was, however, a  form  of
chorea.
   In the Medical Gazette, 1840, Dr.  Pidduck relates his experience with
strychnia, which is important.   He gives six cases, two of infra-orbitar neu-
ralgia, one sciatic, one in  the  arm and  hand, accompanied by loss of power.
The strychnia was given usually one-twelfth  of a grain  twice  or  three times a
day, and always with benefit.   In one case, relief  began after the third dose,
and was complete before the  twelfth;  the pain returned in slighter degree a
few days after, and the medicine was resumed with equally good effect, after
which there was no relapse.   When any mechanical irritation exists, at  any
part of the nerve, it is not likely to do  good.   If  I  understand  Dr. Pidduck
rightly, he ascribes much or all of the power of strychnia over paralytic and
painful diseases, to its tonic properties, and its producing more complete assimi-
lation of food.  From all the reports of strychnia in neuralgia, I should infer
that it was  a  medicine promising much good, and particularly deserving  of
further trial.
   Among tonics, having already spoken of the two most important, iron and
quinia, I need only allude to the employment of zinc.  The  preparations  of
zinc are believed to be valuable tonics, more  particularly in affections of the
nervous power of motion, as chorea.  The pills of Meglin, celebrated in France
as  a remedy for  facial  neuralgia, consist of equal parts of extract of hyos-
cyamus, extract of valerian, and oxide of zinc.  How much the zinc  adds to
their efficacy, I have no means of knowing;  though  it appears that the zinc
is sometimes omitted. 
28
  The valerianate of zinc is  a preparation of great value.   It combines  a
soothing with a tonic power, and has, so far as I have observed, no tendency,
like so many of the sedative drugs, to derange the secretions and impair diges-
tion.   It is found most beneficial in facial neuralgia, not presenting a regular
periodical type, and not connected with rheumatism or syphilis.   I have before
me the notes of three cases, in which its good effects were obvious, after many
other powerful remedies had failed.  I am in the habit of administering three-
quarters of a grain, in pill, two or three times a day.
  Turpentine has succeeded so often, in sciatica  especially, that it ought, I
think, to be ranked next in value to the carbonate of iron and quinia, if  any
general comparison could be instituted between remedies all adapted for differ-
ent varieties of neuralgic disease.   Of all the testimony and advice in regard
to it,  none is so important as that of Martinet.   He settled down on a prefer-
ence for doses of about twenty drops, three times a day,  allowiug of  its  absorp-
tion.   When it produces diarrhoea,  he finds its good influence thwarted.   It
produces a strong sense of heat in the affected part, as well as  in the stomach
and bowels, sometimes a general perspiration.   This sense of heat in the part
is most marked in those who are cured or relieved.
  "This medicine is of approved efficacy," says  one of the notices of Mar-
tinet's essay, "in all cases  of neuralgia affecting the extremities, and particu-
larly  in sciatica, when this disease is  simple iu its character, and evinces no
sign that the nerve is either altered in its structure, or compressed by the for-
mation of a contiguous tumour.  M. Martinet affirms that, whether the com-
plaint be recent or otherwise,  the chance of cure by this remedy is greatest,
cseterts paribus, when the pain is so intense as to indicate distinctly the course
of the nerve, and so obstinate in its nature  as to yield to no other treatment
whatever."   "Twelve days," he says, "usually suffice for curing  neuralgia,
when it affects the extremities, and more commonly only half that  time.  To
continue it too  long would only injure the  organs of digestion,  if not the
urinary organs."
  Of seventy individuals,  affected chiefly  with  sciatica  and other kinds of
neuralgia of the extremities, fifty-eight were cured, viz:  three by frictions, and
all the others by taking it internally; ten (two of whom intermitted the medi-
cine) obtained only temporary relief from its use, and five received  no  benefit.
Of these seventy-one cases of  neuralgia (for one  of  the patients had  two
affections of the kind) forty were acute, and thirty-one chronic.  Of the acute,
thirty-four cases were cured, five relieved, and only one  continued in the same
state.  Of the chronic, twenty-four were cured, three  relieved, and four re-
ceived no benefit.
  Dr. Copland speaks highly of the use of  turpentine in other neuralgiae be-
sides  sciatica.  He says:  "A strong recommendation  of it is found in  its
being equally appropriate to the inflammatory and non-inflammatory states of
the affection, and in the fact of relapses being much less frequent after its use
than  after any other remedy."
  Colchicum and croton oil may both be considered as having more power
over some forms of neuralgia than they owe to their mere effect as  evacuants.
Both act at once on the kidneys and the bowels, but they have a curative in-
fluence beyond this.   Croton oil, as has been observed both by Andral  and
English physicians, has produced cures when given so as to  have no more
cathartic effect than purgatives that  had been previously used in the same
cases.  As it has been proved that colchicum often increases the proportion of
lithic acid and the lithates in the urine, and its  best effects are observed in
gouty neuralgia, we may infer that it acts by promoting  the excretion of these 
29
elements from the blood.   Croton oil also increases the density of the urine;
what solid ingredients it acts upon  particularly, I do not know.  Professor
Easton suggests some analogy as probably existing in  the curative  agency of
these two substances.1  This agency has not won  such  general confidence as
many of the medicines before named.
  External applications form an important part of the resources for treatment.
Some of those which affect in the simplest manner the circulation  and nervous
activity near the skin, are very useful as palliatives.   Pressure  and rubbing
are  often employed instinctively.   We have  stated that, generally,  pressure
on  certain  radiating or focal points aggravates the pain.   But  in ordinary
cases, not inflammatory, pressure bearing pretty evenly along the whole course
of a nerve relieves it.   I have more than once completely stopped a paroxysm
of cubito-digital neuralgia by careful bandaging of the arm.  The  pain is often
pressed away to another spot, and I have succeeded in thus chasing it off from
the fingers' ends.
  Both cold and warm applications have been found excellent palliatives, in
different cases; just as with weak eyes and some forms of chronic inflamma-
tion, it can  only be determined which  will be most soothing, by actual trial.
Compresses with cold water and ice; douches of cold water  have sometimes
carried off paroxysms.
  Dr. Warren  applies very frequently warm and hot fomentations ;  and the
hot douche.  For the latter he  has a vessel of hot water, a stopcock and hose,
and lets on  a stream of water,  say a quarter of an inch in diameter, at a tem-
perature of 110° F., continuing it as long as the patient can bear it, which is
usually for five or ten minutes.   Then he applies frictions with olive or palm
oil  for a few minutes.  He has met with much success from these  applications.
It is only in the severer cases that he adds to hot fomentations some  narcotic
plant, as conium, hyoscyamus, or hops.
   Rubefacients—the ginger or mustard poultice—deserve their reputation in
tic  douloureux.  I have seen a  paroxysm completely cut short  by  a weak solu-
tion of ammonia applied to the cheek, producing most abundant flow of tears.
   Blisters are among the most valuable remedies.  Dr. Warren says  they are
perhaps  the most  frequently useful of all.  They should not be kept open
long, or allowed to run into suppuration, but fresh  ones should be  applied from
time to time.   Two modes of application have been most successful.   One is,
by  placing  rather long blisters along the  track of the nerve, and the other
consists in putting small repeated ones over the uppermost point affected, or
that which  serves as the radiating  centre of pain.  It is in this respect that
Valleix thinks  his  investigation of the " focal  points" of neuralgia will  be
useful in guiding our treatment.  He relates a number of cases, some of them
highly interesting and striking in their results, in which a succession of small
blisters over these points was employed.   The plan is stated to have produced
a cure in many  cases, and to have always given great relief.  Blisters are also
very beneficial in inflammatory cases, after the acute stage has passed.   Fuller
recommends them, when symptoms of effusion exist,  the  active  signs of in-
flammation having disappeared—and advises  long and narrow blisters, along
the course of the  nerve, to be dressed with mercurial ointment,  to aid in ob-
taining the constitutional effects of mercury, or with powdered morphia, to re-
lieve severe suffering.
   In the obstinate affections, sciatica especially, issues and the moxa at times
succeed,  when nothing else will.  A distinguished physician of this city relies
1 London Lancet, 1842. 
30
mainly on issues made with Vienna paste, over the upper part of the ischiatic
nerves in obstinate sciatica.  When the disease shows a disposition to change
place from a nerve it has  long  occupied, we may favour this disposition by
making an issue on  the part it seems inclined to invade.  This is illustrated
by an interesting case in Dr. Rowland's  Essay, where facial neuralgia of the
severest kind had lasted nearly twenty years, when the pain showed an in-
clination to  attack the shoulder, and an issue applied there cured, almost com-
pletely, for  two years at any rate, the excruciating affection of the face, while
a slight neuralgia  persisted in the new seat.
  Many of the sedatives are used externally with even more advantage than
internally.  We have already alluded to the fomentations of hyoscyamus, &c ,
which have often  been  very beneficial in the hands of Dr. Warren—and also
to the use of belladonna in plaster, over the spot of spinal  tenderness.   This
last I have also found  exceedingly serviceable  in  many simple neuralgiae, as
also  chloroform, by itself or combined with camphor in a liniment.1  In many
country districts, where belladonna grows abundantly, poultices made by boil-
ing down  together the roots and leaves of the fresh plant, have attained much
celebrity,  both in  rheumatic and neuralgic  affections.   The narcotic effects
often follow this mode  of employment.   We are assured by a physician of
such a region, that this treatment is often successful without any internal medi-
cine. Permanent  cures are effected, within a fortnight, of facial neuralgia that
had  existed for years.   Ointments and watery solutions of  belladonna are re-
ported, by Dr. De Brayne, Dr.  Todd, and others, as having  been successful in
producing permanent cures.  Dr. Lombard has given very satisfactory results
from the use of lotions of  hydrocyanic acid and its compounds; in neuralgia
of the more superficial nerves, not complicated by inflammation.
  Aconite,  its saturated tincture, and alkaloid, possess  an  extraordinary be-
numbing power, substituting for acute  pain some  disagreeable tingling sensa-
tions.   In my own observation, I have not found them so useful palliatives as
chloroform, and can judge of any curative power they may have only from
books, which give cases treated  by so many other means at the same time as
to have little real  scientific or practical value.  In some of  Dr.  Fleming's re-
ports, the drug was  only used in this mode.   One crural neuralgia, confined
to a spot near the patella, had existed  three years, and been relieved by no-
thing but  the potential cautery; it was cured in eight  days by the external
application  of the tincture of aconite.   This application has sometimes pro-
duced the general symptoms of poisoning by aconite, and should be used with
great care, particularly  if there be any abrasion of the skin.
   Of both  aconite and  veratria, the results have not been near as favourable
in other hands as they were represented by Turnbull, and some others who
first brought them most prominently forward.  Pereira,  Brodie, Rowland, all
agree in this statement.  Pereira found  the veratria generally fail, and  con-
sidered it far inferior to aconite.   Brodie employed it in several cases without
any advantage.  Rowland never obtained permanent relief from it in any case
of long standing.  He says the first friction with an ointment of veratria often
gives very great relief; perhaps  this continues a  good deal longer than  the
usual intervals of  ease, but the pain keeps recurring and the intervals of ease
keep shortening, until they hardly outlast the unpleasant prickling occasioned
immediately by the application.   Atropia,  the  alkaloid of  belladonna,  has
cured an obstinate facial neuralgia, an ointment of five grains in three drachms
of lard being rubbed in a small piece as large as a pea, three times a day.

  1 Cazenave employs a "pommade," containing chloroform giv, cyanide of potassi-
um ajiiiss, lard ^iij. 
31
  The endermic application of narcotic and anodyne substances deserves to be
more used than I have ever known it to be in this country.   A blister should
be raised, better by  ammonia than cantharides, and the exuded  coagulable
matters should be removed at each application of the drug, since they would
interfere with absorption if allowed to remain.   The  substance applied should
be in the form of powder, or perhaps watery solution, not cerate.   Fuller
mentions that the salts of  morphia give much more pain than pure powder of
morphia.  The acetate, however,  has  been  most employed.  The  place of
application should be well  chosen—the same as  in the ordinary use of blisters
for neuralgia, along the track of  the nerve, and at a point where  this nerve is
superficial, and especially one of  the focal points.
  M. Magistel published his results obtained by the endermic use of acetate
of morphia, about twenty  years ago.   His were cases of hemicrania and neu-
ralgia of the face.   His success was great, but Trousseau since thought he
gained  great advantage by substituting the  more soluble  salts, the sulphate
and  muriate.
  An interesting  paper in the Lancet, 1846, contains some successful cases,
treated  by Dr. White, of Newcastle.   The following are some remarks of the
reporter:—
  " This mode of treating pains  which  appear to  depend principally upon
nervous irritation, or it may be chronic inflammation, and are confined in their
extent,  has  been  extensively  employed here,  and  in no  cases has  it been
attended with any disagreeable  effect; but, on the  contrary, with the most
surprising benefit in many, or,  I might say, in most of those patients who, from
their condition, seemed to be suitable for its application.  The pain is generally
soon relieved, and a comfortable feeling of ease, with sometimes  a  little drow-
siness, is experienced.  In fact, in sciatica, or indeed in any case where the
pain can be distinctly traced  along the nerve,  this plan is often the only  one
that affords even partial relief.  The application must be used as  near  the
trunk of the  nerve as possible,  particularly where the pain most  nearly cen-
tralizes. It sometimes requires to be reapplied nearer and nearer  the terminat-
ing branches, as the pain is gradually expelled.  Hence, in sciatica, the nates
first, then the knee, and lastly the foot, sometimes  in succession,  require the
vesication, and subsequent sprinkling of the morphia.  It is quite certain that
this treatment has entirely succeeded when leeches, blisters, moxas, belladonna
externally, &c, had entirely failed."
  I regret that the interesting narrations now before me, of old cases of neu-
ralgia in the sciatic and  trifacial  nerves, treated with great sagacity and happy
results,  and very well reported, by M. Mondiere, cannot be copied  into this
essay, with  their suggestive  details.   Some of  them were of the most exqui-
sitely acute form;  some had tortured the  patients for years, and resisted the
greatest variety of scientific treatment; and relief was obtained in two or three
applications, increased day by day, and the results as to  permanent cure were
most happy.   His cases were published earlier than  the investigations of Val-
leix ; and it is interesting  to observe that his best successes were obtained by
vesication and the sprinkling of morphia over points, exactly such as  this later
observer has indicated.1  In these cases no internal  treatment seems to have
been employed at the same time, though the cures  were afterwards followed
up  and  confirmed by tonics, or other management  as required.   The  inocula-
tion of  solutions or pastes containing morphia  has very often failed,  and  de-
serves to be mentioned rather for curiosity.   Its practical advantages over the
application to a blistered surface do not appear, unless in a slight saving of pain.
1 P^pertoire de Clinique, &c. 1836. 

while its success is much less.  Dr. Rowland obtained good results from  it in
but one case, out of  "at least twenty."  But I have been much impressed
with the success of the "endermic" treatment as above described; and cannot
but think it more deserving of trial than almost any  other  measure  we  have
been considering, which is at all novel.
  After reading a good many papers, on the use of electricity and galvanism
in neuralgia, the result is that I am a good deal disappointed in the  accounts
of their efficacy as means of cure.  In the London and Edinburgh  Journals
are  some communications exhibiting facts of interest.  M. C. James attributes
the failures to the imperfect application—recommending electro-puncture, the
needle (of platina or gold, and fine) carried to the nerve itself, not necessarily
deep enough to transfix it. Needles are inserted near the origin, and near the
end, of the affected nerve, and a current passed between them from  a voltaic
pile of say five or six plates, continued for  a few seconds  only, the positive
pole being made to communicate with the  needle  towards  the  origin of the
nerve.
  M. Hermel has reported cases of cure  by electro-puncture,  almost  all of
lumbo-sacral and sciatic neuralgia, sometimes accompanied by partial  paralysis.
His conclusions are thus stated:1 " 1. Electro-puncture  is applicable to idio-
pathic or essential neuralgias.  2. The violence of the pains is not a counter-
indication to the employment of this therapeutic agent; they have never in any
case been aggravated by its use.2  3. The paralysis which  supervenes in the
progress of idiopathic neuralgias yields to the same  treatment."  It may be
mentioned, for the gratification of our homoeopathic friends, that Halliday knew
of a case aggravated by it, and Berard, of  Paris, gave himself a neuralgia  by
experimenting  with acupuncture  for the purpose of applying electricity.
  Some successes have  been obtained by the electric spark and by galvanism.
The latter has been used by Dr. Thomas Harris, with the result of curing five
out of seven cases, but only after intervals  of from  ten days to five weeks.
Among various affections which I have known to be somewhat relieved by the
use of galvanic rings, was one of sciatica, of thirty years' standing.   The  re-
lief coincided with the appearance of an eruption of an eczematous character,
which spread from the  point  of  application  down to the  leg, and was  more
troublesome than the sciatica itself, while it lasted.   After four or five weeks
the eruption was nearly healed and the sciatica returned, but much  mitigated
in severity.  I am  also acquainted with ladies who count confidently  upon
cutting off an attack of neuralgia by applications of the wires connected with
the galvanic pile.  Their frequent resort to it shows  that it has no curative
powers for them.
  The effects of all  these agencies are not  so well  understood that we can
safely foretell their operation in any particular case.   Empirically employed,
with the slight indications we can gather from our imperfect knowledge, their
workings appear to be capricious.  The words of Pereira, applied to the mag-
net, have too much truth as an  expression of our experience with these  other
powers.   "In some  instances it has  appeared to exercise a most  remarkable
influence over neuralgic pains and spasmodic affections;  at one time apparently
curing, at another palliating, and occasionally augmenting all the  patient's
sufferings.  But, in  a large  proportion of cases, it fails to produce any obvious
effect."
   It remains to speak of surgical operations for neuralgia,  and we shall do it
briefly.   Besides operations already spoken of as called  for by the known  ex-
1 Quoted from Velpeau, in Copland's Diet.
A mistake. 
33
istence of a scar or other local source of irritation, surgery has been called to
render her aid empirically, in cases which resist other modes of treatment.
Three principal operative procedures have been performed, all with occasional
success, namely, section  of the  nerve, excision  of a part of its  length, and
cauterization.   Mere division of the  nerve generally gives ease only for a time,
pain returning in a few days sometimes, oftener a few weeksi   The  case of
Dr. Haighton, who performed this operation on his own mother, is commonly
cited  among the instances of success; but it appears that the pains reappeared
after a long time.1   Cases of reported success by this mode are numerous, but
those of failure far outnumber them.
  Excision and cauterization count a much  larger proportion of favourable
results.   Dr.  Warren has frequently practised the former on parts of the tri-
facial nerve.   He exposes the nerve, passes a curved knife under it, raises it
and cuts out half an inch or so of its length.   He then lets the  wound heal
immediately.   He believes that this operation would be generally successful,
if performed within a few weeks of the origin of the disease.  It should be
done, in his opinion, as soon as other modes of treatment have been tried and
have failed.   By longer delay, " the organic habit" of  pain is  set up, and the
whole course  of the nerve  becomes diseased.   He has observed several in-
stances where the paroxysms did not disappear at once, but the pain abated
only slightly for a while, and then either continued to diminish gradually, or
else  disappeared suddenly, after a time.   " After the  paroxysms have been
cured," says he, "exposure to cold on the occurrence of an injury has repro-
duced them in the same or in neighbouring nerves."
  Cauterization has been thoroughly accomplished by first cutting the nerve
across, and then touching the ends  with nitrate  of silver, or a small heated
iron.   It is considered by Boyer the most effectual operation of all, as "it de-
stroys not only the whole substance  of the nerve for a certain distance, but it
also attacks all the nervous branches proceeding from it through a considera-
ble extent, which as they may participate  in the  disease, might  be sufficient
to keep up the pain, after the resection of the principal  trunk."   In the de-
tailed accounts of cases, cauterization is not mentioned as having been followed
by the same partial relapses and remnants of  disease as  Warren has observed
after excision.  In one case of final success, however, dangerous general symp-
toms, convulsions, &c, occurred.
  The successes of either  excision or  cauterization surpass those of  mere
section of the nerve.  Between the  first two,  the choice must be determined,
not so much by any general law, as  by the convenience  of each case;  in par-
ticular the depth and size of the nerve, and the  importance of avoiding de-
formity in the situation it happens to occupy.   The difficulty of finding and
isolating the nerve, so as  to be sure  of dividing it, and  nothing else with  it,
is spoken of by Boyer as very great, and a serious objection to the operation
by excision.
  It  seemed  to me more convenient,  though  less  logical, to consider the
different modes of operating first, and the question of the  expediency of any
operation afterwards, inverting the order which we should follow in practice.
It is certain that comparatively slight operations have sometimes gained long
respite,  in a disease which is one of  the most  painful we are acquainted with.
It is a disease which has led several sufferers to submit, for the uncertain chances
of relief, to repeated amputations in the large joints, even when  the  disease
had first originated from amputation, and before anaesthesia had charmed away
1 Rowland, p, 90. 
84
the shadows of fear and  agony from the atmosphere of the operating-room.
On the other hand, we know that many forms of neuralgia tend to travel from
one nerve to another, and seem more disposed to invade a new region when
they are dislodged from an  old haunt; that many spring from a constitutional
cause; that others depend on disease in the nervous centres, the presence or
absence of which we cannot always ascertain;  and  that in the limbs we have
motor and sensitive fibres in the same nervous trunk, not separable in an ope-
ration, so  that a permanent loss of function paralyzes the  muscles it supplies,
and would cause the greatest inconvenience, if it occurred in the main nerve
of a limb.  Yet the sciatic nerve has been cut down upon by  Malagodi,  and
eighteen lines in length of  it were cut out, with the effect of leaving a para-
lysis of the leg and foot, instead of the neuralgia.
   To show that there is room to question in a general way the  utility of ope-
rations for neuralgia, let me once more refer to the highest surgical authorities.
Dr. Mott's views are stated as follows by Reese, in his Notes to Cooper's Surgi-
cal Dictionary, 1839:—
   "Dr. Mott has adopted the practice of dividing the nerve in  almost every
case of neuralgia, where  it  is practicable.   He has repeated this operation, on
the infra-orbitary, mental, and other nerves, so frequently and with so great
success that he confidently recommends it to his pupils and patients."  In Dr.
Lee's additions  to Copland's Dictionary of Practical Medicine, 1847, is a
sentence apparently referring to Dr.  Mott's  opinions expressed in his Lectures
on Neuralgia, 1842, and containing these words: "After extensive trials he
laid the operation  aside, as he found the disease very certain to return as severe
as ever."
   Brodie  says of the operation for facial  neuralgia: " It is altogether an un-
scientific operation, from which we have no more right  to expect benefit than
we should have from  the amputation of the testis, in a  case of  pain  referred
to that organ, in consequence of a calculus  being lodged in the urethra."   We
may urge in reply: 1. That the analogy does not hold  between an irritation
temporarily reflected from  one organ to  another, and a fixed  affection, always
haunting  one particular nerve.   2.  That the operations have frequently suc-
ceeded, at any rate, in obtaining a welcome respite  of months or years.
   Many points pertaining  to the general management, or regimen of neuralgic
patients have come up incidentally in this essay.  Their modes of living ought
in all cases to be regular,  the diet  simple, generally nutritious and  compact,
except in  cases of  plethora or inflammation.  Abstinence from tea and coffee
ought always to be enforced, at least long enough  to test its effect.  The habitual
use of these nervines keeps up a morbid sensitiveness of the nervous system.
I have observed this particularly in regard to strong tea used by feeble females.
With some of this class, it is  unfortunately impossible  to avoid a confining
and toilsome life,  often in confined air and constrained position, bent over
the monotonous labours of the needle.  Thoughtfulness and kindness on the
part of employers must here be looked for to  accomplish what science  can
only indicate.  An early hour of going to bed and  rising should be observed.
The mind should be preserved from overstraining and from trying excitements.
Worrying, and  particularly  angry feeling, are  a frequent exciting cause of
paroxysms.   Regular exercise of the different muscles  should be insured, as
systematically as  is consistent  with cheerful employment of the  mind  and
feelings.  A few cases have been cured by exchanging an inactive life for one
of fatigue.  Pinel mentions a gentleman  cured  at  last  of sciatica, by becom-
ing a soldier.  Another patient got rid  of a facial neuralgia by aid of the
practice of boxing, carried often to the point of  great fatigue. 
35
   In quoting often from writers of reputation, I have been influenced only by
a desire to convey, in the simplest and surest way, the results of varied  ob-
servation.   When men of sagacity and large experience have given us their
views, in regard to the disease in hand, or to  the several collateral  subiects,
which each man has studied separately more  thoroughly than one man can
study all  we may well borrow their statements, not  indeed  to  adopt them
blindly, but with all the  deference  due to practical  knowledge  and mature
thought.                                                   ° 
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