An Integrated Approach for an

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Nicolò Marchetti
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Nicolò Marchetti
Giovanna Franco
Stefano Francesco Musso
Maria Benedetta Spadolini Editors

An Integrated
Approach for an
Archaeological and
Environmental Park
in South-Eastern
Turkey
Tilmen Höyük
An Integrated Approach for an Archaeological
and Environmental Park in South-Eastern Turkey
Nicolò Marchetti Giovanna Franco
• •

Stefano Francesco Musso•

Maria Benedetta Spadolini

Editors

An Integrated Approach
for an Archaeological
and Environmental Park
in South-Eastern Turkey
Tilmen Höyük

123
Editors
Nicolò Marchetti Giovanna Franco
Department of History and Cultures Architecture and Design Department
Alma Mater Studiorum - University University of Genoa
of Bologna Genoa, Italy
Bologna, Italy
Maria Benedetta Spadolini
Stefano Francesco Musso Architecture and Design Department
Architecture and Design Department University of Genoa
University of Genoa Genoa, Italy
Genoa, Italy

Additional materials to this book can be downloaded on https://www.springer.com/gp/book/

9783030327538

ISBN 978-3-030-32753-8 ISBN 978-3-030-32754-5 (eBook)

https://doi.org/10.1007/978-3-030-32754-5
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This book is dedicated to the memory of
Giorgio Squinzi, Adriana Spazzoli and Aykut
Tuzcu
Preface and acknowledgements

This book is the final report on a scientific research funded under the FIRB 2003
(Fondo per gli investimenti della ricerca di base) programme by the Italian Ministry
for Education, Universities, and Research, through a project called New method-
ologies related to integrated projects of archaeological parks in the Mediterranean
area. Elaboration, experimentation, verification of advanced technologies and
transferability of results in the enhancement of areas of significant cultural, envi-
ronmental and touristic interest. Selection of study cases in northern Syria and
southern Turkey (principal investigator Paolo Matthiae, Sapienza University of
Rome, Italy).
The core feature of the entire programme was that such a project was going to be
developed and carried out by a multidisciplinary team: it foresaw the planning,
design and implementation of an archaeological park in a sensitive (on multiple
levels) location within the Mediterranean area in order to propose and realize in
practice a ‘model’, potentially transferable to other sites as well.
To achieve this main aim, the work has been divided among five research units
characterized by highly differentiated skills but closely integrated within the
common objective of developing and applying new methodologies and technolo-
gies for the planning and management of archaeological parks in the Mediterranean
areas. The first study case coincided with the first unit of the PI Matthiae and it was
about the archaeological park of Ebla in Syria, which is not reported here and which
was successfully completed just before the outbreak of the Civil War in Syria. The
other four units were all about the second study case, Tilmen Höyük in Turkey
where Nicolò Marchetti had been directing archaeological excavations since 2003.
His unit (based at the then Department of Archaeology, now of History and
Cultures, of the Alma Mater Studiorum—University of Bologna) was about
archaeological research and the definition of contents, another unit from the same
university led by Paola Rossi (from the then Department of Agro-Environmental
Science and Technology, now of Agricultural and Food Sciences) took care of
environmental characterization, a third unit coordinated by M. Benedetta Spadolini
(based at the Faculty of Architecture of the University of Genoa) was tasked with

vii
viii Preface and acknowledgements

the actual planning of the archaeological park and the last unit worked on envi-
ronmental remote monitoring (Vincenzo Fortunati of Ecosearch Ltd.).
Several colleagues from the Universities mentioned above and from other
partner Universities and Institutions in Turkey worked actively on the Tilmen
Höyük project with us through the years 2003 to 2008 and, in addition to those who
are already authors in this volume, we would like to name them here, as a token of
our appreciation and gratitude. Refik Duru and Gülsün Umurtak from Istanbul
University were extraordinary in their generous scientific sharing throughout the
whole project and our debt towards them is immense. Meltem Eti from Marmara
University, Istanbul greatly helped us in solving many logistical issues, like the past
Rector of Gaziantep University, Erhan Ekinci. The Directorate General for Cultural
Heritage and Museums (Ministry of Culture and Tourism, Ankara) supported us in
every possible way through the years: the then Director General Orhan Düzgün
with his then Deputies Ömer Çakır and Abdullah Kocapınar and the Director of
Excavations Melik Ayaz deserve much of our gratitude. In Gaziantep the then
Director of the Provincial Culture Directorate, Salih Efiloğlu, and in Adana the then
Regional Cultural Heritage Conservation Committee Director, Ismail Salman, were
instrumental in 2007 in obtaining all needed permissions for the archaeological
park. The successive directors of Gaziantep Museum between 2003 and 2008—
Hamza Göllüce, Fatma Bulgan, Mehmet Önal, Ahmet Denizhanoğulları—are to be
thanked for their constant cooperation at all levels, even helping us with the difficult
regulations of the Customs Authority. The Representatives of the Ministry of
Culture and Tourism attached to the Expedition—Burhan Balcıoğlu (2003, 2004,
2005, 2008, from Gaziantep Museum), Taner Atalay (2006, from Gaziantep
Museum), Yaşar Ünlü (2007, from Mersin Museum)—not only assisted us in our
daily needs on the field but all became close friends, like our colleague Ahmet
Beyazlar who at the time was serving in Gaziantep Museum.
The Authorities in Gaziantep Province were on our side on countless occasions:
the successive Governors of Gaziantep—Lütfüllah Bilgin (2004, 2005) and
Süleyman Kamçı (2006, 2007)—together with the then Gaziantep Metropolitan
Municipality Mayor, Asım Güzelbey and the then Local Governor of Islahiye,
Bekir Yılmaz inspired us with their enthusiasm for the Tilmen Höyük project. The
then Italian Ambassador in Turkey, Carlo Marsili, the then Italian Consul in Izmir,
Simon Carta, and the then director of the Italian Cultural Institute in Ankara,
Angela Tangianu, have always fully supported us. Finally, the late Aykut Tuzcu
from the Gaziantep Sabah newspaper has always been more than a finest counsellor
for us, truly being a devoted supporter of the Expedition well beyond the termi-
nation of the Tilmen project. Adil Konukoğlu and the Sanko Holding provided
support for the park maintenance after 2007.
As for the members of the Turco-Italian Archaeological Expedition to Tilmen
Höyük who worked on the field for circa 2 months every year it is our pleasure to
list them here: in 2003, the archaeologists Benedetta Panciroli, Alessia Bontempo,
Luisa Guerri, Luciano Cuccui, architects Ivan Solinas and Beatrice Speranza and
topographer Massimo Zanfini; in 2004, the archaeologists Benedetta Panciroli,
Alessandro Colantoni, Luciano Cuccui, Luisa Guerri, Marco Baldacci, Alessia
Preface and acknowledgements ix

Bontempo, Nilüfer Sayıt, Sinem Üstün, Tuğba Güngör, conservator Elisa Spagnoli
and topographer Massimo Zanfini; in 2005, the archaeologists Benedetta Panciroli,
Alessandro Colantoni, Luciano Cuccui, Luisa Guerri, Marco Baldacci, Antonio
Bonomo, Alessia Bontempo, Nihal Akıllı, Işık Aycin, Tolga Ölmezses, conservator
Deniz Hepdinç, draftsman Burhan Gülkan and topographers Giampaolo Luglio and
Massimo Zanfini, in addition to other Faculty members of the University of
Bologna (Paola Rossi, Marco Bittelli, Gabriele Bitelli, Luca Vittuari and Valentina
Girelli); in 2006, the archaeologists Nihal Akıllı, Esra Alp, Işık Aycin, Antonio
Bonomo, Alessandro Colantoni, Luciano Cuccui, Luisa Guerri, Anna Rita Lisella,
Valentina Orsi, Benedetta Panciroli, Ginevra Zoni, conservators Laura Benucci,
Deniz Hepdinç and Suzan Okumuş, draftsmen Kevin Ferrari and Sara De Angelis,
topographers Giampaolo Luglio and Massimo Zanfini; in 2007, the archaeologists
Esra Alp, Ezgi Avar, Antonio Bonomo, Alessandro Campedelli, Ece Cilacı,
Alessandro Colantoni, Luciano Cuccui, Gizem Dertürk, Çetin Gökkaya, Luisa
Guerri, Anna Rita Lisella, Benedetta Panciroli, Ginevra Zoni, conservators Laura
Benucci, Giada Bertocci, Eva Jorge Herrero, Deniz Hepdinç and Fadime Arslan,
draftsmen Kevin Ferrari and Murat Helvacı, botanic specialists Paola Rossi, Halil
Çakan, remote monitoring specialists Luca Berichillo and Salvatore Maiorana,
topographers Giampaolo Luglio, Pietro Baldassarri and Massimo Zanfini, archi-
tectural designer Elena Rosa, architectural conservation specialist Chiara Davite; in
2008, archaeologists Stefano Bassetto, Giacomo Benati, Antonio Bonomo,
Alessandro Campedelli, Luciano Cuccui, Luisa Guerri, Federico Zaina, Ginevra
Zoni, conservator Deniz Hepdinç, remote monitoring specialist Luca Berichillo,
topographer Massimo Zanfini. Members of the Faculty of Architecture of the
University of Genoa, Stefano Musso, Giovanna Franco, Maria Benedetta Spadolini
and Niccolò Casiddu carried out scientific visits at the site in 2005 and 2006.
Elena Rosa and Sandra Antonetti worked on an earlier draft of this volume and
we are very grateful for their efforts. Federico Poole revised the English language of
some chapters.
All photos of Tilmen Höyük and of the work at the site are the copyleft of the
Turco-Italian Archaeological Expedition at Tilmen Höyük.
The company Abet Laminati from Bra, Italy (which in 2007 was celebrating its 50
years of activity) generously supplied the information panels located through the
archaeological park. The Mapei Group (which in 2007 turned 70 years old) freely
supplied every year large quantities of products to be used for conservation activities
both of structures and of the small finds: their enlightened engagement for culture,
especially that of its late president Giorgio Squinzi and its late marketing director
Adriana Spazzoli, is to be commended more than we can write here in words. This
book is dedicated to their memory and to that of our beloved friend Aykut Tuzcu.

Bologna, Italy Nicolò Marchetti

Genoa, Italy Giovanna Franco
Genoa, Italy Stefano Francesco Musso
Genoa, Italy Maria Benedetta Spadolini
Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Nicolò Marchetti and Stefano Francesco Musso

I-The Research Framework: The Archaeological Site, Its Landscape,

a Vision
Never Ending Story. Responsibility, Strategy and Sustainability
in Managing an Archaeological Excavation and Its Public
Presentation from Its Inception to Beyond Its Termination . . . . ...... 11
Nicolò Marchetti
One Centre, Many Alleys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... 13
Storeys and Stories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... 17
Bridging the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... 27
References on Tilmen Höyük by the Turco-Italian Archaeological
Expedition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... 38
A View from Above. Geodesy and Satellite Image Analysis
in the Islahiye Valley . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... 43
Gabriele Bitelli, Valentina Alena Girelli and Luca Vittuari
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Space Geodesy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Satellite Images Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Multi-Scale Surveying at Tilmen Höyük . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

xi
xii Contents

A Holistic Model. The Tilmen Höyük Archaeological Park Amidst

Design, Conservation, Fruition and Communication . . . . . . . . . . . . ... 55
Maria Benedetta Spadolini
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 55
A Design Model, Between Conservation, Fruition and Communication . ... 59
Some Guidelines for the Viewer’s Sight Approach . . . . . . . . . . . . . . . . ... 64
Complex Contents and Representation Techniques: Computer Graphics
for Scientific Dissemination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 65
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 70

II-Conservation and Accessibility: Planning, Designing, Acting

Research and Design. Low-Impact Interventions and Innovative
Solutions at an Archaeological Site . . . . . . . . . . . . . . . . . . . . . . . ..... 73
Stefano Francesco Musso
The Research Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Main Guiding Principles and Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Scientific Basis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Phases and Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Conservation/Restoration Interventions and Guidelines
for Future Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
General Planning and Design of the Archaeological Park . . . . . . . . . . . . . . 102
A Final Remark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Fragility and Durability. Problems and Techniques
of the Archaeological Conservation Campaigns . . . . . . . . . . . . . . . . . . . 115
Chiara Davite
Paths to the Past. Designing Equipment for Sustainable Management
and a Culturally Aware Fruition of the Site . . . . . . . . . . . . . . . . . . . . . . 129
Giovanna Franco
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Visiting the Site: Accesses and Paths . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
The New Access Bridge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Rest Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Didactic Communication: Structures for the Explanatory Panels . . . . . . . . . 140
Protective Shelters in Archaeological Areas: A Preliminary Database
for a State of the Art . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Morphological and Constructive Choices to Protect the Middle Bronze
Age K-5 Residency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Contents xiii

Roofing History. A Protective Shelter for the Middle Bronze Age K-5
Residency Between Project and Construction . . . . . . . . . . . . . . . . . . . . . 177
Giorgio Mor and Pietro Baldassarri
Detailed Design of the Protective Shelter . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Remarks on the Building Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Moving Through. The Issue of Accessibility and Archaeological
Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Niccolò Casiddu
International Legislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
People with Reduced Mobility: Conservation, Enjoyment, Accessibility . . . 186
Strategic Guidelines: Criteria for Expanded Planning . . . . . . . . . . . . . . . . . 188
Strategic Guidelines: Management Criteria . . . . . . . . . . . . . . . . . . . . . . . . . 191
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192

III-Environmental Characterization of the Site

Layered Nature. Assessing and Monitoring the Environment
for the Development of an Archaeological Park . . . . . . . . . . . . . . . . . . . 195
Paola Rossi Pisa, Luca Berichillo, Marco Bittelli, Vincenzo Fortunati
and Marco Vignudelli
Monitoring Soil and Ancient Walls at Tilmen: The Project . . . . . . . . . . . . . 197
The Fieldwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Climate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Soil and Hydrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Integration into a Geographical Information System . . . . . . . . . . . . . . . . . . 206
Site Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
A Safe Hotspot. Plant Biodiversity and the Natural and Cultural
Heritage at Tilmen Höyük . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Maria Speranza, Halil Çakan and Lucia Ferroni
Environment and Archaeological Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Floristic Diversity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Wild Relatives of the Old World Crops . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Environment and Plant Community Diversity . . . . . . . . . . . . . . . . . . . . . . 214
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
About the Editors

Nicolò Marchetti Archaeologist, Ph.D., Professor of Archaeology and Art History

of the Ancient Near East at the Department of History and Cultures, Alma Mater
Studiorum—University of Bologna. He directs since 2011 the Turco-Italian
archaeological excavations at Karkemish in Turkey and since 2019 the Iraqi-Italian
ones at Nineveh East in Iraq, and has directed those at Tilmen Höyük (2003–2008),
Taşlı Geçit Höyük (2009–2010, Turkey), Jericho (1997–2000, Palestine), and
participated in the Ebla excavations in Syria for 8 seasons between 1990 and 1997.
He has authored over 100 research articles and books as La coroplastica eblaita e
siriana nel Bronzo Medio. Campagne 1964–1980 (2001, Sapienza University of
Rome) and La statuaria regale nella Mesopotamia protodinastica (2006,
Accademia Nazionale dei Lincei, translated as Royal Statuary of Early Dynastic
Mesopotamia, 2011, Eisenbrauns, with G. Marchesi), and has edited and co-edited
several excavation reports and proceedings, among which ARCHAIA Case Studies
on Research Planning, Characterisation, Conservation and Management of
Archaeological Sites (2008, British Archaeological Reports, with I. Thuesen), Ebla
and its Landscape. Early State Formation in the Ancient Near East (2013, Left
Coast Press/Routledge, with P. Matthiae), Karkemish. An Ancient Capital on the
Euphrates (2014), Urbanized Landscapes in Early Syro-Mesopotamia and
Prehispanic Mesoamerica. Papers of a Cross-Cultural Seminar held in Honor of
Robert McCormick Adams (2018, Harrassowitz, with D. Domenici). He is the editor
of the open access series OrientLab (www.orientlab.net/pubs) and chairman of the
open access publishing house www.1088press.it.

Giovanna Franco Architect, Ph.D., Professor of Technology of Architecture at the

Department of Architecture and Design, University of Genoa, Director of the
Post-Graduate Program, School of Specialization, in Architectural Heritage and
Landscape since 2015. Her research fields are traditional and contemporary
building techniques, damage and deterioration processes, renovation and refur-
bishment, sustainability, energy efficiency in historic buildings. Author of more
than 180 publications, among which 15 books and 62 international and national
essays and articles, she is member of editorial boards of scientific journals and

xv
xvi About the Editors

member of the Advisory Board in the Ph.D. Course in Preservation of Architectural

Heritage at the Politecnico of Milan. She has a long experience in international
research on urban renovation and regeneration leading multidisciplinary groups and
is participating in the steering committee of Green Cities network.

Stefano Francesco Musso Architect, Ph.D., Professor of Restoration at the

Department of Architecture and Design, University of Genoa, Director of the
School of Specialization for Architectural Heritage and Landscape, past Dean of the
School of Architecture. He is member of the Scientific-Technical Committee for
Landscape of the Ministry of Cultural Goods and Activities, past President of
EAAE-European Association for Architectural Education, President of
SIRA-Italian Society for Architectural Restoration and coordinator of the
EAAE-Thematic Network on Conservation. He has been visiting professor in many
foreign universities and taught in training courses for UNESCO (Albania, Israel)
and chaired the ICOMOS-European Commission Expert Group ‘Cherishing her-
itage: developing quality principles for interventions on cultural heritage’. He is
the author of several restoration projects and of more than 270 scientific publica-
tions in Italy and abroad.

Maria Benedetta Spadolini Architect, Ph.D., Professor of Industrial Design at the

Department of Architecture and Design, University of Genoa, past Dean of the
Faculty of Architecture, past President of the Degree Course in Industrial Design.
From 2004 to 2009, she has been a Member of the Board of the National
Conference of the Deans of the Italian Faculties of Architecture. Since 1987, she
has been coordinating and developing national research projects on accessibility for
people with disabilities and the use of integrated technologies, both in terms of
products and in terms of healthcare structures. In the last two decades, she has also
extended her expertise in the field of public access to the sector of design for
cultural heritage, researching on the enhancement of local heritage in the
Mediterranean area. She has been national coordinator of the MIUR D.Cult
research project ‘The design for the enhancement of cultural heritage, strategies,
tools and project methodologies’. She has authored more than 100 titles including
monographs, curatorships, contributions to national and international journals, as
well collaborating with companies and participating to national and international
conferences and round tables, as well as appearing in the media.
Introduction

Nicolò Marchetti and Stefano Francesco Musso

Abstract The archaeological and environmental park of Tilmen Höyük has been
functioning since 2007 almost without any major problem and with a very low
maintenance cost. This book presents the results of a conservation and presentation
project developed between the years 2003 and 2008. We advocate for an integral open
access of the data elaborated and a global public presentation at an archaeological site
for which a scientific project has been carried out in close contact also with the local
and regional communities: the theoretical issues and actions presented here are useful
for the scientific community in designing field projects, such as the system prototypes
for the public visit of the archaeological areas, with low production costs and modular
features. These are potentially transferable to other similar archaeological sites in
the Mediterranean area, dating both from the Classical and pre-Classical periods.

Archaeology has changed dramatically in the last twenty years: having previously
opened itself to the cooperation with other disciplines, it has broadened its sub-
ject of enquiry deriving historical meanings from the analytical framework, thus
contributing to generating new research horizons with new questions attached. At
the same time, the strive towards explanation has entailed, although regrettably not
too often, an anthropological perspective based on hybridization and cross-cultural
approaches. Thus, if the dialectics between processualism and post-processualism
in archaeology seems now to have been resolved, at least theoretically, within this
extended perspective, we still have to come to terms which the resulting continuum
which we get, where even the accepted basic dichotomy between ecofact and arti-
fact becomes blurred once our vision goes without any discontinuity from cognitive,
behavioral, processual and environmental aspects. We now recognize the peculiarity

N. Marchetti (B)
Department of History and Cultures, Alma Mater Studiorum - University of Bologna,
Piazza S. Giovanni in Monte 2, Bologna 40124, Italy
e-mail: nicolo.marchetti@unibo.it
S. F. Musso
Architecture and Design Department, University of Genoa, Stradone S. Agostino 37, Genoa
16123, Italy

© Springer Nature Switzerland AG 2020 1

N. Marchetti et al. (eds.), An Integrated Approach for an Archaeological
and Environmental Park in South-Eastern Turkey,
https://doi.org/10.1007/978-3-030-32754-5_1
2 N. Marchetti and S. F. Musso

of all processes, with the paradox that environment itself cannot be deemed “altered”
by human activity, but man-environment interaction is a single concept in which both
ends receive mutual feedback at varying degrees.
This conceptual framework does bear on how we research at the field, of course,
and this also creates a new or changed relation with local communities. When we
plunge into the challenges of the present time, we cannot distinguish any more
between a self-contained science, with its intrinsic sets of actions supposedly uncon-
nected with outer contemporary society (not to speak of course of the post-processual
claim that the sciences of “others” are equally viable), and the views, expectations,
hopes and fears about the(ir) past of the people from either a village, a city or a
nation and beyond. This integrality of approach in an archaeological project obvi-
ously results in a complex articulation of it. This book presents the results—not the
archaeological ones, to be presented elsewhere—of a project developed between the
years 2003 and 2008 (Fig. 4). We aim here at substantiating our integrated view for
an integral open access of the data elaborated and a global public presentation at an
archaeological site for which a scientific project has been carried out in close contact
also with the local and regional communities (Figs. 2 and 3). We believe that the
theoretical issues and actions presented here are useful for the scientific community
in designing field projects: the first decade of the 21st century AD offered many
promises but few practical possibilities for taking full avail of digital data integra-
tion in archaeology (which is only becoming possible in these very last years), but
precisely because of this we can offer here a well manageable case study, which is in
part no more state-of-the-art for its technological content but still represents a quite
advanced approach as for publicly presenting the archaeological heritage (Fig. 1).
The archaeological and environmental park of Tilmen Höyük has been functioning
since 2007 almost without any major problem and with a very low maintenance cost,
being quite positively reviewed upon by colleagues and visitors alike. Although there
is no standstill in science, we do feel satisfied with what we achieved there. As it
should, in time another expedition will come and other display methods will be
applied by Turkish cultural authorities at the site. But having gone through most of
the necessary steps for a successful and comprehensive public presentation, we are
glad to report on them here (Fig. 4).
The traditional methods of setting into historical perspective as well as conservating
ancient structures have been considerably enriched by new methods of analysis and
verification. The first aspect has been dealt with by the archaeologists, who defined
the architectural and material culture of the developed Old Syrian period (c. 1850–
1600 BCE) in an alleged cultural backwater such as the valley of Islahiye (Figs. 5, 6,
7, 8, 9, 10 and 11), with the architects systematically referencing comparable sites in
the pre-Classical eastern Mediterranean, as well as their current state as far as their
public presentation is concerned.
This base research was then turned into an applied one assuming as main bench-
mark the requirements of historical, archaeological, architectural, technological,
chemico-physical, environmental and social sciences, with a particular attention to
the problems presented by the foreseen mixed touristical and didactic uses of the site
Introduction 3

Fig. 1 Map of the Northern Levant with the main ancient and modern cities. (by courtesy of Marco
Valeri)

Fig. 2 Fertile fields in the valley of Islahiye (Gaziantep, Turkey)

4 N. Marchetti and S. F. Musso

Fig. 3 Basaltic outcrops at the road junction leading to the archaeological site of Tilmen Höyük,
note the brown road signage indicating heritage sites

Fig. 4 The archaeological park of Tilmen Höyük (orthophoto taken at the end of the 2007 season)
Introduction 5

Fig. 5 View of Residency C (left) and Royal Palace A (right) from West, c. 1700–1500 BCE. This
and all following views of the excavations were taken in 2006 before the start of the works for the
archaeological park

Fig. 6 View of the Islahiye Valley from Royal Palace A looking South-West, in background the
Amanus range

Fig. 7 The throne room of Royal Palace A towards the Kurt Dağları mountain ranges, from North-
West

Fig. 8 Temple E from South-West towards the central square

6 N. Marchetti and S. F. Musso

Fig. 9 Houses in area G, view from North-East, in central foregorund discarded basalt boulders
from the excavations which later on were incorporated into an elevated viewpoint for visitors

Fig. 10 The south-western corner of the Tilmen acropolis from South-West, note the characteristic
vegetation including also wild olive trees

Fig. 11 View of the temenos of Temple M from West

of Tilmen Höyük (Islahiye, Gaziantep Province, South-East Turkey). As a part of this

programme of base and applied research, in particular as far as accessibility and use
are concerned, the architects who had joined the project designed and set up system
prototypes for the public visit of the archaeological areas, with low production costs
and modular features, which were necessary for a correct use of the park (Fig. 4). To
introduce briefly the main results of this research and the accomplished works and
interventions we can list some keywords and phrases:
• Sustainability: eco- and environmental with the choice of local materials, but also
economic and technical, thanks to simple technologies and construction processes
of devices.
• Compatibility and reversibility: at least for structures and elements emerging from
the ground.
• Low impact: limited earth movements to allow a safe and comfortable visit of the
park; limited height of design elements (panels, fences, roofing structure, etc.),
respecting the skyline of the site.
Introduction 7

• Feasibility and maintainability: use of local materials, simple design of new ele-
ments and structures taking into account the local restrains concerning technical
and technological assets.
• Understatement and simplicity: design of elements and structures, which, thanks to
the selected materials, technologies and building techniques, avoid any temptation
to overwhelm the site and its natural assets.
• Authenticity and integrity: selection of materials, restoration techniques and
‘design behaviour’ to grant a rigorous compliance towards the archaeological
remains, in their existing formal and physical consistency and in their historically
acquired relationships with the environment.
• Accessibility and inclusiveness: careful planning of the works, interventions and
elements necessary to allow a safe accessibility to the site and its visit and the
awareness of its historical, cultural, archaeological and naturalistic values.
All research activities have been further conceived and managed in order to acquire
results and products potentially transferable to other similar archaeological sites in
the Mediterranean area, both from the Classical and pre-Classical periods. The wide
range of cultural, technical and informative material produced during three years
(data-base, technical reports, surveys, design drawings and technical descriptions)
can be thus an important ground on which building some guidelines as regards
excavation campaigns and survey methodologies, conservation methods for ancient
structures and planning activities to design and realize an archaeological park to
protect and enhance them.
As a fundamental part of the research, as far as accessibility and use are concerned,
the research unit of Genoa University, in particular, designed and built on site some
modular systems. The first one was a prototype for covering archaeological remains:
that very simple structure, for the many reasons underscored at the beginning of our
work, is characterized by low costs, local materials, easy and simple constructability
and it is thus potentially adaptable to other sites. Besides this modular protective
shelter, the Genoa research unit designed and installed on site several other modular
devices—fixed and mobile—necessary for a correct use of the park as the essays in
this book explain and record in detailed ways.
The research programme included also the design and accomplishment of the visit
paths of the park, by installing a complete and structured system of information panels
characterized by a simple, coordinated and comprehensible design layout (see the
Additional Materials on https://www.springer.com/gp/book/9783030327538). The
panels, of archaeological or naturalistic content, were steadily set on site with dry
techniques and without interfering too hardly with the ancient remains and the
surrounding landscape.
The eco-sustainability of the whole intervention and site management required
vegetation control plans along with a remote monitoring of the features bound to the
environment and to structural stability, obtained through the pilot-project of a GSM-
connected network—developed by the Ecosearch unit—sending the data collected
by sensors located within the park to a web site. The model for soil conservation and
for the enhancement of the area affected by the excavations has been validated in situ,
8 N. Marchetti and S. F. Musso

while the experimentation of the GPR-radar provided high-quality information on

the subsoil and on the buried structures in the unexcavated sectors of the site.
The book is divided into three Sections: the first one details how the archaeological
approach was intermingled with the public presentation of the site, on the basis of
an integrated landscape analysis and the architectural concepts which turn a site
of cultural significance into an educational and touristic one; the second section
puts in parallel conservation actions with those of design and execution of planned
devices for public use; and finally we give an account on how the environmental
characterization of the site is an essential part for any endeavour attempting at its
enhancement.
The park has been opened in 2007 and it is to this day a very lively site, with a
rich cultural, social and natural life of its own.
 I-The Research Framework: The
Archaeological Site, Its Landscape, a Vision
Never Ending Story. Responsibility,
Strategy and Sustainability in Managing
an Archaeological Excavation and Its
Public Presentation from Its Inception
to Beyond Its Termination

Nicolò Marchetti

Abstract At Tilmen Höyük we carried out an experience in Inclusive Archaeol-

ogy, which describes an approach based on an integration of views, techniques and
methods. Multidisciplinarity, interdisciplinarity and hybridization become part of an
anthropological perspective in which archaeology is seen as fully integrated within
the broader frame of social sciences. Inclusive Archaeology is based on openness,
towards local and regional communities (science does not live in isolation but has
an impact on and needs feedback from those communities), towards the scientific
community (dissemination of newly produced data is the core mission of scientists),
towards the global community (digital technologies must be used to build new forms
of integrated datasets which may be used freely through the web). The Turco-Italian
Archaeological Expedition at Tilmen Höyük tried this approach when several tech-
nologies were still in their infancy (digitally speaking) and can now offer after several
years a rare follow-up of the results obtained at the time and managed since.

Reporting after a dozen years since an experience in public archaeology allows at

least two main advantages: a meditated assessment on the faults and gains of the then-
selected approach and how it stood the test of time in terms of material durability and
social interaction. The conclusions which I present here, and which are detailed by the
authors of this volume, concern diverse scientific communities as well as decision-
makers and the public in general. One basic assumption stemming from my own
experience—one which may certainly be challenged—is that field archaeologists
must lead, or at least be strongly involved into the process of turning an archaeological
excavation into a public area equipped for visitors: this must be so because, I believe,
the ultimate vision is embedded in the very excavation strategy which at times must be
changed to accommodate concerns stemming from the project of public archaeology
(as I argued elsewhere, Marchetti 2008e), and which interweaves with conservation.

N. Marchetti (B)
Department of History and Cultures, Alma Mater Studiorum - University of Bologna,
Piazza S. Giovanni in Monte 2, Bologna 40124, Italy
e-mail: nicolo.marchetti@unibo.it

© Springer Nature Switzerland AG 2020 11

N. Marchetti et al. (eds.), An Integrated Approach for an Archaeological
and Environmental Park in South-Eastern Turkey,
https://doi.org/10.1007/978-3-030-32754-5_2
12 N. Marchetti

In other words, public presentation must be an integrated goal from the start of any
excavation project.
It is a basic truism that an archaeological dig is a destructive process and that such
destruction is halted at some time according to the main aims set by the excavation
director (and/or cultural authorities such a State Ministry etc.): when the period at
which the dig especially aims is reached (if indeed present and preserved) the inves-
tigation is often paused in that given area and the resulting remains may potentially
be presented to the public (I do not deal here with cases of temporary presenta-
tions in the course of the sometimes lengthy excavation process or with subsequent,
reframed reprisals of the investigations aiming at deeper, earlier remains). The case
study of Tilmen Höyük provides us with sufficiently general variables and problems
and may thus serve as a useful basis for a modelization of viable approaches to public
archaeology, independently of the case-specific Turkish regulations and constraints.
Tilmen Höyük lies in south-eastern Turkey (UTM 37 S, 295822.00 m E,
4100665.00 m N), in the province (il) of Gaziantep, district (ilçe) of Islahiye. The
site lies in a narrow plain disseminated with basalt outcrops and delimited by the
mountain ranges of the Amanus and the Kurt Dağı to the West and East respec-
tively. The first excavations in the area were undertaken by a German expedition at
Zincirli Höyük, ancient Sam’al, in 1883, but systematic surveys in the valley when
only undertaken when U. Bahadır Alkım of Istanbul University moved there in 1955
coming from Karatepe and started a program, which lasted until 1972, of archae-
ological researches involving also large-scale excavations (see Marchetti 2011b on
the history of studies in the Islahiye valley).
Tilmen Höyük was excavated between 1959 and 1964 and between 1969 and
1972 (Duru 2003; 2013). In 1990 the construction of a small dam on the Kara Su
stream (which flows both East and West of the site) removed a large stretch of the
outer city megalithic walls and created a tiny artificial basin just at the north-western
foot of the acropolis. The resulting wetter environment has generated a flourishing
vegetation cover all over the site. In 2002, Refik Duru, a member of the original team,
carried out a rehabilitation campaign, repairing some of the damaged monuments
and starting to control vegetation at the site.
In June 2003 the Universities of Bologna and of Istanbul agreed on a joint project
(which for the first two years was under the administrative responsibility of Gaziantep
Museum, then University of Bologna then applied for an excavation permit, classified
as “foreign” by the Ministry of Culture and Tourism) and since October 2003 yearly
campaigns have taken place until 2008 with the directorship of Nicolò Marchetti
and the scientific advisory of Refik Duru. The main aim of the new expedition
was “not only to better study the urbanism of this 5 hectares capital city and the
detailed chronology of its monuments and material culture, but also to contribute to
the historical framework of south-eastern Anatolia and northern Syria” (Marchetti
2005a: 129). The extensive excavations in different areas of the acropolis, of the lower
town and of the outer town (the latter in 2007 only) gave notable results but at the
same time fostered our attitude of carrying out conservation at the same time of the
excavations, getting used to the mutual, unavoidable interferences deriving from the
discussions with colleagues from different fields and towards the end even starting to
Never Ending Story. Responsibility, Strategy and Sustainability in Managing … 13

Fig. 1 Composite map of Tilmen Höyük: schematic structures in lighter gray have only been
surveyed by the Turkish Expedition, all the others in black and the detailed ones by the Turco-Italian
one. Most of the structures date from Middle Bronze II (c. 1800–1600 BCE)

plan some of the excavations in order to complete our conservation and presentation
actions, which has since remained one of our key principles in subsequent projects,
such as at Taşlı Geçit Höyük and Karkemish.1

One Centre, Many Alleys

Our aim was to expose extensively the Middle Bronze II (c. 1800–1600 BCE) town
(Fig. 1): previous excavations by Istanbul University had already revealed that this
was the main phase of the occupation of the site (earlier periods were exposed only

1 Funding for the excavations came from grants of Bologna University (2003–2008), the Fondazione

Cariplo (2005), the Italian Ministry for Foreign Affairs (DGPCC 5th Office now DGSP 6th Office,
2004–2008) and that for Education, Universities and Research (2006–2008, through a project unit
within a PRIN 2005 program coordinated by P. Matthiae). The Expedition also benefited of a 2017
grant to V. Orsi by The Shelby White and Leon Levy Program for Archaeological Publications,
which has allowed to digitalize a part of our archives.
14 N. Marchetti

Fig. 2 The central square between areas C and G in 2006 before the start of the works for the
archaeological park, view from WSW. The Deep Sounding by the Turkish Expedition from the
1960s had been backfilled, while the domestic area in area G (left) was greatly extended by the
renewed excavations in order to give a sense to visitors of the ancient urban shape. In left background
discarded stones from the excavations are visible, which were later turned into a raised visit path

in a limited way and only on the acropolis; see Duru 2003, 2013) and—after my
archaeological fieldwork at Tell Mardikh/Ebla in Syria (as an area supervisor) and
at Tell es-Sultan/Jericho in Palestine (as co-director of an Italo-Palestinian expedi-
tion)—I had many research questions about that crucial phase of the urbanization of
the northern Levant. Five full excavation campaigns between 2003 and 2007 (in 2008
we basically carried out only topographical surveying and maintenance work on the
park opened the year before), each lasting around two and half months, enabled us
to establish in detail the continuous stratigraphy of that urban site between Middle
Bronze I and Late Bronze I, with their chronological subphases, down to a Late
Roman and early Byzantine rural settlements, the latter both limited to the acropolis
(see the sections Reports and Studies in the References list below). We uncovered
several new monuments (fortresses H, P, P2, Q, temple M, residency K-5 (Figs. 3, 4,
5), houses in areas L and G (Fig. 2), rooms near gates K-3 and K-5 and the external
sectors R, V and Z) as well as new features of previously excavated ones (in palace
A, temple E, residency C [with B], gates K-1–K-6, K-2, K-3 and K-5), surveying in
detail also almost all the rest of the latter remains (D, F, the casemates and surviving
city walls).
The main underlying scientific idea was to understand the urban organization of
the Middle Bronze II settlement with its inner functional differentiations, by digging
not only buildings but the “empty” connecting spaces in between (Figs. 1 and 2).
Never Ending Story. Responsibility, Strategy and Sustainability in Managing … 15

Fig. 3 Area K-5 in 2006, view from SW: the stratification of the monument is suggested by the
blocked door in foreground, while the slope which had to be managed in order to install the roofing
and bring visitors uphill is well evident

In doing so we understood how the city, probably called Zalwar, came to have a
monumental layout after Middle Bronze IA (c. 2000–1900/1850 BCE) and how it
was reorganized in the period immediately following the destruction inflicted by
the Old Hittite armies at the end of the 17th century BCE. We intended to give
visitors a real insight into the urban shape and functional organization of an early
2nd millennium BC royal citadel, conveying to them the historical data extracted from
material culture and analyses as well (Fig. 5): in fact, the idea of conservation and
public presentation of the site was embedded since the start into the project and this
led to conservation activities carried out in parallel with the excavations, guided but
some firm and simple principles such as avoiding reconstructions and consolidating
all excavated remains (those at least which we decided to leave and not to demolish
further) either in stone or in mudbrick. Even in cases of monuments excavated in
the 1960s and partially collapsed afterwards for which we had photographs of their
original state, we marked redressed stones with the insertion of a thin lead strip
separating the reconstructed part from the one which was still standing (Fig. 6).
If during the very first season we applied this approach (progressively defined
since the last years of my participation to the Ebla excavations in Syria where Paolo
Matthiae was pioneering the realization of an archaeological park in the Near East
and subsequently during my co-direction of the Tell es-Sultan/Jericho 1997–2000
project in Palestine, which included the development of an archaeological park finally
16 N. Marchetti

Fig. 4 Area K-5 in 2006,

view from NE: the room with
basalt grinding tools and a
sunken jar in foreground
highlights the need to
communicate to visitors
contents besides architecture
(which is just part of an
archaeological context)

completed a few years ago, see Nigro 2000) in a quite unsophisticated way,2 I tried
immediately to seek more professional cooperations and external funds in view of
the tasks stated above. Thus, we were lucky enough to obtain in 2004 a competitive
research grant, in partnership with the Faculty of Architecture of Genoa University
and Ecosearch Ltd. (and P. Matthiae of Sapienza University of Rome as coordinator
but on a separate project about Ebla, see Pinnock 2018): the Italian Ministry for
Education, Universities and Research granted us a FIRB 2003 (for the years 2005–
2008, with 4 research units about Tilmen Höyük, see the Preface) aimed at the
conservation and public presentation of the site, which allowed the activities which
we report throughout this book. Furthermore, in 2008 we organized some training
courses on the communication of contents in archaeological parks thanks to an EU-
funded project “ARCHAIA” (a FP6-SSA, i.e. a Scientific Support Action within the

2 Asone can readily see from an unattractive structure of iron pipes which we built in 2003 to
support a dangerously leaning stone wall in area E (Fig. 7, both still standing to this day it must be
acknowledged).
Never Ending Story. Responsibility, Strategy and Sustainability in Managing … 17

Fig. 5 The extraction of a 1850 BCE large preservation jar from its spot of retrieval in area K-5
(see Fig. 4) stands for the dynamic process which an excavation entails, an information which must
be incorporated into the public presentation of archaeological areas

6th Framework Program of the EU, which I coordinated), the proceedings of which
were immediately published thereafter (Marchetti and Thuesen 2008).

Storeys and Stories

The actions undertaken are described in detail in the following chapters, but I would
like here to state, though briefly, our archaeological perspective. Coping with many
external issues (such as for example the expectations of local communities about
touristic development coupled with the threats posed to a fast-changing environ-
ment) is indeed possible within an international cooperation framework, one which
involves not only specialists from many fields, but also several Universities, Muse-
ums, public Authorities and private Bodies uniting their efforts towards shared goals
and priorities. This multidisciplinary and multi-partner perspective responds to a
contemporary view in which integration (also intended as a continuous feedback
between all involved participants) is the method chosen for facing the complexities
and the challenges posed by an anthropological approach, both as far as the past and
the present are concerned. After the conservation actions had been decided together
Another random document with
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Neuralgic attacks are usually characterized, besides the pain, by a
highly-interesting series of symptoms, which are in part transitory
and functional, and in part due to structural changes in the tissues.4
4 See Notta, Arch. gén. de Méd., 1854; Anstie, Neuralgia and its Counterfeits.

The spasm and subsequent dilatation of blood-vessels in the

affected area have already been alluded to. A disturbance of
secreting organs in the neighborhood of the painful region, the
lachrymal gland, the skin, the mucous membranes, the salivary
glands, is of equally common occurrence, and is probably in great
measure due to direct irritation of the glandular nerves, since the
increased secretion is said to occur sometimes unattended by
congestion.

The hair may become dry and brittle and inclined to fall out, or may
lose its color rapidly, regaining it after the attack has passed.

The increased secretion of urine already alluded to attends not only

renal neuralgias, but those of the fifth pair, intercostal, and other
nerves. There may be unilateral furring of the tongue (Anstie).

The muscles supplied by the branches of the affected nerve or of

related nerves may be the seat of spasm, or, on the other hand, may
become paretic; and this is true even of the large muscles of the
extremities.

Vision may be temporarily obscured or lost in the eye of the affected

side in neuralgia of the fifth pair, and hearing, taste, and smell are
likewise deranged, though more rarely. I am not aware that distinct
hemianopsia is observed except in cases of true migraine, where it
forms an important prodromal symptom.

In connection with these disorders of the special senses the

occasional occurrence of typical anæsthesia of the skin of one-half
of the body should be noted, which several observers have found in
connection with sciatica. The writer has seen a cutaneous
hyperæsthesia of one entire half of the body in a case of cervico-
occipital neuralgia of long standing. These symptoms are probably
analogous to the hemianæsthesia which comes on after epileptic or
other acute nervous seizures, or after concussion accidents, as has
lately been observed both in this country and in Europe, and it is
perhaps distantly related to the hemianæsthesia of hysteria. Local
disorders of the sensibility in the neuralgic area are far more
common than this, and, in fact, are usually present in some degree.
The skin is at first hyperæsthetic, but becomes after a time
anæsthetic; and this anæsthesia offers several interesting
peculiarities. When this loss of sensibility is well marked, areas
within which the anæsthesia is found are apt to be sharply defined,
but they may be either of large size or so small as only to be
discovered by careful searching (Hubert-Valleroux). The sensibility
within these areas may be almost wanting, but in spite of this fact it
can often be restored by cutaneous faradization around their
margins, and the functional or neurosal origin of the anæsthesia is
thus made apparent. Where the anæsthesia is due, as sometimes
happens, to the neuritis with which the neuralgia is so often
complicated, it is more lasting, but usually less profound and less
sharply defined.

These changes may be transient, or, if a neuralgia is long continued

and severe, they may pass into a series of more lasting and deeper
affections of the nutrition.

The skin and subjacent tissues, including the periosteum, from being
simply swelled or œdematous may become thickened and
hypertrophied. The writer has known a case of supraorbital
neuralgia, at first typically intermittent, to lead to a thickening of the
periosteum or bone over the orbit, which even at the end of several
years had not wholly disappeared.

Neuralgias of the fifth pair, which are as remarkable in their outward

results as they are in their severity and their relation to other
neuroses, are said to give rise to clouding and ulceration of the
cornea, to iritis, and even to glaucoma.
Herpetic eruptions on the skin sometimes occur, of which herpes
zoster is the most familiar instance.

Muscular atrophy is very common, especially in sciatica, and in

some cases this occurs early and goes on rapidly, while in others it
may be only slight and proportioned to the disease and relaxation of
the muscles, even where the neuralgia has lasted for weeks or
months.

Neuritis of the affected nerve is a common result or attendant of

neuralgia, and may remain behind for an indefinite period after the
acute pain has gone, manifesting itself by subjective and objective
disorders of sensibility, by occasional eruptions on the skin, or by
muscular atrophy.

It is plain that in this list of symptoms a variety of conditions have

been described which would never all be met with in the same case,
and which, as will be shown in the section on Pathology, are
probably due to different pathological causes.

Neuralgia of the Viscera.

These neuralgias are less definitely localized by the sensations of

the patient than those of the superficial nerves, and it is not definitely
known what set of nerves are at fault.

They are deep-seated and are referred to the general neighborhood

of the larynx, œsophagus, heart, or one of the abdominal or genital
organs, as the case may be.

The pain is usually of an intense, boring character, and does not dart
like the pain of superficial neuralgia, but is either constant or comes
in waves, which swell steadily to a maximum and then die away,
often leaving the patient in a state of profound temporary prostration.
Deep pressure often brings relief. A patient of the writer, who is
subject to attacks of this kind in the right hypochondrium, will bear
with her whole weight on some hard object as each paroxysm comes
on, or insist that some one shall press with his fists into the painful
neighborhood with such force that the skin is often found bruised and
discolored.

The functions and secretions of the visceral organs are apt to be

greatly disordered during a neuralgic attack, and it is often difficult or
impossible to tell with certainty which of these conditions was the
parent of the other. Undoubtedly, either sequence may occur, but the
pain excited by disorder of function, or even organic disease of any
organ, is not necessarily felt in that immediate neighborhood. Thus I
have known the inflammation around an appendix cæci, of which the
patient shortly afterward died, to cause so intense a pain near the
edge of the ribs that the passage of gall-stones or renal calculus was
at first suspected.

There seems to be as much variation as to modes of onset and

duration among the visceralgias as among the superficial neuralgias,
but the tendency to short typical attacks of frequent recurrence
seems to be greater with the former.

The visceral neuralgias are quite closely enough related to certain of

the superficial neuralgias to show that they belong in the same
general category. The two affections are often seen in the same
person, and not infrequently at the same time or in immediate
succession. Thus in the case of the patient just alluded to above, the
attacks of deep-seated neuralgia in the neighborhood of the right
flank are at times immediately preceded by severe neuralgia of the
face or head. Similarly, intercostal neuralgia may occur in immediate
connection with neuralgias of the cardiac or gastric nerves.

The phenomenon of tender points is not entirely wanting in the

visceralgias, though less constant and definite than in the superficial
neuralgias.
The liver and the uterus especially become the seat of more or less
localized tenderness, and possibly the tenderness in the ovarian
region which is so common, and so often unattended by real
inflammation, is, in part, of this order.

The secondary results of the visceralgias are not easy to study.

Besides the disorders of secretion and function above alluded to,
swelling of the liver with jaundice and paresis of the muscular walls
of the hollow viscera may be mentioned as having been ascribed to
neuralgia.

It is not known to what degree neuritis occurs as a cause or

complication of these neuralgias, and this is a question which is
greatly in need of further study.

Migraine, or Sick Headache.

This is often classified as an affection of a different order from the

neuralgias, but there seem to be no real grounds for this distinction.

The superficial neuralgias themselves are probably not one, but a

group of affections, with the common bond of severe and
paroxysmal pain.

Neither is what is called migraine always one and the same disease.

Although in its most typical form it presents very striking

characteristics, such as a marked preliminary stage, with peculiar
visual and sensory auras, sometimes occupying one entire half of
the body, a short and regular course and periodical return, deep-
seated pain without tender points, and prominent unilateral vascular
disorders, yet these symptoms shade off by imperceptible degrees
into those of neuralgia of the fifth pair, or more often into one or
another form of unilateral neuralgic headache which stands midway
between the two.
The vascular phenomena of migraine are believed by various
observers, as is well known, to constitute the primary and essential
pathological feature of the disease, and to be the cause of the pain.
But this is a pure hypothesis, and as a matter of fact the cases are
abundant in which no greater vascular changes are present than in
other neuralgias of equal severity.

Migraine seems to occupy an intermediate position between the

grave neuroses, especially epilepsy, and the neuralgias of neurosal
origin.

The symptomatology will be described at greater length below.

GENERAL ETIOLOGY.—The causes of neuralgia may be divided into

predisposing and exciting causes.

The most important of the first group are—

1. Hereditary tendencies;

2. The influences associated with the different critical periods of

life;

3. The influences attached to sex;

4. The action of constitutional diseases, such as phthisis,

anæmia, gout, syphilis, diabetes, nephritis, malarial poisoning,
metallic poisoning.

The most important of the second group of causes are—

1. Atmospheric influences and the local action of heat and cold;

2. Injuries and irritation of nerves;

3. Irritation of related nerves (so-called reflex and sympathetic

neuralgias);

4. Acute febrile diseases.

In most cases more than one cause is to blame, and each should be
separately sought for.

PREDISPOSING CAUSES.—1. Hereditary Tendencies.—It is generally

admitted as beyond question that neuralgias are most common in
families in which other signs of the neuropathic taint are prominent.
Such affections as hysteria, neurasthenia, epilepsy, asthma, chorea,
dipsomania, and even gout and phthisis as it would seem, are akin
to the neuralgic tendency.

The neuropathic family is thought to contain, in fact, a much larger

number of members than this,5 but there is danger of exaggerating
the importance of an influence of which we know as yet so little.
5 Féré, Arch. de Névrologie, 1884, Nos. 19 and 20, “La famille névropathique.”

It should be remembered, moreover, that even where an inherited

taint is present its influence may be but slight as compared with that
of some special exciting cause.

Some neuralgias are more closely associated with the inherited

neuropathic diathesis than others. The connection is especially close
in the case of migraine;6 then follow other forms of periodical
headache and the visceral neuralgias. Even the superficial
neuralgias7 are more or less subject to this influence. This is thought
to be especially true of the facial neuralgias.
6 There is a witty French saying (quoted by Liveing), “La migraine est le mal des
beaux esprits;” which might be rendered, “The disease of nervous temperaments.”

7 For tables of illustrative cases see Anstie, Neuralgia and its Counterfeits, and J. G.
Kerr, Pacific Med. and Surg. Journ., May, 1885.

Reasons will be offered later for suspecting that many cases usually
classed as neuralgia, and characterized by gradual onset and
protracted course, are essentially cases of neuritis; and there is need
of further inquiry as to how far hereditary influences are concerned in
producing them, and whether such influences act by increasing the
liability of the peripheral nerves to become inflamed, or only by
increasing the excitability of the sensory nervous centres.

2. Age.—Neuralgia is oftenest seen in middle life and at the epochs

marked by the development and the decline of the sexual functions.
The affection, when once established, may run over into advanced
age, but cases beginning at this period are relatively rare and very
intractable (Anstie).

Childhood is commonly said to be almost exempt from neuralgia,

but, in fact, there seems no sufficient reason for withholding this term
from the so-called growing pains of young children8 so long as it is
accorded to the almost equally irregular neuralgias of anæmia in the
adult. The same remark applies to the attacks of abdominal pain in
children, which often seem to be entirely disconnected from digestive
disorders.
8 Probably due to anæmia or imperfect nutrition (see Jacobi, “Anæmia of Infancy and
Childhood,” Archives of Med., 1881, vol. v.).

Adolescents and children also suffer from periodical headaches,

both of the migrainoid and of the neuralgic type. These are obstinate
and important affections.9 Migraine especially, coming on in early life,
points to a neuropathic constitution, and will be likely to recur at
intervals through life, or possibly to give place to graver neuroses.
9 Blache, Revue mensuelle de l'enfance, Mar., 1883, and Keller, Arch. de Névroloqie.
1883.

3. Sex.—Women show a stronger predisposition than men to certain

forms of neuralgia, as to the other neuroses, but it is generally
conceded that whereas neuralgias of the fifth and occipital and of the
intercostal nerves are met with oftenest among them, the brachial,
crural, and sciatic neuralgias are commoner among men. This
probably indicates that the neurosal element is of greater weight in
the former group, the neuritic element in the latter.
4. Constitutional Diseases.—The blood-impoverishment of phthisis
and anæmia, the poison of malaria, syphilis, and gout, and the
obscurer forms of disordered metamorphosis of tissue, undoubtedly
predispose to neuralgia and the other neuroses, as well as to neuritis
and others of the direct causes of neuralgic attacks.

Anstie regards the influence of phthisis as so important as to place it

fairly among the neuroses. Gout is likewise reckoned by some
observers among the neuroses,10 but we tread here upon uncertain
ground. Anstie does not regard gout as a common cause of
neuralgia, but most writers rate it as more important, and gouty
persons are certainly liable to exhibit and to transmit an impaired
nervous constitution, of which neuralgia may be one of the
symptoms. The neuralgias of gout are shifting, irregular in their
course, and sometimes bilateral.
10 Dyce-Duckworth, Brain, vol. iii., 1880.

Syphilitic patients are liable to suffer, not only from osteocopic pains
and pains due to the pressure of new growths, but also from attacks
of truly neuralgic character. These may occur either in the early or
the later stages of the disease. They may take the form of typical
neuralgias, as sciatica or neuralgia of the supraorbital nerve
(Fournier11), or they may be shifting, and liable to recur in frequent
attacks of short duration, like the pains from which many persons
suffer under changes of weather, anæmia, or fatigue.
11 Cited by Erb in Ziemssen's Encyclopædia.

There are other obscure disorders of the nutrition, as yet vaguely

defined, in connection with which neuralgia of irregular types is often
found. Some of these are classed together under the name of
lithæmia, and are believed to be due to imperfect oxidation of
albuminoid products.12
12 See DaCosta, Am. Journ. of Med. Sciences, Oct., 1881, and W. H. Draper, New
York Med. Record, Feb. 24, 1883.
Diabetes seems also to be an occasional cause of neuralgia,
especially sciatica, and Berger,13 who has recently described them,
says that they are characterized by limitation of the pain to single
branches of the sacral nerves, by a tendency to occur at once on
both sides of the body, by the prominence of vaso-motor symptoms,
and, finally, by their long duration and obstinacy. There may not, at
the moment, be any of the characteristic symptoms of diabetes
present.
13 Neurologisches Centralblatt, 1882, cited in the Centralbl. für Nervenheilk., etc.,
1882, p. 455.

Chronic nephritis also causes neuralgia, either directly or indirectly;

and severe neuralgic attacks may accompany the condition, which is
as yet but imperfectly known, characterized pathologically by a
general arterio-fibrosis and by increased tension of the arterial
system.

True rheumatism does not appear to be a predisposing cause of

neuralgia.

Anæmia, both acute and chronic, is a frequent cause of neuralgia,

both through the imperfect nutrition of the nervous tissues, to which it
leads, and, it is thought, because the relatively greater carbonization
of the blood increases the irritability of the ganglionic centres.

Even a degree of anæmia which might otherwise be unimportant

becomes of significance in the case of a patient who is otherwise
predisposed to neuralgia; for such persons need to have their health
kept at its fullest flood by what would ordinarily seem a surplus of
nourishment and care.

Under the same general heading comes the debility from acute and
chronic diseases, and the enfeeblement of the nervous system from
moral causes, such as anxiety, disappointment, fright, overwork and
over-excitement, and especially sexual over-excitement, whether
gratified or suppressed (Anstie), or, on the other hand, too great
monotony of life; also from the abuse of tea, coffee, and tobacco.
Lead, arsenic, antimony, and mercury may seriously impair the
nutrition of all the nervous tissues, and in that way prepare the way
for neuralgia.

IMMEDIATE CAUSES.—1. Atmospheric and Thermic Influences.—

Neuralgia is very common in cold and damp seasons of the year, in
cold and damp localities, and in persons whose work entails frequent
and sudden changes of temperature. Exposures of this sort may at
once excite twinges of pain here and there over the body, and may
eventually provoke severe and prolonged attacks of neuralgia.

The action of damp cold upon the body is complicated, and it exerts
a depressing influence on the nervous centres in general which is
not readily to be explained. One important factor, however, is the
cooling of the superficial layers of the blood, which occurs the more
easily when the stimulus of the chilly air is not sufficiently sharp and
sudden to cause a firm contraction of the cutaneous vessels, while
the moisture rapidly absorbs the heat of the blood. From this result,
indirectly, various disorders of nutrition of the deeper-lying tissues or
distant organs; and, among these, congestion and neuritis of the
sensitive nerves.

Neuralgia often coincides with the presence or advent of storms. A

noteworthy and systematic study of this relationship was carried on
through many years under the direction of S. Weir Mitchell14 by a
patient of his, an officer who suffered intensely from neuralgia of the
stump after amputation of the leg. The attacks of pain were found to
accompany falling of the barometer, yet were not necessarily
proportionate to the rapidity or amount of the fall. Saturation of the
air with moisture seemed to have a certain effect, but the attacks
often occurred when the centre of the storm was so remote that
there was no local rainfall. It was impossible to study the electrical
disturbances of the air with accuracy, but a certain relationship was
observed between the outbreak of the attacks and the appearance of
aurora borealis.
14 Am. Journ. of Med. Sci., April, 1877, and Philada. Med. News, July 14, 1883.
This patient's neuralgic attacks were almost certainly of neuritic
origin, and it is possible that the exacerbations were due to changes
of blood-tension in and around the nerve-sheaths. It is also possible
that they were the result of circulatory changes and disordered
nutrition of the nervous centres, already in a damaged condition from
the irritation to which they had been exposed.

2. Injuries and Irritation of Nerves.—Wounds and injuries of nerves15

and the irritation from the pressure of scars, new growths, and
aneurisms are prolific causes of neuralgic pain, partly by direct
irritation, partly by way of the neuritis which they set up. Neuralgias
are likewise common during the period of the healing of wounds, as
Verneuil long since pointed out. The pain may be near the wound
itself or in some distant part of the body.
15 See S. Weir Mitchell, Injuries of Nerves.

Neuralgia due to the pressure and irritation of tumors, new growths,

or aneurisms requires a special word. The pain is apt to be intensely
severe, but what is of especial importance is that the symptoms may
not present anything which is really characteristic of their origin,
except their long continuance; and this should always excite grave
suspicion of organic disease.

These attacks of pain may be distinctly periodical; and this is true

whether they are felt in the distribution of the affected nerve or of
distant nerves.

Not only are direct injuries of nerves a cause of neuralgia, but

sudden concussion or jar may have a like effect—whether by setting
up neuritis or in some other way is not clear. Ollivier16 reports a case
where a blow beneath the breast caused a neuralgia which
eventually involved a large portion of the cervico-brachial plexus;
and the writer has seen a like result from a blow between the
shoulders.
16 Cited by Axenfeld and Huchard, p. 116.
Peripheral irritations, such as caries of the teeth (see below, under
Facial Neuralgia) and affections involving other important plexuses,
such as those of the uterine nerves, are a frequent cause of
neuralgia, and should always be sought for. They act in part by
setting up neuritis, and in part evidently in some more indirect
manner, since the neuralgia which they excite may be referred to
more or less distant regions, forming the so-called—

3. Reflex and Sympathetic Neuralgias.—The term reflex, as here

used, is ill chosen, and the term sympathetic only covers our
ignorance of the real processes involved, and which we should seek
for in detail. Thus, disease of the uterus or ovaries may cause facial,
mammary, intercostal, or gastric neuralgia.

Hallopeau17 suggests that some of these results may be brought

about by the pressure of enlarged lymphatic glands attached to the
affected organ.
17 Loc. cit., p. 766.

Another important centre of nervous irritation is the eye. Slight errors

of refraction, or weakness of the muscles of fixation, especially the
internal recti, are a source of frontal headaches and other nervous
symptoms, and even of typical migraine,18 to a degree which is not
usually appreciated. It is improbable that in the latter case the
irritation acts as more than an exciting cause, but it may
nevertheless be a conditio sine quâ non of the attack.
18 St. Barthol. Hosp. Repts., vol. xix.

Acute and chronic inflammations of the mucous membrane of the

frontal sinuses, perhaps even of the nasal membrane, are likewise
important; and although it is probable that the opinions sometimes
expressed as to the significance of these causes are exaggerated, it
is equally true that obstinate and, as it were, illogical persistence in
their removal will sometimes be richly rewarded.
It is especially worthy of note that there need be no local sign
whatever to call the attention of the patient to the presence of the
peripheral irritation.

Nothnagel19 has described neuralgias which come on in the first

week of typhoid, and are to be distinguished from the general
hyperæsthesia of later stages. He describes an occipital neuralgia of
this sort which finally disappeared under the use of a blister. Other
acute diseases may have a like effect. The writer has seen a severe
facial neuralgia in the first week of an insidious attack of pneumonia
in a person who was not of neuralgic habit, and before the fever or
inflammation had become at all severe.
19 Virch. Arch., vol. liv., 1872, p. 123.

PATHOLOGY AND DIAGNOSIS.—In surveying the clinical history of the

neuralgias and the circumstances under which they occur, we have
grouped together a large number of symptoms of very different
character from each other, and we have now to inquire to what
extent these symptoms are really united by a pathological bond.

Two opposite opinions have been held concerning the pathology of

neuralgic affections. According to one opinion, every neuralgic
attack, no matter how it is excited, is the manifestation of a neurosis
—that is, of a functional affection of the nervous centres—to which
the term neuralgia may properly be applied. This view is based on
the resemblance between the different forms of neuralgia, or the
apparent absence, in many cases, of any adequate irritation from
without, and the fact that the persons in whom neuralgias occur
usually show other signs of a neuropathic constitution.

According to the other opinion, the various forms of neuralgia are so

many different affections, agreeing only in their principal symptom,
and are due sometimes to congestion or anæmia of the nerves or
the nerve-centres; sometimes to neuritis, the pressure of tumors, or
the irritation of distant nerves; sometimes, finally, to a functional
disorder of the nervous centres. The arguments in favor of this
opinion are that the difference between the symptoms of the different
neuralgias as regards their mode of onset and decline, their duration,
the persistence of the pain, and the degree to which the attacks are
accompanied by organic changes of nutrition in the tissues and in
the nerve itself, are so great as to make it appear improbable that we
are dealing in every case simply with one or another modification of
a single affection.

This is a valid reasoning, and it is certainly proper to exhaust the

possibilities of explaining the symptoms that we find in a particular
case by referring them to morbid processes which we can see or of
which we can fairly infer the presence, before we invoke an influence
of the nature of which we understand so little as we do that of the
functional neuroses. At the same time, it must be distinctly borne in
mind that the symptoms of certain neuralgias, and the relation which
the neuralgias in general bear to other neuroses, can only be
accounted for on the neurosal theory, and that in a given case we
can never be sure that this neurosal tendency is not present and is
not acting as at least a predisposing cause. It is especially important
to bear this possible influence in mind in deciding upon prognosis
and treatment.

We may now review briefly the signs which should lead us to

diagnosticate or suspect the presence of the various special causes
of neuralgic symptoms.

Neuritis is indicated by the presence of organic disorders of nutrition

affecting the skin, hair, or nails, or of well-marked muscular wasting;
by pain, not only occurring in paroxysms, but felt also in the
intermissions between the paroxysms, or continuous sensations of
prickling and numbness, even without pain; by tenderness along the
course of the nerve; by anæsthesia, showing itself within the first few
days of the outbreak of a neuralgia; by persistent paralysis or paresis
of muscles.

Neuritis may be suspected, even if one or all of these signs are

absent, in the prolonged neuralgias which follow wounds or strains of
nerves or exposure to damp cold, or which occur in nerves which are
in the immediate neighborhood of diseased organs; also where the
pain is relieved by compression of the nerve above the painful part,
or, on the other hand, where pressure on the nerve excites a pain
which runs upward along the course of the nerve.

It may also be suspected in the large class of superficial neuralgias

which follow a regular and protracted course with gradual onset and
decline, and where the pain is felt not only in the region of
distribution of a nerve, but also along its course—that is, in the
nerve-fibres (either the recurrent nerves or the nervi nervorum)
which are distributed in the sheath of the main trunk or the adjoining
tissues.20
20 See Cartaz, Des Névralgics envisagés au point de vue de la sensibilité récurrente,
Paris, 1875.

It must be remembered that the study of neuritis, and especially of

chronic neuritis, is still in its infancy, and that we are by no means in
possession of its complete clinical history.21
21 See Pitres and Vaillard, Arch. de Névrologie, 1883.

The presence of congestion of the sensory nerves or nerve-centres

may be inferred with some degree of probability where neuralgic
attacks of relatively sudden onset and short duration occur in parts
which have been exposed to heat or cold, or in connection with
suppression of the menstruation, or, it is said, as a result of
intermittent fever. The exacerbations of pain which take place in
cases of chronic neuritis under changes of weather and after fatigue
are very likely due to this cause; and the same may be true of some
of the fleeting pains which occur in chlorotic and neuropathic
persons who are subject to fluctuations of the circulation of vaso-
motor origin.

The same vaso-motor influences which cause congestion may also

cause the correlative state of anæmia, which becomes thus a cause
of transient and shifting though often severe attacks, which may be
irregular in their distribution. General anæmia is also a predisposing
cause of severe typical seizures, as has been pointed out above.
The pressure of new growths or of aneurisms is to be suspected
when neuralgic attacks are unusually severe and prolonged, recur
always in the same place, and occur in persons who are not
predisposed to neuralgias. The pains from this cause are apt to be
relatively continuous, but they may, on the other hand, be distinctly
paroxysmal, and may occupy a part of the body far removed from
the irritating cause.

Bilateral pains should also excite suspicion of organic disease,

though they may be due to other causes, such as gout, diabetes,
and metallic poisoning.

Neuralgic attacks may be supposed to be of neurosal origin when

they are of sudden onset and short duration, or when they occur in
persons of neuropathic constitution, and, by exclusion, when no
other cause is found. These conditions are best fulfilled in the case
of migraine and the visceral neuralgias. It must, however, be borne in
mind that the neuropathic predisposition is sometimes well marked
even in the case of the superficial neuralgias, especially the
epileptiform neuralgia of the face.

GENERAL TREATMENT.—To treat neuralgia with satisfaction it is

necessary to look beyond the relief of the particular attack and
search out the causes by which it was provoked. As has already
been remarked, these are usually multiple, and among them will be
found, in the great majority of cases, some vice of nutrition or faulty
manner of life.

It is safe to say that any dyscrasia occurring simultaneously with

neuralgia, whether gout, phthisis, malaria, or diabetes, should
receive its appropriate treatment, whatever theory we may hold as to
the real connection between the two conditions.

In protracted neuralgias it is always proper to assume that neuritis

may be present—i.e. to treat the nerve itself by galvanism and local
applications. Local irritations, such as diseases of the eye, ear, teeth,
nose, or uterus, should be sought out and removed; and attention
may here be called again to the fact that a neuralgia may be due to
some local condition which does not of itself attract the patient's
attention.

Patients who are subject to pain at changes of weather or on

exposure should be suitably protected by clothing, and should have
their cutaneous regulatory apparatus strengthened by baths and
friction. The best protection, however, is incapable of entirely
warding off the effect of atmospheric changes upon the nervous
centres. Vaso-motor changes of neurotic origin can be, in a
measure, prevented by removing the patient from the influence of
irregularity of life and emotional excitement and through an improved
nutrition.

If the patient has been subjected to chronic fatigue or nervous strain,

not only must these be avoided, but their action should be
counteracted by the requisite rest and tonic treatment.

Long hours of sleep at night may often be supplemented to

advantage by rest during certain hours of the daytime. If the patient
cannot take active exercise, massage is indicated, and in some
cases of anæmia this may advantageously be combined with the wet
pack, in the manner described by Mary Putnam Jacobi.22
22 Massage and Wet Pack in the Treatment of Anæmia.

Where these measures cannot be carried out, the writer has found it
of much service in these, as in a large class of debilitated conditions,
to let the patient rub himself toward the end of the forenoon in a
warm room with a towel wet in cold or warm water, and then lie down
for an hour or so or until the next meal. If acceptable, the same
operation may be repeated in the afternoon.

Neuralgic patients are apt to be underfed, and even where this is not
distinctly the case, a systematic course of over-feeding,23 with
nourishing and digestible food, such as milk, gruel, and eggs, given
at short intervals, is often of great service if thoroughly carried out.
The full benefit of this treatment cannot always be secured unless
the patient is removed from home, and, if need be, put to bed and
cared for by a competent nurse.
23 See S. Weir Mitchell, Fat and Blood; and Nervous Diseases, especially of Women.

A change of climate, and especially the substitution of a dry and

warm for a moist and cold climate, will sometimes break up the
neuralgic habit, for the time at least. In making choice of climate or
locality, however, the physician should keep distinctly in view the end
that he desires to gain. Thus, the debility or anæmia which is the
essential condition of many neuralgias may often be relieved by
surroundings which would not be thought favorable to the neuralgic
tendency as such. Oftentimes the sedative influence of quiet country
life is all that is required.

Of the tonic drugs, cod-liver oil, iron, arsenic, and quinine are by far
the most important, and it is often well to give them simultaneously.
Iron may be used in large doses if well borne, for a short time at
least. Quinine may be given in small doses as a tonic, or in larger
doses to combat the neuralgic condition of the nervous system. This
remedy has long been found to be of great value in the periodical
neuralgias of the supraorbital branch of the fifth pair, but its
usefulness is not limited to these cases. It may be of service in
periodical neuralgias of every sort, and often even in non-periodical
neuralgia.

When the attacks recur at stated intervals care should be taken to

anticipate them with the quinine by about four hours, even if the
patient has to be waked in the early morning for the purpose. Single
doses of fifteen, twenty, or even thirty grains may check the attacks
where smaller doses have failed. Such doses cannot, however, be
long continued, and are not to be classed as tonic.

Of other remedies which directly influence the neuralgic condition,

the following are the most important: opium, aconite, gelsemium,
phosphorus, belladonna, chloride of ammonium, cannabis Indica,
croton-chloral, electricity, hydropathy, massage, counter-irritation,
subcutaneous injections of water, chloroform, osmic acid, etc.;
surgical operations.

Opium is usually employed only for the momentary relief of pain, but
it has also been claimed that in small and repeated doses it may
exert a really curative action. This should not, however, be too much
counted on. Opium should never be used continuously for the simple
relief of pain unless under exceptional circumstances, the danger of
inducing the opium habit is so much to be dreaded. Moreover, both
patient and physician are less likely to seek more permanent means
of cure if this temporary remedy can always be appealed to. It is best
given by subcutaneous injections of the various salts of morphine.
The dose should always be small at first (gr. 1/12 and upward), unless
the idiosyncrasy of the patient is already known; and there is
probably no advantage in making the injections at the seat of pain or
in the immediate neighborhood of the nerve supplying the affected
part, except such as might attend the injection of any fluid (see
below).

Belladonna (atropia), which is so often given with morphine to

diminish its unpleasant effects, seems at times, even when given
alone, to have an effect on neuralgia out of proportion to its
anæsthetizing action, which is very slight. It is considered to be
especially useful in the visceralgias.

Aconite, given, if necessary, in doses large enough and repeated

often enough to cause numbness and tingling of the lips and the
extremities for some days, will sometimes break up an attack,
especially of trigeminal neuralgia,24 better than any other means; but
its use is liable to depress the heart, and it is a dangerous remedy if
not carefully watched. Some patients complain that it causes a
marked sense of depression or faintness, and a feeling of coldness;
and indeed its full therapeutic effect is sometimes not obtained until
such symptoms as these are induced to some degree. The use of
the crystallized alkaloid, aconitia, has the advantage of ensuring
certainty of dose.
24 See Seguin, Arch. of Med., vol. i., 1879; vol. vi., 1881.