It is, however, very doubtful to me whether, in the majority of cases, the direction of the current makes any considerable difference in its effects, provided only that the stream is fairly directed so as to include the locus morbi in the circuit, and care is taken to apply it with sufficient persistence and with not too great intensity. Upon this point I am glad to be able to cite the authority of Dr. Reynolds, whose experience is very large. This author, while admitting that in theory the "direct" and the "inverse" currents would seem likely to have different effects, declares that in practice this does not prove to be the case, either in the instance of pain of nerve or of spasm of muscle. Dr. Buzzard, also, in relating a very striking case (which I had the advantage of personally observing) before the Clinical Society, particularly mentioned that the direct and the inverse currents had a precisely similar effect in relieving the pain. The patient suffered from severe and probably incurable cervico-brachial neuralgia; the poles were placed, respectively, on the nape of the neck and in the hand of the affected limb, and whether the positive was on the nape and the negative in the hand, or vice versa, the effect was the same. Very striking remission of the pain was always produced, and the immunity from suffering sometimes lasted for a considerable time, while no other plan of treatment seemed to have more than the most momentary effect.

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

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

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

Case III.—H. G., a footman, aged twenty-three, applied to me at Westminster Hospital, with neuralgia of the first and second divisions of the right trigeminus, of six weeks' standing. The right eye was bloodshot and streaming with tears, the skin of the right side of the nose and right cheek was anæsthetic, the right levator palpebræ was partially paralyzed. Hypodermic injections of morphia proved only very temporarily beneficial. After a fortnight's treatment with this and with flying blisters to the nape of the neck and the mastoid process, I commenced the use of the constant current daily (ten cells, Weiss). The first application (positive on nape, negative on infra-orbital foramen) stopped the pain, and procured fourteen hours' immunity. On the next day I reversed the current; the pain stopped after three minutes' galvanization; it did not recur for four days, during which time, however, I continued the daily use of the direct current. On the sixth day of treatment the patient came to me with a somewhat severe paroxysm, almost limited to the ophthalmic division; it was accompanied by spasmodic twitchings of the eyelid, and copious effusion of altered Meibomian secretion, looking like pus. Galvanization from supra-orbital foramen to nape stopped the pain in five minutes. The next day the patient presented himself, quite free from pain, which had not returned; the conjunctiva was clear, and there was no visible Meibomian secretion. Inverse galvanization was continued for ten days; but no recurrence of the pain took place. The cure was permanent three months later.

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

Notwithstanding these, and a good many similar facts that could be adduced, I should hesitate to go so far as to say that there is never any importance in the direction of the current. In old-standing cases, where there are well-marked points douloureux that are exceedingly sensitive, I have found that the application of the positive pole, successively, on the most tender points, the negative being placed on the spine opposite the point of origin of the nerve, has had a more beneficial effect than any other mode of application.

There are very considerable differences, both as to the best manner of galvanization, and also as to the chances of doing good with it, in the case of neuralgias of different nerves; and, on the whole, I find Eulenburg's conclusions on this matter very just. He indicates sciatica as the affection which is by far the most curable by the constant current; he says that many cases are cured in from three to five sittings, while others require as many weeks, or even months of treatment; and that a total absence of benefit is only seen in rare cases dependent on central causes, or on diseases which are irremovable (like malignant pelvic tumors). On the other hand, he reports that intercostal neuralgia has never been materially benefited by galvanization in his hands. With regard to ordinary trigeminal neuralgias, he speaks strongly of the current as a palliative, but very doubtfully of its power to cure, in genuine and severe cases. In cervico-brachial neuralgia he speaks of it as dividing with hypodermic morphia the whole field of useful treatment, in the majority of cases. In cervico-occipital neuralgia he says it rarely does much good. I shall return to Eulenburg's estimate of its utility in migraine, presently. Let me here say that I am inclined to indorse everything in the above-detailed statements, excepting that I should place a considerably higher estimate on the curative powers of the current in ordinary trigeminal neuralgias. The remedy, like every other, will doubtless fail in a considerable number of those very bad cases which occur in the degenerative period of life; but if anyone desires to see the proof of the power it sometimes exerts, even in extreme cases, he should study the two most remarkable cases treated by Prof. Niemeyer, of Tubingen, and reported by Dr. Wiesner.[44] The patients were respectively aged sixty-four and seventy-four, and the duration of the neuralgia had been respectively five and twenty-nine years; in both the pain was of the severest type, and in both the success was most striking. In one of them every possible variety of medication, and several distinct surgical operations for excision of portions of the affected nerve, had been quite vainly tried. The cases are altogether among the most interesting facts in therapeutics that have ever been recorded. Dr. Russell Reynolds has also told me of a case under his own care, in which a lady, who had been the victim, for twenty years, of an extremely severe neuralgia of the ophthalmic division of the fifth, which attacked her daily, and had caused great injury to her general health and nutrition, was not merely benefited, but the affection absolutely removed, at any rate for a long period, by a single application of the current. I have personally seen no such remarkable cases as these but I have had some extremely severe cases under my care in which the effect of the current was to arrest the pain in a few applications, and procure a remission for several days, or even weeks. And I have had several slighter cases which were as much cured, to all appearance, as any disease can be, by any remedy.

As a general rule, neuralgia of the limbs requires to be treated with a more powerful current than neuralgia of the face (twenty cells instead of ten). In the latter case, indeed, it is necessary to be exceedingly cautious (commencing with five cells), since a current of high power has been known to produce most serious effects upon the deeper-seated organs; the retina has been permanently paralyzed, by too strong a current applied on the face, and still graver dangers attend the incautious use of galvanization of the brain or of the sympathetic, of which we have now to speak.

Galvanization of the brain is a remedy chiefly employed in true migraine, and is certainly very effective in that disease. I have not found it useful to apply the current in the long axis of the cranium, but transmitted from one mastoid process to the other it has proved most useful; and I am glad to find that my experience on this point coincides with that of Eulenburg. But the use of this remedy is highly perilous in careless hands. In working with either Daniell's or Weiss's battery, it is necessary to use at first only three or four cells, and to increase the number only with the greatest caution. The sittings should never last more than half a minute; but the slightest giddiness should make us stop even sooner. On the other hand, the applications ought to be made daily, and usually twice a day. Ten cells (Daniell or Weiss) is the utmost that will ever be required, few patients will bear so much; and, apart from the possibility of more serious mischief, there is nothing which annoys and frightens patients more seriously than the sudden and intense vertigo which over-galvanization of the brain may induce.

Even more ticklish than the galvanization of the cerebral mass is galvanization of the sympathetic. I am not going to raise here the vexed question in physiological electricity as to the possibility of a galvanization the effects of which shall be accurately limited to the sympathetic. The fact is unquestionable, that very powerful and peculiar effects, utterly unprocurable in any other way, can be produced by placing one pole on the superior cervical ganglion (just behind and below the angle of the jaw) and the other on the manubrium sterni. This is a mode of galvanization which has been highly praised, more especially by Remak, and after him by Benedikt, but it has yielded rather disappointing results in neuralgia in my hands. Either I have not observed any distinct effect at all, or, if a current even a very little too strong were applied, I have repeatedly seen most uncomfortable, and sometimes very alarming, symptoms. I shall not easily forget a patient who applied at the Westminster Hospital, suffering from a severe form of facial neuralgia, and who was persuaded to come to my house and have his sympathetic galvanized. I used only twenty cells of Daniell, but the current had not been applied more than a few seconds when the patient fell on the floor, and remained in a state of half swoon for a considerable time. I allude to this and other less dangerous accidents that I have seen follow galvanization of the sympathetic, not with the view to prove that the method is useless in trigeminal neuralgia—I should certainly hesitate to say that, considering the large amount of respectable evidence in its favor—but I think that it is a procedure requiring the utmost caution, and meantime I have not personally found it nearly so useful as the methods already described.

There are sundry special applications of galvanism to particular forms of neuralgia which require a few words of notice. Of electrical treatment in regular angina pectoris I have had no experience; and in the one case of intercostal neuralgia, complicated with quasi-anginal attacks, in which I applied the constant current to the spine and the cardiac region, in the direction of the affected intercostal nerve, no effect was produced. I shall, however, mention the experience of Eulenburg, as he is a sober and dispassionate writer on the effects of electric treatment in general. He says he believes that in the proper use of the constant current we shall discover the chief, possibly the only direct, remedy for angina; and he describes the apparently favorable results he has already obtained in three or four cases. The current was from thirty cells; the positive pole was placed on the sternum (broad electrode), the negative on the lower cervical vertebræ. The alternative method which Eulenburg suggests, but has not, so far, put in practice, is direct galvanization of the sympathetic and vagus in the neck.

The application of the constant current in neuralgic affections of the larynx and pharynx is of most indisputable service; the experience of Tobold[45] upon this point is fully borne out by my own, as far as it goes. In many cases it will be sufficient to place the positive pole (from fifteen cells Weiss) on the pomum Adami, and the negative on the nape of the neck, and to keep up a continuous current for five or ten minutes daily; but in some cases the direct application of the current to the pharynx or larynx may be required; in such, a modification of Dr. Morell Kackenzie's laryngeal conductor will be found useful. [I shall have occasion, in Part II., to notice the superior action of Faradization in mere hysteric throat-pain, as distinguished from true neuralgia.]

Neuralgia of the testicle can be best treated, if galvanism be thought necessary, by immersing the whole scrotum in a basin of salt and water, in which the positive pole is placed: the negative pole is to be placed on the upper lumbar vertebræ; the current should be from fifteen cells Weiss, and the application should last continuously for ten minutes. In neuralgia of the urethra, I should be inclined to adopt a plan, mentioned to me by Dr. Buzzard, of attaching one conductor to an ordinary silver catheter introduced into the urethra, and placing the other pole upon the perinæum.

Neuralgia of the neck of the bladder I have found to be materially relieved by the constant current from twenty cells passed through from pubis to perinæum; the sittings being rather long. I have also, on one occasion, tried the introduction of a proper porte-electricite, insulated, except at the tip; but the result was not superior to that obtained in the other way.

As a general rule, it may be said that electricity, like other local measures which tend to concentrate the patient's attention on the parts, is only to be applied to the genital organs as a last resort. This is, of course, especially true in the neuralgias of these organs in women.

In concluding what will doubtless seem to some English readers an over-long and over-favorable estimate of the employment of galvanism in neuralgias, I must carefully guard myself against the supposition that I consider it a remedy to be applied in all cases, or likely to meet with uniform success, even in the forms of the disease to which it is most appropriate. It is a weapon which I seldom employ in the first instance, for many reasons; the principal of which is the costliness of the proceeding to the patient. Either the physician must personally administer the remedy, daily, often for a considerable period, or he must make the patient provide himself with an expensive battery; and in the latter case there is, after all, the unsatisfactory consideration that the application (even after the most careful directions have been given) will perhaps be unskilfully and inefficiently made. On the other hand, it is not desirable to delay the employment of galvanism too long, if other remedies have been fairly tried; and the practitioner will do well to remember the distinctions above laid down as to the varieties of neuralgia in which it is specially likely to prove decidedly and quickly beneficial. More especially in sciatica it would really, with our present knowledge, be a decided neglect of duty were we to allow the disease to run any considerable length without giving the constant current a thorough trial. [I can only briefly refer, here, to the novel mode of galvanization introduced by Dr. Radcliffe, and based upon his ingenious theory, according to which the true effects of the voltaic current upon nerve are the result of the charge of free electricity which it sets up, and not of the current directly. The reader will find the whole argument elaborately worked out in Dr. Radcliffe's recent work on "The Dynamics of Nerve and Muscle," Macmillan & Co., 1871. It will be enough to say, here, that the object to be attained, according to this view, is to replace the neuralgic nerve in its healthy physiological state, by charging it with free positive electricity. The manner in which this is done is as follows: In a case, e. g., of cervico-brachial neuralgia, we place the positive pole as near as may be to the central origin of the affected nerve; the negative pole is held in the hand of the same side, which is immersed in a basin of warm salt and water. In this same basin is another electrode, the wire from which is put in communication with the earth—most conveniently by putting it in contact with a gas-pipe. The patient, and the battery, ought properly to be insulated. The result of this arrangement is, that the free negative electricity is carried off by the earth-wire, and the limb remains charged with free positive electricity. I have had no sufficient experience of this method to give any opinion of its merits, but the inventor thinks it decidedly superior to the ordinary modes of applying the constant current.]

(f) The last kind of local remedies for neuralgia of which we have to speak are those by which we seek to mitigate the paroxysm by thoroughly excluding the air from the site of apparent pain. These are chiefly of value in those cases where a distinct inflammation (herpetic or erysipelatoid), or an unusual degree of sensitiveness on pressure, etc., has become developed around the superficial branches of the neuralgic nerve. Very much the best agent of this kind with which I am acquainted is the flexible collodion; in neuralgic herpes and erysipelas the effect of this application, conjoined with the hypodermic injection of morphia (preferably in the immediate neighborhood), is of the greatest possible service in mitigating the pain. In herpes it has this further special advantage, that it prevents the occurrence of sores after the vesicles fall, an accident which otherwise will sometimes happen, and which very much increases the severity and intractability of the consecutive neuralgic pain.

4. Lastly, we have to speak of prophylactic measures, which really ought never to be thought of as a separate matter, but always as an essential and most important part of the treatment of neuralgia. The prophylaxis of neuralgia is divisible into (a) measures for preventing the development of the neuralgic habit in those who may be supposed to have a predisposition to it; (b) measures between the paroxysms; (c) measures to be adopted after the attacks have ceased.

(a) The measures that should be taken to avert neuralgia, in those who may be reasonably assumed to be predisposed to it, have scarcely received any consideration at the hands of systematic writers; yet this is a most important subject. The persons in question are children who belong to families known to be infected with tendencies to neurotic diseases, or persons whose daily occupations submit them to peculiarly strong predisposing influences of an external kind. The hostile influences that should be avoided, or at any rate compensated, are of several kinds: (1) Psychical; (2) defects of nutrition; (3) mismanagement of the muscular system; (4) sexual irregularities; (5) over-fatigue of the special senses, and insufficiency of sleep, especially the latter; (6) unhealthy atmosphere and climate.

(1) The psychical influences which must be especially avoided, if we would avert the formation of the neuralgic habit, form a large and somewhat indefinite group, which it is doubtless difficult to deal with satisfactorily. The matter is, however, highly important, and the attempt must be made. And there are, at any rate, some leading principles that I feel justified in laying down with confidence.

We shall best commence the inquiry by directing our attention once more to the fact, so often insisted upon in this work, that the large majority of neuralgic patients carry in them the seeds of their malady from their birth. It has been amply proved that every child born of a family that has shown strong tendencies to insanity, epilepsy, paralysis, etc., etc., ought to be looked on as a neurotic subject, and as a potential sufferer from neuralgia. It has been shown that such children will be exposed, even under favoring external circumstances, to the danger of neuralgia at certain important stages of their physiological history. The earliest of these critical periods is marked by the occurrence of puberty; and it is not till this time that psychical influences, as such, come to have any serious bearing on the formation of the neuralgic habit. Mischief may, indeed, be done to the brain and the general nervous system, by injudicious mental training, at a far earlier period; but this mischief, serious or even fatal as it may be, usually takes some other form than that of neuralgia. It will be necessary, here, to reflect a little upon certain features of the childish mind, in order that we may rightly estimate the kind of influence which puberty exerts upon it.

A very young child is selfish, in the purely animal sense; it is greedily acquisitive, and its selfishness is unchecked by any sense of shame. With later childhood there comes a sense of right and wrong, and a sensitiveness to shame, which check this tendency; still it is the exception rather than the rule to find any great capacity of self-abnegation in young school-boys. But a moderately healthy-minded child, up to the age of puberty, is only acquisitively selfish; he is not self-centered in the sense of dwelling upon his own mental state, and reflecting upon the nature of his motives and feelings. It is with the age of puberty that self-consciousness begins to be a feature in the mind of the young, and its appearance marks the entrance of a dangerous element into the character. It is an inevitable stage in mental growth, and, if wisely dealt with, is ultimately productive, not of evil, but of good; but it is more perilous to some children than to others, and it is especially fraught with danger to those whose nervous centres are, by inheritance, weak and unstable in whole or in parts. The mental antidote to its possible evil effects is to be found in a vigorous (but not excessive) training of the mind in studies which shall be as far as possible external, and the discouragement of all tendencies to introspection. I would venture to express the decided opinion that the common idea, that close study injures the young, is only true in a modified sense. It is, however, unquestionably the fact, that hasty and imperfect cram-work does very seriously impair the stability of the brain and the nervous system in young people; there is a spurious excitement about this kind of learning (especially when it is mainly competitive, and directed to the gaining of prizes and medals) which must be injurious. But I think it is quite ridiculous to suppose that, in this country, the actual amount of intellectual labor undergone by boys and girls at school is sufficient to do harm, were it only regular and systematic, and carried out in a conscientious manner; on the contrary, though I think that the total daily period occupied in study ought not to exceed some six or seven hours, I believe that the insisting on strenuous diligence during school hours, and the maintenance of a high standard as to the quality of the work exacted, is all on the side of nervous health. But, an even more serious and difficult matter than the regulation of the amount of intellectual work to be done is, the question how we are to deal with the unfolding emotional instincts of the boy or girl who has reached the age of puberty. It is useless to ignore this side of the mental life; it will assert itself either for good or for evil. At the risk of seeming to meddle with matters that belong to the school-master rather than to the physician, I would urge very strongly that a portion of the training be deliberately directed to a serious study of one or other of the fine arts—to that one, whether poetry, painting, sculpture, or music, to which the boy or the girl instinctively leans. I am aware that there is a prejudice among parents that the study of the fine arts renders young people idle and indifferent to other branches of education and other duties of life. I believe that this only applies to the miserably inefficient way of teaching these subjects which prevails at present in all but a few English schools; and that, in truth, a thorough knowledge of the principles of either music or painting, and a real study of the best masters, would be sure to prevent the development of that lazy, conceited manner, and that neglect of other duties, which no doubt unfavorably distinguish a good many of the young ladies and gentlemen who dabble a little in music, or painting, or versification. We want the German rather than the English type of training, we want the acquirement of sound knowledge of the principles of music (at any rate) to be made so common that the accidental possession of two pennyworth of superficial accomplishment in that line shall not enable young ladies and gentlemen to give themselves airs in society. The truth is, that the young people who make music or painting an excuse for idleness respecting other matters are invariably imposters even in that which is their own supposed forte. On the other hand, the serious study of art, a certain definite portion of time being set apart for it, and thoroughness being insisted upon, is, I believe, an admirable vent for the emotional effervescence of commencing sexual life; and I no less firmly believe that the things that are usually substituted for it are intensely pernicious. I have already, in the chapter on Pathology, remarked on the mischief which is often done by the anxiety of religious parents to make their children (usually somewhere about this perilous time of puberty) experience the emotional struggle which is believed to end in a change of heart and principles. I need, therefore, only now repeat the expression of my intense conviction that the results of this process, as seen by the physician to occur within that mental region where the emotions and the organic nervous system come into closest relations, are simply disastrous. It is not my business to suggest the proper alternative to a mode of spiritual training which I think deleterious; I can only intimate, in the most general way, my belief that a calm and systematic training in the simplest principles of duty and religion is greatly more suitable to the immature mind and brain of youth than any strong emotional excitement on such topics. But if ill-regulated spiritual emotion of a religious kind be a dangerous thing for young persons in the most serious crisis of bodily development, far more decidedly pernicious is the spurious excitement of feeling which is directed to lower and often most unworthy objects. The increasing precocity of boys and girls, in their familiarity with the most objectionable aspects of passion and intrigue, is steadily fed, in the present day, by a system that allows them, too often, unlimited access to light literature which (as is strikingly the case with many novels of our day) is at once devoid of true literary and artistic merit and at the same time replete with sensational incident of a vulgarly exciting kind. The same degrading tendency is very distinctly to be noted in the character of the dramatic and other public exhibitions which are most popular at the present day; the main characteristics being, bad art, and thinly-veiled sensuality, all the more pernicious for being veiled at all. It would be a hundred times better that a boy, or even a girl, should study the frank and outspoken descriptions to be found in Shakespeare or Fielding, with all their occasional coarseness, than that they should enervate their minds with the sickly trash that is most current and most popular at the present day, in theatre and circulating library.

(2) The defects of nutrition that assist the development of the neuralgic tendency are often the consequence of a system which, it is to be hoped, is to a large extent becoming effete, but which, nevertheless, survives in sufficient vigor and extent to demand express reprobation. It was till lately the general, and it is still a too common practice, to keep children and young persons on a very insufficient allowance of the most important elements of food; the state of things in this respect, both in public and private schools, in the first half of the present century, is a lasting reproach to the medical practitioners of those days, who scarcely lifted a finger to amend it, even when they did not expressly approve it, under the influence of absurd theories about the dangers of excessive "grossness of blood." It is indeed amazing that, with the palpable fact staring them in the face, of the rapid and incessant additions to tissues which are being made by children and young people, medical men should have failed to perceive the necessity for supplies of food practically unlimited except by the capacity of digestion. Yet this seems hardly ever to have been thought of, and the unfortunate results seem scarcely to have been noticed, except when they led to emaciation or consumptive disease. But the effects were perhaps even more disastrous where, with a maintenance of a fair amount of muscular nutrition, there was only a little dyspepsia, and perhaps some slight tendency to nervousness, to show that anything was wrong. The children who were born of strong and healthy parents, may have suffered comparatively little from this regimen as regards their nervous system, but those who were born of neurotic ancestors undoubtedly suffered extensively. The crisis of puberty was, in such ill-nourished children, too frequently the signal for an explosion of epilepsy, chorea, or neuralgia; and too often the mischief was yet further increased by a most injudicious medical treatment, including a deterioration rather than an improvement in the already insufficient dietary system. At the present day, however, we may fairly hope that common sense is prevailing, so as to put an end to this mischief as regards the children of the upper and middle classes. Unfortunately, with the poor a similar ill-nourishment of the young is too often inevitable, and the consequences are constantly to be traced in enfeeblement of the nervous system, of which neuralgia is a pretty common result.

It cannot be too frequently repeated that for those children, more especially those who come of nervous families, any considerable error in this direction has a fatal tendency to awaken the disposition to nervous disease. At every step of the infancy, childhood, and youth of such persons, the most generous allowance of the more nutritive elements of food is of the first importance. At the same time I am entirely opposed to the practice of giving stimulants to any considerable extent, or indeed to any extent, save in exceptional instances. Good meat, bread, milk, butter, fruit, and vegetables, are really the efficacious means of fortifying the nervous system against the impending dangers. With hospital out-patients, for whom we cannot command such diet, our best course, whenever they show signs of deficient nutrition, will be the steady administration of cod-liver oil for a long period.

(3) The true and proper training of the muscular system is among the most important means of antagonizing the tendency to the development of the neuralgic habit. It is a great mistake to suppose that over-training in athletics of any kind is of use; but the systematic employment of means which tend to make the muscular system hardy and efficient is of very great benefit. The parents of children who may be supposed by inheritance to possess a tendency to neuralgia would do well to study such a methodical series of directions as those which are given by Mr. Maclaren, in his excellent work on physical training. I suspect that the benefit of judicious gymnastics is wrought in two ways: first, by its improving circulation and general nutrition, including the nutrition of the nervous centres; and, secondly, that it gives the nervous centres an education, so to speak, by the variety of difficult co-ordinative movements over which it trains those centres to preside. But unquestionably the matter is a science, not a mere rude art, and requires to be studied as such.

(4) Of unspeakable importance to the object of averting the formation of the neuralgic habit is the prevention of sexual irregularities in the young. Under this heading is included a large and various group of influences; of these the first that requires notice is the prevention of precocious sexual stimulation, whether by talk or by acts, which may precipitate the occurrence of puberty at an unnaturally early age. I know very well how difficult it is to devise any scheme which really would effectively control and antagonize the worst mischief of schools; but it is at least a duty to say here, that no experienced physician can doubt that such a scheme must be found, if we are ever to hope for a healthier race of children and of young men and women, and if we are to break down one of the most potent of the influences that go to the production and maintenance of the neurotic disposition. I would be clearly understood not to suppose for a moment, either that this sort of cause is usually at work in the production of neuralgia in the young, or that of itself it is sufficient to produce the disease; but I would say, for certain, that on children of nervous families such influences act with disastrous energy; and, moreover, that where we see signs, in a neuralgic young person, of that general form of bad health which is connected with precocious puberty, we may be nearly certain that such influences have actually been at work. At all cost, and by all conceivable means, all children, but most especially the delicate and nervous ones, ought to be shielded from the risk of this occurring.

Another form of sexual irregularity which can be counted as a contributor to the formation of the neuralgic habit is menstrual irregularity, especially at the commencement of sexual life. By far the most mischievous in this way is menorrhagia of the young. I have seen exceedingly severe and intractable neuralgia set up by it. As regards the influence of simple amenorrhœa, I am by no means clear: it seems pretty nearly as likely that the deficient excretion (when not dependent on mechanical cause) is a mere sign of the general weakness which also predisposes to the neuralgia, as that the neuralgia is in any way the direct consequence of the amenorrhœa.

Leucorrhœa, especially when profuse and long-continued, is a much more indisputable factor in many neuralgias. It is a point of real importance to put an end promptly to such a discharge, if it exists, and the usual remedies—cold bathing, mild astringent injections, etc.—should be at once prescribed.

Dysmenorrhœa, a painful menstruation, when not dependent on a purely mechanical cause, affords a strong example of neuralgia connected with sexual difficulty; but there is every reason to think that the neuralgia is the primary and not the secondary affection. The only effective prophylaxis, therefore, is the adoption of such general measures as will raise the whole tone of nervous health. It often happens that marriage completely cures the tendency to these attacks.

(5) Insufficiency and irregularity as to the allowance of sleep are potent influences in developing neuralgia in those who are hereditarily predisposed. It is needless to say a single word to prove the imperative need of the young for periodical and prolonged repose from the conscious actions of the nervous system. Full ten hours of sleep in the twenty-four, for boys and girls who are at or near the period of puberty, is an absolute necessity if we would prevent any existing irritability of the nervous system from developing into the fully-formed neurotic temperament. Indeed, I believe that, for all young people (but especially girls) up to the age of twenty-five, this allowance is not the least beyond what is necessary: only the need is most pressing at, and just before, the development of the sexual organs. Of course a much larger allowance of sleep is necessary in actual infancy: from seven to twelve we may be content if we get nine hours clear sleep; but during the two or three years preceding puberty we should insist upon ten hours, at any rate for children who possess the nervous temperament.

(6) Impurity of the atmosphere in which they habitually or daily reside must be carefully shunned for young children, especially for the nervous. The kind of dull and diffused headache which children often complain of, after study for some time in a close, ill-ventilated school-room, is very likely (if the bad influence be continued for a number of years) to develop itself, at puberty, into a regular migraine. Purity of air in the school-room must therefore be scrupulously provided for; and the same thing must be attended to as regards the sleeping rooms.

Of the climatic influences we may speak in a few words. Besides the avoidance of distinctly malarial districts, and also of places where, although there is no distinct ague, there is a prevalence of neuralgic or even of so-called "rheumatic" complaints, it is necessary very carefully to shun damp soils, and places where there is a great deal of harsh and cold wind. Mere lowness of average temperature is not in itself a strong predisposer to neuralgia, at any rate if guarded against by abundant food and the use of such clothes as will prevent children from ever feeling chilly and depressed. But damp and harsh winds are actively bad; and when joined to habitual or frequent lowness of temperature, they constitute very unfavorable surroundings for the nervous systems of delicate children.

(b) We come now to the prophylaxis which is to be adopted in the intervals of the paroxysms when neuralgia has been actually set up. This consists essentially in three things: (1) Physiological rest, as perfect as possible, of the affected parts; (2) protection from cold; (3) protection from sunlight; (4) avoidance of injurious mental emotions.

(1) The maintenance of physiological rest, to the greatest extent that is possible, is an absolute necessity, if we would shield a nerve, which has lately been attacked with neuralgia, from fresh paroxysms. The most evident illustrations of this fact are afforded by those neuralgic affections in which it is most difficult to adopt this precaution. Thus the greatest embarrassment from this cause is met with in the case of sciatica; a mild case is often converted into one of great severity and intractability because the patient, in the early stages, either cannot or will not maintain the recumbent posture. So, too, though in less marked degree, the cure of cervico-brachial neuralgia is often greatly impeded by the difficulty of maintaining complete rest of the limb. Again, in neuralgia affecting the third division of the fifth, the movements of mastication and of speech are a terrible hinderance to the progress of recovery; and it often becomes necessary, in severe cases, to prescribe absolute silence, and even to feed the patient exclusively with such liquid or semi-liquid food as shall require no efforts of chewing.

(2) Preservation from external cold is highly important. When a nerve of the arm, or leg, or trunk, is affected, warm flannel under-clothing ought immediately to be adopted. The patient who has been suffering from cervico-occipital neuralgia should for some time, in anything but quite summer weather, never go out without wearing a warm comforter round the neck. The sufferer from facial neuralgia should for some time after the cessation of actual attacks never face wind without wearing a thick veil.

(3) Exposure to bright light must be scrupulously avoided by sufferers from ophthalmic neuralgia. The affection known as "snow-blindness" is really a neuralgia, with vaso-motor complications, produced by the glare of light reflected from snow; and one of the severest attacks of neuralgia which I personally ever experienced was provoked in this way. Even the comparatively slighter, but for an Englishman unusual, glare of sunlight which one meets with during the first days of a Continental holiday, in wandering about towns made up of clean white stone or whitewashed houses, is enough to provoke an attack, unless the eyes are carefully guarded with colored glasses.

(4) It is scarcely necessary, after what has been already said, to insist upon the absolute necessity of mental quietude, as far as this can be obtained. This precaution is more or less important in all neuralgic affections; but in migraine and in other trigeminal neuralgias it is almost of more consequence than any other prophylactic measure; and in angina pectoris it is so essential that adoption or neglect of it may easily turn the scale between life and death. All forms of abdominal visceral neuralgia, also, are greatly affected by emotion, and passion or strong excitement of any kind must be scrupulously shunned if the neuralgic habit is to be broken through. Unfortunately, it too often happens that the mental surroundings of the patient cannot be so changed as to enable us to carry out this kind of prophylaxis effectually; and neuralgic cases of this class are among the severest trials of the physician's tact and skill, and too frequently defy his efforts.

(c) The precautionary measures which are to be adopted, after the neuralgic habit has apparently been fairly broken through, in order to prevent the patient from sliding again into the old vicious groove, can hardly be defined with exactness though their general character will be readily gathered from the picture of the clinical history and pathology of the disease which has been exhibited at large in this work. They mainly consist in the avoidance of severe, and especially of unequal, strains upon bodily or mental powers; and in redoubled carefulness in these respects at those natural crises in the life of the organism which have been shown to exercise so important an influence upon the neuralgic tendency. To a certain extent, also, but with much precaution, we may attempt to modify the peripheral sensibility by what is commonly called a hardening regimen. Thus, with great care, and proceeding in a very gradual manner, we may by degrees accustom the patient to a larger amount of exposure to free air, and even at last to rough weather, so that in the end he may become less sensitive to some of the commonest immediately exciting causes of neuralgia. If one were to construct an advancing scale of such measures, one might arrange them something like this: First, in-door gymnastics, and gentle horse-exercise for out-door work, in fine weather only; then horse-exercise alternated with pedestrianism, sea-bathing in warm weather; and, finally, we should try to reach a stage at which the patient can well endure a ten or fifteen miles' walk or ride every day, and be comparatively careless about the weather. In reaching this latter stage I have seen some patients helped, in an extraordinary degree, by the frequent use of the Turkish bath, followed by douche. Upon this latter subject I beg to offer some remarks, which are the result of pretty careful and extensive study of the effects of the Turkish bath in a variety of chronic nervous diseases. I believe it to be a very great mistake to suppose that, either in rheumatism or in true neuralgia, the process of the bath should be prolonged to such an extent as is commonly done. Instead of the usual slow heating process, gradually carried to a point at which excessive sweating occurs, I believe that the really scientific is the following: The patient should as quickly as possible get into the hottest atmosphere he intends to expose himself to, which should never be more than about 170° Fahr. He should stay in this place just long enough to get thoroughly hot, and, with the assistance of a glass or so of water drunk, throw himself into a free but gentle perspiration. He should then be rapidly shampooed, exposed to the spinal douche for two or three minutes, and then pass to the cooling-room. Let him beware of too long dawdling in the latter place, and let him avoid smoking there. It is a positively dangerous thing to cool one's self quite down to the normal heat, still more so to induce the slightest chilliness; the body should be still in a universal glow when one issues into the street. Over and over again I have proved upon myself that it is the beneficial method, whereas the prolonged use of the bath, the production of very copious sweating, and above all a lengthened cooling process, most seriously exhaust the nervous energy.

There are certain special considerations as to the habits of life that require a word or two. I need say nothing more to enforce the views already put forward as to the necessity of copious supplies of food. I need only refer to what I have already said about the decidedly mischievous tendency of anything like habitual excess in the use of alcohol, merely adding a special caution against such indulgence during, and particularly toward, the end of the period of sexual activity. There is one more topic upon which something must be said, namely, the extent to which sexual intercourse should be allowed. Speaking of neuralgia generally (excluding neuralgic affections of the sexual organs themselves), it may decidedly be said that the regular and moderate exercise of the function, during the natural period of sexual life, is beneficial; but that excess is always dangerous, and that the continuance of sexual intercourse, after the powers naturally begin to wane, is extremely pernicious in its tendency to revive latent tendencies to neuralgia. As regards neuralgias of the sexual organs, it is very difficult to speak positively; and yet I believe that (once the neuralgic habit broken through by other means) it is very desirable that the patient should live according to the laws of normal physiological life.