r^cJv^ 
 
 ?>\ 
 
 Columbia tHmberSftp 
 in tjic City of ^citi ©otfe 
 
 CotUat of Siipsicfans anb ^utstons 
 
 l^eference ILihxatp 
 
PAIN 
 
 IN ITS 
 
 NEURO-PATHOLOGICAL, DIAGNOSTIC, MEDICO- 
 LEGAL, AND NEURO-THERAPEUTIC 
 
 RELATIONS. Dk. CHARLES K. MILLS. 
 
 1909 Chestnut Street, 
 PHiUDaPHIA. 
 
 BY 
 
 J. LEONAED COElSrmG, A.M., M.D., 
 
 CONSULTANT IN NERVOUS DISEASES TO ST. FEANCIS HOSPITAL, ST. MABY'S HOSPITAL, 
 THE HACKENSACK HOSPITAL, ETC. ; FELLOW OP THE NEW YORK ACADEMY OF 
 medicine; MEMBER OF THE NEW YORK NEUROLOGICAL SOCIETY, THE MEDI- 
 CAL SOCIETY OF THE COUNTY OF NEW YORK, AND THE MEDICAL SOCIETY 
 OF THE STATE OF NEW YORK, ETC. 
 
 AUTHOR OF "a TREATISE ON HEADACHE AND NEURALGIA," "BRAIN-EXHAUSTION, 
 
 WITH SOME PRELIMINARY CONSIDERATIONS ON CEREBRAL DYNAMICS," "LOCAL 
 
 ANESTHESIA," "a TREATISE ON HYSTERIA AND EPILEPSY," " BRAIN-BEST : 
 
 BEING A DISQUISITION ON THE CURATIVE PBOPEBTIES OF FBO- 
 
 LONGED SLEEP," ETC. 
 
 ILLUSTRATED. 
 
 PHILADELPHIA: 
 
 J. B. LIPPINCOTT COMPANY. 
 18 94. 
 
Copyright, 1894, 
 
 BY 
 J. B. LlPPINCOTT COMPANT. 
 
 Printed by J. B. Lippincott Company, Philadelphia. 
 
TO MY 
 
 MATERNAL UNCLE, 
 
 FREDERICK DEMING, 
 
 AS A TOKEN OF ADMIEATION 
 AND AFFECTION. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/paininitsneuropaOOcorn 
 
PREFACE. 
 
 "Pains are the correlatives of actions injurious to the organism, 
 while pleasures are the correlatives of actions conducive to its wel- 
 fare." — Herbert Spencer, Principles of Psychology. 
 
 "The phenomena of feeling constitute the true basis of all that 
 part of philosophy which at all involves the interest of man." — 
 Lester P. "Ward, Dynamic Sociology. 
 
 There is no department of neurology a knowledge 
 of which is so essential to the physician as that 
 which deals with pain. As an aid to diagnosis the 
 importance of this symptom is unique; while to 
 relieve it requires discernment and ingenuity of a 
 high order. 
 
 Kor is its ethical significance less apparent; for 
 surely there is nothing in all the world so con- 
 ducive to an active sympathy with mankind as the 
 habitual relief of suffering. 
 
 Since, during the past ten years, the author has 
 devoted much time to the study of pain, he is led 
 to hope that in presenting this volume he may be 
 able to advance in some degree the cause of scien- 
 tific medicine. 
 
 53 West Thirty-eighth Street, New York. 
 March 1, 1894. 
 
 1* 5 
 
CONTENTS. 
 
 PART I 
 
 PHYSIOLOGICAL, PATHOLOGICAL, AND CLINICAL. 
 
 CHAPTEE I. PAGE 
 
 The Physiology of Pain — Conduction — Definition , . 11 
 
 CHAPTEE 11. 
 
 The Pathology of Pain — Neuritis, or Inflammation 
 OF THE Nerves — Multiple Neuritis — Chronic Alco- 
 holic Neuritis — Neuritis Consecutive to Influenza 
 — The Neuritis of Leprosy — Beriberi 29 
 
 CHAPTEE III. ' 
 
 Concerning Pains located in Definite Nerve-Areas 
 — Neuralgia 62 
 
 CHAPTEE IV. 
 Pain associated with the Eheumatic and Gouty 
 Diathesis 70 
 
 7 
 
8 CONTENTS. 
 
 CHAPTER V. PAGE 
 
 Pains which have their Seat in the Structures con- 
 tained WITHIN the Cavities or the Body — Intra- 
 cranial Pains (Headache) — "Spinal" (Medullary) 
 Pains — Abdominal and Thoracic (Visceral) Pains . 80 
 
 CHAPTEE VI. 
 
 The Diagnostic Value of Pain 92 
 
 CHAPTER VII. 
 
 The Clinical and Medico-Legal Significance of the 
 Phenomena evoked by Pain — Objective Method of 
 diagnosticating Pain 108 
 
 CHAPTER VIII. 
 The Medico-Legal Relations of Pain — Spinal Con- 
 cussion 117 
 
 CHAPTEE IX. 
 
 Of the Insomnia and Melancholia of Pain 128 
 
 PART II. 
 
 THE SPECIAL THERAPEUTICS OF PAIN. 
 
 CHAPTER X. 
 
 Concerning the Importance of Rest in the Treatment 
 of the Nervous Symptoms engendered by Prolonged 
 AND Severe Pain 140 
 
CONTENTS. y 
 
 CHAPTER XI. PAGE 
 
 Of Internal Remedies which are either directly 
 OR indirectly Applicable in the Treatment op 
 Pain 165 
 
 CHAPTER XII. 
 
 Or OTHER AND MORE ReCBNT REMEDIES WHICH HAVE 
 
 BEEN EMPLOYED IN THE TREATMENT OF PAIN 189 
 
 CHAPTER XIII. 
 
 Summary of other Important Facts Relative to the 
 Action of Remedies on the Nervous System .... 198 
 
 CHAPTER XIV. 
 
 On the Author's Methods of employing Remedies so 
 AS TO Increase the Certainty and Duration of 
 their Action on the Peripheral Nerves — Other 
 Measures which have been proposed 206 
 
 CHAPTER XV. 
 Surgical Expedients 227 
 
 CHAPTER XVI. 
 
 Local Medication of the Spinal Cord and Cauda 
 Equina, Author's Plan— Other Measures 241 
 
 CHAPTER XVII. 
 
 The Use of Compressed Air in conjunction with 
 Remedies which tend to diminish the Acuity of 
 Perception, Author's Plan 256 
 
 CHAPTER XVIII. 
 
 Reflex and Spurious or Imaginary Pains— Hypnotism 304 
 
10 CONTENTS. 
 
 CHAPTER XIX. PAGE 
 Concluding Obsekvations on the Prevention of Re- 
 lapse — The Prophylaxis of Pain 313 
 
 CHAPTER XX. 
 Supplementary Observations on Torture, or the In- 
 fliction OF Pain as a Judicial Punishment or for 
 the Purpose of extorting a Confession of Guilt . 318 
 
PART I. 
 
 PHYSIOLOGICAL, PATHOLOGICAL, AND CLINICAL. 
 
 CHAPTER I. 
 
 THE PHYSIOLOGY OF PAIN — CONDUCTION — DEFINITION. 
 
 Definition of Pain. — Various attempts have been 
 made to define pain. Cicero looked upon it as a 
 disagreeable movement within the body, indepen- 
 dent of the senses. According to others, it is a 
 species of sensation which may emanate from both 
 internal and external regions of the body, in which 
 are distributed nerves, " whose office it is to transmit 
 to the brain all impressions." Sauvage calls it a 
 disagreeable perception, originating from any lesion 
 of the nerve-fibres ; Caubius regards it as a sensation 
 which the mind " would rather not experience" (!) ; 
 while Bilon is discontented with all definitions, 
 and believes the word pain to be so universally de- 
 scriptive in itself as to enable one to dispense with 
 
 11 
 
12 PAIN. 
 
 all definitions.^ More recent authors have, never- 
 theless, persisted in further attempts to define it. 
 Thus Valentin^ perceives in pain " sensory impres- 
 sions which, on account of their too great intensity, 
 become disagreeable;" Wundt^ calls it "a feeling 
 that accompanies all powerful or intense stimuli," 
 while Eulenburg* defines it as " a gradual increase 
 of the feeling that accompanies every sensory pro- 
 cess." 
 
 To my mind, the views of Erb° regarding the 
 nature of pain are among the most comprehensive 
 which have been recently expressed. " We hold," 
 he says, " that every increase of ordinary sensory 
 stimuli is capable of producing pain, as soon as it 
 attains a certain intensity. Every excitation, the 
 intensity of which exceeds certain limits, every 
 molecular change of the centripetal series, induced 
 by an abnormally strong stimulus, is perceived as 
 pain. Yery simple experiments, as, for example, 
 pressure or temperature gradually increased till pain 
 
 ^ Dictionnaire des Sciences Medicales, vol. x. p. 179, Paris, 1814. 
 
 * Physiologisclie Pathologie der Nerven, vol. i. p. 240. 
 
 ^ Lehrbucli der Physiologie des Menschen, p. 503, 1874. 
 
 * Functionelle Nervenkrankheiten, p. 31. Vide also Diseases of 
 the Peripheral Oerebro-Spinal Nerves, by Wilhelm Heinrich Erb, 
 Ziemssen's Cyclopaedia, vol. xi. p. 14. 
 
 * Op. et loc. cit. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 13 
 
 is produced, show that, with very gradual increase 
 in the strength of the stimulus, a limit is at length 
 reached beyond which the excitory process is ac- 
 companied by pain, yet no sharp line of demarca- 
 tion can be traced defining the point at which the 
 sensation of pressure or temperature ceases and the 
 sensation of pain commences." 
 
 Regarding, then, the phenomena concerned in 
 their broadest aspect, I would define pain as the 
 feeling (perception) evoked by over-stimulation of 
 the nerves of special and common sensation. By 
 over-stimulation is meant, of course, a degree of 
 stimulation which exceeds the physiological limit. 
 
 We have thus a clue to the genesis not only of 
 those pains which originate in over-stimulation of 
 the nerves of common sensation, with which we are 
 most frequently called upon to deal, but of those 
 likewise which have their origin in an exaggerated 
 stimulation of the nerves of special sense ; for do we 
 not know that intense light and loud inharmonious 
 noises produce sensations which are described by 
 those subjected to them as veritable pains? 
 
 In view of these facts, nothing can be more in- 
 consistent — to give it no stronger name — than the 
 attempts of those extremists whom Brown-Sequard 
 has facetiously alluded to as the " cluster localizers" 
 to ascribe the perception of pain to a limited area 
 
 2 
 
14 PAIN. 
 
 of the cortex. Clearly, a hypothetical spot of this 
 kind could by no possibility serve as the rendezvous 
 for the pain-concepts of both special and common 
 sensation. 
 
 Such a centralization of heterogeneous functions 
 is physiologically, not to say anatomically, un- 
 thinkable. 
 
 From all this it is evident, then, that the modifi- 
 cation engendered in the perceptive mechanisms of 
 common and special sensation by excessive stimula- 
 tion is the principal, if not the only, prerequisite to 
 the development of pain. 
 
 As regards those fine molecular perturbations 
 originating in the nerve and transmitted thence to 
 the sensorium, — perturbations which are evidently 
 the ultimate and essential element of pain, — we are 
 still, and doubtless are destined in future to remain, 
 entirely in the dark. Although we are thus de- 
 barred, on account of the crudity of our physiology, 
 from penetrating the final mystery of pain, we are, 
 nevertheless, enabled to adopt proper means for its 
 arrest when once established. 
 
 As the argument proceeds, we shall find that, in 
 combating pain, we are compelled to invoke the 
 aid of a wide range of agents ; and thus it happens 
 that chemistry, thermo-dynamics, physics, and even 
 surgery have all rendered important assistance. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 15 
 
 Finally, we must not forget to mention a very 
 recent theory regarding the mechanism underlying 
 the pains occurring along the course of nerves. 
 According to Prus,^ who is the promulgator of this 
 theory, there are filaments in the sheaths of nerve- 
 trunks the irritation of which gives rise to the 
 painful points found in neuralgic affections. These 
 filaments, the presence of which was made known 
 by careful microscopical examination, have received 
 the somewhat ponderous appellation of nervi nervo- 
 rum periphericorum. 
 
 It is, of course, impossible at present to prophesy 
 with any degree of certainty what part these struct- 
 ures are destined to play in the physiology and 
 pathology of the future. Perhaps autopsies con- 
 ducted with a special view to further enlightenment 
 on this point may afibrd assistance ; but it is hardly 
 to be anticipated that we shall derive much help 
 from experimentation. 
 
 The Transmission of Painful Impressions from 
 the Periphery to the Perceptive Mechanism. — The 
 next question which naturally suggests itself is, 
 how do painful impressions reach the higher centres 
 of the brain ? or, in other words, along what paths 
 do such impressions travel in their journey from 
 
 ^ Archives Slaves de Biologic ; also Brain, vol. x. p. 557. 
 
16 
 
 PAIN. 
 
 the periphery to the mechanism (" centre") of con- 
 scious perception ? 
 
 It is much to be regretted that only a partial 
 answer can be given to this important question. 
 
 About all we know of the matter is soon told. 
 In the first place, as every one knows, the trans- 
 
 FlG. 1. 
 
 -AKIEBIORHORN 
 
 HORN 
 
 mission of painful sensations from the periphery to 
 the spinal cord is accomplished through the instru- 
 mentality of the sensory nerves. The course pur- 
 sued by such painful impressions through the cord 
 is more obscure. Some physiologists believe that, 
 after crossing to the opposite side of the cord, they 
 are transmitted wholly through the gray substance ; 
 others, again, assign special importance to the sen- 
 sory conducting paths of the posterior columns; 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 17 
 
 Fig. 2. 
 
 while a third class of observers believe that sensa- 
 tions of pain may be transmitted both through the 
 gray substance and the white substance of the pos- 
 terior and lateral columns. 
 
 But while the direction pursued by the sensory 
 pathway after crossing in the cord is not altogether 
 clear, the decussation itself seems adequately demon- 
 strated. Evidence of this intersection of the fibres 
 is afforded by the fact 
 thatj when one lateral half 
 of the cord is divided 
 transversely by traumatism 
 or disease, the parts below 
 it on the same side are 
 paralyzed, while sensation 
 is lost in the corresponding 
 parts on the opposite side. 
 Thus it is that sensory 
 fibres from the right half 
 of the body cross the me- 
 dian line and ascend in 
 the left half of the cord, 
 while those from the left 
 half of the body decussate and pass upward on the 
 right side of the cord. The decussation of the sen- 
 sory fibres in the cord is indicated in the diagrams, — 
 Fig. 1, transverse, and Fig. 2, longitudinal, section. 
 b 2* 
 
 
 
 fX\X 
 
18 PAIN. 
 
 Our knowledge of the route pursued by tlie sen- 
 sory fibres through the medulla oblongata and the 
 pons is quite indefinite, and the same may be said 
 of the relation which these tracts sustain to the 
 gray matter of those regions. From the data 
 available, it would seem, however, that sensation is 
 transmitted onward through the tegmentum to the 
 hindermost portion of the posterior limb of the 
 internal capsule, and thence, by way of the corona 
 radiata, to the cerebral cortex. At its point of 
 transit through the internal capsule the sensory 
 pathway seems to lie in close proximity to the fibres 
 destined for the conduction of the impressions of 
 the special senses. 
 
 The Sensory Regions of the Cortex. — The evi- 
 dence that the nerves of special sense are con- 
 nected with definite areas of the cerebrum may 
 be thus summarized : 
 
 Certain fibres of the olfactory tract have been 
 traced to the hippocampal gyrus in the temporal 
 lobe; and it has been observed that keenness of 
 the sense of smell is materially lessened after lesion 
 of the hippocampus. The so-called " taste centre" 
 has been located in the temporal lobe in the vicinity 
 of that of smell ; but the evidence in favor of as- 
 signing it to this locality is inconclusive. !N"or is 
 the location of the auditory centre altogether cer- 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 19 
 
 tain, in spite of the attempts to associate it with 
 the superior temporal convolution. Some of the 
 phenomena bearing on the question are, however, 
 sufficiently interesting to deserve mention. 
 
 In the first place, it has been observed that, after 
 destruction of the internal ear, the median corpus 
 geniculatum and posterior corpus quadrigeminum 
 atrophy; and, secondly, atrophy of the nuclei may 
 be induced by destroying the superior temporal 
 convolution. Additional experiments and patho- 
 logical investigations are required to establish this 
 somewhat complicated connection. 
 
 The cortical area concerned in visual perception — 
 the so-called optic centre — is much more definitely 
 located than any of those previously considered. 
 It seems, indeed, exceedingly probable, to say the 
 least, that that portion of the occipital lobe called 
 the cuneus is intimately associated with visual per- 
 ception ; for when, for example, the right occipital 
 lobe is removed or rendered inoperative by disease, 
 left hemiopia results, and vice versa, while the ob- 
 literation of both occipital lobes gives rise to total 
 blindness. 
 
 There are other collateral facts bearing on the 
 question, such as the secondary atrophy of the 
 pulvinar of the thalamus, the lateral corpus geni- 
 culatum, and the median corpus quadrigeminum 
 
20 
 
 PAIN. 
 
 after extirpation of the occipital cortex, but the 
 essentially practical scope of this work precludes 
 their consideration. 
 
 An immense amount of discussion has been lav- 
 ished on the question as to what portions of the 
 cerebral cortex are associated with cutaneous sen- 
 sation. In my opinion, the evidence at present 
 available — though certainly to some extent con- 
 
 FiG. 3. 
 
 flicting — goes to show that the so-called "sensory 
 centres" are distributed throughout the "motor 
 area," if indeed they do not extend beyond it. 
 
 It is a well-known fact that irritation of the sen- 
 sory nerves of the skin may produce several kinds 
 of sensations ; or what amounts to the same thing, 
 these nerves are endowed with different kinds of 
 sensibility. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 21 
 
 Thus, we have a sense of locality, tactile sensi- 
 bility, sense of temperature, " sense of pain," and 
 sense of pressure, according to the mode of action 
 of the peripheral irritant. 
 
 In certain diseases of the nervous system some or 
 all of these powers of discrimination may be im- 
 
 FiQ. 4. 
 
 paired or lost; so that from a diagnostic point of 
 view the investigation of cutaneous sensibility is 
 a matter of importance. Whether — as has been 
 alleged and as some facts tend to show — each va- 
 riety of cutaneous sensibility is provided with a 
 
22 PAIN. 
 
 separate and distinct pathway is, however, still an 
 open question. 
 
 The regions previously discussed are shown in 
 the annexed diagrams. The hypothetical areas 
 (" centres") of vision, smell, and taste, as viewed 
 from the mesial aspect of the brain, are shown in 
 Fig. 3, while the sensori-motor region and the lo- 
 cality supposed to be associated with hearing are 
 indicated in Fig. 4, representing the right cerebral 
 hemisphere. 
 
 Identity of the Processes in Motor and Sensory 
 Nerves. — It has often been asked, as a matter of 
 theoretic interest, whether the processes accom- 
 plished in a motor nerve differ radically from those 
 occurring in a sensory nerve. On this point, Rad- 
 cliffe, in concluding an elaborate argument, observes, 
 "that there is reason to believe that there is no 
 essential difference between the action which issues 
 in sen-sation and the action which issues in mus- 
 cular contraction." As a corollary to this proposi- 
 tion, he adds : " that the production of sensation 
 and the production of muscular contraction only 
 differ in this, — that the electrical discharge, analo- 
 gous to that of the torpedo, which is developed in 
 and near the nerve in the state of nervous action, 
 happens to tell upon sensorial ganglionic cells in 
 the one case, and upon muscular fibres in the other." 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 23 
 
 Of course to speak of tlae electricity evolved 
 during the action of a nerve as though it were 
 the nerve-force concerned in the production of 
 sensation or motion is a mistake. In other re- 
 spects, the figure is an apt one. 
 
 It may be of interest, in this connection, to con- 
 sider the experiments which have led Radcliffe and 
 others to these conclusions. Undoubtedly the re- 
 searches of Du Bois Reymond and Matteucci have 
 had a powerful influence in shaping opinion. 
 
 The principal experiment of Du Bois Reymond 
 consists in pouring hot water upon the leg of a 
 frog, the nerve of the same being connected with 
 a galvanometer. When this is done, the galvanom- 
 eter shows a cessation of the electrical current, — a 
 phenomenon which is observed almost as soon as 
 the water touches the integument. This observa- 
 tion in conjunction with the well-known fact that 
 there is also a decrease, amounting sometimes to 
 almost entire absence of " natural electricity," dur- 
 ing the action of motor nerves, led Du Bois Rey- 
 mond to the inference that in sensory as well as 
 motor nerves there is a loss of electricity when the 
 nerves pass from rest into a state of action. 
 
 Matteucci's experiment, performed upon a rabbit, 
 consisted in dissecting out the upper portion of the 
 sciatic nerve and in irritating it with the galvanic 
 
24 PAIN. 
 
 current. "When the current was closed the animal 
 screamed loudly, but when it was opened there was 
 no sign of pain. 
 
 The resemblance of the phenomena evoked by 
 the galvanic current in sensitive and motor nerves 
 has led to the inference that the change in a sen- 
 sory nerve when sensation is produced by the 
 action of voltaic electricity, and the change in a 
 motor nerve when muscular contraction is produced 
 by the same means, are, as Radcliffe puts it, exact 
 equivalents. 
 
 Such, then, are the principal facts which have 
 been assumed to prove the identity of the processes 
 underlying the actions of motor and sensory nerves. 
 While, however, the relation of the two kinds of 
 nerves to the galvanic current points to the truth 
 of this proposition, it is, of course, self-evident that 
 the final result of the action differs radically in each 
 kind of nerve. In the case of the motor nerve, 
 action results in contractions, due to the excitation 
 of the contractile substance of the muscle; in the 
 case of the sensory nerve, on the other hand, action 
 is translated into perception, through the instrumen- 
 tality of the central ganglionic apparatus in the 
 cortex. 
 
 So much for the fundamental features of the 
 argument. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 25 
 
 Concerning' the Correct and Erroneous Refer- 
 ence of Painful Sensations. — While all are aware 
 of that remarkable attribute of the perceptive mech- 
 anism which usually enables the individual to refer 
 with great exactness both agreeable and disagree- 
 able sensations to their point of origin at the periph- 
 ery, few comparatively have given thought to the 
 anatomical arrangement underlying this phenome- 
 non; and fewer still are able to account for those 
 apparent paradoxes, which obscure the physiology 
 involved and tend to discredit its application in the 
 clinic. Hence we shall not, I believe, misuse our 
 time if we devote a few paragraphs to a review of 
 the more important points connected with referred 
 sensations. 
 
 In the first place, then, it must be remembered 
 that a sensory nerve supplies a certain area of the 
 body and transmits to the brain only such impres- 
 sions as emanate from that area. In other words, 
 there is no physiological anastomosis, however much 
 the fibres may interlace or run together. To prove 
 this, it is only necessary to divide a sensory nerve 
 and irritate its distal end, when we find that 
 no sensation is perceived, thus demonstrating that 
 there is no collateral communication M'hatsoever. 
 As a matter of course, irritation of the proximal 
 or central portion of the nerve — that part which 
 
 B 3 
 
26 PAIN. 
 
 is connected with the nerve-centres — ogives rise to 
 distinct sensation. 
 
 In the same way, if we divide the spinal cord of 
 an animal transversely, so as to sever the sensory 
 conducting paths, and irritate the nerves which join 
 the cord below the incision, no sensation will be 
 perceived; but if we stimulate the nerves which 
 enter the cord above the incision, we shall have 
 every evidence that the sensation has been per- 
 ceived. Precisely the same sort of phenomena may 
 be observed in human beings who by reason of 
 injury or disease have suffered a solution of the 
 sensory conducting paths of the cord. 
 
 Another important fact is, that an impression made 
 upon any point in the course of a sensory nerve may 
 be perceived by the mind as though it were made 
 not only upon the point in question, but also upon 
 the part to which the fibres of the nerve are dis- 
 tributed. We have, therefore, under such circum- 
 stances, practically the same effect as if the irritation 
 were applied to the regions supplied by the branches 
 of the nerve. 
 
 An explanation is thus afforded of the fact that 
 when the sensibility of a part is abolished by com- 
 pression or division of the nerve which supplies it, 
 irritation of the central portion may still give rise 
 to sensations which are felt as though they emanated 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLmiCAL. 27 
 
 from the parts below the point of interruption, — i.e., 
 from the parts to which the peripheral terminations of 
 the nerve are distributed. Thus, when a nerve is di- 
 vided for the cure of an intractable form of neuralgia, 
 it sometimes happens that pain still persists. This is 
 undoubtedly due to the fact that the division of the 
 nerve has not been made near enough to the nerve- 
 centres to include the entire affected portion, and 
 hence the continued irritation of the central portion 
 causes pain, which, in accordance with the law under 
 consideration, is felt as though it emanated from the 
 peripheral parts of the nerve. Another illustration 
 of the same thing is found in those paralyses in 
 which the limbs are quite insensible to such external 
 stimuli as pricking, pinching, and burning, and yet 
 are believed by the patient to be the seat of severe 
 pain. Still another example of erroneously referred 
 pains is seen in persons who have suffered am- 
 putation of a limb. "When the divided nerves of 
 the stump are inflamed, or otherwise irritated, noth- 
 ing is more common than to hear the subject com- 
 plain that he experiences pain which appears to be 
 located in the part of the limb which has been 
 removed. 
 
 Such facts as these might, on a superficial exami- 
 nation, lead one to suppose that there was little or 
 no benefit to be anticipated from local therapeutic 
 
28 PAIN. 
 
 measures addressed to the affected nerve itself in 
 cases of pain. It must be remembered, however, 
 that by the aid of chemicals we are in many cases 
 able not only to temporarily cut off the peripheral 
 portion of an affected nerve from its central con- 
 nections, but also to modify the abnormal condition 
 of the nerve itself, thus accomplishing an abolition 
 of pain which is often permanent. From this it 
 follows that we can deal much more effectively with 
 circumscribed neuritis and congestion by the aid of 
 local remedies than with diffuse inflammation of 
 the nerves, which can only be reached by remedies 
 acting through the general circulation. 
 
CHAPTER 11. 
 
 THE PATHOLOGY OF PAIN— NEURITIS, OR INFLAMMATION 
 OF THE NERVES. 
 
 As inflammatory conditions of the nerves con- 
 stitute the most prolific source of pain, it is neces- 
 sary to possess a general knowledge of the more 
 common, and hence important, forms of neuritis. 
 
 General Considerations. — The whole subject of 
 neuritis, and particularly the part of it which relates 
 to multiple neuritis, has received a vast deal of at- 
 tention during the last few years. These studies — 
 many of them at least — are important, not only on 
 account of their immediate clinical bearing, but 
 also because of the light which they have already 
 shed and are destined in future to shed upon many 
 disputed points in neuro-pathology. Let me illus- 
 trate this point. Up to a comparatively recent 
 period most of the text-books contained a more or 
 less elaborate description of a form of paralysis the 
 chief features of which are a motor paralysis which 
 usually begins in the legs and spreads rapidly over 
 the trunk to the arms. As a rule the medulla ob- 
 
 3* 29 
 
30 PAIN. 
 
 longata is involved, and there is usually, thougli 
 not invariably, more or less fever. General sensi- 
 bility and the functions of the bladder and rectum 
 are but slightly aflected ; there is no notable atrophy 
 of the muscles, and consequently no diminution in 
 the electrical excitability. 'Now, this acute ascending 
 paralysis, or "Landry's paralysis," as it has often 
 been called in recognition of the accurate description 
 which this writer was the first to publish, was for a 
 considerable time almost universally classified among 
 the diseases of the spinal cord, and this in the face 
 of the fact that pathology afibrded little or no justi- 
 fication for such a step. It is not to be wondered 
 at, therefore, that in default of tangible changes in 
 the cord pathologists should ultimately have sought 
 elsewhere for lesions of sufiicient extent to account 
 for the symptoms. ISTor is it surprising that they 
 should have turned their attention to the nerves, 
 since by assuming a more or less general disturb- 
 ance of these organs the symptoms — or at least 
 most of them — might be logically accounted for. 
 Thus it happened that as soon as the etiology 
 and symptomatology of neuritis, and more espe- 
 cially general neuritis, had become more thoroughly 
 understood, neurologists were not slow to perceive 
 the parallelism which exists between this affection 
 and the group of symptoms heretofore known as 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 31 
 
 Landry's paralysis. So impressed is Ross with 
 this resemblance that he has undertaken a most 
 exhaustive study of all the cases of Landry's 
 paralysis to be found in literature. From an anal- 
 ysis of these cases (ninety-three in number) he con- 
 cludes that Landry's paralysis is simply a variety 
 of multiple neuritis. In this he agrees with the 
 general deductions of Barth and ISTauwerck, who 
 have also conducted some important studies in the 
 same field. The literature of the subject has also 
 received copious additions from other sources. 
 
 Before, however, pursuing this subject of multiple 
 neuritis further I shall take the liberty of ofiering a 
 few remarks on the simple or local form of nerve 
 inflammation. 
 
 Simple Neuritis. — The most frequent causes of 
 this local form of neuritis are wounds, inflam- 
 matory conditions in the vicinity of the nerve- 
 stem, rheumatic influences culminating in thick- 
 ening of the sheath, and tumors pressing upon 
 the nerve. Severe compression of the nerve, caries 
 of neighboring bones, and bruises may also give 
 rise to it. To sum up the whole question of eti- 
 ology, it may be stated that the restricted form of 
 neuritis is more apt to be due to local than general 
 causes ; while of multiple or general neural inflam- 
 mations the reverse is true ; for toxic agents acting 
 
32 PAIN. 
 
 more or less extensively throughout the organism 
 play a prominent part in their causation. 
 
 Symptoms. — The duration and course of simple 
 neuritis is subject to a certain degree of variation. 
 Usually, however, the onset is quite abrupt, although 
 a gradual beginning is occasionally observed. An 
 initiatory chill and fever are a feature in some cases, 
 but the majority begin without these warnings. 
 
 "Whatever the precise mode of onset may chance 
 to be, the first symptom to excite the apprehension 
 of the patient is pain. This pain is usually severe, 
 and is felt more or less throughout the distribution 
 of the affected nerve. On applying gentle pressure 
 along the course of the nerve, the latter is found to 
 be extremely sensitive; and after the trouble has 
 continued a certain length of time, it is often pos- 
 sible to feel the nerve — which has become consider- 
 ably thickened — ^through the integument. 
 
 Though the pain is more or less persistent, it 
 sometimes abates, but only to return again with 
 renewed intensity. 
 
 I have under my care at this time a patient in 
 whom the intermittent and severe type of neuritic 
 pain is well illustrated. The patient, a lady of high 
 social position, was recently referred to me by Dr. 
 M. S. Ayers, of IS'ew Jersey, for severe brachial 
 neuralgia. On examination, I found the region 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 33 
 
 along the course of the brachial plexus exceed- 
 ingly sensitive to the touch, and the whole right 
 arm hypersesthetic. 
 
 Desiring to ascertain a possible cause for the 
 neuritis, I investigated the case with considerable 
 care, the patient herself aiding me in every way by 
 her prompt and intelligent replies. Without enter- 
 ing into unnecessary details, let me say that my 
 attention was early directed to a swelling situated 
 in the space above the clavicle immediately adjoin- 
 ing the neck. This tumor was somewhat compres- 
 sible ; there was pulsation, — whether external or in- 
 ternal I could not tell, — and the region round about, 
 and more especially at the anterior border of the 
 enlargement, was quite tender to the touch. The 
 point of interest, however, from an etiological point 
 of view, was the fact that whenever the tumor was 
 pressed upon, even to a moderate degree, the most 
 excruciating pains were evoked in the region of the 
 brachial plexus, and indeed throughout the entire 
 arm. This left no doubt in my mind that the neu- 
 ritis had been set up by the pressure of the tumor. 
 Being in doubt, however, as to the nature of 
 the latter, I called in consultation my friend Dr. 
 John A. "Wyeth, who, after a most thorough exam- 
 ination, expressed the belief that the tumor was 
 either a subclavian aneurism or a malignant tumor. 
 
34 PAIN. 
 
 An operation having been decided upon, Dr. Wyeth 
 cut down upon and extirpated the tumor, which 
 on microscopical examination proved to be a sar- 
 coma. Being closely adherent to the nerve, which 
 it compressed, this tumor had given rise to a local 
 neuritis of great severity. The patient made an 
 excellent recovery, and there has been no return 
 of the tumor. 
 
 Disturbances of sensibility and motility also occur 
 in neuritis as the direct result of interference with 
 nervous conduction. Tingling, numbness, and a 
 moderate degree of anaesthesia are observed in 
 cases of medium severity; while in those charac- 
 terized by more extensive and permanent changes 
 in the nerve the anaesthesia may be profound. The 
 magnitude of the motor derangements is also deter- 
 mined by the vehemence of the neuritis : when the 
 destruction in the nerve-fibres is of moderate ex- 
 tent, the subject merely complains of weakness; 
 but when the mischief is more serious, conduction 
 is abolished; the muscle is paralyzed, and eventu- 
 ally atrophies more or less extensively. At the 
 inception of the atrophy the characteristic electrical 
 reaction of degeneration may be obtained, so that a 
 reliable prognosis may be given before the wasting 
 is at all pronounced. 
 
 Finally, extensive changes in the skin have been 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 35 
 
 observed in a certain number of eases. The most 
 common are vesicular and herpetic eruptions, glossy 
 skin, and atrophy. The hair and nails may likewise 
 be affected, the former becoming brittle and the 
 latter stubby. 
 
 Prognosis. — ^l!^o very definite rules can be laid 
 down as to the duration of the disease. Sometimes 
 the symptoms are acute in character, attaining their 
 maximum degree of development in a short time. 
 In other cases the progress of the disease is insid- 
 ious from the very beginning, there being neither 
 chill, fever, nor an extreme degree of pain to mark 
 its inception. Again, there may be an acute begin- 
 ning and a rapid display of symptoms ; or the out- 
 break of the disease is acute, while the evolution 
 of symptoms is gradual. The latter cases belong 
 in the category of so-called chronic neuritis. 
 
 "Whatever the particular mode of development 
 may chance to be, the life of the patient is but 
 rarely in jeopardy, and then only when the neuritis 
 evinces a tendency to pursue an ascending course, 
 in which cases important structures in the cerebro- 
 spinal axis may be destroyed. In acute cases the 
 recovery may often be exceedingly rapid, cessation 
 of the inflammatory process and regeneration of the 
 affected nerve-fibres taking place in an astonishingly 
 short time. The residual mischief in a case of this 
 
36 PAIN. 
 
 kind is insignificant. On the other hand, the 
 chronic cases often last for months, and, even where 
 recovery is apparently complete, there is always 
 danger of relapse. 
 
 Of course the presence of persistent and wide- 
 spread atrophy of the muscles is unfavorable. In 
 cases of this sort there is inevitably more or less 
 pronounced impairment of motion. 
 
 Pathology. — When the course of the disease is 
 acute, the pathological changes are proportionately 
 vehement. The affected nerve is seen to be red- 
 dened, swollen, and thickened ; its vessels are 
 distended and intensely hypersemic, to which cir- 
 cumstance the lividity is due ; there is a trans- 
 udation of cellular elements and fluid from the 
 engorged vessels into the interstitial tissue and 
 nerve-sheaths ; and, in short, we have a typical 
 picture of acute inflammation. On examining the 
 nerve-fibres more closely, by the aid of good lenses, 
 we find that the destructive process is by no means 
 as far advanced in some as in others. In those 
 which present the most marked changes the axis 
 cylinder is completely obliterated, the medullary 
 substance undergoes fatty or granular degeneration, 
 and the sheaths themselves are more or less disin- 
 tegrated. Finally, the disorganized remnants may 
 be to a greater or less degree absorbed, and then 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 37 
 
 nothing remains behind but the empty sheaths. 
 This, as previously mentioned, is the course of 
 events in the more severe cases; in those of a 
 milder type, however, the changes are less far- 
 reaching, nothing more than moderate swelling of 
 the sheath and granulation of the medullary sub- 
 stance being discoverable. 
 
 Finally, cases which begin in a chronic manner 
 do not present the primary stage of engorgement 
 of the vessels and fluid and cellular infiltration. 
 
 It has already been noted in the clinical portion 
 of this chapter that some cases of a severer type 
 get well without loss of power, provided the mus- 
 cular atrophy has not been too extensive. This fact 
 presupposes that the regenerative capacity of the 
 peripheral nerves is prodigious. Considerable dif- 
 ference of opinion exists among pathologists as to 
 the manner in which this restoration of the nerve- 
 filaments takes place. Of late, however, two theo- 
 ries have chiefly claimed attention. According to 
 the one, new axis cylinders are evolved and pro- 
 longed from those which have escaped the ravages 
 of the inflammation; while the other affirms that 
 the young nerve-fibres are derived "from an en- 
 dogenous growth of nuclei within the Schwann's 
 sheath." Beneke and Neumann are adherents of 
 this hypothesis. 
 
 4 
 
38 PALN. 
 
 In connection with traumatic neuritis the facts 
 bearing on the regeneration of divided nerves are 
 strikingly exhibited; for, from what has been 
 learned both experimentally and in the clinic, it is 
 certain that more or less perfect union and restora- 
 tion of function may be obtained in nerves which 
 have been considerably mutilated. 
 
 Thus, Gluck found, in the course of a series of 
 experiments on fowls, that excision of a piece of 
 nerve was not followed by restoration of function, 
 but that, after simple division, such restoration 
 readily took place when the ends were carefully 
 coaptated. This renewal of conduction was, more- 
 over, established with marvellous rapidity, — in two 
 instances in twenty-four hours. As a rule, however, 
 when the sciatic was divided and the ends imme- 
 diately joined with sutures, paralysis of the muscles 
 supplied by the nerve persisted for fifty hours. After 
 the lapse of this interval there was a gradual resump- 
 tion of motion in the afifected muscles, more or less 
 complete recovery taking place in about four days. 
 
 "Waller and Vaulair believe that the regeneration 
 takes place from the central end of the divided 
 nerve, and that the peripheral end degenerates. 
 Tizzoni, on the other hand, holds that the degenera- 
 tion affects both ends of the nerve at the point of 
 incision. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 39 
 
 Eichhorst and Mayer maintain that the reorganiza- 
 tion takes place from the nerve-fibres on both sides 
 of the incision, the new connecting fibres being 
 derived from the axis cylinders ; while Ranvier has 
 indicated the important part played by the mechan- 
 ical support of the tissues in maintaining the physi- 
 ological distribution of regenerated nerves. In my 
 opinion, the regeneration of the nerve is eflfected, 
 or largely eflfected, from the central end, substan- 
 tially as described by "Waller and Vaulair. 
 
 Lastly, Paget has found that after division of the 
 median nerve sensation began to appear in the 
 regions supplied by it within two weeks. Recovery 
 was practically complete in about four weeks. As 
 has already been said, the accurate coaptation of 
 the ends of the nerve at the point of division favors 
 cicatrization and regeneration, and hence the fre- 
 quency and success with which the process has 
 been resorted to by modern surgeons. 
 
 From the above data it is evident that considerable 
 difiference of opinion exists among pathologists re- 
 garding the remarkable series of events which cul- 
 minate in the restoration of function in a nerve 
 previously injured either by the knife or the inroads 
 of active inflammation. Nevertheless, many of the 
 phenomena observed are exceedingly suggestive, 
 and it is, moreover, highly probable that some at 
 
40 PAIN. 
 
 least of the points in dispute will be definitely set- 
 tled in tlie near future. 
 
 The measures applicable in the management of 
 neuritis are such as tend to reduce the inflammation 
 and allay the pain. Of the former, local measures, 
 such as hot applications, vesicants, and rest, are of 
 the first importance. In addition to these, some 
 authors recommend cold, applied either by means 
 of the ice-bag or rubber coil. For my own part, I 
 much prefer heat, which I am in the habit of em- 
 ploying in the form of cloths, which have been 
 previously dipped in hot water and then carefully 
 wrung out before wrapping them about the afiected 
 limb. Blisters, too, undoubtedly do good, especially 
 in the less acute cases ; and, indeed, the same may 
 be said of galvanism, which often sensibly moder- 
 ates the feeling of soreness, possibly by diminishing 
 the hypersemic condition in and about the nerve- 
 stems, or merely by exerting a counter-irritant 
 efffect. 
 
 Eest has also been spoken of; let me once more 
 insist upon its great importance ; for nothing in the 
 mode of life of the patient should be tolerated which 
 allows or compels him to move about a limb which 
 is the seat of neuritis. It is, indeed, advisable to 
 insist upon his remaining in bed when a lower 
 limb is involved, or upon the application of a sim- 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 41 
 
 pie splint or sling when the nerves of the arm are 
 affected. 
 
 Lastly, there should be no hesitancy in invoking 
 the aid of analgesis in order to control the severe 
 paroxysms of pain which are so characteristic of 
 the disease. Morphine in moderate doses, especially 
 when combined with phenacetin or antipyrin, some- 
 times answers ; but, as a rule, it is necessary to give 
 the former remedy in large doses, of from one-quar- 
 ter to one-half grain, in order to obtain appreciable 
 relief. In the section devoted to the general princi- 
 ples of treatment the application of remedies will 
 be more fully considered. 
 
 Multiple Neuritis. — In this form of neuritis we 
 have to do with a symmetrical and more or less 
 widely disseminated inflammation or degeneration 
 of the sensory and motor nerves, particularly the 
 latter. As a rule, the cerebral and bulbar nerves 
 are little or not at all affected. Since Dumenil 
 published his excellent paper in 1864, a multitude of 
 observers have come forward; and, indeed, hardly a 
 year goes by without witnessing extensive additions 
 to the literature of the subject. At the present 
 time the available material is quite overwhelming, 
 so that detailed references to it would only tend to 
 add confusion to a subject already sufficiently in- 
 volved. I shall, therefore, content myself with a 
 
 4* 
 
42 PAIN. 
 
 more general method of presentation, leaving the 
 reader to work up for himself such points as he 
 may be specially interested in. 
 
 To begin with the etiology, it is necessary to 
 bear in mind that disseminated inflammation of 
 the nerves may be induced by an extensive array 
 of causes, among which toxic and infectious agents 
 occupy a conspicuous position. Prominent among 
 these are lead, alcohol, illuminating gas, bisulphide 
 of carbon, arsenic, aniline, dinitro-benziue, phos- 
 phorus, mercury, morphine, and ergot ; and among 
 animal and endogenous poisons fevers of various 
 kinds, diphtheria, tuberculosis, beriberi, leprosy, 
 malaria, la grippe (influenza), and gout, rheuma- 
 tism, the puerperal state, chorea, and diabetes. 
 In addition to these, dyscrasic conditions un- 
 doubtedly play a part in the evolution of certain 
 cases. Thus, an attack of neuritis is a frequent 
 concomitant of diseases of the blood-vessels, ma- 
 rasmus, chlorosis, and cancer. 
 
 A large proportion of cases begin acutely, a 
 smaller number develop more gradually, while 
 a third class display great lethargy in the evo- 
 lution of the different symptoms. Hence it is 
 customary in some of the books to describe an 
 acute, a subacute, and a chronic form of the dis- 
 ease. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 43 
 
 Besides these varieties, Ross, who has recently 
 published a series of most exhaustive papers on 
 the subject, introduces some other forms in his 
 classification. Sensory, vaso-motor, and trophic 
 neuritis, as well as the irritative form, — which in- 
 cludes professional hypercinesia and tetany, — are 
 assigned a prominent place in his classification. 
 Under the head of sensory neuritis he places the 
 so-called neuro-tabes peripherica, or that form of neu- 
 ritis which occurs in ataxia; Weir Mitchell's neu- 
 rosis (erythromelalgia) is classed as a vaso-motor 
 neuritis ; and, finally, Raynaud's disease is the rep- 
 resentative of the trophic form of neuritis. The 
 latter part of this classification of Ross — more espe- 
 cially that which relates to tetany — has not yet met 
 with general acceptance, largely on account of the 
 meagre support which it has thus far received from 
 pathology. With this exception, the classification 
 leaves nothing to be desired. 
 
 It would be a simple waste of time to enter into 
 a separate description of all these different forms of 
 neuritis ; for, however they may difier in causation, 
 they all display a remarkable family likeness. For 
 this reason I shall endeavor to give a general ac- 
 count of the disease, embracing all its more charac- 
 teristic features, by the aid of which I trust the 
 reader will be able to arrive at a diagnosis, even 
 
44 PAIN. 
 
 when the complicating factors in a given case are 
 considerable. 
 
 General Symptoms of Multiple Neuritis. — Quite 
 a large proportion of cases of multiple neuritis, of 
 whatever cause, begin abruptly. It is true that the 
 patient may complain for some days of vague feel- 
 ings of malaise and weakness, especially in the 
 lower limbs ; but these sensations commonly excite 
 little or no attention, and not until more definite 
 symptoms are added is medical aid invoked. At 
 this time he suffers perhaps from vague discomfort 
 in the head, loss of appetite, and mental hebetude, 
 and he may even be delirious. There may also be 
 considerable fever, the temperature reaching 101° 
 or even 105°, while the pulse is correspondingly 
 accelerated. Sometimes, however, the evolution 
 of the symptoms, even in the beginning, is more 
 gradual, and it is then quite difficult to predict 
 what is really impending. Whatever phase these 
 premonitory phenomena may assume, however, they 
 are certain, or almost certain, to be speedily fol- 
 lowed by symptoms of sensory irritation. The 
 subject complains of tingling, numbness, crawling 
 sensations, and pain. These symptoms are especially 
 pronounced in the affected limbs, and they evince, 
 as may readily be imagined, a decided predilection 
 for the regions in the vicinity of the nerves. While 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 45 
 
 sensory irritation is apparent from the beginning, 
 the opposite condition of sensory paralysis is by no 
 means so obvious. It is true that the muscular 
 sense may be so impaired as to give rise to pro- 
 nounced ataxia ; the tactile sense, too, may be more 
 or less affected, and the transmission of sensations 
 of heat and cold, as well as those of pain, may be 
 considerably retarded. Still, it must be borne in 
 mind that, when the sensations reach the central, 
 perceptive mechanism, they possess considerable 
 vigor, and are therefore felt with great distinctness. 
 Complete anaesthesia then is decidedly exceptional. 
 
 The distribution of these parsesthesise is a matter 
 of some interest. Sometimes they are associated 
 with the ramifications of a particular nerve, while 
 at others they are distributed in irregular islands 
 without obvious physiological connection; or, finally, 
 they may pervade the entire limb. In any event, 
 their presence is significant and often of the first 
 importance in forming a correct diagnosis. 
 
 The pains, too, when taken in connection with 
 the other features of the case, are of value in 
 forming an opinion as to the nature of the disease. 
 Though somewhat like those of locomotor ataxia, 
 they differ notably in this, — that whereas in multiple 
 neuritis the pains are readily evoked by pressure 
 upon the nerves, this is not usually the case in 
 
46 PAIN. 
 
 ataxia. "Witli the advent of these pains there is 
 sometimes more or less oedema, profuse diaphoresis, 
 or swelling of the joints; this is especially true of 
 the epidemic variety of neuritis. The last-named 
 symptom has frequently caused the case to he mis- 
 taken for acute articular rheumatism. 
 
 Not less important than the sensory symptoms 
 are the derangements of motility. The latter, 
 unlike the former, are non-irritative in type, paral- 
 ysis of motion being the rule, while spasms are rare. 
 In the majority of cases the paralysis begins first 
 in one leg, speedily involves the other, and may 
 advance thence to one or both arms. As a rule, 
 the invasion is rapid, the loss of power beginning 
 as a simple sensation of weakness on standing or 
 walking, and culminating in more or less complete 
 paralysis in fifteen or eighteen days. The distribu- 
 tion of the paralysis presents some points of interest. 
 In the first place, it is a remarkable fact that the 
 muscles concerned in the manipulation of the small 
 joints of the hands and feet and of the wrists and 
 ankles are much more afiected than those of the 
 elbows and knees. Thus, in a case which I recently 
 saw in consultation with Dr. Eleanora Haines, of 
 iN'ewark, the patient, a man of sixty, who was a 
 sufferer from multiple neuritis of malarial origin, 
 was able to move both elbows and knees without 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 47 
 
 difficulty, while voluntary motion in the wrists and 
 ankles was quite impossible. Another interesting 
 point is, that the paralysis shows quite an irregular 
 distribution at first, but assumes the characteristic 
 form when fully developed. I emphasize this point 
 because one who sees the case at the commence- 
 ment of the paralytic invasion is apt to be puzzled, 
 unless forewarned of the erratic course of the symp- 
 toms. 
 
 Such, then, is the course of events in an ordinary 
 case of neuritis. Exceptionally, however, the clini- 
 cal picture is considerably modified. Thus, as a 
 rule, the cerebral and bulbar nerves are not in- 
 volved; and yet, in fatal cases, the pneumogastric 
 is invaded, deglutition becomes difficult, and the 
 patient dies as the result of complications analogous 
 to those of bulbar paralysis. In another and smaller 
 class of cases some of the cranial nerves — notably 
 those of the eyes, and more rarely those of the face — 
 become implicated. Lastly, in a larger number, the 
 paralysis extends to the muscles of the trunk, and 
 those of the arms and thighs as well. Such cases 
 are liable to prove fatal on account of the implica- 
 tion of the muscles concerned in respiration ; this, 
 indeed, is the most frequent cause of death in the 
 severe multiple neuritis which accompanies alcohol- 
 ism and the disease known as " kakke," or " beri- 
 
48 PADT. 
 
 beri." In a large percentage of cases of ordinary 
 type, however, more or less perfect recovery takes 
 place. The precise amount of power regained by 
 the affected muscles will be determined by the ex- 
 tent to which they have atrophied ; for, as a matter 
 of fact, such atrophy occurs in the majority of cases 
 which pursue an erratic and chronic course. The 
 tendon reflexes are always lost when the paralysis is 
 at all considerable. On the other hand, the function 
 of the bladder and rectum usually remain unaf- 
 fected. Such are the more important features of 
 multiple neuritis. 
 
 SPECIAL TYPES OP NEURITIS. 
 
 CHEONIC ALCOHOLIC NEUEITIS — NEITRITIS FOLLOWLN"G IN- 
 FLUENZA — THE NEURITIS OF LEPEOSY — BEEIBEEI. 
 
 While the foregoing description affords a general 
 survey of multiple neuritis, there are certain types 
 of the disease endowed with sufficient individuality 
 to justify separate consideration. This applies es- 
 pecially to chronic alcoholic neuritis, the neuritis of 
 leprosy, and the disease known as "beriberi," or 
 "kakke." 
 
 Chronic Alcoholic Neuritis, or the Pseudo-Ataxia 
 of Drunkards. — One of the most interesting j)hases 
 of alcoholic poisoning is that characterized by 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 49 
 
 symptoms which bear the closest resemblance to 
 those of locomotor ataxia. The disease commonly 
 begins with lancinating pains in the lower limbs; 
 these may or may not extend to the arms ; but, in 
 any event, they are usually quite severe. In the 
 course of weeks, months, or even years, the gait of 
 the patient becomes more or less affected. "When 
 he attempts to go about, he is troubled by weakness 
 and inability to control the muscles ; and a careful 
 examination reveals the fact that there is more or 
 less true paralysis and atrophy combined with the 
 muscular incoordination, — an important distinction, 
 by the way, from true locomotor ataxia. On tap- 
 ping the patellar tendons, there is little or no re- 
 sponse; and the customary electrical tests, when 
 applied to the affected muscles, elicit the reaction 
 of degeneration. In addition to these symptoms, 
 there may usually be discovered more or less ex- 
 tensive zones of anaesthesia in the affected limbs; 
 while pressure upon the nerves shows them to be 
 quite sensitive, though not to the same degree as in 
 the more acute forms of the disease. 
 
 This is a fairly complete presentment of the affec- 
 tion as we commonly find it. There are cases, 
 however, in which its complexion is greatly altered. 
 This atypical aspect is largely due to the prominence 
 of the atrophic, paralytic changes, the sensory dis- 
 c d 5 
 
50 PAIN. 
 
 turbances remaining quite subordinate from the 
 beginning. 
 
 As may readily be imagined, a group of symp- 
 toms of this kind may be mistaken for true ataxia, 
 especially in the beginning. Later, the absence of 
 such ataxic symptoms as bladder disturbances, gird- 
 ling pains, and the Argyll-Robertson pupils, will 
 assist in the formation of a correct diagnosis. 
 
 Neuritis following Influenza. — During the epi- 
 demics of the " grippe" which have been so com- 
 mon during the last few years, excellent opportu- 
 nities have been afforded of observing the various 
 nervous disturbances so characteristic of that pro- 
 tean affection. 
 
 Among these there are none more interesting 
 than the inflammatory conditions of the nerves, 
 which are the direct result of the systemic poison- 
 ing. The symptoms of this form of neuritis resem- 
 ble somewhat those of the alcoholic form of the 
 disease, if we except the mental manifestations 
 which are absent. 
 
 The inflammation is frequently bilateral, invading 
 corresponding nerves on both sides of the body, 
 and giving rise to more or less extensive paralysis 
 and atrophy. When the disease involves both sciatic 
 nerves, as was the case in a man whom I saw in 
 consultation with Dr. G. F. Pitts, of l!^ew Jersey, 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 51 
 
 it may be mistaken for grave disease of the spinal 
 cord; but the exquisite tenderness of the nerves 
 and the absence of bladder and rectal symptoms 
 will usually serve to reveal its true peripheral 
 nature. 
 
 Gowers has recently published a highly suggestive 
 paper on this type of neuritis. 
 
 The Neuritis of Leprosy. — Although alterations 
 of greater or less extent have been noted in the 
 cerebro-spinal axis, and especially in the cord, in 
 leprosy, these appearances must be regarded as 
 exceptional, inasmuch as many observers have seen 
 them but rarely, while others have altogether failed 
 to find them. On the other hand, nothing is more 
 certain than that inflammations of the nerves, as- 
 suming the form of interstitial and parenchymatous 
 neuritis, play an important part in the evolution of 
 many of the symptoms of this dreadful disease. 
 Leloir,^ in his classical monograph, has given an 
 elaborate account of the genesis of this neuritis. 
 According to his researches, which in their main 
 features coincide with those of ]N"eisser and Hansen, 
 the inflammation of the nerve is due to the virus 
 of the micro-organism of leprosy ; for this bacillus 
 
 1 Traite Pratique et Theorique de la L^pre, by Henri Leloir, 
 Paris, 1886, p. 248. 
 
52 PAIN. 
 
 is to be found either between the nerve-tubules 
 or in the inflamed interstitial tissue. 
 
 To thoroughly comprehend the significance of 
 these changes in the peripheral nerves it is neces- 
 sary to remember that there are two principal forms 
 of leprosy, the tubercular and the auEesthetic or tro- 
 pho-neurotic form ; and that in the first variety the 
 energy of the disease is largely directed to the in- 
 tegument, while in the second it tends chiefly to 
 the nerves. Between these two extreme varieties 
 various transitional forms occur ; so that we some- 
 times find the tubercular phase of the disease merg- 
 ing into anaesthetic or tropho-neurotic leprosy. This 
 combination of the tubercular and anaesthetic forms 
 is referred to by Leloir as " mixed" leprosy. 
 
 Instead of considering the tubercular and trans- 
 itional phases of the disease, which belong, strictly 
 speaking, in the domain of dermatology, I shall 
 proceed at once to a more extended examination 
 of the anesthetic or tropho-neurotic form; for it 
 is in the latter that the changes in the peripheral 
 nerves are at once most extensive and far-reaching 
 in their clinical eft'ects. Another reason for exam- 
 ining the phenomena of this form of leprosy more 
 closely is found in the close resemblance which they 
 bear to those of syringomyelia. I shall return to 
 this point later on. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 53 
 
 Symptoms of the Ansesthetic Form of Leprosy. 
 — As previously intimated, the symptoms of this 
 form of the disease are all, or nearly all, attribu- 
 table to the alterations in the nerves. So certain has 
 this become through the combined evidence of the 
 dead-house and clinic that, as Leloir cogently puts 
 it, the study of the anaesthetic or tropho-neurotic 
 form of leprosy is nothing more than the study of 
 a variety of neuritis. 
 
 While there is usually no fever in the beginning, 
 the onset of the disease is marked by the occur- 
 rence of disturbances of sensibility of various kinds, 
 notably burning, tingling, itching, and hypersesthesia 
 of the skin. The macular spots of the early erup- 
 tive stage are at once pigmented and hypersemic in 
 appearance. In the beginning of their development 
 they are less livid, but by degrees they merge into 
 gray, brown, or yellow. The subsequent evolution 
 of these patches is thus graphically described by 
 Dr. Prince A. Morrow,^ who has devoted careful 
 study to the disease as it appears in the Sandwich 
 Islands and among the Chinese of San Francisco. 
 " They are usually persistent," he says, " and mani- 
 
 ^ The Diagnosis of Leprosy, especially the Differentiation of the 
 Anaesthetic Form from Syringomyelia, by Prince A. Morrow, 
 M.D., etc., Journal of Cutaneous and Genito-Urinary Diseases, 
 January, 1890, p. 7 et seq. 
 
 5* 
 
54 PAIN. 
 
 fest a tendency to clear up in the centre while 
 spreading at the periphery. By this mode of cen- 
 trifugal extension and the coalescence of contiguous 
 patches they form arcs of circles and large gyrate 
 patches, with slightly elevated margins of a reddish- 
 brown, port-wine, sepia, or slaty color." 
 
 Upon their first appearance these macules are 
 hypersesthetic, "but as the central portion closes 
 up the hyperaesthesia recedes to the pigmented 
 periphery and is replaced by anaesthesia of the 
 centre." This interesting phenomenon leads Mor- 
 row to the hypothesis " that in the evolution of 
 these macules, hyperchromia and hypersesthesia, 
 achromia and anaesthesia, are associated and ad- 
 vance jpari passu." Sometimes, however, instead 
 of following the mode of development just de- 
 scribed, the pigmentary changes are achromic or 
 hyperchromic from the beginning. 
 
 Besides the neurotic anomalies just considered, 
 we may also encounter both sensory and motor 
 disturbances of much greater extent. Thus, very 
 large areas of the skin may be the seat of anal- 
 gesia and insensibility to temperature as well as 
 atrophic changes; while, at the same time, the 
 further extension of the neuritic changes to im- 
 portant motor nerves may cause more or less ex- 
 tensive paralysis and atrophy of the muscles. To 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 55 
 
 these changes in the skin and muscles various 
 lesions of the bones and joints are added, and 
 these are apt to culminate sooner or later in 
 more or less extensive mutilations. The macular 
 spots previously described are not the only dermal 
 changes in leprosy ; for, in addition, pemphigoid le- 
 sions of a severe type are common enough. Some- 
 times, however, all, or nearly all, of these dermal 
 appearances are absent; and in such anomalous 
 cases the sensory or motor impairment may be the 
 chief or even the sole feature. Under these cir- 
 cumstances a correct diagnosis is, as a matter of 
 course, most difficult. 
 
 Lastly, the nerves most frequently involved are 
 the nervus cutaneus palmaris, in which the neu- 
 ritic changes commonly begin, when the upper 
 extremity is affected, and the nervus peroneus 
 and nervus cutaneus femoris posterior externus, 
 which are first impaired when the disease begins 
 in the legs. In addition to these changes in the 
 cutaneous nerves, the large deep-seated nerves also 
 undergo degeneration ; hence the extensive paral- 
 yses and atrophy of the muscles. However, even 
 when the disease has lasted a long time, all the 
 nerves are by no means equally affected. Thus, 
 the third or seventh pair of cranial nerves may be 
 predominantly involved, and we then have derange- 
 
56 PAIN. 
 
 ment of the motor apparatus of the eye, or paralysis 
 of the muscles of the face, with the characteristic 
 distortion of the mouth. Again, the neuritis may 
 evince a predilection for the nerves of the arm, 
 and notably the ulnar nerve, and we then have 
 atrophic changes in the muscles of the hand and 
 arm quite like those which constitute the main 
 en griffe of progressive muscular atrophy. The 
 presence of profound anaesthesia will, however, 
 serve to differentiate the condition from the last- 
 named affection. 
 
 Mention has already been made of the great 
 difficulties which sometimes beset the diff'erential 
 diagnosis of leprosy from syringomyelia. A refer- 
 ence to the symptomatology of the last-named 
 affection will serve to show why this should be 
 so. In the face of such obstacles it would probably 
 be rather premature to lay down arbitrary rules 
 governing the differentiation of the two affections, 
 especially when the leprosy is at all atypical. 
 
 For many details of the preceding description 
 and for valuable information regarding the whole 
 subject of leprosy, I desire to express my indebted- 
 ness to Dr. Morrow, whose practical knowledge of 
 the disease gained by prolonged study in the Sand- 
 wich Islands is unsurpassed. 
 
 Beriberi. — Scheube was the first to show that the 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 57 
 
 remarkable disease variously known as "beriberi" 
 and " kakke," wHcli occurs in the East Indies and 
 Japan, is nothing more nor less than a form of mul- 
 tiple neuritis. Since the publication of Scheube's 
 paper it has furthermore been shown that this 
 neuritis is directly due to the presence in the sys- 
 tem of a peculiar micro-organism. These and mi- 
 crococci bacilli may be detected in the blood of 
 persons suffering from beriberi; and, what is still 
 more conclusive, pure cultures of the micrococci 
 cause, when injected into dogs and rabbits, changes 
 in the nerves similar to those found in beri- 
 beri. 
 
 It is probable that the infecting substance usually 
 gains access to the body through the respiratory 
 apparatus, although infection through the clothing 
 is not uncommon. On the other hand, some ob- 
 servers, among whom is Mmra, believe that intro- 
 duction of putrid fish of the genus Scomiridse is 
 the principal, if not the sole, cause of the disease. 
 The bulk of evidence, however, goes to show that 
 beriberi is an infectious disease, principally trans- 
 missible through the air and clothing. 
 
 Symptoms of Beriberi. — It is not an altogether 
 easy task to give a general description of beriberi, 
 since the disease presents itself under a multitude 
 of guises ; still, a certain number of more or less 
 
68 PAIN. 
 
 well-marked forms are discernible. These are, 
 however, closely united clinically by various transi- 
 tional phases, while in a pathological sense they 
 are, of course, identical. 
 
 All forms of the disease present a more or less 
 marked initial stage. The patient is conscious of 
 being unwell ; he is listless, feverish, and easily 
 tired by walking ; his conjunctivae are injected and 
 more or less acutely inflamed ; he has some watery 
 discharge from the nose ; and he suffers from weak- 
 ness and a general sense of bodily discomfort. 
 These premonitory symptoms are soon followed by 
 tingling, numbness, and more or less pain in the 
 lower limbs, as well as pronounced motor impair- 
 ment and cedema. A most important symptom at 
 this time is weakness and rapidity of the heart's 
 action ; and to its presence is doubtless to be ascribed 
 the oedematous condition of the legs and arms pre- 
 viously referred to. 
 
 In addition to the sensory impairment, there is 
 marked paresis and absence of the tendon reflexes. 
 Ataxia as we find it in alcoholic cases is, however, 
 absent. The future course of the disease is either 
 favorable or unfavorable. When favorable, recovery 
 takes place in ten days or six weeks, or exception- 
 ally, in chronic cases, in from sixty to ninety days; 
 when unfavorable, various other grave symptoms are 
 
PHYSIOLOGICAL. PATHOLOGICAL, CLINICAL. 59 
 
 added, and the patient either dies or recovers, but 
 only after a long illness. 
 
 Let U3 consider the symptoms which are peculiar 
 to the less favorable cases. In the first place, the 
 CBdema previously alluded to as a feature of the 
 mild cases may assume unusual proportions, so that 
 effusion takes place into the pleural and peritoneal 
 cavities, as well as into the subcutaneous tissue. 
 The entire body of a person afflicted in this way 
 is enormously swollen, the action of the heart is 
 greatly reduced in vigor, paralysis more or less ex- 
 tensive is always present, and the affected muscles 
 atrophy precisely as in other forms of neuritis. This 
 wasting of the muscles is not visible to the eye on 
 account of the oedema, but it may often be ascer- 
 tained by careful palpation. This is the so-called 
 hydropic form of the disease. Again, there may be 
 little or no oedema ; but, as if to compensate for its 
 absence, the sensory and motor disturbances are 
 more extensive and severe. 
 
 The muscles of the entire body atrophy; sensi- 
 bility is so exalted that the patient can hardly en- 
 dure the weight of the bedclothes ; he suffers more 
 or less acute pain; and his general appearance is 
 that of an individual in the last stages of phthisis. 
 In some cases the hypersesthesia is succeeded by 
 a certain degree of anaesthesia, and there may be 
 
60 PAIN. 
 
 delay in tlie transmission of painful sensations, as 
 in ataxia ; but, as a rule, variations in temperature 
 are perceived even when the disease is at its height. 
 This is the dry or atrophic form of the disease. 
 Finally, the symptoms of the hydropic and atrophic 
 types may be combined. Cases of this kind pursue 
 an acute course, and death usually takes place from 
 heart-failure. In both the hydropic and atrophic 
 phases of the disease recovery takes place in a large 
 proportion of cases, but only after a long period 
 of convalescence. In the fatal cases death results 
 from some intercurrent affection or from exhaustion. 
 Diagnosis. — From what has already been learned, 
 it is evident that the diagnosis of the disease may 
 present certain difficulties. Two affections in par- 
 ticular — ^locomotor ataxia and poliomyelitis — ^have 
 often been mistaken for it. For purposes of dif- 
 ferentiation, the sensory symptoms occurring in the 
 beginning of most cases of multiple neuritis are of 
 the first importance. Especially may this be said 
 of the extreme sensitiveness of the nerves and 
 muscles to pressure, — a condition which is foreign 
 to both ataxia and poliomyelitis. In ataxia, more- 
 over, the characteristic incoordination of the mus- 
 cles is developed slowly, there is no true paralysis 
 of the muscles nor atrophy, and the pupillary reac- 
 tions are interfered with (Argyll-Robertson pupil). 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 61 
 
 In multiple neuritis, on the other hand, the loss of 
 power is rapid, the affected muscles atrophy, and 
 there are no abnormal changes in the pupil. 
 
 Prog-nosis. — From what has previously been said, 
 it is evident that the prognosis is fair in many phases 
 of multiple neuritis. It is, of course, positively un- 
 favorable in those cases of neuritis which develop 
 in the course of leprosy, beriberi, tubercular disease, 
 and less so in alcoholism. In expressing an opinion 
 as to the probable outcome in a given case great 
 caution should, however, be exercised, as both the 
 laboratory and clinic have repeatedly shown how 
 great is the power of regeneration possessed by the 
 peripheral nerves as contrasted with other portions 
 of the nervous system, and notably the spinal cord. 
 
 The anatomical changes in the acute cases are 
 essentially inflammatory, while in those which 
 pursue a chronic course they are of the nature of 
 a degenerative atrophy. Moreover, the ramifica- 
 tions of the nerves are more profoundly affected 
 than the stems. 
 
 As the minute pathological changes have already 
 been discussed under the head of simple neuritis, 
 nothing further need be said of them. 
 
CHAPTER III. 
 
 CONCERNING PAINS LOCATED IN DEFINITE NERVE-AEEAS — 
 NEURALGIA. 
 
 From what has previously been said, it is evident 
 that every painful impression must be due to an 
 irritation of one or several nerves, and it has also 
 been shown that the usual source of such morbidly 
 increased stimulation is neuritis. Inflammation of 
 the nerves cannot, however, be regarded as the only 
 cause of pain, as some authors would have us be- 
 lieve. There are, indeed, certain fugitive pains 
 whose advent and subsidence are so sudden as to 
 preclude the development of true inflammation. In 
 my opinion, such pains are usually attributable 
 either to a molecular or circulatory disturbance in 
 the nerve, due to an external agent, such as cold, 
 or they are traceable to a toxic agent temporarily 
 contained in the blood. Some of the painful ner- 
 vous disturbances consecutive to influenza are ap- 
 parently of this character, though others, as Gowers 
 has recently pointed out, are traceable to neuritis. 
 "Whatever may be the opinion held, then, regarding 
 62 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 63 
 
 evanescent pains, it must be assumed that where the 
 morbid sensation is both localized and persistent, as 
 in neuralgia, we have indeed to do with a veritable 
 inflammation of the nerve. Hence it follows that 
 the causation of these local pains or neuralgias is 
 substantially that of neuritis. 
 
 From the foregoing, it is evident that what is 
 currently known as neuralgia may be defined as an 
 affection of the nerves, characterized by the occur- 
 rence of sudden, severe paroxysms of pain in re- 
 gions supplied by one or several nerves. 
 
 For purposes of exact designation these pains 
 have been classified according to the nerve-stem or 
 branch chiefly implicated. 
 
 All these forms of neuralgia have certain common 
 attributes, the variations in symptomatology being 
 contingent, or largely contingent, upon diflferences 
 of locality. It is apparent, therefore, that some 
 preliminary observations of a general character will 
 save much needless repetition. 
 
 The onset of the aflfection is usually heralded by 
 vague muscular twitchings or sensations of pricking, 
 quickly succeeded by darting pains. The pains are 
 recurrent in character, following each other with 
 ever-increasing frequency and intensity, until, in 
 the more severe attacks, the patient suffers the most 
 excruciating agony. In some cases the pains are 
 
64 PAIN. 
 
 darting or lancinating, whereas in otliers they are 
 compared with the prick of red-hot needles. 
 
 The pains, as previously observed, are usually 
 localized, and the subject declares that, however 
 long may be the intermission between the parox- 
 ysms, the pains always return to the same locality. 
 Such is apt to be the case where the neuritis is 
 restricted to a single nerve or one or more of its 
 principal branches. 
 
 Sometimes, however, the neuritis is much more 
 widely distributed, and, as a consequence, the pains 
 dart about from place to place, first one part of the 
 affected region being assailed and then another. 
 
 When subjected to pressure the nerve is found to 
 be extremely tender, the hypersesthesia being either 
 circumscribed, so as to constitute the so-called ^'■points 
 douloureux" or more widely distributed, giving rise 
 to irregular areas of great tenderness in the skin. 
 
 Should careful exploration with the finger fail to 
 disclose these painful spots, the passage of the fa- 
 radic current through the suspected locality, either 
 by the aid of a small sponge electrode or the wire 
 brush, will at once reveal their presence. 
 
 Another noteworthy circumstance is, that when, 
 in the course of an attack of severe neuralgia, — 
 especially that of an intercostal or lumbar type, — 
 pressure is applied along the spine, painful areas 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 65 
 
 corresponding to the origin of tlie affected nerves 
 are frequently found. 
 
 But pain is not tlie only sensory disturbance met 
 with in neuralgia, since formication, numbness, and 
 even anaesthesia are quite common. 
 
 Where the anaesthesia is well marked and exten- 
 sive, it is evidence that the inflammatory changes in 
 the nerve are severe enough to interrupt conduc- 
 tion, a fact which has an obvious bearing on the 
 prognosis. On the other hand, the irritative phe- 
 nomena may be of such a violent character as to 
 completely overshadow all other elements in the 
 case. Under these circumstances reflex muscular 
 spasms are apt to develop ; so that, in neuralgia of 
 the trigeminal nerve, the facial muscles may be 
 sufficiently convulsed to cause grotesque distortion 
 of the countenance; while, in the same way, the 
 presence of neuralgia in one of the limbs may 
 give rise to muscular contractions which may be 
 restricted in character or involve the entire limb. 
 
 These spasms are so clearly of reflex origin that 
 the mode of their genesis is hardly to be regarded 
 as an open question. 
 
 Persons of weak constitution, or those in whom 
 debility, resulting from disease or excesses, has 
 materially curtailed the powers of resistance origi- 
 nally inherent in the organism, are especially exposed 
 
 6* 
 
66 PAIN. 
 
 to neuralgia. This is equivalent to stating that they 
 inevitably invite an attack of neuritis, since they 
 are susceptible alike to cold and septic influences 
 of all kinds. 
 
 The following are the more important manifesta- 
 tions of the affection in different localities : 
 
 In trigeminal or facial neuralgia the pain may 
 involve the entire lateral half of the face and head 
 when all three branches of the nerve are involved, 
 but is much restricted when but one branch is im- 
 plicated. Thus, when the neuritic condition is con- 
 fined to the supraorbital or ophthalmic branch, the 
 pain is felt in the forehead and upper eyelid, and 
 is accompanied by more or less lachrymation. In 
 neuralgia of the supramaxillary branch the pains 
 are located in the eyelid, cheek, nose, upper lip, 
 nasal cavities, gums, upper teeth, zygomatic arch, 
 and temporal region; whereas implication of the 
 entire inframaxillary branch gives rise to pain in 
 the lower teeth and jaw, the mucous membrane 
 of the mouth, the tongue, the chin, the cheek, and 
 the external auditory meatus and auricle. 
 
 The vaso-motor disturbances of facial neuralgia 
 consist in coldness and pallor, which may later give 
 place to an cedematous and glossy skin. Allusion 
 has already been made to the reflex muscular 
 spasms which sometimes accompany the severer 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 67 
 
 types of the disease, so that nothing further need 
 be said regarding these interesting appearances. 
 
 Severe mental depression, irritability, and insom- 
 nia are common accompaniments of facial neuralgia; 
 and when the paroxysms become chronic, there is 
 a progressive physical and mental deterioration, 
 which may drive the unhappy sufferer to seek 
 relief in self-destruction. In a subsequent chapter 
 I shall indicate the most effective measures to be 
 adopted in dealing with these distressing complica- 
 tions of pain. 
 
 In cervico-occipital neuralgia, the region supplied 
 by the great occipital nerve is the principal seat of 
 pain ; but exceptionally it may be reflected to the 
 neck and lower part of the face. 
 
 The pains of cervico-brachial neuralgia are felt in 
 the subclavian region and throughout the upper 
 extremity. Should, however, the plexus be only 
 partially invaded, the pain is, of course, much less 
 widely distributed. "Where these conditions prevail 
 it may be diflScult to determine what branches of 
 the plexus or nerve-roots are predominantly in- 
 volved. 
 
 In crural neuralgia the pains are chiefly felt along 
 the anterior and inner aspects of the thigh. 
 
 When the first pairs of the lumbar nerves are 
 involved the pain is restricted to the loins ; whereas 
 
68 PAIN. 
 
 in lumbo-abdominal neuralgia it extends to the by- 
 pogastrium, and may also include the scrotum or 
 mons veneris. 
 
 The back and the walls of the thorax are the seat 
 of pain in dorso-intercostal neuralgia; but it often 
 happens that it is more acutely felt in the former, 
 and is then commonly referred to as lumbago. 
 
 In sciatic neuralgia the pain extends from the 
 gluteal region down the posterior aspect of the 
 thigh and leg; and at the point of emergence of 
 the nerve from the plexus a spot of unusual tender- 
 ness is usually present. Plantar neuralgia, which 
 was first accurately described by Dr. "Weir Mitchell, 
 is characterized by severe pain in the sole of the 
 foot. Both feet are usually affected, and there is 
 more or less redness and swelling. 
 
 The designation coccygodynia has been applied 
 to those severe pains in the coccyx due to difficult 
 labor, injuries, inflammation, caries, and other 
 causes which may give rise to secondary inflamma- 
 tory changes in the coccygeal plexus. Extirpation 
 of the coccyx is really the only effectual treatment. 
 
 Mastodynia, or " irritable breast," as it is often 
 called, is nothing more than a variety of intercostal 
 neuralgia, and is amenable to the same treatment 
 as other forms of localized pain. 
 
 Muscular neuralgia is the conventional term em- 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 69 
 
 ployed to designate a painful condition of the 
 muscles, which may exist in the absence of all 
 tenderness of adjacent nerve-stems. 
 
 The muscles of the back and neck are those most 
 frequently implicated. 
 
 Let me add, in concluding this brief survey of 
 the more important features of neuralgia, that the 
 prognosis is substantially that of neuritis, as stated 
 in the preceding chapter. "Where the neuritic 
 changes are of recent occurrence, permanent relief 
 may generally be afforded without much difficulty ; 
 but when they are of long standing, the outlook, 
 though far from hopeless, is less favorable. The 
 whole question of treatment will, however, be thor- 
 oughly discussed in the chapter devoted to the 
 therapeutics of pain. 
 
CHAPTER lY. 
 
 PAIN ASSOCIATED WITH THE EHEUMATIC AND GOUTY 
 DIATHESIS. 
 
 Though the ultimate pathology of both these 
 affections is, in spite of a vast amount of research 
 and discussion, still in an unsatisfactory condition, 
 it will, nevertheless, be advisable to consider them 
 briefly : first, because they are such prolific sources 
 of pain, and, secondly, because of the tendency, at 
 present discernible in some quarters, to ascribe im- 
 portance to a neuropathic principle as an element 
 in their development. 
 
 Rheumatic fever, as is plainly enough indicated 
 by its clinical history, is an acute febrile affection of 
 non-contagious character, the most evident charac- 
 teristics of which are the development of multiple 
 arthritis and a disposition to invade the heart. 
 
 There are three conspicuous theories with regard 
 to the nature of the affection. The first of these 
 affirms that the changes in the joints are due to the 
 presence of a specific microbe ; the second, that they 
 are the outgrowth of defective metabolism, — i.e., the 
 70 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 71 
 
 presence of pathological material in the system, due 
 to derangement of assimilation; and the third, that 
 the arthritis is attributable to a primary disturbance 
 of the nervous system, culminating either in im- 
 pairment of metabolism or in local trophic changes 
 which are the result of the primary effects of cold 
 upon the nervous system. 
 
 It is noteworthy that by some the morbid product 
 due to this defective metabolism is believed to be 
 lactic acid. 
 
 In gout, as all are aware, we have to do with a 
 disease which is characterized by the appearance at 
 irregular intervals of acute arthritis, with subsequent 
 gradual deposit of urate of soda within and in the 
 vicinity of the joints, and by the over-production, or 
 defective elimination, of uric acid. 
 
 Concerning the causation of gout, three theories 
 are likewise worthy of mention. 
 
 The first of these — the so-called uric acid theory 
 — has obtained the widest currency in the profes- 
 sion. According to its tenets, there is an increased 
 accumulation of uric acid in the blood, attributable 
 either to inadequate elimination or over-production. 
 
 The advent of the acute attack is believed to be 
 directly attributable to this morbid accumulation, 
 and the same may be said of the nervous irritability, 
 depression, and gastric derangements which are the 
 
72 PAIN. 
 
 common precursors of the acute inflammation of 
 the joints. 
 
 A second theory is that of Ord, who believes that 
 the changes in the joints are directly due to a degen- 
 erative proclivity of the tissues themselves. This 
 liability to degenerate may be either congenital or 
 acquired. I do not think that there is much justi- 
 fication for this assumption, since dietetic precautions 
 usually prevent the local degeneration. 
 
 Finally, we have the nervous, or rather neuro- 
 humoral, theory of the disease as advocated by 
 Duckworth and others. This theory assumes, on 
 the one hand, the existence of a neurosis, and on 
 the other, a tendency to lethargic or defective meta- 
 morphosis. 
 
 So much, then, for the diversity of opinion which 
 exists regarding the ultimate pathology of the two 
 affections. But while these differences are striking 
 enough in themselves to discourage one from at- 
 tempting to elaborate a scientific method of treat- 
 ing the disease, it must nevertheless be admitted 
 that quite a good deal has been accomplished within 
 the last few years — largely in an empirical way — 
 for the more effective management of both dis- 
 orders. This may be said with especial emphasis 
 of the painful symptoms which are so striking a 
 feature of both diseases. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 73 
 
 It is hardly necessary to enter upon a lengthy 
 description of the regular forms of gout and rheu- 
 matism : the metatarso-phalangeal pain and redness, 
 confined, as a rule, to one of the great toes, the 
 premonitory gastric symptoms, the sudden onset of 
 the pain, — usually at night, — and the moderate chil- 
 liness and fever, are quite characteristic of the 
 former; whereas the presence of acute inflamma- 
 tion and pain in several joints is decided evidence 
 of the rheumatic nature of the trouble. 
 
 But while these typical manifestations of both dis- 
 eases are known to every physician, the irregular 
 modes of expression have commonly received, I 
 believe, much less attention than they deserve. 
 These observations are especially applicable to 
 " concealed" or " irregular" gout, which is certainly 
 often responsible for the development of nervous 
 symptoms, and notably neuralgia. Again, the 
 chronic interstitial nephritis which frequently de- 
 velops in severe cases of gout is responsible, no 
 doubt, for the advent of some of the milder forms 
 of nervous disturbance. Eventually, as in ordinary 
 cases of contracted kidney, death may occur from 
 cerebral hemorrhage (or embolism, where there is 
 concurrent heart-trouble) or uraemia. One of the 
 most frequent cerebral manifestations, commonly — 
 and probably justly — ascribed to the morbid accu- 
 
74 PAIN. 
 
 mulation of uric acid, is headache; which, though 
 usually of the less vehement type, may exceptionally 
 manifest great severity. 
 
 "With the occurrence of renal troubles and arterio- 
 sclerosis, the cerebral disturbances may be much 
 increased in severity and persistency. It is self- 
 evident that symptoms of this kind may readily be 
 misinterpreted where the question of causation is 
 involved; so that nothing is more common than 
 to find these patients wandering about from one 
 medical practitioner to another, without obtaining 
 any considerable benefit. The chief difficulty in 
 such cases is usually a failure on the part of the 
 physician to appreciate the true chronology of the 
 various symptoms. 
 
 Too great pains, then, cannot be bestowed upon 
 the framing of a correct diagnosis, without which 
 there is scant probability of our suggesting thera- 
 peutic measures of much utility. 
 
 Treatment. — Little need be said of the manao-e- 
 ment of the acute phases of rheumatism, since 
 every practitioner is doubtless familiar with essen- 
 tials. As all are aware, two methods of treatment 
 are especially conspicuous; the one involving the 
 copious use of salicylic acid, the other the admin- 
 istration of alkalies. The use of salicylic acid is 
 especially satisfactory, since the pains yield to its 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 75 
 
 influence with remarkable promptness. On the 
 other hand, alkalies are more liable to prevent 
 the occurrence of secondary heart-trouble; and 
 besides this, it is a remarkable fact that patients 
 who have been treated with them are usually able 
 to leave the hospital and attend to their affairs 
 much sooner than those who have taken salicylic 
 acid alone. It is evident, then, that each plan of 
 treatment has its own special advantages; and for 
 this reason I prefer the mixed treatment, or that 
 which involves the use of both acid and alkalies. 
 
 The salicylate of sodium may be used in twenty- 
 grain doses every hour for the first six or seven 
 hours. The patient may then be instructed to 
 discontinue all medicine for the next eight hours. 
 After the lapse of this interval of rest he may be 
 given the iodide or citrate of potash in twenty- or 
 thirty-grain doses every three hours, until the saliva 
 becomes alkaline. Whether, as stated by some, this 
 recommendation originated with Fenwick, I do not 
 know; but I can certainly vouch for its efficacy, 
 especially when combined with the use of phenace- 
 tin and salol. The local application of the oil of 
 wintergreen by the aid of lamb's wool or absorbent 
 cotton will naturally suggest itself, and the same 
 may be said of the use of liniments, blisters, and 
 sinapisms. 
 
76 PAIN. 
 
 "When recovery has taken place, great caution 
 should be exercised in the use of stimulants; and 
 indeed, all foods the ingestion of which is liable to 
 add to the acidity of the blood should be avoided as 
 much as possible. This is all the more necessary 
 since those who have had one visitation, far from 
 having obtained immunity, are more than ever liable 
 to be attacked by the disease. 
 
 Very much the same class of recommendations 
 are applicable in the management of gout, whether 
 of the common, acute type or of the concealed 
 variety. 
 
 When the great toe is very painful, the entire 
 limb should be elevated and the painful joint 
 wrapped in wool or treated with hot applications. 
 Should the pain refuse to yield to local measures 
 of any kind, it may be necessary to invoke the aid 
 of analgesis; and, if the patient be of a nervous, 
 irritable disposition, the best way out of the diffi- 
 culty will be to give him a moderate dose of mor- 
 phine. 
 
 Colchicum in twenty- or thirty-minim doses, either 
 of the tincture or wine, may be given every four 
 hours ; for, though much less used at present than 
 before the introduction of salicylic acid, this remedy 
 exerts an undoubted influence in reducing the red- 
 ness and abating the pain in the joint. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 77 
 
 Mineral waters of various kinds have been found 
 useful in gout. Among those commonly recom- 
 mended are the waters of Vichy, Carlsbad, Sara- 
 toga, and White Sulphur Springs. 
 
 When the disease becomes chronic, warm baths — 
 and notably those of Wiesbaden, Teplitz, Carlsbad, 
 Aix, and Ems — may be prescribed with advantage. 
 
 It has become fashionable of late to prescribe a 
 special diet for those afflicted with gout; and, 
 though nominally founded on the theoretic exigen- 
 cies of the disease, a glance will reveal discrepancies 
 of opinion which it is hard to reconcile by even the 
 most adroit sophistry. The chief desideratum, after 
 all, is to reduce the quantity of food ingested, — a 
 precaution which of itself cannot fail to diminish 
 the dangers of defective metabolism and consequent 
 accumulation of uric acid. As may readily be in- 
 ferred, both the acid and saccharine foods are to be 
 excluded as far as possible; and, without burden- 
 ing the mind of the patient too much with details, 
 he should be informed at once that the success of 
 treatment is largely a question of his own volitional 
 ability. 
 
 In concluding these brief observations on the 
 management of rheumatism and gout, it will be 
 well to consider a remedy which has been much 
 written about of late in connection with its reputed 
 
 7* 
 
78 PAIN. 
 
 quality as a solvent of uric acid. I allude, of course, 
 to piperazin (C^H^o'N'g). The routine quantity of 
 fifteen grains pro die in divided doses is applicable 
 in the cases characterized by moderate uric acid 
 accumulations, whereas in severe and obstinate 
 rheumatism this amount may be much exceeded. 
 The remedy is quite soluble in water, and forms an 
 alkaline but non-caustic solution. Its power of dis- 
 solving uric acid has been shown, by the researches 
 of Schmidt and Biesenthal, to be much greater than 
 that of sodium carbonate, lithium carbonate, or 
 borax solution. In dissolving uric acid, piperazin 
 combines with this body, forming urate of pipera- 
 zin, which in turn is exceedingly soluble in water. 
 This piperazin urate is, moreover, much more 
 readily diffusible through animal membranes than 
 the lithium and sodium urates. All this is equiva- 
 lent to stating that a piperazin solution is able to 
 penetrate to the most remote tissues, dissolve the 
 uric acid which may be deposited there, and fi.nally 
 escape in the form of urate of piperazin by way of 
 the kidney. Piperazin is best given in solution in 
 order to insure rapid absorption. It may also be 
 exhibited with great effect, in cases accompanied by 
 much pain, in combination with an equal dose of 
 phenocoll, the analgesic properties of which are well 
 known. To carry out this idea in a practical way. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 79 
 
 a phenocoll-piperazin water has been prepared, each 
 pint of which contains eight grains of phenocoll and 
 eight grains of piperazin. Two or three pints of 
 this water may be drunk daily without the least 
 unpleasant consequences. 
 
 Space will not permit a more extended discussion, 
 of details, which properly belong in special mono- 
 graphs and treatises on general medicine. One of 
 the most recent and practical of the former is Dr. 
 Satterlee's little book, which will be found to abound 
 in helpful suggestions. 
 
CHAPTEE Y. 
 
 PAINS "WHICH HAVE THEIR SEAT IN THE STRUCTTJBES CON- 
 TAINED WITHIN THE CAVITIES OF THE BODY — INTRA- 
 CRANIAL PAINS (headache)— "spinal" (medullary) 
 
 PAINS — ABDOMINAL AND THORACIC (VISCERAL) PAINS. 
 
 The pains associated with inflammatory changes 
 in the nerves which supply the exterior of the body 
 having been previously considered, it now remains 
 to examine in a general way those pains that have 
 their seat in the structures contained in the various 
 cavities of the body. Prominent among such pains 
 are what are currently known as headaches, all or 
 most of which — if we except those due to syphilitic 
 periostitis of the cranium and disease of the internal 
 ear — are attributable to intracranial causes. 
 
 These pains which are directly or indirectly refer- 
 rible to disturbances within the cranial cavity are 
 characterized by the presence of more or less mental 
 irritability, prostration, and sensory hypersesthesia, 
 and less frequently by vertigo, nausea, and vomiting. 
 
 Various attempts to classify these intracranial 
 pains have been made; but as our knowledge of 
 80 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 81 
 
 their causation is still incomplete, all such efforts 
 are necessarily imperfect. 
 
 The following nomenclature, which is a slight 
 modification of that adopted in my book on " Head- 
 ache and E"euralgia," is perhaps open to as little 
 criticism as any. 
 
 Pains -which have their Seat within the Cranial 
 Cavity — Intracranial Pains — Headache. — Anaemic 
 headache, as its name implies, is proximately due to 
 a deficiency of the blood-supply within the cranial 
 cavity. It is an almost invariable accompaniment 
 of general anaemia and chlorosis, and hence young 
 persons, and more especially girls, are particularly 
 subject to its attacks. Any morbid condition which 
 culminates in a reduction of the normal amount of 
 blood in the system may cause it. Hence it may 
 be associated with widely-different diseases. De- 
 bility, then, is the great prerequisite to its occur- 
 rence. 
 
 The more important symptoms of this anaemic 
 form of headache are clawing pains at the vertex, 
 vertigo evoked by suddenly changing from an erect 
 to a recumbent position, increased compressibility 
 of the carotids, facial pallor, fatigue upon slight 
 exertion, mental depression, hyperaesthesia of the 
 special senses, particularly sight and hearing, droop- 
 ing of the eyelids, drowsiness during the day and 
 / 
 
82 PAIN. 
 
 sleeplessness at night, and finally, pronounced car- 
 diac weakness, 
 
 Hypersemic headache, the opposite condition of 
 that previously described, is due to an increase in 
 the arterial blood-tension with accompanying relax- 
 ation of the cerebral capillaries. Its characteristic 
 symptoms are sensations of fulness in the head; 
 vertiginous attacks appearing spontaneously or fol- 
 lowing changes of position ; morbid irritability, as 
 exemplified by sudden anger upon trivial provoca- 
 tion; throbbing of the carotids; and attacks of 
 palpitation. 
 
 Kervous or cerebral headache is sometimes hemi- 
 cranial in type, but more frequently there is little 
 that is distinctive about it either in quality or lo- 
 cation. Sometimes the pain is predominantly felt 
 in the forehead, vertex, or occiput; whereas, in a 
 smaller percentage of cases, it evinces a predilec- 
 tion for the temple, or, as already mentioned, for 
 one-half of the head. 
 
 Whatever the precise location of the pain may 
 be, however, there is always more or less mental 
 irritability, and usually also nausea and vertigo. 
 Visual and auditory hypersesthesia are likewise 
 characteristic and quite constant accompaniments. 
 
 The cerebro-hypersemic and cerebro-ansemic forms 
 of headache represent merely modifications of the 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 83 
 
 nervous type of head-pains, the alterations in the 
 clinical picture being due, or largely due, to the 
 presence of a marked degree of circulatory dis- 
 turbance. 
 
 The neurasthenic type of headache is usually 
 much like that just described as " nervous" head- 
 ache. There are, however, occasional deviations in 
 type, — deviations which vividly recall the symptoms 
 more particularly described under the head of 
 anaemic headache. Then, too, there are also present 
 in varying degrees of intensity the well-marked 
 phenomena of nervous exhaustion, — ^the so-called 
 neurasthenic symptoms; and these, taken in con- 
 junction with the general history of the case, will 
 serve to facilitate diagnosis. 
 
 The lymphatic or bilious headaches include the 
 various head-pains which are obviously due to some 
 peripheral source of irritation, — to some cause origi- 
 nating outside the cerebro-spinal canal. While 
 hemorrhoids, ovarian disease, and uterine derange- 
 ments may give rise to it, its most prolific cause 
 must be sought for among the manifold disturbances 
 of the organs of digestion. 
 
 It is highly probable, however, that, inasmuch as 
 these disorders may exist in the absence of all head- 
 symptoms, a certain neurotic predisposition is es- 
 sential, in order that the peripheral disturbances 
 
84 PAIN. 
 
 shall culminate in intracranial derangements of a 
 painful character. In consonance with this opinion, 
 we find that impressionable young people, and more 
 especially girls, are subject to this form of headache. 
 
 The symptomatology presents nothing of especial 
 interest, and its principal features are soon told. 
 There are local pains of a constant, heavy, clawing 
 character ; yellow appearance of the skin ; stomachic 
 discomfort; general malaise and depression; and 
 not infrequently attacks of giddiness, which are 
 erroneously ascribed by the subject to cerebral 
 causes, but which primarily, at least, are due to 
 irritation emanating from the stomach. 
 
 In the toxic form of head-pain we have — in so far 
 as the causation is discoverable — to do with some 
 change in the normal constitution of the blood, 
 due either to the evolution of some toxic condition 
 within the organism itself, or to the introduction of 
 some poisonous agent from without. Uraemia af- 
 fords an excellent example of the one, and chronic 
 alcoholism of the other, mode of poisoning. Let 
 the method of poisoning be what it may, its results, 
 a toxic condition of the blood and consequent irri- 
 tation of the nervous system, are the same. 
 
 The pains have nothing especially characteristic 
 about them, when considered collectively. Some- 
 times they may be dull and heavy, as we find them 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 85 
 
 among brass-workers, or they may be splitting, as 
 in the headache of syphilis. 
 
 In all cases permanent relief is contingent upon 
 removal of the poison from the system. This is not 
 possible where the source of the poison is found in 
 some organic alteration of the viscera, as in Bright's 
 disease. It is, however, more readily attainable 
 when the toxic agent has been introduced from 
 without, as in syphilis and lead-poisoning. These 
 are, however, matters which will be treated more in 
 detail in the chapter especially devoted to the treat- 
 ment of pain. 
 
 The lesions which are largely responsible for 
 organic head-pain are syphilis and the various 
 kinds of tumors, disease of the cerebral arteries, 
 tuberculosis, cerebral softening, bony formations 
 within the cranial vault, and meningitis. Organic 
 disease is, however, by no means as frequent a 
 cause of headache as might be imagined from the 
 percentage of gross cerebral lesions. Nor is the 
 diagnosis of this variety of headache always an 
 easy matter; for, in the first place, there may be 
 nothing especially characteristic about the pain ; and, 
 secondly, more or less profound organic changes 
 may be present without evoking painful manifes- 
 tations of any kind. 
 
 Speaking in a general way, it may be said that 
 8 
 
86 PAIN. 
 
 headaches due to organic disease of the brain are 
 usually more or less continuous in character, and 
 are referred to a circumscribed portion of the cra- 
 nium. Concomitant disturbances of sensation and 
 motion, assuming the form either of local spasms, 
 paresis, or impairment of vision, or combinations 
 of all of them, may help to clarify the diagnosis; 
 but these are by no means always present. Some- 
 times the loss of muscular power is very gradually 
 accomplished; and under these circumstances ver- 
 tigo, impairment of memory, and loss of visual 
 efficiency (optic neuritis) assume a prominent place 
 in the symptomatology. 
 
 Headache accompanied by epileptic phenomena, 
 facial paralysis, and disturbances of speech, occur- 
 ring at the period of adolescence, may, in the ab- 
 sence of negative testimony, be ascribed to syphilis. 
 In such cases copious mercurial inunctions and the 
 administration of large doses of the iodides are 
 sometimes followed by a reduction and eventual 
 disappearance of the symptoms. 
 
 Unfortunately, such a happy issue is rather the 
 exception than the rule, and is only to be anticipated 
 in cases with undoubted syphilitic antecedents. In 
 the vast majority of cases of organic headache we 
 are indeed quite unable to extricate the patient 
 from his deplorable plight. Occasionally, it is true, 
 
PHYSIOLOGICAL,, PATHOLOGICAL, CLINICAL. 87 
 
 cerebral surgery has been able to accomplisli some- 
 thing ; but this field of the art is necessarily limited: 
 first, by the imperfections of diagnosis ; secondly, by 
 the fact that a large proportion of cerebral growths 
 are malignant; and, thirdly, because extensive intra- 
 cranial extirpations mean a commensurate oblitera- 
 tion of important cerebral organs. ISTo amount of 
 sophistry can modify the situation in this regard 
 one whit. 
 
 In a large proportion of cases, then, treatment is 
 purely palliative, and consists for the most part in 
 the amelioration of the pains by opiates. 
 
 Pains -which have their Seat within the Thoracic 
 Cavity. — The majority of pains located within the 
 thoracic cavity are due either to the presence of 
 neoplasms or aneurism, or they occur in the course 
 of acute afiections of the heart or lungs. The 
 more detailed consideration of these pains belongs 
 without doubt in the domain of general medicine. 
 There is, however, one variety of prsecordial pain 
 which may properly be considered in a work of this 
 kind; I refer to the afiection variously known in 
 the books as angina pectoris, stenocardia, nervous 
 heart-pain, or cardiac neuralgia. Kow, it is a well- 
 known anatomical fact that the superior and infe- 
 rior cardiac branches of the vagus join the cardiac 
 branches of the sympathetic to form the cardiac 
 
88 PALN. 
 
 plexus. In accordance with current physiological 
 opinion, three kinds of fibres are assumed to exist 
 in this plexus : those whose stimulation accelerates 
 the heart-beat ; those whose stimulation retards the 
 heart-beat; and, finally, those whose function is 
 the conveyance of sensory impressions from the 
 heart. 
 
 Inasmuch as pain is the cardinal symptom of 
 angina pectoris, the affection in its idiopathic form 
 is commonly regarded — and it must be confessed 
 with considerable reason — as a neurosis of the pneu- 
 mogastric nerve. Some participation of the sympa- 
 thetic system of nerves is also probable, as Lance- 
 reaux and others have been able to show from the 
 results of a number of autopsies. 
 
 A sharp differentiation of this, the true or idio- 
 pathic form of the affection, as contrasted with the 
 angina-like pains due to organic disease of the heart, 
 must of course be maintained. Among the cardiac 
 lesions which most frequently give rise to pseudo- 
 angina, if I may so call it, are valvular disease, fatty 
 degeneration of the muscle, and disease of the cor- 
 onary arteries. 
 
 The clinical phenomena of angina pectoris have 
 been described in the text-books over and over again 
 during the last century, so that all practitioners are 
 doubtless well able to recognize the affection. The 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 89 
 
 most obvious symptoms are a severe pain occurring 
 in paroxysms in the neighborhood of the left nipple, 
 a feeling of impending dissolution, profuse cold 
 perspiration, and occasional dyspnoea. 
 
 As a rule, there is no aura whatever, the seizure 
 taking place without warning by day or night, re- 
 gardless of all ascertainable physical or psychical 
 incentive. "Where there is absence of organic 
 changes in the heart, there is complete cessation of 
 all symptoms during the intervals, the patient de- 
 claring at such times that he feels as well as ever. 
 Under these circumstances, when we have appar- 
 ently to do with a neurosis of the sensory filaments 
 of the heart (" vagus neurosis"), the danger to life 
 is practically nil. "When, however, atheroma of the 
 coronary arteries or some other grave cardiac lesion 
 is present, the outlook is threatening, death during 
 a paroxysm being a frequent sequence. 
 
 The really efficacious remedies at our command 
 for combating the paroxysm are few in number 
 and well known to the profession. The inhalation 
 of from four to eight drops of the nitrite of amyl 
 is generally regarded with favor ; and those who 
 are the victims of inveterate angina should be told 
 to carry about a few of the well-known hollow glass 
 beads, each of which contains a medium dose of 
 the drug. One or more of these may be broken 
 
 8* 
 
90 PAIN. 
 
 upon a handkercMef and inhaled as soon after tlie 
 inception of the attack as possible. 
 
 Hypodermic injections of morphine and inhala- 
 tions of chloroform or ether have, in my experience, 
 often rendered good service. All kinds of remedies 
 have been exhibited during the intervals with a 
 view to aborting the attacks and eventually ob- 
 taining exemption from the difficulty. It must be 
 confessed, however, that the results thus far ac- 
 complished are not brilliant. Digitalis, spartein, 
 strophanthus, and indeed the whole group of 
 cardiac stimulants have been tried, and the same 
 may be said of the so-called alteratives. Kothing, 
 however, save disappointment has come of all this. 
 
 Speaking generally, it may be said that the fac- 
 tors which are likely to engender a predisposition 
 to neuritis are those which are most carefully to be 
 avoided. Among these tobacco has been assigned 
 — and rightly so, it would seem — a prominent posi- 
 tion. And yet many cases of idiopathic angina 
 occur among women, — cases in which a subsequent 
 autopsy has failed to reveal any organic disease 
 which might reasonably be supposed to account for 
 the symptoms, and in which, moreover, the entire 
 clinical history may be absolutely negative in so far 
 as it affords a clue to questions of causation. 
 
 The whole matter of etiology, then, in so far as 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 91 
 
 so-called functional or idiopathic cases are con- 
 cerned, is enveloped in more or less obscurity. 
 
 Pains which have their Seat in the Cavities of 
 the Abdomen and Pelvis. — To enumerate and dis- 
 cuss even a small number of the pains which are 
 intimately associated with the development of acute 
 diseases or neoplasms would overtax the limits of 
 the present publication. Indeed, the more detailed 
 consideration of such pains is in the nature of 
 things intimately connected with that of the dis- 
 eases themselves, of which the pains are but one of 
 the modes of expression; hence the whole subject 
 belongs in the domain of general medicine, and 
 there I shall leave it. 
 
 Let me add, however, that in a subsequent por- 
 tion of this work I shall offer a few observations 
 on the practical management of pain the source of 
 which is located in one of the large cavities of the 
 body, and is therefore inaccessible to local means of 
 attack. 
 
CHAPTER VL 
 
 THE DIAGNOSTIC VAI,UE OF PAIN. 
 
 It has already been shown that the peripheral 
 (sensory) nerves afibrd the only routes by whicli 
 painful impressions are transmitted to the cerebro- 
 spinal axis, and thence to the centres of conscious 
 perception. Moreover, it is equally clear that the 
 greater the supply of such filaments to a part, the 
 greater must necessarily be the susceptibility of 
 that region to pain-provoking influences. Herein 
 lies the explanation of the striking variations in 
 the intensity of painful sensations emanating from 
 the different tissues. 
 
 Every physician is cognizant of this immense 
 diversity of sensibility as a matter of practical 
 experience, but few pause to consider the simple 
 anatomical fact which lies at the basis of the 
 phenomenon. The sensibility of bone (even if we 
 include the periosteum) is not equal to that of the 
 skin ; nor is that of cartilage comparable with that 
 of the muscle. 
 
 The varying degrees to which the sensory nervous 
 
 92 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 93 
 
 system lias been developed in these tissues are suffi- 
 cient, then, to account for quantitative diiferences 
 in the pains. 
 
 But variations in the abundance of the sensory 
 nerve-supply, while certainly the main factor in 
 determining the differences in pain-susceptibility 
 of the tissues, do not give rise to qualitative 
 modifications. 
 
 These differences in the kinds of pain which 
 we feel are far more likely to be contingent upon 
 the nature of the pathological process prevailing 
 in the tissue. At all events, this seems to hold 
 good with regard to the nerves of common sensa- 
 tion. 
 
 Another important fact is, that the mind usually 
 refers the painful sensations perceived by it to the 
 seat of irritation (disease). The exceptions to this 
 rule will be considered later. Thus it happens that 
 one of the greatest services, if not the very greatest, 
 which pain renders the clinician consists in its abil- 
 ity to point out the seat of trouble. The result of 
 this is that, even when the pain itself is not suffi- 
 ciently characteristic to admit of our deriving from 
 it exact inferences as to the nature of the disease, 
 our attention is, nevertheless, at once drawn to the 
 seat of trouble ; investigation reveals a number of 
 collateral symptoms; and these, in conjunction 
 
94 PAIN. 
 
 with the pain, enable us to form an exact diag- 
 nosis. 
 
 Regarded from this stand-point alone, it is almost 
 impossible to over-estimate the diagnostic value of 
 pain. The wonder is that so little attention has 
 been accorded it in current works on diagnosis. 
 
 In view of the importance of the subject on the 
 one hand, and the paucity of helpful literature on 
 the other, I trust that by citing some of the more 
 important examples of the helpfalness of pain in 
 diagnosis I shall not trespass unduly upon the 
 patience of the reader. 
 
 Pains about the Head, including" the Bye and 
 Ear. — In the headache of anaemia there is present 
 quite a characteristic kind of pain, — the clawing 
 sensation at the vertex, with concomitant vertigo 
 and drowsiness, and morbid susceptibility to light 
 and sound. In the opposite condition of cerebral 
 engorgement the pain is more diffuse, and is ac- 
 companied by a feeling of fulness and constric- 
 tion. 
 
 Severe unilateral pain, with photophobia and 
 gastric derangements, constitute the more striking 
 features of megrim. 
 
 Pain over the orbit is also quite characteristic 
 of the headache due to malarial poisoning (" brow 
 ague," supraorbital neuralgia). Of this type of 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 95 
 
 headache we have already had something to say 
 when discussing the various forms of neuralgia, — 
 that phase of pain in which the symptoms are prac- 
 tically restricted to the ramifications of one or more 
 nerve-stems. 
 
 Syphilis, too, frequently gives rise to a very 
 characteristic kind of head-pain, — ^the well-known 
 " splitting, boring" headache. 
 
 Again, in the severe headaches due to tumors 
 and other organic lesions located within the cra- 
 nium, the pain is apt to be constant and more or 
 less confined to definite regions of the cranium. 
 
 This reference of the pain by the patient to cer- 
 tain areas cannot, however, be regarded as posi- 
 tive proof of the correct localization of the central 
 lesion; for it has frequently happened that a sub- 
 sequent post-mortem examination has shown the 
 conceptions of the subject to have been entirely at 
 fault, the lesion being found in quite a different 
 portion of the intracranial structures. In addition 
 to the severe pain, organic headache is frequently 
 accompanied by more or less profound derange- 
 ments of sensation and motion. These disturbances 
 usually assume the form of spasms, paresis, and 
 visual impairment (optic neuritis, paralysis of ex- 
 trinsic ocular muscles, etc.). 
 
 Again, vertigo, derangements of memory, and 
 
96 PAIN. 
 
 progressive loss of muscular power are tlie con- 
 comitant factors in other cases. 
 
 Some of the pains found in and about the eye 
 are of the highest importance from a diagnostic 
 stand-point, since, in conjunction with other symp- 
 toms, they enable us to detect the presence of 
 severe disease of the eyeball in time to act effect- 
 ively against it. 
 
 This is especially true of acute glaucoma, panoph- 
 thalmitis, and plastic iritis. 
 
 In acute glaucoma there is present severe pain 
 in the eyeball, with concomitant dilatation of the 
 pupil, shallow anterior chamber, increased tension 
 of the eyeball, impairment of vision, photophobia, 
 redness of the eye, and lachrymation. The pain is 
 hemicranial in type, and may involve not only the 
 area supplied by the supraorbital nerve, but also 
 that to which other branches of the fifth nerve are 
 distributed. 
 
 The pain of panophthalmitis, on the other hand, 
 is usually less intense ; the cornea is opaque from 
 ulceration or inflammatory changes, which obscure 
 the pupil and iris; chemosis is present; and there 
 is much swelling of the eyelids and protrusion of 
 the eyeball. 
 
 In plastic iritis the pain may be slight or severe ; 
 the pupil is contracted ; the eyeball is red, the iris 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 97 
 
 discolored; and, on instilling a mydriatic, the pupil 
 fails to dilate regularly on account of the presence 
 of adhesions. On the other hand, serous iritis pre- 
 sents somewhat different appearances. There is 
 pain, but it is not vehement ; the pupil instead of 
 being contracted is dilated; the anterior chamber 
 is abnormally deep, and the posterior aspect of 
 the cornea is covered with small spots of exuda- 
 tion. 
 
 Some of the pains associated with severe ear-dis- 
 ease are quite significant. 
 
 Thus, in mastoiditis (abscess of the mastoid cells) 
 there is pain of varying intensity, which is most 
 acutely felt directly behind the ear. Inspection of 
 this locality, when the disease is at all advanced, 
 reveals swelling and redness ; while even moderate 
 pressure demonstrates the existence of exquisite 
 local tenderness. 
 
 It is self-evident that the prompt recognition of 
 the true significance of this state of aflfairs is of the 
 utmost importance, since it renders early operative 
 interference possible, thus probably averting a fatal 
 meningitis. In acute otitis media the pain in the 
 ear is vehement, is increased by the recumbent 
 posture, and usually ceases on operative or sponta- 
 neous perforation of the membrana tympani. That 
 the pain is due to intratympanic pressure is revealed 
 s. g 9 
 
98 PAIN. 
 
 by the bulging of the red and swollen drum towards 
 the meatus. 
 
 In addition to these pains, there is an earache, 
 which is obviously due to neuritis of the sensory 
 filaments of the ear. 
 
 Carious teeth, post-pharyngeal abscess, and caries 
 of surrounding bony structures may give rise to this 
 kind of ear-pain. 
 
 Paina Eeferrible to Disease of the Organs -within 
 the Thorax. — ^Besides the pains which are associated 
 with the extensive organic changes present in pul- 
 monary cancer and phthisis, aneurism of the ascend- 
 ing aorta and mediastinal abscess, there are others 
 which serve as warnings in a number of acute affec- 
 tions of both heart and lungs. Thus, in acute 
 pleurisy, during the dry stage, we have local pain 
 with the well-known friction sound and impairment 
 of movement of the chest-wall. Later, in the stage 
 of effusion, there is the usual dulness on percussion 
 over the accumulated fluid; and in severe cases, 
 displacement of the liver or heart. 
 
 Again, in acute pneumonia the thoracic pain asso- 
 ciated with fever, cough, and the cherry-colored 
 expectoration constitute an eminently characteristic 
 group of symptoms. The diagnosis should not, 
 however, be hastily made, the crepitant rSles, the 
 dulness with blowing respiration, increased vocal 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 99 
 
 fremitus, and broncliophony yielding the necessary 
 confirmation. 
 
 Pain in the chest is also present in both acute and 
 chronic pulmonary phthisis. In the former affec- 
 tion we find it associated with the usual premoni- 
 tory chill, fever, anorexia, emaciation, and night- 
 sweats; to which more or less irregular physical 
 symptoms — dulness over a tubercular deposit, cav- 
 ernous breathing, and moist ri,les — may be added. 
 
 Prsecordial pain is a more or less significant 
 symptom in affections of the heart and its mem- 
 branes. Thus, in both acute pericarditis and endo- 
 carditis there is more or less pain. In the former 
 affection it is associated, at first, with a more or less 
 well marked friction sound, and later, as the peri- 
 cardium becomes distended with fluid, with an 
 increase in the area of percussion dulness. The 
 characteristic pyramidal shape of this area of dul- 
 ness, while the patient is standing, is one of the 
 familiar observations of the sick-room. 
 
 In endocarditis the pain, while severe at times, 
 is accompanied by a blowing instead of a friction 
 sound; and later there is usually little or no in- 
 crease of percussion dulness. 
 
 Finally, in all valvular diseases, especially aortic, 
 in fibroid disease of the heart, in thrombosis of 
 the pulmonary artery, and in cardiac affections of 
 
100 PAIN. 
 
 purely functional character, there is more or less 
 pain. 
 
 Pain associated with Disease of the Organs con- 
 tained in the Abdominal Cavity. — In cancer of the 
 stomach the pain is gnawing in character, and is 
 felt with special intensity in the epigastrium. Much 
 the same kind of pain is present in cancer of the 
 pancreas, a fact which has often given rise to errors 
 in diagnosis. It would lead us too far were we to 
 enter into the details involved in the symptoma- 
 tology of abdominal troubles ; that is a task which 
 we gladly assign to the systematic treatises on in- 
 ternal medicine. On the other hand, it may be of 
 interest to recall the more important derangements 
 of the abdominal organs in which pain of varying 
 degrees of intensity is a noteworthy symptom. "We 
 have already spoken of cancer of the stomach and 
 pancreas, both of which are accompanied by more 
 or less continuous and severe pain; but, in addi- 
 tion to these, pain is conspicuous in a large array 
 of other diseases of the abdomen. Prominent 
 among these are the following : gall-stones, the 
 passage of which produces severe epigastric pain 
 which may be mistaken at first for colic. The 
 location of the pain in the epigastrium, the pres- 
 ence of jaundice, the severe vomiting, and the com- 
 paratively brief duration of the paroxysm serve, 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 101 
 
 however, to characterize the latter sufficiently for 
 diagnostic purposes. 
 
 Pain in the abdominal region is also a more or less 
 striking feature of irritant poisoning, ulcer of the 
 stomach, — especially manifest shortly after eating, — 
 suppressed gout, acute gastritis, — ^likewise evident 
 after the ingestion of food, — colic, cholera, enter- 
 itis, intussusception, the gastric crises of locomotor 
 ataxia, lead colic, peritonitis, perityphlitis, organic 
 diseases of the liver, aneurism, organic disease, and 
 obstruction of the intestine. In the region of the 
 pelvis we have, moreover, the characteristic pain 
 which radiates from the ovary in a downward direc- 
 tion, and may extend, and usually does extend, to 
 the anterior aspect of the thigh. This pain is com- 
 monly traceable to more or less severe disease of the 
 ovaries, tubes, or both. It is, however, an unfortu- 
 nate circumstance that extirpation of the diseased 
 ovaries and tubes does not always result in a per- 
 manent removal of the neuralgia. It would seem 
 that in such cases the irritable condition of the 
 nerves involved is perpetuated by some extraneous 
 factor as yet unknown to us. More or less severe 
 pain in the region of the pelvis is also associated 
 with cancer of the uterus, pelvic abscess, pelvic 
 cellulitis, vesical calculus, dysmenorrhoea, acute and 
 chronic endometritis, pelvic hsematocele, fibroid dis- 
 
 9* 
 
102 PAIN. 
 
 ease of the uterus, cystitis, pelvic peritonitis, and 
 the various displacements of the uterus. 
 
 In concluding this brief summary of the more 
 important pains associated with diseases of the 
 organs of the abdominal cavity, we must not forget 
 those eminently characteristic and terrible pains 
 which are associated with the passage of a stone of 
 considerable size and roughness from the pelvis of 
 the kidney through the ureter. 
 
 These pains shoot from the lumbar region, follow 
 the course of the ureters, and may even extend as 
 far as the testicles. They constitute the so-called 
 " renal colic," and are by far the most striking 
 feature of nephrolithiasis. The duration of these 
 pains, as is well known to all physicians of experi- 
 ence, is contingent upon the length of time the 
 stone remains incarcerated in the ureter. Some- 
 times a few hours suffice for the completion of the 
 descent of the stone into the bladder; whereas at 
 others several days, during which the patient is 
 kept as much as possible under the influence of 
 opiates, are necessary to complete the operation. 
 
 Pain associated with Organic Diseases of the 
 Nervotis System. — Pain is in greater or less degree 
 a characteristic concomitant of most organic af- 
 fections of the nervous system, and particularly 
 those of the spinal cord. This is strikingly illus- 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 103 
 
 trated in acute spinal meningitis, where the pains 
 in the back and along the course of the principal 
 nerve-trunks constitute, with the distortions of 
 the limbs and opisthotonus, due to the spasm of 
 the muscles, a most characteristic picture. In 
 the various inflammatory conditions of the cord, 
 involving in greater or less degree the sensory 
 mechanism, pain is a symptom of considerable im- 
 portance. The terms acute, subacute, and chronic, 
 as applied to myelitis, relate more particularly to 
 the variable length of time required for the develop- 
 ment of the symptoms; unusual vehemence of the 
 pains and rapid evolution of the paralysis of the 
 muscles, especially those of the lower extremities, 
 as in transverse myelitis, coupled with bed-sores 
 and bladder disturbances, being characteristic of 
 the acute phase of the disease. The location of 
 the pains will, of course, be contingent upon the 
 seat and size of the central lesion; so that in a 
 general way, it may be said, that the wider the 
 distribution of the latter the greater will be the 
 extent of the painful area. 
 
 Headache, parsesthesia, and lancinating pains in 
 the limbs are comparatively rare in multiple cere- 
 bro-spinal sclerosis, but are characteristic of loco- 
 motor ataxia. In the latter disease, the so-called 
 lightning pains, which shoot down the limbs, con- 
 
104 PAIN. 
 
 stitute with the stamping gait, and other evidences 
 of incoordination, a complex of symptoms so char- 
 acteristic as to be hardly mistakable for any other 
 disease. Tumors of the spinal cord do not, as a 
 rule, give rise to marked sensory irritation in the 
 beginning. After a time, however, when their 
 location in the spinal cord is favorable, their pres- 
 ence is announced by the appearance of shooting 
 pains, parsesthesia, and, eventually, anaesthesia; in 
 short, by the series of phenomena known in the 
 books as " root-symptoms." 
 
 Still later, the further compression of the cord, 
 in consequence of the growth of the neoplasm, is 
 shown by loss of power in the muscles, culminating 
 at length in complete paralysis. 
 
 The resemblance of these symptoms, both in 
 character and manner of evolution, to those of 
 diffuse chronic myelitis, cannot have escaped the 
 reader. Indeed, this similarity in the phenomena 
 of the two diseases is so great as in many instances 
 to preclude the differentiation of medullary tumor 
 from transverse myelitis. Sudden exacerbations of 
 pain and general irregularity of the symptoms are 
 believed by some to be an indication of tumor ; but 
 little reliance can be placed upon this assumption, 
 or upon that which perceives in irregularity of de- 
 velopment a token of syphilis. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 105 
 
 "We may note in passing that the condition in- 
 duced in the cord by pressure of the tumor is 
 known as compression myelitis, and may likewise 
 be engendered by caries and various injuries of the 
 spine. As a matter of course, the intensity and 
 rapidity of evolution of the pains and other symp- 
 toms will depend very largely upon the nature and 
 extent of the injury or morbid change to which the 
 myelitis is due. 
 
 As may readily be inferred from the character of 
 the central lesion, pain is but a subordinate element 
 of poliomyelitis anterior acuta, the paralysis and 
 muscular atrophy being the significant features. It 
 likewise occupies the same position in spastic spinal 
 paralysis, the weakness in the legs, observed in the 
 beginning, and the spasmodic condition of the mus- 
 cles subsequently developed, with the inevitable 
 sequences, — exaggerated tendon reflexes and ankle- 
 clonus, — constituting the characteristic symptom 
 group. Elsewhere will be found a description of 
 the more significant pains due to organic changes 
 in the brain, so that the subject need not be re- 
 opened. 
 
 Before terminating the discussion of the diag- 
 nostic relations of pain, let me say that the pains 
 felt in the muscles are sometimes significant. Thus, 
 in trichinosis, the muscular pains occurring at the 
 
106 PAIN. 
 
 end of the second week or later are due to tlie 
 rayositis engendered by the parasites. It is true 
 that when the number of trichinae is relatively 
 small the pains may be so slight as to remain 
 almost unperceived. "When, however, the invasion 
 is extensive, the chain of symptoms is most char- 
 acteristic. The muscles become enlarged and swol- 
 len; they are exceedingly painful and intolerant 
 of pressure ; and the same may be said of voluntary 
 movements. Hence the patient remains in one 
 position, avoiding motion as much as possible. 
 
 Inasmuch as the masseters, as well as the laryngeal 
 and pharyngeal muscles, are involved, the subject 
 experiences much diificulty in masticating and swal- 
 lowing food. But a still more serious complication 
 is the invasion of the diaphragm and abdominal 
 and intercostal muscles by the parasites, — a condi- 
 tion which may cause such difficulty in respiration 
 as to endanger the life of the patient. Undoubtedly, 
 in some of the fatal cases of trichinosis, death is 
 largely or entirely due to this interference with 
 respiration. 
 
 Finally, the characteristic pains of muscular rheu- 
 matism are important, as they point to possible 
 presence of redundant uric acid, thereby enabling 
 us to effect in time the necessary modification in 
 the dietetic regimen of the patient. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 107 
 
 While the scope and purpose of this work will 
 not admit of our pursuing the subject further, I 
 think that enough has been said to illustrate in a 
 striking manner the very great — I had almost said 
 paramount — importance of pain as an element in 
 general as well as neurological diagnosis. 
 
CHAPTER YII. 
 
 THE CLINICAL AND MEDICO-LEGAL SIGNIFICANCE OF THE 
 PHENOMENA EVOKED BY PAIN — OBJECTIVE METHOD OF 
 DIAGNOSTICATING PAIN. 
 
 Inasmuch as it often happens that individuals, 
 either of their own volition or on account of an 
 hysterical predisposition, erroneously declare that 
 they feel pain, it becomes self-evident that every 
 sign, however insignificant, which can aid the phy- 
 sician in arriving at a true conclusion as to the 
 sensations of the patient is of importance. 
 
 This objective determination of the existence or 
 non-existence of pain is, however, often beset with 
 difficulty: first, because — as in certain obscure phases 
 of visceral pain — a possible cause is not demon- 
 strable; and, secondly, because the secondary effects 
 of pain — cardiac, gastric, nutritive, and psychic — 
 are not at all or but slightly developed. The evo- 
 lution of these collateral effects is indeed dependent 
 not only upon the intensity of the pain, but also 
 upon its continuance ; so that it may very well hap- 
 pen that, when the pain is of brief duration and of 
 
 108 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 109 
 
 relatively minor intensity, little, if any, change in 
 the corporeal or psychic condition of the patient is 
 discernible. In a large percentage of cases of severe 
 chronic pain collateral phenomena of this sort are, 
 however, present ; and when their existence as a 
 direct sequence of the painful onset is demonstrable, 
 they possess a distinct diagnostic value. 
 
 As the medico-legal significance of these things, 
 though great, is often entirely overlooked, I shall 
 take the liberty of enumerating the more striking 
 facts. 
 
 In the first place, there are often well-defined ap- 
 pearances at the seat of pain. The most common 
 are redness, heat, oedema, and tumefaction. Some- 
 times, however, as in myalgia, there are no local 
 changes whatever discernible ; and when the attack 
 is acute, the testimony of the patient is about all 
 we have to guide us. 
 
 Among the common effects produced upon the 
 organism at large by severe and long-continued pain 
 are chronic, or at least persistent, nervous irri- 
 tability, imperative conceptions of a disagreeable 
 character, hypochondria, and melancholia, culmi- 
 nating — as has often occurred in severe forms of tic 
 douloureux — in self-destruction. Again, the subject 
 may become the victim of obstinate insomnia, which 
 in turn gives rise to moroseness, hallucinations, 
 
 10 
 
110 PAIN. 
 
 and perhaps ultimately to complete mental alien- 
 ation. 
 
 Althougli the facial expression of persons who 
 are the victims of pain is not to be relied upon in 
 a pathognomonic sense, it must nevertheless be ad- 
 mitted that the physiognomy often affords valuable 
 data of a corroborative character; moreover, in 
 the case of the deaf and dumb or the aphasic, or, 
 above all, when little children are concerned, it may 
 constitute our only source of information as to the 
 patient's true state of feeling. When, however, 
 malingering is suspected, the data to be gained from 
 a study of the face of the subject are of no value. 
 That this is so will be readily understood when it is 
 remembered that such persons are able to assume 
 the states of feeling which lie at the root of the 
 facial contortions ; so that, like actors, they are able 
 to mentally " live in their role." 
 
 The character of the facial mimicry peculiar to 
 those who suffer pain is so familiar to all physicians 
 as scarcely to merit detailed description. Indeed, I 
 question very much whether a mere analysis of the 
 muscular contractions involved would begin to con- 
 vey the definite impression obtainable from a good 
 photograph or, better still, from the contemplation 
 of the individual himself. 
 
 In addition to the psychical disturbances, grave 
 
 i 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. Ill 
 
 modifications in the physical economy have often 
 been observed. Chief among these are the cardiac 
 derangements, described by a number of authors and 
 experimentally investigated by Franck and Claude 
 Bernard. 
 
 Commenting on the discrepancies in the accounts 
 given by difierent authors of these cardiac disturb- 
 ances, Franck^ observes that at all events the imme- 
 diate efiect is an arrest or slowing of the heart with 
 the resultant changes in arterial pressure. He also 
 confirms the previous observations of Magendie 
 and Bernard, that excitation of the sensory roots or 
 filaments of the spinal nerves gives rise to reflex 
 stoppage of the heart with consecutive diminution 
 in arterial pressure. 
 
 Precisely similar facts have been ascertained clini- 
 cally. Thus, Potain drew attention some ten years 
 ago to the palpitations and syncope which were the 
 direct sequence of certain neuralgias and injuries 
 of the arms. 
 
 Derangements of motility are a frequent concom- 
 itant or sequence of pain. This is especially ex- 
 emplified by the tonic and clonic spasms so char- 
 
 ^ Eecherches ezperimentales sur les effets cardiaques, vasculaires 
 et respiratoires des excitations douloureuses, Comptes-Eendus des 
 Seances de 1' Academic des Sciences, vol. Ixxxiii. p. 1109. 
 
112 PAIN. 
 
 acteristic of the visceral neuralgias and so-called 
 convulsive tic. The muscular contractions with 
 which we are here confronted are clearly of reflex 
 origin and require no special elucidation. The mus- 
 cular relaxation sometimes encountered as an accom- 
 paniment of pain is much less characteristic and 
 consequently of subordinate diagnostic value. 
 
 Disorders of nutrition, assuming the form of pro- 
 gressive emaciation, and loss of muscular and mental 
 vigor, are familiar to all physicians. 
 
 Such vaso-motor anomalies as local hypersemia 
 or ansemia, more especially the former, are common 
 phenomena of various painful conditions ; and the 
 same may be said of the derangements of the special 
 nerves, particularly those of sight and hearing. 
 
 Arrest or appreciable diminution of the secretions, 
 notably of the kidneys, is another well-known effect 
 of pain. 
 
 The irritability, insomnia, melancholy, and other 
 nervous and psychical effects of pain have already 
 been alluded to. Dyspepsia, loss of appetite, and 
 appreciable diminution of the activity of the sali- 
 vary glands are some of the most common compli- 
 cations of various painful conditions. These gastric 
 disorders are frequently accompanied by a consider- 
 able elevation of temperature, which has been justly 
 ascribed to the intensity of the pain alone. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 113 
 
 Finally, pain, when of great severity, may result 
 in immediate death, the fatal termination being evi- 
 dently due either to nervous exhaustion or syncope. 
 
 It would be a manifest omission were we to forget 
 to mention what have been aptly termed subjective 
 pains. Here we are confronted with painful sensa- 
 tions which are referred by the patient to definite 
 localities, the most careful inspection of which fails 
 to reveal any morbid changes whatsoever. 
 
 These so-called subjective pains, or ^^ phantom 
 pains'' of the hysterical, are in reality nothing more 
 than painful hallucinations, upon which, however, 
 the subject, being ignorant of their genesis, is but 
 too apt to construct erroneous ideas of various 
 kinds.^ 
 
 It must not be forgotten, therefore, that these 
 phantom pains though of erratic development are 
 none the less real to the subject herself. Hence 
 undue harshness is to be avoided, and the same may 
 be said of the old-fashioned expedient of taxing the 
 patient with untruthfulness or other forms of moral 
 turpitude. 
 
 Concerning' the Method to be Pursued in the 
 Clinical Determination of the Existence or Non- 
 Bxistence of True Pain. — From what has already 
 
 * Vide author's monograph on "Hysteria and Epilepsy." 
 h 10* 
 
114 PAIN. 
 
 been said, it is evident tliat the investigation of an 
 essentially subjective phenomenon like pain is beset 
 vpith no little difficulty. In the first place, it may 
 be in consonance with the material interests of the 
 patient to declare that he feels pain as the result of 
 a real or imaginary injury. This has been witnessed 
 again and again after railway or other accidents, 
 when attempts have been made to collect large 
 damages from corporations. 
 
 Again, in the absence of all criminal intent, as in 
 certain phases of hysteria, the subject declares that 
 she suffers acutely; and yet we are quite unable to 
 discover, even by the aid of the most careful exami- 
 nation, any adequate cause for the alleged sensations. 
 Here, as has previously been said, we have evidently 
 to do with hallucinations pure and simple, the pain- 
 ful conceptions being of central origin, and directly 
 traceable to some general neuropathic condition. 
 Finally, the subject may declare that he feels pain 
 in a certain definite locality. We examine the 
 region in question, but find absolutely no lesion 
 whatever; and yet the patient may be making 
 his statements in perfect good faith, and he may 
 even be in a condition of complete mental com- 
 petency. In such a case as this, we should make 
 every effort to determine, if possible, whether there 
 be not some central irritation or organic lesion, 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 115 
 
 which may be held responsible for the morbid sen- 
 sations, erroneously referred by the subject to the 
 periphery. The pains of ataxia and of some forms 
 of neuritis are illustrations in point. 
 
 And these preliminary observations bring us to 
 the important question, How shall we conduct the 
 clinical exploration in cases of suspected malingering, 
 when pain is alleged to be the dominant or only 
 symptom? I shall only attempt to give a general 
 reply, leaving the elaboration of the special points 
 demanded by individual cases to the perspicacity and 
 tact of the physician. In the first place, let there 
 be a careful examination made of the periphery, 
 and more especially of the alleged site of the pain- 
 ful sensations. 'Now, experience has shown that 
 much may be learned from careful palpation of 
 the part, provided the patient be taken off his 
 guard, so that the element of expectancy is ex- 
 cluded. To this end, it is well to engage him in 
 conversation on irrelevant matters, so that the 
 examination may appear as of quite collateral im- 
 portance. By such an examination we are able 
 to determine whether there is increased sensitive- 
 ness on pressure, whether there is inflammation, 
 or whether there is tumefaction or other sign of 
 gross lesion. As a further precaution against de- 
 ception, the examination may be undertaken sev- 
 
116 PAIN. 
 
 eral times, the agreement or discrepancies in the 
 phenomena evoked serving as a basis of argument. 
 The sensibility to temperature may also be tested 
 in the same way. 
 
 Finally, we may administer in the food of the 
 patient, or otherwise without his knowledge, an 
 hypnotic of suificient potency to remove the pain 
 complained of. If in the face of this, after a suffi- 
 ciently long interval to insure absorption of the 
 medicament, he still declares that the pain per- 
 sists as before or has increased in vehemence, we 
 may conclude, in the absence of hysteria or other 
 psychical defect, that wilful deception is in all 
 probability being practised. 
 
 Let me also add that the failure of the collateral 
 symptoms described by the subject to agree at all 
 with any known type of disease is of itself calcu- 
 lated to arouse suspicion. 
 
 When all has been said, however, that can reason- 
 ably be said on the objective recognition of pain, it 
 must be confessed that in some cases even the most 
 expert diagnostician may find himself embarrassed. 
 
CHAPTER VIII. 
 
 THE MEDICO-LEGAL RELATIONS OF PAIN, CONTINUED — SPINAL 
 
 CONCUSSION. 
 
 In the majority of cases of surgical injury accom- 
 panied by pain the determination of the amount of 
 damages consistent with equity is a comparatively 
 easy matter, the degree of interference with the sub- 
 ject's occupation occasioned by the accident itself 
 serving as a basis of computation, quite irrespective 
 of pain or other collateral effect engendered. 
 
 When, however, the extraneous appearances of 
 injury are little or not at all in evidence, the 
 alleged phenomena being purely subjective, the 
 difficulty of determining the genuineness of the 
 latter is enormously enhanced. These observations 
 are especially applicable to the curious affection of 
 the nervous system which is the sequence of railway 
 or other accidents, and to which the name " spinal 
 concussion" has been given. Let me say, however, 
 at once that, in my opinion, " cerebro-spinal con- 
 cussion" would be a designation more in accord- 
 ance with the symptoms, since not a few of these 
 
 117 
 
118 PAIN. 
 
 are clearly due to derangement of tlie intracranial 
 structures. 
 
 Since this spinal, or cerebro-spinal, concussion 
 has probably given rise to more litigation than any 
 other painful affection, it is eminently important 
 that every physician should at least be thoroughly 
 acquainted with its more important features. I 
 have therefore decided to devote a short chapter 
 to its consideration, which, should the reader be 
 already acquainted with the subject, may be passed 
 over. 
 
 Symptoms. — If a man be suddenly precipitated 
 from an elevation, so that he strikes with violence 
 upon his back, or if he be caught between two 
 seats of a railway car in the course of an accident, 
 so as to bruise, say, the lumbar portion of the spine, 
 a train of grave symptoms may be developed 
 pointing to more or less profound derangement of 
 the functions of the cord. There may be imme- 
 diate paraplegia or some other phase of paralysis; 
 there may be retention of urine ; there may be 
 various forms of parsesthesise, — formication, numb- 
 ness, or even total anaesthesia of the affected parts ; 
 or, finally, there may be paralysis accompanied by 
 one or more of these phenomena. Sometimes, too, 
 after a certain amount of febrile disturbance of 
 brief duration, the symptoms begin to abate, and 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 119 
 
 eventual complete recovery takes place. Again, the 
 termination may not be so favorable. We may have 
 to do with more or less persistent dorsal pain, with 
 numbness or sensations of pins and needles, accom- 
 panied by depression, derangements of memory, and 
 other symptoms pointing to profound implication 
 of the cerebro-spinal system. The spinal tender- 
 ness present in such cases is often of an exquisite 
 and obstinate character. K, in addition to direct 
 concussion of the spine, a blow upon the head has 
 also been received, it not infrequently happens that, 
 in the course of time, epileptiform seizures are 
 added to the cord symptoms. The clinical history 
 is, of course, somewhat changed by such a compli- 
 cation, and the same may be said of the prognosis, 
 which is much clouded. Finally, the blow upon 
 the spine may be but slight or altogether absent, 
 the subject being merely thrown violently about, as 
 in certain railway accidents. Under these circum- 
 stances the symptoms are often slowly evolved, and, 
 though frequently less severe than when the se- 
 quence of a direct and violent traumatism, they 
 nevertheless partake of an insidious and lethargic 
 character, which puts the patience of both client 
 and physician to a severe test. 
 
 Accidents of this class have now become common, 
 in consequence of the manifold complications of 
 
120 PAIN. 
 
 ■modern society, and especially of those which relate 
 to transportation. 
 
 As already noted, the painful localities along the 
 spine, which are such constant features of these 
 cases, are eminently worthy of the attention of the 
 physician, since they bear a significant relation not 
 only to a scientific diagnosis, but to effective thera- 
 peutics as well. 
 
 At this portion of the discussion I believe that I 
 cannot do better than cite a case or two from my 
 own case-book by way of illustration. 
 
 H. C, merchant, aged fifty-two years, of strong 
 muscular constitution, consulted me in February, 
 1884, for a train of severe nervous symptoms, which 
 caused great anxiety both to himself and family. 
 
 The following are the more prominent points in 
 the history of the case : 
 
 One year previous to consulting me he had the 
 misfortune to travel on a railway train which met 
 with a serious accident. The casualty in question, 
 as it afterwards appeared, was caused by the spread- 
 ing of the rails immediately in front of a long 
 trestle-work. Several of the coaches were thrown 
 from the trestle into the water, many of the occu- 
 pants being caught between the seats or thrown 
 about and severely injured. Others, again, were 
 confined beneath the fiying debris and drowned; 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 121 
 
 while yet others succeeded in making their escape 
 from the windows of the coach. Among the latter 
 was a distinguished officer of the United States 
 army and the gentleman with whose history we are 
 now concerned. Had the coach, after striking the 
 bottom, not rolled over upon its side, it is probable 
 that those within, who had not been killed outright, 
 would have perished by drowning. As it happened, 
 however, a large proportion of those within the 
 submerged cars escaped with their lives. It cannot 
 be said, however, that these persons were all un- 
 scathed, for, though the wounds received were in 
 most cases not serious, the after-effects caused by 
 the violent shaking were of a severe character. 
 Among those who developed severe symptoms a 
 considerable time after the accident was the gentle- 
 man who forms the subject of this brief history. 
 On emerging from the water, he became conscious 
 that the right shoulder and the lower portion of the 
 back were somewhat stiff and sore. At the same 
 time he felt a dull pain throughout the whole 
 dorsal region. These pains and the accompanying 
 soreness in the shoulder soon disappeared, however, 
 and the patient was beginning to regard himself as 
 perfectly well, when, several weeks after the acci- 
 dent, he complained of numbness in the third, 
 fourth, and fifth fingers, particularly pronounced in 
 F 11 
 
122 PAIN. 
 
 the right hand. This numbness was accompanied 
 by tremor of both hands, evoked by every attempt 
 to execute voluntary movements. At the same 
 time, he experienced " dull, tired" feelings after 
 walking even short distances, accompanied by great 
 mental depression. As a coexistent factor of the 
 above symptoms, the patient remarked a progres- 
 sive decline in his sexual powers, so that, at the 
 time of visiting me, his abilities in this direction 
 were nil. The testicles seemed unusually small, 
 the scrotum was tightly contracted about them, and 
 the penis was retracted, so as to expose only about 
 half an inch. Altogether, the sexual apparatus was 
 in size and general appearance analogous to that 
 of an infant. On examining the spine, no great 
 tenderness could be discovered ; but on passing the 
 wire brush along the spinous processes, from the 
 cervical region to the sacrum, an exceedingly tender 
 point was discovered in the neighborhood of the 
 eleventh dorsal vertebra. The course of this case 
 was a long and tedious one. 
 
 Sleep being profoundly deranged, the patient was 
 placed on twenty-grain doses of the bromides, to be 
 taken three or four times a day. Small doses of 
 chloral were also given at night, during the first 
 few weeks of treatment, combined with the tincture 
 of hyoscyamus. Strychnine was not well borne, and, 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 123 
 
 according to the patient's statement, exaggerated 
 the lumbar pains. In order to reheve the latter, 
 blisters were applied throughout the painful region, 
 but without greatly diminishing the spinal soreness. 
 Prolonged applications of galvanism were more ef- 
 fectual in abating the irritation; and accordingly 
 the constant current was applied every other day 
 for two months, at the end of which time marked 
 benefit had been obtained. The tingling and numb- 
 ness of the limbs remained for some time longer; 
 but after the lapse of four or five months it, too, 
 had entirely vanished. Walking had also begun 
 to afford pleasure, and could be indulged in without 
 the fear of subsequent lassitude. 
 
 The most difficult complication to combat in this 
 case was the complete loss of sexual power, ac- 
 companied by the retraction of the organ. This 
 retraction of the penis was certainly phenomenal, 
 as already observed. In order to remedy the condi- 
 tion dry cupping of the penis was resorted to, and 
 continued daily for over three months, and every 
 other day for the subsequent four months. By the 
 aid of this treatment, combined with douches, the 
 passage of the cold sound, such remedies as the 
 chloride of gold, iron, and the cocoa preparations, 
 I finally succeeded in completely restoring the 
 patient's sexual powers, so much so, in fact, that 
 
124 PAIN. 
 
 in due time a further addition was made to his 
 family. 
 
 This case affords an excellent illustration of the 
 slow insidious onset of the affection, of the evo- 
 lution of severe and obstinate symptoms without 
 local traumatism of commensurate importance, and, 
 finally, of the ultimate success attending the treat- 
 ment of what at the outset had all the features of a 
 practically hopeless case. This patient remained 
 under my immediate care nineteen months. At 
 the end of that time, with the exception of occa- 
 sional attacks of depression, the cure was complete. 
 Since discontinuing treatment I have seen the pa- 
 tient from time to time, and some months ago he 
 informed me that these attacks of depression had 
 entirely left him, and that, in short, he is " as well 
 as he has ever been in his life." 
 
 The following case, also taken from my case-book, 
 is a good illustration of some of the milder phe- 
 nomena sometimes evoked by concussion. As in 
 the cases already cited, marked localized tenderness 
 of the spine was present; but the condition was 
 treated in a more direct and effective manner. 
 
 J. M., a married man of forty-five years of age, 
 of nervous temperament and slight physique, con- 
 sulted me four years ago on account of a train of 
 nervous symptoms which caused him both anxiety 
 
PHYSIOLOGICAL, PATHOLOGICAL/ CLINICAL. 125 
 
 and annoyance. The salient points in his case were 
 these : 
 
 About eighteen months before consulting me he 
 had met with an accident on the Long Branch Rail- 
 way. He was violently thrown about the car; his 
 head was cut, and he received a severe bruise in the 
 left lumbar region. On extricating himself from 
 the wreckage, he noticed that his legs felt " sleepy" 
 and that there was a tingling sensation in the right 
 side of the face. These sensations disappeared en- 
 tirely within the following week, so that he was able 
 to resume the obligations of an active business life. 
 All went well for a time, the duties of society and 
 business receiving a punctilious attention, which 
 had never been exceeded, even when the patient 
 enjoyed the most perfect health. Some five months 
 subsequent to the accident, however, he began to 
 complain of great lassitude, particularly during the 
 early morning hours. At the same time sleep be- 
 came profoundly deranged, and even when he was 
 certain that he had slept for a few hours, he com- 
 plained that his sleep " did him no good." For- 
 merly of a cheerful disposition, he now became the 
 victim of protracted periods of depression ; and his 
 memory, previously of average strength, had be- 
 come so fickle that he was obliged to carry a note- 
 book in which to record his most trivial routine 
 
 11* 
 
126 PAIN. 
 
 engagements. He also suffered from soreness of 
 the back and occasional attacks of facial neuralgia. 
 
 On examination, his muscular system was found 
 to be weak and flabby, his heart's action feeble and 
 irregular, and his general condition one of pro- 
 nounced anaemia. Pressure along the spinal column 
 revealed two points of marked soreness, the one in 
 the dorsal region, the other at the level of the 
 second lumbar vertebra. From the first of these 
 tender spots radiated — especially on sudden changes 
 in temperature — intercostal pains of considerable 
 intensity. 
 
 Having placed the patient on a tonic regimen 
 and prescribed the iodide and bromide of potash, 
 the latter to be taken in cumulative doses during 
 the afternoon and evening, I directed my attention 
 to the points of tenderness in the spine. Instead 
 of treating these by the long and tedious method 
 of local galvanization, I decided to try the efficacy 
 of local injections of cocaine and pyrogallic acid in 
 solutions of low percentage. I will merely add 
 that I succeeded in affording much relief to the 
 patient; so that, after the injection had been re- 
 peated a few times, the soreness disappeared en- 
 tirely. 
 
 When I compare the promptness of the relief 
 obtained in this case with the long course of pallia- 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 127 
 
 tive treatment required in the case detailed at the 
 beginning of this chapter, I am the more surprised 
 that greater efforts have not heretofore been made 
 to influence the functions of the cord by resort to 
 more direct methods. 
 
 Having thus detailed some of the complications 
 often encountered in even the milder phases of 
 concussion of the spine, it now becomes necessary 
 to leave this interesting field, for it is self-evident 
 that to pursue the matter further would be to tran- 
 scend the natural limits of a work of this general 
 character. 
 
CHAPTER IX. 
 
 OF THE INSOMNIA AND MELANCHOLIA OE PAIN. 
 
 ' We tave already referred in previous chapters 
 to the nutritive and cardiac disturbances, both of 
 which are so frequently evoked by severe pain, es- 
 pecially when long continued. But there are other 
 sequences of pain which are, if anything, even 
 more important than these; and this may be said 
 especially of the sleeplessness and melancholy so 
 often met with in the course of painful affections. 
 I repeat that these two complications are invested 
 with unusual significance from a prognostic point 
 of view ; for it not infrequently happens that singly, 
 but more often together, they are the forerunners 
 of suicide or insanity. In view, then, of the gravity 
 of their significance in this respect, it will not be 
 time misspent if we devote a short chapter to the 
 consideration of insomnia and melancholia, more 
 especially as they occur as the direct result of pain. 
 For the sake of convenience, from both a physio- 
 logical and a clinical point of view, insomnia may be 
 divided into an idiopathic and a symptomatic variety. 
 
 128 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 129 
 
 In idiopathic insomnia the etiological conditions, 
 though not always discoverable, reside apparently 
 in the brain itself, since factors extraneous to that 
 organ, which might account for the occurrence of 
 the sleeplessness, are entirely wanting. 
 
 Symptomatic insomnia, on the contrary, is trace- 
 able to sources of irritation outside the cranial cav- 
 ity. This is the variety of sleeplessness which we 
 encounter in the course of painful affections, espe- 
 cially those of long duration. 
 
 It will be well to examine the phenomena of 
 these two varieties of insomnia somewhat more 
 in detail. 
 
 As has been previously noted in connection with 
 the discussion of the phenomena of pain, it often 
 happens that the painful paroxysms exhibit re- 
 markable regularity in their occurrence, the most 
 frequent manifestation of this periodicity being 
 the appearance of the seizure at a certain time in 
 the evening. Under these circumstances, the pa- 
 tient passes the greater portion of the day in a 
 condition of lassitude, but also of comparative ex- 
 emption from suffering. 
 
 The skin has usually a dull sallow appearance, 
 and the eyes are sunken and devoid of their normal 
 lustre. 
 
 The urine is often scant and highly colored. 
 
130 PAIN. 
 
 and a constipated habit is the usual but not in- 
 variable rule. Exceptionally, there may be ob- 
 stinate diarrhoea, which contributes not a little 
 to the general enfeeblement of the subject. In 
 the idiopathic variety of insomnia, the lassitude 
 during the interval of wakefulness is quite char- 
 acteristic, amounting, as it often does, to the most 
 pronounced lethargy. Uncontrollable yawning is 
 present in almost every case. "When expostulated 
 with on account of his listlessness, the subject be- 
 comes morose and sullen, regarding the well-meant 
 advice as an impertinent interference. The small 
 ills of life assume commanding proportions, and 
 by a system of loose, pessimistic reasoning he is 
 led to regard them as the forerunners of an im- 
 pending catastrophe. 
 
 On betaking himself to bed, sleep fails to put a 
 quietus to the gloomy train of thought; he tosses 
 from side to side; he removes the bedclothes; he 
 replaces them again; he changes his position a 
 hundred times, all in a vain attempt to win uncon- 
 sciousness. When at last, after a prolonged vigil, 
 sleep supervenes, — partaking, as it inevitably does, 
 of the perverted cerebration of the previous hours 
 of wakefulness, — it utterly fails to refresh the sub- 
 ject either physically or mentally. Indeed, from 
 an extensive practical experience with the various 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 131 
 
 derangements of sleep, I am convinced that per- 
 verted dreams and unconscious cerebration are more 
 frequently encountered in the sleepless than among 
 any other class of sufferers. In view of the im- 
 perfect nature of this sleep, it is not surprising that 
 daylight finds the subject completely prostrated, 
 and quite unable to resume his accustomed activities 
 with even moderate energy. 
 
 Tea, coffee, brandy, and even morphine are now 
 invoked with the hope of obtaining a renewal of 
 vigor. But the relief thus obtained is necessarily 
 transitory, since there is no known stimulant capa- 
 ble of replacing the regenerative processes in the 
 cerebral ganglia which are carried on during nor- 
 mal sleep. 
 
 The temperament of the individual has, as may 
 readily be conceived, an appreciable influence in 
 determining the character of the attack. "When he 
 is predominantly emotional, the insomnia is of a 
 far graver kind than would be the case were the 
 mind of an essentially intellectaal cast. Worry, 
 adversity, and suspense are, indeed, things which 
 are especially disastrous to emotional persons, whose 
 powers of adaptation in the face of such exigencies 
 are limited. 
 
 Precisely the opposite is true of those in whom 
 the ratiocinative faculties predominate; for, when 
 
132 PAIN. 
 
 they are assailed by an acute attack of insomnia, 
 we find sucli persons much less irritable and de- 
 pressed, simply because the emotional element in 
 the psychical organization is either inhibited by the 
 reasoning faculties or is practically wanting. 
 
 Finally, as may be readily deduced from the fore- 
 going remarks, a vivid imagination is certain to add 
 to the severity of an attack of insomnia ; since the 
 fancy, instead of becoming progressively subdued, 
 increases in activity, with the result that myriads 
 of fantastic, semi-incoherent ideas arise spontane- 
 ously, disappearing again, but only to return with 
 new combinations added to their grotesque array. 
 
 Such is a true picture of idiopathic insomnia; 
 and I may add, also, that many of its attributes are 
 likewise common to the symptomatic type of sleep- 
 lessness, which it will now be well to consider briefly. 
 
 Symptomatic insomnia, as its name implies, is that 
 form of sleeplessness which accompanies chronic af- 
 fections, especially those in which pain more or less 
 severe or long continued is a prominent feature. 
 
 As most persons are aware from personal experi- 
 ence, sensory impressions should be eliminated as 
 far as possible in order to insure the occurrence of 
 the most perfect type of sleep. Hence, when there 
 is present neither irritation within nor at the sur- 
 face of the body, and when, moreover, there is an 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 133 
 
 absence of impressions through the special senses, 
 it is evident that the physiological requirements of 
 the proposition are fulfilled. 
 
 During normal sleep, it is true, the perceptive 
 mechanism is obtunded, because of the exhaustion 
 due to the previous stage of activity, and, as a con- 
 sequence, slight sensory impressions which during 
 wakefulness would have led to active perception 
 leave no imprint upon the sluggish protoplasm. 
 When, however, impressions of considerable inten- 
 sity are transmitted to the exhausted receptive cen- 
 tres, the latter become irritated and aroused from 
 the lethargy consequent upon exhaustion, and finally 
 the entire cerebral mechanism is aroused : the indi- 
 vidual is awakened. Herein lies the explanation of 
 the sleeplessness engendered by pain, which, as in- 
 dicated in an earlier chapter, is nothing more nor 
 less than exaggerated common or special sensation. 
 But even in cases where the pain is slight, but of 
 relatively long duration, wakefulness of a distressing 
 character, coupled with irritation of the central ner- 
 vous system out of all proportion to the exciting 
 cause, may be engendered. An excellent illustra- 
 tion of this fact is afforded by the insomnia due to 
 the application of blisters, concerning which Dr. 
 Eobert J. Graves wrote in the following suggestive 
 way over forty years ago : " The bad effects on the 
 
 12 
 
134 PAIN. 
 
 nervous system occasionally produced by the appli- 
 cation of blisters are somewhat analogous to those 
 which result from wounds and other external inju- 
 ries, and to be accounted for on the same prin- 
 ciple. . . . The delirium and sleeplessness arising 
 from blisters constitute a by no means uncommon 
 disease." 
 
 It is quite evident, then, that irritative processes 
 involving the terminal organs of the centripetal 
 nerves represent the pathological factor of chief 
 importance in the genesis of secondary insomnia. 
 Hence it follows that those acute and chronic dis- 
 eases which are accompanied by severe or prolonged 
 pain are the most prolific sources of this variety of 
 sleeplessness. 
 
 The Melancholy of Pain. — ^When a person has 
 suffered acutely for a short time, or, as more fre- 
 quently happens, when the pain has been of less 
 severity but of longer duration, a condition of 
 mental atony may be engendered, ranging from 
 more or less irresponsiveness to ordinary impres- 
 sions to melancholia, — simple, delusional, or sui- 
 cidal. 
 
 With these conditions of depression occurring in 
 the course of, or as the sequence of, painful affec- 
 tions the physician is often enough confronted. 
 The subject, therefore, is clearly invested with prac- 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 135 
 
 tical interest ; and for this reason I believe that no 
 apology will be required for the insertion of the 
 following brief remarks. 
 
 Simple and Hypochondriacal Melancholia. — This 
 is by far the most common form of depression en- 
 countered in the course or as the sequence of vehe- 
 ment or prolonged pain. Its most striking char- 
 acteristic is a predominance of purely emotional 
 disturbances, the intellectual or volitional aberra- 
 tions being little or not at all in evidence. In the 
 beginning the patient suffers from loss of appetite 
 and constipation, followed, in a short time, by more 
 or less disturbance of sleep and listlessness during 
 the day. Though formerly, it may be, of an ener- 
 getic, sanguine disposition with definite predilec- 
 tions, both as regards work and amusements, he 
 now manifests a positive dislike for all pursuits; 
 and this aversion may culminate in change in pro- 
 pensities and ideals. This inversion of the instincts 
 may be exhibited in dislike for the familiar associa- 
 tions of the family, by irascibility, by loss of cour- 
 age, and by distaste for society. Loss or at least 
 marked decrease of sexual vigor is a striking feat- 
 ure at this time, and the same may be said of the 
 diminution in weight and augmented sensitiveness 
 to cold, which latter feature leads the subject to dis- 
 like bathing in water of low temperature, subse- 
 
136 PAm. 
 
 quent reaction being but sligbtly marked, or even 
 entirely absent. 
 
 Like the neurasthenic, the subject of melancholia 
 is usually worse in the morning than at night, when, 
 for some unaccountable reason, there is a partial 
 though temporary revival of vigor. The lustreless 
 appearance of the eyes, the coated tongue, the 
 dry, inactive appearance of the skin, the mental 
 inertia, the emotional irresponsiveness, may all be 
 observed during these early hours, and they consti- 
 tute a complex of symptoms so characteristic as to 
 be practically unmistakable. 
 
 ISTot only is the initial period of simple melan- 
 cholia to be looked upon as of essentially sane 
 character, but, in a large percentage of cases, the 
 entire course of the disease must likewise be so 
 regarded. This at least is true in the light of cur- 
 rently-accepted definition. The same may likewise 
 be said of certain mild phases of hypochondriacal 
 melancholia^ where the erroneous ideas are shifting 
 in character and devoid of the inherently impossible 
 character exemplified by the more serious varieties 
 of the affection. Where this grave delusional type 
 of the disease prevails, the subject may proclaim 
 that he has three stomachs or none at all, that " his 
 liver fills the entire abdominal and thoracic cavi- 
 ties," that " he has seven kidneys," and the like. 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 137 
 
 The shifting, less preposterous types of hypochon- 
 driacal delusion are those most commonly evolved 
 in the course of painful affections. They consist for 
 the most part in abortive attempts to explain the 
 origin of the painful sensations; and, though un- 
 scientific enough in themselves, are nevertheless 
 well within the limits of mental sanity, for they are 
 no worse than might reasonably be anticipated from 
 persons ignorant, or largely ignorant, of medical 
 matters. Thus, we find ataxics strenuously insisting 
 that their pains are due to " rheumatism," and suf- 
 ferers from lumbago declaring that their "kidneys 
 are affected," in the face of the most conclusive 
 proof to the contrary. As we have said, these 
 things are common enough as the sequence of pain, 
 especially of a prolonged, unyielding type ; but since 
 they are rarely the precursors of serious conse- 
 quences, nothing more than a humorous considera- 
 tion is usually accorded them. 
 
 Suicidal Melancholia. — Self-destruction represents 
 the culminating catastrophe, the most drastic expres- 
 sion of mental depression. That this is indeed the 
 truth will be readily conceded when it is remem- 
 bered that the love of life, the instinct of self-preser- 
 vation, is the strongest impulse in man, as well as 
 the lower animals. When this fundamental instinct 
 is obliterated, or even reversed, so that the patient 
 
 12* 
 
138 PAIN. 
 
 is not only indifferent to life, but actually craves 
 death, the change in the affective and instinctive 
 faculties is certainly the most profound imaginable. 
 
 The motive which impels the subject to desire 
 or attempt self-destruction is, however, not always 
 the same. Sometimes it assumes the form of a 
 desperate attempt to avoid imaginary evils; or it 
 is the outgrowth of an imperative and often sudden 
 impulse; or, as sometimes undoubtedly happens, 
 it is the result of a deliberate process of reasoning. 
 1 The last-mentioned motive is that most frequently 
 encountered in severe intractable pain, as we find 
 it, for example, in tic douloureux. In despair at the 
 fruitless efforts to obtain relief, and worn out by 
 ceaseless vigils, the horrors of which are too great 
 to be expressed in words, the unfortunate grasps 
 deliberately at death as the sole means of obtaining 
 release. 
 
 The essentially sane character of the ratiocination 
 which has led to the unnatural and tragic ending is 
 revealed by the epistles written by such persons im- 
 mediately before the commission of the fatal deed. 
 
 Delusional Melancholia. — By this designation 
 is to be understood that form of melancholy in 
 which one or several delusions are the most strik- 
 ing feature from the beginning. Indeed, it is this 
 early appearance and prominence of the erroneous 
 
PHYSIOLOGICAL, PATHOLOGICAL, CLINICAL. 139 
 
 ideas which leads those unfamiliar with mental 
 pathology to regard the general morbid condition 
 as the sequence of the delusions. This, however, 
 is crude reasoning, as the persistent disturbance of 
 cerebral nutrition is the principal thing. 
 
 As this form of melancholia is, however, much 
 more rarely met with in painful conditions than 
 the varieties of depression previously described, it 
 will not be advisable to pursue the subject further. 
 
 In the following chapter the means at our dis- 
 posal for dealing most effectively with those two 
 distressing complications of pain, insomnia and 
 melancholia, will be considered with much fulness. 
 
PART IL 
 
 THE SPECIAL THERAPEUTICS OF PAIN. 
 
 CHAPTEK X. 
 
 CONCERNING THE IMPORTANCE OF REST IN THE TREATMENT 
 OP THE NERVOUS SYMPTOMS ENGENDERED BY PROLONGED 
 AND SEVERE PAIN. 
 
 In the previous chapter the insomnia and melan- 
 choly which constitute such important sequences of 
 severe and protracted pain have been considered at 
 some length. What has there been said has served, 
 I trust, to exhibit the exceeding importance of the 
 subject, so that further insistence on that point is 
 unnecessary. !N"othing, however, has yet been said 
 of the best manner of dealing with those compli- 
 cations; this we shall now attempt to do as suc- 
 cinctly as possible. 
 
 Let me say, then, at once, that in my judgment 
 the most effective means of neutralizing the ill 
 effects of both the melancholy and the sleeplessness 
 140 
 
THE SPECIAL THERAPEUTICS OP PAIN. 141 
 
 engendered by protracted pain is found in the series 
 of expedients commonly grouped together under 
 the general designation of "Rest," or the "Rest 
 Treatment." 
 
 But, as there has been much crudeness in the 
 conceptions entertained by many as to the signifi- 
 cance of these terms, I shall take the liberty of dis- 
 cussing the whole question of rest with some elabo- 
 rateness, trusting that by so doing I shall be able to 
 remove some of the nebulousness which has sur- 
 rounded the whole subject, alike in its physiological 
 and clinical relations. 
 
 Of Rest in General. — When we associate the idea 
 of rest with a mechanism, we involuntarily think 
 of cessation of motion. When, however, we speak 
 of rest in connection with living organisms, — when 
 we employ the term in its true physiological sense, 
 ■ — not only does the element of functional quiescence 
 enter into the conception, but that of repair as well. 
 The demonstration of the truth of this idea has 
 been one of the many services of modern physi- 
 ology. Still, it must be admitted that mankind has 
 always entertained more or less true, though crude, 
 ideas of the nature of rest as exhibited by living 
 beings. 
 
 The laborer, after the noonday remission, is con- 
 scious of reinvigoration, is aware of certain changes 
 
142 PAIN. 
 
 in Ms stiffened and unwilling muscles wliicli render 
 the latter supple and serviceable once more. The 
 student or weary professional man, after a night's 
 sleep, becomes aware of certain changes in his 
 mental mechanism which enable him to resume 
 intellectual labor with positive enjoyment. 
 
 It is clear, therefore, that such familiar facts as 
 these must at an early date have led men of intelli- 
 gence to associate the idea of repair with that of 
 rest. The conception was, however, more or less 
 vague; and not until modern experimental physi- 
 ology had shown the inseparable relation between 
 fanction and tissue metamorphosis did crude sur- 
 mises give place to definite scientific proof. 
 
 One of the greatest practical benefits accruing 
 from the knowledge of the physiological significance 
 of rest has been the adaptation of such rest to the 
 treatment of disease. iN'ow, the fulfilment of the 
 requisites of physiological rest, when applied to 
 the organism as a whole, is a simple matter. In 
 short, we have merely to pay heed that there be 
 neither an excess of mental nor physical work ; and 
 then, translating the word "repair" into "nutri- 
 tion," it only remains to see to it that the indi- 
 vidual is 'provided with food of a kind suitable to 
 the reparative exigencies of the organism at large. 
 "When, however, it becomes expedient to afford 
 
THE SPECIAL THERAPEUTICS OF PAIN. 143 
 
 rest to a single organ, for example, the solution of 
 the problem is by no means so simple ; for we have 
 then to "rest" a particular physiological system 
 over and above the remainder of the economy, and, 
 at the same time, to make provision for the specific 
 nutritive demands of the organ which we desire to 
 benefit. It follows, therefore, that, clinically speak- 
 ing, there is not one system of rest, but, on the 
 contrary, there must be several. In the following 
 paragraphs I shall consider three kinds of rest : (1) 
 muscular rest ; (2) spinal or medullary rest ; and (3) 
 cerebral rest. 
 
 Muscular Rest. — This is the simplest of the three 
 forms of rest which we are about to consider, and 
 its realization makes demands upon none but the 
 most ordinary resources of therapeutics. The day- 
 laborer who has passed many hours in toil experi- 
 ences a certain amount of fatigue in the muscles, — 
 a local weariness which is relieved in a short time 
 by keeping the muscles in a state of simple quies- 
 cence. This is not, however, the form of muscular 
 rest which the physician has occasion to employ in 
 practice ; for instead of healthy, robust muscles, he 
 has usually to do with a flabb}'", ill-developed mus- 
 cular apparatus requiring attention of a special 
 kind. In dealing with this latter class of cases, it 
 is first necessary to cause a sufficient flow of blood 
 
144 PAIN. 
 
 througli the ill-developed muscle to facilitate repair 
 of the stunted organ ; and, secondly, it is advisable 
 to place the latter in a state of complete repose for 
 a considerable length of time after the blood-current 
 has been diverted, so that the processes of repair 
 may be realized to their fullest extent. The deri- 
 vation of the blood-current for the benefit of the 
 muscle may be accomplished in a variety of ways : 
 
 1. The patient may be urged to employ his mus- 
 cles in vigorous exercise for a certain length of 
 time, and to follow such exercise by more or less 
 complete repose of the motor apparatus. This is 
 the system pursued in gymnasia and in the training 
 preceding athletic contests; to its beneficial influ- 
 ence is to be ascribed the enormous muscular devel- 
 opment often attained by men of sedentary pursuits. 
 
 2. By resort to profound and vigorous massage 
 it is possible to cause a copious flow of blood to 
 the muscles. This method of derivation is the 
 most generally applicable, and will be found use- 
 ful in the treatment of a large class of feeble in- 
 dividuals. 
 
 3. Finally, the blood-current may be caused to 
 flow through the muscle in copious measure by 
 means of Junod's apparatus, — a method of treat- 
 ment which has, however, a more or less re- 
 stricted application, being perhaps best adapted 
 
THE SPECIAL THERAPEUTICS OF PAIN. 145 
 
 to the management of peripheral paralysis asso- 
 ciated with muscular atrophy. 
 
 There is one other factor of importance in con- 
 nection with muscular rest, — viz., the introduction 
 of proper nourishment into the system. "Where 
 the stomach is in good condition there is no great 
 difficulty in solving this portion of the problem. 
 The patient is to be put upon a diet consisting 
 largely of meat, eggs, and milk, a menu which 
 may be varied from time to time to suit the varying 
 wants and idiosyncrasies of the patient. Should 
 the stomach prove recreant, or should that organ 
 have been the seat of severe and long-standing 
 dyspepsia, resort may be had to rectal alimentation. 
 In addition, we may employ subcutaneous injections 
 of cod-liver oil with a view to further improvement 
 of the processes of nutrition. 
 
 Spinal Rest. — A moment's reflection upon the 
 offices of the spinal cord will serve to show that 
 any system designed to affi)rd physiological rest 
 to that organ must fulfil a twofold end, — viz. : 
 
 1. The elimination of those motor and sensory 
 impulses which under ordinary circumstances are 
 transmitted through the conducting paths of the 
 cord; and, 
 
 2. The curtailment, as far as possible, of reflex 
 action. 
 
 G k 13 
 
146 PAIN. 
 
 The requisites of physiological cord-rest are very- 
 well realized in the system adopted by Dr. S. "Weir 
 Mitchell. The essential features of this system are 
 the combined use of rest, massage, electricity, and 
 over-feeding. 
 
 As regards the utility of Dr. Mitchell's method in 
 the treatment of functional affections of the spinal 
 cord, there can, I believe, be but one opinion. It is 
 impossible, indeed, to say too much in praise of it 
 when thus employed. As to its applicability in the 
 treatment of those affections which are unquestion- 
 ably cerebral in origin and directly traceable to ex- 
 haustion, irritation, and other forms of malnutrition 
 of the brain itself, that is a matter which I believe 
 is open to serious question. But of this I shall have 
 something to say at a future stage of the argu- 
 ment. 
 
 Cerebral Best. — It is clear from the foregoing 
 remarks that, as applied to the brain, rest means 
 something totally different from that which is under- 
 stood by the term when used in connection with the 
 muscle, the joint, or the spinal cord. This radical 
 difference is chiefly owing to the fact that, the brain 
 being the organ of the intellectual processes, rest, in 
 so far as it concerns that mechanism, means nothing 
 less than a cessation of mentalization, with all thereby 
 implied. It is impossible by a mere fiat of the will 
 
THE SPECIAL THERAPEUTICS OP PAIN. 147 
 
 to cause cessation of thought; the very idea itself 
 embodies a contradiction ; for will itself, as physio- 
 logically understood, is not to be looked upon as 
 something sui generis, as an abstract impalpable unit, 
 but rather as the outgrowth of a series of exceed- 
 ingly complex psychical processes. From this propo- 
 sition it follows, therefore, that the exercise of will 
 is quite as much a consumer of cerebral energy as 
 the mental processes which are necessary, for ex- 
 ample, to the solution of a problem in Euclid. The 
 same may be said of consciousness and the impres- 
 sions which underlie it. To sum up the argument, 
 the whole drift of modern psychical and physio- 
 logical research goes to show that all phenomena 
 known as mental are contingent upon a consump- 
 tion of cerebral energy. It now becomes pertinent 
 to inquire : 
 
 1. Does nature provide an intermission in these 
 mental processes ? and, 
 
 2. If so, can such cessations in cerebral activity 
 be induced or prolonged, and finally utilized, in the 
 treatment of functional brain affections ? 
 
 To the first question the reply is sufficiently ob- 
 vious : nature does unquestionably afford more or 
 less complete repose to that portion of the cerebral 
 mechanism engaged in the evolution of mental 
 phenomena; such repose being undoubtedly the 
 
148 PAIN. 
 
 chief office of sleep. True, it is questionable 
 whether absolute quiescence of the mental faculties 
 is always attainable, even during sleep; the ideal 
 rest affiDrded by the latter being frequently marred 
 by the occurrence of dreams and more or less un- 
 conscious cerebration. Still, the fact remains that 
 during sleep cerebration is at a minimum. Then 
 again, unconscious cerebration and dreaming are 
 after all to be regarded rather as exceptional feat- 
 ures than as physiological phenomena of sleep. 
 
 To the second question. Can a cessation in cere- 
 bral activity be induced and prolonged? I reply, 
 most certainly, and that too without inordinate 
 drugging, which is considered so indispensable by 
 those little accustomed to deal with insomnia, ex- 
 haustion, and other anomalies of nutrition affecting 
 the cerebral centres. Before entering upon a de- 
 scription of the scheme of treatment by which I 
 have sought to practically realize the benefits of 
 cerebral rest, I desire to cast a retrospective glance 
 at my early publications on the subject, as certain 
 of them seem to have given rise to some misunder- 
 standing. 
 
 In 1882 I published a brief article ^ in which were 
 detailed sundry experiments undertaken by myself 
 
 1 Medical Eecord, February 18, 1882. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 149 
 
 with a view to elucidating certain problems con- 
 nected with cerebral physiology. 
 
 On a subsequent occasion ^ I added, " If it be ad- 
 mitted that the ganglia are directly or ultimately 
 dependent for their functional activity on the good 
 offices of the blood-stream, it becomes perfectly 
 evident that limitation of blood-supply means cur- 
 tailment of ganglionic function." By this state- 
 ment I did not wish to imply that cerebral rest, in 
 a clinical sense, was to be obtained by simply caus- 
 ing anaemia of the brain; my sole desire was to 
 draw attention to the well-established fact that the 
 oxidative processes within the cerebral ganglia are 
 diminished during the repose of the latter, and that 
 the anaemia of sleep, though occurring as a conse- 
 quence of the exhausted condition of the ganglia, 
 was not, therefore, to be regarded as of no impor- 
 tance in the chain of physiological events. A few 
 months after the publication of this little memoir 
 I took occasion to give further expression to my 
 views relative to the physiology of sleep. On that 
 occasion I said that the two most important factors 
 of sleep are ganglionic exhaustion and a physiologi- 
 cal degree of anaemia. 
 
 ^Carotid Compression, Anson D. F. Kandolph & Co., New 
 York, 1882. 
 
 13* 
 
150 PAIN. 
 
 The experimental data which I cited in corrobo- 
 ration of these views were not derived from the 
 observations of others, but were mainly the out- 
 growth of personal investigation and experience in 
 the clinic. I felt, therefore, that, if treading upon 
 ground of acknowledged difficulty, I was at all 
 events not trusting to the fickleness of mere deduc- 
 tive reasoning. The logic of subsequent events has 
 in no wise shaken my confidence in the opinion 
 then expressed, so that, at the present, I see no 
 reason for changing the tenets upon which the 
 system of cerebral rest — presently to be described — 
 is essentially based. 
 
 The practical problem of cerebral rest I have 
 therefore sought to systematize as far as possible, 
 but in communications on the subject I have not 
 omitted to exhibit the many-sided aspect of the 
 question. Thus, in a paper ^ published in 1883, I 
 took occasion to show the paramount importance 
 of systematized, physiological rest in the treatment 
 of aggravated cases of cerebral exhaustion. I 
 showed, moreover, that the essential feature of such 
 a system was 'prolonged sleep. In a paper ^ read 
 
 1 " Exhaustion of Brain Energy," Medical Eecord, April 7, 1883, 
 vol. xxiii. No. 14. 
 
 ""Brain Exhaustion," New York Medical Journal, December 
 29, 1883. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 151 
 
 before the Medical Society of the County of Kew 
 York, I^ovember 26, 1883, I took occasion to enter 
 somewhat more into details. For the sake of 
 brevity I extract from the above paper the follow- 
 ing description of the scheme of cerebral rest pre- 
 sented on that occasion : 
 
 The essential features of this system are, 1. Cere- 
 bral rest (prolonged sleep); 2. Increased general 
 and cerebral nutrition ; 3. Elimination of psychical 
 irritation and sensory impressions, particularly those 
 of light and sound (isolation of the sensorium). 
 
 General Description of Treatment by Cerebral 
 Rest. — The subject is isolated in a darkened room, 
 eventually from ten to fifteen hours at a time, ac- 
 cording to the amount of sleep which it is desired 
 shall be had during the twenty-four hours. The 
 amount of sleep is progressively increased by habit, 
 hydro-therapy, appropriate food, and moderate med- 
 ication. When I speak of appropriate food, I mean 
 such aliments as exert a demonstrably soporific 
 effect, such as the various preparations of hops and 
 the different kinds of dishes in which lettuce is em- 
 ployed as a principal ingredient ; hence salads, etc. 
 It is impossible to over-estimate the importance of a 
 carefully-regulated diet in a system of treatment, 
 the corner-stone of which is prolonged sleep, — that 
 is, sleep protracted far beyond what is common or 
 
152 PAIN. 
 
 necessary to the welfare of persons in ordinary 
 mental health. In the books which ostensibly treat 
 of sleep and its disorders, reference is sometimes 
 made to the digestibility of food as related to that 
 function. But among the various papers and books 
 treating of insomnia which have come under my 
 observation I have found no reference to the direct, 
 promotive influence exercised by a goodly number 
 of aliments upon the function of sleep. The sopo- 
 rific effects of some kinds of food are indeed of 
 the most striking character, and I feel justified in 
 stating, after an extensive experience in these mat- 
 ters, that one cannot hope to cope with the ordinary 
 problems of insomnia, much less with those pre- 
 sented in the course of treatment by prolonged 
 sleep, without first thoroughly mastering this aspect 
 of the subject. 
 
 As to sedatives and other forms of medication, 
 I can only say that I resort to them as little as 
 possible. In cases of functional brain-trouble, com- 
 plicated by inordinate irritability and worry, I am in 
 the habit of giving the bromides in moderate doses 
 during the day, with a view of bringing the brain 
 into a condition of sufiicient tranquillity towards 
 evening to render the supervention of sleep possible. 
 
 In conjunction with coca, I have used the prepa- 
 rations of absinthe (usually the extract) for the pur- 
 
THE SPECIAL THERAPEUTICS OF PAIN. 153 
 
 pose of allaying the worry and depression which 
 are at times such distressing features of insomnia, 
 cerebral irritation, and exhaustion. On this point I 
 shall have something further to say in the section 
 devoted to internal therapeutics. I will only add, 
 in this connection, that I never attempt, by the 
 reckless use of sedatives, to produce that form of 
 unconsciousness which has been called sleep, but 
 which, after all, bears a far closer kinship to stupor. 
 
 When the patient awakes, which may occur not 
 at all or two or three times during the hours set 
 apart for rest, nourishment is administered ; but the 
 latter is always not only digestibly prepared but, 
 what is of hardly less importance, it contains a 
 soporific adjunct such as lettuce. 
 
 As a matter of course, the amount of sleep re- 
 quired is necessarily not the same in all cases ; in 
 a considerable percentage of persons under treat- 
 ment, from ten to fifteen hours in the course of the 
 day will prove sufiicient. I have, however, in 
 exceptional cases, prolonged the quotidian period 
 of unconsciousness up to eighteen hours ; and in a 
 recent case of severe cerebral exhaustion, which 
 was referred to me for treatment, I succeeded in 
 inducing unconsciousness for a period of twenty- 
 one hours out of the twenty-four, and that without 
 excessive medication, unless hydrotherapy, soporific 
 
154 PAIN. 
 
 alimentation, and isolation in a perfectly dark room 
 be so denominated. 
 
 At this point in the discussion it will be appropri- 
 ate to say a word concerning isolation as I under- 
 stand it, which I need hardly say is in a wider sense 
 than that usually imputed to the term. 
 
 The Isolation of the Sensorium from its Envi- 
 ronment. — The less the exhaustion of the brain- 
 cells the greater will be the power of all sensory 
 impressions to cause wakefulness. The truth of the 
 above proposition has been amply proven by the 
 experiments of Kohlschiitter.^ 
 
 It is clear, then, since sensory impressions only 
 fail to cause wakefulness when the exhaustion 
 is great, and hence the state of unconsciousness 
 profound, that, therefore, the occurrence of such 
 impressions in persons who exhibit but slight pre- 
 disposition to unconsciousness must be detrimental, 
 if not absolutely fatal, to sleep. As a natural con- 
 sequence, it follows that the elimination of sensory 
 impressions of all kinds is absolutely necessary if 
 we desire to procure protracted sleep for those who 
 are "light sleepers," or who are sufferers from 
 chronic insomnia. I have been thus explicit in 
 
 1 Messunger der Festigkeit des Scblafes, Inaugural Dissertation, 
 von Dr. Ernst Kohlschutter, Leipzig, 1862. See also criticisms 
 upon the same in Schmidt's Jahrbucher, 1863, vol. cxviii. 
 
THE SPECIAL THEEAPEUTICS OP PAIN. 155 
 
 order to demonstrate that not only is it expedient, 
 as Dr. Mitchell has shown in the case of hysterical 
 women, to separate the patient from her friends, in 
 order to eliminate the deleterious influences arising 
 from ill-judged sympathy, but, what is still more 
 important, it is necessary to eliminate peripheral im- 
 pressions of all kinds, particularly those arising from 
 light and sound. This, of course, is true when we 
 desire to obtain cerebral rest for our patient. "When 
 spinal rest is the object sought after, the chief point 
 is, of course, the avoidance of those tactile impres- 
 sions which evoke reflex response on the part of 
 the cord (the consciousness or unconsciousness of 
 the patient being a matter of entirely subsidiary 
 importance). "When an individual is secluded in 
 an isolated and perfectly dark room, it is evident 
 that those impressions of light and sound which 
 ordinarily attend and usher in consciousness are 
 entirely eliminated, so that the brain, if previously 
 predisposed to tranquillity by the means to which 
 we have already had occasion to refer, may be 
 maintained in a state of quiescence for a period of 
 far greater duration than is possible under ordinary 
 circumstances. It is surprising, indeed, to what an 
 extent sleep may be prolonged under these condi- 
 tions, especially when, to the other means of per- 
 petuating unconsciousness at our disposal, is added 
 
156 PAIN. 
 
 tlie subtle force of carefally and progressively culti- 
 vated habit. IlTothing can exceed the astonishment 
 of persons who have submitted to this scheme of 
 rest when told of the number of hours which they 
 have passed in a state of unconsciousness. It is 
 true that after thus oversleeping there is, in the 
 beginning, some little mental inertia, — some difB.- 
 culty in "getting thoroughly awake;" but this is 
 soon dissipated by the aid of a mild sponge- or 
 shower-bath, followed by vigorous friction, or by a 
 moderate dose of caffeine. 
 
 It now remains to say a word respecting the 
 manner in which the patient is to occupy himself 
 during the period of wakefulness which succeeds 
 the interval of unconscious rest. In the severer 
 cases of cerebral irritation, melancholia, and ex- 
 haustion, in the treatment of which I employ rest, 
 I am in the habit of absolutely prohibiting both 
 reading and writing. Any occupation, in fact, 
 which causes undue concentration of the intellect- 
 ual faculties, or which arouses unpleasant emotions, 
 or which predisposes to morbid brooding, is to be 
 avoided. A chronic habit of introspection is one 
 of the most disagreeable features with which we 
 are called to contend when it is a question of 
 affording prolonged rest to the sensorium. 
 
 Otherwise to be considered are those amusements 
 
THE SPECIAL THERAPEUTICS OP PAIN. 157 
 
 which, while diverting the mind from self-consuming 
 reflections, do not materially exhaust its energies. 
 Gay music, hilarious theatrical representations, — 
 these are potent remedies against the insidious 
 inroads upon the tranquillity of the mind born 
 of chronic introspection and inordinate worry. It 
 matters, indeed, little what the character of the 
 amusement he so long as indulgence in the same 
 is not coupled with late hours, — a characteristic 
 which, unfortunately, is inseparable from many 
 recreations indulged in by the inhabitants of 
 cities. 
 
 The matter of food has already been alluded to, 
 in so far as the important group of soporific ali- 
 ments is concerned. There are, however, other 
 foods of importance to a rational system of cerebral 
 rest, — I mean those nitrogenous compounds which 
 are indispensable to brain and muscle alike. I have 
 already had occasion to point out that experimental 
 inquiry has shown that mental work involves the 
 consumption of both the nitrates and phosphates, 
 and that these observations are supported by direct 
 analysis of the chemical constitution of the brain 
 itself, so far as such have been attempted.^ 
 
 1 The experiments here referred to are those of Byasson, quoted 
 in my monograph on Brain-Exhaustion, D. Appleton & Co., New 
 York, 1884, p. 41 et seq. 
 
 14 
 
158 PAIN. 
 
 While, therefore, it is impossible with the present 
 means at our command to elucidate the more inti- 
 mate chemistry of cerebral metamorphosis, we are 
 clearly justified in inferring that the introduction 
 and assimilation of nitrogenous and phosphatic 
 compounds is of importance in exhaustive condi- 
 tions of the cerebral ganglia. In entire consonance 
 with these views is the observation that the amount 
 of phosphorus contained in the brain is greatest 
 among those of active intellects, and that it in- 
 creases in amount with the growth of the indi- 
 vidual, attaining the maximum quantity at the 
 period of adult life. In the aged, on the other 
 hand, the quantity is considerably reduced; and it 
 has also been alleged that among idiots the amount 
 of phosphorus contained in the brain is much 
 below the normal standard (?). 
 
 It is not surprising, therefore, that the flesh of 
 animals (or its extracts), eggs, milk, and unbolted 
 cereals are the aliments which experience has 
 proven to be of the greatest value where a direct 
 augmentation of cerebral nutrition is the object 
 sought. To these foods may also be added cod- 
 liver oil or its preparations, where the fatty tissues 
 are imperfectly developed. Should the condition 
 of the digestive mechanism preclude the introduc- 
 tion of oils by the way of the stomach, they may 
 
THE SPECIAL THERAPEUTICS OF PAIN. 159 
 
 be injected hypodermically, in doses of from one 
 to four drachms; and, in exceptional cases, the 
 quantity injected at one time may be increased 
 beyond half an ounce, provided the skin is suffi- 
 ciently loose to preclude the occurrence of painful 
 tension. The injection should, therefore, usually 
 be accomplished slowly ; and, in order to avoid the 
 needless detention of the physician by the operation, 
 I have devised an apparatus which accomplishes 
 this injection automatically, the supervision of the 
 same being intrusted to the patient himself. 
 
 In cases of profound disturbance of the digestive 
 organs there should, of course, be no hesitancy in 
 resorting to systematic alimentation per rectum, a 
 procedure which may be combined advantageously 
 with hypodermic injection of oil. 
 
 This, then, is a brief outline of the system of 
 cerebral rest to which I have resorted in the treat- 
 ment of a large class of functional cerebral derange- 
 ments during the last few years. Of the success 
 attending this mode of treatment I will speak in 
 guarded terms, lest I should develop a degree of 
 enthusiasm which to some might appear inordinate. 
 This much I will say, however, that I have em- 
 ployed it in the treatment of cerebral irritability 
 and exhaustion and in cases of insomnia which 
 had resisted all ordinary remedies. I have also had 
 
160 PAIN. 
 
 recourse to it in the treatment of chorea and the 
 
 first stages of melancholia. 
 
 It would be a conspicuous omission did we fail, 
 in concluding this chapter, to give an account of 
 the special precautions to be observed in the man- 
 agement of the condition of melancholy which is 
 often so serious a complication of severe pain. 
 "WTiile, as previously shown, it is of the greatest 
 importance that those who suffer from profound 
 depression should be made to sleep, — for only in 
 this way can the emotional stress be adequately 
 compensated, — it is equally incumbent upon us to 
 diminish, as far as possible, the mental pain from 
 which such persons suffer during the hours of 
 wakefulness. Indeed, it may as well be stated at 
 once that our efforts to procure sleep for the pa- 
 tient are almost certain to result in failure, unless 
 we succeed in abolishing or, at least, relieving his 
 melancholy as the time set apart for unconscious 
 rest approaches. 
 
 Should there be marked physical pain it must, 
 of course, be removed by the application of one or 
 several of the expedients to be subsequently dis- 
 cussed. Such relief will of itself tend to facilitate 
 the occurrence of sleep. Sometimes, however, in 
 spite of the exemption from acute physical suffer- 
 ing, the mental pain — the melancholia — still persists. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 161 
 
 This is especially true of those who have borne the 
 brunt of a long and painful illness. Under such 
 circumstances nothing in the world is comparable 
 in efficacy with the judicious use of stimulants 
 while the subject remains in a condensed atmos- 
 phere, by which we mean air which is compressed 
 until it is at least twice as dense as the normal 
 atmosphere. The object of this exposure of the 
 patient to a condensed atmosphere is to augment 
 the action of the previously-administered stimulants 
 and to promote the circulation in the cerebro-spinal 
 axis, for it is a matter of experience, as I long since 
 showed by the statistics of the populations whose 
 vocations necessitate a prolonged sojourn in com- 
 pressed air, that these remedies, especially those of 
 a diffusible character, are materially re-enforced in 
 their effects when thus exhibited. 
 
 The stimulants which are best suited to this mode 
 of administration are absinthe, caffeine, and alco- 
 hol. Although ether might perhaps be added to 
 the list, I have purposely omitted it, since, though 
 its stimulating properties are greatly enhanced by 
 the immersion of the patient in compressed air, the 
 exhilaration thus evoked is too evanescent, and is, 
 moreover, speedily followed by increased irritability 
 and depression. This criticism applies neither to 
 alcohol, caffeine, nor absinthe, when medicinally 
 I 14* 
 
162 PAm. 
 
 employed, by which we understand that the patient 
 should not be informed of the nature of the remer 
 dies, and that the latter should be continued no 
 longer than seems absolutely necessary, their gradual 
 withdrawal being undertaken as soon as there is a 
 return of appetite and normal sleep. 
 
 Another extremely important measure in the 
 management of melancholia is the stimulation of 
 the excretory functions. To this end a sufficient 
 cathartic should be given to insure at least one 
 operation of the bowels a day ; for nothing is more 
 certain than that constipation is of itself quite 
 capable of provoking and perpetuating a state of 
 mental depression. 
 
 The action of the kidneys, too, should be in- 
 creased by the administration of appropriate diu- 
 retics, the substance known as diuretin being one 
 of the best. 
 
 Finally, it is of very great importance to augment 
 the excretory functions of the skin; for numerous 
 observations have shown that in this way foreign 
 materials which exert a depressant action upon the 
 central nervous system may, in part at least, be 
 eliminated. 
 
 To thoroughly appreciate the importance of these 
 injunctions, it must be remembered that in melan- 
 cholia all the vital processes are more or less cur- 
 
THE SPECIAL THERAPEUTICS OF PAIN. 163 
 
 tailed, as revealed by the loss of weight, as well as 
 by the inertia of the affective and intellectual facul- 
 ties. We have, in a word, to do with a predomi- 
 nance of the processes of waste over those of 
 integration, with a defective metabolism of which 
 the final effect must be the inordinate accumulation 
 of waste products in the organism. 
 
 1^0 physician of large practical experience in the 
 management of this class of cases will, I believe, be 
 inclined to question this exposition of the pathology 
 of melancholia. JSTor will the conclusion that the 
 elimination of these waste products must be thor- 
 oughly accomplished — must proceed, indeed, side 
 by side with our attempts to build up the devital- 
 ized tissues by the aid of appropriate nutrition — be 
 gainsaid. 
 
 And let me observe, parenthetically, that the 
 effects of some diuretics and diaphoretics, and per- 
 haps of all, are notably enhanced by their exhibition 
 while the patient remains under a pressure of two 
 atmospheres. This fact will be readily understood 
 when it is remembered that one of the chief effects of 
 compressed air, when used in this way, is to increase 
 the blood-pressure in the interior of the organism, 
 the blood being driven from the periphery towards 
 the centre. The effect of this is, of course, to in- 
 crease the action of those nervous mechanisms 
 
164 PAIN. 
 
 which control the secretory and excretory functions, 
 and also to raise the blood-pressure in the organs 
 themselves and, notably, in the kidneys and liver. 
 
 In a subsequent chapter the various physiological 
 and clinical data connected with the employment of 
 compressed air in the treatment of melancholia and 
 pain, notably that of intracranial origin, will be dis- 
 cussed in full, so that, having anticipated enough in 
 the present chapter to render the argument intelli- 
 gible, we must beg permission to leave the subject 
 for the present, avoiding thereby needless repetition. 
 
 Finally, the good effects sometimes obtainable 
 from the use of moderately cold shower-baths are 
 not to be ignored. It must not be forgotten, how- 
 ever, that this mode of treatment is admissible only 
 when the condition of the heart and circulation 
 is such as to insure a proper reaction, — i.e., in- 
 creased redness of the lips and skin, a diminution 
 of the feeling of malaise, accelerated heart-beat, 
 and at least a temporary disappearance of apathy. 
 
 It need hardly be added that the diversion of the 
 patient, in every possible manner, and his eventual 
 exposure to changes of scene and climate, — but the 
 latter only after he has proceeded well along the 
 road to recovery, — are things which render valu- 
 able assistance in confirming the good work accom- 
 plished by more direct measures. 
 
CHAPTER XL 
 
 OP INTERNAL REMEDIES WHICH ARE EITHER DIRECTLY OR 
 INDIRECTLY APPLICABLE IN THE TREATMENT OF PAIN. 
 
 From what lias previously been said regarding 
 the causation and collateral phenomena of pain, it 
 is evident that the remedies which are applicable 
 in its management are manifold. They include, in 
 the first place, a large number of substances broadly 
 and somewhat roughly classified as nervous seda- 
 tives and stimulants ; secondly, a somewhat smaller 
 category of analgesics which are, strictly speaking, 
 perhaps neither sedatives nor tonics; and, thirdly, 
 chemicals which are supposed to effect more or less 
 profound changes in the morphological process, — 
 the so-called alteratives. 
 
 It will be well to bestow a glance upon the more 
 important of these remedies. 
 
 Nervous Sedatives. — In this category belong 
 those agents which exert a depressing effect upon 
 the cerebro-spinal axis, the brain being often that 
 portion of the nervous system most obviously af- 
 fected. I^arcotic substances are representative of 
 this class of remedies. 
 
 165 
 
166 PAIN. 
 
 Opium and its derivatives constitute, in some 
 respects, the most important remedies which we 
 possess for combating painfal paroxysms of great 
 severity. Physiologists are by no means agreed 
 as to the manner in which opium exercises its 
 eftects upon the organism. Thus, some writers of 
 distinction assert tliat it is a sedative pure and sim- 
 ple, while others insist that it is to be regarded as 
 a stimulant. The truth of the matter is, however, 
 that its action may be both sedative and stimulant, 
 the diversity of physiological effect being in great 
 measure contingent upon the difference in the mag- 
 nitude of the dose. Thus, small doses are produc- 
 tive in most instances of marked stimulating effects, 
 whereas large ones are sedative in their action. 
 
 The hypnotic property of opium has been as- 
 cribed by some to its influence in lessening the 
 amount of blood in the brain; but, for my own 
 part, while fully recognizing the importance of the 
 circulatory phenomena induced, I cannot forbear the 
 conviction that the latter are of purely secondary 
 origin, being in the main attributable to the primary 
 action of the drug upon the substance of the brain. 
 This ability of the drug to retard cerebral meta- 
 bolism is the essential feature of hypnosis. 
 
 It would transcend the limits and objects of the 
 present work were I to enter into a discussion of 
 
THE SPECIAL THERAPEUTICS OF PAIN. 167 
 
 the various conflicting opinions which have been 
 advanced from time to time as the result of exten- 
 sive experimentation. Much of the discrepancy in 
 the nature of these results is doubtless attributable 
 to variation in the size of the dose, as well as to 
 fluctuation in the quantity of the very numerous 
 active principles contained in the drug. lN"o less 
 than nineteen difierent alkaloids have been sepa- 
 rated from this exceedingly complex substance, so 
 that, in introducing the crude drug into the system, 
 we necessarily have to do with an aggregate eflect 
 of all of them. In their relative therapeutic value, 
 however, the alkaloids of opium difier widely ; but, 
 if extensive applicability as an analgesic be a cri- 
 terion of excellence, pre-eminence must unquestion- 
 ably be ascribed to morphine. 
 
 The stimulating effects of morphine upon the 
 circulation and central nervous sj^stem are not as 
 pronounced as those of opium, and its soporific in- 
 fluence is also less positive. The anodyne effects 
 of opium and morphine are so thoroughly under- 
 stood as to render even a reference to them almost 
 superfluous in a work of this kind. We are, how- 
 ever, too liable to forget that previous to the intro- 
 duction of chloral, the bromides, and the coal-tar 
 derivatives, opium occupied the highest position in 
 the treatment of all forms of insomnia, and that 
 
168 PAIN. 
 
 even at the present day, in spite of the great prog- 
 ress made in pharmacy, the poppy may sometimes 
 be invoked as a soporific medicine. When com- 
 bined with one or more of the modern remedies, 
 such as chloral, the bromide of potash, and hyos- 
 cyamus, the result is a preparation possessing unique 
 virtues in the management of certain cases of in- 
 somnia. 
 
 Where there is severe pain, as in tic douloureux 
 and other aggravated forms of neuralgia, preference 
 should, of course, be given to morphine, adminis- 
 tered in conjunction with atropine, — one-hundredth 
 of a grain of atropine to a quarter of a grain of 
 morphine. In the delirium of fevers and mania, in 
 insomnia preceding various forms of insanity, as 
 well as in the wakefulness due to the various acute 
 and chronic diseases, morphine often renders inval- 
 uable assistance. 
 
 In spite of the extensive abuse in the use of alco- 
 hol, which has become such a crying evil of modern 
 social life, it must be admitted that this is a most 
 useful remedy in the management of a large num- 
 ber of painful conditions associated with ansemia. 
 For this reason a knowledge of its more obvious 
 physiological efiects is essential to its intelligent 
 employment. 
 
 When used in moderation, alcohol is absorbed by 
 
THE SPECIAL THERAPEUTICS OF PAIN. 169 
 
 the tissues with benefit, contributing in a certain 
 degree to the nutrition of the latter, and causing a 
 sensation of exhilaration. The effects produced by 
 its excessive use are, however, quite different. 
 
 Under these circumstances the normal chemistry 
 of the tissues is profoundly deranged ; their func- 
 tions are interfered with ; and, as an ultimate result, 
 the characteristic phenomena of starvation become 
 established. The functions of the nervous system 
 which are disturbed by the presence of an excessive 
 amount of alcohol in the blood and tissues are those 
 of voluntary motion, reflex action, and sensation. 
 Small doses of alcohol produce more or less stimu- 
 lation of the cerebro-spinal functions, and, as a con- 
 sequence, moderately painful sensations, especially 
 those of intracranial origin, are speedily relieved. 
 The secretory functions, too, are exalted, as shown 
 by increased secretion of saliva and perspiration. 
 The heart-beat is also increased in frequency, and 
 the skin, especially about the head, becomes suffused 
 with blood. Respiration is also more or less accel- 
 erated; the eyes glisten because of the increased 
 lachrymal secretion, and the pupils are slightly con- 
 tracted. In consequence of the general nervous 
 exaltation the individuals desire to move about, and 
 even to dance and run. For a time there is con- 
 siderable hypersesthesia of the special senses; the 
 H 15 
 
170 PAIN. 
 
 acuity of perception is increased ; ideation is more 
 vivid; and, in a word, all the intellectual faculties 
 are exalted. As may readily be imagined, ttie emo- 
 tions participate in the general exhilaration; im- 
 moderate laughter is engendered upon the slightest 
 provocation, and the dominant psychical peculiarities 
 of the individual become conspicuous. At the same 
 time the reasoning faculties lose their restraining 
 influence, and the inhibitory effects of conscience 
 and experience are thrown to the winds. These 
 are the typical manifestations engendered by mod- 
 erate doses of alcohol, subject, of course, to tem- 
 peramental variations. "When, however, the amount 
 ingested is large, the primary exaltation gives place 
 in a short time to all the symptoms of depression ; 
 co-ordination is impaired; the gait becomes un- 
 certain ; articulation is interfered with ; and ideation 
 becomes confused and incoherent. At length sensa- 
 tion and motion become impossible, consciousness 
 is suspended, and the patient lies in a state which is 
 practically comatose. 
 
 Though at first sight the physiological explana- 
 tion of such heterogeneous symptoms impresses one 
 as little short of impossible, a more careful analysis 
 shows that they can all be traced to the inhibitory 
 or paralyzing action of alcohol, when present in 
 animal and vegetable protoplasm. 
 
THE SPECIAL THERAPEUTICS OP PAIN. 171 
 
 The action of alcohol upon the circulation is a 
 matter of profound practical interest from a thera- 
 peutic point of view; and this is especially ex- 
 emplified by functional affections of the nervous 
 system, in which the condition of the vaso-motor 
 system is often a factor of some importance. With- 
 out entering into the intricacies of the subject, it 
 may be stated in general terms that the first efiect 
 of alcohol upon the circulation is to cause increased 
 arterial pressure : the muscular coats of the ar- 
 teries are contracted, and the diameter of the ves- 
 sels consequently reduced. These primary effects 
 are, however, of brief duration, for in a short time 
 the increase in arterial pressure is followed by a 
 corresponding decrease ; the relaxation of the vessels 
 becomes universal, and, at the same time, the energy 
 of cardiac action is diminished. These phenomena 
 are in themselves of the greatest importance, and 
 their interest to the neurologist is enhanced from 
 the fact that the circulation of the cord and brain 
 — particularly the latter — is pre-eminently affected. 
 
 The hypersemic condition evoked by alcohol is 
 evidently due to the paralyzing action of this agent 
 upon the terminal (peripheral) apparatus of the 
 vaso-motor nerves. This terminal apparatus, as is 
 well known, is situated in the walls of the vessels 
 themselves. 
 
172 PAIN. 
 
 It is evident from the foresroinsi: data reorardino: 
 its physiological effects that alcohol possesses pecu- 
 liar advantages in the treatment of a variety of 
 painful intracranial conditions characterized by the 
 presence of more or less anasmia. The insomnia, 
 too, which so frequently accompanies general anae- 
 mia, is readily relieved by its administration in 
 moderate doses. When, however, the relief of 
 severe neuralgia is in question, large doses alone 
 are applicable, as may readily be deduced from 
 what has previously been said. This question of 
 correct dosage has indeed given rise to much con- 
 troversy, as is abundantly shown by the discrep- 
 ancies of opinion prevalent in current literature 
 and the special treatises on therapeutics. While it 
 is difficult to enunciate rules which shall cover the 
 exigencies arising in all cases, it may be stated in 
 general terms that where stimulating effects are 
 required moderate doses (from four to five drachms 
 of spirits), repeated at regular intervals, are indi- 
 cated. On the other hand, when the principal 
 object of treatment is to cause relaxation of the 
 cerebral blood-vessels, the doses should be full. It 
 is impossible, however, to lay down infallible rules 
 of exhibition on account of the variable suscepti- 
 bility of different persons, and hence the symptoms 
 of the patient should be studied and the quantity 
 
THE SPECIAL THERAPEUTICS OF PAIN. 173 
 
 increased until tliere is well-marked throbbing 
 of the carotids and flushing of the face and con- 
 junctivae. 
 
 Inhalation of ether is sometimes employed to 
 mitigate the atrocious pain of tie douloureux. Its 
 effects are, however, evanescent in character, owing 
 to the rapidity with which this agent is eliminated 
 from the system through the lungs, and hence the 
 expedient can never replace remedies introduced 
 into the system in solution, and which, owing 
 to their gradual elimination from the organism, 
 exert an analgesic influence for relatively long 
 periods of time. These objections do not apply 
 to the same extent to the internal administration 
 of ether in the form of Hoffmann's anodyne, which 
 is a mixture of alcohol, ether, and ethereal oil. 
 This preparation may be exhibited in doses of from 
 one-half to one drachm, to be repeated every half- 
 hour or oftener, till physiological effects are ob- 
 tained. The same objections which apply to inha- 
 lations of ether hold good in the case of chloroform, 
 and hence by far the most serviceable mode of 
 administration is in the form of chlorodyne, a prep- 
 aration which has long held a deservedly high place 
 in the esteem of the profession, both in this country 
 and England, where it was first introduced by Dr. 
 Browne. 
 
 15* 
 
174 PAIN. 
 
 Among the general nervous sedatives the bro- 
 mides occupy a deservedly high place. It must be 
 confessed, however, that while they are capable of 
 relieving minor grades of intracranial pain, due to 
 passive engorgement, their analgesic powers are 
 not suificient to cope with even moderately severe 
 peripheral neuralgia. Still, they render a certain 
 amount of assistance in the management of nervous 
 irritability and other collateral effects of pain. The 
 physician should, therefore, be equipped with a 
 general knowledge of their physiological effects in 
 order to employ them intelligently. 
 
 The bromide of potassium is, strictly speaking, a 
 general nervous sedative rather than an hypnotic; 
 and consequently it may be employed with advan- 
 tage in allaying irritability of the brain, spinal cord, 
 and sexual system. In this way it may indirectly 
 induce sleep.^ Of this something more will be said 
 hereafter. 
 
 It seems clear, indeed, that the bromide of potas- 
 sium exerts its sedative action in a twofold manner : 
 1, by causing a diminution in the intensity of the 
 vital processes of the ganglia; and, 2, by causing 
 more or less retrocession of the intracranial blood. 
 
 1 On the Action of Medicines in the System, by Frederick Wil- 
 liam Headland, M.D., Philadelphia, 1878. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 175 
 
 Even the most superficial knowledge of cerebral 
 physiology will serve to exhibit the importance of 
 a remedy which combines two such valuable quali- 
 ties. The potency of the bromides in the treatment 
 of epilepsy and other irritable and explosive condi- 
 tions of the nervous system is undoubtedly attribu- 
 table to this duality of effect. 
 
 The soporific energy of the bromides may be 
 ranked, approximately, as follows : 
 
 Bromide of potassium first, bromide of lithium 
 second, and bromide of sodium third. 
 
 It is clear, then, from their action, that the bro- 
 mides find their chief application in irritable ex- 
 plosive and exhaustive conditions of the central 
 nervous system. They have also been largely em- 
 ployed in the treatment of insomnia due to worry 
 and morbid emotionality. I am convinced, how- 
 ever, that we should exercise caution when thus 
 resorting to them, in order to avoid the depression 
 which follows a too copious administration. 
 
 The insomnia of sexual excitement, of mania, of 
 hysteria, of cerebral exhaustion and cerebral irri- 
 tability, may be combated effectively by the ad- 
 ministration of the bromides in conjunction with 
 hypnotics. It is necessary to bear in mind, how- 
 ever, that the bromides should be given repeatedly 
 during the day, beginning m the afternoon at two 
 
176 PAIN. 
 
 o'clock and continuing the dose every hour until 
 shortly before retiring. We may then supplement 
 the sedative action of the bromides by a moderate 
 dose of some hypnotic, such as trional or chloralamid. 
 In persons who suffer from general and local anae- 
 mia it may happen that, instead of promoting sleep, 
 the bromides serve only to augment the insomnia. 
 Under these circumstances alcohol should be given 
 in quantities sufficient to cause slight flushing of 
 the face. Should these measures prove ineffectual, 
 ten to twenty drops of the tincture of opium may 
 be added, or the tincture of hyoscyamus (two 
 drachms) with chloral (fifteen grains). The dose 
 of the bromides which is required to produce the 
 characteristic sedative effect varies much more than 
 is commonly supposed. Thus, cases are seen in 
 which ten grains of the potassium salt were suffi- 
 cient to produce drowsiness. Such cases must, 
 however, be regarded as somewhat exceptional, 
 since in most subjects scruple doses of the lithium 
 and potassium salts may be repeated every hour or 
 two until hebetude is pronounced. When a rapid 
 sedative effect is required the dose may be increased 
 to thirty, forty, or sixty grains ; and this applies to 
 the sodium and calcium salts as well as to the 
 bromides of lithium and potassium. 
 
 Hydrobromic acid has also been employed to 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 177 
 
 some extent as an hypnotic, in doses of from twenty 
 to thirty grains, diluted with a sweet, aqueous vehi- 
 cle of some kind. On account of its offensive taste, 
 however, it is not a preparation which is destined to 
 occupy a place of much importance. 
 
 Gelsemium was formerly considerably employed 
 in the treatment of pain, but of late, since the in- 
 troduction of the coal-tar derivatives, its use has 
 been much restricted. The extremely poisonous 
 effects of the plant, which make their appearance 
 suddenly, and often without ascertainable cause, 
 have had much to do with this. 
 
 Nervous Stimulants. — It now remains to consider 
 briefly those substances which exert a demonstrably 
 stimulating effect upon the central nervous appa- 
 ratus. As is well known, some of these agents 
 may be both sedative and stimulating in their ac- 
 tion, according to the size of the dose and other 
 circumstances of administration. This duality of 
 effect is particularly exemplified in the case of 
 opium, as we have already had occasion to observe 
 when considering the sedative properties of that 
 drug. Although we are most frequently called 
 upon to invoke the sedative property of the drug 
 in the management of painful conditions, it must 
 nevertheless be conceded that under some circum- 
 stances its stimulating properties are capable of 
 
178 PAIN. 
 
 rendering substantial assistance. This is especially 
 true of pain whicli is associated with well-marked 
 debility; for, as has already been pointed out, the 
 nervous system — ^though, perhaps, the last to share 
 the impairment consequent upon such malnutrition 
 — ultimately suffers with the rest of the organism, 
 and hence measures specially directed to the re- 
 habilitation of its functions are indicated. 
 
 Cannabis Indica is a remedy of the same order, 
 its effects being conspicuously exerted upon the 
 central perceptive mechanism, which is stimulated, 
 perverted, or exaggerated in various ways, accord- 
 ing to individual susceptibility. In most persons 
 its most obvious effect is an agreeable intoxication. 
 The mental faculties are exalted; the subject laughs 
 in an inordinate, hysterical manner, and becomes 
 unusually loquacious ; while the countenance wears 
 a beatific expression, indicative of the satisfaction 
 which reigns within. The flow of ideas is stimu- 
 lated to an inordinate degree, and as a consequence 
 the thoughts are disconnected and wholly irrelevant, 
 as indicated by rapid and incoherent utterances. 
 Sometimes surrounding objects — such as articles of 
 furniture — assume unusual shapes, and thus verita- 
 ble illusions are developed. Sometimes the sexual 
 functions are excited, and the gestures, facial ex- 
 pression, and conversation are of the most libidi- 
 
THE SPECIAL THERAPEUTICS OF PAIN. 179 
 
 nous character. Sensibility may also be affected; 
 and there may be sensations of numbness and 
 pricking in the soles of the feet, accompanied, in 
 some instances, by burning, when pressure is ap- 
 plied to the integument. Sometimes, too, there 
 may be anaesthesia of such intensity as materially to 
 interfere with all attempts at locomotion, the sub- 
 ject, while standing, being totally unconscious of 
 the presence of his feet upon the ground. It may 
 readily be imagined that an agent which possesses 
 such qualities is capable of rendering substantial 
 assistance in the management of pain. And, in- 
 deed, experience has shown that, when it is admin- 
 istered in sufficient quantities to produce these 
 phenomena, a variety of painful conditions, and, 
 notably, certain headaches, may be ameliorated and 
 sometimes permanently abolished. "When, how- 
 ever, its administration is still further increased, 
 sleep may be produced, but a sleep so far removed 
 from the normal prototype, accompanied as it is by 
 delirium and morbid cerebral erethism, that its 
 exhibition in this manner is not usually to be com- 
 mended. But it is a noteworthy circumstance that 
 its usefulness is appreciably enhanced by combina- 
 tion with opium, belladonna, or hyoscyamus, and 
 when thus administered its effects are often most 
 happy, since it promotes the tolerance of the sys- 
 
180 PAIN. 
 
 tern to opiates, and probably supplements their 
 action. Cannabis Indica, then, has a wide range 
 of applicability in the management not only of 
 pain, but of the collateral nervous disturbances of 
 that condition as well. Thus, it has been employed 
 in the different varieties of insomnia, neuralgia, 
 headache (migraine), and convulsions. In head- 
 aches of a local character, accompanied by sensa- 
 tions of throbbing and lachrymation, it has been 
 highly spoken of by Ringer, and I have frequently 
 had occasion to verify its efficacy in this connection. 
 It must be remembered, however, that all persons 
 are by no means affected in an identical manner; 
 and, consequently, too much should not be antici- 
 pated from its employment on purely a 'priori 
 grounds. Race, climate, and constitutional idio- 
 syncrasy have all been cited from time to time as 
 affording the true explanation of this inconstancy 
 of action; but it must be conceded that such 
 theories are not altogether explanatory. In the 
 face of such discrepancy, then, empiricism is our 
 best guide ; and the use or abandonment of the 
 drug in a given case may safely be decided by the 
 results obtained by careful trial. As all practi- 
 tioners are aware, the large and variegated group 
 of symptoms included under the name of hysteria 
 are often relieved by the administration of valerian. 
 
THE SPECIAL THERAPEUTICS OF PATIST. 181 
 
 Ringer has found it useful in relieving hot and cold 
 perspiration, flushing of the face, and the restless- 
 ness and mental depression so often found among 
 neurotic persons. As an antispasmodic it has also 
 been used in chorea and whooping-cough, and oc- 
 casionally mild neuralgia has been relieved by it. 
 It must be confessed, however, that its eflfects upon 
 pain are slight, and not to be relied upon. 
 
 Belladonna has long been employed in neurologi- 
 cal medicine in the most diverse conditions. Owing 
 to a lack of comprehension of its somewhat com- 
 plicated physiological effects it has also been much 
 abused ; and I believe, therefore, that it will not be 
 time misspent if we examine somewhat in detail 
 the knowledge of its action, which has been gained 
 by most elaborate experimental investigation. 
 
 Belladonna or its alkaloid, atropine, when intro- 
 duced into the system subcutaneously or by the 
 mouth, increases the irritability of the gray sub- 
 stance of the spinal cord. This influence is especially 
 pronounced in the domain of the vaso-motor centre, 
 and respiration as well as the action of the heart 
 is appreciably increased. It has been found, how- 
 ever, that belladonna does not act in the same 
 manner upon the heart of the dog as upon that of 
 man. According to some observers the pulsations 
 of the heart in frogs are not increased after the 
 
 16 
 
182 PAIN. 
 
 administration of this substance; neitlier is there 
 any appreciable dilatation of the pupil. After con- 
 siderable doses of belladonna there is marked dimi- 
 nution of muscular power ; this effect is particularly 
 manifest in the gait, which becomes uncertain and 
 staggering. So great may this weakness become 
 that the subject is absolutely unable to direct his 
 movements, and staggers about like a person labor- 
 ino; under the influence of alcoholic intoxication. 
 When the amount of the drug absorbed by the 
 system is sufficiently large, these phenomena may 
 develop into complete paralysis. The muscles of the 
 trunk are first affected ; then the terminations of the 
 pneumogastric in the heart and lungs become im- 
 plicated ; and, finally, the endings of the secretory 
 nerves of the salivary and sweat glands and the termi- 
 nations of the nerves supplying the iris are involved. 
 
 Flushing of the face, dryness of the mouth, 
 tongue, pharynx, and larynx, dilatation of the pupil, 
 and a certain bright appearance about the eyes are 
 among the more obvious phenomena evoked by full 
 doses of belladonna. 
 
 The effects produced upon the mental faculties are 
 often grotesque, and at times alarming. Sometimes 
 the subject labors under the influence of extreme 
 restlessness. He wanders about, paces to and fro in 
 a nervous, excitable condition ; and, in a word, he is 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 183 
 
 impelled to keep constantly moving, in spite of a 
 strenuous desire to remain quiet. At the same time 
 the intellectual faculties keep pace with the motor 
 excitement ; ideas come and go with great rapidity, 
 but are at first connected, — a quality which they 
 afterwards lose. Sometimes, too, the movements of 
 the patient appear to be governed by a species of au- 
 tomatism which induces the constant repetition of 
 the same gesture. These movements savor often of 
 the trade or occupation of the patient. Thus, I know 
 of a shoemaker who, under the influence of large 
 doses of belladonna, executed with great precision 
 the movements peculiar to his calling, a process 
 which was sometimes continued for an hour or more. 
 
 The exalted condition of the mental faculties is 
 progressively increased; the rapidly evolved but 
 previously connected ideas become more and 
 more incoherent, and gradually give place to hal- 
 lucinations and a condition of delirium — sometimes 
 characterized by acts of violence — necessitating the 
 employment of restraint. 
 
 Sometimes mental disturbances of this character 
 may result from comparatively insignificant doses ; 
 so that too much care cannot be exercised in order 
 to ascertain the susceptibility of the subject. Pain 
 in th.e head — over the forehead or in the eyes — is a 
 frequently observed symptom after moderate doses ; 
 
184 PAEsr. 
 
 and tinnitus may accompany it, giving rise to the 
 opinion on the part of the patient that he is under 
 the influence of quinine. A scarlet rash about the 
 joints has sometimes been observed after poisoning 
 by belladonna; but this symptom is not very 
 characteristic. 
 
 To give all the therapeutic indications of bella- 
 donna would exceed the objects and scope of the 
 present work; I shall, therefore, only refer to the 
 more important applications of the drug. 
 
 Aside from its usefulness in the treatment of 
 epilepsy and profuse perspiration, which possess less 
 interest for us, belladonna has been employed to 
 check the paroxysms of whooping-cough, urinary in- 
 continence, and chronic inflammation of the spinal 
 cord. Brown-Sequard is its chief exponent in the 
 last-named connection, basing his advocacy on the 
 belief that it causes contraction of the small vessels 
 of the cord. Belladonna has long been used in the 
 treatment of a wide range of painful affections, and, 
 notably, in combination with morphine and codeine. 
 
 The paroxysms of asthma, too, are often arrested 
 by belladonna. It must be confessed, however, that 
 many instances are recorded in medical literature 
 in which belladonna has failed to afford the results 
 anticipated fi-om it, chiefly because it was given in 
 too small doses. As Ringer long since observed, it 
 
THE SPECIAL THERAPEUTICS OF PAIN. 185 
 
 may be necessary to give as much as ten minims 
 of the tincture every two or three hours, in order 
 to allay the discomfort of chronic asthmatics. 
 
 The physiological effects of stramonium are quite 
 similar to those of belladonna, and, like the latter, 
 it has been much employed in bronchial spasms 
 and nervous asthma. It is not directly soporific in 
 its action, but, when employed as above indicated, 
 it promotes sleep indirectly, by allaying irritative 
 symptoms which prevent unconsciousness. As is 
 well known, the effects of the drug are best ob- 
 tained by smoking. 
 
 Fifteen or twenty grains of the dried leaves, or 
 ten of the powdered dried root, are placed in an 
 ordinary pipe, and the smoke is slowly inhaled. 
 The addition of tobacco has been suggested; but 
 only persons thoroughly habituated to the use of 
 the drug are able to inhale the latter without great 
 discomfort. This is especially true of children and 
 delicate women, who are frequently thrown into 
 violent paroxysms by crude attempts of this kind. 
 Some of the medicated pastilles found in the shops 
 may occasionally serve as substitutes for the dried 
 leaves ; the practice of mixing the latter with salt- 
 petre and allowing them to be slowly consumed 
 while the fumes are inhaled is a time-honored ex- 
 pedient, but decidedly inferior to smoking. 
 
 16* 
 
186 PAIN. 
 
 Stryclinine is a remedy which has long been used 
 in the treatment of various atonic conditions of the 
 spinal cord. From this it may be readily inferred 
 that its effects manifest themselves principally in 
 the domain of this structure, the irritability of the 
 cord being increased by its administration. "When 
 a large quantity of the remedy is introduced into 
 the system symptoms which bear the closest resem- 
 blance to those of tetanus are evoked. These phe- 
 nomena are exhaustively discussed in the systematic 
 treatises, so that nothing further need be said of 
 them. 
 
 Strychnine is especially useful in the treatment 
 of spinal irritation and other painfal conditions due 
 to nutritive derangements of the cord. 
 
 Calabar bean and its alkaloid, physostigmine, are 
 opposed in their action to that of strychnine, and 
 hence they may be employed with good effect in 
 case of poisoning by that drug, as well as in tetanic 
 spasms from other causes. In all cases of pain, 
 therefore, where it is desirable for any reason to 
 diminish the irritability of the cord, physostigmine 
 may confidently be exhibited. 
 
 The physiological effects of physostigmine have 
 been most thoroughly investigated by Dr. Fraser. 
 Did the scope of this work permit I should be glad 
 to quote these experiments in full, but, on account 
 
THE SPECIAL THEEAPEUTICS OF PAIN. ]87 
 
 of the limited space available, I shall be obliged to 
 summarize them briefly, as follows : 
 
 When physostigmine is introduced into the system 
 it gradually diminishes and finally destroys the irri- 
 tability of the gray substance of the spinal cord. 
 It also causes a diminution of the number of the 
 heart's contractions when given in moderately large 
 doses; and when the amount of the substance in- 
 troduced into the system is considerable cardiac 
 action is almost immediately arrested. Large doses 
 of physostigmine also cause paralysis of respiration. 
 
 If, after introduction of the poison into the sys- 
 tem, the galvanic current be applied to the vagus, 
 it will be found that a weaker current is required 
 to arrest the action of the heart than when the 
 animal is in health. 
 
 From what has been said it is evident that Cala- 
 bar bean is rather a sedative than a stimulant; but 
 I have referred to it in this place because of its 
 antagonistic action to that of strychnine. 
 
 Quinine, phosphorus, zinc, and arsenic are among 
 the valuable tonics which have been employed in 
 the treatment of a large number of painful condi- 
 tions characterized by marked debility of the ner- 
 vous system. Quinine is especially useful in the 
 treatment of those painful conditions due to mala- 
 rial influences. This is well exemplified in its rapid 
 
188 PAIN. 
 
 curative action in supraorbital neuralgia due to 
 malaria. There are, however, besides these brow- 
 pains, others which do not yield to even the largest 
 doses of quinine, a fact which has not been suffi- 
 ciently accentuated in the books. 
 
 By promoting metamorphosis in the tissues phos- 
 phorus increases the intensity of the vital processes, 
 and much of the benefit incident to its administra- 
 tion is doubtless due to this fact. It must not be 
 forgotten, however, that if such benefits are to be 
 permanently realized the general nutrition must 
 be augmented to such a degree as to compensate 
 for the destructive changes in the tissues which are 
 inevitable when phosphorus is present in consider- 
 able quantities in the organism. 
 
 Though the manner in which zinc exercises its 
 efiects is less obvious, its use in the clinic has shown 
 it to be of very considerable value as a tonic. This 
 is especially shown by its almost specific effects in 
 many cases of chorea. 
 
 Arsenic, too, has likewise been employed in the 
 treatment of a number of painful affections of pe- 
 ripheral origin, and notably in sciatica and in the 
 ambulatory pains sometimes encountered in choreic 
 children. Its specific effects upon the irregular 
 movements of St. Yitus's dance are too well known to 
 the profession to require more than cursory mention. 
 
CHAPTER XII. 
 
 OF OTHER AND MORE RECENT REMEDIES WHICH HAVE BEEN 
 EMPLOYED IN THE TREATMENT OF PAIN. 
 
 During the past few years a number of new sub- 
 stances have been added to organic chemistry, some 
 of which have certainly proved themselves to be of 
 great value in the treatment of pain. Some of these 
 bodies have been obtained directly from coal-tar, 
 and hence they are known in the shops as the coal- 
 tar derivatives. Others, again, are the reward of 
 only the most elaborate and ingenious synthesis. 
 It is not a matter of surprise that the Teutonic 
 mind, with its resourceful vigor and tenacity of 
 purpose, should have been chiefly instrumental in 
 giving us these new and valuable remedies. 
 
 Obviously, a short resume of the salient character- 
 istics of the more important of these new analgesics 
 is indispensable to completeness of statement. 
 
 Antipyrin, first produced by Knorr, of Erlangen, 
 is an antipyretic and analgesic of very great value. 
 It has a number of scientific designations, of which 
 dimethyloxyquinizin is the least] polysyllabic. Anti- 
 
 189 
 
190 PAIN. 
 
 pyrin is soluble in water and chloroform, less so in 
 ether. On account of its depressant influence on 
 the heart's action it is best given in half a tumbler 
 of water to which a teaspoonful of the aromatic 
 spirit of ammonia has been added. 
 
 As a rule, doses of from ten to thirty grains will 
 be found sufficient. 
 
 Antipyrin is one of the most universally applica- 
 ble analgesics which we possess. It has been em- 
 ployed with success in the various forms of neuralgia, 
 spinal irritation, headache, and tubercular meningi- 
 tis. In the last-named affection I have injected it, 
 in combination with cocaine, directly into the spinal 
 canal. For the technical points involved in the 
 last-named procedure see the subsequent chapter on 
 local medication of the cord. Even the pains of 
 locomotor ataxia, labor, and those of cancer and 
 dysmenorrhoea have been relieved by it. When 
 given hypodermically it acts much more rapidly, 
 and hence its exhibition in this way has been rec- 
 ommended in angina pectoris, renal and biliary 
 colic, and dysmenorrhoea. 
 
 Phenacetin, like antipyrin, is a derivative 'of coal- 
 tar. It is likewise known in the technical litera- 
 ture of chemistry as acetophmetidin. Phenacetin is 
 sparingly soluble in cold water, somewhat more so 
 in boiling water, and quite soluble in alcohol. It 
 
THE SPECIAL THERAPEUTICS OF PAIN. 191 
 
 is, perhaps, best given in cachets, in doses of from 
 ten to fifteen grains. 
 
 Though inferior to antipyrin in rapidity and 
 certainty of efiect, phenacetin is, nevertheless, an 
 analgesic and antipyretic possessed of special ad- 
 vantages. In the first place, it has, in addition to 
 its anodyne qualities, a sedative and soporific action, 
 which is often most useful where we have to deal 
 with pain accompanied by marked restlessness and 
 extreme irritability. In such cases the mere re- 
 moval of the pain is not always sufficient to induce 
 sleep, though, of course, a desideratum of the first 
 importance. Consequently, a supplementary sopo- 
 rific action is required, and this, in the case of phe- 
 nacetin, is afforded by the drug itself; whereas the 
 same cannot be said of antipyrin, the administration 
 of which, while usually followed by relief from 
 pain, is more likely to engender wakefulness than 
 sleep. 
 
 Phenacetin has been extensively employed as an 
 analgesic in the milder kinds of neuralgia and 
 migraine ; and it has also rendered good service in 
 the treatment of pain of rheumatic origin. In the 
 last-named afifection it has been advantageously com- 
 bined with salol in tablets, which have obtained a 
 wide currency, and are now probably well known 
 to all practitioners. 
 
192 PAIN. 
 
 Exalgin is closely allied in its structure to acetan- 
 ilid. It is, in fact, methyl-acetanilid, a compound re- 
 sulting from the interaction of monomethyl-anilid 
 and acetyl chloride. Though quite soluble in alco- 
 hol it is only sparingly so in water, and hence it is 
 usually given in cachets, in doses of from two to six 
 grains. 
 
 As an analgesic, antipyretic, and antiseptic, exal- 
 gin has obtained some reputation, chiefly because 
 its administration is devoid of such unpleasant 
 symptoms as irritation and rash. It must be ad- 
 mitted, however, that when the dose is carried be- 
 yond the bounds of prudence, trembling and even 
 paralysis of respiration may be induced. 
 
 Salol is the phenyl ether of salicylic acid, or, to 
 express it more simply, it is the salicylate of phenyl. 
 
 The white, crystalline appearance of this sub- 
 stance is doubtless familiar to the majority of phy- 
 sicians. 
 
 Though insoluble in water, salol dissolves with- 
 out difficulty in alcohol, the fixed oils, and ether. 
 It is best given in milk or cachets. The dose is 
 from five to thirty grains. 
 
 A noteworthy circumstance in connection with 
 its exhibition is the fact that it passes unaltered 
 through the stomach, — so that digestion is unaf- 
 fected by it, — and only becomes split up into its 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 193 
 
 phenyl and salicyl elements in the duodenum by 
 the action of the pancreatic juice. Both alone and 
 in combination with phenacetin it has been em- 
 ployed as an analgesic ; but its chief field of useful- 
 ness is acute rheumatism, where it frequently acts 
 with remarkable promptness. 
 
 Besides many pains of rheumatic origin, which 
 are promptly relieved by the administration of salol, 
 neuralgia of the eyeball and even earache have 
 been subdued by it. 
 
 Salipyrin, as its name implies, is a chemical com- 
 bination of salicylic acid and antipyrin. It is a 
 white, crystalline substance, little or not at all solu- 
 ble in water, but dissolving readily in alcohol, and 
 may be exhibited in doses of from fifteen to thirty 
 grains. In my opinion, not more than seventy-five 
 grains should be given in the course of twenty-four 
 hours. From its composition the conclusion is 
 almost inevitable that salipyrin must be a useful 
 remedy in a large category of painful affections, 
 among* which those of rheumatic origin are not the 
 least. "What I have been able to ascertain of its 
 efficiency by trial in the clinic has convinced me that 
 these conclusions are fully justified. In fact, sali- 
 pyrin seems to possess a unique value as a means of 
 combating those ambulatory pains whose origin is 
 often so obscure, but whose capacity for engender- 
 I n 17 
 
194 PAIN. 
 
 ing distress in the patient and annoyance in the 
 physician is so positive. 
 
 These observations are especially applicable in the 
 case of that protean distemper, the "grippe" (in- 
 fluenza), the pains of which are readily controlled 
 by the administration of salipyrin, in doses of 
 twenty grains every three or four hours. 
 
 When giving it in this way it is well to counteract 
 its depressing effect on the heart's action by the 
 simultaneous exhibition of a heart tonic. I usually 
 employ for the purpose a tablet of strychnine, spar- 
 teine, and digitalis. 
 
 Salophen contains over fifty per cent, of salicylic 
 acid; and its efficacy in rheumatic affections, and 
 especially in acute rheumatic arthritis, is doubtless 
 attributable to this fact. The small, white crystals 
 in which it occurs are quite soluble in ether and 
 alcohol. As a rule, from ten to fifteen grains are 
 a sufficient dose, and the daily maximum amount 
 should not greatly exceed sixty or seventy grains. 
 
 Solanine is a glucoside derived from the Solanum 
 nigrum and other Solanacese. The crystalline powder 
 in which it occurs is practically insoluble in water, 
 but dissolves in hot alcohol. As an analgesic sola- 
 nine has been highly praised by some authors, hav- 
 ing on several occasions afforded prompt relief in 
 neuralgia of considerable severity. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 195 
 
 The dose of tlie glucoside is from one-fifth to one 
 grain, and may be exhibited either in tablet form 
 or as a powder. 
 
 Where hypodermic administration is desirable the 
 hydrochloride should be employed in like doses. 
 
 Thymacetin is a derivative of thymol, and is 
 nearly related to phenacetin, which it also resembles 
 quite closely in its physiological action. Occurring 
 as a white, crystalline powder, it has been used, in 
 doses of from four to fifteen grains, as an analgesic 
 and hypnotic. Doses of from eight to ten grains 
 are usually sufficient to cause drowsiness. 
 
 Urethane, a carbonate of ethylic ether, occurs in 
 colorless, prismatic crystals, is soluble in diluted 
 alcohol, and is used principally as a hypnotic and as 
 an antagonist to the convulsions of tetanus. In the 
 last-named role it is said to be decidedly more potent 
 than chloral. Its analgesic properties are, however, 
 quite subordinate to its hypnotic qualities. The 
 dose is variously given as fifteen, forty, forty-five, 
 and even sixty grains. 
 
 PhenocoU, which is closely related to phenacetin, 
 has been recommended both as an antipyretic and 
 analgesic. In the latter capacity it has shown itself 
 of special value in rheumatism, the pains of which 
 often yield to it readily. 
 
 It occurs as a crystalline powder of whitish color. 
 
196 PAIN. 
 
 is soluble in water, and may be given several times 
 a day, in doses of from ten to fifteen grains. 
 
 Para-acetophenetidin, or "phenidin," is an anal- 
 gesic of considerable value, being regarded by some 
 as superior to antipyrin. It is closely related in its 
 chemical structure to phenacetin, and may be given 
 in doses of from ten to fifteen grains several times 
 a day. 
 
 IsTapelline is an alkaloid derived from Aconitum 
 napeUus, and is said to be an analgesic of considera- 
 ble value. I have not as yet had occasion to employ 
 it. The remedy, which is soluble in water, has 
 been given in doses of from one-fifth to one-half of 
 a grain. 
 
 Methylene blue, as its name sufficiently denotes, 
 is a crystalline powder of bluish tinge, and has 
 been considerably employed as an analgesic. It is 
 soluble in diluted alcohol, but is best given in 
 cachets or capsules, in doses of from two to six 
 grains. 
 
 lodopyrin, as its name implies, is a chemical 
 combination of antipyrin and iodine. It has been 
 principally employed as an antipyretic and anal- 
 gesic, but in the latter capacity it hardly equals 
 antipyrin. 
 
 On account of its insolubility the remedy is given 
 in cachets, in doses of from two to ten grains. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 197 
 
 Methacetine, or jparaoxymethyl-acetanilid, is a rem- 
 edy which of late has been commended as an anal- 
 gesic and antiseptic. It is soluble in alcohol and 
 chloroform, and may be given in cachets, in doses 
 of from two to four grains. 
 
 Local Analgesics. — Among the substances the 
 local application of which (hypodermically) to pain- 
 ful areas is capable of relieving pain by the induc- 
 tion of insensibility in the part are cocaine and 
 its various salts, methoxy-caffeine, kava-kava, and 
 helleborein. 
 
 Of these cocaine easily stands at the head, though 
 the last-named substance, which is quite soluble in 
 water, would be more valuable could it be employed 
 more freely without danger of producing constitu- 
 tional symptoms. 
 
 Methoxy-caffeine may be given in doses of from 
 three to four grains. 
 
 Subsequently I shall detail at some length the 
 various means to be employed in order to realize 
 the fullest benefit from the use of these substances 
 in the treatment of local pain. 
 
 17* 
 
CHAPTER XIII. 
 
 SUMMARY OF OTHER IMPORTANT FACTS RELATIVE TO THE 
 ACTION OF REMEDIES ON THE NERVOUS SYSTEM. 
 
 In the previous chapters have been enumerated 
 Bome of the more conspicuous and important sub- 
 stances used in the treatment of pain. It would be 
 an error to suppose, however, that what has already 
 been said is sufficient to enable us to proceed with- 
 out further ceremony to the effective employment 
 of these remedies. To appreciate this fact it must 
 be borne in mind that substances introduced into 
 the organism for remedial purposes are capable 
 of being materially modified in their action by a 
 variety of circumstances which concern both the 
 individual acted upon and his environment. 
 
 Let us consider for a moment some of the more 
 important phenomena bearing on this question, and 
 especially those which relate to the action of reme- 
 dies on the central and peripheral nervous systems ; 
 for it is with the latter that we shall be chiefly con- 
 cerned in dealing with pain. 
 
 The first and, indeed, the cardinal fact connected 
 with the action of remedies upon the central nervous 
 
 198 
 
THE SPECIAL THERAPEUTICS OF PAIN. 199 
 
 system is that they exert their influence upon that 
 system through the circulation ; for only so long as 
 they remain dissolved in the blood are they con- 
 veyed to the structures contained in the cerebro- 
 spinal canal. Moreover, it follows that, as the 
 heart's action is dependent upon nervous innerva- 
 tion, it, too, can be modified only by remedies ac- 
 tively circulating in the blood-stream. The truth 
 of this proposition, being capable of easy demon- 
 stration, is generally accepted, and needs, therefore, 
 no further elucidation. But the fact, indisputable 
 as it is, suggests this question : If remedies act 
 through and by the circulation upon the cerebro- 
 spinal nervous system, are changes in the blood- 
 pressure followed by corresponding modifications 
 in the physiological action of the remedy? The 
 reply to this is that, at least in the case of some 
 remedies, changes in the blood-pressure are indeed 
 accompanied (followed) by commensurate variations 
 in the physiological activity of the remedy. This 
 applies with especial force to cerebro-spinal stimu- 
 lants, and more particularly to those of an alcoholic 
 and diflfusible nature. It is applicable, moreover, 
 to certain analgesics, notably antipyrin, and to some 
 sedatives, — more especially the bromides. Hence 
 it is that when the administration of these sub- 
 stances is preceded by the exhibition of a cardiac 
 
200 PAIN. 
 
 tonic a notable increase in effect is observed to 
 follow. 
 
 The same fact may, I believe, be invoked to ex- 
 plain another interesting phenomenon. "What I 
 refer to is this, that differences in altitude of suffi- 
 cient magnitude to cause marked variations in at- 
 mospheric pressure are capable of modifying (in- 
 creasing or decreasing) the physiological activity 
 of drugs. That this is true has been attested again 
 and again by travellers in the lofty regions of South 
 America, where the atmospheric pressure is so re- 
 duced as to cause the constitutional disturbances 
 known collectively as " mountain fever." 
 
 Inversely, it is a fact — which I was the first to 
 show, as well as to make practical application of — 
 that medicinal fluids, and more especially stimu- 
 lants, are enhanced in their effects when exhibited 
 while the subject remains in an atmosphere con- 
 densed to a notable degree beyond the pressure of 
 the normal atmosphere. 
 
 To this conclusion I was inevitably compelled by 
 a study of the habits of those persons who are 
 obliged to labor in caissons and other devices em- 
 ployed in laying the foundations of bridges and 
 submarine tunnels. In a subsequent chapter, deal- 
 ing with the practical application which I have 
 made of this principle in neuro-therapeutics, the 
 
THE SPECIAL THERAPEUTICS OF PAIN. 201 
 
 various matters at issue will be more thorougUy 
 discussed ; for the present, however, let me say that 
 in my opinion these effects of compressed air are 
 due to the increased vaso-motor tension consequent 
 upon the augmented action of the heart on the one 
 hand, and the pressure of the blood from the sur- 
 face towards the cerebro-spinal canal on the other. 
 This increased activity of the heart and augmented 
 vaso-motor pressure in the central nervous system 
 are the direct sequences of the air compression at 
 the surface of the body; and their combined result 
 must be a material increase of exosmosis of medi- 
 cated blood within the organs of the cerebro-spinal 
 canal. Herein we find, I believe, the explanation 
 of the increased physiological effect. 
 
 The ability of heart tonics to augment the effects 
 of certain stimulating, analgesic, and sedative sub- 
 stances is doubtless explicable in the same way. 
 Another principle of considerable theoretic and 
 practical interest connected with the administration 
 of remedies designed to affect the cerebro-spinal 
 axis is that the longer a remedial substance, dis- 
 solved in the blood, can be made to linger in con- 
 tact with surrounding nervous structures the greater 
 will be its physiological effect upon those struct- 
 ures. This is the fundamental principle underlying 
 the localization of remedies upon the central and 
 
202 PAIN. 
 
 peripheral nervous system as elaborated and ex- 
 pounded by the author. In a subsequent chapter 
 the various technical details involved in its practical 
 application will be more fully considered. 
 
 Yet another fact of importance connected with 
 the administration of cerebro-spinal remedies is, 
 that not a few of them are materially modified, 
 both in the intensity and duration of their action, 
 by the degree of activity prevalent in the excretory 
 organs, and more especially in the kidneys. When 
 elimination proceeds rapidly the duration of the 
 action of the remedy will be proportionably short- 
 ened; whereas when there is present either renal 
 disease or some other obstacle to excretion the drug 
 accumulates in the system, and its physiological 
 effects are necessarily prolonged. Moreover, it fol- 
 lows that if the doses be too large or their exhibi- 
 tion too frequent the accumulation may assume 
 dangerous proportions. It is then that we are sud- 
 denly confronted with the phenomenon of " cumu- 
 lative" action, the significance of which, though 
 often enough alluded to in the books, is but too 
 frequently lost sight of. And yet to ignore the 
 possibilities of danger implied by the process is to 
 court fatality. This applies especially to the ad- 
 ministration of many of the coal-tar derivatives 
 previously described, substances which, though emi- 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 203 
 
 nently useful in the management of pain, are at the 
 same time burdened with the disadvantage that they 
 exercise a decided depressant effect upon the heart 
 when allowed to accumulate to an inordinate degree 
 in the system. 
 
 "When called upon to give these remedies I am in 
 the habit of safeguarding their administration in a 
 twofold manner : first, by due examination of the 
 kidneys, which enables one to determine whether 
 there be grave disease, contraindicating the admin- 
 istration of the remedy, or only a lethargy of action 
 which may be adequately overcome by a diuretic ; 
 and, secondly, by the previous exhibition of a heart 
 tonic, even though there be no evidence of feeble 
 action or organic disease. By the observance of 
 these simple rules I have been able, I am sure, to 
 ward off trouble on more than one occasion. 
 
 There is hardly an analgesic or, indeed, for that 
 matter, a remedy of real potency which is not capable 
 of exercising some collateral ill effect on the organ- 
 ism. Our aim should be to ferret out these asso- 
 ciated disadvantages and to neutralize them as best 
 we may by the simultaneous exhibition of correc- 
 tives. This is self-evident. 
 
 And yet there are those who are never weary of 
 decrying the use of drugs on account of this con- 
 comitant harmfulness, forgetting that if the logic 
 
204 PAIN. 
 
 underlying such outlawry were really carried to its 
 obvious sequences we should soon find ourselves 
 bereft of practically all the really good things of 
 internal therapy. 
 
 Another point connected with the administration 
 of cerebro-spinal remedies which is not always suffi- 
 ciently appreciated is that old age is remarkably 
 tolerant of stimulants, which seem, indeed, to afford 
 substantial aid to the vital processes. This tolerance 
 of stimulants is directly due to the relative obtuse- 
 ness of the nervous system, which is so character- 
 istic of the aged. Inversely, it is this very insensi- 
 bility of the central nervous system in old persons 
 which renders them intolerant of depressants, for 
 these serve but to clog still further the already 
 decrepit and irresponsive mechanism. 
 
 A condition closely resembling this senile lethargy 
 of the nervous system may be induced artificially, 
 notably by the prolonged and immoderate use of 
 alcohol. In persons who have suffered from such 
 addiction narcotics, and especially stimulants, fail 
 to act with their accustomed energy, and hence 
 considerably increased doses are demanded in order 
 to obtain even moderate effects. 
 
 Herein lies the explanation, or, at least, the partial 
 explanation, of the fact that the majority of patients 
 encountered in public hospitals require much larger 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 205 
 
 doses than the refined persons met with in private 
 practice. Destiny has decreed for the former class 
 severe physical toil, with alternating excesses of a 
 brutal character. The ultimate result of this low 
 living is a distinct loss in nervous resiliency, and the 
 consequent establishment of a condition of obtuse- 
 ness as regards extraneous stimuli of all kinds. 
 Quite the opposite condition is discernible in persons 
 of refinement, for with them a sedentary and com- 
 fortable mode of life — the exigencies of which are 
 a constant appeal to the mental rather than the 
 physical side of life — has culminated in the devel- 
 opment of increased nervous irritability, of which 
 marked susceptibility to drugs is but one of the 
 modes of expression. Every practitioner of experi- 
 ence will, I am sure, be able to recall many cases 
 illustrative of this point. 
 
 Finally, the various peculiarities of temperament 
 and idiosyncrasy should all receive due considera- 
 tion in determining the character of the remedies 
 to be employed as well as their proper dosage. 
 
 In the following pages an attempt will be made 
 to apply in practice some of the principles enun- 
 ciated in this chapter, and, notably, those pertaining 
 to the localization of analgesics and the administra- 
 tion of stimulants and sedatives under increased 
 atmospheric pressure. 
 
 18 
 
CHAPTER XIY. 
 
 ON THE author's METHODS OF EMPLOYING REMEDIES SO 
 AS TO INCREASE THE CERTAINTY AND DURATION OF THEIR 
 ACTION ON THE PERIPHERAL NERVES — OTHER MEASURES 
 "WHICH HAVE BEEN PROPOSED. 
 
 From what has been said regarding the conduc- 
 tion of sensory impressions, it is evident that pain 
 may be abolished in one of two ways : 1, by pre- 
 venting the propagation of the morbidly intense 
 impressions through the centripetal conducting 
 paths (nerve and cord) to the sensorium ; and, 2, 
 by so obtunding the perceptive mechanism that mor- 
 bidly intense impressions, even when transmitted to 
 the brain, are not felt to be painfal. The first of 
 these methods embraces all of those means which 
 are applied to the nerve or cord with a view to pre- 
 venting irritation, or at least interfering with its 
 propagation to the brain. In this category belong 
 the various chemicals, the surgical expedients, the 
 counter-irritants, the thermic agents, and, in short, 
 all therapeutic measures addressed to the nerve 
 itself. To these must also be added all such means 
 
 206 
 
THE SPECIAL THEEAPEUTICS OP PAIN. 207 
 
 as we are able to bring to bear upon the sensory- 
 conducting paths of the cord, for, as Erb long since 
 observed, pain is seldom quite absent in diseases 
 of the cord, though it may vary extremely in form 
 and distribution. These pains are usually attribu- 
 table to irritation of the posterior root-fibres, and 
 their distribution will, of course, depend upon the 
 extent to which the structures in question are impli- 
 cated. 
 
 The degree of permanency, and, consequently, 
 the prognosis of such pains, will, however, depend 
 upon the nature of the central lesion ; if the latter 
 be due to the inflammatory condition present in the 
 disease known as locomotor ataxia, or to pachymen- 
 ingitis, the chances of permanent recovery are re- 
 duced to a minimum ; whereas if passive congestion, 
 as we find it, for example, in the caisson disease, be 
 the cause of the central irritation, the prospect of 
 getting rid of the pains is proportionately enhanced. 
 
 Finally, under the head of the second method 
 are included all appeals made to the receptive (per- 
 ceptive) mechanism of the sensorium, in the form 
 of opiates or other agents which tend to diminish 
 acuity of sensory perception. 
 
 1. The Application of Remedies to the Centrip- 
 etal Conducting Paths — Medication of the Nerves. 
 — A large number of remedies may be applied to 
 
208 PAIN. 
 
 affected nerve-filaments, either by tlie aid of the 
 hypodermic syringe, endermically, or electro-chem- 
 ically. Of the last-mentioned method I shall speak 
 at once, not only because I was the first in this 
 country to draw attention to its merits in connec- 
 tion with the use of local analgesics in the treat- 
 ment of pain, but because I have devised a procedure 
 for carrying out the details of this form of medica- 
 tion which I believe to be far more practical and 
 effective than anything of the kind heretofore pro- 
 posed. Before describing this method, however, let 
 me observe that it is not my intention on the present 
 occasion to enter into an extended discussion of the 
 intricate pharmaco-dynamical questions involved in 
 the treatment of pain. To do this would presuppose 
 an intimate knowledge of the chemical constitution 
 of nerve-tissue, — and such knowledge is at present 
 denied us. "While we cannot, therefore, know what 
 chemical reactions are produced by the contact of a 
 given medicament with the substance of a nerve, we 
 may at least take cognizance of any considerable 
 modification in the function of the latter thereby 
 induced. 
 
 Adopting this mode of reasoning, we find that 
 with the remedies and methods available we are 
 able to accomplish three things : we may tempo- 
 rarily suspend the conduction in a nerve; or we 
 
THE SPECIAL THERAPEUTICS OF PAIN. 209 
 
 may change its constitution sufficiently to allay 
 irritation, and thus prevent the genesis of the ex- 
 aggerated stimulus which gives rise to painful 
 perceptions ; or, finally, we may destroy the morbid 
 nerve-filaments altogether. The first result is best 
 accomplished by the use of a local ansesthetic ; the 
 second, by the subsequent application of chloro- 
 form, ether, or similar agents, or by mechanical or 
 thermodynamic aids ; while the last is attained by 
 the use of the knife. The first of these procedures 
 is the one to which I give preference in cases of 
 moderately acute pain, of unmistakably local char- 
 acter ; the second finds its true field of application 
 in those cases where it is desirable to produce a 
 profound alterative efi'ect upon the nerve; while 
 the last, or surgical method, should be resorted to 
 only in extreme cases, and after all other forms 
 of treatment have failed to give relief. 
 
 My first object, therefore, will be to show how 
 remedies may best be introduced into the vicinity 
 of affected nerves, and particularly those of the 
 skin ; and how, when desirable, the action of me- 
 dicinal substances upon the painful regions may be 
 perpetuated. 
 
 Introduction of Remedies into the Skin by the 
 Aid of the Galvanic Current. — The procedure 
 which I have found effective for the purpose is an 
 o 18* 
 
210 PAIN. 
 
 improvement on that first described by me in 1886.^ 
 Its essential features are as follows : tbe region to 
 be saturated with the chemical is first perforated 
 by a large number of delicate needles,* which are! 
 driven into the part by releasing a spring, much 
 after the plan of the old-fashioned spring lancet. 
 The object of this manipulation is to increase the 
 porosity of the skin, thus enabling the current to 
 propel the chemical into the deeper tissues. As 
 observed in the foot-note, however, it is of the 
 utmost importance to employ only needles of the 
 finest make, as, when larger ones are used, coarse 
 openings are made, which no longer belong in the 
 category of " pores," and through which the chemi- 
 cal refuses to pass. On the other hand, the minute 
 openings made with extremely fine needles are not 
 visible to the naked eye, but are seen by the aid of 
 a strong magnifying-glass as a collection of dots. 
 
 ^New York Medical Journal, vol. xliv., November 19, 1886. 
 See also Dr. David Webster, on " Coming's Method," Medical 
 Kecord, March 5, 1887. Benjamin Kichardson, of London, was 
 one of the first to employ the galvanic current in conjunction with 
 a chemical (chloroform) with a view to inducing local anaesthesia. 
 This was long before cocaine was even heard of, 
 
 * This is nothing more than the instrument of the once famous 
 charlatan Baunscheidt, supplied with unusually fine needles. The 
 coarse instruments sold in the shops are of no value whatever, the 
 needles being much too large. 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 211 
 
 Having thus increased the porosity of the skin, 
 it only remains to introduce the chemical into the 
 tissues by the aid of the galvanic current. In order 
 to accomplish this we proceed as follows : 
 
 Two or three thicknesses of linen cloth are satu- 
 rated with a five or six per cent, solution of the 
 analgesic (cocaine), to which may be added, if con- 
 sidered desirable, a few drops of the tincture of 
 aconite. The linen cloth thus treated is then laid 
 carefully over the perforated area of the skin, 
 care being taken to avoid folds or other inequalities 
 of its surface. A layer of potter's clay, of a con- 
 sistency to be readily fashioned to any inequality of 
 the body, is then spread over the linen cloth to the 
 depth of about an inch. In this layer of clay we 
 then imbed a thin sheet of copper or wire gauze. 
 This clay electrode is then maintained in place by 
 the aid of an elastic strap. 
 
 The sheet of gauze or copper is then secured to 
 the positive pole of an ordinary galvanic battery by 
 means of the conducting cord, so that the current 
 passes directly through the clay electrode and exer- 
 cises its influence upon the analgesic contained in 
 the cloth. 
 
 As to the negative pole, I will merely state that 
 it is to be placed as near as possible to the positive 
 pole, but without touching it. A broad, flat sponge. 
 
212 PAIN. 
 
 saturated with warm water, and held in place by an 
 elastic strap, is quite sufficient. With regard to the 
 strength of the current to be employed, much will 
 depend upon the situation and extent of the terri- 
 tory to be medicated. The greater the area to be 
 anaesthetized the stronger and more protracted must 
 be the application, always bearing in mind, how- 
 ever, that treatment of the head and face must be 
 conducted with caution, care being taken to avoid 
 currents of too great strength. As for myself, I 
 usually begin with three cells, gradually increasing 
 their number until five or six are brought into 
 requisition. When the application is made to other 
 parts of the body, as, for example, to the extremi- 
 ties, currents of very much greater strength may 
 be employed. Currents of considerable quantity, 
 such as those obtainable from large zinc and carbon 
 cells, are preferable to all others. It is quite impos- 
 sible to lay down infallible rules as to the length of 
 time the current should be allowed to operate, since 
 much must depend upon the strength of the battery 
 and the extent of the territory which it is desired 
 to medicate. From ten to twenty minutes are often 
 quite sufficient, while under exceptional circum- 
 stances it may even be advisable to let the current 
 do its work for a longer time. In the majority of 
 cases the pain will have left the part after the cur- 
 
THE SPECIAL THERAPEUTICS OF PAIN. 213 
 
 rent has operated for eight or ten minutes. As a 
 matter of course, should it be deemed advisable, 
 supplementary injections of pyrogallic acid, theine, 
 antipyrin, or other remedies may be made with a 
 view to producing more pronounced and permanent 
 effects upon the nerve. 
 
 Again, it is often desirable to expose the affected 
 nerve-filaments to the action of chemicals for a con- 
 siderable length of time. This is not, however, to 
 be attained by merely depositing the remedy in the 
 vicinity of the nerve or its ramifications without 
 further precautions. In order to prolong the action 
 of a remedy when thus injected we are obliged — as 
 I long since pointed out — to resort to certain sup- 
 plementary expedients. These I shall now proceed 
 to describe. 
 
 The Prolongation of the Local Action of the 
 Remedy — Author's Methods. — When a remedy is 
 injected into one of the extremities it is an easy 
 matter to perpetuate its action to any reasonable 
 extent. "We have only, in fact, to suspend the action 
 of the arterial and venous circulation, as I long 
 since demonstrated,^ by the aid of an appropriate 
 
 ^ " On the Prolongation of the Anaesthetic Effects of the Hydro- 
 chlorate of Cocaine when Suhcutaneously Injected : an Experi- 
 mental Study," New York Medical Journal, Septemher 19, 1885; 
 " Prolonged Local Ansesthetization by Incarceration," ibid., Janu- 
 
214 PAIN. 
 
 bandage. By this simple means we are enabled to 
 keep the remedy for a certain length of time in 
 contact with the nerve-filaments; for, the circula- 
 tion in the part being suspended, the blood cannot 
 dissipate it (the remedy) throughout the organism. 
 Likewise, about the breast and back, we can accom- 
 plish the same thing, though in a much less perfect 
 manner, by resorting to compression by the aid of 
 rings, clamps, and the like. When, however, we 
 desire to perpetuate more completely the action of 
 the drug in the dorsal or thoracic region, the 
 problem is wholly different, since rings and similar 
 devices are not adequate. To meet this difficulty 
 I have devised the following procedure : ^ 
 
 Having introduced the remedy throughout the 
 
 ary 2, 1886; "Spinal Anaesthesia and Local Medication of the 
 Cord," ibid., October 31, 1885; "Local Anaesthesia," New York, 
 D. Appleton & Co., 1886. See also Wyeth, John A., on " Com- 
 ing's Method of inducing Cocaine Anaesthesia," " A Text-Book 
 on Surgery," New York, 1887, p. 22; also Smith, Stephen, on 
 Coming's method, " Principles and Practice of Surgery," Philadel- 
 phia, 1887, p. 54 et seq. See other communications on the subject 
 by J. K. Conway, J. Williston Wright, Kobert F. Weir, M. J. 
 Koberts, and others. 
 
 ^ " The Medication of Nerves, and its Application in the Treatment 
 of Neuralgia and other Painful Affections," a paper read before the 
 Medical Society of the State of New York, February 1, 1887, pub- 
 lished in the Medical Record for March 19, 1887. 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 215 
 
 painful territory, according to tlie method previ- 
 ously described, I place over the part a piece of fine 
 wire gauze, vs^hich is trimmed with a pair of scissors 
 so as exactly to cover the medicated zone. A 
 T-shaped block of wood (Fig. 5) is then placed upon 
 the wire gauze, and a considerable degree of press- 
 ure applied, by means of an elastic strap which encir- 
 cles the body and is secured in place by means of a 
 buckle. The same thing may -pj^ 5^ 
 
 be accomplished by placing 
 a heavy lead weight upon the 
 wire gauze while the patient 
 remains in a recumbent posi- 
 tion. As a result of this the 
 gauze is pressed well into the 
 skin, and the septa of the same 
 cause occlusion of the subjacent capillaries, but with- 
 out pressing out the remedy, which remains caught, 
 as it were, in the meshes. By this method I have 
 often produced a state of complete anaesthesia (by 
 the use of cocaine alone or with antipyrin) lasting an 
 hour and a half. It is not surprising, therefore, that 
 such a protracted exposure of the nerve-filaments to 
 the influence of chemicals should often result in per- 
 manent abolition of the painful sensations. Where 
 the pain is located above the eyes, as in supraorbital 
 neuralgia, or in the temple, this mode of treatment 
 
216 PAIN. 
 
 often acts like magic ; but let me add that cocaine 
 alone is by no means always adequate to secure this 
 end; its ftmction is rather to render the painless 
 employment of other remedies possible. 
 
 Sometimes, in uncomplicated cases, one applica- 
 tion is sufficient to abolish the pain for weeks or 
 even months. In others, again, the pain may return 
 after a few days, but with less intensity. In any 
 event, constitutional treatment should always be 
 continued side by side with local measures, so that 
 septic or other conditions which incite or favor the 
 development of neuritis may be removed. 
 
 Therapeutic Thrombosis, or the Localization and 
 Prolongation of the Action of Analgesics and other 
 Remedies without Mechanical Aids. — It is obvious 
 that the mechanical aids previously described are 
 not equally applicable in all parts of the body ; and 
 hence it would be a great advantage if one could 
 attain the same end — ^localization of the remedy — 
 in some other way. Appreciating this fact, I ad- 
 dressed my efforts, some time since, to the problem 
 of dispensing with them altogether; and in the 
 ITew York Medical Journal of December 26, 1891, 
 vol. liv., I have given an account of these re- 
 searches. 
 
 Let me describe this method of perpetuating the 
 action of remedies, and more especially local anal- 
 
THE SPECIAL THERAPEUTICS OF PAIN. 217 
 
 gesics and ansestlietics ; and, to facilitate the recital, 
 let it be assumed that we wish to perpetuate the 
 action of an anaesthetic upon the cutaneous nerves. 
 
 In the first place, four principles are embodied in 
 the procedure ; these are : 
 
 1. Injection of the medicinal solution (anaesthetic) 
 into the skin. 
 
 2. Subsequent introduction through the same hy- 
 podermic needle, and without its removal from the 
 part, of a non-irritant oil. 
 
 3. Precipitation of this oil, after its injection into 
 the skin, by the aid of moderate cold, but without 
 freezing the tissues. 
 
 4. Taking up the slack of the skin near the seat 
 of injection. 
 
 The technique involved in the practical applica- 
 tion of these principles may be thus described : 
 
 In the first place, we inject an aqueous solution 
 of the anaesthetic, cocaine (CiyHgiNO^, HCl), into 
 that portion of the skin which we desire to render 
 insensible. Then, without removing the hypodermic 
 needle, we immediately inject a considerable quan- 
 tity of the oil of theobroma, or cacao butter, as it is 
 commonly called. 
 
 Finally, by the application of cold to the skin 
 directly after the execution of these manoeuvres, we 
 cause the oil to solidify within the parenchyma, 
 K 19 
 
218 PAIN. 
 
 thus obstructing tlie circulation in tlie capillaries 
 and causing more or less complete stasis. 
 
 To carry these manipulations into effect a double 
 syringe is required, one barrel containing a two or 
 three per cent, solution of the hydrochlorate of 
 cocaine and the other the oil of theobroma, which 
 is maintained in a fluid state by occasionally dip- 
 ping the syringe into warm water of about 110° F. 
 
 Fig. 6, 
 
 The capacity of the barrel containing the anaes- 
 thetic is one hundred minims, while that destined 
 for the oil will readily hold four or five hundred 
 minims. 
 
 Both of these barrels are connected by means of 
 a bifurcated tube with the same needle; so that, 
 by pressing first upon one piston-rod and then 
 upon the other, the two liquids may be injected 
 alternately through the needle at the will of the 
 operator (Fig. 6). 
 
 I wish to acknowledge the carefulness with which 
 
THE SPECIAL THERAPEUTICS OF PAIN. 219 
 
 Mr. W. F. Ford, the instrument-maker, has fol- 
 lowed my instructions in making the syringe. 
 
 It is absolutely necessary that both the aqueous 
 solution of the anaesthetic and the oil should pro- 
 ceed along the same path, so that the occlusion of 
 the capillaries shall occur immediately after anaes- 
 thetization of the sensory filaments in their im- 
 inediate vicinity. Hence the necessity of employing 
 a double syringe and an aqueous solution of the 
 anaesthetic, — a solution that does not combine or 
 solidify with the oil of theobroma, but remains fluid, 
 and therefore physiologically potent, about the fila- 
 ments of the sensory nerves. It is evident that 
 oleaginous solutions of the alkaloid (cocaine) are 
 inapplicable, for the simple reason that they com- 
 bine and then solidify with the oil of theobroma, 
 and are thus rendered inoperative, as is shown by 
 the immediate disappearance of the anaesthesia. 
 
 The precipitation (solidification) of the oil in the 
 tissues may be accomplished by the application to 
 the skin of either cold water, ice, or the ether spray. 
 I prefer the latter expedient. It is by no means 
 necessary to spray the parts continuously, occasional 
 refrigeration being all that is required to maintain 
 the oil in a solid state within the tissues. To ap- 
 preciate this point, it must be borne in mind that 
 the melting-point of the oil of theobroma is from 
 
220 PAIN. 
 
 86° to 95° F., so that a reduction in temperature of 
 from 15° to 20° is sufficient to keep the oil in a solid 
 state within the parenchyma. Moreover, the oil 
 of theobroma is specially applicable on account of 
 its bland, non-irritating properties, which admit of 
 its injection in large quantities without the least 
 chance of unpleasant consequences. 
 
 As a matter of course, having served its purpose, 
 the oil is melted and deported by the general circu- 
 lation when the application of cold to the skin is 
 discontinued. 
 
 But even during the application of cold there is 
 a gradual melting of the solidified oil, beginning at 
 the periphery and proceeding towards the centre. 
 In consequence of this the anaesthesia tends also 
 to disappear at the periphery. 
 
 This subsidence of the anaesthesia may be enor- 
 mously retarded by simply taking up the slack of 
 the skin outside the zone of anaesthesia. To accom- 
 plish this it is only necessary to make a fold in the 
 sMn and maintain the latter by means of a strip or 
 two of ordinary elastic adhesive plaster or by the 
 application of a small spring clothes-pin, which may 
 be had in the shops for a few cents. It must not, 
 however, be inferred that stretching the skin is 
 requisite to the attainment of the most complete 
 results ; all that is required is the elimination of the 
 
THE SPECIAL THERAPEUTICS OF PAIN. 221 
 
 excessive elasticity of the skin at the seat of injection. 
 "When this is done in the simple manner previously 
 described the tissues above the solidified fatty mass 
 — and nowhere else — retain a milky-white appear- 
 ance as long as the oil is maintained in a compact 
 condition by the judicious application of cold. As 
 soon, however, as the fatty mass is allowed to melt, 
 or, in other words, when we neglect to spray the 
 injected area vdth ether from time to time, the skin 
 resumes its normal appearance and the anaesthesia 
 is at an end. Here we have the absolute demon- 
 stration of the efficacy of the hardened oil to prac- 
 tically arrest the capillary circulation at the seat of 
 injection. 
 
 By the application of these principles I have suc- 
 ceeded in maintaining a limited zone of anaesthesia 
 for considerably over an hour, and I see no reason 
 why the anaesthesia should not be maintained for 
 two hours or more. 
 
 I fancy that, to the practical members of the 
 profession, this procedure will speak for itself, and 
 I shall therefore refrain from commenting further 
 upon it. 
 
 The expedients heretofore discussed are such as 
 have reference to the treatment of pain when due 
 to implication of the superficially-located nerves, 
 and, notably, those of the skin. But pain is by no 
 
 19* 
 
222 PAIN. 
 
 means always due to implication of these nerve- 
 branclies; on the contrary, it is often traceable to 
 changes in or about the trunk itself, which may be 
 profoundly located, as in the case of the sciatic 
 nerve. How to deal eftectively with pain when 
 originating in this way is one of the interesting 
 problems of medicine. 
 
 As for myself, I have striven to meet the indica- 
 tions in a variety of ways. Sometimes I have in- 
 jected chemicals, such as pjTogallic acid, cocaine, 
 and aconite, down to the nerve by the aid of a long, 
 fine needle and syringe. Then, in order to insure 
 a more complete exposure of the affected nerve- 
 tissue to the influence of the chemicals, I have 
 passed a tourniquet around the limb, above the 
 point of injection, securing it with sufficient tight- 
 ness to shut off the circulation in both artery and 
 vein. The obvious effect of this is to prevent the 
 deportation of the injected chemicals into the gen- 
 eral circulation; consequently, they linger about 
 the nerve, and are able to do their work as long as 
 the tourniquet remains in place. 
 
 To render the pressure of the tourniquet bearable, 
 however, it is imperatively necessary, before apply- 
 ing it, to exsanguinate the limb with an Esmarch 
 bandage. 
 
 Several years ago I published some cases illus- 
 
THE SPECIAL THERAPEUTICS OF PAIN. 
 
 223 
 
 trating the favorable results which are sometimes 
 attainable by this plan of treatment. 
 
 In addition to the measures previously described 
 a large number of other expedients have been re- 
 sorted to in the treatment of pain. Prominent 
 among these is electricity, which in the form of the 
 galvanic, and more especially the induced (Faradic), 
 current has been extensively employed. Within 
 
 a short time, too, a -c -, 
 
 ' ' Fig. 7. 
 
 great improvement 
 has been made in the 
 construction of the 
 Faradic battery, and, 
 notably, in the vibra- 
 tor or rheotome, by 
 means of which an 
 enormous number of 
 interruptions is se- 
 cured, thereby en- 
 hancing to a material 
 extent the analgesic 
 properties of the cur- 
 rent. By far the best battery of this kind is that 
 suggested by Dr. Augustin N. Goelet (Fig. 7); it 
 is constructed in a most elegant manner by the 
 Galvano-Faradic Manufacturing Company, of ISew 
 York. 
 
 ^I^ 
 
224 
 
 PAIN. 
 
 Fig 8. 
 
 It has long been known that pressure applied to 
 the stem or larger branches of a nerve is often in- 
 strumental in arresting pain. But the procedure is 
 much more effective v^hen combined with the use 
 of the Faradic current, as was pointed out by the 
 author several years ago. 
 
 To carry out this combined treatment I have had 
 made for me an electrode provided with a stout 
 leather band to encircle the limb. This band is 
 
 pierced by a screw, by the 
 rotation of which the press- 
 ure may be increased or 
 decreased at will. A bind- 
 ing post at the top of this 
 screw serves to attach the 
 conducting cord, which 
 unites the electrode with 
 one of the poles of a 
 Faradic battery (Fig. 8). The pad of this elec- 
 trode is covered with chamois-skin, which should 
 be thoroughly moistened before applying it to the 
 part. As a rule, the electro-pressure should be 
 applied centrally, — i.e., as high up as possible; 
 whereas the electrode designed to complete the 
 circuit should be located at the periphery. Thus, 
 in treating sciatica, the foot of the patient may be 
 allowed to rest on a metal electrode, while the 
 
THE SPECIAL THERAPEUTICS OF PAIN. 225 
 
 pressure-electrode is placed over the nerve, as near 
 its point of exit from the pelvis as possible. 
 
 The application of cold to the painful area is an 
 old expedient. The usual mode of accomplishing 
 it is by projecting an ether spray upon the part, as 
 suggested by Sir Benjamin Richardson. Packing 
 the whole limb with ice has also been resorted to, 
 notably in the treatment of sciatica. 
 
 Heat has been even more extensively employed 
 than cold in the treatment of pain, either in the 
 form of cloths saturated with hot water and re- 
 newed at frequent intervals; or by means of hot 
 plates of metal enveloped in flannel ; or by the aid 
 of rubber bags filled with hot water, as suggested 
 by Dr. Chapman. When applied to the spine in 
 this way some effect upon the central nervous 
 system is doubtless produced; but the miraculous 
 phenomena described by Chapman and some of 
 his followers are, in my experience, not forth- 
 coming. But, while this indirect method is of 
 relatively restricted utility, it is a matter of com- 
 mon professional experience that the direct appli- 
 cation of heat to the seat of pain is often, though 
 certainly not invariably, productive of relief. 
 
 Counter-irritation, either in the form of blisters or 
 acupuncture, has been extensively resorted to from 
 a remote period. In the last-named form it has 
 P 
 
226 PAIN. 
 
 been employed in China for centuries, special vir- 
 tues being ascribed to the long needles of gold and 
 silver, which are thrust, it is said, without hesitancy 
 into almost all the accessible regions of the body. 
 Such empirical procedures have, however, hardly 
 more than an historical value, being manifestly in- 
 ferior to modern scientific methods. 
 
 Ointments of various kinds have long been em- 
 ployed in the treatment of pain. 
 
 The remedies best suited to be applied in the 
 form of salves in neuralgic affections are veratrine, 
 morphine, belladonna, aconitia, and extract of 
 opium. 
 
 Aconitia (one part to thirty) should be rubbed 
 into the painfal areas until numbness is induced. 
 
 Veratrine (one part to twenty-five) may be ap- 
 plied twice or thrice daily, care being taken to con- 
 tinue the friction until pricking sensations are 
 experienced. Erb recommends one part of bella- 
 donna, four parts of glycerin, and four parts of 
 starch, the ointment to be applied on a compress or 
 rubbed into the painful cutaneous districts. 
 
CHAPTER XV. 
 
 SUEGICAL EXPEDIENTS. 
 
 As is well known to every medical man of ex- 
 tensive experience, cases of pain are occasionally met 
 with wliich we are not able to relieve, much less 
 to cure permanently. In such desperate cases as 
 these it is customary, as a last resort, to invoke 
 the assistance of surgery. 
 
 The two procedures commonly employed are 
 neurotomy and neurectomy. The first operation 
 consists in simple division of the nerve above the 
 point of irritation ; while the second is a more radi- 
 cal procedure, involving resection of a portion of 
 the affected nerve. 
 
 Both of these operations are, of course, under- 
 taken with a view to preventing the propagation of 
 the painful sensations to the brain. 
 
 Interference with the circulation in a painful 
 region has been known to abolish permanently all 
 unpleasant symptoms in the part. 
 
 This observation has led surgeons to ligate the 
 arteries supplying the painful area. Thus, Trousseau 
 
 227 
 
228 PAIN. 
 
 frequently divided and subsequently ligated the 
 temporal and occipital arteries in neuralgia of the 
 head; and the results thus obtained were some- 
 times quite remarkable. 
 
 Guided by a similar train of reflections, l^uss- 
 baum, of Germany, ligated the carotid artery in 
 a desperate case of neuralgia of the face, with the 
 happiest results, the cure effected being to all intents 
 and purposes complete. 
 
 Inveterate cases of tic douloureux are, fortunately, 
 not so very common ; but when they occur, the 
 misery which accompanies them is inexpressible. 
 "Until 1851, when Dr. J. M. Carnochan operated by 
 completely resecting the second branch of the fifth 
 nerve, we were in a state of more or less helpless- 
 ness when confronted by one of these old cases 
 of tic. 
 
 Dr. Carnochan's mode of operating is thus de- 
 scribed by Dr. Robert Abbe,^ who has improved it 
 in some important particulars : " A V incision was 
 first made below the eye, and from its apex a 
 straight cut was extended downwards through the 
 entire cheek and lip half-way between the nose and 
 the corner of the mouth. The nerve ends were 
 
 ^ " The Surgical Treatment of Inveterate Tic Douloureux," by 
 Eobert Abbe, M.D., the New York Medical Journal for August 3, 
 1889. 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 229 
 
 then gathered up at the foramen of exit, and a 
 trephine was applied to the front of the jaw, re- 
 moving the front bony wall of the antrum. The 
 roof of this cavity, being of thin bone, is readily 
 broken in, and the nerve drawn down from the 
 orbital cavity. The back of the antrum is next 
 broken away and removed, which exposes the 
 spheno-maxillary fossa, which at this point is little 
 more than half an inch deep. The nerve can now 
 be cleaned away from its cellular surroundings and 
 traced to the foramen rotundum, which is on a line 
 with the inner wall of the antrum. Here it is 
 readily cut square off. The posterior dental nerves 
 and Meckel's ganglion connect in front of this, 
 and thus all communication of the jaw with the 
 nerve-centres is cut off beyond the chance of re- 
 pair." 
 
 Dr. James E,. "Wood employed Carnochan's method 
 of operating in a number of cases, and modified it 
 only to the extent of abbreviating the incision, so 
 as not to carry it clear through the lip. 
 
 Dr. Abbe has adopted some changes of technique 
 which clearly enhance the value of the operation ; 
 for he observes, " the simplifying of dressings and 
 attainment of primary union in the wounds now 
 possible make certain valuable modifications of the 
 operation practical." 
 
 20 
 
230 PAIN. 
 
 " I have adopted these expedients," lie continues, 
 " in three cases. 
 
 " The best point is the small skin incision, which 
 leaves a small scar. One inch and a quarter, either 
 horizontally, vertically, or obliquely, over the infra- 
 orbital foramen gives ample room for operating. 
 I have found a gouge better than a trephine for 
 penetrating the antrum front and back. A narrow, 
 forked, blunt instrument to straddle the nerve and 
 assist in dragging it down into the antrum saves it 
 from laceration. 
 
 " Ko bleeding occurs that is not readily checked 
 by sponge-pressure, even the sharp welling-up that 
 occurs when the nerve and its companion vessel are 
 cut. The dressing of the wound is of special im- 
 portance, and the most perfect result is obtained by 
 packing iodoform gauze tightly into the antrum, 
 the end of a long strip being folded into a small 
 pad to be placed deep in the wound against the 
 foramen rotundum, and the rest lightly added on 
 top, and allowed to keep the wound apart on the 
 cheek. After thirty-six or forty-eight hours this 
 gauze is entirely removed and the wound sutured 
 with care. 
 
 " The anaesthesia of the cheek allows of secondary 
 suturing without pain to the patient. What little 
 exudation may follow this dressing is retained and 
 
THE SPECIAL THERAPEUTICS OF PAIN. 231 
 
 needs no drainage, primary union invariably result- 
 ing if the dressing is made with care. The de- 
 pressed scar becomes flattened after a few weeks," 
 
 The histories of the three cases operated upon by 
 Dr. Abbe may be found in the paper from which 
 the above extracts are taken. 
 
 I will finally observe in this connection that 
 Dr. Frederic S. Dennis,^ of ISTew York, collected 
 twenty-one cases of this operation several years 
 since, an analysis of which afibrds ample proof of 
 the merits of this surgical expedient. A perusal 
 of Dr. Dennis's admirable paper will be found 
 alike interesting and instructive. 
 
 It is much to be regretted that in a large number 
 of painful conditions, owing to the fact that so many 
 nerve-trunks contain both sensory and motor fibres, 
 division of the nerve cannot be resorted to without 
 the simultaneous induction of paralysis of motion. 
 
 Division of the Sensory Nerve-Roots for Invet- 
 erate Pain. — Attention has just been drawn to the 
 fact that the majority of those nerves most liable 
 to become the seat of neuritis contain both motor 
 and sensory fibres. Hence division of such nerves 
 with the knife, for the permanent relief of severe 
 and chronic pain, is not usually justifiable, for the 
 
 1 The New York Medical Journal for June, 1879. 
 
232 PAIN. 
 
 simple reason that the operation not only destroys 
 the sensibility in the part but (what is much more 
 deplorable) it also induces paralysis. In order to 
 avoid causing such paralysis of the muscles it has 
 been proposed to divide the posterior nerve-roots, 
 from Trhich the sensory filaments of the affected 
 nerves are derived. To do this successfully involves 
 a knowledge of what nerve-roots go to make up 
 the various plexuses and nerves most liable to be 
 attacked by severe neuritis. Thus, if we are con- 
 fronted with an inveterate brachial neuralgia which 
 has resisted all forms of medical treatment, the cj[ues- 
 tion of an operation may imperatively suggest itself 
 to the mind of the patient or his friends. Under 
 such circumstances, rather than reduce the arm to 
 a state of helplessness by cutting or resecting the 
 nerves, we may divide some or all of the posterior 
 nerve-roots which contribute sensory filaments to 
 the affected nerve or plexus, whereby sensation is 
 lost but motility retained. All this has quite a 
 plausible ring: but the practical realization is not 
 always correspondingly satisfactory. There are two 
 reasons for this. In the first place, as every physi- 
 cian is aware, it is not always easy to determine with 
 absolute certainty just how many branches of a 
 plexus (or nerve) are actually implicated in a given 
 case of neuralgia, since some of the pains may be 
 
THE SPECIAL THERAPEUTICS OF PAIN. 233 
 
 "reflected;" and, secondly, if the simple nerve 
 relations be often difiicult to decide upon, how 
 much more intricate must be the question as to 
 the exact number of sensory nerve-roots which 
 must be divided in order to obtain the maximum 
 relief with the minimum of anaesthesia ! 'No ana- 
 tomical statistics, however well tabulated, afford an 
 infallible key to the situation. ISTor is any one to 
 blame for this, since, as has just been shown, the 
 complications are inherent and not readily amenable 
 to simple a priori solution. Dispensing with theo- 
 retic refinements, we must make up our minds, 
 then, to produce anaesthesia so extensive as to abso- 
 lutely insure the abolition of the pain. This we 
 may accomplish by dividing at once a sufficient 
 number of posterior nerve-roots to rob the plexus 
 of its sensory functions. The remedy is drastic, 
 but vastly to be preferred to the ruthless expedient 
 of division of the nerve itself with the attendant 
 motor paralysis. 
 
 Removal of the Semilunar Ganglion for Ob- 
 stinate Facial Neuralgia, as Practised by Rose and 
 Andrews. — It would be a manifest omission were 
 we to neglect to give a description of the radical and 
 comparatively new operation of excision of the semi- 
 lunar ganglion for intractable trigeminal neuralgia, 
 as first practised by Dr. Rose, of London. An 
 
 20* 
 
234 PAm. 
 
 exceedingly lucid and instructive account of this 
 operation has been given by Dr. Edmund Andrews, 
 of Chicago, who has already removed the ganglion 
 several times. 
 
 The following description with diagrams illus- 
 trating the technical points involved are taken from 
 Dr. Andrews's admirable paper.^ I desire also to 
 express my acknowledgments to Messrs. Lippincott 
 Company for kindly furnishing me the electrotypes 
 from which these illustrations are made. 
 
 " The first operation of Rose was modified by the 
 demands of the patient, who insisted that he should 
 remove the superior maxilla, where he felt the 
 principal pain. Professor Hose, in this instance, 
 therefore, consented to remove that bone. This 
 uncovered the fossa behind it, thus gaining an easy 
 access to the foramen ovale, from which the inferior 
 maxillary nerve emerges. Placing the centre-pin 
 of a trephine in the foramen, he took out a half- 
 inch disk surrounding the orifice; then, opening 
 the capsule of the ganglion, he divided the superior 
 maxillary branch, and, with some difficulty, picked 
 out and removed almost all of the ganglion. This 
 
 1 " Two Cases of the Kemoval of the Semilunar Ganglion through 
 the Floor of the Skull for Facial Neuralgia," by Edmund An- 
 drews, M.D., etc., International Medical Magazine, vol. i., No. 5, 
 June, 1892, p. 479 et seq. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 
 
 235 
 
 was twenty-two montlis ago, and the patient still 
 remains free from pain. In his second and third 
 operations, Rose avoided the removal of the superior 
 
 Fig. 9. 
 
 Rose's first operation, with the long, blunt centre-pin of the trephine 
 inserted into the foramen ovale. S, S, S, the floor and side of the cranium ; 
 O, the Gasserian ganglion ; F, the foramen ovale ; T, the trephine ; D, the 
 dura mater ; C, the carotid artery ; J, the lower jaw. 
 
 maxillary bone by uncovering the parts from the 
 side of the face, as is shown in Fig. 12. In his 
 fourth and fifth operations, he proceeded in essen- 
 tially the same way, but on reaching the floor of 
 
236 PAIN. 
 
 the cranium he selected the place for the applica- 
 tion of the trephine, which I had previously urged 
 before the American Medical AssociatioD, — that is, 
 not directly upon the foramen ovale, but just ex- 
 ternal to it, as shown in Figs. 10 and 11. In a 
 letter to me. Professor Rose gives the opinion that 
 the new place of opening the skull is preferable to 
 the former one. 
 
 " The anatomy of the parts is briefly this : The 
 fifth nerve emerges from the medulla oblongata in 
 a flat, soft trunk, which is easily torn, and is very 
 difierent in structure from the divisions issuing 
 from the distal side of the ganglion to supply the 
 facial organs. Passing forward over the crest of 
 the petrous portion of the temporal bone, it enters 
 a small opening in the dura mater, and expands 
 into the semilunar ganglion on the anterior slope 
 of the petrous portion of the temporal bone. The 
 dura mater here divides into two layers, enclosing 
 the ganglion in a sort of capsule ; the upper layer 
 is thick and strong, and the ganglion is firmly ad- 
 herent to it. The lower layer, next to the bone, is 
 very thin and delicate, and the ganglion easily sepa- 
 rates from it. The ophthalmic, with the superior 
 and inferior maxillary trunks, is given off from the 
 anterior edge of the ganglion to proceed to the face. 
 The largest of these divisions is the inferior maxil- 
 
THE SPECIAL THERAPEUTICS OF PAIN. 237 
 
 lary, which emerges from the skull through the 
 foramen ovale as a somewhat thick cord, very firmly 
 invested with a prolongation of the dura mater, so 
 that it is strong and will withstand a good deal of 
 tension without breaking. Soon after leaving the 
 foramen it divides into two branches, — the inferior 
 dental, which enters the canal in the inferior maxilla 
 and supplies the teeth, lower lip, etc., and the gusta- 
 tory nerve, running to the side of the tongue. The 
 direction of the parts is such that a probe carried 
 along the trunk of the inferior dental nerve, from 
 its point of entrance into the ramus of the jaw, 
 upward and inward to the foramen ovale, passes 
 through the foramen straight onward into the centre 
 of the semilunar ganglion. Fig. 9 shows this rela- 
 tion, with the trephine applied with its centre-pin 
 in the foramen, according to Rose's first and second 
 operations. Fig. 10 shows the same general rela- 
 tions with the trephine applied to the surface, just 
 external to the foramen ovale, and advocated by me 
 as the best point before Professor Rose adopted it, 
 though the latter's selection of it was the result of 
 his own investigations without communication with 
 me. Fig. 11 shows the relation of the parts at the 
 base of the skull ; i'^ is the foramen ovale, which 
 gives exit to the inferior maxillary nerve; F S is 
 the foramen spinosum, through which the middle 
 
238 
 
 PAIJf. 
 
 meningeal artery enters the skull; ^P is the ex- 
 ternal pterygoid plate, whose free external edge 
 runs directly to the anterior extremity of the 
 
 Fig. 10. 
 
 Fig. 11. 
 
 A, the cranium; Q, the ganglion; X, 
 the carotid artery ; S, the sphenoidal sinus ; 
 D, the dental branch of the nerve ; T, the 
 gustatory branch, natural size. 
 
 Shows the relation of the 
 parts at the base of the skull. 
 For description see text. 
 
 foramen ovale, but is sometimes prolonged by a 
 ridge on the inner side, and sometimes on the outer 
 side, but always close to it ; hence it is an important 
 landmark for finding the foramen ; P is the ptery- 
 
THE SPECIAL THERAPEUTICS OF PAIN. 239 
 
 gold ridge, sometimes also an important landmark. 
 The black circle on the drawing, just external to 
 
 Fig. 12. 
 
 Rose's second operation. Z, lower flap, containing zygomatic arch; T, 
 upper flap, carrying up the coronoid process; P, external pterygoid muscle; 
 A, superior maxillary artery ; N, the gustatory and inferior dental nerves. 
 Their course behind the pterygoid muscles is indicated by dotted lines. 
 The foramen ovale is just back of P. 
 
 the foramen ovale, shows the place for applying the 
 trephine." 
 
 In concluding his most instructive paper Dr. 
 Andrews observes that " of the seven cases done 
 
240 PAIN. 
 
 by Professor Rose and myself no one has shown 
 any dangerous symptoms, and not one has failed to 
 obtain perfect relief from the pain. The operation 
 is so utterly new in its present form that there has 
 been no time to decide by experience on the perma- 
 nency of the cures, but, as I before remarked, there 
 is reason for hoping that in the majority of instances 
 the disease has not extended beyond the semilunar 
 ganglion, and, hence, the operation of removing the 
 whole of it may be expected to be followed by 
 permanent relief." 
 
CHAPTER XVI. 
 
 LOCAL MEDICATION OF THE SPINAL CORD. 
 
 I HAVE already referred to the frequency with 
 which pain is associated with affections of the spinal 
 cord, and I now desire to offer some suggestions 
 regarding the most practical means to be adopted 
 in the management of this troublesome symptom. 
 
 Let me preface the specific rules to be observed 
 in treatment by a retrospective glance at the argu- 
 ment upon which those maxims are based. 
 
 To begin with my first paper on the subject of 
 direct cord medication, I may state that as long ago 
 as 1885 ^ I showed that when a given amount of 
 chemical substance, in aqueous or oleaginous solu- 
 tion, is injected into the vicinity of the spinal cord 
 certain modifications in the functions of the latter 
 may be induced. 
 
 Thus, when strychnine is injected in this manner, 
 the functions of the cord, and, notably, the reflexes, 
 are greatly exalted ; much more so, in fact, than if 
 the medicament had been simply injected into the 
 
 1 The New York Medical Journal for October 31, 1885. 
 ■L q 21 241 
 
242 PAIN. 
 
 general circulation, as in ordinary hypodermic med- 
 ication. On the other hand, the modifications in 
 function which I have observed after injection of an 
 anaesthetic, such as cocaine, were sensory in charac- 
 ter, — such, for example, as more or less complete 
 anaesthesia, tingling, numbness, and various other 
 parsesthesise, these phenomena being principally re- 
 stricted to the lower limbs, scrotum, and other 
 parts below the point of injection. The line of 
 argument which led up to these results it is not 
 necessary to detail on the present occasion ; enough 
 that the whole chain of experimental proof then 
 and afterwards adduced^ was amply verified in the 
 clinic. 
 
 So convinced have I become of the necessity of 
 making some radical improvement in our methods 
 of dealing with pain originating in difficulties of 
 the cord that, when I observed how vastly more 
 potent are the effects of remedies when brought 
 directly in contact with the cord than when intro- 
 duced into the system in a merely general way, I 
 determined to perfect the technique of making 
 local applications to the organ, so as to place the 
 procedure on a sound basis. 
 
 ^ " Further Contribution on Local Medication of the Spinal Cord, 
 with Cases," the Medical Kecord for March 17, 1888. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 243 
 
 There was one obstacle in particular to be over- 
 come in order to accomplish the practical ends 
 of the undertaking. 
 
 Briefly stated, the problem in question is this : 
 How is the physician to know how far he may 
 thrust the hollow needle, used in transmitting the 
 medicament from the syringe to the vicinity of the 
 cord, without danger of wounding the latter ? 
 
 As I have said, this problem puzzled me for a 
 time ; and yet there was no evading it, for I saw at 
 once that if the procedure were to prove effective 
 it could only do so by enabling one to deposit the 
 medicinal solution close to the cord. This is how 
 the matter was at length accomplished. Having 
 examined the vertebrae of the lower portion of the 
 spinal column, I observed that the posterior surface 
 of the transverse process, even at its greatest de- 
 pression, though almost on a level with the pos- 
 terior aspect of the foramen vertebrae, did not fall 
 at all, or, in rare cases, possibly very slightly below 
 it. This is especially true of the ninth, tenth, 
 eleventh, and twelfth dorsal and of the first and 
 second lumbar vertebrae. As soon as I had ob- 
 served this anatomical coincidence, I saw at once 
 that, in so far as the lower vertebrae were concerned, 
 the problem of approaching the immediate vicinity 
 of the cord with the point of a hypodermic needle, 
 
244 PAIN. 
 
 without danger of wounding it, was solved. In 
 a word, to make the matter short, the simple 
 technique which I elaborated on the basis of these 
 observations is as follows : 
 
 1. I first, as a rule, induce a condition of cuta- 
 neous anaesthesia in the vicinity of the spinous 
 processes of the tenth and eleventh dorsal vertebrae 
 almost as large as a silver dollar. This I do simply 
 for the comfort of the patient, and for no other 
 
 Fig. 13. 
 
 purpose. The electro-chemical method ^ previously 
 described or refrigeration with the ether spray may 
 be invoked for the purpose. 
 
 2. I now call into requisition a fine needle, about 
 three inches long, provided with a handle and a 
 sliding nut (Fig. 13). The latter may be fixed at 
 any portion of the continuity of the needle by 
 means of the screw. This needle I thrust down 
 (about half an inch laterally from the spinous 
 process of the tenth dorsal vertebra) until the bone 
 is reached (Fig. 14). The nut is then pushed down 
 till it rests lightly upon the skin, and is secured in 
 
 ^ See the New York Medical Journal for November 6, 1886. 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 
 
 245 
 
 place by means of the screw. I then withdraw the 
 needle. 
 
 It is now clear, from what has already been said, 
 that the space between the nut and the point of the 
 
 Fia. 14. 
 
 needle corresponds almost exactly with the distance 
 from the surface of the integument to the cord. 
 To make assurance doubly sure, however, I am in 
 
 21* 
 
246 PAIN. 
 
 the habit of subtracting two or three millimetres 
 from the measurement thus attained. 
 
 3. Upon a fine canula (Fig. 15), likewise provided 
 with a sliding nut, the distance previously noted 
 upon the needle is measured off (minus two or three 
 millimetres), and the nut secured firmly in place. 
 
 This hollow needle is then attached to a syringe 
 (Fig. 16) of one hundred minims capacity, filled 
 
 Fig. 15. 
 
 with a one and a half per cent, solution of the 
 anaesthetic (cocaine); antipyrin or methoxy caffeine 
 may also be employed in the same way. 
 
 So much, then, for the technique of this mode of 
 treatment. Relatively long as is necessarily the 
 description, the execution of the manipulations 
 themselves is by no means so difficult as might be 
 imagined. I have employed the procedure many 
 times, sometimes using cocaine alone, and sometimes 
 combined with the tincture of aconite or pyrogallic 
 acid, antipyrin, methoxycaffeine, or strychnine. 
 
 In the affection commonly known as spinal irrita- 
 tion — whether there be a condition of congestion or 
 anaemia, I care not — its effects are certainly in the 
 highest degree beneficial, as I have already had 
 
THE SPECIAL THERAPEUTICS OF PAIN. 
 
 247 
 
 occasion to demonstrate to my entire satisfaction in 
 several cases. How much may be obtained in in- 
 flammatory affections of the cord only an extended 
 experience can, of course, determine. In purely 
 functional derangements, however, its efficacy is 
 beyond question. 
 
 In the second paper alluded to in the foot-note — 
 that published in the Medical Record of March 17, 
 
 Fig. 16. 
 
 1888 — will be found a number of cases illustrative 
 of the efficacy of this procedure. Several cases 
 may also be found in the third edition of the au- 
 thor's monograph on " Headache and JSTeuralgia." 
 
 The Irrig-ation of the Cauda Equina with Me- 
 dicinal Fluids. — While I was engaged in testing the 
 method of medicating the spinal cord just described 
 I became impressed with the desirability of intro- 
 ducing remedies directly into the spinal canal, with 
 a view to producing still more powerful impressions 
 
248 PAIN. 
 
 upon the cord, and more especially upon its lower 
 segment. 
 
 As is well known to every physician, the cord, 
 properly speaking, extends only to the first, or at 
 most to the second, lumbar vertebra. The nervi 
 lumbales, sacrales, and coccygei are therefore 
 obliged to traverse a long distance within the 
 spinal canal in order to attain their respective 
 points of exit. It is thus that the parallel nerve- 
 stems are formed at the lower end of the cord. 
 These fasciculi, in their totality, constitute the so- 
 called Cauda equina. Now let us recall two well- 
 known facts of anatomy : the first of these is that 
 the pia mater, properly speaking, comes to an 
 abrupt conclusion at the end of the spinal cord 
 proper (the conus terminalis) ; ^ while the second is 
 that the blind sac of the dura mater extends to the 
 end of the canalis sacralis. 
 
 "With the above data vividly before us we shall 
 readily understand that when a needle is thrust 
 down between the spinous processes of the third 
 and fourth lumbar vertebrae, for example, close to 
 the ligamentum interspinosum, the point of such 
 a needle, after penetrating the dura mater, will 
 
 ^ The filum terminale has no practical bearing on the argument ; 
 I therefore ignore it altogether. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 249 
 
 find itself directly in contact with the filaments of 
 the Cauda equina, which from this point downward 
 occupies the space of the spinal canal. 
 
 If such a needle be hollow and attached to a 
 hypodermic syringe charged with a medicinal fluid, 
 it is, moreover, evident that the solution may be 
 readily deposited upon the filaments of the cauda. 
 Again, there can be no doubt, especially if the injec- 
 tion be made between the second and third lumbar 
 vertebrae, that the functions of the lower segments 
 of the cord itself may be powerfully affected in this 
 manner. We have only to conceive of the cerebro- 
 spinal fluid being, at this point, thoroughly impreg- 
 nated with the medicinal fluid and lying in direct 
 contact with the pia, — we have only to conceive of 
 this, I repeat, in order to be convinced of the 
 potency of such a procedure. 
 
 As to the question of possible injury arising from 
 pricking the filaments of the cauda with the needle, 
 it must be borne in mind, in the first place, that 
 serious disturbances of sensation and motility, 
 having their origin in the cauda, are always due 
 to gross lesions, and not to insignificant, circum- 
 scribed causes. The very fact that the cauda is 
 composed of a great number of filaments, that 
 these fill out the entire canal and are widely dis- 
 tributed, would a priori lead us inevitably to this 
 
250 ' PAIN. 
 
 conclusion, did we not know inductively from clini- 
 cal histories and subsequent post-mortem investi- 
 gation that such is the case.^ 
 
 Secondly, we must remember that the wounding 
 of a nerve-stem (and the cauda is nothing more 
 than an aggregation of nerve-stems) with a fine, 
 sharp needle is practically without significance. 
 There is an interesting observation bearing on this 
 point in Weir Mitchell's well-known book on nerve- 
 injuries, which we may here apply with perfect 
 legitimacy. " The passage of a needle into the 
 nerve of an animal causes," he says, "usually a 
 little bleeding, which passes away without grave 
 result."^ 
 
 Such a statement applies to simple puncture with 
 a fine needle ; wounds made with an awl or other 
 coarse instrument may, of course, set up the symp- 
 toms of circumscribed neuritis. 
 
 After a survey of the various factors involved as 
 above indicated, and after some preliminary ob- 
 servations on animals, I decided several years ago 
 to put to a practical test the possibilities of direct 
 
 1 FifZe " Injuries of the Cauda Equina," by "William Thorburn, 
 M.D., Brain, vol. x. page 381 et seq. 
 
 '*" Injuries of Nerves and their Consequences," by S. Weir 
 Mitchell, M.D., Philadelphia, 1872, page 92, nineteenth line from 
 the bottom of the page. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 251 
 
 medication of the cauda equina as soon as a suitable 
 case should present. 
 
 The first case in which I resorted to it was one 
 of spinal irritation following an operation upon 
 the urethra. I was called in consultation in the 
 case ten days after the operation. At that time the 
 spine was sensitive to pressure ; there were several 
 points of unusual tenderness located in the lower 
 dorsal and lumbar regions; while the marks of 
 frequent blisterings were still visible on both sides 
 of the spinous processes. Various internal reme- 
 dies, such as strychnine, ergot, and analgesics of 
 diflerent kinds, were prescribed, but without sensible 
 improvement. 
 
 The patient readily consenting, I decided, there- 
 fore, to try the efficacy of an injection composed of 
 Tinct. aconiti, gtt. v; cocainse, gr. ss; aquse, 5i. 
 Sig. — For one injection. 
 
 The foregoing amount of medicated solution I 
 deposited directly upon the cauda equina in the 
 following manner : 
 
 A small trocar, half an inch long, and of the 
 diameter of a wax match, was first thrust through 
 the skin between the second and third lumbar 
 vertebrse. A long, fine, hollow needle, screwed to 
 an ordinary hypodermic syringe, was then passed 
 through the opening in the trocar and down through the 
 
252 PAIN. 
 
 soft tissues adjoining the ligamentum interspinosum 
 till the spinal canal was entered. The trocar and 
 needle are shown in Fig. 17. The entire contents 
 of the syringe were then emptied upon the fibres 
 of the Cauda equina. 
 
 In from five to eight minutes the subject described 
 a tingling sensation in both lower limbs, slightly 
 more marked, perhaps, in the left than in the right 
 leg. On examination there proved to be a decided 
 
 Fig. 17. 
 
 impairment of tactile sensibility, amounting, in 
 certain localities, particularly in the lower third of 
 the thigh and ankle, to a positive anaesthesia. 
 
 Within a quarter of an hour, or at most twenty 
 minutes, every remnant of pain had disappeared, 
 and pressure upon the vertebrae failed to reveal any 
 special degree of tenderness. These phenomena 
 are certainly remarkable when we consider the 
 facility and rapidity with which they were evoked. 
 
 I will merely add that there was entire exemption 
 from pain during the next thirty-six hours; and 
 when the pain and tenderness finally reappeared 
 they exhibited a decided diminution in acuity. 
 
 The future course of the disease differed in no 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 253 
 
 essential particular from that of an ordinary case 
 of acute spinal irritation. Recovery was soon com- 
 plete ; and, by avoiding severe bodily strain, partic- 
 ularly rapid walking, sitting for a long time, or 
 bending the body forward and backward, the patient 
 was able to avoid relapse. 
 
 The second case in which I resorted to local medi- 
 cation of the Cauda equina was one of " caisson 
 disease," many exquisite examples of which I had 
 the pleasure of studying at St. Francis' Hospital, 
 Jersey City, as well as at Christ Hospital, to which 
 institutions cases of the kind were brought during 
 the construction of the Hudson River tunnel. I 
 will merely mention that, in the case in question, 
 the injection was made with the hope of relieving 
 the severe vesical and abdominal pains which are a 
 peculiarly distressing feature of certain phases of 
 this remarkable disease. 
 
 The injection was made in the same manner as 
 in the previous case, but was repeated within the 
 next five hours, as the pain, which was greatly, 
 though not entirely, removed, showed a tendency 
 to return. "Within the next forty-eight hours the 
 improvement was, however, so great as to render 
 further local treatment for the alleviation of pain 
 unnecessary. 
 
 Since the above cases were reported I have occa- 
 
 22 
 
254 PAIN. 
 
 sionally resorted to the procedure in properly se- 
 lected cases. 
 
 Methods of Treatment Previously Proposed. 
 — Among the older devices which have been re- 
 sorted to in the treatment of pain originating in 
 the affections of the cord may be mentioned 
 counter-irritation with blisters, or the actual cau- 
 tery, galvanism, and faradism, hot and cold appli- 
 cations, baths, — Turkish and Russian, — and various 
 internal remedies, which either act directly upon 
 the cord — strychnine, ergot, etc. — or which exert 
 their influence by stupefying the subject — opiates 
 and hypnotics. 
 
 To enter into a discussion of these measures 
 would be merely to repeat what has already been 
 said with sufficient explicitness in the chapter on 
 internal remedies. 
 
 One of the least philosophical means of dealing 
 with pain is the " suspension treatment," proposed 
 by Motschukowky in 1893, and subsequently en- 
 dorsed by Charcot. The patient is suspended by 
 the head, the arms assisting somewhat, precisely as 
 though he were about to be enveloped in a plaster- 
 of-Paris jacket. In this condition he is allowed to 
 remain for several minutes. This manipulation 
 may be repeated more or less often as circumstances 
 seem to demand. The pains of locomotor ataxia 
 
THE SPECIAL THERAPEUTICS OP PAIN. 255 
 
 and other spinal symptoms are reported to have 
 been relieved by this treatment ; and even cerebral 
 disturbances are said to have been abolished by it. 
 Hirt, however, who has used the method one 
 hundred and three times in the same number of 
 patients, states that in no single instance was he 
 able to note any marked or lasting improvement. 
 It has also been proposed to bend ataxic patients 
 over barrels ; and one writer, in sheer exuberance 
 of spirit, has suggested that it might be well to 
 "hang them up by the heels." To accept such 
 propositions as this with any degree of seriousness 
 would be to prove one's self devoid of humor. 
 l!Tot even on the score of empirical evidence, much 
 less on theoretical grounds, are such procedures 
 likely to gain a foothold in practice. Indeed, as a 
 matter of fact, the results obtained have been so 
 insignificant that the suspension treatment and its 
 grotesque derivatives have been practically aban- 
 doned. 
 
CHAPTER XYIL 
 
 THE USE OF COMPRESSED AIR IN" CONJUNCTION WITH REME- 
 DIES WHICH TEND TO DIMINISH THE ACUITY OP PERCEP- 
 TION. 
 
 We have already seen in the course of the pre- 
 vious discussion that the effects of drugs are not 
 only subject to variations dependent upon subjective 
 causes, conventionally spoken of as idiosyncrasies, 
 but are also capable of being greatly modified by 
 extraneous circumstances, among the most impor- 
 tant of which are changes in atmospheric pressure. 
 Thus, we have seen that on the summit of a high 
 mountain stimulants act in a different manner than 
 when taken in air condensed beyond that of the 
 normal atmosphere, as we find it, for example, in a 
 diving-bell or in a caisson employed in the con- 
 struction of submarine works. 
 
 It is self-evident that a principle so valuable must 
 be capable of practical application in neuro-thera- 
 peutics, as I was the first to point out over two years 
 ago. In a word, stimulants when administered 
 while the subject remains in compressed air are 
 
 256 
 
THE SPECIAL THERAPEUTICS OF PAIN. 257 
 
 greatly enhanced in their pharmaco-dynamic effects ; 
 and this influence of the air begins to be felt at a 
 pressure of one atmosphere and a half, and is quite 
 pronounced at two atmospheres. 
 
 But not only may this be said of stimulants, but 
 also of a number of sedatives, analgesics, and diu- 
 retics. 
 
 Upon what physiological principle does this phe- 
 nomenon depend ? How is it explicable ? 
 
 The answer, in a few words, is this : 
 
 In the first place, the air pressing upon the surface 
 of the body, and also upon the parenchyma of the 
 lungs, — by way of the bronchial tubes and air-vesi- 
 cles, — will inevitably cause the blood to gravitate in 
 the direction of the least resistance. I^ow, as the 
 cerebro-spinal canal is to all practical intents and 
 purposes an unyielding, air-tight tube, the surround- 
 ing highly-compressed air is unable to exert pressure 
 upon the contents of the canal , — the brain and cord ; 
 and hence the blood will gravitate to these organs, 
 — i.e., in the direction of the least resistance. The 
 result of this will be a notable enhancement of vaso- 
 motor pressure with concomitant increase of exos- 
 mosis ; so that, if the blood be impregnated with a 
 medicament, the latter will penetrate with greater 
 rapidity than under ordinary circumstances through 
 the cell-wall and into the surrounding parenchyma. 
 
 r 22* 
 
258 PAIN. 
 
 An increase of physiological eiiect is, of course, the 
 inevitable result of such augmented transudation in 
 the cerebro-spinal structures. 
 
 But there is another principle connected with the 
 action of remedies upon the central nervous system 
 which is important both theoretically and practi- 
 cally; I refer to the fact that stimulants and seda- 
 tives act much more energetically when caused to 
 linger in the nervous tissues, or, what is the same 
 thing, in the capillaries which supply those tissues. 
 Let me illustrate this point. Some years ago I was 
 called to see a woman — the wife of a hotel clerk — 
 who was a sufferer from neuritis of the brachial 
 nerve, due, probably, to traumatism. The chief 
 seat of irritation was at a point about three inches 
 above the internal condyle of the humerus. Twenty- 
 five grains of antipyrin, with ammonia, were given 
 with a view to arresting the pain, but without avail. 
 Being desirous of avoiding the use of morphine, I 
 passed a ligature around the arm two inches above 
 the seat of pain, tightening it sufficiently to interfere 
 considerably with the venous circulation. At first 
 there was some increase of pain; but gradually it 
 began to decrease, and ultimately — within fifteen 
 minutes — it disappeared entirely, so that the liga- 
 ture was removed. In this case the ligature was 
 applied nearly three-quarters of an hour after the 
 
THE SPECIAL THERAPEUTICS OF PAIN. 259 
 
 administration of the antipyrin by the mouth, so 
 that most, if not all, of the remedy must have been 
 absorbed. The effect of the ligature was to so retard 
 the circulation in the capillaries that the antipyrin 
 contained in the blood was enabled to fully exert its 
 characteristic anaesthetic effects upon the inflamed 
 nerve-filaments. 
 
 IsTow, what is true of the peripheral nerves in 
 this regard is likewise true of the central nervous 
 system. This is shown by the fact that if we ad- 
 minister a remedy like alcohol, and subsequently 
 partially interrupt the flow in the internal jugular 
 veins by compression, the physiological effects of 
 the drug are materially augmented. 
 
 From what has been said, it is evident that if we 
 could practically combine these two principles — 
 increased vaso-motor pressure and retardation of 
 the medicated blood-stream in the capillaries of the 
 locality to be most affected — we should be placed in 
 possession of a most potent means of influencing 
 the nervous system, and more especially the 
 brain. 
 
 Recognizing the importance of the subject, I have 
 sought to combine these two cardinal principles: 
 first, by exposing the subject in a metal chamber, 
 containing compressed air; and, second, by inter- 
 rupting the venous circulation in those parts which 
 
260 PAIN. 
 
 it is desired should be brought most fully under the 
 influence of the remedy. 
 
 Let me describe in detail the rather elaborate 
 apparatus which I employ in carrying out this plan 
 of treatment; and let me also add that the proced- 
 ure as here presented differs somewhat from that 
 originally described in the Medical Record of August 
 29, 1891. 
 
 The Author's System of rising Compressed Air, 
 in Conjunction with Medicinal Solutions, in the 
 Treatment of Cerebro-Spinal Affections of Func- 
 tional Origin. — In the first place, I have had con- 
 structed a large metal chamber, capable of hermetical 
 closure, and able to withstand a pressure equal to 
 that of a locomotive boiler (Fig. 18). This chamber 
 is cylindrical; it is six feet in diameter, six and 
 one-half feet high, and its walls are composed of 
 soft steel. The ends of the cylinder, which com- 
 pose the top and bottom of the chamber, are five- 
 eighths of an inch in thickness, while the cylindrical 
 walls are somewhat less heavily constructed. The 
 seams are not secured by rivets, but by bolts, so 
 that the chamber was brought into my house in 
 sections, and erected in one of the consulting-rooms 
 without noise or other disturbance. 
 
 Access to this chamber is afforded by a massive 
 door, swung from the centre upon ponderous hinges, 
 
THE SPECIAL THERAPEUTICS OF PAIN. 
 
 261 
 
 which peculiar arrangement admits of a very exact 
 coaptation of the door to its frame. The edges of 
 the latter are, of course, armed with a thick roll of 
 
 Fig. 18. 
 
 india-rubber. To further insure a hermetical closure 
 an adjustable cross-lever has been provided, so that 
 a screw, acting by the aid of a hinge from the centre 
 of the door upon this lever or cross-bar, enables one 
 
262 PAIN. 
 
 to draw tlie door — ^which opens inwardly — firmly 
 against its frame. 
 
 The ingress and egress of the air, which is derived 
 from a pump actuated by an electric motor of one 
 horse-power, are regulated by adjustable valves. By 
 this arrangement it is possible to accurately regulate 
 the amount of air-pressure deemed applicable in a 
 given case. In addition to these appliances a safety- 
 valve and pressure-indicator have also been pro- 
 vided. The amount of pressure commonly employed 
 is, however, vastly below the maximum point of 
 endurance of the chamber, which, on account of 
 its unusually solid construction, is capable of with- 
 standing enormous strains. How great is this 
 strength may be gleaned from the fact that, in its 
 completed condition, it weighs over three tons. I 
 feel that great credit is due to the Cockburn Barrow 
 and Machine Company, of Jersey City, for the con- 
 scientious manner in which they have performed 
 this portion of the work. As is well known to the 
 engineering fraternity, this firm has had an exten- 
 sive experience in the use of compressed air in 
 caisson- and tunnel-work, notably, in the case of 
 the Hudson River tunnel and the foundation-work 
 of the Hatteras light-house. It gives me pleasure to 
 acknowledge my special indebtedness to Mr. "Wil- 
 liam C. Barr and Mr. D. B. S. Cockburn, both of 
 
THE SPECIAL THEKAPEUTICS OF PAIN. 263 
 
 whom have been assiduous in their endeavors to 
 render the mechanical details all that they should be. 
 
 I cannot leave this portion of the subject with- 
 out indicating briefly the principal features of the 
 mechanism employed in condensing the atmosphere 
 within the chamber. For this purpose I have had 
 placed in the cellar of my house a one-horse-power 
 electric motor, actuated by the current derived from 
 the street conduit of the Edison Electric Illumi- 
 nating Company. To the motor is joined, by appro- 
 priate belts and counter-shafting, an air-pump (Fig. 
 19) of superior construction, and with a capacity 
 of more than one hundred and forty strokes to 
 the minute, the length of each stroke being six 
 inches, and the diameter of the cylinder of the 
 pump being also six inches. 
 
 By the aid of a system of wires, switches, and a 
 resistance-box one is able to start this mechanism 
 from the floor above, in the immediate vicinity of 
 the air-chamber, without the slightest danger of 
 causing a derangement of the belts and pulleys em- 
 ployed in joining the pump and motor together. 
 
 A strong tube of iron conducts the air from the 
 pump through an aperture in the floor to the metal 
 chamber; while a similar tube affords passage for 
 the redundant air from the automatic exhaust-valve 
 previously described. It is possible, in this way, 
 
264 
 
 PAIN. 
 
 to obtain pressures of from fifteen to thirty pounds 
 in a few minutes. 
 
 It gives me pleasure to express my indebtedness 
 to Mr. Hadley, of the Edison Electric Illuminating 
 
 Fig. 19. 
 
 \ 
 
 Company, who has superintended this elaborate 
 installation with much diligence and skill. 
 
 Let me now describe, in as few words as possible, 
 the manner in which I am accustomed to employ 
 this apparatus, in conjunction with medicinal solu- 
 tions, for the purpose of increasing and adding 
 
THE SPECIAL THEEAPEUTIOS OF PAIN. 265 
 
 permanency to the pharmaco-dynamic effects of the 
 latter. 
 
 For convenience' sake, we may assume that we 
 have to deal with a severe case of the so-called 
 angio-spastic variety of hemicrania, — that form of 
 migraine accompanied by facial pallor which is sup- 
 posed by some to be the counterpart of partial 
 intracranial ansemia. 
 
 Twenty-five grains of antipyrin, with ammonia, 
 have been given the patient, who is suffering acutely; 
 and yet, after the lapse of over three-quarters of an 
 hour, — a period of time amply sufficient to insure 
 absorption, — there is little, if any, relief. At this 
 juncture he is placed upon a couch within the air- 
 chamber, and around his neck is passed a light 
 elastic band, secured behind by an ordinary buckle. 
 The function of the band is to maintain in place, 
 over the jugular veins, two small dry cups. The 
 cups, which are joined together in front by a slotted 
 band provided with a screw, are about two inches 
 long and half an inch wide; they are made of 
 metal, — silver or steel, — and are somewhat concave 
 in an antero-posterior direction, on the open side, 
 which is in immediate contact with the tissues above 
 the veins. On the upper or closed side is a hollow 
 nipple connecting with the interior of the cup. A 
 long, bifurcated, non-collapsable rubber tube joins 
 M ' 23 
 
266 
 
 PAIN. 
 
 these nipples to a small valve in the wall of the air- 
 chamber, by opening which the interiors of both 
 cups are placed in communication with the external 
 atmosphere. For the time being, however, this 
 
 Fio. 20. 
 
 valve remains shut ; the door of the air-chamber is 
 closed; and the air-pump is set in motion. After 
 the lapse of a few moments, the gauge shows that 
 we have eight pounds more pressure in the air- 
 chamber than outside of it, or 15 pounds + 8 pounds 
 = 23 pounds. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 267 
 
 The small valve in the side of the air-chamber, 
 which is connected by the bifurcated rubber tube 
 with the dry cups, is then opened, and its immediate 
 result is to place the interiors of the cups in com- 
 munication with the external atmosphere. As a 
 result of this the pressure inside the cups is only 
 fifteen pounds, while that outside is twenty-three 
 pounds; and the difterence between the two, eight 
 pounds, is the amount of pressure exerted upon 
 each square inch of cup, and, consequently, upon 
 the subjacent veins. The effect of the manoeuvre 
 is, however, much enhanced by the fact that the 
 tissues of the neck, and, to some extent, the veins 
 also, are drawn in an upward direction by the cups, 
 so that the edges of the latter act energetically upon 
 the lumen of the vessels. The pneumatic jugular 
 compressor, and its use in conjunction with the air- 
 chamber, are well shown in Fig. 20. 
 
 In the case of the patient under consideration, 
 the hemicrania disappeared completely after the 
 pressure upon the jugular had been continued five 
 or six minutes ; and there remained no other souve- 
 nir of its presence than the usual feeling of soreness. 
 ^Nevertheless, although compression was discontin- 
 ued, the patient was allowed to remain in the com- 
 pressed air for another half-hour, as experience has 
 taught me that this is a useful precaution in the 
 
268 PAIN. 
 
 management not only of migraine, but all kinds of 
 intracranial pain due to other than organic changes. 
 Indeed, it is well, when there is reason to fear a 
 recurrence of the pain, to still further increase the 
 air-pressure, say up to two atmospheres ; for by so 
 doing it is self-evident that modifications in the 
 cerebral circulation may be attained of sufiicient 
 importance to materially modify the morbid condi- 
 tions. These are not theoretic deductions, but they 
 are rather conclusions at which I have arrived after 
 a vast deal of experience. 
 
 A brief synopsis of a few cases in which I have 
 invoked this method of employing compressed air 
 for arresting intracranial pain may not prove unin- 
 teresting. 
 
 Mrs. N. J. G-., age forty-four years, the wife of a 
 distinguished clergyman, was referred to me by 
 Dr. David Webster, over a year ago, on account 
 of intractable head-pain of several years' duration. 
 The pain usually begins over the right eye, and 
 extends backward to the temple, and thence to the 
 right occipital region. More rarely it is also felt 
 over the left eye, but, as a rule, it is hemicranial in 
 type. 
 
 Although she has received benefit from the cor- 
 rection of a refractive error (hypermetropic astig- 
 matism) at Dr. Webster's hands, she still suffers at 
 
THE SPECIAL THERAPEUTICS OF PAIN, 269 
 
 irregular intervals, even moderate emotional dis- 
 turbance being sufficient to call forth a paroxysm 
 of great severity. "While the seizure lasts, her face 
 is slightly flushed; and, as she is quite thin, the 
 pulsation of the carotids is visible to the eye. She 
 has been under the care of a number of physicians 
 at different times ; has been operated upon for lacer- 
 ation of the cervix, without apparent benefit; and 
 has taken a large assortment of internal remedies, 
 likewise without result. Having found no evidence 
 of organic trouble of any kind, I requested her to 
 return at the first intimation of impending pain. 
 Accordingly, five or six days later, she again called, 
 suffering from an attack which had come on during 
 the early morning hours. As a matter of scientific 
 interest I applied pressure to the jugulars, — hut 
 without 'previous medication^ — as heretofore described, 
 for fifteen minutes, and then, having ceased the 
 compression, she was allowed to remain in the 
 compressed air (of two atmospheres) for upward of 
 three-quarters of an hour. At the end of this time 
 pressure was gradually reduced; and she declared 
 on coming out that she felt relieved, but not wholly 
 so. Accordingly, after allowing her to wait for 
 an hour, I gave her fifteen grains of antipyrin in 
 ammonia, — which she had often tried before, but 
 without success, — applied compression to the jugu- 
 
 23* 
 
270 PAIN. 
 
 lars, and had her remain in the compressed air at 
 two atmospheres for an hour. On leaving the 
 chamber at the end of this time she declared that 
 all pain had entirely left her. Her diet having 
 been restricted to poultry, fish, and vegetables easy 
 of digestion, the compressed-air treatment was con- 
 tinued, with the occasional addition of two drachms 
 of the extract of absinthe, as she suffers much from 
 depression. 
 
 As a result, there was no pain whatever for 
 nearly a month, so that on April 9, 1892, Dr. 
 "Webster wrote me that " she had called to say that 
 she had been much benefited by the compressed-air 
 treatment." 
 
 From what I have since seen of her, I am inclined 
 to believe that this benefit has become permanent. 
 
 Mr. L. was likewise referred to me by Dr. David 
 "Webster on account of " paralysis of his left third 
 nerve," accompanied by persistent headache. There 
 is a distinct history of syphilis, imperfectly treated, 
 so that both symptoms are doubtless of specific 
 origin. 
 
 Though he has been treated with large doses 
 of the iodide with considerable benefit. Dr. Webster 
 feels that applications of electricity to the affected 
 muscle should also be tried. 
 
 I first saw this patient October 31, 1892; and, on 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 271 
 
 referring to my case-book, I find that on ITovember 
 5 I had made five applications of faradism, which 
 had resulted in an abolition of double vision for 
 several hours. 
 
 On the same date he was seen by Dr. "Webster, 
 who wrote me, " Mr. L. shows marked improve- 
 ment. When I sent him to you it took 40° base 
 in and 18° base down to correct the deviation. 
 To-day it takes 33° base in and 14° base down over 
 left, a gain of 7° in one direction and 4° in the 
 other." 
 
 The headaches, too, had improved under one- 
 hundred-grain doses of the iodide of potash; but 
 he still sufiered at times from exacerbations of 
 severe pain. These I was always able to abolish 
 for several hours by the use of fifteen grains of 
 antipyrin, given under an air-pressure of an atmos- 
 phere and a half; while the internal jugulars were 
 compressed pneumatically, as in the previous case. 
 The same amount of this drug had been repeatedly 
 given before, — without the use of the compressed 
 air, — and the efiect, so far as amelioration of the 
 pain was concerned, was nil. 
 
 It may readily be imagined that, while the iodide 
 was the principal thing, the compressed-air treat- 
 ment rendered valuable assistance in a collateral 
 way by relieving the severe pain while the alterative 
 
272 PAIN. 
 
 was doing its work. Eventually, both the head- 
 pains and the diplopia disappeared entirely. 
 
 Miss H., referred by Dr. Koplik, was first seen by 
 me May 6, 1893. The doctor writes "that she is 
 a patient suffering from periodic headaches," for 
 which " she has tried many physicians, both in 
 Germany and elsewhere, but found no relief." 
 
 Since puberty she has suffered periodically — on 
 an average every five or six days — fi-om these head- 
 aches, which, beginning as a dull pain over the left 
 eye, progress to the temple and side of the head, 
 where they usually remain fixed for twelve hours, 
 and then suddenly disappear. They are always 
 accompanied by sickness of the stomach, and occa- 
 sionally by vomiting. In the beginning they are 
 dull, but later, lancinating in character. 
 
 After trying a number of conventional expedients 
 without much success, I determined to endeavor to 
 abolish, or at least mitigate, the seizures by the aid 
 of the compressed air. 
 
 Accordingly, she was told to come at once to the 
 office on the first intimation of an attack. This she 
 did in the course of three or four days, the pain 
 being firmly seated, and exceedingly severe at the 
 time of her arrival. As she suffered from nausea, 
 she was given one-fourth grain of cocaine in a tea- 
 spoonful of water to which ten grains of the bicar- 
 
THE SPECIAL THERAPEUTICS OF PAIN. 273 
 
 bonate of soda were added. This seemed to relieve 
 the nausea considerably, so that in half an hour it 
 was possible to proceed with treatment. Fifteen 
 grains of salipyrin were given her, and half an 
 hour afterwards she entered the air-chamber, where 
 compression of the jugulars was carried out, as in 
 the previous cases, for fifteen or twenty minutes. 
 The compressor was then removed (by the patient), 
 and the air condensed to two atmospheres, at which 
 point it was maintained for an hour. Pressure was 
 then gradually reduced, and the patient removed 
 from the chamber. She then declared that shortly 
 after the compression of the jugulars the pain had 
 been much relieved in severity, and at the time 
 of leaving the chamber it had been entirely abol- 
 ished. 
 
 This was the most severe attack which she experi- 
 enced while under my observations. Ultimately they 
 seemed to lose their vehemence to such a degree that 
 I am confident proper attention to diet and the occa- 
 sional use of simple remedies will do much for her. 
 
 In view of this amelioration in the severity of 
 the attacks, which is even more marked in some 
 other cases which I have seen, I cannot repress the 
 conviction that the air itself, through its influence 
 on the circulation in the interior of the body, must 
 tend to readjust — for I can find no better word— 
 
274 PAIN. 
 
 any nutritive disturbances of a local character in 
 the cerebral organs or their appendages. Certainly 
 the simple drug alone could hardly be expected to 
 accomplish so much. The hyperdistention of the 
 capillaries in the cerebro-spinal organs, consequent 
 upon the increased vaso-motor tension during treat- 
 ment, has doubtless much to do with this continued 
 improvement. 
 
 These are fair examples, then, of the way in 
 which remedies may be made to concentrate their 
 effects upon the intracranial structures. In all 
 but very fleshy persons the method is readily appli- 
 cable ; but when the adipose covering of the neck 
 is very dense it is impossible to act upon the in- 
 ternal jugulars with any degree of certainty, and 
 without great inconvenience to the patient. 
 
 In conclusion, let me add that the chief field of 
 usefulness of the method is in the management of 
 intracranial pain of a severe type. When it is a 
 question of dealing with head-pain, combined with 
 spinal symptoms, as often enough happens, or with 
 melancholia or neurasthenia, the procedure origi- 
 nally advocated by me in 1891 should be invoked. 
 
 As completeness of the argument demands a 
 presentation of this system of affecting the cerebro- 
 spinal axis, I shall proceed to describe it as briefly 
 as possible. 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 275 
 
 Showing how Compressed Air may be used to 
 Advantage where it is desired to Focalize the 
 Action of Remedies upon the Entire Cerebro- 
 spinal Axis — Application of the Principle of Ex- 
 clusion. — In carrying out the exigencies of this 
 problem we are obliged to invoke a somewhat dif- 
 ferent principle than when it is desired to concen- 
 trate the action of remedies upon the brain : to put 
 it succinctly, we cannot compress the medullary 
 veins, and hence we are obliged to resort to exclu- 
 sion, — i.e., cut off certain portions of the economy, 
 such as the limbs, from the field of activity of the 
 remedy. This we may do by the application of 
 ligatures to the extremities. Let us examine some- 
 what more closely the principle of action with which 
 we are here confronted. 
 
 In the first place, it must be remembered that the 
 amount of ether, chloroform, chloral hydrate, the 
 bromides, strychnine, and many other remedies re- 
 quired to produce physiological effects upon the 
 cerebro-spinal mechanism, may be reduced by first 
 securing a ligature around the central portion of 
 one or several of the limbs of an animal, so as to 
 interrupt both the arterial and the venous circula- 
 tion. 
 
 The proof and explanation of this may be thus 
 presented : 
 
276 PAIN. 
 
 In the first place, it is well known that children 
 and small animals are afiected by much smaller 
 quantities of anaesthetics and other medicinal sub- 
 stances than are required to produce equal effects in 
 men and large animals. 
 
 At first sight there appears to exist a certain defi- 
 nite relation between the weight of the animal and 
 the quantity of medicament required to produce 
 physiological effects. On closer inquiry, however, 
 we find behind this proposition the deeper truth 
 that the real 'proportion is between tlie magnitude of the 
 blood-mass and the amount of medicament. Thus, if 
 we withdraw a considerable amount of blood from 
 a large dog, we may be able to influence him by 
 much smaller doses than those required under ordi- 
 nary circumstances ; and, among human beings, we 
 find the anaemic much more susceptible to remedies 
 than the fall-blooded of equal weight. The degree 
 of saturation of the blood-mass with the remedy is 
 obviously, then, the principal thing; the greater 
 the amount of blood, the more remedy — everything 
 else being equal — we shall have to give in order to 
 obtain definite results. 
 
 If we wish to embody the proposition in a mathe- 
 matical statement, we may do so in the following 
 simple manner : 
 
 Let a represent the total quantity of blood, b the 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 277 
 
 amount of remedy exhibited, and x the magnitude 
 of the physiological effect. "We shall then have the 
 
 simple formula x = -. 
 a 
 
 Again, if we withdraw a certain quantity of blood 
 
 from the circulation by venesection, and call that 
 
 amount d. we shall then have the formula x = ,. 
 
 a — a 
 
 But, if we wish to act upon the organs of the trunk, 
 and more especially upon those contained within 
 the cerebro-spinal canal, it is not necessary to resort 
 to such a drastic expedient as copious blood-letting ; 
 for, in place of this, we may dam up and effectually 
 eliminate from the rest of the body a certain amount 
 of blood by passing a ligature around the central 
 portion of one or several extremities, so as to inter- 
 rupt the circulation in both artery and vein. When 
 this has been done, it is clear that we may introduce 
 a remedy into the system by way of the stomach, 
 or hypodermically into some portion of the trunk ; 
 and it is equally certain that a remedy so introduced 
 will be diluted only in the ratio of the amount of 
 blood freely circulating, and more especially by that 
 contained within the trunk and head. That which 
 is incarcerated behind the ligatures is as effectually 
 withdrawn from the realm of physiological action 
 as though it had been abstracted by the surgeon's 
 
 24 
 
278 PAIN. 
 
 knife. Elimination by the knife and elimination 
 by the ligature are, for present purposes, then, one 
 and the same thing. Hence, if we let d' represent 
 the amount of blood incarcerated behind the liga- 
 tures, X the magnitude of the physiological effect, 
 which we are seeking, h the amount of remedy ex- 
 hibited, and a the total amount of blood contained 
 in the whole organism, we shall have the formula 
 
 ^^ h ^ h 
 a — d' a — d 
 
 Several years since I had an excellent opportunity 
 of proving the truth of the foregoing, in connection 
 with the administration of ether, in the case of a 
 patient who resisted all attempts to anaesthetize him 
 in the ordinary way. 
 
 The case in question was a man under treatment 
 at the Manhattan Eye and Ear Hospital, upon whom 
 it was deemed advisable to perform an operation. 
 As has been said, the ordinary means of inducing 
 anaesthesia had proven ineffectual, for the man was 
 a confirmed drunkard ; and it was at this juncture 
 that I was called in consultation, and requested by 
 my friend Dr. David Webster, one of the surgeons 
 of the hospital, to endeavor to devise some means 
 of getting the man under the influence of the anaes- 
 thetic. 
 
 The procedure which I suggested was this: 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 279 
 
 Around the upper part of each thigh a flat rubber 
 tourniquet was tightly drawn, and secured in place 
 in the usual manner. By this means the sequestra- 
 tion of all the blood contained in the lower limbs 
 was accomplished; but, inasmuch as both artery 
 and vein were compressed, only the amount of 
 blood usually contained in each limb was shut off 
 from the rest of the body, — which would not have 
 been the case had we contented ourselves with 
 merely compressing the veins, as some have done.^ 
 In subsequently commenting on my published re- 
 port of this case, that most accomplished writer 
 and physician, Henry M. Lyman, — than whom 
 there is no greater authority on anaesthesia, — ob- 
 serves that the plan proposed and adopted by me 
 on this occasion (that of compressing both vein and 
 artery) is far preferable to compression of the vein 
 alone. 
 
 The reason for this is not far to seek. When 
 we compress the veins alone there is a rapid accu- 
 mulation of blood in the extremities, through the 
 accessions derived from the uninterrupted arteries. 
 E"ow, as this blood is derived from the trunk, and, 
 
 1 " On the Effective and Eapid Induction of General Anaesthe- 
 sia," the New York Medical Journal, October 22 and December 24, 
 1887. 
 
280 PAIN. 
 
 consequently, also from the organs contained witMn 
 the cerebro-spinal canal, there is danger of syncope, 
 and even heart-failure. When, on the other hand, 
 both artery and vein are compressed no such deriv- 
 ative action occurs, and all danger is consequently 
 removed. With an apology for this brief digression, 
 I now return to the interesting case which has given 
 rise to it. 
 
 Having, as previously stated, applied tourniquets 
 to the central portion of the lower limbs, the ether- 
 cap was placed over the mouth and nose of the 
 patient, and in an incredibly short time he was 
 unconscious, and the surgeons were able to go on 
 with the operation. 
 
 The late Dr. Cornelius R. Agnew and many other 
 members of the staff of the hospital were present, 
 and gave emphatic expressions of approval. 
 
 Dr. F. W. Ring, assistant surgeon to the Man- 
 hattan Eye and Ear Hospital, declared that both 
 the amount of ether and the time consumed in its 
 administration were infinitesimal, when compared 
 with what had been expended in previous efforts at 
 inducing anaesthesia in the usual way. The facts 
 brought out on this occasion with regard to the 
 administration of ether have since been repeatedly 
 verified by different observers ; so that at the pres- 
 ent day their validity cannot be questioned. I 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 281 
 
 desire to add, however, that I have long known 
 that the dosage of phenacetin, antipyrin, morphine, 
 chloralamid, chloral, the bromides, and many other 
 remedies might be reduced by resort to the same 
 procedure; all of which is merely equivalent to 
 stating that their pharmaco-dynamic energy may be 
 increased in this way. 
 
 The reduction of the amount of blood to be 
 impregnated with the remedy, by the application 
 of ligatures to the extremities, and the concurrent 
 exposure of the subject to the influence of com- 
 pressed air, so as to increase the vaso-motor tension 
 of the medicated regions, — i.e., interior of trunk and 
 cerebro-spinal canal, — constitute, then, the essential 
 features of this plan of medication. By invoking 
 its aid melancholia, the lassitude of neurasthenia, 
 and pains of an ambulatory character, as well as 
 those of definite spinal or cerebro-spinal type, may 
 be treated with an effectiveness attainable in no 
 other way. 
 
 Let me now describe, in as few words as possible, 
 the manner in which I am accustomed to employ 
 this apparatus, in conjunction with medicinal solu- 
 tions, for the purpose of increasing their pharmaco- 
 dynamic effects, more especially as related to the 
 cerebro-spinal functions. 
 
 As stated at the beginning of the argument, 
 24* 
 
282 PAIN. 
 
 I esteem it of advantage, before introducing the 
 remedy into the system, to sequestrate a certain 
 amount of blood in one or more of the extremities. 
 This may be done by passing a ligature around the 
 limb so as to arrest the circulation in both artery 
 and vein; or the ligature may be drawn only suffi- 
 ciently tight to check the circulation in the cuta- 
 neous veins alone. While in the latter case the 
 ligature is much better borne than in the former, 
 so that it may be worn for protracted periods with- 
 out inconvenience, it possesses the inconvenience 
 that it causes an abnormal accumulation of blood 
 in the extremity, with consequent inordinate exsan- 
 guination of the trunk, and hence of the spinal cord 
 and brain. To avoid this depleting influence, how- 
 ever, it is only necessary to have the patient apply 
 a moderately tight bandage, in the form of an elastic 
 stocking or sleeve (when the ligatures are applied 
 to the arms), before adjusting the ligature (Fig. 21). 
 In this way stasis of the blood circulating in the 
 veins may be obtained without depleting to any 
 considerable extent the brain or cord, and without 
 special inconvenience to the patient, provided that 
 the elastic stocking or bandage has been applied in 
 such a way as not to compress the veins, but merely 
 to limit their expansion. This point I hope to have 
 made sufficiently intelligible. The ligatures having 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 283 
 
 been applied, and the medicinal solution adminis- 
 tered, — either by the mouth, rectum, or hypodermi- 
 cally, — ^the patient enters the pneumatic chamber, 
 the air-pump is set in motion, and by degrees the 
 
 Fig. 21. 
 
 condensation of the atmosphere progresses until the 
 desired pressure is obtained. When this point is 
 reached the redundant air passes off through the 
 blow-off valve, which, as previously mentioned, is 
 automatic in its action, and readily adjustable to 
 any desired pressure. 
 
284 PAIN. 
 
 I have rarely deemed it necessary to employ 
 greater pressure than thirty pounds to the square 
 inch (two atmospheres), and I often employ lower 
 ones, especially when the delicate state of the pa- 
 tient's health seems to demand such a course. How 
 long should the patient remain in the condensed 
 atmosphere? This question cannot be answered 
 dogmatically : as a rule, an hour will be sufficient 
 to insure an active therapeutic effect; but, excep- 
 tionally, I have allowed the patient to remain in 
 the air-chamber for two hours or more. 
 
 And now let me add a few injunctions respecting 
 the precautions to be observed in connection with 
 the removal of the patient from the air-chamber 
 into the normal atmosphere. In the first place, it 
 is of the utmost importance that this transition 
 from an atmosphere of high to one of relatively 
 low tension should be gradually accomplished. To 
 this end the air should be allowed to escape very 
 gradually, so that fi'om fifteen to twenty minutes 
 are consumed in the operation of reducing the 
 pressure in the chamber to that of the external 
 atmosphere. While the reduction of pressure is 
 in progress the tourniquet or straps employed in 
 compressing the vessels are removed, but the 
 elastic stockings (or bandages) are allowed to re- 
 main. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 285 
 
 It is also sometimes advisable to have the subject 
 swallow thirty drops of spiritus ammonise aromati- 
 cus, in water, at this time ; for, as the pressure de- 
 creases, there is always a diminution in the energy 
 and number of the heart-beats. 
 
 This cardiac stimulant stands properly prepared 
 upon a table in the air-chamber, and the patient is 
 instructed beforehand when and how to take it. 
 The combined effect of the elastic compress and the 
 cardiac tonic is to increase the vaso-motor pressure 
 in the cerebro-spinal system of vessels at the very 
 moment when the compressed air is ceasing to per- 
 form that function. As a result of these precautions 
 I have yet to meet with a single untoward effect 
 from this system of treatment. 
 
 Finally, the ventilation in the air-chamber should 
 be carefully looked to, so as to avoid the inordinate 
 accumulation of carbonic acid gas in the chamber, 
 and hence in the system ; for when the tissues — and 
 more especially those of the cerebro-spinal system — 
 are overloaded with carbonic acid, grave disturb- 
 ances of function may be induced, which manifest 
 themselves after the subject leaves the compressed 
 atmosphere. It is ignorance or disregard of this 
 fact, in connection with submarine work, which 
 has, I believe, given rise to many cases of severe 
 caisson disease. 
 
286 PAIN. 
 
 In the elaborate and roomy apparatus which I 
 employ there is fortunately no danger of this or any 
 other kind of accident, since the circulation of air 
 is continuous, and the pressure capable of exact and 
 automatic regulation. 
 
 The next question which naturally suggests itself 
 is, " What are the remedies most suitable to be 
 administered under pressure, where a direct action 
 upon the nervous system, and especially the cerebro- 
 spinal system, is sought after ?" This question has 
 already been referred to at the beginning of this 
 chapter, but I should like to answer it somewhat 
 more explicitly. In the first place, all chemicals 
 which possess an affinity for nervous matter, as 
 revealed by their ability to modify the functions of 
 the central and peripheral nervous system, more 
 especially the former, may be given with advantage 
 while the subject remains in a condensed atmos- 
 phere. When I say that such substances may be 
 given with advantage in this way, I mean that the 
 intensity and permanency of their effects may be 
 thus enhanced; or, in other words, they may be 
 given with equal if not greater effect in much 
 smaller doses, and the benefit derived lasts much 
 longer. 
 
 A moment's reflection will suffice to convince any 
 thoughtful physician of the significance and magni- 
 
THE SPECIAL THERAPEUTICS OF PAIN. 287 
 
 tude of these things from a practical point of view. 
 It is, indeed, at once apparent that the discovery is 
 capable of a wide application in the treatment of 
 nervous derangements, especially those involving 
 the brain or cord, or both. I have said that the 
 remedies may be given hypodermically, by the 
 mouth, or per rectum. I may add, however, that 
 their exhibition by the mouth, dissolved in some 
 diffusible stimulant of an alcoholic nature, is to be 
 commended. 
 
 Illustrative Oases. — A brief synopsis of a few of 
 the cases in which I have resorted to this system 
 of treatment will best serve to give an idea of its 
 effectiveness and wide applicability. 
 
 Case I. Pain due to Morbid Irritability of the Cord ; 
 Spinal Irritation. — Miss C, aged forty-five, had 
 been treated by a number of physicians for obstinate 
 dorsal and intercostal pain. The cautery, galvan- 
 ism, and all the usual drugs, including strychnine, 
 had been tried without avail. She was brought to 
 my consulting-room by one of my former patients, 
 whom I had been fortunate enough to cure of obsti- 
 nate headaches. 
 
 On physical examination I found the spine tender 
 on pressure in the cervical, dorsal, and lumbar re- 
 gions; while such parsesthesise as tingling, numb- 
 ness, and "burning" pains were promptly evoked 
 
288 PAIN. 
 
 •when she attempted to walk or bend the trunk 
 forward or laterally. 
 
 These symptoms had manifested themselves more 
 or less constantly for the past three years ; but there 
 was no evidence of any organic alteration involving 
 the nervous system. The pulse was somewhat 
 sluggish, but the heart and lungs and the kidneys 
 were healthy. 
 
 While the interview was still in progress she 
 complained of feeling a great deal of pain, and 
 wishing, if possible, to afford her some relief, I 
 gave her twenty grains of antipyrin in a teaspoon- 
 ful of the aromatic spirits of ammonia, well diluted 
 with water. Although she was somewhat anasmic, 
 there was no unpleasant symptom; but, unfortu- 
 nately, neither was there the slightest relief, the 
 pain persisting as energetically as before. 
 
 On the following morning she was again brought 
 to my office in a carriage. Learning that she still 
 suffered from the painfal paroxysm of the day 
 before, I gave her ten grains of antipyrin in a little 
 alcohol, applied two ligatures above the knees, and 
 then installed her upon a comfortable couch within 
 the air-chamber. During the first fifteen minutes 
 the pressure reached eight or ten pounds to the 
 square inch. Subsequently it was increased to 
 twenty-five pounds, which point it was not allowed 
 
THE SPECIAL THEKAPEUTICS OF PAIN, 289 
 
 to pass, the blow-off valve being adjusted to tbat 
 purpose. After remaining in the condensed atmosT 
 phere for three-quarters of an hour, the pressure 
 was gradually reduced; and fifteen minutes later, 
 the equilibrium between the air in the chamber and 
 the external atmosphere being established, she rose 
 from the couch and passed through the open door 
 without assistance. She then stated to me in the 
 most positive manner that not only was she now 
 quite free from all discomfort, but that she had been 
 quite relieved of pain after the first fifteen or twenty 
 minutes of her sojourn in the condensed atmos- 
 phere. 
 
 There being no considerable return of pain the 
 following day, treatment was continued as before, 
 except that one-twentieth grain of the sulphate of 
 strychnine was given hypodermically, instead of the 
 antipyrin, before entering the condensed atmos- 
 phere. She was also placed upon the albuminate 
 of iron and quinine, both of which she took for 
 some time after the principal meal. 
 
 At the end of three weeks, there being no return 
 of pain, she was allowed to discontinue treatment. 
 Quite a long time has elapsed since then, but she 
 writes me that she is quite well, and has gained 
 considerably in weight. 
 
 Case II. A Case of Nervous Headache promptly 
 N t 25 
 
290 PAIN. 
 
 relieved. — This case is cited merely to show how 
 promptly a distressing phase of headache may be 
 relieved by this plan of treatment, with a minimum 
 of drugging. 
 
 Mrs. D. E., a married lady forty years of age, 
 has suffered from severe attacks of headache of a 
 "nervous" type for many years. As a rule, the 
 paroxysm begins with more or less visual disturb- 
 ance, the sight becoming clouded ; and all attempts 
 to use the eyes are followed by marked feelings of 
 discomfort in the eyes and head. N^evertheless, 
 there are no tangible ocular defects ; the pain is not 
 located in the eyeballs, but is ambulatory, predomi- 
 nating at times in the occipital region, at others in 
 the forehead. The circulatory disturbances are 
 inconsiderable, and do not merit special attention, 
 either from an etiological or therapeutic point of 
 view. 
 
 Although all the usual remedies have been tried, 
 she has, until within the past six months, derived 
 the greatest benefit from the use of the bromides. 
 For some time, however, these have failed to abort 
 the attacks of pain, so that she now refuses to 
 further continue their use. 
 
 By dint of some persuasion, I finally induced her 
 to take something less than her usual dose of the 
 bromide of potassium, the constricting ligatures 
 
THE SPECIAL THEEAPEUTICS OP PAIN. 291 
 
 being first placed above the knee and elbow, and 
 the elastic stockings being just tight enough to pre- 
 vent inordinate distention of the vessels. In this 
 way a very complete stasis of the circulation in the 
 superficial veins of all four extremities was ob- 
 tained; so that the amount of blood sequestrated, 
 and hence uncontaminated by the drug, must have 
 been considerable. On the other hand, the elastic 
 stockings served to prevent any appreciable exsan- 
 guination of the cerebro-spinal axis or the trunk as 
 a whole, as was shown by the carotid pulse remain- 
 ing unaltered. 
 
 Twenty minutes after taking the remedy the 
 patient declared that she was no better. She was 
 then placed in the air-chamber, and the pressure 
 increased to fifteen pounds to the square inch, at 
 which point it was maintained for nearly half an 
 hour. The pressure was then gradually reduced, 
 as she intimated that the pain had entirely left her. 
 
 Case III. A Case showing that the Effects of Alco- 
 hol may be greatly enhanced by exposing the Subject 
 in a Condensed Atmosphere. — R. E. A., a young un- 
 married man, has been addicted to the habitual 
 abuse of alcohol for many years. He states that at 
 the present time he is obliged to take double the 
 quantity which he formerly drank in order to obtain 
 the slightest stimulating effect. I had him indicate 
 
292 PAiK 
 
 on a tumbler his usual dose ; and, as there exhibited, 
 it could not have been less than two ounces, his 
 tipple being whiskey or brandy. Wishing to ascer- 
 tain whether in so old an habitue the compressed 
 air might be invoked as an aid to decreasing the 
 amount of alcohol taken at one time, I gave him 
 half his accustomed dose of whiskey, and had him 
 enter the air-chamber (without ligatures or elastic 
 stockings). The pressure was then gradually in- 
 creased to eighteen pounds to the square inch, and 
 at this point it was maintained for twenty minutes, 
 the air being renewed from time to time to insure 
 a plentiful supply of oxygen. It was then gradu- 
 ally decreased till the pressure within the chamber 
 equalled that of the external atmosphere. The 
 door was now opened, the patient having been ex- 
 posed to the influence of the condensed atmosphere 
 for forty-five minutes, and to a maximum pressure 
 of eighteen pounds for twenty minutes. He then 
 stated that he was certain that the degree of exhila- 
 ration experienced was quite equal, if not greater, 
 in degree to that usually derived from twice or even 
 thrice the quantity of alcohol exhibited under ordi- 
 nary circumstances. 
 
 The capital significance of such an observation as 
 the foregoing will, I am sure, impress itself upon 
 every thoughtful practitioner. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 293 
 
 Case IV. A Case showing the Beneficial Influence 
 of this System of Treatment in Simple Melancholia 
 (without Delusions). — A. S. E., young girl, aged 
 eighteen, has suffered for the past few months from 
 hysterical attacks, followed by periods of marked 
 depression. She has neither hallucinations nor 
 delusions, but she is irritable and obstinate, and at 
 times di:Scult to control. Of late she has lost con- 
 siderable flesh, her bowels are constipated, and, in 
 fact, her whole physical condition is far from satis- 
 factory. 
 
 Eecognizing the paramount necessity of improv- 
 ing the general bodily state, I have had her drink 
 warm milk, — often as much as four or five tum- 
 blers a day; I have given her, in addition, both 
 cathartics and diuretics ; and I have sought to have 
 her take more air and exercise, at the same time 
 endeavoring to promote sleep by the conservative 
 exhibition of soporifics. 
 
 These things have already begun to do good ; but, 
 while she is more tractable and less inclined to cause 
 worry to those about her, her attacks of depression, 
 though perhaps not as frequent, are quite as severe 
 as formerly. While suffering from one of these 
 attacks of depression she was recently brought to 
 my ofS.ce by her mother; and, at my suggestion, 
 she was placed in the air-chamber, a small dose of 
 
 25* 
 
294 PAIN. 
 
 the extract of absinthe and brandy having pre- 
 viously been given her. 
 
 In a short time the pressure was shown by the 
 indicator to be fifteen pounds, and at this point it 
 was maintained for twenty minutes or more. After 
 the lapse of this period a marked change took place 
 in the patient's appearance, as could readily be 
 ascertained by looking through one of the large 
 glass port-holes. Her face, which had previously 
 worn a dejected, indifierent appearance, now dis- 
 played a contented and even happy expression, and 
 she occupied herself with reading the newspaper, 
 — something that she had not done before for 
 weeks. 
 
 On leaving the air-chamber this air of content- 
 ment remained, and, according to her mother's 
 statement, she showed no further evidences of de- 
 pression for the next three days. 
 
 Though I had employed the above remedies, and 
 various others as well (without the compressed air), 
 on former occasions and in larger doses, it had never 
 been my good fortune to obtain any appreciable 
 immediate good from them. I feel, therefore, en- 
 tirely convinced — more especially as I have since 
 been able to produce the same class of effects over 
 and over again, both in this and other patients — 
 that the enhanced potency of the drugs was entirely 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 295 
 
 due to the concomitant influence of the compressed 
 air. 
 
 Case V. A Case showing the Enhancement of the 
 Soporific Powers of Hypnotics, and more especially of 
 Chloralamid, by the Administration of the same while 
 the Subject remains in a Highly- Condensed Atmosphere. 
 — E. 'N., a neurasthenic woman who has suffered 
 from acute insomnia for several weeks, and who is 
 inappreciably influenced by the usual hypnotics or 
 their combinations, even when given in large doses. 
 
 Among other soporifics I have given her chloral- 
 amid in doses of forty-five grains, but with quite 
 insignificant success ; for in spite of the remedy she 
 declares that she never sleeps more than one hour 
 or two out of the twenty-four. At my suggestion 
 she consented to try the effects of the compressed- 
 air treatment. 
 
 Accordingly, I gave her a dose of thirty grains 
 of choralamid, — fifteen grains less than she had 
 previously taken at night; and fifteen or twenty 
 minutes after its administration — the elastic straps 
 having been previously adjusted to the lower extrem- 
 ities, above the knees — she entered the air-chamber. 
 The pressure was then raised to fifteen pounds to 
 the square inch, as shown by the gauge ; and at this 
 point it was maintained for upward of half an hour, 
 the air being renewed from time to time, but without 
 
296 PAIN. 
 
 altering the pressure. While thus exposed to the 
 concomitant influence of the drug and condensed 
 air she became drowsy, and finally fell asleep. 
 From this state of unconsciousness she was only 
 aroused by the noise of the escaping air as I 
 opened the valve of the outlet-tube in order to 
 empty the chamber. 
 
 On the following day she stated that at the con- 
 clusion of the treatment she had gone home, and, 
 lying down upon the lounge, had immediately fallen 
 asleep, only awaking after the lapse of five or six 
 hours. In other words, she had slept the entire 
 afternoon, — something that she was quite unable to 
 accomplish even previous to the attack of insomnia. 
 
 This case is instructive, as exhibiting the con- 
 tinued good effects of this plan of treatment; by 
 which I mean that the soporific tendency persists 
 even after removal of the patient from the condensed 
 atmosphere. I will merely add that this case went 
 on to complete recovery, natural sleep supervening 
 regularly, without artificial assistance of any kind, 
 after treatment had been continued for four weeks. 
 
 Case YI. Showing the Arrest of the Painful Crises 
 of Locomotor Ataxia hy the Compressed-Air Treatment. 
 — One of the most effective applications of the com- 
 pressed-air treatment is in the arrest of the periodic 
 attacks of pain so characteristic of tabes dorsalis. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 297 
 
 A good illustration of this is afforded by a gentle- 
 man who has been a sufferer from ataxia nearly five 
 years, and who has been under my own observation 
 more or less during the last three years. He ex- 
 hibits the pupillary and sensory phenomena peculiar 
 to the disease ; but the incoordination, though pro- 
 nounced, does not as yet give rise to serious dis- 
 turbance of locomotion. On the other hand, he 
 suffers from periodic attacks of pain of great 
 severity in both arms and legs, as well as about the 
 chest (" girdling" pains). A crisis of this kind 
 usually occurs about once in six or eight weeks, and 
 lasts — if allowed to run its course — from thirty-six 
 to forty-eight hours. For the purpose of mitigating 
 these attacks he has invoked every species of medi- 
 cation, including morphine, which he has had to 
 abandon on account of marked idiosyncrasy. 
 
 Recently, on the advice of the late Dr. Charcot, 
 of Paris, he has taken antipyrin in large quantities, 
 frequently, indeed, in doses of forty grains. It is 
 true that these enormous doses of the drug con- 
 trolled the pain ; but they accomplished this at the 
 expense of the heart-beat, which suffered gradual 
 but distinct impairment of vigor. 
 
 Being desirous of reducing these monstrous doses, 
 the detrimental influence of which on digestion and 
 the heart's action he recognized, I proposed that 
 
298 PALN. 
 
 we should endeavor to reenforce the action of the 
 analgesic by the aid of the compressed air. He 
 consented immediately; and accordingly, on the 
 next appearance of pains, a week or ten days later, 
 he repaired to my consulting-room at once. 
 
 Twenty grains of antipyrin — ^half the former dose 
 — ^were then given him, combined with a drachm of 
 the aromatic spirits of ammonia, and shortly after- 
 wards he entered the air-chamber, where he re- 
 mained for upward of an hour. During this time 
 the air-pressure was maintained at two and a half 
 atmospheres. After the lapse of twenty minutes 
 he wrote on a piece of paper, which he displayed 
 before the window of the chamber, that he was 
 "feeling much better," and, fifteen minutes later, 
 that the pains had disappeared. 
 
 In fact, on leaving the chamber, twenty-five 
 minutes later, he declared in the most emphatic 
 manner that he was more relieved by the com- 
 pressed-air treatment, with reduced doses, than by 
 the enormous quantities (forty grains) of antipyrin 
 which he had formerly been addicted to. Though 
 the pains seemed to be completely aborted, — ^there 
 being no return during the succeeding twenty-four 
 hours, — he insisted, nevertheless, on taking the same 
 treatment the following day, fearing, as he said, that 
 the pain "might not forget to stay away." This 
 
THE SPECIAL THERAPEUTICS OF PAIN. 299 
 
 precaution was perhaps not altogether superfluous, 
 for, as has previously been said, the painful crisis 
 generally persists thirty-six or forty-eight hours. 
 Whether this second stance in the air-chamber was 
 really necessary or not is, however, of little moment, 
 the chief point of interest being that we were able 
 to effectually abort the attack with a minimum of 
 drugging. Another interesting feature is the fact 
 that the next attack was much delayed in its appear- 
 ance, three months having elapsed before the advent 
 of the first darting pains. 
 
 This, of course, may have been a coincidence 
 only; and I was careful to so inform the patient, 
 who seemed inclined to ascribe too much impor- 
 tance to it. 
 
 I must say, however, that this element of improve- 
 ment continues ; for, since the first successful attempt 
 to relieve him, he has always insisted on coming for 
 the same purpose, as soon as the characteristic sen- 
 sations are felt ; but the intervals between the attacks 
 of pain are increasing in length. 
 
 Since the publication of some of these cases in 
 the Medical Record of August 29, 1891, I have 
 treated over two hundred other cases, involving 
 the use of the compressed air more than three thou- 
 sand times. Though the pressure was occasionally 
 carried up to three atmospheres, and generally to 
 
300 PAIN. 
 
 two atmospheres, I have never had the slightest 
 approach to an accident. This exemption from all 
 unpleasant consequences I ascribe to two circum- 
 stances: first of all, to the excellent ventilation; 
 and, secondly, to the invariable habit of allowing 
 the air to escape quite gradually. As at present 
 arranged, it is possible for the patient to let himself 
 out of the air-chamber at any time, without external 
 help of any kind. This fact tends, of course, to 
 give him a feeling of perfect personal security, all 
 that is required on his part being the simple opening 
 of a valve inside the chamber, which in turn allows 
 the escape of the air and the opening of the door, 
 the latter being allowed to remain unfastened, the com- 
 pressed air being itself sufficient to insure hermetical 
 closure. 
 
 All that has been said of compressed air in this 
 chapter is confirmed, and more than confirmed, by 
 the experience of those populations who are obliged, 
 as in bridge- and tunnel-building, to work under 
 unusual atmospheric pressures. So convinced are 
 many of these persons by actual experience of the 
 power of compressed air to augment the action of 
 stimulants, that they vastly prefer to take their 
 coffee and alcohol in the condensed atmosphere; 
 and, in order to attain their end, they do not hesi- 
 tate to conceal these articles in bottles and smuggle 
 
THE SPECIAL THERAPEUTICS OF PAIN. 301 
 
 them into the delectable region, in spite of all rules 
 to the contrary. I myself have seen the entire floor 
 of extensive submarine workings covered with such 
 bottles, and have had abundant occasion to hear 
 from the lips of scores of workmen corroborative 
 testimony as to this remarkable phenomenon. It 
 was, indeed, the study of the habits and experiences 
 of these submarine workers which led me to an 
 appreciation of the importance of compressed air 
 as a means of treating a variety of functional de- 
 rangements of cerebro-spinal origin. 
 
 Finally, certain definite effects are obtainable from 
 compressed air without the concomitant assistance 
 of remedies of any kind ; and to this circumstance 
 some of the more permanent good derivable from 
 this agent is possibly attributable. 
 
 As space does not permit of pursuing the sub- 
 ject further, I must refer those who are sufficiently 
 interested to my original paper in the Medical 
 Record, which has already been several times re- 
 ferred to. 
 
 Limitations of the Method. — N'othing in the 
 world is more unwise than to claim too much for 
 a new departure in therapeutics, however worthily 
 conceived ; for the exaggeration at once overshadows 
 the good in it, and the result is immediate con- 
 demnation and the loss to science of what would 
 
 26 
 
302 PAIN. 
 
 have proven a valuable expedient had. its field of 
 legitimate action been accurately determined. 
 
 This danger I am resolved to overcome by abso- 
 lute openness of statement. 
 
 In the first place, then, the compressed-air treat- 
 ment, as previously described, is of no use whatever 
 in the management of the inflammatory and degen- 
 erative conditions of the spinal cord or its mem- 
 branes. I have tried it in disseminated sclerosis, in 
 spastic spinal paralysis, in poliomyelitis, with purely 
 negative results. In cerebral hemiplegia its use is 
 absolutely contraindicated ; and the same may be 
 said of articular rheumatism, the pains of which 
 are increased by air-pressure. l^sTor is neuritis a 
 disease which lends itself to this mode of treatment, 
 the increased pressure at the surface serving rather 
 to augment than to diminish the pain. 
 
 "What, then, are the affections to which the com- 
 pressed-air treatment, as previously described, is 
 best adapted ? Speaking generally, it may be said 
 that cerebral and cerebro-spinal difficulties of a 
 functional character, in which pain, exhaustion, in- 
 somnia, or depression are prominent features, are 
 the most suited to this plan of treatment. Indeed, 
 I have no hesitancy in saying that in the manage- 
 ment of the last-named class of affections it is abso- 
 lutely unapproachable. The cases already cited and 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 303 
 
 commented upon, as well as the immutable physi- 
 ology involved in the method, will, I trust, have 
 carried conviction on this point. I would observe, 
 however, that, did the space available permit, I could 
 multiply the clinical evidence tenfold. 
 
 In conclusion, let me add that not the least inter- 
 esting influence of the compressed air is its ability 
 to greatly enhance the effects of diuretics, a quality 
 which is especially conspicuous in the case of coffee 
 and diuretine. 
 
CHAPTER XVIII. 
 
 KEFLEX AND SPUEIOUS OB IMAGINARY PAINS — HYPNOTISM. 
 
 " Reflex" Pain. — ^Within the last few years a great 
 deal has been said and written regarding a class of 
 pains which, while originating at the periphery, are 
 referred to some other locality, and, notably, the 
 central nervous system. The backaches which so 
 frequently accompany uterine displacements, and 
 the headaches consecutive to eye-strain, are instances 
 in point. 
 
 It is not always, however, an easy matter to decide 
 whether a painful sensation is due to a local cause 
 or is traceable to some distant source. This is espe- 
 cially true of certain intracranial pains, the associa- 
 tion or non-association of which with a local cause 
 cannot be determined — if inspection were indeed 
 of any value — on account of the inaccessibility of 
 the parts. What, then, are the maxims to be ob- 
 served when pain exists, in the absence of neuritis 
 or other common cause, and when there is no 
 evidence of autointoxication of any kind? The 
 reasonable reply I believe to be this : Remove all 
 
 304 
 
THE SPECIAL THERAPEUTICS OF PAIN. 305 
 
 ascertainable causes of peripheral irritation, where 
 the mutilation or danger to life is not great; for, 
 even though the sequel may prove that the pain 
 was not of reflex origin, it is certain that had the 
 irritative element been allowed to remain its pres- 
 ence would have interfered with and possibly en- 
 tirely neutralized all our efi:brts to obtain relief in 
 other ways. Let me again repeat, however, by way 
 of qualification, that this is the logical course to 
 pursue when neither the life of the patient nor 
 extensive mutilation is concerned. Only pain of 
 the greatest atrocity, which has resisted all other 
 means to relieve it, and which is clearly the result 
 of the peripheral difficulty, can justify measures in- 
 volving great peril to life. 
 
 But when we have said this we have sufficiently 
 indicated the course which a reasonable conserva- 
 tism may dictate; and we shall carefully abstain 
 from wholesale condemnation of the efforts of 
 gynaecologists, ophthalmologists, and other surgeons 
 to render the removal of peripheral sources of irri- 
 tation more certain ; for such condemnation, though 
 originally in part justified by some very obvious 
 exaggerations, has been carried to an extreme which 
 is alike at variance with the facts and the canons of 
 good taste. 
 
 For my own part, I am free to confess that I 
 
 u 26* 
 
306 PAm. 
 
 have long made it a practice to have all sources of 
 peripheral irritation eliminated, as far as possible, 
 in those who come under my care for pain, or, 
 indeed, for any kind of nervous trouble. My expe- 
 rience has, in fact, taught me that such peripheral 
 disturbances — though they may not always be, and, 
 indeed, frequently enough are not, the real source 
 of the trouble — possess the quality of interfering 
 with, and even absolutely neutralizing, everything 
 that may otherwise be done for the patient. 
 
 This applies in an exceptional degree to anomalies 
 of refraction, which are often the source, and, if not 
 the source, then the perpetuating factor of various 
 head-pains. Dr. David Webster has lately written 
 with great lucidity and conservatism on this point. 
 
 Spurious or Imaginary Pains. — When a person 
 has long been the victim of more or less continuous 
 pain of either a local or general character, but more 
 especially the former, it inevitably follows that the 
 mind gradually assumes an anticipatory attitude 
 towards the unpleasant feeling ; so that, even when 
 the latter is temporarily absent, the " concept" pain 
 still haunts the mind, and the patient believes that 
 he suffers. The foundation of these delusions is 
 substantially that of the analogous phenomena ex- 
 hibited by hypnotism, — to wit, expectant attention 
 awakened by the continual repetition of the un- 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 307 
 
 pleasant sensation. Hysterical and imaginative 
 persons are especially prone to become victims of 
 this subjective kind of pain; and it is interesting to 
 note that tbey are likewise amenable to hypnotic 
 influence. While it is of importance, as may readily 
 be imagined, to determine, in a given case, v^hether 
 the pains be really objective or purely of subjective 
 origin, it must not be forgotten that, in so far as 
 the sufferings of the individual are concerned, one 
 variety is about as bad as the other. Hence violent 
 and mandatory conduct on the part of the physician 
 is to be discouraged, as being both unscientific and 
 inhuman. 
 
 Powerful moral influence, coupled with adroit 
 suggestions of an opposing character, — the attention 
 of the subject being meanwhile directed away from 
 the imaginary seat of pain, — will be found to yield 
 the best results. All this can generally be accom- 
 plished while the patient remains in his usual 
 waking condition, and without invoking the aid of 
 hypnotism, the induction of which is often beset 
 with great difliculty, and is, in a considerable per- 
 centage of cases, quite impossible. Concerning the 
 dangers of ^hypnotism, as well as the therapeutic 
 uses to which this agent might possibly be put, I 
 have expressed some opinions which, though rather 
 pessimistic, are, I believe, strictly in accordance with 
 
308 PAm. 
 
 the facts.^ The following observations are taken 
 from my original paper : 
 
 Possible Dangers of Hypnotism. — As long ago 
 as 1784 some of the dangers of hypnotism were 
 pointed out by De Puysegur, a pupil of Mesmer. 
 The danger to which he referred more particularly 
 was the criminal use which an unprincipled person 
 might make of the ascendency gained over the sub- 
 ject. These warnings, frequently repeated of late, 
 are not without reason, as the annals of crimes 
 committed during the last sixty years abundantly 
 prove. Rape, kidnapping, and murder are some of 
 the crimes charged to the account of the nefarious 
 hypnotizer. 
 
 But these are not the only sources of danger ; for 
 experience has abundantly shown that the subject 
 himself may be prompted to commit theft and other 
 species of crime after emerging from the hypnotic 
 condition. This fact, which has already been men- 
 tioned, has become the subject of special judicial 
 enactment in several countries. 
 
 Finally, the repeated hypnotization of the subject 
 is liable to be followed by more or less dangerous 
 consequences. Inordinate emotionality, impairment 
 
 1 " Some Practical Considerations on the Nature and Induction 
 of the Hypnotic State," the Medical Kecord of November 8, 1890. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 309 
 
 of volition, and a tendency to become spontaneously 
 hypnotized, or, at least, excessively drowsy, are some 
 of the more obvious features of this post-hypnotic 
 condition. I have at the present time under my 
 care a gentleman who exhibits this neurosis — for 
 neurosis it certainly is — in a striking manner. He 
 is a man of rare gifts : he has maintained, and still 
 enjoys, a high position in the community; and yet 
 his mental decrepitude is so obvious that it is matter 
 of astonishment to me that he has been able to 
 disguise its source so long. Currently, he is re- 
 garded as a sujQferer from mental overwork, and I 
 must confess that I should have had great difficulty 
 in arriving at the true nature of his difficulties had 
 he not confessed that he had been hypnotized scores 
 of times, and that his present infirmity had come on 
 as the direct result of these abuses, — for abuses they 
 certainly were. 
 
 Such a person as this is exposed to manifold 
 dangers, for he has become so susceptible that not 
 only is it possible for any one to hypnotize him, but 
 he is able, without further assistance, to induce in 
 himself the sleep-like state. 
 
 These, then, are the more manifest dangers of 
 hypnotism. 
 
 Concerning possible Therapeutic Uses of Hyp- 
 notism. — I am not very sanguine as to the future 
 
310 PAIN. 
 
 of hypnotism as a curative agent in nervous or 
 other diseases. According to my own researches, — 
 and those researches date back eight years or more, 
 — ^the method is vastly more limited than one would 
 imagine from the exaggerated claims which have 
 been of late advanced in its behalf by over-zealous 
 medical men. Let me mention a few of those lim- 
 itations. In the first place, only a certain (unknown) 
 percentage of persons are amenable to the hypnotic 
 influence; or, to express it more exactly, only a 
 limited number of persons are hypnotizable with 
 the present means at our command. Secondly, the 
 effects obtainable are evanescent; for, unless we 
 hypnotize the patient so often as to incur the risk 
 of doing him an injury, we cannot hope to per- 
 petuate the suggestions sufficiently to do any good. 
 
 From these considerations it follows that the per- 
 manent effects which one may hope to produce upon 
 the material economy through this class of ps^^chical 
 forces must be insignificant. Functions may, it is 
 true, be exalted or depressed for the time being, but 
 qualitative changes in the structures themselves are 
 impossible. The internal capsule, the thalamus, the 
 motor convolutions, the sensory tracts in the cord 
 once destroyed are not to be restored by any form 
 of interference. Moreover, a physiological substitu- 
 tion (in Bernheim's sense) for these and analogous 
 
THE SPECIAL THERAPEUTICS OP PAIN. 311 
 
 structures seems well beyond the farthest bounds of 
 physiological probability. Hence, as I have pre- 
 viously mentioned, all attempts to apply hypnotism 
 to the treatment of organic disease are opposed to 
 sound thinking. Indeed, I regard such proposals as 
 hurtful to science, and particularly medical science, 
 inasmuch as the reputation of the profession for 
 sound judgment is thereby greatly jeopardized. 
 The facts which the advocates of such questionable 
 methods have to present are still too few in number, 
 and too meagrely substantiated, to form the basis of 
 affirmative argument. What, then, is the position 
 which hypnotism may be expected to assume in the 
 neuro-therapy of the future ? In my opinion, the 
 rdle which it is destined to play is a subordinate one. 
 In the light of its present and past history I do not 
 see how it can be otherwise. As an adjunct in the 
 management of minor degrees of hypochondria, 
 morbid apprehension, depression, and hysteria, it 
 may sometimes be invoked, but then only as a col- 
 lateral expedient, and largely with a view to render- 
 ing the patient more tractable and amenable to other 
 elements in the plan of treatment. The assistance 
 afforded by an appeal to the expectancy of the sick 
 is familiar to every physician. By invoking the aid 
 of the hypnotic state such an appeal may be made 
 with an energy which is not attainable while the 
 
312 PAIN. 
 
 patient remains in the ordinary mental condition. 
 But, while the miracles recorded by enthusiastic 
 writers make, like Munchausen's tales, entertaining 
 reading, they are not likely to enter into the sober 
 realities of the consulting-room. 
 
 In view of what we now know of it, hypnotism 
 is to be dealt with by the physician ; for it is evident 
 that a competent medical man is alone in a position 
 to judge of its real or imaginary advantages. Cer- 
 tainly, only such a man should be allowed by our 
 statutes to invoke its assistance in the treatment of 
 diseases, however insignificant. 
 
CHAPTER XIX 
 
 CONCLUDING OBSERVATIONS ON THE PREVENTION OF RE- 
 LAPSE — THE PROPHYLAXIS OF PAIN. 
 
 A VERY large proportion of pains exhibit a ten- 
 dency to return. We must, therefore, do everything 
 in our power to antagonize this baneful propensity, 
 by interrupting the periodicity of the attack, and 
 by continuing to employ such agents as experience 
 has shown us to be useful in perpetuating the good 
 already obtained. Some of the remedies previously 
 mentioned, and, notably, quinine, iron, arsenic, aco- 
 nitia, and cannabis indica, are very useful for this 
 purpose. It is, indeed, necessary to do something 
 more than to interrupt the paroxysm, though this 
 of itself tends to permanent good by breaking up 
 the painful habit; but, in addition, we must examine 
 each case thoroughly, neglecting nothing in the 
 history of the case which may possibly serve to 
 enlighten us regarding the true origin of the pain. 
 Sometimes we shall be able to trace the painful 
 manifestations to some organic disorder; under 
 these circumstances we may profitably invoke the 
 o 27 813 
 
314 PAix. 
 
 aid of general medicine. In other cases the pain 
 is manifestly due to nerve-injury or' some other 
 accident, and we may then have recourse to sur- 
 gery. 
 
 In by far the greater number of cases, however, 
 we are able to trace the pain to neither injury nor 
 organic disease; but, if we examine such cases 
 attentively as to the state of the general health, we 
 are usually able to discover some qualitative or 
 quantitative change of nutrition of sufficient gravity 
 to account for the phenomenon. It is, indeed, self- 
 evident that where these derangements of nutrition 
 exist such a complicated structure as the nervous 
 system must inevitably deteriorate; and, as the 
 whole history of neuritis shows, the peripheral 
 nerves are especially liable to suffer. Sometimes 
 the vitiated condition of the system is traceable to 
 malarial poisoning; sometimes to syphilis; some- 
 times to gout; and sometimes, doubtless, to some 
 form of autointoxication with which we are still 
 unacquainted. Whatever the cause of the debility 
 may chance to be, it should be removed as speedily 
 as possible. Sometimes the pain disappears as soon 
 as the general condition of the patient begins to 
 improve ; in other cases, supplementary measures — 
 which have for their object the elimination of the 
 propensity to return, so common to most forms of 
 
THE SPECIAL THEEAPEUTICS OF PAIN. 315 
 
 pain — must be adopted. The latter phase of the 
 subject has already been sufficiently discussed. 
 
 But not all debilitated persons are necessarily the 
 victims of obstinate pain, as every physician is fully 
 aware. Certain extraneous circumstances, certain 
 phases of environment, are required, in order that 
 malnutrition shall express itself in pain. 
 
 Among such external circumstances may be men- 
 tioned intense cold, with moisture, and sudden 
 changes in temperature. These are the things 
 which must be borne by those who, in the regular 
 course of their daily vocations, are obliged to go 
 from hot apartments into the cold, external atmos- 
 phere ; or who are compelled to live in a climate of 
 sudden changes, which really amounts to the same 
 thing. Against circumstances of this kind it is, of 
 course, impossible to provide an absolute remedy. 
 We may counsel frequent changes of clothing to 
 suit the fluctuations of temperature ; we may advise 
 that persons who go from hot to cold apartments, 
 in the pursuit of their daily duties, shall make such 
 transitions as gradually as possible ; we may do this 
 and more, and yet find that our injunctions are 
 not of much avail, in so far as the attainment of 
 permanent good is concerned. 
 
 Such being the unfortunate situation, one is often 
 at a loss what to recommend. Sometimes I have 
 
316 PAIN. 
 
 advised persons tlaus exposed to dress in thick 
 woollen garments, — those next the skin being spe- 
 cially made with a view to facilitating the absorp- 
 tion of the cutaneous secretions; and over these 
 conventional garments I have the patients wear a 
 perforated vest of thick paper, lined with silk. 
 
 As a matter of course, great attention should be 
 paid to all matters of diet. The patient should be 
 put upon nutritious food, which at the same time 
 must be digestible. Beefsteaks, mutton-chops, milk, 
 cod-liver oil, and eggs are the staples where the 
 ansemia is pronounced. Should the powers of as- 
 similation be impaired, we must then resort to a 
 good preparation of malt. I prefer that of Trom- 
 mer, which acts upon starch with great energy, as 
 every physician can ascertain by applying the iodine 
 test. Pepsin and acids may, of course, be given 
 when indicated. As a matter of course, red meats 
 are to be avoided in rheumatic cases. 
 
 These, then, are the principles to be observed in 
 the management of pain. As may well be imagined, 
 the intricacy of the whole subject of pain is such, 
 and its connection with a vast array of pathological 
 conditions so intimate, that it is impossible to do 
 more than formulate general rules for its manage- 
 ment. Many cases will necessitate much tact in 
 overcoming complicating circumstances of various 
 
THE SPECIAL THERAPEUTICS OF PAIN. 317 
 
 kinds. These I shall not attempt to discuss here, 
 as they properly belong in the domain of general 
 medicine or surgery. 
 
 If, however, I have succeeded in indicating prin- 
 ciples of general utility, I shall be content. But if, 
 in addition, I shall have been able to abate some- 
 what the use of enslaving drugs, I shall also feel 
 that the ethical value of the work has been pro- 
 portionately enhanced. 
 
CHAPTER XX. 
 
 SUPPLEMENTARY OBSERVATIONS ON TORTURE, OR THE IN- 
 FLICTION OF PAIN AS A JUDICIAL PUNISHMENT OR FOR 
 THE PURPOSE OF EXTORTING A CONFESSION OF GUILT. 
 
 There is no chapter in the history of the human 
 race so well calculated to cause a blush of shame as 
 that which deals with torture. 
 
 That creatures with any discernible resemblance 
 to men could have been found to conceive and exe- 
 cute such abominations; that society should have 
 tolerated them; that the learned classes, or what 
 passed for such, should not only have condoned the 
 infamy, but actually invoked it, is an enigma before 
 which even the astute psychologist stands aghast. 
 
 Whatever may be said of the corruption of civil 
 and ecclesiastical government, which is such an 
 apparent feature of the Dark Ages, this of itself is 
 not sufficient to account for the systematized cruelty 
 which found expression in the thumb-screw, the 
 rack, and the fagot. The true cause of such moral 
 obliquity is rather to be sought for in the unutter- 
 able ignorance, superstition, and moral debasement 
 of the whole population, which alone made possible 
 318 
 
THE SPECIAL THERAPEUTICS OF PAIN. 319 
 
 the tyrannies of the feudal and ecclesiastical author- 
 ities throughout Europe. That the degradation of 
 the common people was the real source of this or- 
 ganized brutality is shown by the fact that even 
 in the republic of Switzerland, under a relatively 
 liberal form of government, torture was a recog- 
 nized element of ecclesiastical and judicial disci- 
 pline. It was, moreover, precisely in such a soil as 
 this that retributive ideas of justice, as opposed to 
 the reformatory principles of modern criminology, 
 were certain to flourish. As a result of this uni- 
 versal intellectual and moral debasement it was 
 possible for both the civil and ecclesiastical powers 
 to enforce their authority by incredible cruelty, and 
 without fear of a popular uprising. 
 
 'No revolutionary movement could, indeed, have 
 succeeded, even had a portion of the population 
 been disposed to throw off' the yoke of despotism, 
 since persons competent to lead such a movement 
 were only to be found among the privileged classes, 
 whose interests were bound up with existing insti- 
 tutions. The league of the civil authorities with 
 the Church would, moreover, have rendered such an 
 attempt abortive from the start, since the supersti- 
 tion of the peasantry rendered them abject slaves 
 to the ecclesiastical power. In a word, it is only 
 through the percolation of enlightened sentiment 
 
320 PAIN. 
 
 among tlie masses of the people that one may hope 
 to antagonize that fundamental predisposition to 
 cruelty which is the birth-mark of animalism. The 
 self-inflicted tortures of Oriental and European as- 
 cetics are but extreme manifestations of the belief 
 in the retributive character of punishment. Even 
 in our own day the great reforms in prison disci- 
 pline, and the humane instincts which actuate the 
 most enlightened persons, have not sufficed to elim- 
 inate from the minds of the ignorant the conception 
 of revenge as an essential feature of judicial penal- 
 ties. The conceptions which such persons entertain 
 of the Deity are also colored by their brutish in- 
 stincts ; and, what is still more to be regretted, they 
 have been able to foist their crude and barbarous 
 conceptions upon persons who are infinitely their 
 superiors in the scale of moral and intellectual 
 enlightenment. 
 
 In 1640 occurred the last-recorded instance of 
 judicial torture in England; but there is reason to 
 believe that it was often secretly applied long after- 
 wards. However this may be, it is certain that the 
 revolting practice was in vogue both in France and 
 G-ermany long subsequent to its official abolition in 
 Great Britain. But even in the Irish dependencies 
 of the latter country there was a sporadic revival of 
 torture by the military judges in 1798. 
 
THE SPECIAL THERAPEUTICS OF PAIN. 321 
 
 As a means of extorting a confession it was com- 
 monly resorted to in various parts of Europe till 
 the close of the last century. This seems incredi- 
 ble ; but the fact is adequately attested. 
 
 It may readily be imagined that cries of protest 
 were not lacking in the midst of this systematized 
 barbarity ; in fact, some of the most eminent men 
 of the day were loud in their denunciations. Among 
 those who gave vent to their disapproval were Bec- 
 caria and Voltaire ; and to their endeavors the final 
 disappearance of torture from Europe was largely 
 due. 
 
 The following are some of the more common 
 modes of inflicting torture, prevalent throughout 
 the continental countries during the Dark Ages : 
 
 Pouring boiling oil or molten lead on various 
 portions of the body by the aid of a perforated spoon 
 or sieve. Flagellation with scourges of barbed iron, 
 so that the flesh was extensively lacerated. Tearing 
 the tongue out, a penalty for blasphemy. Stretch- 
 ing the victim on a species of couch and flaying 
 him alive. Crushing the thumbs, toes, feet, hands, 
 or shinbone by the aid of vice-like arrangements 
 constructed with diabolical ingenuity. Suspected 
 persons were made to submit in all European 
 countries to the ordeal of the thumb-screw; and 
 so fearful was the torture endured that the victim 
 
322 PAIN. 
 
 frequently implicated himself and others by forced 
 confessions of crimes of which all were entirely 
 innocent. Breaking on the wheel, and burning to 
 death, — the latter penalty being at one time ex- 
 ceedingly common in Europe. Among the chief 
 victims were poor old women accused of witchcraft. 
 Stretching the victim on the rack and pouring 
 boiling oil or molten lead down his throat was 
 also a common mode of judicial punishment. 
 
 These awful details of a nightmare of cruelty, 
 which held all Europe in Satanic bondage for 
 several centuries, are at once a warning against 
 the dangers of primitive animalism, and an appeal 
 to the spirituality and altruism which inevitably 
 flow from the highest knowledge. 
 
 It should be a source of congratulation to all 
 medical men to know that the physicians of the 
 Middle Ages — or those who passed for such — usu- 
 ally did what they could to mitigate the sufferings 
 of those of their unfortunate fellow-beings who 
 were condemned to inquisitorial pain. 
 
 These, I believe, are the principal sources of the 
 barbarity which pervaded all Europe during the 
 Dark Ages, — a barbarity which found a most awful 
 expression in tortures, the devilish ingenuity and 
 cruelty of which seem incredible in the light of 
 modern meliorism. 
 
INDEX. 
 
 Alcoholic intoxication, neuritis in, 48. 
 Angina pectoris, 87. 
 
 due to organic disease of the heart, 88. 
 idiopathic form of, 88. 
 symptoms of, 89. 
 treatment of, 89. 
 Beriheri, neuritis in, 56. 
 
 Calabar bean, action of, opposed to that of strychnine, 186. 
 Cerebral cortex, sensory regions of, 18. 
 Cold in the treatment of pain, 225. 
 
 Compressed air, author's method of employing it as an adjunct in 
 the treatment of pain of cerebro-spinal origin, 256. 
 as a means of focalizing the effect of remedies upon the 
 
 intracranial structures, 275. 
 illustrative cases, 287. 
 limitations of the method, 301. 
 Counter-irritation in the treatment of pain, 225. 
 Electricity in pain, 223. 
 Gout, 71. 
 
 a prolific source of pain, 70. 
 mineral waters in, 77. 
 theories regarding the nature of, 71. 
 treatment of, 76. 
 Headache, 81. 
 anaemic, 81. 
 bilious, 83. 
 cerebro-anaamic, 82. 
 cerebro-hypersemic, 82. 
 
 323 
 
324 INDEX. 
 
 Headache, hypersemic, 82. 
 
 nervous, 82. 
 
 neurasthenic, 83. 
 
 organic, 85. 
 
 toxic, 84. 
 Heat in the treatment of pain, 225. 
 Hypnotism, possible utility of, in pain, 309. 
 Influenza, neuritis in, 50. 
 Insomnia as a complication of pain, 128. 
 Leprosy, neuritis in, 51. 
 Melancholia as a complication of pain, 134. 
 
 compressed air and stimulants in, 161. 
 
 shower-baths in, 164. 
 Mineral waters in gout, 77. 
 Nerves, sensory and motor, 22. 
 
 Du Bois Eeymond's experimental researches regarding, 23. 
 
 evolution of electricity in, 23. 
 
 identity of processes in, 22. 
 
 Eadcliffe on, 22. 
 Neuralgia, 62. 
 
 cardiac, 87. 
 
 cervico-brachial, 67. 
 
 cervico-occipital, 67. 
 
 coccygodynia, 68. 
 
 crural, 67. 
 
 dorso-intercostal, 68. 
 
 general symptomatology of, 63. 
 
 intercostal, " mastodynia," 68. 
 
 lumbar, 67. 
 
 lumbo-abdominal, 68. 
 
 muscular, 69. 
 
 prognosis of, 69. 
 
 sciatic, 68. 
 
 trigeminal, 66. 
 Neuritis, 29. 
 
 alcoholic, 48. 
 
 differentiation of, from ataxia, 50. 
 symptoms of, 48. 
 
 "beriberi" as a factor of, 57. 
 
INDEX. 325 
 
 JNeuritis, general considerations on, 29. 
 influenza (" grippe") as a cause of, 60. 
 
 Gowers on, 51. 
 leprosy as a cause of, 51. 
 
 Leloir on, 51. 
 
 Morrow on, 53. 
 multiple, 41. 
 
 cause of death in, 47. 
 
 diagnosis of, 60. 
 
 functions of bladder and rectum in, 48. 
 
 prognosis of, 61. 
 
 symptoms (general) of, 44. 
 
 tendon reflexes in, 48. 
 simple, 31. 
 
 pathology of, 36. 
 
 prognosis of, 35. 
 
 symptoms of, 32. 
 
 treatment of, 40. 
 Pain, appearances at the seat of, 109. 
 
 cardiac derangements in ; Franck and Potain on, 111. 
 definition of, 11. 
 
 Bilon on, 11. 
 
 Cicero on, 11. 
 
 Corning on, 12. 
 
 Erb on, 12. 
 
 Eulenburg on, 12. 
 
 Gaubius on, 11. 
 
 Sauvage on, 11. 
 
 Valentin on, 12. 
 
 Wundt on, 12. 
 derangements of motility in. 111. 
 diagnostic value of, 92. 
 
 in diseases of the organs within the thorax, 98. 
 
 in organic diseases of the nervous system, 102. 
 
 when located in the head, eye, and ear, 94. 
 diminution of the secretory and excretory functions in, 112. 
 disorders of nutrition in, 112. 
 facial expression in 110. 
 immediate death from, 113. 
 
 28 
 
326 INDEX. 
 
 Pain, infliction of, as a judicial punishment, 318. 
 insomnia in, 128. 
 intra-abdominal, 91. 
 intracranial (headache), 81. 
 intra-thoracic, 87. 
 
 location of, in definite nerve-areas, 62. 
 loss of appetite in, 112. 
 medico-legal significance of, 108, 117. 
 melancholia in, 134. 
 nervous irritability in, 109. 
 
 objective method of determining the presence of, 113. 
 perception of, not confined to an isolated cortical area, 14. 
 prevention of relapse in, 313. 
 prophylaxis of, 314. 
 reflex, author on, 304. 
 spurious, 306. 
 
 in hysteria, 113. 
 suicide in, 137. 
 therapeutics of, 140. 
 
 aconitia in, 226. 
 
 acupuncture in, 225. 
 
 alcohol in, 168. 
 
 antipyrin in, 189. 
 
 arsenic in, 188. 
 
 baths in, 77. 
 
 belladonna in, 181. 
 
 bromides in, 174. 
 
 by local medication of the spinal cord (author's method), 
 241. 
 
 by medication of the cavda equina (author's method), 247. 
 
 by "suspension," 254. 
 
 cannabis Indica in, 178. 
 
 chlorodyne in, 173. 
 
 chloroform in, 173. 
 
 cocaine in, 197. 
 
 cold in, 225. 
 
 compressed air with analgesics in (author's method), 256. 
 
 counter-irritation in, 225. 
 
 electricity in, 223. 
 
INDEX. 327 
 
 Pain, therapeutics of, ether in, 173. 
 exalgin in, 192. 
 gelsemium in, 177. 
 heat in, 225. 
 helleborein in, 197. 
 Hoffmann's anodyne in, 173. 
 hydrobromic acid in, 176. 
 hypnotism in, 309. 
 iodopyrin in, 196. 
 kava-kava in, 197. 
 methacetine in, 197. 
 methoxy-caffeine in, 197. 
 methylene blue in, 196. 
 napelline in, 196. 
 ointments in, 226. 
 opium in, 166. 
 para-acetophenetidin in, 196. 
 phenacetin in, 190. 
 phenocoll in, 195. 
 pressure in, 224. 
 quinine in, 187. 
 rest in, 141. 
 salipyrin in, 193. 
 salol in, 192. 
 salophen in, 194. 
 solanine in, 194. 
 strychnine in, 186. 
 thrombosis, therapeutic in, 216. 
 thymacetin in, 195. 
 urethane in, 195. 
 veratrine in, 226. 
 zinc in, 187. 
 surgical therapeutics of, 227. 
 
 Abbe on the surgical treatment of inveterate tic douloureux 
 
 in, 228. 
 Carnochan on resection of the affected nerve in, 228. 
 Dennis on the resection of nerves in, 231. 
 division of sensory nerve-roots in, 231. 
 ligation of arteries in, 228. 
 
328 INDEX. 
 
 Pain, surgical therapeutics of, resection of semilunar ganglion for 
 inveterate facial neuralgia in. Rose and Andrews on, 233. 
 vaso-motor anomalies in, 112. 
 Painful impressions, transmission of, 16. 
 
 correct and erroneous reference of, 25. 
 through the cord, 17. 
 through internal capsule, 18. 
 through the peripheral nerves, 16. 
 Pressure in the treatment of pain, 224. 
 Eeflex pain, author on, 304. 
 
 Remedies, enhancement of their effects upon the peripheral nerves 
 (author's methods), 206, 213, 216. 
 internal, applicable in the treatment of pain or its complica- 
 tions, 165, 189. 
 introduction of, into the skin by the aid of the galvanic cur- 
 rent, 209. 
 laws regarding the action of, on the nervous system, 198. 
 local analgesic, 197. 
 
 recent, which have been employed in the treatment of pain, 189. 
 sedative, 165. 
 stimulating, 177. 
 surgical, in pain, 227. 
 Rest, cerebral, author's plan of, 151. 
 Rheumatism, 70. 
 
 a prolific source of pain, 70. 
 Satterlee on, 79. 
 
 theories regarding the nature of, 70. 
 treatment of, 74. 
 Sensorium, isolation of, from environment (author's plan), 154. 
 Spinal concussion, 117. 
 
 illustrative cases of, 120. 
 symptoms of, 118. 
 Spinal irritation, 186. 
 
 strychnine in, 186. 
 Therapeutic thrombosis, author's method of inducing, 216. 
 Torture, or the infliction of pain as a judicial punishment, 318. 
 Webster, David, on anomalies of refraction in pain, 306. 
 
 THE END. 
 
i * 
 
^^