The cases are of interest from the fact 
that the first was treated by medicines 
pushed to an extreme limit; the second, fail- 
ing to improve under medicines, was treated 
by exsection of the infra-orbital nerve; while 
the last was treated by stretching the facial 
nerve. 
The cases are not reported because of any 
supposed rarity, or because they are in any 
way particularly remarkable; but merely to 
show what is the practice of the hospital, 
and to invite an interchange of views as to 
the relative merits of the treatments adopted. 
Mrs. H., suffering with neuralgia of the 
right side of the face, entered the Infirmary 
for Nervous Diseases November 9, 1885. 
She is sixty-two years old, was born in New 
Jersey, and has always lived there. She 
considers her home dry and healthy and 
free from malaria. Her father died with 
phthisis. The patient herself has never had 
malaria or chills and fever, but had an at- 
tack of pleurisy fifteen years ago, associated 
with severe eough. This has been her only 
severe illness. She has been married forty- 
two years, and has had fourteen children, of 
whom two only are living. Eighteen years 
ago she experienced a severe shock in the 
loss of six children from diphtheria within a 
period of four weeks: she had previously 
lost others in their infancy. 
Twenty years ago the patient began to 
have twinges of pain in the lower jaw. Four 
or five years ago she suffered from attacks of 
neuralgia of the right side of the face two 
or three times a year: these attacks lasted 
from one to three months. In 1884 she had 
four or five attacks, one of which lasted two 
months; though quite weak, she was not con- 
fined to her bed at any time. Fever some- 
times accompanied the attacks, without any 
chill, but with a cold sweat when the pain 
was very severe. 
A year or two ago the pain occurred at 
any time during the day, but passed away 
at evening, upon retiring and remaining 
quiet. In April, 1885, the pain began to be 
worse at night, but it cannot be said that 
any special hour was observed. Cold air, 
eating, or drinking very hot drinks, motion 
in bed, bad news, mental trouble, aggravated 
the pain. Rest, peppermint essence dropped 
on the tongue, sweating the face with hot 
bricks dampened with whisky and wrapped 
in cloth, did for a time relieve the pain. 
The treatment adopted consisted of rest in 
bed, good feeding, and the use of an ascend- 
ing galvanic current. This was applied to 
the right side of the tip of the tongue and 
to the right side of the lower jaw for fifteen 
FACIAL SPASM AND TIC-DOULOU- 
REUX FOR WHICH NEUREC- 
TOMY AND NEURO-TENSION 
WERE EMPLOYED* 
BY GUY HINSDALE, M. D., 
Of Philadelphia. 
I have the pleasure of asking your atten- 
tion to the records of two cases of persistent 
trifacial neuralgia, and also a case of pain- 
less facial spasm. The two former were un- 
der the care of Dr. S. Weir Mitchell at the 
Infirmary for Nervous Diseases, and the last 
under the care of Dr. W. Sinkler, by whose 
permission they are brought before this So- 
ciety. 
♦Read at the Philadelphia Neurological Society, Decem- 
ber 27, 1886. minutes, morning and evening. This was 
the chief locality of pain. Cod-liver oil,3iv., 
and tinct. aconiti rad. were given after meals. 
The aconite was gradually increased in quan- 
tity until, on the nineteenth day, she was 
taking seventeen drops four times a day. 
Elixir of iron, quinine, and strychnia, one 
teaspoonful thrice daily, was then added. 
The early doses of aconite, of two and three 
drops each, produced some tingling of the 
fingers and tongue, with numbness of the 
right arm and hand; the larger doses did 
not produce any more pronounced symptoms. 
The pulse varied in frequency from 67 to 82 
per minute. Hydrochlorate of cocaine in 
four per cent, solution was applied two or 
three times a day to the painful spot on the 
right side, of the extremity of the tongue; 
this gave relief for about twenty- or thirty 
minutes. Failing to control the pain notwith- 
standing this persistent use of aconite, on De- 
cember 1 fluid extract of gelsemium was used; 
four drops were given thrice daily, and the 
dose gradually increased until the physiologi- 
cal effect was produced. Hunyadi water was 
given occasionally, and massage of the spine 
was adopted. On the following morning a 
blister was applied to the right temporal and 
zygomatic region ; a cold-water dressing con- 
taining half a grain of morphine was used. 
The blister had caused considerable local 
irritation by evening, and the pain in the 
face and tongue was relieved; the pain, how- 
ever, recurred the next day, with dull ach- 
ing in the forehead and across the eyes. 
Lunar caustic was applied to the right 
side of the tip of the tongue on December 
4; the area cauterized was about half an 
inch square. Electricity was suspended for 
three days. Subsequently applications of 
nitric acid were made to the tongue. 
Swimming of the forehead, dimness of 
vision, and drowsiness accompanied the in- 
creasing doses of gelsemium. The dose of 
gelsemium was increased for twenty days, 
until the patient took thirty-six drops of the 
fluid extract three times a day ; there were 
then dizzinesss, headache, some drooping of 
the eyelids, but no pronounced symptoms 
or apparent benefit from the medication. 
I have prepared a chart from the careful 
daily records taken by Miss Kenealy, the 
chief nurse of the Training School, showing 
for each day the treatment, the pulse, respir- 
ation and temperature, and subjective symp- 
toms. 
At the end of seven weeks the patient was 
discharged, although still suffering at inter- 
vals from pain in her tongue. The facial 
pain was very much less than when she ap- 
plied for treatment. The use of nitric acid 
on the painful spot in the tongue was ad- 
vised. 
At the end of six months the patient was 
still suffering with neuralgia, but not so 
severely as at first. 
Mrs. E. H. H., set. 64. No hereditary 
nervous disease. She was delicate in 
early life, and as a child had chills and 
fever for three years, but never had any 
serious illness. Thirty years ago she be- 
gan to have pain in the infraorbital, and 
then in the supraorbital region, darting and 
of intermittent character. It was serious 
enough to confine her to bed. The attacks 
were influenced by weather and exposure. 
Sometimes attacks came on every few days ; 
sometimes not once in three or four months. 
Exposure to draught, to cold, or to wind, 
would bring them on. Warmth would re- 
lieve the pain. Liniments failed ; warmth 
always gave the most relief. Duration of 
attacks,.one to seven days, or even a month. 
For seventeen years she had noticed a singu- 
lar sensation in the right nostril, as though 
pierced by a dozen needles. Pain extended 
to the cheek and under the eye. The pa- 
tient for four years had a severe attack, last- 
ing the whole month of February. It 
would take an entire month to recover from 
its effects. 
November 21, 1885, the pain was constant 
and more or less severe, both diurnal and 
nocturnal, and she was kept awake a great 
deal at night. Teeth had been extracted 
from both jaws before applying for treat- 
ment. 
A general tonic treatment, consisting of 
massage, lactate of iron, cod-liver oil, and 
malt, was adopted, and galvanism was ap- 
plied gently to the side of the face. Blister- 
ing, morphine, quinine, arseniate of iron, and 
bromide of lithium, were applied in succes- 
sion, without relief. 
Finally, the infra-orbital nerve was ex- 
sected by Drs. Hunt and Morton, a small 
portion of the floor of the orbit being also 
removed. The patient suffered a good deal 
of pain in the same spot as before: this, 
however, subsided to a certain extent, and 
two weeks after the operation she returned 
i to her home in Maryland. While not alto- 
[ gether free from neuralgic pain, she consid- 
; ered herself much more comfortable than 
before, and greatly improved in general 
health. Nine months later she was reported 
to be in good health, with little or no neu- 
ralgia. 
In a case of painless spasm of the face, 
Dr. W. W. Keen has recently operated on oinkier. me patient had twice been para- 
lyzed. Five years ago the right eyelids be- 
gan to twitch, and in six months the whole 
face and the platysma were incessantly in 
spasm, which was increased by mental or 
muscular effort; lattr, this was accompanied 
with constant pain. In June, 1884, the right 
infra-orbital nerve had been resected, with 
partial relief for only six weeks. Not long 
after this the twitching extended to the right 
side of the body and to the leg. 
April 2, 1886, Dr. Keen laid bare the 
trunk of the nerve, using an electric current 
to facilitate its discovery. The nerve was 
then stretched; the force used was just short 
of enough to lift the head. Total paralysis 
of the face followed, with relief not only of 
the spasm of the face and neck, but also of 
that of the side and leg. 
Stretching of the facial nerve for cramp 
had been performed by Baum and Schiiss- 
ler in 1878, Eulenberg, Godlee, Hahn, and 
others. 
In Eulenberg's case, stretching the nerve 
was resorted to after a neurotomy of the 
supraorbital had failed ; a tolerably severe 
paralysis resulted, lasting several weeks, but 
finally disappeared. In Godlee's case, 
twenty-eight months after the stretching the 
favorable result remained. In Hahn's case 
there were spasms over the whole right side 
of the face ; after the operation, which did 
not induce any paralysis, there was only par- 
tial benefit. Two years after the operation 
the cramps persisted. 
In 1880 Langenbeck stretched the tem- 
poro-orbital division of the left facial nerve, 
and also a branch going to the zygomatic 
muscles. After twelve days the eye re- 
mained wide open, paralyzed; the angle of 
the mouth drooped. Two months later pare- 
sis of the left side of the face was still ap- 
parent ; return of spasm. After four months 
the spasm was as severe as ever, and the par- 
esis was apparent. The patient thought the 
paralysis the lesser evil of the two. 
In a case of Godlee's in which there 
was painful spasm of both sides of the face, 
the left facial was stretched; paralysis fol- 
lowed. Four months later the right nerve 
was stretched. Several months after this the 
paralysis had disappeared, and the condition 
was as bad as before the operations. 
In Putnam's two cases the results were 
not encouraging. 
In a case of Southam's, in 1881, the par- 
alysis vanished in sixteen weeks ; two and a 
half years later the good result was still ap- 
parent. 
gave permanent good results in three, doubt- 
ful in two, considerable improvement in four, 
failure in ten. In ten cases temporary ben- 
efit followed the operation. 
AN ANALYSIS OF THE OCULAR 
SYMPTOMS OBTAINABLE IN 
EPILEPSY IN THE MALE 
ADULT* 
Visiting Physician and Ophthalmologist in the State Hos- 
pital for the Insane, Norristown, Pent syivania; Oph- 
thalmic and Aural Surgeon to St. Mary's 
Hospital, Philadelphia. 
BY CHARLES A. OLIVER, M. D., 
The clinical material for these observa- 
tions was obtained at the State Hospital for 
the Insane at Norristown, Pennsylvania. 
The report embraces a study of all the oph- 
thalmic symptoms that could be gotten from 
fifty male adult epileptics, without reference 
to any past etiological factor or present men- 
tal condition. This method was pursued for 
several reasons, most prominent being: 
1. A special form of symptomatic disease 
was taken in preference to any mental con- 
dition, because similar mental states may be 
present in the many and bizarre forms of 
nerve-lesions, making and hiding the true 
significance of the objective symptoms pecu- 
liar to any one disease to such an extent as 
to render differentiation impossible. 
2. A definite variety of disease was chosen, 
so as to avoid obtaining mere percentages of 
the ophthalmoscopic signs (which, as a rule, 
have been limited to an arbitrary designa- 
tion of the tint of the optic disk and the size 
of the retinal vessels) of the total number 
of cases occurring in one asylum-practi- 
cally giving, if at all correct, a resume of 
the different varieties of optic-nerve color 
and retin al-vessel size of the gross amount of 
residents of that asylum ; an answer which is 
liable to alter at any time through change of 
number of patients and character of mental- 
ity, or to be totally diverse from the results 
obtained by another observer placed in a 
different situation. 
3. A large percentage of similar cases 
was taken. This was done so that the dif- 
ferent mental states which are seen during 
the course of any one disease might be 
united into a theoretical average case, which 
would represent a typical example of the 
physical and physiological conditions of that 
disease. 
4. Males were used. This is important, 
•Read before the Philadelphia Neurological Association, 
December 27, 1886. any errors that might arise from additional 
ocular changes dependent upon diseases 
which are peculiar to the sex are avoided. 
It may be interesting to know that native 
American stock has been used. There is 
nothing absolutely important in this selec- 
tion, because, by reason of many obvious 
causes, a true American type of man has 
not as yet been established among us ; yet it 
was intentionally done, so that results ob- 
tained from subjects born on American soil 
could be contrasted and compared with sta- 
tistics of foreign-born population, in order to 
see whether the data would exhibit any de- 
cided peculiarity in ratios. 
portions of the eye-ground, even hiding the 
edges of the disk itself in many instances. 
13. Retinal vessels large in size and car- 
rying rather dark-colored blood, this being 
more pronounced than usual with the veins. 
14. Retinal veins exceedingly tortuous, 
and in a few instances pulsating. 
15. Retinal arteries frequently wavy and 
sometimes tortuous, especially the temporal 
and macular twigs. 
16. Retinal lymph-channels visible in the 
majority of cases, particularly seen along 
the larger vascular distributions and at the 
vessel-entrance as glistening and yellowish- 
white opacities. 
17. No other visible changes of any sig- 
nificance throughout the eye-ground, except 
a granular condition of the choroid in the 
macular region. 
In addition, it may be mentioned that, as 
far as possible, nearly all of the deep and 
superficial reflexes were obtained throughout 
the body. These, as a rule, were above nor- 
mal, and presented some curious anomalies, 
which will be reserved for a later publica- 
tion. 
As was to be expected among this class of 
patients, many of the subjective signs were 
negative; but, withal, sufficient data have 
been produced to warrant proper conclusions 
in this direction. The results obtained from 
tne study made of the visible ocular changes 
are of special value, and may be cited as of 
sufficient importance to be useful in diag- 
nosis. 
Thanks are due to Drs. Charles A. Wood- 
nutt and Henry Sykes, assistant resident- 
physicians, for good work and carefulness 
displayed throughout these researches. 
1507 Locust street. 
1. Direct vision for form, as a rule, nor- 
mal in both emmetropia and corrected ame- 
tropia. 
2. Accommodative action uormal in due 
proportion to age and refractive error. 
3. Visual fields for form and color re- 
duced from one-third to one-twentieth of 
normal areas. 
4. Visual fields for form and color regu- 
larly diminished without any indentations or 
scotomata. 
5. Order of color-field follows the regular 
physiological sequence, without transposition 
or reversion. 
6. Subnormal color-perception to a slight 
extent, as evidenced by faulty selection of 
delicate tints and shades containing low per- 
centages of green and red. 
7. Pupils are, as a rule, equal in size and 
alike in shape. 
8. Irides freely and equally mobile to 
light-stimulus, accommodation, and conver- 
gence. 
9. Extra-ocular motion intact in all direc- 
tions. The presence of insufficiency of the 
interni in the majority of cases is readily ex- 
plained by association with existing H V Ah, 
and probably has no relation to the epileptic 
condition. 
10. Optic disk superficially over-capillary, 
with a decided grayness in its deeper layers, 
showing a low grade of incipient optic-nerve 
degeneration. 
11. Scleral ring rather more sharply cut 
and broader, especially to the temporal side 
of the disk, than in the healthy eye ; this 
being probably due to a slight shrinkage of 
lowered nerve-tissue. 
12. Fibre-layer of retina increased in 
thickness, as evidenced by dense and coarse 
massings of striation extending in all direc- 
tions from the disk, these being more partic- 
OBSERVATIONS AND CONCLUSIONS. 
Medical Societies. 
THE PHILADELPHIA NEUROLOG- 
ICAL SOCIETY. 
A stated meeting was held December 27, 
1886; the President, Dr. S. Weir Mitchell, 
in the chair. 
Dr. Guy Hinsdale read a paper entitled 
Facial Spasm and Tic-Douloureux for which 
Neurectomy and Neuro-Tension were 
Employed. (See page 166.) 
The President, Dr. S. Weir Mitchell: "I 
have several points to make with reference 
to these cases. The woman operated on by 
DISCUSSION. Dr. Keen I have seen within the past few 
days, and she presents no paresis of the face 
at all. As yet, the case is a perfect success. 
She is entirely free from any twitching. Her 
case recalled others, and in looking over my 
note-books I found that within the past 
twelve years I had seen fifteen cases of pain- 
less tic, in none of which was the slightest 
relief afforded by any method of treatment. 
It so happened that shortly after Dr. Sink- 
ler's case was treated so successfully, Mrs. G., 
aged forty-nine, the widow of a physician, a 
very intelligent woman, consulted me. She 
stated that her tic had begun about three 
years ago. It first appeared under the eye, 
where it nearly always begins, although I 
may say that as yet the history of these cases 
is not complete. Then the twitching ap- 
peared in the cheek, which, as a rule, has 
been the point next attacked in my cases. 
The spasm afterwards extended to the mouth. 
In those cases in which it became general it 
extended beyond that, and in the last case 
that I have seen the levator muscles of the 
ear were involved, so that the ear was drawn 
upward every time that the face twitched. 
But extension to the neck or more distant 
parts is seen at times in rare cases. 
" In Mrs. G. the spasm is very violent, and 
she described it by saying that 'the whole 
side of the face migrated under the left ear 
and stayed there awhile.' The length and 
endurance of the spasm were remarkable. 
She had from ten to fourteen attacks every 
minute. They were pretty regular. At 
certain times she was comparatively free, 
but scarcely five minutes passed without 
twitching. 
" I observed in this case, as in some others, 
a certain amount of appearance of paresis 
on the affected side of the face-that is to 
say, the muscles on the sound side of the 
face appeared to predominate. I have so 
far been unable to observe any difference in 
the electrical reactions of the affected mus- 
cles. Perhaps more careful observation will 
show some change. It has been suggested 
to me that this paresis was the result of fa- 
tigue; but, as we know, in most spasms the 
muscles become larger and stronger, and do 
not present evidences of fatigue. 
"In this case I began to think whether 
there was not something which had not been 
done which might give relief. The idea of 
weakening the facial nerve or its branches 
by freezing suggested itself. If I had re- 
flected a little I should have recognized the 
fact that it is impossible to affect the deeper 
nerves in this way. Freezing by vapor-jets 
applied to the surface acts very little beneath 
the skin. I have tried this by putting the 
finger in the mouth and trying to freeze 
through the cheek by means of the rhigolene 
spray. I have never succeeded in produc- 
ing more than a slight chilling. In this 
case I have on sixteen occasions frozen with 
the rhigolene-jet a large portion of the skin 
of the cheek, sometimes covering the whole 
of the side of the face, taking care to pro- 
tect the eyes and to prevent the inhalation 
of the vapor. 
"The result has been an interesting and a 
curious one. The very first freezing, like 
all the subsequent ones, brought on instan- 
taneous spasm. The moment the jet struck 
the face there was violent twitching. When 
freezing was effected the spasms ceased and 
did not return for many hours. This result 
surprised me very much, and it appeared 
that while I was attempting to accomplish 
the result in one way I had done it in an- 
other. 
"Under these daily freezings this case has 
gained so far as to pass days without more 
than such rare twitches beneath the eye as 
excite no attention. Enough has been won 
to satisfy her if the gain should last, as to 
which I will report. 
I observed that a vigorous freeze over the 
points of nerve exit was better than a gen- 
eral freeze. I am about to try if localized 
freezing by ice and salt, or other means 
which act more deeply, may not answer. The 
influence seems to be exerted through the 
sensory nerves, from which possibly arise 
also the impressions which create these 
spasms. With my remembrance of former 
cases, I cannot say that I feel hopeful as to 
the remote future of the present one. 
" I have tried the same plan of treatment, 
in a second case of nine years' standing. 
She came to me some years ago, but, as I 
knew of nothing that would afford relief, I 
refused to treat her. I sent for her ten days 
ago, and began the use of the rhigolene 
spray. She too has slight paresis. The face 
is apparently pulled to the right, the spasm 
being on the left side, which is the side com- 
monly affected. The results obtained with 
the individual freezings are practically the 
same as in the first case. The touch of the 
spray brings on the spasm. When the part 
is frozen the spasms remain absent for a 
considerable length of time, although not so 
long as in the first case. The period varies 
from half an hour to two hours. Under this 
plan of treatment the attacks have dimin- 
ished in frequency and in intensity. 
"This is as far as I have gone, but I 
thought it well to bring this matter before you, for some of you may have one of these 
rare cases under observation and may desire 
to try the same experiment. As we know of 
no method of treating these cases except by 
operation, I consider it perfectly proper to 
try the effect of rhigolene. After the spray 
has been used for some days, care must be 
exercised that a slough is not produced. I 
have never had a slough, although I have 
made the skin very sore. This has led me 
to think that possibly the good result was 
due to counter-irritation, and I shall not be 
satisfied until I have tried extensive counter- 
irritation over the origin of the facial nerve 
in some suitable case." 
Dr. J. Madison Taylor: " I have had under 
my care a case in which a severe spasm of 
the right side of the face had been present for 
twenty years. The woman was nervous, and 
came of a family, many members of which 
were in a general way nervous, yet quite 
strong and robust. The spasm, although 
very annoying, was not sufficiently marked 
to call for special treatment. About fourteen 
months ago the youngest daughter of this 
woman passed through a severe attack of ty- 
phoid fever. The mother, from nursing the 
child, became very much exhausted. Then 
the spasm grew worse, and was at times suffi- 
cient to shake the head. When the child 
became convalescent the mother was taken 
with the disease and had a severe attack, 
with high fever and delirium for six days. 
Upon her recovery from the typhoid fever 
the spasm had entirely disappeared, and to 
the present time, a period of ten or twelve 
months, there has been no return. It is in- 
teresting to note the curative effect of a se- 
vere illness on this intractable disorder. 
Hers was a veritable purgation with fire."