CHAPTER VIII.

So firmly is the idea of an essential connection between rheumatism and neuralgia implanted in the popular mind, and, indeed, in the minds of a certain portion of the medical profession, that the two complaints are continually confounded. In the great majority of instances, the mistake made is that of calling neuralgia a "rheumatism." But the opposite error occasionally occurs, and a patient is styled "neuralgic" who is really suffering from chronic rheumatism.

As true neuralgia is an essentially localized disease, there can be no excuse for mistaking for it the more typical cases of chronic rheumatism, in which a number of different joints, muscles, or tendons, are affected, more especially in the advanced stages, when the characteristic fixed contractions of the limbs and extremities have occurred. But there are a few cases in which, either with or without a previous history of acute rheumatism, one, or perhaps two, joints begin to suffer vague pains, which after a little time begin to shoot down the course of the limb, and are aggravated from time to time in a manner which superficially much resembles neuralgia; and when the malady has reached a certain intensity the pains may be so much more severely felt in the longitudinal axis of the limb than in the immediate neighborhood of a joint, that the patient forgets that in reality they commenced either within a joint (as the elbow or hip), or in the fibrous structures immediately outside it. Certain localities are much more frequently the seat of this kind of affection than other parts of the body; thus it occurs, perhaps in nine-tenths of the cases, in the neighborhood either of the shoulder (especially involving the insertions of the deltoid and triceps muscles), of the elbow (particularly affecting the tendinous insertions of the muscles on the internal aspect of the forearm), or the hip (extending to the aponeuroses on the outer and back part of the thigh): in all these cases there is a considerable superficial resemblance to true neuralgic pains. Nevertheless, the diagnosis need not present any serious difficulties after the earliest stages; for there soon arises a very diffuse and acute tenderness of the parts, and usually an amount of generalized swelling, which, though it may not be readily detectable by the eye, is sensible enough to the touch. Movement of the parts is also very painful; but usually not with the acute and agonizing pain which occurs in myalgia.

It is, however, upon signs which are of a more general character that we ought chiefly to rely for diagnosis. The fact that the patient has previously experienced a genuine attack ofacute rheumatism, though of some value, is by no means to be taken as a conclusive argument that the present attack is of a rheumatic nature. The really important matter is, that whether the patient has or has not suffered acute rheumatism before the occurrence of the subacute or chronic form, the latter will always be attended by more or less of the specific constitutional disturbance of rheumatism. I would carefully abstain from the assumption that rheumatism is originally dependent on a blood-poisoning, a theory which I believe to be most doubtful and very probably false; but there is, nevertheless, a truly specific character about the general phenomena in acute rheumatism, and I maintain that similar though less-marked phenomena are always to be seen even in the mildest and least acute forms of rheumatism. Thus there will be, invariably, more or less of the peculiar sallow anæmia, together with red flushing of the cheeks when the pain is at the worst; and there will be a certain amount of the oily perspiration which makes the faces of rheumatic patients look shiny and greasy. No doubt these characteristics will sometimes be very slightly developed, but I believe that attentive observation will always discover them in any case which is genuinely rheumatic. One case, in particular, which has been under my care, very strongly impresses me with the value of these diagnostic signs, where otherwise the symptoms are obscure:

L. P., aged thirty-one, single, a printer by trade, applied to me, January, 1863, suffering from what I at first decidedly thought was cervico-brachial neuralgia, the pain having followed exposure to cold and wet, situated in the lower part of the neck, the shoulder, elbow and inner side of the right arm, and existing nowhere else. The character of the pain was described as at least remittent, if not distinctly intermittent. The pulse was not more than 78; the tongue was thickly coated with white fur, but the man did not complain of thirst, and there were no evident signs of fever. As the pains had only existed for about a fortnight, it appeared an excellent case for cure by the hypodermic injection of morphia; and, accordingly this was used in quarter-grain doses twice a day. After about ten days an attempt was made to do without the morphia, but the pains returned, worse than before, and meantime the tongue had remained uniformly coated, and was now very yellow; the appetite was bad, and there was some increase in frequency of pulse. It now struck me, for the first time, that the man presented, in a slight degree, the sallow and red tint and oily features of a rheumatic patient; it was now found that sweat and urine were distinctly acid. Acting on this idea, I administered five grains of iodide of potassium, and thirty grains of bicarbonate of potassium, four times every twenty-four hours, after giving a moderate saline aperient. The resultwas manifest improvement within twenty-four hours, and almost complete relief of the pain within three or four days (the urine never becoming distinctly alkaline, however.) As the attack subsided, the oily appearance of the skin disappeared, and the rheumatic tint was replaced by mere ordinary pallor, which the patient lost after taking a short course of steel.

At the time this case occurred to me, I was not aware of the importance, in doubtful instances, of looking to the temperature; but subsequent experience has convinced me that in every truly rheumatic case, however limited in extent, there is a real, though it may be a small, rise of temperature. The thermometer will be found to mark from 99-1/4° to 100° Fahr., and this, joined with the appearances above mentioned, and a strong acidity of urine, will be sufficient to distinguish the complaint as rheumatic; and the striking effect of such remedies as iodide with bicarbonate of potash, followed up with sesquichloride of iron, in full doses, helps still further to distinguish the cases from true neuralgias. Since the introduction of the full doses of the iron-tincture in the treatment of acute rheumatism, I have had the opportunity of treating two of these cases of subacute rheumatism in the same manner, viz., with the iron from the first, and the results have been most satisfactory in every way. These cases were independent of a much larger number, treated in the same way, in which the symptoms of rheumatism were more generalized and more severe.

Pains which are connected with a chronic and more or less latent form of gout not unfrequently receive the designation "neuralgic," and are treated upon that erroneous theory of their pathology. I have already endeavored to show that there is by no means that intimate causal relation between gout and neuralgia which is very commonly assumed to exist: true neuralgia is, I believe, only caused in an indirect and secondary manner by the gouty condition setting up changes of the blood-vessels, which precipitate the occurrence of the neuralgic malady, to which the patient was otherwise predisposed from birth. But the common idea, both without and within the profession, seems to be that neuralgia is only one expression, and that a quite common one, of the gouty habit. Nevertheless, with strange inconsistence, the kind of truly gouty painsof which I am now speaking are constantly treated upon a special plan, upon the supposition that they are neuralgic.

There are six situations in which gouty pains are apt to be developed in a way to lead to the false diagnosis of neuralgia: (1) In the eye; (2) more indefinitely within the cranium; (3) in the stomach, simulating gastralgia; (4) in the chest, simulating angina pectoris; (5) in the dorsum of the foot, simulating neuralgia of the anterior tibial nerve; (6) in a somewhat diffuse manner about the hip and back of thigh, simulating sciatica.

It is not really a common thing to find such cases very difficult of diagnosis, provided that the possibility of their occurrence has been carefully noted; for the gouty habit has a number of slight manifestations which are usually enough to discover it even when its more decided symptoms are entirely wanting.

Thus, in the first place, it will be almost invariably found, on inquiry, that the patient has always been intolerant of beer and of sweet wines. Also, he has been liable (either after a single large excess in eating or a prolonged course of a diet too highly animalized in proportion to the amount of exercise taken) to attacks of general malaise, with or without uneasiness, just short of decided pain, about the metacarpo-phalangeal joint of the great-toe, and ending after a few hours or days with a free discharge of uric acid. Less frequently, but still very often, it will be found that he has some deposit of lithate of soda (chalk-stone) in some situation where its presence does not necessarily arrest attention; Dr. Garrod has shown how often these little tophi are found in the cartilage of the ear. Careful examination will sometimes detect their presence in the sclerotic of the eye. But in doubtful cases it would be always well to make a cautious trial of colchicum, which, if the case be gouty, will nearly always produce an amount of relief sufficient to confirm the diagnosis of gout. At least, this rule holds goods for the external forms; but in the case of the supposed gouty pseudo-angina it is far best to trust to opium, as colchicum may prove too depressing to a heart which may quite possibly be already the subject of organic disease. My own impression is, that it was these cases of gouty heart-pain, which are not true angina at all, that procured for opium its high reputation for relieving the latter disease, a reputation which is by no means confirmed by my own experience, since I have found that drug enormously inferior to stimulants like ether in its power to relieve genuine angina.

Lastly, if there be no other possibility of making ourselves certain whether there is or is not a gouty taint at the bottom of the quasi-neuralgic pains, we may adopt Dr. Garrod's test of subjecting the serum of the blood to a search for uric acid (thread-test).

Colic, or painful half spasm, half paralysis of the large intestines, is the best example of a kind of spasmodic pains to which some authors accord the name of neuralgia, as it seems to me without good reason. They appear to be quite independent of the operation of the neurotic temperament, and to be caused entirely by the operation of some local irritant, or narcotic irritant, upon the muscular fibres of the viscus. In the case of colic this influence is most frequently and most powerfully exerted by lead, which undoubtedly becomes locally deposited in chronic poisoning with that metal; at other times it is produced by the irritation of indigestible food passing along the alimentary canal.

That there may be such a thing as enteralgia, of really neuralgic character, I do not deny; on the contrary, so far as regards the rectum, I have myself seen such a case. But true neuralgia of the large bowel is exceedingly uncommon; what goes by the name is usually either colic from local irritation of the viscus; or a mere hysterical hyperæsthesia of the lining membrane, which is one of the occasional phenomena of spinal irritation; or else it is a case of neuralgia of the abdominal wall, such as is included in the description of "lumbo-abdominal neuralgia," in Part I. of this work.

There is no occasion to describe minutely the symptoms of so familiar a disease as lead-colic, or as colic from irritation by indigestible food, when they occur in their typical forms. In the former case the marked constipation which ushers in the attack of pain, and the peculiar greenish-yellow sallowness nearly always seen in the countenance, ought to be sufficient to direct examination to the gums (for the blue line) and inquiry as to any possible impregnation of the system with lead, owing either to the nature of the patient's occupation, or to some accidental entry of the poison into the drinking-water, or its inhalation from the walls of newly-painted rooms, etc. In the latter case, the fact that the attack of colic was shortly preceded by a meal, either of obviously indigestible food, or too copious in quantity and heterogeneous in kind, or too hastily eaten without sufficient mastication, supplies a clew.

But there are a few cases representing minor degrees of either of these kinds of colic, that are much less easy to diagnose distinctly.

Lead-poison sometimes enters the system continuously, for a long period, but in proportions too minute to produce the effects which we identify as an attack of lead-colic. I believe that for the production of the latter complaint it is necessarythat the poisoning shall be sufficiently intense completely to paralyze a considerable piece of bowel, thus altogether hindering peristalsis, or, rather, making the peristaltic acts of the non-paralyzed portions above worse than fruitless. But there is a minor degree in which it may happen that the local affection (owing, I believe, to a less extensive deposit of lead in the bowel) does not reach the decidedly paralytic stage; the state then is one of irregular and painful spasm of individual fibres (quite possibly intermingled with paralysis of a few others), and the practical result is irregularity of evacuation—now diarrhœa, and again constipation—and the frequent recurrence of twinges of pain that are easily mistaken for abdominal neuralgia. Such symptoms as these are nearly always found to have occurred, if proper inquiry be made, in those examples of chronic lead-poisoning in which the toxic process goes on to the development of epilepsy, or marked symmetrical paralysis of the wrist-extensors, without the patient having ever suffered an attack of ordinary colic. In these slow and insidious cases the constitutional affection may not have reached the height at which the complexion and general aspect of the patient suggests metallic poisoning: and the case may present very neuralgia-like features. The absence of thepoints douloureuxis not, as we have seen, conclusive against neuralgia in its early stages. It is therefore an excellent rule, in all cases of chronic recurrent spasmodic pain in the abdomen, especially in men, to investigate the possibilities of lead-poisoning; and, if the slightest suspicious appearance of the gums be found, this track of inquiry must be followed up exhaustively before we abandon the idea. The absence of all special neurotic history in a patient's family should increase our suspicions respecting pains of this character that continue with an obstinacy which makes it unlikely they are due to improper food.

Pains of abdominal irritation are, however, without doubt produced in some cases by unsuspected faults of diet, and may even recur in such a quasi-periodic manner as to strongly suggest the idea of neuralgia in the lumbo-abdominal nerve. One special variety of this happens, I believe, much more often than is thought. A patient will habitually take considerable quantities of some article of food which he does not readily digest, but which is not at all acutely irritant: under these circumstances a simple accumulation is apt to take place in the colon, especially at the top of the ascending colon, the top of the descending colon, or just above the sigmoid flexure, or else in the cæcum. The result of accumulation in the last of these places is not unfrequently typhlitis and perityphlitis, this part of the bowel having (for some reason) a special tendency to inflammation. Deposits in the other localities named are rarely the cause of inflammation, but they very frequentlygive rise to violent pain, which is exceedingly apt to be taken for the pain either of gall-stone, of renal calculus, or else of some abdominal neuralgia. In cases, therefore, where there is any possibility that accumulation is the cause of pain, it is highly desirable to commence with a dose of castor-oil and laudanum, followed up, if needful, by the administration of a large warm-water enema, given through an O'Beirne's tube. The most violent and recurrent attacks of pain in the renal region, the flank, the abdomen, or the groin, will sometimes be instantly cured by such means, sufficiently proving the non-neuralgic character of the complaint.

I have elsewhere explained that the impaction of a renal or an hepatic calculus, in the ureter or the ductus choledochus, may set up a true neuralgia in persons with the requisite congenital predisposition. The passage of renal or hepatic calculi may give rise to symptoms falsely suggesting neuralgia, which require just to be mentioned here. But there is no need to dwell much upon the diagnosis, for the passage of renal or hepatic calculi has always attendant symptoms and features of constitutional history, which ought to preserve the physician from mistake. The sensation of constriction, of nausea and vomiting, the faintness approaching to collapse, the persistent and constantly increasing severity of the pain up to the moment at which mechanical relief occurs, to say nothing of other phenomena, are distinctive to the skilled observer, and, when taken in conjunction with the history of past attacks, if any, will always prevent mistakes. In the few cases which might still be doubtful it will be well to try the effect of a relaxing dose of chloroform, which, in the case of calculus, will often put an end to the paroxysm at once and finally.

A final word or two must be given to the distinction between neuralgia of the head and an affection so utterly different that it is surprising that they should be so frequently confounded. One constantly hears medical men speak of "sick headache" (migraine) as if it were the same thing as headache from indigestion; and, unfortunately, they often treat migraine upon this confused and erroneous notion, doing no little mischief thereby.

But, although migraine, already amply described, is entirely independent of the state of digestion, and its stomach-phenomenaare purely secondary to the affection of the fifth nerve, there is a kind of headache really dependent on imperfect digestion. The sufferers from these headaches are dyspeptics whose stomach troubles are the result of chronic gastric catarrhal inflammation. (In the acute form of gastric catarrh there are even more severe headaches; but the general symptoms of the disorder are too marked to allow us to mistake the case for neuralgia complicated with secondary stomach disturbance.) The patients in question have frequently passed so gradually into the dyspeptic condition as to have become accustomed to it, and inclined to forget that the stomach was the organ which first gave them annoyance. The headaches, which occur from time to time, are either frontal or (more frequently) occipital in position, and they are usually quite evenly bilateral; still, there is not enough uniformity of difference between them and true migraine, in this respect, to enable us to establish a decided diagnosis upon it. This much may be said, however: that the pain is rarely or never seated in one parietal region, as is frequently the case with migraine and with clavus. The patient suffers very strikingly, in almost every case, from languor and a feeling of inability to exert himself; and has also much aching pain in the limbs, and usually a pain (sometimes very severe) in the scapular region. The tongue may vary a good deal in appearance, especially as regards the degree of general redness; but it always has enlarged papillæ, most prominent toward the tip, and more or less thick furring at the back, and reaching forward, in some cases, nearly to the tip, to which the "strawberry" aspect is then confined. The headache is frequently joined with nausea, but never with absolute vomiting, unless the stomach has been provoked with a meal that gives it more trouble than usual. The desponding frame of mind which this kind of dyspeptics always exhibit distinguishes them, in most cases, quite sufficiently (together with the unwholesome complexion, the appearance of the tongue, and the great complaints of general malaise and aching and feebleness of the limbs) from the victims of migraine, who are often persons of bright spirits and lively intelligence in the intervals of their attacks; but, above all, there is nothing of the regular and characteristic sequence of events which distinguishes the attacks of migraine. The attacks are not periodic, but nearly always depend on some chance dietary indiscretion, or other imprudence, which has visibly aggravated the stomach irritation. And, when the pain does come on, it has no uniform tendency to go on intensifying for some hours and culminate in vomiting, followed by sleep, after which the patient is free. On the contrary, the digestive disturbance is the provocation, and the pain itself is of a heavy character, with a sense of tension or fulness, and it does not go on intensifying in a regular manner, up to a climax,but hangs about in a dull, tormenting way, and frequently is just as bad after sleep as it was before. The diagnosis of these headaches from neuralgic headache is not really difficult; it only requires the use of a fair amount of caution in observation. It would, however, be exceedingly advantageous that the word "sick-headache" should be dropped altogether, and that migraine should always be called by that name (or "megrim," if you will), and that headaches really proceeding from chronic catarrhal disease of the stomach should be called "dyspeptic" headaches. The present state of nomenclature does much to perpetuate a confusion of ideas which ought not to exist any longer, and which leads to much practical mischief.

FOOTNOTES:[1]See, on this subject, some remarks, in my work on "Stimulants and Narcotics" on Sir W. Hamilton's "Theory of the Relations of Perception and Common Sensation."A very distinct and careful statement of the distinction between pain and hyperæsthesia will be found in a prize essay "On Neuralgia" by M. C. Vanlair, Jour. de Bruxelles, tom. xl., xli., 1865.[2]"Senses and Intellect."[3]"Gunshot Wounds and other Injuries to Nerves." Philadelphia: Lippincott & Co., 1864.[4]Med. Times and Gazette, March 26, 1864.[5]"London Hosp. Reports," 1866.[6]"Stimulants and Narcotics," Macmillan, 1854, p. 86.[7]Trousseau, Clinique Medicale. Vanlair, "Des dieffrentes Formes du Nevralgies," Journ de Med. de Bruxelles, tome xl.[8]Amer. Jour. Med. Science. Jan. 1850.[9]"Diseases of the Heart and Great Vessels." Third edition, 1862.[10]Gaz. des Hop., 114, 117, 120. 1862.[11]Wien Med. Presse, xxiv., 1866; Syd. Soc. Yearbook, 1865-'66, p. 120.[12]Berlin Klin. Woch., 1865; Syd. Soc. Yearbook, 1865-'66, p. 120.[13]See Wahn,Journ. de Med. et Chir. Prat.1854. Also several original and quoted cases in Dr. Handfield Jones's "Functional Nervous Disorders," second edition, 1870.[14]Journ. de Med. etChir.Prat., July, 1862.[15]Archiv fur Ophthalmologie, B. xii., Abth. 1, 1866.[16]Eulenburg, to whose excellent work ("Lehrbuch der functionellen Nervenkrankheiten," Berlin, 1871) I shall have frequent occasion to refer, has partly misunderstood the drift and scope of my argument, a misfortune which I owe to the impossibility of giving, in the "System of Medicine," more than the briefest and most superficial sketch, both of my ideas and of the facts on which they rest.[17]Op. cit., p. 60.[18]This opinion is somewhat stronger than that expressed in my article in the "System of Medicine." I can only say it is the result of much increased experience.[19]Journal de la Physiologie, v.[20]"Ernährungsstörungen der Augen bei Anæsthesie des Trigeminus." Mitgetheilt von Dr. v. Hippel in Konigsberg in Preussen. Archiv f. Ophthalm. Band. xiii.[21]Zeitsch. f. rat. Med., 1867. There is corroborative evidence, from independent sources, of the truth of Meissner's views. His own observation only proved half the case; but he quotes an observation of Buttman's in which the exact converse of his own experience happened, the external fibres being affected without the inner band, and anæsthesia without trophic changes being the result. Moreover, Schiff (Gaz. hebdom., 1867) obtained experimental results (in operating on cats and rabbits) which coincide with Meissner's.[22]London Hospital Reports, vol. iii., p. 305.[23]Wegner, loc. cit.[24]Archiv f. Ophthalm., xv., 1.[25]"Deutsches Archiv f. klin. Med.," ii., 2, 1866. I am not aware whether Piotrowski has at all altered his opinions since the (subsequent) observations of Ludwig and Cyon upon the "depressor" nerve.[26]"Functional Nervous Disorders." Churchill, 2d edit., 1870.[27]"Prize Essay of the New York Academy of Medicine." New York: Wood & Co., 1869.[28]Volkmann's Sammlung klinischer Vortrage, No. 2. "Ueber Reflex Lahmungen," von E. Leyden. Leipzig, 1870.[29]"Cases of Urinary Paraplegia," Med.-Chir. Trans., 1856.[30]Wurzburg. Med. Zeitsch., iv., 56-64.[31]Med. Cent. Ztg. 21, 1860.[32]Op. cit., pp. 65, 66.[33]Idem, p. 8.[34]"Elektrotherapie." Wien, 1868.[35]Art. "Neuralgia" ("Reynolds's System of Medicine," vol. ii. 1868.)[36]Practitioner, vol. iv., 1870.[37]Berlin. klin. Wochensch., 1865.[38]In a paper on the "Hypodermic Use of Remedies," in thePractitionerof July, 1868, I gave the reasons for this opinion in full; and I see no reason to alter any thing I then said.[39]Practitioner, vol. iv.[40]Berlin. klin. Wochensch., 17, 1868.[41]"System of Medicine," vol. ii.[42]The English reader may consult Althaus ("A Treatise on Medical Electricity," second edition, Longmans), or Meyer ("Medical Electricity," translated by Hammond: Trubner & Co.)[43]"A Treatise on Medical Electricity," second edition, Longmans.[44]Op. cit.[45]Berlin. klin. Wochensch., 22, 1865.[46]Op. cit.[47]"Les Paraplegies et l'Ataxie du Mouvement." Par S. Jaccoud. Paris, 1864.[48]Reynolds's "System of Medicine," vol. ii., Art. "Spinal Irritation."[49]The most complete and careful work of the German school, on this subject, is the "Lehre von der Tabes dorsualis," of E. Cyon. (Berlin, 1867.)[50]Lancet, June 10, 1865. (Comment on a case of Dr. J. Hughlings Jackson's.)[51]Radcliffe, in "Reynolds's System of Medicine," vol. ii.[52]Berkeley Hill, "Syphilis and Local Contagious Disorders," p. 153.

[1]See, on this subject, some remarks, in my work on "Stimulants and Narcotics" on Sir W. Hamilton's "Theory of the Relations of Perception and Common Sensation."A very distinct and careful statement of the distinction between pain and hyperæsthesia will be found in a prize essay "On Neuralgia" by M. C. Vanlair, Jour. de Bruxelles, tom. xl., xli., 1865.

[1]See, on this subject, some remarks, in my work on "Stimulants and Narcotics" on Sir W. Hamilton's "Theory of the Relations of Perception and Common Sensation."

A very distinct and careful statement of the distinction between pain and hyperæsthesia will be found in a prize essay "On Neuralgia" by M. C. Vanlair, Jour. de Bruxelles, tom. xl., xli., 1865.

[2]"Senses and Intellect."

[3]"Gunshot Wounds and other Injuries to Nerves." Philadelphia: Lippincott & Co., 1864.

[4]Med. Times and Gazette, March 26, 1864.

[5]"London Hosp. Reports," 1866.

[6]"Stimulants and Narcotics," Macmillan, 1854, p. 86.

[7]Trousseau, Clinique Medicale. Vanlair, "Des dieffrentes Formes du Nevralgies," Journ de Med. de Bruxelles, tome xl.

[8]Amer. Jour. Med. Science. Jan. 1850.

[9]"Diseases of the Heart and Great Vessels." Third edition, 1862.

[10]Gaz. des Hop., 114, 117, 120. 1862.

[11]Wien Med. Presse, xxiv., 1866; Syd. Soc. Yearbook, 1865-'66, p. 120.

[12]Berlin Klin. Woch., 1865; Syd. Soc. Yearbook, 1865-'66, p. 120.

[13]See Wahn,Journ. de Med. et Chir. Prat.1854. Also several original and quoted cases in Dr. Handfield Jones's "Functional Nervous Disorders," second edition, 1870.

[14]Journ. de Med. etChir.Prat., July, 1862.

[15]Archiv fur Ophthalmologie, B. xii., Abth. 1, 1866.

[16]Eulenburg, to whose excellent work ("Lehrbuch der functionellen Nervenkrankheiten," Berlin, 1871) I shall have frequent occasion to refer, has partly misunderstood the drift and scope of my argument, a misfortune which I owe to the impossibility of giving, in the "System of Medicine," more than the briefest and most superficial sketch, both of my ideas and of the facts on which they rest.

[17]Op. cit., p. 60.

[18]This opinion is somewhat stronger than that expressed in my article in the "System of Medicine." I can only say it is the result of much increased experience.

[19]Journal de la Physiologie, v.

[20]"Ernährungsstörungen der Augen bei Anæsthesie des Trigeminus." Mitgetheilt von Dr. v. Hippel in Konigsberg in Preussen. Archiv f. Ophthalm. Band. xiii.

[21]Zeitsch. f. rat. Med., 1867. There is corroborative evidence, from independent sources, of the truth of Meissner's views. His own observation only proved half the case; but he quotes an observation of Buttman's in which the exact converse of his own experience happened, the external fibres being affected without the inner band, and anæsthesia without trophic changes being the result. Moreover, Schiff (Gaz. hebdom., 1867) obtained experimental results (in operating on cats and rabbits) which coincide with Meissner's.

[22]London Hospital Reports, vol. iii., p. 305.

[23]Wegner, loc. cit.

[24]Archiv f. Ophthalm., xv., 1.

[25]"Deutsches Archiv f. klin. Med.," ii., 2, 1866. I am not aware whether Piotrowski has at all altered his opinions since the (subsequent) observations of Ludwig and Cyon upon the "depressor" nerve.

[26]"Functional Nervous Disorders." Churchill, 2d edit., 1870.

[27]"Prize Essay of the New York Academy of Medicine." New York: Wood & Co., 1869.

[28]Volkmann's Sammlung klinischer Vortrage, No. 2. "Ueber Reflex Lahmungen," von E. Leyden. Leipzig, 1870.

[29]"Cases of Urinary Paraplegia," Med.-Chir. Trans., 1856.

[30]Wurzburg. Med. Zeitsch., iv., 56-64.

[31]Med. Cent. Ztg. 21, 1860.

[32]Op. cit., pp. 65, 66.

[33]Idem, p. 8.

[34]"Elektrotherapie." Wien, 1868.

[35]Art. "Neuralgia" ("Reynolds's System of Medicine," vol. ii. 1868.)

[36]Practitioner, vol. iv., 1870.

[37]Berlin. klin. Wochensch., 1865.

[38]In a paper on the "Hypodermic Use of Remedies," in thePractitionerof July, 1868, I gave the reasons for this opinion in full; and I see no reason to alter any thing I then said.

[39]Practitioner, vol. iv.

[40]Berlin. klin. Wochensch., 17, 1868.

[41]"System of Medicine," vol. ii.

[42]The English reader may consult Althaus ("A Treatise on Medical Electricity," second edition, Longmans), or Meyer ("Medical Electricity," translated by Hammond: Trubner & Co.)

[43]"A Treatise on Medical Electricity," second edition, Longmans.

[44]Op. cit.

[45]Berlin. klin. Wochensch., 22, 1865.

[46]Op. cit.

[47]"Les Paraplegies et l'Ataxie du Mouvement." Par S. Jaccoud. Paris, 1864.

[48]Reynolds's "System of Medicine," vol. ii., Art. "Spinal Irritation."

[49]The most complete and careful work of the German school, on this subject, is the "Lehre von der Tabes dorsualis," of E. Cyon. (Berlin, 1867.)

[50]Lancet, June 10, 1865. (Comment on a case of Dr. J. Hughlings Jackson's.)

[51]Radcliffe, in "Reynolds's System of Medicine," vol. ii.

[52]Berkeley Hill, "Syphilis and Local Contagious Disorders," p. 153.

Transcriber's Notes:

Punctuation and spelling errors fixed. Variant spellings and hyphenations changed when there is a clear majority. Other unusual spellings retained.

Hover notes were added in the text to show original versions of changed texts for the following notes:

Discrepancies in headings and outline labels repaired. In some cases, this required adding headings implied but not present in the original, to agree with headings that were present.

Table of Contents, Part 1, Chapter IV: original reads "Diagnosis and Progress of Neuralgia." "Progress" has been corrected to "Prognosis" as shown in the Chapter heading.

P. 51, "but her mensural troubles" changed to "but her menstrual troubles".

P. 67, footnote #14. Original reads "Journ. de Med. et Chim. Prat." "Chim." is typo for "Chir." as in footnote just above.

P. 96, "investigation of neralgi" changed to "investigation of neuralgia".

P. 105, "genealogical connection between migraine and epilepsy": in all reviewed copies of this 1882 edition, original shows "aological" with 4 or 5 spaces in front of it, an apparent printer error. However, in the 1872 edition, the entire sentence reads as presented here.

P. 206, "I have already causually" changed to "I have already causally".

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