tion fifteen years; attacks about once a week. Eyes trained two weeks.

October 7, 1883. Is in perfect health. Has not had attack of migraine since first week in June, 1882. No such respite has been known in past fifteen years.

Miss Alice S. was brought by her physician, Dr. William Stevens, October 2, 1882.

The patient is twenty-nine years of age. Is rather tall, of fine form, but thin in flesh and extremely pale. The lips are colorless and the ocular conjunctiva of pearly white. She has had migraine once or twice a week during the past nine years. The pain is always unilateral, attacking one or other eye and supraorbital region, and extending downward along the course of the branches of the fifth nerve. With each attack she is forced to retire to her bed, and intense nausea and vomiting are always present. A night's sleep often brings relief.

In this case there was found to exist compound myopic astigmatism (M. 3:50 D. + A M. 1.25 D), with insufficiency of the internal recti muscles 27°.

Glasses for correcting the refractive error were prescribed, and tenotomy of one, and soon after of the other, external rectus was made, fully correcting the insufficiency of the interni while maintaining full abducting power.

She has been seen from time to time, and careful observations have been made of the ocular conditions as well as of her general health. There continues

perfect adducting and abducting power, and the equilibrium test shows no insufficiency.

Her health improved from the time of the operations, the color returned to her face, she gained in weight and strength, and, although a year has passed, she has not had an attack of migraine.

The results of treatment of migraine, by the removal of, or assistance to, ocular defects, have been no less successful than of the more ordinary forms of headaches by similar means; but, as before intimated, migraine is frequently a manifestation of more complicated ocular conditions than the ordinary headache, and consequently greater care in discovering, and greater skill in removing, these defects may be demanded in this than in the more ordinary forms.

It is a fact worthy of consideration that the most violent and characteristic symptoms of migraine are directly referable to the orbit or its immediate surroundings.

We may well suppose that the paroxysm represents the last degree of perturbation of the nerves connected with the muscles of accommodation or of consensual movements, and that the pain in and about the eye and the intolerance of light are direct manifestations of this condition of incomplete surrender of their appropriate functions.

NEURALGIA.

Passing, now, to the consideration of neuralgia, we shall find not only close relations with the forms of neuroses already discussed, but that difficulties in the

performance of the visual act constitute an important causative factor.

Before proceeding to discuss the therapeutics of the disease, it will be well to determine, first, precisely what is meant by the word as used in this essay, in order that there may be no misunderstanding as to the character of the cases which may be adduced. The word neuralgia (from veûpov, a nerve, and anyos, a pain) is in itself almost a definition. The great characteristic of the disease is pain, which is located usually along certain nervous trunks or their branches, not always confined to their peripheral distribution, but often following the whole course of the nerve. A single branch, or all the branches, of a nerve may mark the seat of pain. In its character it is usually of great intensity, rather sharply defined in its location, remitting or intermitting, not necessarily attended with any vascular excitement, although pyrexia sometimes accompanies the paroxysm.

Attacks sometimes commence in the most sudden manner. The patient, engaged as usual, possibly in cheerful conversation or in laughing, suddenly feels a stab of pain dart through the affected part as though thrust with a knife. From this time hours or days of agonizing torture may continue with more or less remission, or with entire intermissions. Again, the pain is first manifested as a dull ache, becoming more and more acute until the height of agony is reached. The pain is described as cutting, darting, boring, or burning, by different individuals, and all grades in the impetuosity of the attack are experienced, from the

onset of dull pain, rapidly increasing, to the instantaneous flash of agony.

The general health during the intermissions may suffer little, but the initial attack of neuralgia is usually a sequence of general debility, and in many instances this debility continues during the whole history of the disease. While some sufferers from this complaint are ruddy and apparently in robust health, others are exceedingly anæmic and feeble to an alarming degree.

The presence of painful points during the intermissions of paroxysms is not uniform but frequent. These painful points may be along the course of the nerves most affected or not.

Females subject to chronic neuralgia, and who suffer from anæmia and debility, almost always experience these points douloureux, but they are in no sense peculiar to neuralgia. Indeed, they are more generally associated with the more common forms of headache already described. The points most generally painful are: 1. At the spinous process of the first or second vertebra, or over the tendon of the trapezius, on a plane with the upper vertebræ. 2. Over the spinous process of the seventh cervical vertebra; this is by far the most frequently painful point in these cases, and it is very often associated with pain at the lower angles of the scapulæ. Although not an invariable rule, it may generally be assumed that, if the point over the last cervical vertebra is painful, pain will also be found at the lower scapular angles. 3. A point midway between these last-named positions.

4. At the junction of the lower lumbar vertebra with the sacrum. Other points less frequent are at the turn of the shoulder, and a point below the middle of the clavicle. These points have been referred to in connection with headaches, and they seem to indicate a weakened and disturbed state of the nervous system. They are often found in cases of long-standing chorea and in epilepsy, and are peculiarly characteristic of the conditions known as spinal irritation and neurasthenia. They are sometimes found in men, but much less frequently than in women. The pain is not imaginary, as some believe, but is often a source of suffering even from the pressure of clothing.

Intimately associated with neuralgia are certain disturbances of nutrition, as shown in the eruption of herpes; and of motion, as illustrated in the twitchings of tic, but more marked convulsions are not uncommon, and paralyses are sometimes observed.

Vaso-motor and even inflammatory symptoms are among the less common phenomena.

Irradiation of pain to nerves of distant parts is one of the interesting characteristic symptoms of neuralgia, as it has an important bearing upon the reflex nature of all the phenomena of the complaint.

Some cases of neuralgia run their course quickly, a single, or, at most, a very few attacks making up the history of the complaint so far as this peculiar form of neuroses is concerned. Such cases recover spontaneously, or under the influence of remedies real or supposed. Other cases are most chronic, continuing during many months or years, and, if cured, are fre