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The susceptibility of different persons to this drug is so different that
the dose should first be as small as 1/400 gr., but this may be repeated
every three hours, and gradually increased to 1/100 gr., or until its
physiological effects are felt. Patients must sometimes be kept under
its influence for weeks together.25 It is, however, a remarkable fact
that occasionally a few full doses will secure an immunity from pain
for a long period. Although most useful in facial neuralgias, the writer
has known it to be effective in brachial and mammillary neuralgia.
Aconitia can now be had in granules of 1/400 gr., or can be given in
alcoholic solution.
25 See Seguin, Arch. of Med., vol. vi., 1881.

Gelsemium is also occasionally very useful in facial and even in

intercostal neuralgia, and is said to be of special service in the
neuralgia due to carious teeth. The commencing dose of the fluid
extract is five minims, which may be gradually increased to twenty,
or until a slight degree of muscular prostration, ptosis, or dilatation of
the pupil is induced.

The use of phosphorus has been revived of late years, chiefly

through the efforts of J. Ashburton Thompson, and it is at least
occasionally of service. Success is said to be best obtained by full
doses (about 1/20 gr. every three or four hours, up to 1/5 or 1/4 gr. daily
for some days), watch being kept for signs of gastric irritation. The
best preparation is an alcoholic solution (Thompson's), such as the
following:

Rx. Phosphorus, gr. j;

Abs. alcohol, fluidrachm vi.
Dissolve with heat.
Glycerin, fluidounce iss;
Alcohol, fluidrachm ij;
Spts. peppermint, minim v.
One teaspoonful represents gr. 1/20.
Electricity, if properly used, is capable of temporarily, and even
radically, relieving the neuralgic state. The forms most often
employed are faradic and galvanic electricity, though frictional
electricity has also been coming into use of late, mainly as a
substitute for faradism. The galvanic current is by far the most
efficacious of all. This probably acts mainly by directly inducing
better nutritive and better functional conditions in the nerves and
nerve-centres, but the fact that it is often of use in cases of
undoubted neuritis seems to indicate that it may also influence the
grosser structural changes in the affected parts, if such are present.
It is impossible to explain its action more exactly, and the teachings
of physiological experiments do not lend us much aid.

It is probably not of much consequence which pole is used in the

neighborhood of the affected nerve. It should be remembered that
the peripheral nerve-trunks are so deeply buried that the electrodes
cannot be directly applied to them, as they are to the exposed nerve
of a frog in the laboratory, and, further, that instead of being isolated
they are surrounded with tissues of good conducting power, into
which the current must rapidly flow off. For these reasons the nerve
near which either electrode is applied is virtually exposed to the
action of both poles in almost equal degree; and although it is more
customary to use the positive pole in the neighborhood of parts
which are considered to be in a state of irritation, yet clinical
experience has not justified the conversion of this custom into a rule.
Neither is the direction of the current of material consequence.

It is, however, very important in acute cases to take care that the
current-strength should not be rapidly changed; and for this reason
the electrode should be drawn slowly to a distance from the nerve
before it is removed, or left in situ while the current is gradually
diminished by a suitable rheostat. As a rule, the former method is the
more practicable.

In the treatment of acute cases moderate currents and short

applications, frequently repeated, are the best. On the other hand, in
cases of long standing, especially cases of sciatica, strong currents
are sometimes more effective, and even interruptions and reversals
of the current may be in place.

The choice of a battery is not a matter of indifference. Any stationary

battery of high interior resistance will answer the purpose, but most
of the portable (zinc-carbon) batteries in common use are
objectionable,26 for the reason that their interior resistance is so low
in proportion to that of the body that it may almost be counted out as
a factor in determining the strength of the current. The latter is liable
to rise, therefore, quite suddenly as the resistance of the body—i.e.
the vascularity of the skin—becomes modified. This objection is
obviated if a large, constant resistance (water or graphite rheostat) is
attached to the battery and kept always in the main circuit.
26 Archives of Medicine, April, 1884.

Faradism probably owes its efficiency to the indirect effects of

stimulation of the sensitive nerves of the skin. This may be produced
either by the wire brush, which causes a sharp irritation and
reddening, and is to be compared with the counter-irritants, or by the
milder application of a moist or dry electrode or the hand of the
operator. The latter procedure may be compared to the superficial
manipulation which is sometimes so grateful, especially in nervous
headaches.

The value of electricity as a general tonic should be remembered in

this connection.

Hydropathy.—Douches and baths of various kinds have doubtless

proved of much value in the treatment of neuralgia. The majority of
them, however, are difficult of application for the general practitioner,
and we confine ourselves to mentioning the tonic and soothing
action of the wet pack and of the prolonged warm bath, which should
be followed by sponging with cool water, and used under every
possible precaution against exposure.

Long-continued local applications of gentle heat (bags of sand or

salt, or hot water) are often temporarily grateful, and in the treatment
of chronic cases the daily application of hot water or ice-bags to the
spine is said to have a good effect. In acute and subacute neuritis,
and in those forms of neuralgia in which neuritis plays a large part,
such as sciatica, the persistent application of ice-bags along the
course of the affected nerve, even for days together, is sometimes of
great service. Even where we cannot be sure that neuritis is present,
long-continued applications of ice may be of use, but alternations of
cold and heat, on the other hand, are usually to be carefully avoided.
This treatment is safer in chronic than in acute cases, though it may
be useful in either.

Counter-irritation.—A spray of ether may be substituted for ice when

only a temporary chilling is desired, for its counter-irritant effect. This
has even been used on the face, the eye being protected by some
suitable covering, and a good deal of benefit is to be hoped for both
from this and from the similar use of chloride of methyl.

Debove27 has found the chloride of methyl, used in this manner,

singularly effective in the treatment of sciatica. A considerable and
long-continued counter-irritation is thus made over a large surface
and without great pain. The neuralgia is said to be greatly relieved
and a rapid cure sometimes affected.
27 Bulletin générale de Thérap., cited in the Boston Med. and Surg. Journ., vol. cxii. p.
210.

Counter-irritation is also practised by making applications of

cutaneous irritants, such as blisters, mustard, turpentine, chloroform,
or of the actual cautery carried in light superficial stripes over the
skin, and repeated if necessary at short intervals. As a rule, the
counter-irritation is more effective the larger the surface which is
covered.

The use of the cautery and of blisters is in place in almost every form
of neuralgia where the temporary disfigurement is of no
consequence.
Of other cutaneous applications, aconite and chloroform liniments,
menthol in substance or in alcoholic solution (drachm j or drachm ij
to fluidounce j), aconite and veratrine ointments, are the most useful.
A strong aconitine ointment, made with Duquesnet's aconitia and
lard (drachm j to ounce j), has been recommended by Webber28 to
be used in portions of the size of half a split pea, but, though
effective, it needs to be employed with great caution.
28 Nervous Diseases, Boston, 1885.

These applications act in part as irritants, by keeping up a play of

sensitive impressions in virtue of the lodgment which they effect in
the skin, but also, no doubt, by reducing the sensitiveness of the
cutaneous nerve-fibres, and thus removing one source of excitation
of the diseased nervous centres. The remarkable temporary benefit
sometimes obtained from the instillation of cocaine into the eye in
cases of neuralgia of the ophthalmic division of the fifth nerve bears
testimony in favor of this explanation.

Surgical operations for neuralgia are of three kinds—section

(neurotomy), removal of a piece of nerve (neurectomy), and nerve-
stretching. The two former operations are of course rarely practised,
except upon the purely-sensitive fifth pair of nerves, the latter upon
mixed nerves also.

Neurectomy is now almost always substituted for simple neurotomy,

and sometimes still more effective means are taken to prevent the
reunion of the nerve, such as doubling over the cut end, destroying
the nerve throughout the length of the bony canal in which it lies, and
even plugging the canal with cement.29
29 Heustis (Med. News, Dec. 8, 1883) found that the infraorbital nerve could be
readily drilled out with a piece of piano wire.

The inconvenience following nerve-section is as nothing compared

to the pain of a severe and intractable neuralgia. It has rarely
happened that the disease has been increased by the operation, and
under proper antiseptic precautions the surgical risks are not great.
There is some chance of permanent cure, and a much greater
chance of securing an immunity from pain for a long period.

It is important to remember that when the neuralgia occupies the

distribution of several branches of the fifth nerve, an operation on the
one primarily or most severely affected may relieve the pain in all.
On the other hand, the converse may be true,30 inasmuch as the
same district is supplied by recurrent fibres from several different
sources. Before any operation is decided on it should be
remembered that even in apparently desperate cases of trigeminal
neuralgia the persistent and thorough use of tonic and other
remedies may in the end be crowned with success, perhaps at the
moment when it is least expected.
30 Cartaz, Des névralgies envisagés au point de vue de la sensibilité récurrente.

During the past few years the operation of nerve-section has been to
some degree superseded by that of nerve-stretching, as being less
serious in its immediate (though not necessarily in its remote)
consequences, and sometimes more efficacious. Hildebrandt,
indeed, raises the question whether the traction which is apt to be
exerted when a nerve is cut is not an important element in bringing
about the result. On the other hand, cases are reported where
neuralgia which had not been relieved by stretching was cured by
resection.31
31 Nocht, Ueber die Gefolge der Nerven-dehnung.

The best showing for the operation is in the treatment of sciatica, but
most of the other superficial nerves, including the intercostals, have
been successfully treated in the same manner.

On the other hand, this treatment is not without its dangers. Apart
from the risks of the operation itself, cases have been reported in
which the spinal cord has been injured, so that chronic myelitis has
been set up, and a greater or less degree of paralysis—rarely
permanent, it is true—may be induced by the direct injury to the
nerve.
This means of treatment is therefore certainly to be thought of in
serious and obstinate cases, but not lightly decided on.

A substitute operation for sciatica is the so-called bloodless

stretching, in which, the patient having been etherized, the thigh is
forcibly flexed on the pelvis, and then the leg extended on the thigh
and the foot on the leg (dorsal flexion), and held for a short time in
this position. A very material degree of stretching of the sciatic nerve
is doubtless possible in this way, and a number of cures have been
thus effected. But, though less dangerous than the stretching of the
exposed nerve, this operation is not a trifling one.

In one case of sciatica the writer has seen a neuritis of some severity
lighted up by this operation, perhaps because the disease was in too
active a state, although it had lasted some months. The operation is
probably most indicated in chronic cases.

The anatomical effects of nerve-stretching are manifold. Nerve-fibres

are usually destroyed in greater or smaller number, and the
conducting power of the nerve correspondingly impaired. Small
blood-vessels are broken and the circulation and nutrition of the
nerve-trunks altered, and it is probable that adhesions in and around
the nerve-sheaths, where such exist, are severed. The nerve-fibres
ramifying in the inflamed sheaths of the large trunks may also be
ruptured, and it may be that the displacement of the fluid contents of
the nerve brings about better nutritive conditions.32 It is also probable
that the operation either directly or indirectly affects the nutrition of
the nerve-centres,33 and although this is not without its dangers, the
chances are in favor of a beneficial result.
32 See “Die Rückenmarks-dehnung,” Hegar, Samml. klin. Vorträge, 239.

33 Hegar, loc. cit.

Another means of directly acting on neuralgic nerves is by

subcutaneous injections of water, chloroform, ether, osmic acid,
nitrate of silver, and other substances. The deep injection of water
over the affected nerve is attended with but little danger, and is
occasionally successful. The similar use of chloroform, in doses of
15 to 30 minims, is much more often effective, but sometimes
causes great pain, and even abscess. It has been mainly used in
sciatica, also in other neuralgias, even those of the fifth pair. In this
case the injection is best made through the buccal mucous
membrane. This treatment is not without danger of causing collapse,
or even death, probably due to the wounding of a small vein. In one
case of sciatica treated by the writer the chloroform probably entered
the nerve itself to some extent, as the injection was followed by very
severe pain lasting for several hours, and eventually by some degree
of muscular wasting. The neuralgic pain, which had continued
obstinately for a long period, was, however, cured, and had not
returned at the end of some days, when the patient was lost sight of.

Osmic acid has been used recently in the same way, and the reports
show about an equal number of successes and failures. The dose is
about 8 minims of a 1 per cent. solution, and the injection may be
repeated at intervals of a few days. It has been used successfully in
various parts of the body, including the face and the fingers. The
injection causes no great pain, but occasionally, though rarely,
excites abscess.

Under the general heading of massage a number of manipulations

may be grouped which are of value in the treatment of neuralgia,
even of long-standing cases of sciatica and the like.34 When, as
often happens in the case of sciatica, the nerve is the seat of
congestion and exudation, strong and deep kneading along its
course, with vigorous stroking upward in the direction of the lymph-
vessels, is the important part of the treatment. Besides this, however,
the prolonged and gentle manipulation of the painful region may
greatly relieve the patient for a time, apparently by acting on the
sensitive nerves and exerting a sort of inhibitory action, in which it is
not at all impossible that an influence upon the attention analogous
to that of Braidism plays a part.
34 See Reibmayr, Die Massage, etc., Wien, 1883.
A striking instance of the effect of this treatment is seen in the case
of nervous headaches, which are often very greatly relieved by a
series of gentle, monotonous movements of the finger-tips, as well
as by the domestic remedy of gently and persistently combing or
brushing the patient's hair. A still more efficient application of a
similar kind is the regular vibration communicated by a large magnet
or by the instrument devised by Mortimer Granville. A thoroughly
satisfactory explanation of the action of this treatment is yet to be
furnished.

There is no doubt that in the treatment of neuralgia a persistent and

thorough use of the remedies suggested is usually the key to
success. Nevertheless, special cases are sometimes reached by
special means of treatment, and the following are appended as
occasionally useful: Ammonio-sulphate of copper (grs. ij-vj, taken in
divided doses in the course of the day); salicylate of soda, in full
doses; caffeine; tonka (fluidrachm j of the fluid extract at repeated
intervals of a few hours); oil of turpentine; muriate of ammonia.

Special Forms of Neuralgia.35

35 Consult, in connection with this subject, the sections on Symptomatology and

Treatment.

MIGRAINE AND PERIODICAL HEADACHE.—In many of the recent treatises

upon nervous disease migraine and headache are removed from the
category of the neuralgias and placed in that of the functional
affections of the sympathetic vaso-motor system of nerves. This
classification is based upon the fact that in many of these cases
marked vascular changes—congestion or anæmia, as the case may
be—are observed in the external tissues of the affected parts, while
the sensations of the patient often lead us to infer the presence of
similar conditions within the cranium. The pain and the other
symptoms of the outbreak, it is thought, are due to the changes in
blood-tension in the cortex cerebri or in the region of expansion of
sensitive nerves, or, in part, to the spasm of the muscular walls of
the vessels themselves. This theory is seductive from its appearance
of pathological simplicity and exactness, but the writer believes, with
Anstie, Latham, Allbutt, and other observers, that it is not borne out
by clinical experience, and that its adoption tends to cloak the wider
relationship that exists between the sensory neuroses.

Migraine, nervous headache, and the superficial and the visceral

neuralgias hardly differ more fundamentally from each other than
individual cases of either affection differ among themselves. It is not
improbable, as we have seen, that all the phenomena of some
neuralgic attacks are wholly or in part the expression of irritation of
the sensory nervous system from without; but in many cases, on the
other hand, the signs of the neurosal tendency are clearly marked,
and there is hardly one of the symptoms of a typical migraine of
which the analogue may not be found, though perhaps faintly
pronounced, in one or another form of superficial neuralgia, while the
relation of both to the whole family of the neuroses is still more
clearly evident.

Migraine is a disease of youth and middle life, characterized, in its

most typical form, by attacks of severe headache of a few or many
hours' duration, of gradual onset and decline, ushered in by well-
marked auras involving one or more of the cerebral functions, and
terminating in nausea or vomiting or profuse secretion of pale urine,
or in some other critical nervous outbreak. The pain is usually, but
not invariably, deep-seated. It may be confined to one side of the
head, most often the left, or may involve both sides, either from the
outset or in the course of the attack. The forehead or temple is
usually the first part to become painful, but in severe or prolonged
seizures the parietal and occipital regions are prone to be affected
likewise.

The auras are manifold and important. On the day before an attack
the patient may feel remarkably well, or may complain only of such
sensations as thirst or giddiness. The attack itself is apt to be
ushered in by visual hallucinations of dazzling and vibrating points or
serrated images, sometimes with prismatic outlines, accompanied by
a loss or obscuration of vision over one-half or some other portion of
the field, which lasts half an hour or more, and sometimes clearing
up in one part while it advances in another. Simultaneously or
immediately after this there may be tingling and a sense of
numbness of the tongue, lips, hand, or one-half of the body,
sometimes followed by partial hemiparesis, and, if the right side be
affected, by more or less aphasia or mental confusion. Occasionally
the other special senses are affected. Sometimes the aura may
constitute the whole of the seizure.

The writer has observed a case in which migraine was represented

throughout boyhood by repeated attacks of subjective numbness
and tingling of the entire right side of the face, the right arm, and the
right half of the body, with aphasia and hemianopsia, followed during
many years by trifling headache or none at all; later in life by severe
pain. Here migraine as well as neuralgia in other forms was a well-
marked family disease.

These auras are especially worthy of notice, because they

occasionally point to epilepsy, an affection with which migraine is
allied.

The pain may begin on the same side with these prodromal
symptoms or on the opposite side. Sometimes drowsiness is a
marked symptom throughout the attack, and this differs in
significance from the sound, refreshing sleep with which the
paroxysm often comes to an end. Sometimes the arteries of the
affected side seem strongly contracted, as shown by pallor and
coldness of the face and dilatation of the pupil (angio-tonic form);
sometimes, on the other hand, they are dilated and pulsate strongly,
or the latter condition may follow the former (angio-paralytic form).
The radial pulse may show corresponding modifications. These
vascular phenomena are often, however, entirely wanting.

Migraine appears to be slightly more common in women than in

men. The liability to the attacks often shows itself in extreme youth,
usually increases at puberty, and generally ceases at the age of forty
or fifty. The attacks sometimes recur at regular intervals of a week, a
month, etc., but, on the other hand, they may remain absent for
years unless brought on by some exciting cause.

ETIOLOGY AND CLINICAL RELATIONS.—Migraine is a directly inheritable

disease, and one which stands in a close relationship to the other
grave neuroses, as well as to the neuropathic temperament. Cases
are occasionally seen in which the migraine of youth gives place to
epilepsy in later years. It is often met with also in families and
individuals of neuralgic tendency, and in fact it shades off into
neuralgia of the fifth and occipital nerves on the one hand and into
periodic nervous headaches on the other. It frequently occurs in
gouty persons, and is thought to be related to the brow ague of
malaria. The attacks may be brought on by any of the causes which
depress the vitality of the nervous system, and by various special
irritations, among which errors of refraction are prominent.

The PROGNOSIS is unfavorable in well-marked cases, in which the

habit of regular recurrence is established, and where the neuropathic
predisposition is pronounced and no special exciting cause can be
found. On the other hand, there are many cases where the tendency
is less deeply rooted, and where with the removal of the exciting
cause or causes the outbreaks cease.

Finally, there is great probability that the disease will cease of itself
with advancing years, not always, however, without having left its
mark on the patient's mental and bodily vitality.

The TREATMENT should be directed first to the detection and removal

of special sources of irritation, whether in the eye, stomach, uterus,
or elsewhere. Causes of anxiety and mental strain should be as far
as possible avoided, and great caution enjoined in the use of
stimulants and narcotics. The nutrition should be maintained at its
highest level by tonics, and, if need be, by electricity, massage, and
hydropathy. Sometimes, besides this a special diet is advisable, for it
seems beyond question that some patients have fewer headaches if
they abandon all animal food, while others—whether because of a
gouty tendency is not clear—do best on a nitrogenous diet with
exclusion of sugar and starch.

Of the drugs used to control the liability to the attacks, the most
important is cannabis Indica, given in doses of about half a grain of a
good preparation of the extract several times daily for weeks or
months together. Valerianate of zinc and the iodide and bromide of
potassium in full doses are also recommended, but are less
efficacious.

In the treatment of the attack itself, besides absolute rest and quiet,
large and repeated doses of guarana or caffeine, either alone or
combined with drachm doses of bromide of potassium, are
sometimes of use if given at the very outset.

It is thought by some observers that ergot or ergotin is of value if the

vessels are dilated, and conversely nitrite of amyl or glonoine if they
are contracted. It must not be forgotten, however, in case of doubt,
that the throbbing due to the latter drugs may increase the pain.

The writer has known a strong faradic current applied with the
moistened hand to the back of the neck to relieve an attack, and
prolonged but gentle manipulation of the painful area with the finger-
tips may have a like effect if the pain is not too severe; as, for
example, toward the end of a paroxysm.

Neuralgias of the Fifth Nerve.

Three varieties of these neuralgias may conveniently be

distinguished:

1. Ordinary facial neuralgia, analogous to the neuralgias of the

other superficial nerves;

2. Intermittent supraorbital neuralgia, sometimes called brow

ague, though by no means always of malarial origin;
 3. Epileptiform neuralgia (tic douloureux).

These varieties are of course closely allied, and have many features
and causes in common.

THE ORDINARY FACIAL NEURALGIA is a painful and obstinate malady,

although not so serious as the typical tic douloureux. The pain may
remain fixed in one position or it may shift from one part of the face
to another; and the latter is especially common in those forms which
occur in anæmic or ill-nourished persons. It associates itself readily
with occipital neuralgia, and sometimes also with neuralgia of the
pharynx and other parts. It occurs most often in persons of neurotic
tendencies or impaired nutrition, and may be provoked by disorders
of the ears, teeth, and even distant organs. The possibility of
aneurisms of the internal carotid or of cerebral tumor should also be
borne in mind, and signs of herpes zoster and locomotor ataxia
carefully sought for.

The relation of caries of the teeth to neuralgia of the fifth pair forms a
very important chapter, which is admirably treated by J. Ferrier.36
Opinions on this subject are conflicting and unsatisfactory, and the
fact that many patients have had nearly all their teeth drawn in the
vain attempt to get cured of one of the severe forms of facial
neuralgia often creates an impatience of further investigation in the
matter. Ferrier points out that as a rule it is not the severest cases of
epileptiform tic douloureux that arise in this way, but, on the other
hand, that it is a mistake to conclude, because a neuralgia is
benefited by medical treatment and made worse by fatigue,
exposure, etc., and because it occurs in a person of neurotic
temperament, that it is not likely to be due to this form of irritation.
The teeth need not themselves be the seat of pain, and the disease
in them may be detected only after diligent search.
36 Les Névralgies reflexes d'Origine dentaires, Paris, 1884.

The most important lesions are said to be caries, exostosis, and

other affections involving the pulp-cavity, exposure of the sensitive
dentine, ulcerations of the gums, injuries caused in extraction, and
other diseases of the alveolar process. The wisdom tooth, by its
pressure on other roots and on the gums, is not infrequently the one
at fault.

Chronic inflammation of the mucous membrane of the nose or

pharynx is said to be an occasional cause of neuralgia of the face,
as well as of the upper portions of the body.

THE INTERMITTENT NEURALGIA OF THE SUPRAORBITAL is an interesting

affection to which too little attention has been paid. One variety
seems to bear a certain relationship to migraine, inasmuch as it
occurs under similar circumstances—i.e. in distinctly neuropathic
individuals and families, and in attacks of about the same duration
and periodicity of recurrence.

Another variety approaches the other neuralgias in the longer

duration of the attacks, but is characterized by a daily seizure which
recurs with absolute regularity, coming on usually at about nine in
the morning and increasing in severity for an hour or so, then
persisting unchanged until midday or later, when it gradually
diminishes, finally disappearing in the course of the afternoon. As a
rule, it is brought on by catarrh of the frontal sinuses, often following
an acute attack of coryza. A certain amount of neurosal
predisposition is often found in this form, and the first attacks may
show themselves in early youth, rarely in the decline of life. The
writer has seen one family in which a number of members in at least
two generations have been attacked in this way, the seizures having
been brought on by exhaustion or coryza, or both combined.

This form of neuralgia is often greatly controlled by quinine if given in

sufficiently large doses (15 to 20 or 25, or even 30, grains) and as
long as four hours before the attack.

Lange37 thinks the action of galvanism is remarkably successful, but

the writer's experience does not fully bear this out.
37 Cited in the Centralbl. für Nervenheilkunde, etc., 1881, p. 10.
Seeligmüller38 speaks very highly of the effect of the nasal douche,
used for the sake of curing the catarrh of the frontal sinuses, and
potassic iodide may be useful by rendering the secretions more fluid.
38 Centralbl. für Nervenheilkunde, etc., June 1, 1880.

THE EPILEPTIFORM FACIAL NEURALGIA, OR TIC DOULOUREUX, is a chronic

affliction, characterized by the suddenness of onset and the severity
of its paroxysms of pain, which may recur every few minutes with
lightning-like rapidity, either spontaneously or brought on by motion
of the jaw or the taking of food, and disappear again as quickly. After
a group of such paroxysms as this there may be an intermission of
some hours or days. During the attack the patient is apt to rub the
seat of pain with great violence. The path pursued by the darts of
pain may be either in the direction of the nerve-trunks or in an
irregularly inverse direction.

In spite of their sufferings, these patients may present an

appearance of health. In its worst forms, and especially in advanced
life, this variety of neuralgia may be incurable, and at the best it is
sure to tax the care and skill of the physician. Anstie thinks that it is
apt to be associated with a taint of insanity.

The best TREATMENT consists in the most painstaking attention to

hygiene, in the persistent use of galvanism, arsenic, cod-liver oil,
quinine, aconite (see under General Treatment), and phosphorus.
Croton chloral is occasionally of service.

As a last resort, surgical measures (see above) may be appealed to,

but it should be borne in mind that even when the prospect seems
most hopeless the relief under medicinal and hygienic treatment may
really be near at hand. Where section of nerves is without result, the
operation of tying the larger vessels, the carotid or vertebral, on the
affected side may be tried, and offers some chance of success.

OCCIPITAL AND CERVICO-OCCIPITAL NEURALGIAS are second only to

trigeminal neuralgia in severity, though, fortunately, less common,
and either is liable by extension to give rise to the other.
Neuralgic pains in the occipital region may attend Potts's disease of
the cervical vertebræ; and this is especially important to bear in mind
because the osseous deformity is often wanting for a long time.

The writer has known a persistent pain in this region to be due to

intracranial syphilitic disease, and to cease suddenly with the advent
of more serious cerebral symptoms.

CERVICO-BRACHIAL AND BRACHIAL NEURALGIAS are less often indicative

of the neuropathic taint than the facial neuralgias; and, on the other
hand, they are, like sciatica, relatively often due to neuritis set up by
injury, amputation, strains, enlarged cervical glands, periarthritis of
the shoulder,39 etc., or associated with herpes zoster. When not due
to an unremovable cause the prognosis is favorable. The treatment
needs no special description.
39 See J. J. Putnam, “A Form of Painful Periarthritis of the Shoulder,” Boston Med.
and Surg. Journ., 1882.

INTERCOSTAL NEURALGIA is a very important form, both on account of

its frequency and obstinacy, and because it is often associated both
with anæmia and chlorosis and with affections of the visceral organs,
especially the uterus. The distressing cardiac palpitation of
neurasthenic patients often associates itself with pain in the left side,
and there is an intimate connection between neuralgia of the cardiac
plexus (angina pectoris; see below) and neuralgia of the intercostal
and brachial nerves.

Pain in this region, often due to neuritis, may accompany acute and
chronic thoracic disorders, and may be the precursor of herpes
zoster. Caries of the vertebræ and meningitis should be thought of,
and cancer if the neuralgia is very persistent, even if it is paroxysmal
in character.

TREATMENT.—Besides the general indications for treatment referred

to above, it is worthy of special note that nerve-stretching has been
successfully tried for intercostal neuralgia. In one interesting case
seven nerves were stretched at one operation.40 The reporter
discusses the surgical aspects of the operation, and points out that
the nerves should be sought for, not directly beneath the rib, but
behind and beneath it, and thinks that the failure to bear this fact in
mind might lead to puncturing the pleura.
40 Lesser, Deutsch. Med. Wochenschr., Sto. 20, 1884.

MAMMILLARY NEURALGIA (irritable breast of Astley Cooper), though

often met with in company with intercostal neuralgia, may occur
entirely independently. It is sometimes bilateral, and is apt to be
associated with irregularity of the uterine functions. Cutaneous
hyperæsthesia is often present to a distressing degree, and small
tumors of either temporary or permanent duration may make their
appearance (A. Cooper), which, however, do not affect the
prognosis.

There is no especially effective TREATMENT beyond what has been

spoken of. Surgical interference is not especially to be
recommended, though it has occasionally been useful.

LUMBO-ABDOMINAL NEURALGIA, or neuralgia of that part of the lumbar

plexus which supplies the flank and abdomen and the external
genital region. These neuralgias are apt to accompany those of the
intercostal nerves and share in their significance.

The most important facts with regard to them are that they are
intimately associated, in relation both of cause and of effect, with
affections of the abdominal and the pelvic organs and of the testis.
Neuralgias of the terminal branches of the lumbar plexus, the
obturator and anterior crural nerves, though well recognized, are
comparatively rare.

One of the chief respects in which they are important is in calling

attention to the possible presence of disease of the hip-joint or of
periarthritis of the hip, as well as of tumors or inflammation within the
pelvis.
NEURALGIA OF THE SCIATIC NERVE is one of the most severe and
common forms. While sharing in the common etiology and history of
the other neuralgias, it is peculiarly prone to be due to peripheral
causes, which give rise to thickening of interstitial and investing
connective tissue of the nerve. The distribution of the pain may be
coextensive with the whole distribution of the great and little sciatic
nerve, but far oftener the patient indicates certain regions as the seat
of his severest suffering; and these are especially the sacral region
of one side, the neighborhood of the sciatic notch, the popliteal
space, the calf, and the outer side of the foot and ankle. Not
infrequently the whole course of the sciatic nerve is traced out by the
darts of pain; and in this case it is the nerves which supply the
sheath of the sciatic itself which are supposed to be the seat of the
neuralgic process.

Sciatica is usually unilateral, but exceptionally bilateral, or attacks

the two sides alternately. The tender points most often met with are
at the sacro-iliac synchondrosis, the posterior border of the great
trochanter, just beneath the head of the peroneal bone, below and
behind the external malleolus, but numerous others are likewise
noted by Valleix. Sometimes no tender points can be found.
Sometimes, also, it is one or more of the collateral branches of the
sciatic plexus that are the seat of the neuralgia, and the distribution
of the pain and of the tender points varies accordingly.

It is in sciatica pre-eminently—in part, no doubt, because of the

frequency of neuritis—that disorders of sensibility of the skin are
noticed, as well as muscular paresis or spasm. This anæsthesia has
been studied with great care by Hubert-Valleroux and others, and it
has been shown that it is often confined to limited spots, a
centimeter or so in diameter, within which the loss of sensibility may
be nearly absolute. Nevertheless, their functional origin is proved by
the fact that under faradization they may rapidly disappear.

The duration of an attack of sciatica varies from a week or two to

months or even years, and it shows a marked liability to recur,
especially with changes of weather. First attacks occur pre-
eminently, though not exclusively, in middle life, and oftener in men
than in women, evidently because they are oftener exposed to
mechanical injury and, through their occupations, to sudden changes
of temperature and the like.

The occasional causes are numerous, and include sudden wrenches

and jars, even if not very severe, interpelvic pressure from tumors or
impacted feces, etc. Gout, syphilis, and diabetes may act as
predisposing and even exciting causes, and, it is said, gonorrhœa
likewise. Periarthritic inflammations of the hip-joint and varicose
veins frequently excite pains in the various sciatic nerve-branches
which simulate true sciatica.

As has been indicated, although sciatica may be a pure neuralgia

(see under Pathology), running its course without leading to any
appreciable change in the nerve, yet subacute and chronic neuritis is
very common, either as a primary condition or a complication, and its
presence puts a graver aspect upon the case. The pain of neuritis,
when severe, is relatively constant, remittent instead of intermittent,
dull rather than lancinating, increased by motion and pressure;
whereas the purely neuralgic pains are sometimes relieved by
movement. It is, however, doubtful whether an accurate differential
diagnosis is possible (see above). It is to this neuritis that the
muscular atrophy is due which is often so marked, and it may
likewise give rise to various cutaneous lesions of herpetic character.
The severe pain that accompanies typical herpes zoster of this
region is well known.

The TREATMENT of sciatica must vary with the probable cause of the
disease and its stage of progress. Diathetic taints are to be met if
present, and the greatest measure of physical health secured that
the circumstances possibly admit. It is a good precaution in all cases
to secure free evacuation of the bowels and to guard against
hemorrhoidal congestions.

As against the neuralgia itself, the proper means vary with the
acuteness of the attack and the presence or absence of neuritis. For
the acute stage absolute rest is almost always desirable as a prime