of the cord were found slightly sclerosed; in all the later observations the cord was found healthy. The post-mortem lesions explain the symptoms very well, and also account for the diversity which we observe, according as the one or the other set of nerves are chiefly involved.

from time to time, and only disappeared when the patient was put under restraint, in her own home.

Another lady, æt. 27, who was suspected to be an alcoholic, suffered from attacks which resembled very much angina pectoris; there was excessive cardiac dyspnoea; the pain As regards differential diagnosis, the disease radiated into the left arm, slightly also into the resembles in many respects the progressive right, and there was also some epigastric pain. multiple neuritis described by Leyden, Strüm- Physical examination of the chest-organs pell, Pierson and others, of which indeed it showed nothing abnormal, and beyond a very forms simply a particular species. It differs, visibly pulsating abdominal aorta, nothing abhowever, from this non-alcoholic multiple normal could be detected in the abdominal neuritis in several particulars; it runs a less cavity. The cause of these symptoms was acute course, is less progressive, the paralysis very doubtful to me; but when they disapis more confined to the extensor groups of peared, along with some other neuralgic troubles muscles, and though there is a considerable (chiefly affecting the trigeminus) after the amount of pain in the non-alcoholic form, there patient was put under restraint in a home for is not usually the very characteristic hyperæs- dipsomaniacs, I strongly suspected that they thesia and hyperalgesia described above; the had been due to alcohol; in this view I was cerebral symptoms also are absent in the non-confirmed, for the symptoms reappeared, when alcoholic form.

It further resembles other intoxications, notably those produced by lead. Lancereaux has long ago drawn attention to this, and, pathologically considered, the lesions are the same in both; just as in alcoholic paralysis, so in lead paralysis, we have to do chiefly with peripheral nerve changes; though lead seems to select the motor nerves par excellence. The similarity of the action of lead and alcohol is further evident when we consider other diseases in which both play the important etiological element, as in gout, in the true cirrhotic kidney, and, I may perhaps also add, chronic endocarditis and some brain affections.

The treatment of alcoholic paralysis, which is often successful in the less advanced and uncomplicated cases, must have for its prime object the withdrawal of the stimulant. Of other remedies, the opiates, cinchona (recommended by Leudet and Wilks), strychnia, hydropathy and the application of electricity seem indicated. The iodide potassium, which I have tried in some cases, has not given me any very encouraging results.

the patient left the home and recommenced her old habits. She was placed a second time into the home, and again improved; but died subsequently from pneumonia. I had no opportunity of making a post-mortem.

These visceral neuralgias again resemble those produced by lead. Lead colic is common enough, and in a small epidemic of acute leadpoisoning produced by the inhalation of particles of lead-chromate, I have seen two cases, where, after the acute symptoms had passed off, symptoms very much like angina pectoris came on. These symptoms resemble most a vaso-motor disturbance, and as such we can easily understand their appearance in chronic alcoholism.-Brain, July.

TREATMENT OF EPILEPTIFORM NEU-
RALGIA, OR THE SO-CALLED IN-
CURABLE FACIAL TIC.

BY W. J. WALSHAM, F.R.C.S. 'ALTHOUGH," says Trousseau, "epileptiform neuralgia from its nature must be considered as an almost incurable affection, I have always felt it a duty to combat it by therapeuI wish now to draw attention to certain tic means. . . . Of all the therapeautic agents visceral neuralgias which, either alone or in that I have tried, and I have tried a great combination with other nervous symptoms, are number with the utmost perseverance, opium found in chronic alcoholism, and which I is the one that has given me the least disapbelieve are caused by the alcohol. Thus, I pointment. But remember this, gentlemen, was asked to see a lady who was an alcoholic, that opium in the treatment of epileptiform and who suffered from very intense colicky pains; these attacks would last for days; they were unaccompanied by vomiting or any other gastric disturbance. There was marked constipation. There was no reason to suppose lead-poisoning, nor did the gums show any blue line-yet iodide potassium was freely given without benefit. Opium gave some temporary relief; the pains, however, recurred

neuralgia must be given in large doses." And in large doses indeed did Trousseau give it— ten, twenty, or even thirty grains daily were in some cases found barely sufficient to relieve the pain; one patient took as much as 400 grains a day, and spent 1,200 francs during one year alone in the purchase of the drug. Here is a choice of evils Either to bear, as best one may, the agony of this terrible mal

ady, or to be reduced to the pitiable condition of an opium or morphia habitué. Since Trousseau published his lecture, a new field for the relief of pain has been opened to us; and nerve-stretching, if it cannot cure the affection, can give the sufferer the prospect of months or years of immunity from it.

During the last few years I have had six cases of this form of neuralgia, and I desire here to call attention to a method of treatment which, although it may not permanently cure, has at any rate given to these patients many months and, to some, years of freedom from their suffering.

suffused, a tear perhaps trickles over his cheek. Suddenly the attack ceases, and with a sigh of relief he resumes the history of his sufferings. A second paroxysm may not occur for half an hour, even though the irritation which produced the first is repeated; but more frequently there will be two or three during the next ten minutes, The number of paroxysms during the 24 hours varies greatly; they may occur during the day only, but more frequently during both night and day. Sometimes there may not be more than twenty or thirty in the 24 hours; at other times there may be two or three or even more every half-hour. They vary at different times in the year and are usually worse in the spring. When severe, they make the patient's life almost unbearable, preventing sleep and rendering the taking of food, which invariably brings them on, a dreaded evil.

The treatment may be divided into the Medical and Surgical, Of the former little need be said. Nearly every drug in the Pharmacopoeia has, at one time or another, been tried with but little success. Opium in large doses, as given by Trousseau, undoubtedly relieves the pain for a time; but little permanent benefit can be expected from it, and the remedy, if remedy it can be called, would appear almost worse than the disease. Aconitia, given internally, has been strongly advised by Gubler as a specific. I tried it in two cases but was disappointed. In one patient, the pulse under its use became intermittent every third beat, and it had to be relinquished after a few doses. In neither was any benefit apparent. Among the surgical measures may be mentioned neurotomy or division of the nerve, neurectomy or cutting a piece out of the nerve, nerve-stretching, removal of one of the ganglia connected with the fifth, the application of the actual cautery, the introduction of hot needles into the supra-orbital, infra-orbital, or mental canal. Of the last-mentioned method of treatment I have had no practical experience, and the accounts I have heard of it are not encouraging. The actual cautery was employed in one of the cases before it came under my care, and seemed to give some relief for a few hours after each application, but no more. That merely temporary benefit is obtained by division of the nerve is well known; and even after a piece has been cut out the pain has soon returned. In three of my patients one or other of these operations

The terms epileptiform neuralgia and incurable tic are, to say the least, unfortunate ones, inasmuch as the former implies that the affection is a form of epilepsy, which it is not, and the latter that it is incurable, which I think cannot now be affirmed of it. The disease is characterized by neuralgic paroxysms occurring in one or more branches of the fifth nerve, and is always, as far as I know, confined to one side only of the face. The pain as a rule is not constant, or, if so, is increased during the characteristic paroxysms. These seldom last more than half a minute at a time. In one of my patients they were said to last half an hour; but they seemed to be rather a series of paroxysms following in quick succession than a single prolonged one. The pain almost invariably begins at one spot, that is, in one branch of the nerve, thence centrally spreads along that branch, and is radiated to the other branches of that division; or it may be transmitted to a second or even to a third division of the fifth. A paroxysm may be determined by very various causes-speaking, eating, washing the face, a draught of cold air, a sudden noise, pressure on a certain spot, a fly settling on the beard-in short, anything even of the most trifling nature. During a paroxysm the action of the patient is characteristic. rubs the part violently, or grasps his head between his hands, stamps upon the floor, or paces hurriedly about the room, convulsively clutches at anything within his grasp, or throws himself upon his couch or bed and writhes in agony. The pain is variously described by the patients as agonising, "like a bundle of redhot wires being driven into the face, and then twisted in all directions," "like the seizing of all the teeth at once with dental forceps and rocking them to and fro," "like crushing the part in a vice," or "stabbing it in a thousand places at once with bradawls or sharp needles." | on several occasions had been previously perA paroxysm comes on whilst the patient is formed, but with the most evanescent relief, describing his symptoms. He breaks off in the pain returning as severe as before in a few the middle of a sentence or even a word, to days. Nerve-stretching on the other hand has undergo his torture; the muscles of his face been attended with the most happy results. may visibly twitch, his conjunctivæ become | In the first patient with this disease who came

He

yield to any appreciable extent. The pain was as severe after the operation as ever. On more closely questioning him it was found that although he said the pain began in the cheek and darted upwards over the head, it really began in the gums in the region of the molar teeth, which had been previously extracted, i. e. in the posterior dental nerves, and shot upwards towards the back of the orbit. Jan., 1883, I removed Meckel's ganglion and the whole of the superior maxillary nerve, after having forcibly stretched its proximal end, from the foramen rotundum to the spot where it emerges on the cheek. The patient had no bad symptom; he slept well the night after the operation, better than he had done for months; he was up and about the ward in a few days, and has had no pain since.

under my care I stretched the infra-orbital endeavor made to stretch it, but it did not nerve; the neuralgia was of ten years' duration, and for two years of this time the patient had been actually bedridden, as the pain was beyond endurance when she attempted to get up. All medical remedies had been tried and failed. The operation was performed in February, 1879. She was completely relieved, and three years afterwards expressed herself as having been cured. The second patient, a man of 32, who had been an out-patient of Dr. Lauder Brunton's, had had the neuralgia for nine years. He had formerly been in good circumstances, but in consequence of his pain had been rendered unfit for any mental exertion and had gradually lost his business. The neuralgia was confined to the regions supplied by the auriculo-temporal and inferior dental nerves. He had consulted many of the most eminent physicians in London and Paris, and various homopaths, medical rubbers, and electricians, and had had the inferior dental and mental nerves divided. In April, 1883, I stretched the auriculo-temporal nerve, and a week later the inferior dental from within the mouth. The relief from pain was complete; he has had none since, and is now again making headway in his business. The third patient, 60, had suffered for eight years. The pain was confined principally to the inferior dental nerve. I stretched this in May, 1883. Since then he has had no pain except some slight twinges in the infra-orbital nerve (none in the inferior dental) for a few days in March, 1884, ten months subsequent to the operation, afer having got wet through and taken a violeat cold whilst following his occupation as a gardener. The fourth patient, a man 56, had suffered for five years. In Nov., 1883, I stretched the inferior dental and infra-orbital nerves, and he has remained well since. The fifth, a man 73, had suffered for ten years with pain chiefly in the inferior dental. He had had the mental branch cut and stretched with little or no benefit. In March, 1884, I stretched the inferior dental from within the mouth; the patient, notwithstanding his age, had no bad symptom, and at present has had no return of his neuralgia.

n

In the sixth case a man, 59, had suffered for upwards of fourteen years. He had been under the care of several physicians, and had had the supra-orbital and infra-orbital stretched on various occasions. Looking to the success of the above cases I attempted to stretch these nerves again, but found on cutting down upon them, that the tissues were so matted together, as the result of the previous operations, that it was impossible to isolate them. An aneurism needle was passed under the cicatricial tissue in the situation of the nerves, and an

A few words on the methods of stretching the inferior dental and auriculo - temporal nerve. The operations for stretchings the supra- and infra-orbital are too well known to call for any remarks. The inferior dental has been exposed in various ways: (1) by division of the cheek, through the entire thickness, at a spot corresponding with the anterior edge of the ramus of the jaw, without dividing the mucous membrane; (2) by divison of the cheek at a spot corresponding with the sigmoid notch; (3) by division of the soft parts over the posterior border of the ramus of the jaw in a direction from behind and below, inwards and upwards; (4) by removal of a portion of the angle of the jaw; (5) by trephining the ramus after division of the soft parts just above the commencement of the inferior dental canal; (6) from within the mouth. The last method of exposure was the one used for stretching the nerve in the above cases, and although I worked it out in the dissecting room-not knowing that it had been already employed-I found, on looking up the subject, that it would appear to have been first resorted to by Paravicini. Its superiority over the other methods cannot, I venture to think, be questioned. No scar is left externally, and if the anatomy of the parts be borne in mind, the question should not be attended with much, if any, difficulty. The mouth having been opened by a gag, an incision through the mucous membrane only is made from the last molar tooth in the upper jaw to the last molar tooth in the lower. The finger is now introduced into the wound and insinuated between the ascending ramus of the jaw and the internal pterygoid muscle. The small spur-like projection of bone at the entrance of the inferior dental canal'is next felt for, and serves as a guide to the nerve. An aneurism needle with a very short curve is now passed and