PART II.

REVIEWS AND BIBLIOGRAPHICAL NOTICES. A T

Cyclopcediaof the Practice.of Medicine. Edited by DR. H. VoN ZIE~SSEN. Vol. XL--Diseases of the Peripheral Cerebro-spinal Nerves. London: Sampson Low, Marston, Searle, and Riving- ton, Crown Buildings, 188, Fleet-street. 1876. Pp. 623.

THIs fine volume, which is translated by Mr. Henry Power, of London, is the work of Professor Wilhelm t/einrich Erb, of Heidelberg, Baden. The professor, though still a young man, has much distinguished himself in the kindred specialities of electro- therapy and diseases of the nervous system. The volume is divided into two portions--the first and larger treating of Func- tional Diseases (neuroses) of the Peripheral Nerves; the second part dealing "with the Anatomical Diseases of the Peripheral Nerves. This old-established division of the diseases of the nervous system into functional and organic cannot yet be altered with advantage. We meet, in the first place, with an extensive group of diseases of the peripheral nerves in which well-marked func- tional disturbances--as pain, anaesthesia, convulsion, paralysis, and the like--are present, and in which we are unable to point to any constant anatmnical lesions; these are consequently termed func- tional affections, or "neuroses" of the peripheral nerves. In the second place we have a smaller group, comprising those in which there are distinct anatomical changes--as inflammatory and dege- nerative processes, and neoplastic formations--which are named "anatomical" or "organic" diseases of the peripheral nerves. The author candidly observes that the great progress that has been made in all departments of neuropathology in the course of the last ten years has been essentially in one direction--that is to say, the advance in our information has been almost exclusively limited to the accumulation of accurate descriptions of clinical phenomena and to the appropriate application of remedial measures. He appeals to the relatively small space devoted in the best recent text-books on nervous disorders to the anatomical, as compared with that which is devoted to the functional diseases of this system.

212 Reviews and Bibliographical Notices.

The following important physiological laws are briefly exposed-- laws which, governing the normal sensory processes, frequently afford us welcome information in pathological conditions. The law of isolated conduction, according to which any excitation applied to a centripetal fibre, is conducted by this alone to the central apparatus, and is not transmitted to other adjoining fibres. The law of excentric projection, according to which excitations affecting either the central sensory apparatus itself, or any part of the centripetal conducting fibres, are referred by the mind to the peripheric extremities of the conducting fibre, from Whence experience has shown that physiological stimuli usually proceed. [Examples of this are found in the cases so frequently cited where irritations of the nerve-stumps of amputated limbs have been referred to their peripheric extremities, and cases where irritations of the centripetally-conducting fibres of the spinal cord or brain have been referred to the cutaneous surface of the limbs. The law of associated sensation or irradiation, according to which irrita- tion of centripetal fibres in the central organ (probably through the intervention of ganglion cells in the gray substance) can be transferred to other centripetal paths, and thus excite co-sensatlons, which are again referred by the mind, in accordance with the laws of excentrlc projection, to the periphery. According to ?,his law, the peripheral excitation of a centripetal fibre may be accompanied by a sensation in a more or less distant part of the periphery; as an example, the occurrence of an "irradiated" pain in the back on strong irritation in the region of the sciatic nerve. The law of reflex action, according to which irritations of centripetal fibres in the central organs (probably owing to the intervention of ganglionic apparatus in the gray substance) may be transferred to centrifugal fibres--motor, vaso-motor, and secretory nerves--and exhibit their special action at the periphery. These reflex actions take place according to laws that are accurately laid down, and play a great part in the phenomena accompanying sensory neuroses.

The author, in accordance with the practical character of his work, considers that at pre~ent all discussion with regard to the essence of pain is idle. He thinks the hypothesis most worthy of discussion is that advocated with so much ingenuity by Griesinger, which is to the effect that the essence of paln lies in " a disturbance of the organisatlon" of the nerve at some point in its course, but no step in advance is made by this hypothesis, because no such molecular changes are discernible by us, and because there is no

Cyclopcedia of the Practice of Medicine. 213

sharply-defined line of demarcation between the molecular change which we are now accustomed to consider accompanies every excitation, and that which accompanies pain-producing "disturb- ances of the organisation." The pathological anatomy of pain is an old and a strange secret. So obscure are the accounts of the older physicians as to neuralgia--facile princeps among palns--that it has been inferred that in former times it was comparatively rare. Nothing definite in regard to it is stated by Hippocrates. Aret~eus is the first who gives a recognisable dgscription of it, though with- out any accurate insight into its etiology, and the same may be said of Galen and Paulus Z]~gineta. ]n the Middle Ages, and even up to the middle of the eighteenth century, only imperfect description and recognition of neuralgia existed. The first correct explanation of neuralgia as a painful affection of the nerves dates from Andrd, who, in 1756, first described " Tic douloureux."

In the etiology of neuralgia the predisposing and exciting causes are carefully discussed, and Anstie's views as to a neuropatMe ]~ereditary predisposition are fully noticed. By this phrase is under- stood a pathological constitution affecting the functional activity of the nervous system (Griesinger), by virtue of which those who are thus constituted manifest throughout life the most varied patholo- gical symptoms in regard to sensory, motor, or psychical processes. No one has as yet been able to show in what this peculiar anomaly consists, and while some console themselves with the hypothesis of "delicate trophic disturbances," or "modifications of molecular arrangement," without thereby getting any nearer to the facts, we must rest satisfied with the fact that such constitutional neuro- pathies really exist, and that they play an important part in the history of neuralgia. After dwelling on the more familiar exciting causes, reference is made to neuralgia resulting from overwork of the eyes, and chiefly affecting the fifth nerve, to true neuralgia belonging to the secondary stages of syphilis, occurring with tolerable frequency, particularly in women, and affecting especially the supra-orbital and sciatic nerves. In strongly-mercurialised individuals we very frequently see obstinate and not easily curable neuralgias develop, which affect the body more or less generally. Both these forms are to be distinguished from the well-known dolores osteocopi (bone-shattering pains). I t is worthy of 'note that in ~nalarial neuralgia certain nerves, and especially the first branch of the fifth, are particularly liable to be affected. These malarial neuralgias have a well-marked periodic course, are often

Q

214 Reviews andBibliographical Notices.

accompanied by febrile phenomena, and yield very readily to anti- periodic means. From the frequent submission of any form of neura]gla to quinine, it is only in those cases where a tertian or quartan type is present that the malarial origin of the disease can be positively a~rmed. The great majority of these malarial neural- gias, according to Griesinger, occur in somewhat advanced age-- above the age of forty.

In making the diagnosis of an attack of neuralgic disease, it is in the first place requisite to determine whether neuralgia is really present. :No term is more loosely or conveniently used. The diMculties, which are occasionally considerable, may, in general, be surmounted by recollecting that the following are essential and characteristic symptoms of neuralgia:--" 1. That the pain is limited to a definite nerve-path, either trunk, branch, or area of distribution, and that it is usually confined to one side. 2. That the pain is, without any obvious reason, either intermitting, or at least distinctly remitting, in character. 3. That the pain presents very peculiar characters, and is extraordinarily acute. 4. That there are certain spots in the course of the nerve, or in the area of its distribution, that are very sensitive to pressure (points doulou- reux). 5. That the pain is associated with,certain sensory, motor and vaso-motor, and secretory phenomena. 6. That the pain is unaccompanied by any inflammatory or �9 symptom, or any general disturbance of health at all corresponding with the amount of subjective disorder. The diagnosis will be greatly strengthened by the ascertainment of the various predisposing conditions. The painful affections, which are especially liable to be mistaken for neuralgia, are all those painful affections, "myalgias," that are loealised in the muscles, muscular pain, muscular ~heumatism, and which are known under the names of lumbago, pleurodynia, torti- collis, and the like, and which arise either from catching cold or from over-exertlon of the muscles. The diagnosis between such pains and the various forms of neuralgia is to be established by attention to the following points:--Myalgia, or muscular pain, corresponds to the position of a muscle, and not to the course of a nerve; it is fixed in some definite circumscribed area; it does not usually occur in paroxysms, and is caused and increased by every contraction of the affected muscle; local sensitiveness is only pre- sent over the extent of the affected muscle and its tendons. Pro- fessor Erb considers that in many cases it is a matter of taste whether the group of symptoms termed spinal irritation shall be

Cyclopc~dia of the Practice of Medicine. 215

charaeterised as such or as neura|gia. The differential diagnostic point lles in the migratory character of the pain in spinal irritation. When the pains, he observes, are limited to a definite nerve, and there is also sensitiveness of one or two spinous processes, we assume the existence of a neuralgia with a well-marked apophysiary point; when the pains wander, leaping from one nerve-terrltory to another, whilst the hypersensitiveness to pressure affects first one and then .another vertebra, we speak of the case as being one of spinal irritation. This distinction may be of considerable import- ance in the treatment, and the view is more tolerant than that of Romberg,* who speaks of spinal irritation as " a fantastic caricature dragged into neuropathology .. . . by certain English physicians who, to the present day, have failed to achieve a reputation in their native country."

The decision of the question, whether neuralgia is of central or peripheral origin, is one of the greatest importance, because neuralgic affections are in many cases the very first precursors of intrinsic disease in the brain or spinal cord. The recognition of the concomitant phenomena indicating disease of the brain or spinal cord demands the greatest care and the widest knowledge on the part of the physician. Benedict's attempts to determine the seat of a neuralgia, from the character and situation of the pain, are detailed. After a fitll consideration of this matter, the author observes that earnest endeavours must still be made to extend our knowledge in this direction.

The data upon which the prognosis of the curability and dura- tion of neuralgia in any particular case should be more especially based are principally--the cause and seat of the disease; the par- ticular nerves affected ; the age and sex of the patient ; the violence and frequency of the attacks, as well as the protracted duration of the whole complaint; and the existence of complications. The manner in which our opinion should be swayed by a consideration of these various matters is pointed out.

The t rea tment is discussed at great length. The physician who would most succesfully respond to the earnest solicitations of his neuralgic patients must be thoroughly acquainted with, and possess a complete mastery over, all the resources for relieving pain, which have, undoubtedly, been increased in number of late years, and at the same time been rendered more precise. Prophylactic measures should be adopted by those who are predisposed to the disease.

a Dis. of :Nervous Syst., I., pp. !52, 154. Syd. Soc. Transl.

216 Reviews and BibliograpI~ical Notices.

Good diet, abundant and nourishing, is of primary importance, and no apprehension need be entertained that such diet will prove too strong or stimulating. Regular and systematic exercise, as an essential correlate o f abundant supplies of nourishing food, is a powerful strengthener of the nervous system. Plenty of sleep; pure fresh air; avoidance of stimulants; restraint of the sexual impulses at any cost, however difficult this may appear in many cases; systematic direction of the mind towards interesting and useful objects of study form the basis of measures which, if thoroughly carried out, will produce satisfactory results. Such nerve-invigorating treatment often strikes at the root of the neuro- pathic diathesis. Among specific remedial measures there are three groups of remedies that occupy the foremost place in the treatment of neuralgia, as being the most effectlve--1. Electricity in its various forms; 2. The narcotics, especially when applied hypodermically; 3. Certain nervine specifics, which experience has shown to be useful in many cases. Electricity has recently become the most important remedy in the treatment of neuralgia, in consequence of the brilliant success that has attended its application in many different forms of the disease, and in no other disease are the results of electro-therapeutlcal treatment so certainly established as in neuralgia. Of the two kinds of electricity now in constant use, the galvanic current (continuous current) is found to be the more active and applicable to a greater variety of forms of the disease than faradic electricity. Faradic electricity (the interrupted current) is chiefly useful in peripheric neuralgia, when the nerves can be reached by the current, and in cases where no remakable anatomical change, as neuritis or the like, is present , and thus especially in the so-called purely idiopathic, or " habitual," neuralgia. The galvanic current (continuous current) has at least the same action upon peripheric neuralgia, whilst, in addition, it is very effective in the central and deep-seated forms of the disease (spinal and cerebral neuralgias, and neuralgias of the roots of nerves). Moreover, by its "catalytic" effects--that is to say, by its influence on the vessels, upon exudations and the processes of nutrition--it exerts a wide influence on those neuralgias which are uninfluenced by the faradic current. There are two methods of applying faradic electricity (interrupted current)--a. By conducting a strong current of the secondary spiral, for a few minutes, through the nerve, by means of moist electrodes, one of them being placed on the nerve trunk as near as possible to its central origin; this plan must, for the most

Cyclopoedia of the Practice of Medicine. 217

part, be frequently repeated, b. By producing energetic irritation of the skin with an electric brush, or by means of an electric mona, in the region of distribution of the nerve, at its point of emergence, and over the points douloureux. The application of galvanic elec- tricity (continuous current) is especially intended to modify the nutritive processes taking place in the nerve, to produce the so- called catalytic effects, and to lower the irritability of the nerves. The results of its application, either according to the polar or the direction method, seem to be equally good. In the polar method, tile anode (positive electrode) is applied first upon the nerve trunk (when possible in the immediate vicinity of the proper focus of the disease), and then upon the points douloureux, and the cathode (negative electrode) upon some indifferent point. In the direction method, the descending direction of the current is used by preference, and the anode (positive electrode) is then to be placed upon the plexus, or upon the roots of the nerve, and the cathode (negative electrode) upon the nerve trunk and the painfhl points. As a rule, the duration of the sittings should be short, extending over from two to eight minutes, and repeated daily, or every other day. The strength of the current must, in general, be moderate. The effects are usually experienced at once, and con- tinue for a variable period, from two o~ three to twenty-four hours, ultimately, after a variable number of sittings, becoming permanent. If, after a moderate number of sittings, as from six to ten, no appreciable benefit is experienced, the case must, in general, be regarded as one not adapted for the electrical plan of treat- ment.

Narcotics (and ancesthetics) constitute palliative means of treating neuralgia that are uncommonly certain and agreeable in their mode of action, arid are unsurpassed by any remedies, especially when used subcutaneously. When a decided local action is intended, as is usually the case in neuralgia, the injection should be made as near as possible to the nerve trunk affected, or into the painful point. Injections of morphia are contra-indicated in cases of great debility, in advanced age, hypera~mia of the brain, and organic disease of the heart. Atropine alone, of the other narcotics, deserves special mention; it exerts an anti-neuralgic effect similar to that of morphia, and may even prove serviceable when the latter fails. The dose for injection ranges from the one one-hundred-and- thirtieth to the one twenty-second of a grain. Although but little confidence can be placed in the effects of the external application of

218 Reviews and Bibliographical Notices.

narcotic remedies, we cannot, however, afford to dispense entirely with the use of narcotic ointments and embrocations in ordinary practice, since it cannot be denied that their application is often followed by favourable results. Chloroform may be used in the form of inhalations, or internally, or in the form of an enema, in which both ether and chloroform can be given in doses of from fifteen to twenty minims suspended in starch paste. �9 Administered in this form, they may be ordered in neuralgia of the sacral plexus or of the pelvic nerves. Although hydrate of chloral may be inef- fective in cases of severe neuralgia, its well-marked hypnotic action is useful in many cases, and for this purpose it may be advan- tageously combined with small doses of morphia, in the proportion, for example, of fifteen grains of chloral to one-sixth of a grain of morphia.

The group of sjoec~c remedies includes a great variety of reme- dial measures, some of which have been discovered empirically, and their value demonstrated by experience; others of which are the outcome of physiological researches or pathological considera- tions. The influence of some of these specifics is undoubted, and has been satisfactorily established by the testimony of excellent observers. In the very first rank amongst specific remedies is to be placed arsenic, which acts not only as an anti-periodic remedy in neuralgias of malarial origin, but also as a proper nervine tonic. I t is especially effective in cases where there is a general nervous diathesis and imperfect formation of blood. In such cases Fowler's solution may be given in doses of from three to ten drops three times a day, in gradually increasing doses, or the arsenious acid may be given dissolved in water, in doses of from one-elghth to one-half of a grain per diem, in divided doses. Recently arsenic has been injected hypodermically (Eulenberg), and there are certain advantages in this method of using the remedy. Zinc, in the form of oxide, or of valerianate, or of sulphate, if used, must be prescribed in large doses. Phosphorus is warmly recommended, especially in anaemic and neurasthenic neuralgias~ The preparations of iron are of undeniable value in the anaemic forms of neuralgia. The prepa- ration to be employed must be decided by the practitioner, and on this point there is a legitimate difference of opinion--for example, according to Anstie, ~ " the carbonate, in large doses, is the best form, when iron is needed at all;" whereas Erb says, " the carbo- nate of iron in particular, which was formerly given in such

System of Medicine. Reynolds. W'ol. II., p. 745.

DE CtIAUMONT--Lectures on State Medicine. 219

enormous doses, appears to possess no specific action on neuralgia." Quinine has a very decided action on neuralgias, even where they are not dependent on malaria. Strychnia is highly praised, whether given internally or injected hypodermically, and it may be given combined with the solution of chloride of iron. Iodide of potassium proves serviceable in many cases of neuralgia, as in those of chronic rheumatic character, and in very obstinate idiopathic cases. Bromide of potassium is extremely valuable, especially in cases where it produces an hypnotic effect. The author coincides with Anstie's opinion of its utility in neuralgia attacking those who, whilst otherwise in good health, exhibit a certain restlessness and irritability of disposition, which is often the consequence of insuf- ficient gratification of the sexual passion, as in women condemned to celibacy; and he observes that but little experience in the treat- ment of the somewhat more matured women of the better educated classes is required to demonstrate the use of his (Anstie's) practical observations on this point. As in epilepsy, large doses are requisite.

The foregoing notice can hardly convey any adequate impression of the value of the volume alluded to. I t would be impossible, unless at extreme length, even to epitomise the information upon the various forms of nervous disease it contains. The volume is one of the best yet issued of the Cyclopmdia, and cannot fail to raise the series to the highest rank among the medical publications

of modern times. A~THUR WY/~SIE FOOT.

Zectures on State Medicine. Delivered before the Society of Apo- thecaries. By F. S. B. F. DE CHAUMO~T, M.D., F.R.C.S.E., Joint Professor of Military Hygiene, Army Medical School, Netlcy. London: Smith, Elder, & Co. 1875. Large 8vo, pp. 196.

THIs volume consists of six lectures, delivered in May and June, 1875, before the English Society of Apothecaries. The iMbrma- tion given is imparted in a very agreeable, taking style, but, at the the same time, not in that loose manner which distinguishes so many of so-called "popular works." The subjects treated of are the history of sanitation, enactments relating to public health, venti- lation, water supplies, soil in relation to health, the sewage question, disposal of the dead, food, exercise, vital statistics, prevention of

220 Reviews and Bibliographical Notices.

dlsease, epidemics, &c. A very fair amount of information is imparted in relation to these subjects, and though they are by no means exhaustively treated, yet they are in many respects examined with an amount of originality which one might expect from so eminent a sanitarian as the author.

W e find that Dr. De Chaumont is in favour of cremation as the best means of disposing of the dead; but we think that the policy of consigning the remnants of mortality to the earth, as practised in all clvilised countries, has been fully vindicated in the admirable Report on that subject, published in 1875, by the Board of Health of Massachusetts.

Army Medical Report for 1873. Vol. X V . London. 1875. Pp. 508.

WE have only recently received this volume, for though it relates to the events of 1873, it was only published in 1875, and actually sent out in 1876. This delay in publishing the Report arises chiefly from the fact that the British army is scattered all over the world, and, therefore, the statistics in relation to it can only be gathered in very slowly. In addition to the usual information relating to the health of the army at home and abroad, the report contains several valuable papers on special subjects, by Drs. Parkes, Porter, Gore, Nicholson, &e., some of which will be taken advantage of in our "Reports on Public Health."

Army Medical Report for 1874. Pp. 220.

T~Is volume followed closely its immediate predecessor. In addition to the usual statistics relating to the health of the army contained in this volume, we find in it five papers on various subjects by Dr. Porter, and one on the topography of districts near the Persian Gulf by Dr. Evatt.

Des Propridtds Physiologiques de Bromure de Camphre. Par Lou i s PATIIAULT. Paris : Delahaye. 1875.

THIS pamphlet conveys, in a convenient form for reference, the information relating to this new aspirant for notice up to the date of its publication. The author made some personal observations on himself, respecting the elimination of this substance by the kidneys.