Neuralgia and Other Neuroses 
ARISING FROM CICATRICES OF THE SCALP, 
AND 
THEIR SURGICAL TREATMENT. 
BY 
Frederick D. LeSte, m.d. 
Reprinted from Transactions of the American Neurological Society, 1875. 
S. W. Green, Printer and Eiectrotyper, 1G and 18 Jacob Street, New-York. NEURALGIA ANl) OTHER NEUROSES 
ARISING PROM CICATRICES OP THE SCALP, 
AND THEIR SURGICAL TREATMENT. 
FREDERICK D. LEYTE, M.D. 
The'; attention of tlie writer was first called to the effect of 
cicatrices of the scalp by a case which fell under his care 
while resident surgeon of the New-York Hospital in 1850, 
which was published, with remarks, in the July, 1862, num- 
ber of the American Journal of the Medical Sciences, and 
later, by a.case which fell under his care in 1870, the details 
of which he will now proceed to relate. 
Case.—Miss M. M., a young lady in the enjoyment of a 
sound constitution and good health, was thrown down a rocky 
precipice from a carriage in July, 1870, by which accident she 
received numerous cuts and bruises, the most important wound 
being on the scalp. When I saw her a couple of weeks after 
the accident, she presented a scar on the left side of the forehead, 
about half an inch in length and somewhat irregular, and one 
straight cicatrix nearly two inches in length, and about a line 
in breadth, about an inch and a half above the left ear, and in 
front of it. The wounds had healed with great rapidity, and 
the cicatrices were not tender. 
For some months, she experienced no ill effects from these; 
but, during the succeeding winter, she felt twinges of sharp 
pain shooting over the left side of the forehead, and the larger 
cicatrix became painful. Gradually the pains increased, and 
she had, in addition, a feeling as if a heavy weight was press- 
ing on the top of the head, and weighing her down. The pain 2 
NEURALGIA AND OTHER NEUROSES. 
became constant, and very severe ; but she bore it with great 
fortitude until the latter end of the spring of 1871, when she 
called on the writer at his office in the city, to ask relief. Ex- 
cision was advised as the only chance for cure ; and, as she re- 
quested some temporary means of relief while she and her pa- 
rents were coming to a conclusion regarding the operation, an 
ointment of aconitine was prescribed. During the summer, 
the patient sent for the writer, and stated that she was willing 
to submit to any treatment, as her suffering was incessant and 
almost intolerable; the sensation as of weight on top of the 
head was particularly distressing. 
The trouble evidently originated in the upper cicatrix, as 
she felt that the pain always radiated from that point, and 
pressure upon it produced considerable distress, and an increase 
in the shooting pains. She stated that she had consulted Pro- 
fessor Willard Parker, and that he also advised an operation, 
but only the incision, not the removal, of the cicatrix. 
With the patient under the complete influence of ether, and 
with the assistance of Dr. G. W. Murdock, of Cold Spring, 
and (as it happened) on the anniversary of the accident, the 
entire cicatrix was exsected, some bleeding vessels tied, and 
the edges of the wound accurately brought together with line 
silk sutures. 
From the very time when the patient recovered conscious- 
ness, she felt greatly relieved of the peculiar distress from 
which she hid suffered for so many months; and by the time 
that the wound had healed, which it did by first intention, and 
within three or four days, her neuralgic pain and the sense of 
oppressive weight were entirely gone. Subsequently, during 
the latter part of the summer and autumn, she sometimes com- 
plained of headache, which alarmed her a good deal, though 
she had been subject to attacks of this kind before the acci-- 
dent. For this, arsenious acid was prescribed, with prompt 
relief. She has never had any trouble from the traumatic 
neuralgia from that day to this—nearly four years. But she 
has had malarious attacks, and then headache, and some pains 
resembling those for which the operation was performed, and 
which always excite lively apprehension, but which have al- 
ways yielded promptly to quinine or arsenic, or both com- NEURALGIA AND OTHER NEUROSES. 
s 
bined. She stated that, on her first visit to the city after her 
recovery, it seemed, all the while, as she walked the streets, as 
if she had lost something from her head, which caused her, 
now and then, involuntarily to put her hand to her head. 
When consulted with reference to this case, and especially 
as to the probability of a permanent cure by means of the pro- 
posed operation, the writer, not having met with any similar 
case, consulted the in >dern surgical works, and several surgical 
friends of large experience, and was surprised to find that 
others seemed to know as little about it as himself; the not 
uncommon occurrence of painful cicatrices of stumps leading 
him to infer that superficial cicatrices in other parts of the 
body, and especially where nerves are so abundantly distribut- 
ed as on the scalp, would be likely, now and then, to be simi- 
larly affected. Scarcely a reference to the subject could be 
found in any of the more recent treatises on surgery or on af- 
fections of the nerves; and an extensive though not ex- 
haustive search as far back as the earliest authentic surgical 
records, resulted only in finding a few scattered cases and 
brief references. Two surgeons appear to have had an excep- 
tional experience in these cases. Professor Gross, in a letter 
just received, says, “ I have repeatedly cured neuralgia by the 
excision of indurated scars, especially of the scalp, after inju- 
ries of the head yet it is singular, with such an experience, 
that he should pass over this subject, in the last edition of his 
great work on surgery, with only the following notice: “ Pain- 
ful scars are very common after amputations, owing to some 
peculiar change in the terminal portions of the nerves after 
such operations. Lacerated, contused, punctured, and gun- 
shot wounds are not unfreqnently followed by similar effects. 
The pain, which often assumes a neuralgic character, is liable to 
serious exacerbations from the most trivial causes, especially 
exposure to cold, atmospheric vicissitudes, and disorder of the 
general health; and, from its persistency and obstinacy, may 
become a source of great suffering and annoyance, rendering 
life perhaps almost insupportable.”* 
Professor Parker’s experience has already been referred to. 
He says, in a letter to the writer, of recent date, “ I have per- 
* System of Surgery, S. D. Gross, 5th edition, vol. i. p. 351 4 
NEURALGIA AND OTHER NEUROSES. 
formed the operation (incision) a number of times, many of the 
patients being clinical [presenting themselves at liis cliniqne.— 
L.], and in all cases which have remained under my observa- 
tion, improvement, if not permanent cure, was the result.” 
He also states that he got the idea of the operation from Gib- 
son’s Surgery, where it speaks of the French surgeon, Pou- 
tean, as having performed it. Pouteau’s cases will be referred 
to further on. Professor Parker’s plan is to make a free inci- 
sion to the bone, and let it granulate slowly. Thus we see 
that two, who may be considered representatives of American 
surgery, differ as to the operative procedure. My friend, 
Professor II. P. Sands, says, “ I can not recall a single in- 
stance in which the healing of a superficial wound has been 
followed by neuralgia. I think such an occurrence must be 
exceedingly rare.” Dr. Weir Mitchell, in his extensive expe- 
rience in injuries of the nerves, with the records of the late 
war at his command, mentions no similar case in his remark- 
able work on “ Injuries of Nerves,” and has recently informed 
the writer that he lias never met with such a case, and 
with very few, in which neuralgia has followed even deep ci- 
catrices. Professor Hammond’s experience appears to be si- 
milar. Such being the case, it may not be uninteresting or 
uninstructive briefly to allude to some of the histories record- 
ed by the earlier writers, who appear to have paid more at- 
tention to these cases than those of later times, especially as 
they are introduced, not merely as pathological curiosities, but 
as bearing a practical relation to the observations and refer- 
ences to be presently offered for the consideration of the Asso- 
ciation. A disease, which so distinguished an author as Pro- 
fessor Gross has found to be not uncommon, and which he de- 
scribes as “ rendering life perhaps almost insupportable,” de- 
serves more consideration than it has yet received from an- 
cient or modern writers. 
Gibson records, in his Surgery, p. 374, “ In the case of 
Prince Charles, son of Philip II., King of Spain, who suffered 
immensely from a neuralgic affection of the scalp, succeeding 
a wound, Vesalius, by dividing the integument to the bone, 
effected a perfect cure in a short time. Pouteau,” he says, 
“ details two very interesting cases of the same kind, and, by NEURALGIA AND OTHER NEUROSES. 
5 
pursuing a similar practice, was equally successful.” Pouteau 
also cured a neuralgia of several years’ standing, caused by a 
cicatrix over the tibia, by a crucial incision. 
In the surgical volume of the Medical and Surgical History 
of the Rebellion, ten cases of gunshot contusion of the cra- 
nial bones are alluded to, in which persistence of pain either in 
cicatrices or distinct spots of the cranium, constituted the pro- 
minent symptom. “ Three of these belong to the class of 
cases described by Quesnay (Memoires de l’Academie Royal 
de Chirurg., Paris, 1819, t. I. p. 169). “ All these patients,” 
says the reporter, “ were spared the incisions of the scalp, or 
the application of the rougine or the trephine, and five reco- 
vered and went on duty, while five were discharged for disabi- 
lity, two of whom were subsequently pensioned.” An ac- 
quaintance with the history of this class of cases, and the al- 
most uniform good results which have followed the simple 
and safe operation of either incision or excision, would proba- 
bly have led to much better success than is here reported. 
“ As a consequence of a blow on the inferior part of the orbit, 
a woman was attacked with an abscess, after which, violent 
pains recurred almost constantly, radiating all over the face 
and the antero-lateral and superior parts of the head. Mare- 
chal divided the infra-orbital nerve, and at once the patient 
was free from pain. The wounds healed, however, and the 
pains reappeared. The nerve was then destroyed by caustics, 
and the patient seemed cured. Ten months after, there were 
new attacks. The cicatrix was then opened and kept suppu- 
rating, and the cure was definitive.”* 
Downing, in his work on neuralgia, the Jacksonian Prize 
Essay for 1852, relates a few cases of painful cicatrix, but not 
of the scalp. He quotes also the following observations of 
Dr. Bright, in his work on neuralgia : “ We find cases which 
lead us to believe that tic douloureux sometimes originates in the 
affections of the extremities of the nerves, and may be derived 
from wounds of fleshy parts, and cured by application to the 
cicatrices.” Dr. Bright also records the case of a young girl, 
who had received a cut over the parietal bone, long in healing, 
and leaving a scar always tender. Years after, neuralgia of 
* Annales de Chirurgie, 1844, vol. iv. p. 69. 6 
NEURALGIA AND OTHER NEUROSES. 
the temple set in, which did not yield to a variety of reme- 
dies. lie does not mention any operation. “ Dr. Mott dis- 
sected out a cicatrix, where irritation proceeded from it, with 
success.” (Mayo, p. 136.) 
Mr. Hancock speaks of painful cicatrices of the scalp, and 
recommends, when they are adherent to the bone, the subcu- 
taneous division of the connections. This he has found more 
successful in painful stumps than excision of the cicatrix; it 
having succeeded in one case where the latter operation was 
twice practiced unsuccessfully. The operation, however, myst 
be followed by systematic sliding of the parts over the bone, 
until all danger of recurrence of the adhesion lias ceased. He 
attributes the neuralgia to the compression of the nerves 
against the bone. The cause, however, is still unexplained. 
It is difficult to account for the excessive pain which some- 
times attaches to these cicatrices, as it is for that which some- 
times attends some cicatrices of stumps, many, which are quite 
painless, exhibiting precisely the same condition as those 
which cause so much suffering as to necessitate re-amputa- 
tion. As Paget remarks, it is not the bulbous extremity of the 
nerve. But it is scarcely more difficult to explain than the 
local nerve lesion which causes tetanus, or that only one out 
of a hundred or more apparently similar wounds should be 
followed by that neurosis. There seems to be some analogy 
between these superficial cicatrices, which we are considering, 
and the “ painful, subcutaneous tumor,” which, though so 
acutely sensitive, has no connection yet discovered with a 
nerve. Like cicatrices, these remain for a long time painless, 
then rather suddenly give rise to severe neuralgic suffering. 
When removed, the pain sometimes persists, at all events, for 
a long time. Mr. Paget concludes his consideration of these 
singular tumors with the following remarks, which are proba- 
bly quite applicable to cicatrices : “ Without entering further 
on their history, I would suggest that the account of all these 
painful tumors makes it probable that the pain which the 
patients feel is, in a great measure, neuralgic or subjective; 
that it has the tumor, indeed, for an exciting cause ; but that 
it owns, besides, some morbid condition inherent or cumula- 
tive in the nerves themselves, so that at times they respond NEURALGIA AND OTHER NEUROSES. 
7 
with a morbid exaggeration, to an habitual or slightly in- 
creased stimulus. And if this be true of the most painful 
tumors, it is probably true in various degrees of others.”* 
We may draw this practical conclusion from Mr. Paget’s re- 
flections, and from what we know of the persistence of neural- 
gia of stumps, and of the head, after amputation on the one 
hand, and the excision of large portions of nerve-trunks on 
the other, that the less time wasted in general treatment or 
local applications, in such cases, and the sooner we resor to 
the radical operation, the better the chance of a permanent 
cure. If, however, the pain persists after the operation, these 
measures may be resorted to, with more hope of success, to 
subdue what Mr. Paget styles ‘£ that morbid state of nerve- 
force which we call neuralgic.” An inflammation or some 
other organic change spreads along the nerves, from the source 
of irritation, or perhaps, as some have suggested, and Mr. Paget 
himself supposes possible, only a functional disturbance be- 
comes by persistence a confirmed habit, that may not be sub- 
dued even by removal of the causes. 
Surgeons appear to be about equally divided as to incision 
or excision, and both appear to have been very successful. 
But it would, dpriori, appear more scientific and suitable to 
excise and unite the edges carefully, than to incise and leave 
to granulate, since the latter process is analogous to that 
which led to the difficulty ; there being a chance apparently 
that, during the new process of cicatrization, the same acci- 
dent may recur as in stumps, the involving of the nerve, in 
some morbid manner, in the scar. Besides, caster is paribus, 
the wound heals much sooner. 
These cicatrices of the scalp may produce other and even more 
serious disorders than neuralgia. Among these is amaurosis. 
The attention of the writer was called to this fact by a remarka- 
ble case, which occurred in his practice while serving as resident 
surgeon of the New-York Hospital, in 1850. . The case was 
briefly this. A wound was inflicted by the explosion of a cop- 
per cap on the dtli of July, on the forehead, near the edge of 
the orbit, a little to the left of the median line. The patient, a 
girl eleven years of age, was brought to the hospital two days 
* Surgical Pathology. Phi la. ed. 1854. 8 
NEURALGIA AND OTHER NEUROSES. 
after. She had, in the right eye, only a perception of light, 
no vision. The sight of the left eye was good.* An’incision 
was made, a fragment of copper cap found firmly imbedded 
in the pericranium, and removed. Immediately, with the left 
eye closed, she could count my fingers held before her. This 
led to an investigation of the subject, and several unequivocal 
cases of a similar character were discovered. The histories of 
these, with that of the case just alluded to, were published in 
the Am. Jour, of the Med. Sci. for July, 1862. The more re- 
cent writers on diseases of the eye do not even allude to such 
cases. Dr. II. Knapp, during a discussion before the Patho- 
logical Society of New-York, and in answer to a query of the 
writer, stated that he had never met with a similar case. 
Earlier writers, as Lawrence, Middemore, Sichel, Tyrrell, W. 
Jones, Walton, Mackenzie, were cognizant of such cases, but 
attribute the impaired vision to other causes than irritation 
of the branches of the fifth pair. The writer deems the sub- 
ject of sufficient importance to warrant him in reproducing 
here some of his cases and remarks, in an abbreviated form. 
Mackenzie, though he relates several cases very plainly in- 
dicating the injury of the terminal branches of the fifth pair, 
as the direct cause of the amaurosis, yet concludes his remarks 
thus: “ The consideration of these facts naturally leads us 
to regard, with still greater doubt, the alleged occurrence of 
purely sympathetic amaurosis from slight injuries of the fifth 
pair, and to suspect that, in supposed cases of this sort, there 
has been, in addition to the external injury, either concus- 
sion of the eyeball, or disease excited within the cranium.” 
This could scarcely have happened in the writer’s own case. 
This question was introduced in an important suit between 
the London and K. W. Railway Co. and a watchmaker, who 
had received a very trivial injury of the brow, followed by 
amaurosis. Mr. Walton testified that, in his opinion, “mere 
injury of the nerve-branch, on the head, can have no effect 
* “ An injury on one side of tlie body may even produce a neuralgia on 
the other side. A girl had neuralgia of the left temple and side of the head 
caused by a severe cut over the right parietal bone. A blister over the cic- 
atrix relieved the neuralgia for some time.” Paper by Brown-Sequard on 
Neuralgia, in Holmes’s Surgery, vol. iii. NEURALGIA AND OTHER NEUROSES. 
9 
on the function of the retina; that loss of sight, when asso- 
ciated with such lesion, is due to coincident lesion of the eye- 
ball.” That there could not possibly have been any such in- 
jury in several of the cases related by the writer in the article 
from which he is now quoting, is certain. The case furnished 
the writer by the late J. Kearney Rodgers, one of the most 
eminent surgeons of this country, and an authority on the eye, 
in his day, was one of this sort. One of the late W. C. Wal- 
lace’s cases also, in which vision was restored by dissecting out 
a cicatrix containing a piece of steel: in this case there were 
also neuralgic symptoms, which were relieved by the opera- 
tion. “When defective vision follows a wound of the fore- 
head,” says the late Mr. Guthrie, “the only hope of relief 
which we are at present acquainted with lies in a free incision 
down to the bone, in the direction of the original wound.” 
He says further on, every case failed. (Holmes’s Surgery.) 
These facts did not escape the observation of Hippocrates. 
Beer also says, “He has had frequent opportunities for accu- 
rately observing and curing amblyopia and amaurosis, occur- 
ring in consequence of wounds of the eyebrow.” He also 
makes the important remark, bearing on the question as to 
whether, in neuralgia or amaurosis, the proper course is exci- 
sion, or incision with subsequent granulation, that, “where such 
wounds are judiciously managed and speedily healed by adhe- 
sion, no bad consequence ensues ; but when suppuration occurs, 
followed by the granulating process necessary for secondary 
union, the divided nerves are involved in the inflammation, 
and subsequently included in the hard cicatrix, and, as he con- 
ceives, compressed and irritated.”* Larrey seems to have had 
the same idea ; for he says, “ In incisions about the orbit, we 
should avoid, as far as possible, injury of the ramifications of 
the frontal nerve ; or, if we injure it, we should be careful to 
make a complete section.” 
Middemore relates a case in which “ a man received a 
wound just above the right eyebrow from a piece of glass, 
which was removed immediately after the accident. When 
the wound had healed, the right eye was very nearly lost; he 
had a painful sensation in the neighborhood of the cicatrix, 
* Laurence, Am. edit. 1854, p. 124. 10 
NEURALGIA AND OTHER NEUROSES. 
and a singular sense of creeping and pinching and quivering 
of the upper eyelid and the integuments of the forehead. I 
made a free incision of the cicatrix down to the bone, and all 
# . 7 
uneasiness at once ceased, and the eye, shortly after, assumed 
its healthy character and functions, and vision was 'permanent- 
ly restored.” Scarpa, Valsalva, Iley, Larrey, and Aricq-d’Azye 
allude to similar cases. Ilennen* says, “I have met with one 
or two cases of amaurosis from wounds of the supra-orbital 
nerve.” The writer has quoted numbers of cases of amauro- 
sis caused by injuries or diseases of the teeth, and cured by a 
removal of the source of irritation. (Op. cit.) Morgagni, 
Nott.a, Duval, Tavignot, and others, says Al. Echevefria, “ have 
known amaurosis to be caused by neuralgia, and to disappear 
as soon as the neuralgia was cured.” For those who may still 
doubt the reflex origin of the visual disturbance in these 
cases, the writer would call attention to the following remark- 
able case. “A woman, aged 48, pricked the forefinger of the 
right hand with a thorn. At first, swelling and redness, ex- 
tending over the wounded finger, and partly over the middle 
finger; but, after three months, the swelling went off, except 
that over the first two phalanges of the wounded finger. 
Nine months after the accident, the finger was exceedingly 
painful to the touch, although there was pnly a bright red spot 
on the skin at that point. Two or three times a day, there 
were attacks, during which the pain extended along the fingers, 
up the back of the arm and the neck to the head, producing 
a sensation at the roots of the hairs as if they had become erect. 
To these feelings succeeded a dimness of sight, and the pain 
afterward went suddenly into the stomach, followed by sick- 
ness and vomiting.” . . . “ The finger was amputated at 
the second joint. Ho sooner had she got into bed, after the 
operation, than the sensation of a lump in the stomach, and 
the sickness, immediately subsided, and, in half an hour after, 
she said she felt, for the first time, as well as before the acci- 
dent. Her general.health improved, and she never had the 
smallest return of any of the nervous symptoms.” f 
This subject is not one of mere theoretical interest. It has, 
* Principles of Mil. Surg. 2d Edin. edit. p. 346. 
f Ain. Jour. Med. Sci. Oct. 1854, p. 423. NEURALGIA AND OTHER NEUROSES. 
11 
as we have seen, a medico-legal bearing. But it has a more 
important practical connection with the management of some 
obscure cases of asthenopia, in which .a knowledge of the 
above facts should lead the surgeon to institute a careful inquiry 
as to previous slight injury of the scalp, and a searching 
investigation as to the possible existence of *some such insigni- 
ficant cicatrix, hidden by the hair, which produced such serious 
disturbance in Dr. Rodgers’s case, and which the acuteness 
and skill of that surgeon enabled him to relieve by a trifling 
operation. More than this; these pathological facts point to a 
method of treatment for impaired vision which may be uncon- 
nected with any wound. Admitting that the function of the 
eye can be so seriously compromised by injury of the branches 
of the fifth pair, one would naturally infer that defective 
vision from other causes might be improved by direct applica- 
tions to these nerves. Accordingly, soon after the occurrence 
of his own case, the writer was led to employ induced electri- 
city to the supra and infra-orbital branches of the fifth pair 
for partial amaurosis, in a patient who happened to be in the 
hospital at the same time. Immediately after each applica- 
tion, he could see more clearly, by actual test, and eventually 
improved so as to be able to read large type. Dr. I. Hays, 
surgeon to Will’s Hospital, Philadelphia, in 1839, used galva- 
nism witli success in similar cases. In two cases, the trouble 
followed injury of the brow or forehead. He remarks, “ The 
remedy which was most successful in this case was unques- 
tionably galvanism. We have an evidence of this not only in 
the Improvement which followed its application, but in the 
still more striking fact that the patient actually saw better 
while subjected to the galvanic action.” The reality of this 
was put to a thorough test both by himself and Dr. John Neill. 
He further remarks that “We tried electro-magnetism in seve- 
ral instances in the hospital during our service in 1839, and 
also in private practice in a number of cases, but we are not 
sensible of its having been productive of the slightest benefit in 
a single instance.” In the writer’s case it was electro-magne- 
tism which succeeded. But Dr. Hays speaks of the “ violent 
shocks ” produced by interrupted currents, as contrasted with 
“ a regular and constant galvanic current.” This probably 12 
NEURALGIA AND OTHER NEUROSES. 
explains his ill success with the induced currents, and the fail- 
ures which are every day experienced. Unless in cases of 
paralysis or poisoning, there should never be shocks of any 
kind, however mild, especially in applications to the head. 
With the old batteries, such shocks were not generally avoid- 
able; but with the, perfect instruments of the present day, es- 
pecially with Gaiffe’s, the current may be as mild and uni- 
form as that of a galvanic battery, and a necessity for a resort 
to the latter less frequent than is generally supposed. Dr. 
Addinell Hewson, Surgeon to the Pennsylvania Hospital, pub- 
lished, about fifteen years ago, a number of cases of cure of 
intense photophobia by one or two applications of electricity 
“ around the orbit.” lie alleged almost invariable success. 
The success of the free application of tinct. iodine to the 
forehead in these cases, is probably referable rather to stimu- 
lation of the branches of the fifth pair than to counter-irrita- 
tion in the sense usually attached to it. 
There is good reason to infer, from cases scattered here and 
there in works on surgery, and from the remarks of surgeons 
on the consequences of injuries of the head, that epilepsy not 
unfrequently results from cicatrices of the scalp. Hence the 
importance of bearing this in mind, in the treatment of this 
disease, and of instituting the most careful inquiries as to trivial 
and perhaps long-forgotten accidents to the head, and the most 
careful search for cicatrices or tender spots, just as we look for 
tender spots over the spine in any fault, of innervation, or trou- 
blesome neuralgic symptoms in the lower parts of the body. In 
fact, Gross enumerates, in the first edition of his work on sur- 
gery, epilepsy as one of the secondary effects of injury of the 
scalp. Velpeau states, in his “ Hew Elements of Operative 
Surgery,” that Mr. II. Smith, of the Bristol Infirmary, had 
been in the habit of employing long and deep incisions of the 
scalp, “whether there be or be not symptoms of depression;” 
and that Dr. George W allis, of Bristol, taking the hint from Dr. 
Smith’s practice, had employed this treatment, in “ a variety 
of cases of organic affection of the brain.” Several other dis- 
tinguished physicians are mentioned by Velpeau as having 
found this practice of great utility. Dr. Blackmore employed 
it in hemiplegia, mania, etc., “ especially when there has been NEURALGIA AND OTHER NEUROSES. 
13 
‘ a fixed pain in the head,’ or a tender portion of tlie scalp, so 
that gentle percussion lias produced great pain.” He states 
that the treatment was suggested by Dr. Abercrombie, who had 
himself used it with great success. It is not singular that, in 
those days, all these physicians should have attributed the suc- 
cess of the procedure to the very considerable bleeding follow- 
ing the incisions, and the subsequent suppuration, especially to 
the former. But, in the light of our advanced neuro-patholo- 
gy, notably as regards epilepsy, we must regard the hemorrhage 
as hindering rather than expediting the cure, and refer the lat- 
ter to a reflex influence on the encephalon. Cullen thought 
that epilepsy might arise “ from an affection of the extremities 
or other parts of a nerve acted upon by some irritating matter, 
and following the course of such nerve.” “ Several authors,” 
says Cooke (Treatise on Nervous Diseases), “ mention cases, in 
which the aura epileptiea appeared clearly to arise from a dis- 
tinct local cause. (Fonetus, Fernelius, Haller, etc.)” 
Prof. William A. Hammond, who has had an exceptionally 
large experience in trephining for epilepsy, having lately per- 
formed his twenty-second operation, most of them within the last 
few years, says, in a recent letter to the writer, “ I find I have 
trephined five times for epilepsy without finding spieuloe or de- 
pression. Of these, two had no more attacks. One, a young 
man from Georgia, I heard from only yesterday. He has re- 
mained free since last July, when I performed the operation 
over the seat of a severe blow on the head. The other was a 
lady of this city, who was struck on the head; epilepsy super- 
vened a year after, and I trephined two years after the acci- 
dent. There was no fracture. The lady had but one fit after, 
and is well to this day.” The writer assisted Dr. Hammond in 
his last operation, on a boy in whom the fits recurred several 
times daily ; had one while we were preparing for the opera- 
tion. There was a very obvious cicatrix of the scalp, but, upon 
removing a considerable portion of the skull, the depression 
was found to be very slight, and distributed over quite a con- 
siderable space. The boy had but one or two fits after. 
Prof. W. Parker informs the writer, in a letter just receiv- 
ed, that, “in several cases of epileptiform seizure, following a 
blow on the head, he has found much benefit to result from a 14 
NEURALGIA AND OTHER NEUROSES. 
free incision over the point of injury, kept open by issue-peas.” 
Those who are familiar with the extraordinary phenomena, 
sometimes resulting from reflex nervous action in various parts 
of the body, both in the production and cure of disease, can 
readily comprehend the rationale of this operation. 
APPENDIX. 
During the session of the Association, and before the read- 
ing of the above paper, the writer met with another tolerably 
well-marked case of neurosis, arising apparently from a cica- 
trix of the scalp. 
The gentleman is at present the patient of my friend, Dr, 
li. F. Weir, of this city, for an aural affection. lie has not 
been called upon to investigate or prescribe for his other ail- 
ments. We examined him together last evening with refer- 
ence to his neurotic troubles, and, with some difficulty, owing 
to his incoherent and disconnected manner of answering ques- 
tions and relating his history, we made out the following ac- 
count. 
In March, 1862, in consequence of a railway accident, his 
head was thrown violently against the corner of a car, which 
caused a scalp-wound of small extent, about in the same loca- 
tion as that of Miss M. M. During the following summer, he 
had neuralgia of the left side of the head, that corresponding 
to the cicatrix, which so increased as almost to set him crazy, 
as he expresses it; sometimes causing the forehead and tem- 
ple on that side to become swollen to a considerable degree. 
He continued to suffer more or less in this manner until about 
three years after, when, after a more than usually severe at- 
tack, and several sleepless nights, Prof. A. C. Post was call- 
ed in, and, as the patient states, wished to incise the cicatrix, 
which he discovered at the site of the wound. But he finally 
got relief by means of hypodermic injections of morphia. 
Subsequently, some unpleasant cerebral symptoms set in, and 
he gave up business, and travelled, visiting, during several 
years, Europe, China, Japan, etc. About three years ago, 
while in China, he says he was sun-struck, and that after his 
recovery his cerebral symptoms increased. .He then visited 15 
Paris, and saw B. Sequard, and other physicians there. As 
combing or brushing the hair over the'cicatrix produced irri- 
tation, this physician advised him to part his hair in the mid- 
dle, which he has since done. Other physicians in Europe 
subsequently saw him, and as a general rule, prescribed the 
bromide of potassium. He does not nowr appear to suffer much 
from pain, though the latter has extended, in a mild degree, 
down the neck * to the left shoulder. But he says there is 
always a sense of stricture in the cicatrix, which feels to him 
“ as if bound down, and as if something ought to be cut to 
liberate it.” There is a “ numb” feeling, but no pain on 
pressure. He formerly drank hard, though he says not to in- 
toxication, but that, of late, he can take no stimulant without 
seriously aggravating his cerebral symptoms. 
At a meeting of the Dutchess County Medical Society, in 
Eishkill, a few days subsequent to the reading of this paper, 
Dr. W. G. Stevenson, of Poughkeepsie, related the following 
very interesting and instructive case. 
W. P., aged about 30, of good habits, and good general 
health, was a member of Company G, 123d Regiment, New- 
York State Volunteers, and received a shell-wound on the 
right parietal bone ; the fragment of shell “ scooping” out 
the scalp and a thin portion of bone, to the extent of two and 
a half inches. This was followed by serious disturbance of his 
general health, and especially of his nervous system, and 
eventually by attacks of epileptic convulsions. He came 
under my observation about a year and a half after the receipt' 
of the injury, during which time the fits had increased in 
frequency and severity. Had from four to six each week, and 
t 'ey had already impaired the use of the left arm and hand, 
and also his mind. The aura was distinctly felt, beginning in 
the fingers of left hand; and, if hot brandy or brandy and 
pepper was immediately taken, on the first sensation of the 
aura, the attack would frequently be prevented. lie had 
been under the care of different physicians, who had prescrib- 
ed various remedies without benefit. The counsel of my 
father, Dr. William Stevenson, and myself persuaded him to 
permit the operation of trephining, which I performed in 
August, 1865. 
NEURALGIA AND OTHER NEUROSES. 16 
NEURALGIA AND OTHER NEUROSES. 
Making a circular incision sufficiently large to include the 
entire cicatrix, I trephined the skull at the point of injury. 
There was no evidence of thickening of bone or membranes, 
and no depression ’ in short, nothing was discovered which 
would account for convulsions ; and yet, for eighteen months 
after the operation, there had been no return of the epileptic 
attacks; and a gradual improvement had taken place in the 
left arm and hand, and also in his mental condition. I have 
no information relative to his condition beyond the eighteen 
months after trephining, but this at least is very evident, that 
the operation produced great benefit for one year and a half. 
The fact mentioned by Dr. Stevenson, that a prompt and 
powerful stimulant would arrest the attack, is worthy of note. 
Nitrite of amyl would be still more efficient; has been. In 
the discussion which followed the recital of this case, and as 
an illustrative explanation of a certain point regarding re- 
flex action, upon which Dr. Stevenson requested information, 
the writer alluded to a phenomenon, which twice occurred 
during the treatment of a case now under his charge. lie 
first saw the case in New-York, with Drs. De Wolf and H. B. 
Sands, during the session of the Association. They stated that, 
while injecting an empyemic cavity, upon which Dr. Sands 
had previously cut down, and which injection had been done 
a number of times before, the patient suddenly fell in an 
epileptic convulsion, and did not recover consciousness for 
twenty-four hours. On another occasion, during a subsequent 
injection, a similar but less severe attack occurred. Dr. Sands 
attributed it to a rather forcible pressure of the column of 
water, in order more effectually to cleanse the bottom of the 
cavity. The patient had never had a similar attack, and 
through care in using the syringe, has had none since. 
Dr. Hosea Fountain, a delegate to the Society from West- 
chester, alluded to a very similar case, as regards the reflex 
phenomenon. He was kind enough to furnish the writer with 
the following notes: 
The patient, a rather slender youth of fifteen years, has 
been afflicted with epilepsy for some few years; the attacks 
occurring two or three times a week, with a disposition to 
more frequent occurrence. Some time before having had any 17 
NEURALGIA AND OTHER NEUROSES. 
sign of the disease, he fell on a pointed stick, which penetrat- 
ed deeply in the side, about midway between the last rib and 
the crista ilii. After the wound had been healed some time, 
the epilepsy appeared. lie was fully impressed with the idea 
that the wound was the cause of his fits : whether from a ten- 
der cicatrix, or an aura, I do not remember. On examining 
the site of the wound, a large puckered cicatrix was discover- 
ed, which was tender to the touch. Thinking that a piece of 
wood still remained in the tissue beneath, an exploring inci- 
sion was proposed. The incision was carried nearly through 
the thickness of the abdominal wall, and only a few small 
grains of softened wood found ; not enough, it was inferred, 
to account for the great disturbance of the nervous system. 
The epileptic symptoms disappeared at once. Thinking the 
operation and loss of blood had the effect to prevent the con- 
vulsions, the wound was kept open for some time, with the 
idea that it might act as an issue or counter-irritant, thus keep- 
ing at bay the disease, which was confirmed somewhat, as, 
after a time, when healed, he had symptoms of recurrence of 
the epilepsy, slight, however, and not at all frequent. This 
was always one of the unaccountable cases. I now think it 
was a clear case of irritable cicatrix; and that, had it been ex- 
cised, it would have been permanently successful. 
Dr. Fountain also related the following case : 
Mrs. S., aged about 22 or 25 years. Flad been married a 
few years. Flad been troubled with an increasing neuralgia. 
For years had felt it, and was growing worse and worse, until 
the mother said that, at times, “ she would go almost in a fit 
would stiffen and become unconscious. The pain would be- 
gin in the back of the head, and would shoot, as she expressed 
it, around both sides. On inquiry, I learned that, before the 
trouble commenced, she had had a fall on the back of her 
head, breaking a horn comb, a tooth of which was driven into 
the integuments, and, the mother was sure, remained in the 
wound. Remembering the other case, I proposed an explora- 
tive incision, which resulted in finding a small bit of horn, 
smooth and rounded by absorption, evidently not sufficient to 
produce all this suffering. She recovered at once. I never 18 
NEURALGIA AND OTHER NEUROSES. 
could understand why, until you called the attention of the 
society to the probable cause. 
Professor Edward H. Parker, of Poughkeepsie, also allud- 
ed to a case of epilepsy possibly caused by cicatrix, upon 
which he was called to perform a post-mortem examination. 
The case had been under the charge, at different periods, of 
I)rs. Van Duser, of Wappinger’s Falls, and Dr. I. C. C. Down- 
ing, now of Dobb’s Ferry. To the latter I am indebted for 
the following particulars, which I condense from his very 
interesting letter. 
J. Ik, aged 36. Had led a dissipated life. No history of 
syphilis. Was wounded in 1863. Leg shot off and almost 
simultaneously struck by a musket-ball in the head. The 
gash or furrow in scalp healed well. Began in July, 1872, to 
have increasingly severe and frequent epileptiform attacks. I 
first saw him in October, during an attack, a typical one, of 
epilepsy. There has been evident failure of the intellectual 
faculties. During several months of treatment, I exhausted 
all the usual anti-epileptic remedies without the least effect. 
For a long time the attacks occurred only during sleep, but 
they subsequently occurred in the day. He suddenly expired 
July 10th, 1874, during a fit, from spasm of the glottis ; was 
interred July 12th. I was telegraphed on the 15th to make an 
autopsy, but being unable to respond, Drs. Parker and Steven- 
son examined the head ; but it was, of course, unsatisfactory as 
regarded the condition of the brain, which was disorganized. 
There was only a trace externally of the injury of the scalp. 
It must have healed with little or no suppuration. No injury 
of skull. Although much of the trouble might have been 
attributable to bad location, business difficulties, tobacco, etc. 
etc., yet I felt justified in furnishing such a certificate as 
would lead to the inference that the injuries, received in the 
line of duty, caused the disease, and I have understood that a 
pension was granted his widow. I did attribute the peri- 
pheral irritation in this case more to the leg than scalp, and 
could see no clear indication to interfere surgically. Neither 
pressure nor manipulation of the stump or the scalp-wound 
elicited any symptom, which, in my judgment, would warrant 
a recourse to the knife. NEURALGIA AND OTHER NEUROSES. 
19 
The above is by no means a clear case of reflex epilepsy. 
But, taken in connection with the preceding histories, and 
noting the utter failure of remedies, which almost always 
produce at least a temporary and palliative influence on idio- 
pathic or centric epilepsy, it is possible, at least, that the exci- 
sion of the1 cicatrix, which existed, slight though it was, 
might have been of more service than all the other means so 
generously employed. 
It would appear, from the facts contained in this appendix, 
so many instances of this supposed rare occurrence having pre- 
sented themselves among a collection of only forty, mostly 
country practitioners, that its rarity is only apjyarent, and that 
it has been overlooked or unappreciated by the mass of the 
profession.