seen in the female sex. It occurs in two forms-symptomatic and idiopathic. These two types possess well-marked and distinct features, and each may show modifications depending upon the the causal factor. The first form is the more common and is generally confined to the period of life between the twentieth year and middle age, while the second form, ordinarily known as tic douloureux, is almost invariably an affliction of the second half of life. In this latter the pain is fixed, severe, often intractable, and seldom entirely remits; in the symptomatic form it is usually migratory, tractable as a rule, and characterized by complete. remissions.

The causes of trigeminal neuralgia are manifold. Perhaps there is no disease in the category of human ills that may be excited by so many different factors. This is especially true of the symptomatic variety. In general all influences detrimental to the general health may favor its development. Individuals of feeble constitution, as well as those who are irritable, emotional, excitable and nervous are especially prone to attacks. A neuralgic diathesis appears to underly a certain proportion of cases, and I have no doubt that the neuropathic condition is the predisposing cause in the greater number. Exposure to cold and wet, over fatigue, excessive venery, carious teeth, aural irritation, ocular muscle insufficiencies, gastrointestinal derangements, and peripheral irritations wherever situated are among the most frequent causes. An important etiologic element in neuralgias of every kind is the toxemic state, such as arises from alcoholism, lead-poisoning, and autointoxication, or is induced by diabetes, malaria and la grippe.

The pathology of neuralgia in the ordinary form is obscure. Unless in long standing cases of a severe grade, there are rarely any pathologic changes in the affected nerves that can be disclosed either with knife or microscope. In tic douloureux, however, the reverse is true, and, in fact, this particular type is the one form of neuralgia that can lay claim to the distinction of a pathology. Indeed, it is questionable, from the tenderness of the nerve and the continuous character of the pain, whether many of these cases should not properly be regarded as examples of neuritis. As the most severe instances of tic douloureux are seen in the aged, it is probable that we have here a nutritional or degenerative weakness impairing the integrity of the sensory neurons. If the assertion that pain is the cry of a nerve for nourishment can ever he applied with truth, it certainly is applicable here. The pathologic condition most frequently observed in such cases is a shrunken and defective condition of the cell bodies in the Gasserian ganglion. A slow, insidious blight seems to be at work in the nerve cells, strangling them one by one, in much the same manner as the motor cells in the anterior horns of the spinal cord are stifled in cases of progressive muscular atrophy.

The most constant and characteristic symptom of trigeminal neuralgia is pain-lightning-like in its onset, sharp, darting in character, and of varying intensity. Generally it is unilateral, as often found on one side as on the other, and, as a rule, is confined to one division of the nerve, although two or all may be affected at the same time. The paroxysmal character of the pain is more pronounced in trigeminal neuralgia than in other forms. A series of sharp stab-like pains occur every few moments; a series of pains in succession constitutes a paroxysm; and a series of paroxysms constitutes an attack. An attack may last from several minutes to a few hours. Then follows a more or less prolonged interval of freedom,

varying from several hours to several months. Occasionally the attacks show a certain periodicity, tending to recur at fixed intervals. Very often, especially in long established cases, a paroxysm or an attack is easily provoked by the slightest breath of cold air, by atmospheric influences, motions of the jaw in talking, eating or drinking, changing of posture, and even by lightly touching the skin of the part. Among the minor and inconstant symptoms are flushing of the face, lacrimation when the ophthalmic division is involved, and spasmodic movements of the facial muscles when the inferior maxillary division is affected.

Neuralgia of the ophthalmic division of the fifth nerve is frequently spoken of as supraorbital neuralgia, and popularly known in malarial districts, as "brow ague." The chief point of pain is over the supraorbital - foramen, and from this point it follows the ramifications of the nerve over the forehead. Pain is also felt along the side of the nose following the nasal branch and occasionally deep in the orbit, with lacrimation-usually during a paroxysm. In neuralgia of the second division the pain has its point of greatest intensity at the infraorbital foramen, whence it radiates over the area bounded by the upper lip, the side of the nose, the orbit and the malar bone. Pain in the teeth of the upper jaw is likewise not infrequent. When the inferior maxillary division is affected the pain has a much greater range than in either of the other divisions. The chief points of tenderness are the posterior part of the temple, area in front of the ear, over the mental foramen, and occasionally pain in the side of the tongue and the teeth of the lower jaw.

The prognosis in all cases of neuralgia is favorable when it depends upon some conspicuous cause that can be removed, and unfavorable when it depends upon causes that cannot be demonstrated, or upon causal factors that cannot be removed. It is more encouraging in the young than in the old, but discouraging if it has been established a long time, and has proved intractable to treatment. All cases are likely to prove stubborn if reinforced by a pronounced inheritance. As a general rule cases are intractable in proportion to their duration, their severity, and the frequency of attacks. As far as life is concerned neuralgia does not abridge it to any appreciable extent. It simply makes it intolerable, and I have known at least one instance in which the hopelessness of relief from the periodic occurrence of agonizing pain had caused the individual to voluntarily snap life's slender thread. On the other hand, even among victims of tic douloureux, one frequently meets with admirable examples of cheerfulness, patience and fortitude under adverse circumstances. Strange to say, and contrary to what would naturally be expected, the frequent occurrence of pains of great intensity, over a long period of time, is attended by little or no apparent deteriorating effect upon the mental or physical state.

The question of treatment of trigeminal neuralgias is one that is often perplexing and difficult to solve. I know of few conditions, the treatment of which require so much diligence and patience, and in which the best efforts of the physician are so often unrewarded by satisfactory results. At the outset the important task is to search for a cause, for it is a peculiarity of all forms of neuralgia that they persist until their causes are removed. In anemic and debilitated states surprising results sometimes follow improvement in the general condition. In all cases it is desirable that the strength and nutrition be maintained at the highest point of efficiency. For the relief of pain applications of ice or dry heat over the painful area are often serviceable. When the paroxysms are severe hypo

dermics of morphin or cocain are imperative, the former being perhaps more efficacious, as the latter is strictly temporary in its effects. Atropin is also recommended by some authortities, but its anodyne properties are not sufficiently great to compensate for its undesirable constitutional effects, especially the dryness of the throat. The crystalline alkaloid aconitin is a drug which possesses a fairly good reputation in tic douloureux. It should be given in two-hundredth grain doses, every two hours, until numbness of the tongue ensues. In cases of weak heart it should not be used. A combination of morphin one-twelfth grain, and strychnin one-eightieth to one-hundredth grain, has given remarkably good results in a large number of cases. This is well adapted for continuous use, as given three or four times a day, it has the merit of being not only sedative but curative, the morphin allaying irritability in the nerve, and the strychnin promoting alterative changes which enhance its nutrition. Nitroglycerin in one-hundredth grain doses, twice or thrice a day, is strongly recommended for similar reasons, since by dilating the capillaries it flushes both nerve and nerve centers. Croton chloral appears to have a special anodyne influence over the fifth nerve, but is, however, frequently disappointing. Combined with small doses of morphin it is sometimes exceedingly useful. Blisters, cauterization and liniments of various kinds are common and helpful agents in certain cases, but in others the inconvenience and discomfort of their use simply adds to the patient's misery. Electricity is an agent of more general utility. The positive pole of the galvanic current applied to the painful area for a few minutes, with a current of eight to fifteen milliamperes has usually a very gratifying effect. The cataphoric action of this current is also powerfully effective. A piece of folded gauze wet in a twenty per cent. solution of cocain, or in chloroform, or in tincture of aconite, and laid over the painful area to which is applied the positive pole, and a current of twelve to twenty milliamperes allowed to run for a few minutes, generally brings about considerable mitigation, if not entire relief of the pain, in a short time. The coal-tar derivatives are occasionally helpful, but their use for any length of time is attended, unfortunately, by depression of the vital functions. Antipyrin I consider the most powerful analgesic of the group, and perhaps the most depressing. It is always advisable to fortify the system. against its untoward effects by administering brandy or whisky in conjunction. In attacks of moderate severity phenacetin is often of service, especially so when combined with codein phosphate-an ideal combination in minor pains of every kind. Sometimes the factors which excite, aggravate or perpetuate the trouble may be discovered in the habits, mode of life, or surroundings of the individual. Cases are not uncommon wherein attention to hygiene, avoidance of irregular habits, correction of errors of diet, or changing one's residence from a low and damp situation to a high and dry one, has resulted in immunity, more or less permanent. It is asserted by some authorities that the administration of a nervine stimulant, as valerianate of ammonia, alchohol, kola, coca, or caffein, when an attack is threatened, will frequently succeed in warding it off. Although the tranquilizing effect upon the nervous system of drugs of this class is undoubted, I do not think they possess any real influence in aborting genuine attacks of neuralgia. From observation in a large number of cases I am inclined to believe that every chronic case of neuralgia, if at all severe, becomes sooner or later set in a hysterical background. Repetition is the law of habit, and a long series of impressions upon the sensorium

will increase the susceptibility and power to respond of the centres involved, forming so to speak a pain-habit. The activity of the susceptible centres may be manifested by a state of subconscious pain, in the entire absence of peripheral stimuli of whatever kind. Such pain is generally relieved by any simple measure, as suggestion. I have often been able to charm away apparent neuralgic attacks by hypodermic injection of water, while at other times in the same individual nothing but a substantial dose of morphin would suffice. Why placebo should be effective at one time and not at another seems best explained by assuming that attacks at one time may be real and at another pseudo or subconscious. As to a court of last resort, the victim of intractable trigeminal neuralgia may turn to surgery. The knife of the surgeon may resect or excise the painful branch, or strike at the citadel of the nerve's nutrition and remove the ganglion entire. However, the results of neurectomy are rarely permanent, the pain returning in a few weeks or months with unabated vigor. This is especially the case in tic douloureux, and proves the cause of the trouble to be the slow, insiduous implication of the cells in the Gasserian ganglion. Of late years the ganglion has been removed a goodly number of times with about twenty-five per cent. of deaths and return of pain in nearly half the cases. Recurrence of pain is usually ascribed to failure of the operator to effect a complete removal. Trophic changes in the eye often follow as a consequence of ablation of the ganglion, sometimes bringing about destruction of the cornea. The most favored method of reaching the ganglion-the Hartley-Krause-is really a formidable and heroic procedure, and after pointing out the risks and possible advantages, I have never been able to prevail upon a' patient to submit to it.

On the whole it must be said that in severe and long established cases, there is no royal road to permanent relief from the distressing complaint. No panacea or procedure exists that can be regarded as being uniformly successful. Difficulties now as ever beset the path of the therapeutist, and he who can point out the better way will have justified the end of his existence, and conferred a priceless boon upon multitudes of sufferers whose sunset of life is darkened by fitful storms of pain.

THE PATHOLOGY AND THE ANTISEPTIC TREATMENT OF THE SMALLPOX.*

BY ALONZO BRYAN M. D., DETROIT, MICHIGAN.

[PUBLISHED IN The Physician and Surgeon EXCLUSIVELY)

So far as the etiology of the smallpox is concerned, we do not know much. It may be a specific germ, or it may not be. At present the world has not evolved an answer to this question. Instinctively, only, the world thinks of the smallpox as if it were caused primarily by a germ which brings about the inception of no other disease. Instinct in science is often correct, is frequently a foreshadowing of the truth, and of facts to be discovered; but of this one truth we are already assured by concensus of opinion, that the smallpox is both contagious and infectious. The identi. cal cause of its communicability seems to be unknown.

In grossly considering its symptomatology, the following is to be observed. The onset consists of a fever of three or four days' duration;, *Read before the DETROIT MEDICAL SOCIETY, November 7, 1900.

this is followed by an eruption, the stages of which are described as macular, papular, vesicular and pustular. It is the pustular stage that is destructive to life; persons seldom die during the primary fever, or during the macular, papular or vesicular stages of the eruption. A remarkable phenomenon is the almost total disappearance of the primary or initial fever upon the appearance of the papular and vesicular stages of the eruption. The term remission is perhaps the more appropriate expression. It is during the pustular stage of the eruption that the secondary fever supervenes, and it might fitly be spoken of as a violent exacerbation of the primary fever. It is this last fever that very frequently proves fatal, the patient, as I believe, having his life destroyed by purulent septicemia. Were it not for the supervention of septicemia the patient would not die, the preliminary trouble being not at all a dangerous affection.

The radical differentiation between the smallpox and varicella has not been made by the world. There is special differentiation; but a most remarkable fact is, that varicella never exists to any great extent unless variola is prevalent in the same locality at the same time. A pathologic relation almost certainly exists between the two diseases. The radical basis for these diseases may ultimately be found to be the same.

In North America, what might very appropriately be denominated a pseudosmallpox has lately and recently prevailed extensively. This kind of disease from time to time pervades the world often, as now, upon a large scale. It occurred in the days of DOCTOR JENNER, and annoyed him exceedingly while he was engaged in establishing his principle of vaccination.

Having made the foregoing premises, I would (as modestly as I can) ask the medical profession to allow me to make the following declaration: It is, that so far as I know, I was the first person to affirm that the true smallpox extends only so far as the vesicular stage of the disease; and that I am the original author of the theory and practice of its antiseptic treatment, and especially of the theory of its treatment by antiseptic baths. In confirmation of this statement I hope to be allowed to quote as follows a paper of mine entitled "Arrest of the Smallpox in its Vesicular Stage," which may be found published in the "Transactions of the Michigan State Medical Society for 1896;" and which was also published in the Medical Record, New York, July 18, 1896:

"On Monday, January 14, 1895, at a stated meeting of the Detroit. Medical and Library Association, I advanced the theory that the smallpox can be arrested in its vesicular stage. About twenty persons were present, all or most of whom were members of the society, and they accorded my theory considerable applause and encouragement.

"In the paper which I then read, I maintained that the eruption of true smallpox only extends to and includes the vesicular stage; and that the vesicles are simply infection-atria through which pus germs and saprophites are intromitted to the structure of the true skin and to the general system. The paper claimed that the germs of suppuration and of putrefaction are lying in wait, imbedded in the epidermis, ready to commence their ravages upon the true skin and the system at large as soon as their liberation is effected through the instrumentality of the maceration of the epidermal layers by the fluid of the vesicles.

"Furthermore, in the same paper I declared it as my opinion that the aforesaid pathologic germs might be forestalled in their pernicious action by means of germicidal fluids applied to the general surface of the body