Neuralgia And The Diseases That Resemble It Part 11

That is precisely what the judicious use of chloral does; and I may mention, as resembling though not equalling it, the action of Indian hemp, which has been particularly recommended by Dr. Reynolds. From one-fourth to one-half of a grain of good extract of cannabis, repeated in two hours if it has not produced sleep, is an excellent remedy in migraine of the young. It is very important, in this disease, that the habit of long neuralgic paroxysms should not be set up; and if the first two or three attacks are promptly stopped, by the induction of sound, non-narcotic sleep, we may get time so to modify the const.i.tution, by tonics and general regimen and diet, as to eradicate the neuralgic disposition, or at least reduce it to a minimum. But I would decidedly express the opinion that such remedies as either opium or belladonna are mostly unsuited to this purpose. If the migraine of young persons does not yield to chloral, to cannabis, or to muriate of ammonia (in twenty or thirty grain doses), it will not be advisable to ply the patient with any remedies of the narcotic-stimulant cla.s.s, but to trust to tonic regimen and the use of galvanism.

The mention of muriate of ammonia, which, for migraine and clavus and the milder forms of sciatica, not unfrequently proves useful in stopping the violence of a paroxysm and enabling the patient to get some refreshing sleep, leads me to notice that not only may a variety of the milder narcotic-stimulants be employed in this way, but the external stimulus of heat to the extremities (very hot pediluvia) greatly a.s.sists the action of any such remedies; especially if mustard-flour be added, so that a mild vapor of mustard rises with the steam and is inhaled. Perhaps the ideal medication, to arrest a bad sick-headache, is to give twenty grains of chloral, and make the patient plunge his feet in very hot mustard-and-water and breathe the steam. He can hardly fail to fall asleep for a longer or shorter time, and awake free from pain.

(_d_) The use of bromide of pota.s.sium in neuralgia is a subject of great importance, and which requires much attention and discrimination. In common with, I dare say, many others, I made extensive trial of this agent when it first began to be much talked of, but was so much disappointed with its effects in neuralgias, that at one time I quite discarded it in the treatment of those affections. Renewed experience has taught me however, that, though its use is restricted, it is extremely effective if given in appropriate cases and in the right manner. For the great majority of neuralgias it is quite useless, and, what is more, proves often so depressing as indirectly to aggravate the susceptibility of the nervous system to pain. The conditions, _sine quis non_, of its effective employment seem to be the following: The general nervous power, as shown by activity of intelligence, and capacity of muscular exertion and the effective performance of co-ordinated movements, must be fairly good, find the circulation must be of at least average vigor; the patient must not have entered on the period of tissue-degeneration. Among neuralgics who answer to this description, those who will benefit by the bromide are chiefly subjects--especially women--in whom a certain restless hyperactivity of mind and perhaps of body also, seems to be the expression of Nature's unconscious resentment of the neglect of s.e.xual functions. That unhappy cla.s.s, the young men and young women of high principle and high mental culture to whom marriage is denied by Fate till long after the natural period for it, are especial sufferers in this way and for them the bromide appears to me a remedy of almost unique power. But I wish it to be clearly understood that it is not to the sufferers from the effects of masturbation that I think the remedy specially applicable: on the contrary, it is rather to those who have kept themselves free from this vice, at the expense of a perpetual and almost fierce activity of mind and muscle. The effects of solitary vice are a trite and vulgar story; there is something far more difficult to understand and at the same time far more worth understanding in the unconscious struggles of the organism of a pure minded person with the tyranny of a powerful and unsatisfied s.e.xual system. It is in such cases, which it heeds all the physician's tact to appreciate, that it is sometimes possible to do striking service with bromide of pota.s.sium; but it will be necessary to accompany the treatment with strict orders as to generous diet, and, very likely, with the administration of cod-liver oil.

Having decided that bromide of pota.s.sium is the proper remedy, we must use it in sufficient doses. Not even epilepsy itself requires more decidedly that bromide, to be useful, shall be given in large doses. It is right to commence with moderate ones (ten to fifteen grains), because we can never tell, beforehand, that our patient is not one of those peculiar subjects in whom that very disagreeable phenomenon--bromic acne--will follow the use of large doses. But we must not expect good results till we reach something like ninety grains daily. Let me add that it is not so far as I know, by reducing any "hyperaesthesia" of the external genitals, of which the patient is aware, that the remedy acts; I have not seen such a nexus of disease and remedy in these cases.

3. Local Measures.--The external remedies which may be applied for the treatment of neuralgia may be divided into (_a_) skin-stimulants; (_b_) paralyzers of peripheral sensory nerves; (_c_) remedies adapted to diminish local congestion; (_d_) remedies adapted to diminish arterial pulsation; (_e_) electricity; (_f_) mechanical means of protection.

(_a_) Among the skin-stimulants blisters hold the highest place as a remedy for neuralgia; indeed the a.s.sertion of Valleix, that they are the best of all remedies, is still not very wide of the truth. They are by no means universally applicable, and the degree to which their action should be carried varies materially in different forms of the disease, but they are of the greatest possible service in a large number of instances.

It is possible to view the action of blisters in neuralgia in more than one way. When applied in such a manner as to vesicate decidedly, and especially if kept open and suppurating for some time, they cause considerable pain of a different kind from that of neuralgia itself and the mental effect of this, operating as a diversion of the patient's thoughts from his original trouble, may be thought to a.s.sist in breaking the chain of nervous actions by which he is made to feel neuralgic pain.

There may be something in this, but I confess that I do not believe this kind of effect goes for much in genuine neuralgia. It is rather in the pain of hypochondriasis, and the so-called spinal irritation (to be described in the second part of this work), that such an action of blisters proves useful.

Another action of blisters, which some authors hold to be perhaps the most effective portions of their agency, is that which is produced by the drain of fluid, specially when they are kept open, by which means a kind of depletion is set up, and the morbid irritation that causes the nerve pain removed. I cannot at all a.s.sent to this view. In the first place, I believe that any one who has large experience of blistering in neuralgia will ultimately come, as Valleix did, to believe that prolonged drain from a blister is rarely or never useful, and that a far better plan is that of so-called flying blisters, renewed at intervals if necessary. The most genuine successes that I have procured from blistering have certainly been got in this way. But I should go further, and say that the prolonged drain and the peculiar kind of chronic irritation produced by a suppurating blistered surface can very decidedly aggravate a neuralgia; this is more especially the case when the blister is applied immediately over the focus pain.

The view which I am strongly convinced alone explains the beneficial action of blisters is that which supposes them to act as true stimulants of nerve-function. In order that this effect shall be produced, it will be necessary that the skin-irritation be either produced at some distance from the seat of the greatest pain, or that, if applied in that spot, it shall be comparatively mild in degree. And accordingly, I have been led, in my observations to apply the blister at some distance from the focus of pain. An indifferent point, however, will not do--there must be an intelligible channel of nervous communication between the irritated portion of skin and the painful nerve. This object is accomplished by placing the blister as close as may be to the intervertebral foramen from which the painful nerve issues; the effect of this is probably a stimulation of the superficial posterior branches, which is carried inward to the central nucleus of the nerve. I must say that the results which I have derived from this plan of treatment have been far more satisfactory than those which I used to obtain when I habitually applied the vesication as near as might be to the focus of peripheral pain; and I think that this result tallies well with the idea that the essential mischief in neuralgia consists in an enfeebled vitality of the central end of the posterior root. An exceedingly interesting confirmation of this idea as to its _modus operandi_ has been afforded me by the fact that not merely neuralgic pain, but also trophic and inflammatory complications attending it, have been sensibly relieved, in several cases that I have seen, by this mode of reflex stimulation. This has been particularly the case in herpes zoster, where the process of inflammation and vesiculation has been very promptly checked by the application of a tolerably powerful blister by the side of the spine at the proper level; and I am gratified to mention that Dr.

J. K. Spender, of Bath, pointed out this fact[39] at a time when he had only seen my statement that the pain could be relieved in this way. In the case of the trigeminus, the same kind of reflex stimulation is most effectively obtained by applying the blister over the branches of the cervico-occipital, at the nape of the neck; and it is remarkable what powerful effects are sometimes thus produced, even in cases that wear the most unpromising aspect. For example, in the desperate epileptiform tic of old age, I have more than once seen a complete cessation of suffering, which lasted for a very long time--so long, in fact, as to make me hope against hope that it might never return. I do not now entertain any such expectations from this remedy; still, its value is very great.

There are curious differences between the effects of blistering in trigeminal or intercostal neuralgia and in sciatica. On the whole, it would appear that blistering in the neighborhood of the spine is less frequently effective in the latter, and we sometimes, after failing with this method, obtain immediate success by two or three repet.i.tions of the flying blister, somewhere over the trunk of the nerve, especially just outside the sciatic notch. I have one lady patient in whom this series of phenomena has several times been observed; and I have seen it occur in a particular attack, in other patients, in whom, nevertheless, on another occasion the spinal blistering has been promptly effective.

I consider blistering of the posterior branches to be an important, and usually an essential, element in the treatment of all cases of sciatica in the middle period of life which have reached some severity and lasted long enough to become complicated with decided secondary affections.

In all cases where blistering is employed it is advisable to adopt the simultaneous use of hypodermic morphia or atropine; this combination of remedies is exceedingly powerful.

Lastly, it must be said of blistering, that, on the whole, it is a remedy not well fitted to be applied to aged subjects; and in its severer forms it should never be applied to patients who are greatly prostrated in strength. For it must be borne in mind that the remedy may miss its aim of relieving the neuralgia, in which case it is necessary to remember, more accurately than many pract.i.tioners appear to do, what a very serious element of misery and prostration will be introduced into the case by the vesication itself.

I am not convinced that any of the other forms of severe skin-irritation (_e. g._, tartar-emetic inunction, or the use of veratrine-ointment to such a degree as to produce not the anaesthetic but the irritant effects) are of any particular value; if blistering failed, I should not expect to see them succeed.

A milder degree of skin-stimulation is represented by rubefacient liniments of various kinds, which may be briskly rubbed into the skin along the track of the painful nerve, without any danger of producing vesication. Among this cla.s.s I continue to prefer chloroform diluted, with six or seven parts of chloroform, to any other; in the milder forms of neuralgia, especially in young persons and first attacks, it is surprising how frequently the paroxysm may be greatly relieved, if not arrested. Still, this can only be regarded as the merest palliative; and in severer cases such applications are useless. Occasionally, when chloroform-liniment has failed, a mustard plaster will do good.

The mildest degree of skin-stimulation is represented by the continuous application of moist warmth, which is best effected by the simple application of moistened spongio-piline; so far as I have observed, however, it is rather in cases of myalgia than in true neuralgia that this does good; in the latter it is probably little more than a mere protector against cold.

(_b_) A variety of agents can be employed with the object of temporarily interrupting the conductivity of the painful nerve; by this means a period of rest is obtained during which the centres--sensory and psychical--have time to regain a juster equilibrium, and the habit of pain is, _pro tanto_, broken through.

There is one agent of this cla.s.s which for general purposes I do not think is worth retaining on our list of sensory paralyses--namely, cold.

Cold, to be of any value, ought to be of the degree which is represented by ice allowed to melt slowly in contact with the skin; and for the majority of neuralgias this is decidedly inferior to other remedies that can be applied by painting or inunction. The one case in which ice is supremely useful is in neuralgia of the testis; here I make no doubt that it is almost, if not quite, the most useful remedy we can employ, although of course other means must be taken to modify the neuralgic temperament. It should be applied the moment an attack comes on.

Far more useful, in neuralgias generally, is the external application of aconite or of veratrine. Aconite may be employed in the milder or the stronger form; in the former case, we simply paint the ordinary tincture on the skin over the painful nerves (avoiding any cracks or sores); in the latter, we rub in an ointment containing one grain of the best hydrate of aconitine to the drachm of lard, about twice a day, and to such an extent as to maintain complete numbness of the parts continuously, for two, three, or four days. I do not believe that this will ever, by itself, cure a true neuralgia of any considerable severity; but I have more than once known its intervention, at a crisis in treatment when it seemed that other remedies might fail, produce a striking change in the progress even of a very bad case.

A milder, but still very useful form of the same kind of action, is produced by veratrine-ointment. I would recommend, however, as a rule, that it be employed, at any rate at first, of weaker strength than that recommended in the Pharmacopoeia, for with some persons it is easy to pa.s.s the anaesthetic, and to enter on the irritant, action of veratrine upon the skin. This leads me to give a caution that should properly have come earlier, when I was speaking of skin-stimulants. In aged subjects, especially, we rather frequently meet, in neuralgia, with a specially irritable state of the skin, even although there may be at the same time some loss of common and tactile sensation; and the pract.i.tioner must be warned against the danger of producing an amount of skin-irritation which will fearfully annoy his patient. I speak feelingly, having by such an indiscretion lost the richest patient who ever favored my consulting-room with his presence!

The inunction of mild veratrine-ointment is extremely useful, as an adjunct to other treatment, in migraine and supra-orbital neuralgias of suckling women, and of chlorotic girls. I have also seen it do much good in mammary neuralgia.

The last division of the subject of paralyzing agents in the treatment of neuralgia includes the surgical operations for division or resection of a painful nerve. Upon this question there is much difficulty in speaking decidedly. I admit at once, of course, that surgical interference is evidently indicated when, along with decided and intractable neuralgic pain, there is plain evidence either of the existence of a neuromatous tumor, or the presence of a foreign body impacted, or a tight cicatrix pressing upon a nerve. I admit, also, though with much greater qualifications, that carious teeth may need to be extracted before we can cure a neuralgia; but even here I should put in the decided caveat that we must consider whether the system is in a state to bear the shock, and that in any case we probably ought to mitigate the effects of the operation by performing it under chloroform.

And I need hardly tell any one, who is familiar, either practically or from reading, with the subject, that thousands of carious teeth have been extracted from the mouths of neuralgic patients, not only without benefit, but with the effect of distinctly aggravating the disease. And I am yet more doubtful as to the advisability of such surgical procedures as the division or the resection of a piece of the painful nerve. Theoretically, as the reader will understand from the strong opinion I have given as to the mainly central origin of neuralgias, I never could antic.i.p.ate that such a procedure would be more than temporarily successful; on the contrary, the mischief in the central end of the nerve remaining, I should suppose that the trying process of the reunion of the nerve (which always takes place) would be almost certainly attended with a revival of the neuralgia, too probably in an aggravated form. The only two cases of excision of a piece of the nerve, that I have ever seen, completely answered to this antic.i.p.ation. In common fairness, however, I must admit that there is a large amount of evidence on the other side. Neuralgias of the trigeminus are pretty nearly the only cases in which the proposal of neurotomy or neurectomy ought to be entertained; in mixed nerves the inconvenience of the muscular paralyses that would follow would be usually too serious to allow of our incurring them. But resection of painful branches of the trigeminus has been performed in a great number of instances, more especially by German surgeons, with results that merit our attention; the cases recorded by Nussbaum, Wagner, Bruns, and Podratzki, may be especially referred to. On the other hand, with the exception of simple division of the nerve, which can be subcutaneously performed, and is a trivial proceeding (but has very short-lived effects), these operations are by no means without danger, especially when they are pushed to such a length as the opening of bony ca.n.a.ls, and the resection of considerable portions of bone in order to get sufficiently far toward the centre, and fatal results have in more than one case followed. Above all, we can never too seriously reflect on the most interesting case of Niemeyer's reported by Wiesner,[40] in which the most formidable operations of this kind have been performed, in an apparently desperate case of epileptiform facial tic, and in which, after all, the application of the constant current painlessly effected an infinitely greater amount of good than had been done by all those severe and painful surgical manipulations. I think it is impossible, after this, not to conclude that neurectomy ought never to be even thought of except as a last resort, in cases of extreme severity, after other measures had been patiently tried and had decisively failed.

(_c_) Of remedies that are intended to relieve local congestion, I must speak with very doubtful approbation. Leeches or scarifications are, I think, very seldom of value. The only remedy that has sometimes seemed to do good is local compression, and, after all, it is quite as likely that this acts by anaesthetizing the nerve as by reducing congestion.

(_d_) Remedies that interfere mechanically with arterial pulsation are of considerable value where they can be effectively applied. I have already pointed out the specially aggravating effect of the momentarily-repeated shocks of arterial pulsation upon neuralgic pain.

Where, then, it is possible, effectively to control an artery pretty near to the point where it divides into the branches that lie close to the painful part of the nerve, it is always worth while to try the experiment. But such a measure as the compression of the carotid in trigeminal neuralgia is of very doubtful propriety; I suspect the consequent anaemiation of the brain more than does away with any benefit that might be mechanically produced. And any attempt to interfere with the general arterial circulation by cardiac depressants is not to be permitted for an instant.

(_e_) We enter now upon a most important subject, the treatment of neuralgia by electricity. It is necessary to exercise much caution in speaking upon this topic, and, as I shall have to express somewhat decided opinions, I may be excused for referring to the circ.u.mstances under which I have arrived at my present stand-point upon this question.

I can hardly be accused of having, with any very rash haste, espoused the cause of medical electricity in the therapeutics of pain, as any one will see who cares to turn to my article on Neuralgia[41] written only three years ago. At that time I had already been studying the subject for a considerable period, but was so convinced of the mult.i.tude of opportunities for fallacy that beset the student of electro-therapeutics, that I was unwilling to state more than the minimum of what I hoped and believed might be affected by this mode of treatment. Since that time I have become more fully acquainted with the researches of foreign observers, and, with the help of their indications, have been able to apply myself more fruitfully to my personal inquiries into the matter.

The result is, that I am now able to speak with far greater a.s.surance of the positive value of electricity as a remedy for neuralgic pain. I shall make bold to say that nothing but the general ignorance of the facts can account for the extraordinary supineness of the ma.s.s of English pract.i.tioners with regard to this question.

In the first place, I have arrived at a decided conviction that Faradic electricity is of little or no value in true neuralgias, and that the cases which are apparently much benefited by it will invariably be found, on more careful investigation, to belong to some other category.

On the effect of frictional electricity I have had such very small experience that I cannot venture to speak with any confidence, and the accounts that I have heard from others whose experience is much larger have not led me to attribute much importance to this agent. If I am to judge at all, I should say it merely acts as a skin-stimulant, and is, in that capacity, inferior to many other simpler and more facile applications.

Very different is the verdict of experience as regards the effects of the constant current; here the results which I have obtained have been so remarkable that even now I should distrust their accuracy, were it not that they are in accord with the general result which (among minor discrepancies) may be gathered, we may fairly say, from all the more important researches that have lately been carried out in Germany. The constant current, as I now estimate it, is a remedy for neuralgia unapproached in power by any other, save only blistering and hypodermic morphia, and even the latter is often surpa.s.sed by it in permanence of affect; while it is also applicable in not a few cases where blistering would be useless or worse.

The English medical profession has not as yet adequately appreciated the necessity for great care in the choice of apparatus and the mode of application of electricity. It is all-important, however, and especially in the case of applying galvanism for the relief of pain. The first quality that must be absolutely required in a battery, that is to be used for this purpose, is that it shall deliver its current with as little as possible variation of tension, in fact that it shall be constant, and not merely continuous; a vast majority of all the various galvanic apparatus that have been used have been merely the latter, and have consequently been almost valueless for the relief of pain. Such are Pulvermacher's chains, the voltaic piles made with elements of metallic gauze, Cruickshank's battery, and many others that have been used. A sufficiently constant current may be obtained from either of the following apparatuses, (1) Daniell's battery, (2) Bunsen's, (3) Smee's.

For hospital use, the Daniell battery (in Muirhead's modification, or with the form of cells introduced by Siemens-Halske) is perhaps the most desirable; but for private practice it is worth while to sacrifice something of the superior constancy which we gain in the Daniell battery for the sake of comparative portability. All purposes which we aim at in the electric treatment of neuralgia may be sufficiently obtained by the use either of the Bunsen battery (zinc-carbon, excited by dilute sulphuric acid), as modified by Stohrer, or by the Smee battery (zinc and platinized silver, excited by dilute sulphuric acid), as in the highly convenient apparatus devised by Mr. Foveaux, of Weiss & Son's. It must be remarked that, for the purpose of treating neuralgia, we shall never need to employ more than fifteen, or at the utmost twenty, cells of either of these batteries. Both the Stohrer's Bunsen and the modified Smee of Weiss are made so that the elements are not immersed in the exciting fluid until the moment when the battery is going to be used; a simple mechanism at once throws the battery into or out of gear. In this way, destruction of the elements is minimized; and either of these two batteries may be used for from three to six months without any renewal, supposing the average work done to be one or two daily seances. If the battery is worked harder, it will require more frequent revivification.

I strongly recommend London pract.i.tioners to deliver themselves from all care and trouble about the repair of their batteries, by making an agreement with the manufacturers to inspect and set them in order at stated intervals. The country pract.i.tioner, on the other hand, will do well to familiarize himself with the process of renewing the acid, of cleaning the plates, of amalgamating the zinc, etc.; in fact, to make himself independent of the manufacturer in every thing short of an actual renewal of the elements, when that becomes necessary. For all further details respecting the above-named, and other batteries, I must refer the reader to systematic works on medical electricity.[42] I must now pa.s.s on to the various modes of application, and the cautions to be observed.

It is, in the first place, necessary to say, that all the best observers coincide in the statement that the use of a current intense enough to produce actual pain or severe discomfort is never to be thought of in the treatment of true neuralgias; such practice will infallibly do harm.

Only such a current is to be employed as produces merely a slight tingling, and (on prolonged application) a slight burning sensation, with a little reddening of the skin at the negative electrode. This being the case, it is perhaps not unnatural for those who have not had practical experience, to suspect that an application which causes so little palpable perturbation is devoid of any positive influence at all.

Such skepticism will certainly not survive any tolerably lengthened observation of the actual facts; but, as some persons may be deterred by this _prima-facie_ view of the case from making any fair trial of the current, it may be worth while, here, to allude to the unmistakable physical effects which similarly painless constant currents are repeatedly observed to produce in cases of motor-paralysis attended with a wasted condition of muscles. Those who have had experience of the treatment of such cases know that it is a by no means infrequent thing to see both muscles and nerves aroused from a state of complete torpidity, and brought into a condition in which the Faradic current, quite powerless before, is again able to excite powerful contractions, while, at the same time, the bulk of the muscles has increased most sensibly. These, surely, are sufficient indications of a positive action of the painless constant current; and such facts have now been recorded, in mult.i.tudes, by most competent observers.

The next maxim of first-rate importance is that the applications of the current should be made at regular intervals, and at least once daily; in most instances, this is enough, but occasionally it will be found useful to operate twice in the day. The matter of regularity is, I find, of great consequence, and it will not do to intermit the galvanism immediately on the occurrence of a break in the neuralgic attacks: it should be continued for some days longer.

The length of sittings is a point as to which there is considerable difference of opinion between various authorities; but my own experience coincides with that of Eulenburg, that from five to ten, or, at the utmost, fifteen minutes, is almost the range of time.

Closely connected with the question of the length of sittings, is that of the continuity with which the current is to be applied. I have seen the best results, on the whole, from pa.s.sing a weak current, without any breaks, for about five minutes. But, where there are several foci of intense pain, it will often be advisable to apply the current to each of these, successively, for three or four minutes.

The places to which the electrodes should be applied vary much according to the nature of the case.

Benedikt's rule, that the application of electricity, to be useful, must be made to the seat of the disease, is undoubtedly true; but it is capable of being applied in a somewhat different manner from that which he recommends in particular cases, the difference being due to the view of the pathology of neuralgia which is taken in this work. That view is, that the essential _locus morbi_ is always in the posterior nerve-root (and usually in that portion of the root which is within the substance of the cord), and that the peripheral source of irritation, if any, is only of secondary--though sometimes of considerable--importance. Hence the main object, in electrization, would seem to be to direct the influence of the current upon the posterior nerve-root. This may, however, be done in different ways, according to the situations in which we place the electrodes, and the direction in which we send the current.

There are, as yet, very considerable differences of opinion among electro-therapeutists as to the principles which should govern us, both in the localization of the effect and the direction of the current.

Benedikt, for example, recommends that the current should be directed toward the supposed seat of the mischief. Thus, if we suppose a neuralgia to depend on morbid action within the spinal cord, then we may galvanize the spine, taking care to make the current come out through any vertebra over which we detect tenderness. If we suppose the seat of the disease to be in the nerve-root in the mere ordinary sense of the word, then we apply the positive pole to the vertebra opposite the highest nerve-origin that can be concerned, and we stroke the negative pole down by the side of the spinous processes, some forty times in succession. The proportion of cases of idiopathic neuralgia in which this treatment succeeds is, according to Benedikt, very large. In other cases, he sends the current from the cord to the apparent seat of pain.

On the other hand, Althaus[43] tells us that, whether the application be central or peripheral, it is the positive pole, alone, which should be applied to the part which we intend to affect: and that the application of the negative pole in this situation is rather likely to do harm than good, as proving too exciting. Eulenburg, also, says that in general the positive pole should be applied to the seat of the disease, the negative on an indifferent spot, or on the peripheral distribution of the nerve.

It is, however, very doubtful to me whether, in the majority of cases, the direction of the current makes any considerable difference in its effects, provided only that the stream is fairly directed so as to include the _locus morbi_ in the circuit, and care is taken to apply it with sufficient persistence and with not too great intensity. Upon this point I am glad to be able to cite the authority of Dr. Reynolds, whose experience is very large. This author, while admitting that in theory the "direct" and the "inverse" currents would seem likely to have different effects, declares that in practice this does not prove to be the case, either in the instance of pain of nerve or of spasm of muscle.

Dr. Buzzard, also, in relating a very striking case (which I had the advantage of personally observing) before the Clinical Society, particularly mentioned that the direct and the inverse currents had a precisely similar effect in relieving the pain. The patient suffered from severe and probably incurable cervico-brachial neuralgia; the poles were placed, respectively, on the nape of the neck and in the hand of the affected limb, and whether the positive was on the nape and the negative in the hand, or _vice versa_, the effect was the same. Very striking remission of the pain was always produced, and the immunity from suffering sometimes lasted for a considerable time, while no other plan of treatment seemed to have more than the most momentary effect.

My own experience tells the same story very decidedly, for I have on very many occasions obtained great benefit, both by the direct and by the inverse currents, in the same patient. I shall here relate a few instances:

CASE I.--A married woman, aged forty-eight, whose menstrual periods had ceased quietly some six years previously. She was, on the whole, a healthy person, but had suffered from migraine in her youth, and came of a neurotic family. She was attacked with severe cervico-brachial neuralgia, which resisted all treatment for nearly three months, and, on her then trying a month's change of air and absence from medication, became worse than ever. The constant current was applied, from ten (and afterwards fifteen) cells of Weiss's battery, daily for twenty-four days, the pain vanished finally at the end of thirteen days, and the accompanying anaesthesia and partial paralysis disappeared before the treatment was concluded. In this case the negative pole was applied by the side of the three lower cervical vertebrae, and the positive was applied, successively, to three or four different parts of the most intense peripheral pain.

CASE II.--A young lady, aged twenty-four, suffered from neuralgia in the leg. Galvanization (twenty cells Daniell), from the anterior tibial region to the spine was found invariably to cut short the pain. I now reversed the current; the effect was the same. After ten sittings I suspended the treatment, as there had been no attack for three days; but a week later the neuralgia returned in full fury. I resumed galvanization from periphery to spine; after twelve more sittings the attacks had become rare and slight. I continued treatment for eight days longer, during the whole of which time there was no pain. It had not recurred when I saw her fifteen months afterward.

CASE III.--H. G., a footman, aged twenty-three, applied to me at Westminster Hospital, with neuralgia of the first and second divisions of the right trigeminus, of six weeks' standing. The right eye was bloodshot and streaming with tears, the skin of the right side of the nose and right cheek was anaesthetic, the right levator palpebrae was partially paralyzed. Hypodermic injections of morphia proved only very temporarily beneficial. After a fortnight's treatment with this and with flying blisters to the nape of the neck and the mastoid process, I commenced the use of the constant current daily (ten cells, Weiss). The first application (positive on nape, negative on infra-orbital foramen) stopped the pain, and procured fourteen hours' immunity. On the next day I reversed the current; the pain stopped after three minutes'

galvanization; it did not recur for four days, during which time, however, I continued the daily use of the direct current. On the sixth day of treatment the patient came to me with a somewhat severe paroxysm, almost limited to the ophthalmic division; it was accompanied by spasmodic twitchings of the eyelid, and copious effusion of altered Meibomian secretion, looking like pus. Galvanization from supra-orbital foramen to nape stopped the pain in five minutes. The next day the patient presented himself, quite free from pain, which had not returned; the conjunctiva was clear, and there was no visible Meibomian secretion.

Inverse galvanization was continued for ten days; but no recurrence of the pain took place. The cure was permanent three months later.

On the contrary, we sometimes see complete failure of the current to affect any good whatever; and in these cases the reversal of the current has not, so far, appeared to me to make any particular change in the result. Such was the case with a patient whose history I detailed (along with that of Case I.) to the Clinical Society. She was an ill-fed and overworked unmarried needle woman, aged thirty; the neuralgia was a most violent double occipital pain, with foci, on each side, where the great occipital nerves become superficial. The current was pa.s.sed daily, for some days, from one focus to another (necessarily pa.s.sing through the nerve-roots and the spinal cord), and the positions of the conductors were occasionally reversed; this not succeeding, the current was applied altogether to the spine, the negative pole being placed on the highest cervical vertebrae, but no good effect was produced after a treatment, altogether, of sixteen days.