The future welfare of the patient and the early control of the disease rests mainly with the general practitioner, who sees these cases in the earliest period of their development. A patient thus complaining of facial pain should be carefully examined, and the source of the trouble eliminated as soon as practicable. This is possible in almost every case. It behooves you as medical practitioners to be very thorough in your examination, especially of patients in the middle period of life. Even when the pain is slight, it should not be neglected and looked upon as trivial. The paroxysms of pain involving the lower branches of the nerve are at times accompanied by tonic spasm of the facial muscles, and quite regularly by vasomotor and secretory disturbances. Such a painful condition, if it persists, interferes with the various functions of the body, and nutrition becomes materially reduced, partly on account of the pain excited by mastication, and partly by the prevention of sleep. It also occasionally leads to mental disturbance, such as depression or even melancholia. Only those who have witnessed the excruciating and uncontrollable agony manifested during a paroxysm of tic douloureux, when the disease is fully developed, will appreciate the gravity of the affection. It is not at all surprising that such patients have sometimes been driven to suicide.

At first our attention should be directed to the mitigation of the pain, this being the urgent and obtrusive symptom. The cause must then be sought and removed if feasible, and the physical and mental condition studied, with a view toward improving the general health.

When we consider that the neuralgia is generally the result of constitutional causes, which have disturbed the stability of the nuclei or nerve centres, or interfered with the nutrition of the nerve, we can readily comprehend the futility of basing our entire management of the case upon symptomatic treatment of the pain alone. And yet this is of common occurrence.

I have observed the inflexible rule, never to institute syste. matic treatment until the teeth are pronounced in good condition by a competent dentist. Apparently healthy teeth may have exostoses or other disease at the roots, and thus be the cause of the pain. The practice, or rather malpractice, of extracting healthy teeth is only mentioned to be condemned. Experience

has taught me that very few of these patients who consult the neurologist have escaped this unwarranted mutilation. The stereotyped statement familiar to our ears is: "I have had a number of (or all) teeth extracted, but the pain continues just the same. On the other hand, old and middle-aged people who have had diseased teeth extracted, are sometimes attacked by a very severe neuralgia of the toothless alveolar processes. It has been assumed that this is caused by pressure on the torn nerve filaments by the newly formed bony tissue.

One of the most essential therapeutic measures is rest of the muscles of mastication and articulation, and quite often complete bodily rest in bed. This can usually be accomplished by forbidding conversation and the use of solid food. The latter may be replaced by fluid or semifluid food, such as milk, eggs, meat juice, beef pulp, etc. Rest and nourishment are equally as important in neuralgia as in other affections of the nervous sys. tem. In the beginning of treatment it has been my custom to instruct the patient to have the food either poured into the mouth and swallowed while recumbent, or to draw it into the mouth through a glass tube. In some cases even this procedure is too painful. In two instances the patients were successfully fed by means of a nasal tube for nearly two weeks.

One of these was a druggist, forty-eight years of age, who consulted me about five years ago. He had long been a sufferer from trigeminal neuralgia, which had gradually developed into a genuine tic douloureux. When I first saw him, the paroxysms .ecurred every ten or fifteen minutes during the day, and every half-hour at night. It was impossible for him to chew his food, and he therefore bolted it. The slightest touch upon the face by the finger, the contact of the handkerchief in blowing the nose, or of food in the mouth, would at once excite an attack. The nasal mucous membrane was so sensitive that a soft nasopharyngeal tube could not be inserted without a preliminary application of cocaine. Food and medicines were thus administered for nearly two weeks, with the most remarkable benefit. Under the use of aconita, in conjunction with rest and good feeding, the attacks rapidly diminished in frequency and severity, and at the end of a week the paroxysms occurred only every hour, and subsequently every three or four hours, until at the

end of six weeks he was practically well. It is hardly necessary to mention that such active measures are not required in all cases, but that the means for relief must be adapted to suit the individual.

Relapse is not all infrequent, and may result from various exciting causes, or be due to the sudden or ill-advised discontinuance of all medical treatment. Hence the subsequent management of these cases requires serious consideration.

Such patients should be kept under medical supervision and direction for a long time after all pain has subsided. It is well to bear in mind that remissions occasionally occur spontaneously, and sometimes a neuralgia that has occurred at intervals for many years gradually ceases as age advances.

The drugs that have been utilized and recommended for the pain are legion, and I will not attempt to enumerate them. While some have survived the tests of careful clinical investigation, the majority have fallen by the wayside and will ultimately pass into oblivion. Among those that have proved indispensable in my experience are morphine, opium, aconitia, the various coal-tar derivatives, cocaine, and nitro-glycerine. Quinine, arsenic, and the fluid extract of ergot are all exceedingly useful and remarkably beneficial in neuralgia of a periodic character. There are other drugs and remedial agents that are curative in neuralgia of other parts, but as they are not applicable in this class of cases I have refrained from mentioning them. Neuralgia of the supra-orbital branch of malarial origin promptly subsides under the administration of quinine or Warburg's tincture. At least ten or fifteen grains of quinine should be given morn. ing and evening for five or six days. Smaller doses are generally useless. This is preceded by a cathartic dose of calomel, and followed by the use of Fowler's solution of arsenic three times a day, in doses of from three to five drops well-diluted. This should be continued for a few months, unless there is some contraindication. Permit me to mention the following as one of many similar illustrative cases:

Mrs. M. H-, forty years of age, married, has nine children. For the last fifteen years she has had frequent attacks of neuralgia at varying intervals, and always affecting either the right or left supraorbital region. She never vomits. She was

seen by me for the first time on January 5th. During the preceding ten weeks and up to the present, there has been severe continuous pain, affecting the left supra-orbital region. The attack begins daily at 7 A.M., gradually subsides by noontime, and then disappears, only to return promptly the next morning. She sleeps well; has never had attacks of "chills and fever.' Bowels have been active, as she has taken Rochelle salts daily for many weeks. The pain is getting worse.

On examination the pulse is feeble but regular, and the temperature normal. There is exqusite tenderness over the left. supraorbital nerve, and slight tenderness over the right. Examination otherwise negative. I ordered ten grains of quinine, to be taken night and morning. After the first dose the pain did not appear until noon of the following day and lasted only a few hours. She has had no pain since, but is still under observation. At the end of the first week the dose was reduced to five grains. The blood was not examined.

Opium or morphine is usually the drug par excellence for the relief of pain. In neuralgia the judicious use of morphine is preferable, but it should not be employed until other means have failed, excepting to tide over a period of acute suffering, while other measures are being adopted. There are several serious objections to this use, however the disturbance to the digestive organs and the probability of the "morphine habit" being engendered,

When other methods of treatment have been unsuccessful after a fair trial, I have not hesitated under suitable conditions to order subcutaneous administration in sufficient dose to insure absolute freedom from pain. The patient should be kept in bed under constant observation, and the general nutrition improved as rapidly as possible.

One of my patients, a women fifty years of age, free from evidence of organic diseases and sufferer from this malady, had tried all forms of medical treatment, including aconitia, galvanism, etc., for nearly four years, with comparative little benefit. She weighs 118 pounds, and her general nutrition was poor. She was kept in bed for over six weeks. During the first three or four days she required six injections daily (given in the arm or thigh), each containing morphia, one-sixth of a

grain. She was not aware that morphine was being administered. This was gradually diminished, until at the end of four weeks she was recieving but two injections daily, and two weeks later it was discontinued. The pain decreased as her nutrition improved. At the end of three months she weighed one hundred and thirty-five pounds, and made a complete recovery. I saw her a number of times subsequently for about a year, but there has been no return of the pain.

The morphine may often with advantage be injected at the seat of the pain. We need feel no apprehension regarding the "morphine habit" in old people who suffer from tic douloureux, and have obtained no relief by other means. It seems to me that under such circumstances the "morphine habit," if it relieves the patient's pain, is an acceptable substitute for the "pain habit."

The various coal-tar products, such as acetanilid, phenacetin, exalgin, and antikamnia, are more or less useful in mitigating or stopping the pain, but should be utilized only as a temporary expedient, as their continued employment is likely to depress the vitality by causing anæmia.

The only form of aconitine that has proved exceptionally valuable in my hands is the crystalized aconitia of Duquesnel. This is a very powerful drug, and should be used with caution. Merck's aconitine is less reliable and much feebler in its action, and, on the whole, unsatisfactory as compared with Duquesnel's preparation. In cases that have resisted other forms of treatment, this drug is remarkably efficacious. At first one-threehundredth of a grain should be given two or three times a day, in order to ascertain if any idiosyncrasy exists.

Women seem to be more susceptible to its influence than men. It may then be given in doses of one-two-hundredths of a grain every three or four hours, preferably when the stomach is empty, and increased according to indications. It is desirable that some of the physiological effects be obtained, such as numbness of the tongue and finger tips. The difference in the action of these two preparations was forcibly brought to my attention a few years ago.

The patient was a bookkeeper, forty-five years of age. I prescribed Duquesnel's aconitia in pills containing one-two-hun