ON THE 
TREATMENT OF NEURALGIA 
BY 
SUBCUTANEOUS INJECTION, 
WITH CASES. 
A. RUPPANER, A.M., M.D. 
[Re-printed from the Boston Medical and Surgical Journal.] 
BOSTON: 
DAVID CLAPP 184 WASHINGTON STREET. 
1860. ON THE 
TREATMENT OF NEURALGIA 
BY 
SUBCUTANEOUS INJECTION, 
WITH CASES. 
BY A. RUPPANER, A.M., M.D. 
FELLOW OF THE MASSACHUSETTS MEDICAL SOCIETY. 
[Re-printed from the Boston Medical and Surgical Journal.] 
BOSTON: 
DAVID CLAPP 184 WASHINGTON STREET, 
1860. SUBCUTANEOUS INJECTION IN NEURALGIA, 
WITH CASES. 
I purpose to lay before the profession the detailed account of 
several cases of severe neuralgia, under my care during the 
last fifteen months, and treated principally by the injection of nar- 
cotics, after the method advocated by Dr. Alex. Wood, of Edin- 
burgh. I shall offer no apology for doing so. The neuralgic 
affections form a class of diseases in which our present mode of 
treatment offers little that is satisfactory. Every practical physi- 
cian must confess, that after exhausting the most judicious, persever- 
ing, rational and radical methods of treatment (and what article 
in the materia medica and what surgical expedient has not been 
pressed into service ?), he has often been compelled to fall back on 
the empirical administration of remedies. 
To point out a method of treatment which, although not always 
curative, might at least be generally palliative, when employed in 
cases adapted to the treatment, has ever been the great desidera- 
tum to be reached. Hence it is easy to account for the enthusiasm 
with which the proposed treatment by 11 subcutaneous injection ” has 
been received by the profession everywhere, both in Europe and 
America. Indeed, about the time Dr. Wood published his little 
treatise “ On a New Method of treating Neuralgia, by the Direct Ap- 
plication of Opiates to the Painful Points,” I found myself in the 
same predicament in which, no doubt, many a physician has often, 
before and since, found himself. I had, for instance, the doleful 
opportunity of witnessing very often the most excruciating parox- 
ysms of a highly respected friend of mine. Eor more than seven 
years had the disease, with ever-increasing violence, asserted its 4 
Subcutaneous Injection in Neuralgia. 
supremacy over every mode of treatment the most eminent and 
skilful medical men could devise; and the patient was finally consoled 
with the delusive hope that another seven years’ revolution of the 
time of suffering would bring the desired rest to her head, to which 
the neuralgia was confined, and with it to her whole constitution, 
much impaired by this time. This patient’s case will be given in 
this report. I resolved to try subcutaneous injection at the earliest 
convenient moment, and had soon an excellent opportunity of do- 
ing so. Other cases presented themselves. Although some of 
these were not at all adapted to this treatment—the cause being 
central and not centripetal—yet even in those cases where a cure is 
out of the question, I was greatly encouraged by the relief afford- 
ed ; the more so, because it enables the sufferer patiently to per- 
severe in a course of treatment adapted to the morbid state in 
which his disease has originated. 
For the sake of brevity in detailing my cases, and to avoid 
otherwise necessary repetition, I shall call attention— 
First, to that most important symptom in this disease—pain, and 
its localization. 
Secondly, to the conditions on which the success of the opera- 
tion in a great measure depends. 
Thirdly, to cases, given in the order in which they occurred in 
my practice, and with the results up to the time of writing this re- 
port. The history of each case will be given more or less minute- 
ly, as its importance may demand, as well as any constitutional 
measures and treatment which were pursued at the same time. 
Fourthly, I shall perhaps venture to offer a few suggestions as 
to the probable modus operandi of the remedy. 
Pain and its localization.—By whatever name we may designate 
that variety of affections comprehended under the term neuralgia, 
they possess in common the one important symptom of pain, more 
or less violent, situated in the course of a nerve. The greatest 
disparity of the attacks exists. They may be sudden and violent, 
gradual or increasing in intensity as the disorder makes progress. 
It may pay its unwelcome visits with the certainty of the clockwork 
which announces the departed hour on the dial, or rush into any 
breach which it may espy in the citadel of the constitution, with 
the ferocity of an exasperated enemy. Neither the robust and 
plethoric nor those of feeble habit of body, are exempt from its Subcutaneous Injection in Neuralgia. 
5 
inroads. Care, mental anxiety, profuse and weakening discharges, 
predispose greatly to the malady. No clime nor country, no race 
nor sex, nay, hardly any age, except perhaps the first years of infancy, 
is free from it. The inhabitant of the forest writhes under a par- 
oxysm of tic douloureux, as well as the most delicate habituee 
of the fashionable saloons in the capital of Southern Europe or 
those of the United States. Sciatica pays its unwelcome visits to 
the celestial Chinese as often, and in as good earnest, as to the 
serf of the soil of Russia, or the planter of Brazil. 
Nevertheless, genuine cases of neuralgia are not so common as 
is generally supposed. Hence, to test the value of the present 
proposed method of relieving the pain, it is essential that its ap- 
plication be limited to real neuralgic affections—where the pain is 
actually seated in the course of the nerve; and it must, moreover, 
be remembered, that agreeably to the laws by which nervous action 
is propagated, the irritation, that is, the pain, may be seated di- 
rectly on, or reflected indirectly on the nerve, at any point between 
its extreme peripheral distribution and the point at which it joins 
the brain. To determine the precise seat of irritation, that is, to 
localize the pain, is, then, the first step to be taken towards the pro- 
per application of this local treatment, namely, the injection of 
sedatives. 
M. Valleix, in his book entitled “ Traite des Nevralgies, Paris, 
1841,” first laid particular stress upon that most characteristic 
symptom, pain, and states that while, on the one hand, the superfi- 
cial nerves of the body are of all others the ones most commonly 
affected with this disease, there are some points in their course in 
which this .pain is more liable to be seated than in others; that no 
structural alterations have been discovered in the nerves to ac- 
count for this greater predisposition to pain. He gives to these 
painful points, or seats of departure of pain, the name of “foyers.” 
These are of the utmost importance to us in regard to the treatment. 
Ample observations and experiments have repeatedly convinced 
me of the correctness of M. Valleix’s statement—that these points 
are usually more or less morbidly sensible to pressure, even in the 
intervals between the attacks of the sharp, sudden and intermittent 
pain. Nay, so great is the morbid irritability in many cases, that 
whilst firm pressure is borne without any complaint whatever in 
the rest of the course of the nerve, the slightest touch in these fay- 6 
Subcutaneous Injection in Neuralgia. 
ers, or principal points, is often sufficient to excite acute suffering, 
sometimes the most acute imaginable. I shall give the history of 
a case hereafter, in which slight pressure upon the supra-orbital 
nerve, where it emerges from the supra-orbital foramen, excited 
such a paroxysm of pain that the patient trembled all over; the 
spectacle was too sad to be witnessed more than once. But this 
was not the only painful point in the case; in fact, the whole sys- 
tem was so invaded by erratic suffering that the unfortunate pa- 
tient seemed to have inherited the threatened doom of Caliban: 
“ Thou shalt have cramps, 
Side-stitches that shall pen thy breath up ; urchins 
Shall, for that vast of night that they may work, 
All exercise upon thee; thou shalt be pinched 
As thick as honeycombs, each pinch more stinging 
Than bees that made them.” 
Yalleix has classified the painful points in the course of any 
nerve thus:— 
1. The place of emergence of the nervous trunk; for example, 
the trifacial at the supra- and infra-orbital and mental foramen. 
2. The point where a nervous twig traverses the muscles to 
ramify on the integuments; similar to the parts which are travers- 
ed by the posterior spinal nerves. 
•3. The point where the terminal branches of a nerve expand in 
the integuments, as the terminal principal branches of all the 
cutaneous nerves, among which we may mention the anterior part 
of the intercostal nerves, &c. 
4. The point where nervous trunks become superficial during 
their course, as the peroneal nerve. 
Fortunately, the above points are exactly those where the nerve 
tends towards the surface, and where, consequently, it is most 
amenable to the treatment by injection. 
But Yalleix did not confine himself to the above four important 
landmarks, to be kept constantly in view. With admirable indus- 
try and precision, he has described the points of emergence of 
every branch of the great divisions of nerves which come into con- 
sideration in the treatment advocated by himself, namely, the ap- 
plication of successive small blisters in the course of the affected 
nerve. It is equally important to be perfectly familiar with all 
these points, in order to apply the method proposed by Prof. Wood 
where it will prove most effectual and can be most promptly 
applied. Subcutaneous Injection in Neuralgia. 
7 
These points of emergence are particularly numerous in the fifth 
pair of nerves, which, in at least two thirds of all the cases of neu- 
ralgia, is the seat of the suffering, the whole or a branch being affect- 
ed. For convenience of reference in the cases to be detailed, as well 
as for practical purposes, and for the benefit of those readers who 
are not familiar with Valleix’s work, I give here the points of 
emergence of the trifacial, arranged in tabular form. By means of 
it, is indicated nearly the exact position, at least in very many 
cases, where the instrument by which the narcotic is injected is to 
be inserted, when the pain is prominent in a principal trunk, or 
in some particular branch. 
Points of emergence of 
the ophthalmic branch 
of the trifacial. 
1st. The point of emergence 
of the lachrymal nerve at the 
external angle of the eyelid, or 
a. The palpebral point. 
2d. Of the frontal nerve (ex- 
ternal) at its emergence from 
the supra-orbital foramen, or 
b. The supra-orbital point. 
3d. Of the nasal nerve, less 
determined, and situated a lit- 
tle within and below the inter- 
nal angle of the eye, or 
c. The nasal point. 
Points of emergence of the supe- 
rior maxillary branch of the 
trifacial. 
1. The point of emergence 
of the orbital nerve towards the 
skin of the cheek, or 
a. The temp or o-malar point. 
2. The point of union ofl 
the petrosal branch of the vidi- \ 
an with the facial, giving ori- I 
gin to the chorda tympani, or J 
b. The internal auricular point. 
3. The emergence of the su- { 
perior alveolo-dental nerve, or < 
c. The superior dental point. 
4. The emergence of the' 
superior maxillary from the in- : 
k fra-orbital foramen, or 
d. The infra-orbital point. 
P tints of emergence of the inferior maxillary branch 
of the trifacial. 
f 1. The emergence of the mas- ' 
seter nerve where it passes> 
through the sigmoid notch, or ; 
a. The temporo-maxillary point. 
2. The emergence of the buc- 
cal nerve into the skin and mu- 
cous membrane of the lips. 
b. Point not well determined. 
3. The emergence of the tem- 
poral branch of the auriculo- 
temporal or anterior auricular 
nerve, between the temporo- 
maxillary articulation and the 
auditory canal, or 
c. The auriculo-temporal point. 
4. The emergence of the lin- 
gual between the sub-lingual 
gland and the tongue, or 
d. The lingual point. 
5. The emergence of the in- 
ferior dental from the mental 
foramen; one of the most re- 
markable points, or 
e. The mental pointt 8 
Subcutaneous Injection in Neuralgia. 
Point of interlacement not 
belonging exclusively 
to the fifth pair. 
r There must also be mention- 
ed the interlacement of the 
frontal nerve with the superficial 
temporal and the occipital ma- 
jor and minor, situated at the 
posterior part of the sagittal 
suture and almost immediately 
above the parietal protube- 
rance, or 
The parietal point. 
It would, however, be erroneous to believe that these painful 
points are met with equal frequency in practice. On the contrary, 
some present themselves very rarely. If we may be allowed to 
judge from a large number of cases which we have examined, re- 
ported by such authors as Yalleix, Sandras, Piorry, Romberg, 
Downing and others, and from our own observation of fourteen 
cases, these painful points will be found to occur in frequency very 
nearly in the following order: 
Points of emergence in the or- 
der of their frequency. 
1st. The supra-orbital point 
2d. “ mental “ 
3d. “ infra-orbital “ 
4th. “ temporal “ 
5th. “ nasal “ 
6th. “ malar “ 
7th. “ dental “ 
8th. “ labial “ 
9th. “ lingual “ 
10th. “ palpebral “ 
11th. “ parietal “ 
N. B.—With the mental point, the auriculo-temporal point is 
almost always present. 
Frequently, the patient will complain of severe pain just in 
front and a little below the ear, the place of anastomosis of the 
portio dura with the divisions of the fifth pair. Whatever may be 
our opinion as to the real function of the facial nerve, whether it 
is ever affected by this disease, it is quite certain that this form of 
neuralgia is difficult to diagnosticate, on account of the intimate 
connection of the 11 pes anserinus ” with the trifacial nerve. I have 
more than once met with cases where the pain was principally 
confined to this position. Hence arises a most important ques- 
tion for us in regard to subcutaneous injection, namely, where 
to introduce most properly the sedative in such cases ? This dif- 
ficulty may be overcome if the practitioner will bear in mind the 
place and mode of union of the portio dura with the three divi- 
sions of the fifth. The branches of the facial being three, the as- Subcutaneous Injection in Neuralgia. 
9 
cending, transverse, and descending, they are found to form three 
principal unions. 
Ascending, transverse and descending branches of the portio dura. 
Place and mode of union of the portio dura with 
the three divisions of the fifth. 
ls£ union.—a. Beneath the eye. 
b. Between the cheeks (buccal). 
c. The side of the nose (nasal). 
d. Terminating offsets of the superior maxillary. 
2d union.—a. Between the mandibulo-labialis branch of the inferior 
maxillary. 
b. The cervico-facial branches of the portio dura (on the 
chin and lower lip). 
3d union.—a. On the temple. 
b. On the eyebrow; union of the temporal branches of the 
facial nerve with branches of the frontal nerve just 
emerged from the supra-orbital foramen. 
Unions less important.—a. On the side and crown of the head. 
b. “ eyelids. 
c. “ cheek. 
d. “ lower jaw. 
e. The front of the ear. 
I shall now, in the second place, speak of The conditions on which 
the success of the operation in a great measure depends. 
This may be done briefly, as much that has been said above of 
pain and its localization is directly applicable here. But we must 
go a step further, and endeavor to ascertain whether the disease 
is central or centripetal; in other words, whether the morbid pro- 
cess on which the neuralgia depends be seated in the brain, from 
whence, as the great centre, all nervous influence emanates, or in 
one of the conducting trunks by which irritations affecting the 
ultimate distribution of the nervous fibrils are conveyed to that 
central organ. We are of opinion that, in cases where the disease 
arises from within the cranium, the result of this treatment will 
not answer the expectations, for obvious reasons; and although 
the local manifestation in the conducting nerve is to a great ex- 
tent under the influence of treatment, specially directed to it, yet 
it will do little good, being unable to reach the cause of the dis- 
ease—I ought to say, its proximate cause—if, indeed, it ever 
proves beneficial at all. In one case, where the disease is seated 
unmistakably in the cranium, and in another where there exists 
caries of the superior maxillary bone, I have failed to perceive 
any improvement in the violence of the paroxysms, or any cessa- 
tion of the pain, after repeated and powerful injections. In such 
and similar cases, as well as in all others where the pain is deep-: 
seated, the result is at variance with the expectations, Subcutaneous Injection in Neuralgia. 
10 
On the other hand, in all cases where the cutaneous, and par- 
ticularly the superficial cutaneous, nerves have been the seat of the 
malady, this treatment has answered my most sanguine hopes. 
Even in cases of long standing, when combined with appropriate 
constitutional treatment, I have succeeded in giving relief, for a 
considerable period of time, to the painfully harassed patient, af- 
ter all other possible expedients had been tried in vain.- 
And let me here append a few words in regard to constitutional 
treatment in neuralgia, as one of the conditions of success. In 
almost every case that has come under my observation, a tonic 
treatment has been indicated. I have tried both mineral and vege- 
table tonics, and must give the preference to vegetable tonics. I 
have used the sulphate of quinine in many cases, and in all but 
one it was followed by good results. I am of opinion that a tonic 
treatment' ought at once to be adopted, with few exceptions; and 
that the same ought to go hand in hand with the local treatment. 
Even the local treatment ought only to be resorted to when 
other remedies have failed. In mild cases of neuralgia, or in cases 
of recent standing, I have succeeded well with the solution of the 
valerianate of ammonia, used either in conjunction with injection or 
alone. I look upon the valerianate of ammonia as a preparation 
which deserves more the attention of physicians than it has hith- 
erto received. But I proceed to give the cases, as being best 
adapted to illustrate the above statements. 
Case I.—Neuralgia of all the branches of the Trifacial Nerve, of 13 
years' standing; non-success of the ordinary modes of treatment; in- 
jection at the infra-orbital point; relief 
In February, 1859, I was requested to visit Mrs. , at that 
time residing in Malden, Mass. The following notes were taken 
at the visit. Patient is 30 years old, married, mother of a child 3 
years old, of a nervous temperament and feeble constitution. 
Hardly had I entered the room, when I was impressed by the sad 
object of suffering before me, in a rocking chair. Complexion 
sallow; skin of the forehead and cheeks drawn together in wrin- 
kles ; eyes deeply sunk in their sockets; the lower jaw without 
teeth; the expression of the countenance anxious, and as if in ex- 
pectation of some violent paroxysm of pain to disturb the mo- 
mentary but deceitful calm 5 the left hand already raised to arrest, Subcutaneous Injection in Neuralgia. 
11 
at the first inkling, the delicate muscles of the face, moving, as if 
charged and agitated by an electric current: giving the face at 
times a peculiarly distorted and strange expression; patient hard- 
ly able to walk for want of strength in her limbs. Such was 
the ensemble presented by this wreck of a long and cruelly torment- 
ed frame, grown prematurely old—sustained only by a remarkable 
strength of character and a determined will. For thirteen long- 
years, she had borne her sad lot. There is but little doubt, that 
the malady in her case is hereditary. Her mother and a sister 
have both been subject to neuralgia. She has been more or less 
unwell from childhood. Experienced, about thirteen years ago, 
occasional sharp pains in the left shoulder, for which no cause 
could be assigned, but which, ere long, passed upwards to the left 
side of the face. Had a tooth extracted, which made the pain 
worse. For two years, the pain troubled her more or less in the 
same place, being always aggravated upon taking cold, when, all 
on a sudden, it made its appearance in the occiput, and extended 
thence to the right side of the face, where it remained stationary 
till this day. The intensity of the pain had varied, being, perhaps, 
better in summer and worse in winter. Short intervals of rest 
were enjoyed now and then till two years ago, when she miscar- 
ried. From that day dates an almost uninterrupted period of suf- 
fering, which seemed to reach its climax, when the paroxysms, or 
rather spasms, obliged her to keep the head turned to the right for 
two days. The least motion of the head would induce horrible 
suffering. The pain invaded also, about this time, the back and 
legs. Since her miscarriage, she had not been free from pain for 
a single day, and the greater part of the night was passed in a 
sleepless state. As a last resort, in the vain hope of obtaining 
relief, about six weeks before my visit, she had all the teeth of the 
lower jaw extracted, some of which were decayed; but all in vain. 
The paroxysms came and went away as usual. They still come 
and go, harassing her more than ever. Her general health is much- 
impaired. Appetite poor and capricious; bowels very irregular. 
Is exceedingly nervous and excitable. All possible means of treat- 
ment have proved nugatory. Nor did she omit to worship at the 
shrine of “ infallible Homoeopathy f with the glorious satisfaction of 
testing the efficacy of the wonderful Hahnemannic potencies. She 
waited for their effect upon the neuralgia with “ expectant ” hope, 12 
Subcutaneous Injection in Neuralgia. 
till she found she could not afford to wait any longer. At this 
stage of my interrogatories, the patient was quite free from pain. 
“ I fear,” she remarks, “ you can do nothing for me just now, doc- 
tor, for I am not suffering at this moment.” I told her I would 
see to that, and resolved at once to verify the principles first laid 
down by Valleix as to finding the most painful point by pressure, 
the same being also the most eligible one for the operation of 
injection. She declared herself willing to undergo any operation 
for the sake of obtaining relief. I determined to try subcutane- 
ous injection; her dentist from Boston, her family physician, Dr. 
Sullivan of Malden, her husband and sister, being present. 
Having placed her in an easy chair, I began to produce slight 
pressure with the edge of a coin—a ten-cent piece answered my 
purpose—along the ridge of the forehead. Patient complained of 
considerable pain, when I pressed near and upon the supra-orbital 
foramen. But this pain could not be compared in intensity with 
that which was experienced when I pressed, even slightly, upon the 
second division of the fifth pair at its point of emergence at the 
infra-orbital foramen. Pressure there produced the most intense 
agony. At the same point of emergence on the left side of the 
face, on the contrary, pressure, even the most firm, caused no pain. 
Pain was also absent at the mental foramen. Though the patient, 
when previously asked, could not recollect the exact point where 
the pain was most severe, so sudden and unexpected was the ad- 
vent of the paroxysm, and which seemingly affected the whole side 
of the face equally, now she remembered, at once, that on the 
cheek, to use her own words, was the beginning of all the trouble. 
Having thus found the infra-orbital point to be the most painful 
(although, no doubt, all the three divisions of the trifacial were in 
this case affected), I charged my syringe with twenty drops of a 
solution of one grain of acetate of morphia to one drachm of sher- 
ry wine, or one third of the drachm solution—which would be 
equal to two grains of solid opium contained therein—and inject- 
ed the whole at the infra-orbital point, bringing the point of the 
needle directly to the foramen; a point easily ascertained in this 
case, because the patient was very much emaciated.* 
* I am in the habit of using different solutions of the sedative, adapted to the susceptibility and 
strength of the patient. For some patients, a very weak solution of the acetate is sufficient to 
produce distressing nausea and vomiting, even when injected in small quantity, namely, six to ten Subcutaneous Injection in Neuralgia. 
13 
The pain of the application was very severe, but the effect not 
less speedy. Immediately upon the instrument being withdrawn, 
the surrounding part became oedematous, extending as far as to 
the nose and upwards to the eye. Mark, however, the effects of 
drops; but I have observed, that the stronger the injection, and the greater the disturbance caused 
thereby in the system, the more permanent is the result. The great desideratum is to find a seda- 
tive to be injected, which does not produce nausea or vomiting. 1 find that this can only be avoid- 
ed by using very weak solutions, and then injecting repeatedly, so as to arrive ultimately at the 
same result as if a stronger solution had been used. I inject the following solutions 
One grain of acetate of morphia dissolved in one drachm of sherry wine, 
Two grains “ “ “ “ “ “ “ “ “ “ “ 
Three 4i i( 44 44 44 44 44 44 44 44 44 44 
Four “ 44 44 44 44 44 44 44 44 44 •* 44 
When not particularly stated, when I speak of using the solution in my cases, related above, I 
have used the one-grain solution. In all other cases, 1 shall mention the strength of the solution 
employed. I have experimented with hyoscyamus and with the Indian hemp. I succeeded in 
avoiding the nausea and vomiting; but neither produced the desired sedative effect upon the pain 
when injected. 
In Championniire’s Journal of Practical Medicine and Surgery, of September, 1859, Vol. I., 
No. 9, Art. 5680, there is an extract from a paper read by Dr. EUhier, physician of the Hospital 
Beaujon, before the Academy of Medicine, on this important therapeutical question. 
Mr. injected a solution of sulphate of atropia, in the proportion of five grains of sulphate 
of atropia to one ounce of distilled water, which gives about l-160th grain of the drug to every 
drop. This mode of treatment was applied in fifty-three cases, of which there were eighteen 
cases of sciatic neuralgia, but only one case of facial neuralgia. Out of the eighteen instances of 
sciatic neuralgia, twelve have been manifestly cured ; in six others, cure was more than probable. 
“ Upon the whole,” 1 quote directly from the article before me, “ out of fifty-three cases, in which 
injections of the sulphate of atropia have been used, Mr. has witnessed eighteen com- 
plete cures, usually obtained by a solitary injection, by two at most, and in fifteen other cases he 
has ascertained constant beneficial effects from this mode of treatment, even when he has been 
unable completely to follow up his observations. In several patients, four days treatment and 
two or three injections only, were sufficient to effect complete cure. In some cases, as many as 
fifteen injections were requisite.”—Pp. 386, 387. It may also be mentioned here, although only 
indirectly connected with the subject of neuralgia, but directly with that of injection, that Mr. Bi- 
hier has made injections of sulphate of strychnia in seven cases of paralysis. The liquid he used 
contained five grains to one ounce distilled water, as in the case of sulphate of atropia. Among 
the facts adduced in support of this mode of treatment, the Gazette des Hopitaux reports several 
which seem very conclusive. 
I have injected the sulphate of atropia, of the strength used by Dr. in one case only, of 
facial neuralgia; the patient is still under my observation, and I shall report the result, perhaps, at 
some future time, after having tried the effects of this medicine in other cases. 
Something ought also to be said here, in regard to the instrument used. The glass syringe, 
made first by Mr. Young, of Edinburgh, and that of caoutchouc, by Tiemann, of New York, are 
both good, and answer all common purposes. But they are not exact enough when we wish to 
reduce the number of drops to a very small fraction; and when we wish just exactly to know how 
much we have injected, or to limit the amount to be injected. I had, therefore, an instrument 
made by Mr. Tiemann, of New York, similar to the syringe invented by Pravay for injection of 
perchloride of iron. At each quarter of a turn of the piston, which is screwed, one drop of the 
medicated liquid escapes. The body of the syringe holds one half a drachm. To the syringe 
are screwed trocar needles of the finest kind, and of different lengths. The only objection to 
this instrument is its high price ; the one I have, cost me fifteen dollars, a serious objection to its 
ever being extensively used, unless the price is much reduced. 14 
Subcutaneous Injection in Neuralgia. 
the injection upon the nervous system. When asked whether she 
had any pain now, she answered—u none at all." In about five 
minutes after the operation, patient said her eyes felt very heavy; 
she could hardly keep them open; felt as if all her nerves were 
unstrung. In a feAv minutes more she was fast asleep. Pulse rose, 
rapidly at first, from 86 to 104 per minute. In this condition I 
left her—being obliged to return to Boston. I gave directions, in 
case she should be attacked by nausea and vomiting—an effect of 
the injection which I fully anticipated, and requested her husband 
to report to me, next day, her condition. 
Feb. 16th.—This afternoon, nearly twenty-four hours after the 
operation, patient’s husband reports to me the following facts. 
About an hour and a half after my departure (Mrs. being 
soundly asleep during the whole of that time, just as I left her), 
she was attacked with nausea and vomiting, similar to sea-sickness, 
which continued for several hours at intervals, and obliged her to 
go to bed. The oedema seemed rather to increase, but she felt no 
neuralgic pain whatever. When vomiting had ceased, she passed 
a perfectly quiet night, and was free from pain all the next 
day. The swelling began to diminish during the night, and was 
considerably less on Saturday morning. Felt somewhat sick at 
stomach all day. R. Bismuthi sub. nitratis, 9i.; infus. gentianse, 
comp., | iss.; aqua menth. viridis, § ss. Ft. mistr. One tea- 
spoonful every half hour till vomiting ceases. Ordered warm 
hops to be applied to the cedematous part. 
17th.—Patient is still free from pain. Slept well all night. 
Swelling much decreased. Nausea subsided, after taking the medi- 
cine prescribed yesterday, twice. 
18th, 11, A.M.—To my great surprise, patient enters my office, 
in person, accompanied by her sister. Seeing her, 1 expressed my 
satisfaction and surprise. But she interrupted me :—“ I considered 
it my duty, to come myself this morning, and thank you for the 
relief you have given me. For the first time, in three years, have 
I slept three entire nights without pain, since the injection on Fri- 
day.” In fact, the patient seemed to be very happy at the result; 
although I told her I feared a return of the paroxysms sooner or 
later. Is free from pain in the face and head; swelling has almost 
entirely disappeared. Nothing could be seen of the point where 
the instrument had been inserted. Thought she felt a little pain Subcutaneous Injections in Neuralgia. 
15 
in the fore-arm on her way to the city. I prescribed, also, quiniae 
sulphas in one-grain doses, twice per day, and tinct. quassias 
comp. Told her to call on me on the first reappearance of the pain. 
April 29th.—Had not heard from my patient, except indirectly, 
till to-day, when she called at my office in excellent spirits. Has 
not experienced the least pain whatever in the face or head since 
I saw her, the 18th of February. A few evenings ago she went 
out, and it being damp, caught cold; she felt, afterwards, a few 
pains shooting through the occiput down the neck and spine. Has 
gained much in strength, in appearance and color of the face. Is 
able to do again her own sewing. Has taken the quinine and gen- 
tian since her last visit. 
She complains, however, of occasional pains, shooting down her 
arms and legs; requests me to inject some morphia into the 
thigh. I consented; and having ascertained the most painful point 
to be situated about the middle of the anterior part of the thigh 
(in the course of the middle cutaneous nerves), I injected ten 
drops of the solution. The same phenomena presented themselves 
again, as after the first operation; pain, oedema and nausea. But 
the injection was not powerful enough this time to produce vomit- 
ing. Patient left my office, after an hour or thereabouts, quite 
comfortable. 
May 4th.—The very morning I was about to sail in the steamer 
Arabia from East Boston for Europe, Mrs. called on me; 
and during the short interview I had with her, I ascertained that 
she reached Malden well, free from pain in the thigh, and free from 
the distressing vomiting of the former operation. Advised her to 
persevere, during my absence, with the tonic treatment; and re- 
commended in addition such hygienic measures as might tend to 
invigorate her constitution. 
Oct. 2d.—Patient presented herself to-day, being informed of 
my return from Europe. She informs me that she has had no re- 
turn of the paroxysms of pain; although she had been kept, for 
several days and nights, in a constant state of excitement and men- 
tal anxiety, owing to the dangerous and nearly fatal illness of her 
husband. Her general appearance is much improved; has gained 
strength; is more fleshy than she was six months ago; has perse- 
vered constantly in the constitutional treatment; intends to re- 
move to the State of Maine. For a period of seven months, then, 16 
Subcutaneous Injections in Neuralgia. 
and in fact after the first injection, this patient has been free from 
her pain, and has continued doing well up to the present time. 
Case II.—Neuralgia of the Lachrymal Branch of the Ophthalmic 
division of the Trifacial, of seven years' standing; injection at the 
palpebral point; relief. 
March 3d, 1859, I was consulted by Mrs. , Boston, aged 35; 
mother of one child; of nervo-sanguineous temperament. Has 
been troubled with neuralgia of the face and head for seven years. 
The pain is wholly confined to the right side; extends just as far 
as the sagittal suture; has never invaded the left side of the face 
at all. It seems to be of a dull, heavy character, almost constant, 
but at one time more severe than at another. Patient indicates 
the right malar bone as the seat of her trouble; also, the external 
angle of the eye, but particularly the spot where the lachrymal 
branch of the ophthalmic division of the fifth pair emerges. Pro- 
ducing pressure along the course of the nerve with a small coin, I 
find the pain at and about the supra-orbital foramen less severe than 
at the palpebral point; but still pain is felt there, extending from 
thence over and along the sagittal suture, down to the parietal 
foramen. Lately, it has also extended downwards and backwards 
from the angle of the eye, and become stationary in front of the 
ear. The important diagnostic question occurred here, whether 
this pain in front of the ear originated in the portio-dura or one 
of its branches; or whether it was merely symptomatic pain, caus- 
ed by the disordered action of the fifth ? Subsequent events 
showed that it was only symptomatic. This pain around the ear 
has, however, troubled the patient only for the last two weeks. 
It is neither lancinating nor spasmodic, but a constant, dull and 
heavy pain. Neither cold nor heat affects it. The general health 
is much affected; has sometimes so severe pain that she does not 
know what to do; feels then so perfectly miserable that she is 
unable even to dress herself. Sometimes the right eye is very 
painful. Is accustomed to press her hand against the cheek while 
the paroxysm lasts, and thinks pressure relieves her. 
Operation.—I injected fifteen drops of the solution directly at 
the palpebral point. Patient felt very little pain from the injection. 
A few minutes after, she told me she thought the pain was less 
than before the operation, but still there was some pain. The Subcutaneous Injections in Neuralgia. 
17 
pain around the ear, but particularly in front of it, continued to 
be very severe. Introduced the needle again, and injected ten 
drops more at the same point. About five minutes after, she de- 
clared herself entirely free from pain. The swelling at the point 
of injection was very trifling, but a distinct rash appeared. Felt 
a little nauseated, but soon recovered from its effects. No 
vomiting. 
4th.—Mrs. called on me this morning, and told me she had 
passed the whole time up to the present moment free from pain; 
although the weather was very chilly, damp and unpleasant, which 
has generally affected her unfavorably. The swelling had subsided, 
but the part was still a little sore. As her general health had 
suffered much in consequence of her continued suffering (the coun- 
tenance being exsanguine, and the lips nearly colorless), I ordered 
the following medicine, with generous diet:—R. Citratis ferri, 5ij- 5 
syrupi aurantii, aquse menth. pip., aa § ij.; aquas purse, § iv. M. 
Sumat coch. parv. ter in die. 
16th.—Called on my patient. She has been free from pain till 
within a day or two, when she again experienced pain in the right 
temple. I detected the most painful spot still to be situated in the 
course of the lachrymal branch, at the palpebral point. Injected ten 
drops of my solution No. 2 ; patient felt a severe pain and scream- 
ed aloud. The part immediately surrounding the puncture became 
oedematous and exceedingly tender to the touch. Patient had 
nausea, but did not vomit; had to retire to bed, feeling too unwell 
to sit up. About fifteen minutes after the injection, she told me 
that the neuralgic pain had vanished. Except the tenderness at 
the point of injection, she did not feel anything at all. 
17th.—Part still a little oedematous, but not so tender as yes- 
terday. No pain since the injection. 
18th.—(Edema has altogether disappeared, as well as the sore- 
ness. Patient is free from pain. 
From that period up to the time of writing this report, Mrs. 
has been mostly free from pain. She had a severe attack of 
fever, followed by varioloid, within the last three months, but no 
return of the neuralgia. Except during my absence in Europe, 
the patient has been constantly, and is still, under my observation. 18 
Subcutaneous Injections in Neuralgia. 
Case III.—Neuralgia of the Superior and Inferior Maxillary Nerves, 
or the second and third divisions of the Trifacial. Injection at differ- 
ent points ; relief 
Mrs. , of Boston, aged 59 years, married, mother of seven 
children, of nervous temperament; has suffered from neuralgia for 
about eight years. The pain is confined to the right side of the 
head and face, principally to the upper and lower jaw. 
What degree of excitability the nerves of sensation of the face 
may reach, was here most fully illustrated. Would that I were able 
to describe in adequate terms the indescribable sufferings of my 
patient; not that I find delight in the recital of a, seemingly, too 
highly-colored tale; no ! but to do thereby inadequate justice and 
homage to the fortitude and resignation with which Mrs. has 
so long borne her suffering. The least breath of air—loud con- 
versation—a sudden noise—the riding in an omnibus over the 
pavement—even the noise of a passing carriage or other vehicle, 
over the street—the act of laughing and talking—the taking of 
fluids, warm or cold, into the mouth—the touching of the gums 
with the tip of the tongue, would induce a sudden paroxysm of 
pain, and cause the patient to give vent to her distress in loud 
screams. At such times, the muscles of the upper lip and cheek 
of the right side are convulsed; and by placing the hand upon the 
affected part, which is exceedingly painful to the touch, a regular 
throbbing sensation is distinctly felt, going tick—tick—tick, with 
perfect regularity, and reminding one very forcibly of the appropri- 
ateness of the French name of this malady, “ Tic douloureux.” The 
course the pain takes, as it shoots along, is generally regular. 
Starting from the central and lateral incisor tooth, it shoots up- 
wards to the ala of the nose, thence obliquely upwards and out- 
wards to the infra-orbital foramen, thence to the temple, and finally 
upwards either to the vertex and again along the suture down to 
the neck, or from the temple down to the pes anserinus and into 
the lower jaw. 
Is it surprising that the patient’s health broke down gradually 
under so much suffering ? For the paroxysms would come on often 
several times during the day and night—often daily for a week or 
more, and after a short interval of rest, return to assail her anew. 
Every thing was tried to give relief, from the medicaments ordered 
by the most able physicians—which gave temporary relief at least 
—to the most extolled nostrums of the day. Subcutaneous Injections in Neuralgia. 
19 
Sept. 14th.—Examined the patient for the first time, with refe- 
rence to trying subcutaneous injection. From the direction the 
shooting pain generally takes, and from the fact of its starting 
always from the two incisor teeth of the right side,.I suspected 
that much of the trouble was owing to the disordered state of the 
teeth and gums. Such, upon close examination, did not prove to 
be the fact exclusively. The gums, however, were in an unhealthy 
state, and the superior and inferior maxillary bones are, I fear, 
not in the most healthy condition. Much of the mischief in neu- 
ralgia is, no doubt, often owing to decayed teeth; but much harm 
is also done in indiscriminately extracting teeth, believing them to 
be the cause of the neuralgia; whilst by removing the tooth, the 
nerve, the true seat of the pain, is by no means reached. Many cases 
are on record, where no benefit at all was derived from such a 
procedure (vide case No. 1, of this report); and the present fur- 
nishes another illustration of the uselessness of extracting one or 
more teeth, and the benefit derived from the opposite course when 
warranted by a correct diagnosis. Several years ago, the subject 
of the present case had one or more teeth extracted, hoping there- 
by to get cured of her neuralgia, but in vain. And I believe she 
was advised by her physician, and her dentist too, not to have 
them removed. She has still a strong hope, that if her teeth were 
extracted, there would be an end to her neuralgia. The success- 
ful removal of the right molar tooth, of late, seems to have strength- 
ened her in this belief. But the reasons for extracting that tooth, 
done by my advice, after consultation with Dr. Keep, senior, of 
this city, and for not extracting the others, will be apparent very 
soon. 
I decided first to try the effect of the valerianate of ammonia 
on this patient—a preparation, of which I have already spoken. I 
prescribed, as follows:—R. Solutionis ammoniae valerianatis, 
5ii.; syrupi simplicis, § ii. M. Cochlear, parv. pro re nata. Also 
generous diet and pure grape wine. Patient was relieved for the 
time, but the pain soon returned. I concluded to resort to subcu- 
taneous injection the first time it should return and be severe. 
Sept. 15 th.—Mrs. sent for me, having a terrible access of 
pain. Pressure revealed the infra-orhital point to be the most sen- 
sitive ; I injected ten drops of the solution at that point. Patient 
felt a sudden warmth pass over her whole body; (complains of 
having always cold feet and hands, but particularly of the right 20 
Subcutaneous Injections in Neuralgia. 
side;) five minutes after the operation, or thereabouts, she felt no 
pain at all, and became drowsy. Left her in that state, lying on 
the sofa. (Edema at the point of injection inconsiderable; very 
tender to pressure. Some hours later, she said to me: “ What 
did you inject ? That drowsy feeling was splendid; I saw such 
beautiful visions.” Towards afternoon she was seized with 
nausea, which was shortly followed by vomiting. This con- 
tinued at intervals until evening, when I prescribed: R. Bismuthi 
subnitratis, Bi.; infus. gentianas comp., § iss.; aquae menth. pip., 
§ ss. M. One teaspoonful every hour till relieved. Vomiting 
ceased after taking the first dose. Slept well all night, and was 
free from pain. 
16th.—Still free from pain, except directly over the first molar 
tooth, at the root of which the pain seems to be situated. Patient 
is very nervous and weak. Prescribed the following: R. Infus. 
gentianae comp., § iij.; extract, valerian., fl § i. M. Two tea- 
spoonfuls three times per day. 
17th.—Patient had, last evening, a severe paroxysm of pain 
in the upper maxillary bone, caused by sudden excitement and 
much conversation. It subsided after about an hour, under the 
use of the valerianate of ammonia. 
20th.—Was sent for. Patient was very comfortable yesterday, 
but to-day buffers much from pain in the superior maxillary bone, 
just at the root of the first molar tooth. Has also pain in the 
infra-maxillary bone. Injected five drops at the mental point, be- 
ing the most painful point, and about five drops more, close by the 
right ala of the nose, in a line with the margin of the same. 
Pain subsided in about ten minutes, and patient felt quite com- 
fortable, with the exception that there was some burning sensation 
from the puncture made with the instrument. In about ten minutes 
more a general, comfortable warmth was diffused over the body, 
and she again passed into a half drowsy state. 
21st.—Reports no pain. Comfortable all the rest of yesterday, 
during the night, and this morning at the hour of my visit. Feels 
very much debilitated. 
26th.—Was requested to see my patient. She reports herself 
as having been mostly free from pain and more comfortable than 
ever before, although the weather was very stormy, which had 
usually affected her very unfavorably. Complains of some pain in 
the lower jaw, not where I had previously injected, but at the au- Subcutaneous Injections in Neuralgia. 
21 
ricuLo-temporal point, and also at the root of the first molar, as 
usual. Injected five drops at the auriculo-temporal point, and five 
more near the ala of the nose. Patient was at once relieved from 
pain, and felt easier. I must not omit to state that the patient 
had mental trouble last week, which may be regarded as the excit- 
ing cause of these last paroxysms. 
Oct. 1st.—Quite free from pain, with the exception of some 
slight twinges over the first molar tooth. All the suffering seems 
to be confined to that place. Patient still takes infusion of gen- 
tian and valerian. Tried iron and quinine, but neither agrees 
with her. Appetite excellent. Pulse 82. 
2d.—Complains still of pain over the same tooth as yesterday. 
Very nervous and excitable about the least thing that is said. In- 
jected again four drops near the ala of the nose. Patient was 
relieved of pain, but felt very sleepy. 
3d.—Beports no pain, but feels much prostrated. 
4th and 5th.—Patient exercised both days quite violently. Was 
exposed to sharp winds. Had, each evening, a paroxysm of most 
excruciating pain, all starting from the molar tooth. Pain lasts 
about two hours—from 7 to 9, P.M. Was sent for; when I ar- 
rived, somewhat late, pain had subsided. All the pain, which is of 
a pulling, tearing character, is confined to the tooth. Complains 
of no pain anywhere else. 
6th, 9£, A.M.—Was sent for. Patient had another attack in the 
same region as on the two previous evenings. Peels very feeble; 
pulse 72. Injected, directly, five drops over the molar, followed 
soon by relief. Is sensibly affected by the injection; compares it 
to a crawling sensation all over the body. Begins to sleep. 
7th.—Free from pain. Slept well. Feels weak and prostrated, 
but not so much as yesterday. Continues her tonic and wine. 
16th.—Was called to the patient, who has repeated paroxysms, 
situated, as before, over the molar. The least touch or motion of 
the lip produces a paroxysm, which lasts about a minute. Pain 
does not spread. Injected again with good results. 
18th.—Is free from pain, but very nervous. Pulse 104. 
19th.—Had several severe, though short, paroxysms this morn- 
ing. Is entirely prostrated by pain, and extremely nervous. Any 
and everything brings on pain. Suffered so severely in my pre- 
sence, that I injected eight drops of the solution near the infra- 
orbital point, with immediate good result. Patient insists upon 22 
Subcutaneous Injections in Neuralgia. 
having the first molar tooth removed, it being the source of all 
her trouble. Pulse 98. 
1 o’clock, P.M.—Consulted with Dr. Keep, Sen., as to the remo- 
val of the tooth in question, at the patient’s request. Dr. Keep 
had extracted several teeth, within the last few years, for the pa- 
tient, with no good effect as far as the neuralgia is concerned. 
The pain always shifted afterwards. Patient is still free from pain, 
and under the influence of the injection of this forenoon. The lip 
can be raised without trouble. Is very nervous; pulse 120, with 
violent palpitation of the heart. For these reasons the operation 
on the tooth is postponed till next day, in the hope of getting the 
patient more calm, and pulse reduced. 
20th, 9, A.M.—Met with Dr. Keep at patient’s house. Has 
passed the previous afternoon and night free from pain. Went 
down stairs to breakfast, and had a paroxysm. Pulse 88. Lip 
comparatively free from pain. Dr. K. extracted the tooth without 
trouble. The appearance of the tooth presents nothing abnormal, 
except that its fang is very rough, almost serrated on one side and 
more transparent than usual. Says she feels better. At the eve- 
ning visit the lady is found to be comfortable, free from pain, but 
still very nervous. 
22d.—No pain. Very weak and nervous. Has little appetite. 
Pulse 92. 
24th.—No pain. Feels stronger. Thinks the vegetable bitters 
and the wine agree with her. 
28th.—Patient is still free from pain. Continues to gain strength. 
Nov. 3d.—No pain, and much improved. Can eat without diffi- 
culty ; sleeps well; has been out in the fresh air almost daily; can 
ride, &c., without suffering from pain. 
11th.—Gives a favorable account to-day since I saw her last. 
Looks better; has a good appetite, and is in good spirits. 
From this date my visits ceased; and patient has continued, as 
I hear, doing well. 
I have reported this case in full, in order to present the effects 
of often-repeated subcutaneous injection; and to show its power 
of stopping the pain, at least for a considerable period of time, 
when a possibility of cure is almost, if not entirely out of the 
question, thus giving, at least, relief from time to time. Here the 
tic douloureux was so well marked as to leave no doubt in my 
mind about the nature of the case; the pain was evidently seated Subcutaneous Injections in Neuralgia. 
23 
principally in the terminal branches of the superior maxillary 
nerve, in the mandibulo-labralis and some muscular twigs of the 
inferior maxillary, and to a slighter extent also in the pes anseri- 
nus of the portio-dura. Another fact must also not be overlooked 
in this case. Patient had always a good appetite, although she 
was unable to eat on account of the pain caused by the motion of 
the jaws. Having become much debilitated, a tonic treatment was 
indicated and vegetable bitters produced the desired effect; whilst 
iron and quinine could not be borne at all. Much benefit, no 
doubt, was also derived from the constant use of pure Rhine wine. 
Case IV.—A7 euralgia seated in the right temple ; Injection at the Tem- 
poro-malar point; Use of the Valerianate of Ammonia; relief 
Mr. , residing in Boston, aged 20, book-keeper by occupa- 
tion, was attacked, some two weeks ago, with violent pain in the 
right temple, during the night. Is of the sanguineous tempera- 
ment, and has always enjoyed good health. Is, however, not ro- 
bust, but rather delicate. Can assign no cause for the pain. Con- 
sulted his physician, who prescribed palliative remedies, in the form 
of ointment, to be applied externally. Did not derive any benefit 
therefrom. 
Sept. 21st.—Consulted me at my office. Pain has been more 
or less constant; rather dull and heavy instead of lancinating. 
His teeth are sound. Upon pressure, I discovered the temporo- 
malar point to be the most painful spot of the affected surface. I 
advised injection, but he rather objected to it, and expressed his 
preference for internal remedies. Prescribed the valerianate of 
ammonia in the usual form, and told him to call on me if he did 
not get relief till morning. 
22d.—Reports having obtained no relief from the use of the 
medicine. Persuaded him to consent to injection. I injected ten 
drops of the strong solution at the temporo-malar point. About 
fifteen minutes after the insertion of the narcotic, he complained 
of giddiness, but declared himself free from pain, which was very 
violent when he entered my office. Went to sleep for almost an 
hour. Had no pain when he left me, but the point of injection 
was very tender to the touch, and slightly oedematous. Patient 
took tonics for a considerable period afterwards. Pain has not 
returned, up to the present time. 24 
Subcutaneous Injections in Neuralgia. 
Case Y.—Severe pain in the teeth of the right side of the Upper 
Jaw, occurring during Pregnancy; Injection of Opiates into the 
gums ; temporary and partial, hut not permanent relief. 
The patient was a German woman, aged 34 years, of nervo-san- 
guineous temperament, mother of two children, and four months 
advanced in her third pregnancy. When I arrived, she complain- 
ed of pain in all the teeth of the right side of the upper jaw. 
Suspecting them to be at fault, I examined them carefully, and 
found them perfectly sound; but on the left side there were two 
decayed ones. Here, however, she experienced no pain at all. I 
determined to try the effect of opiates by injection, as everything 
else had been tried. By means of a curved needle, I injected into 
the gum fifteen drops of solution No. 4. In about twenty minutes 
the patient declared her pain to be somewhat less. This being in 
the forenoon, I called again towards evening, in order to inject 
once more, so as to give the patient rest over night, if possible, 
as she had already lost two nights’ sleep. Injected again twenty 
drops of the same solution. Pain was somewhat relieved after 
half an hour. Patient felt nausea, and soon began to vomit. 
When I called next morning, patient informed me that for about 
two hours after the injection she felt but little pain, but shortly 
after that time it returned with more violence than ever, and kept 
her awake all night. 
This case not being adapted to the treatment, and having inject- 
ed for the sake of experiment rather than in the expectation of 
giving permanent relief, I desisted from any farther operation. 
The pain subsided, a few days after, spontaneously. 
Case YI.—Case of Cervico-Brachial Neuralgia of many years' 
standing ; failure of all other remedies ; Injection at the Post-Clavi- 
cular Point; relief. 
Mr. , German, 46 years of age, married, a carpenter by 
trade, has suffered for many years from severe lancinating pain in 
his left arm, which he fractured, at the upper third of the hume- 
rus, when 12 years old. The pain is generally most severe after 
exposure to damp or cold weather, or after a hard day’s work. 
Can generally predict, with considerable certainty, the advent of a 
paroxysm. Pain is sometimes sharp and lancinating, sometimes it 
partakes of a dull and heavy character. It shoots along the neck, 
from whence it starts, downwards, is felt all over the shoulder, and Subcutaneous Injections in Neuralgia. 
25 
is often most severe at the external angle of the clavicle, at its 
articulation with the scapula. Pressure revealed that the most 
tender spot was the post-clavicular jjoint of Yalleix. I inserted my 
syringe within the angle formed by the clavicle and acromion pro- 
cess, and injected twenty drops of the solution I generally use. 
Not long after the instrument was withdrawn, the patient felt 
sleepy and drowsy. No nausea nor vomiting. He remained lying 
on my sofa for an hour, and when he awoke, declared himself free 
from pain. 
Some weeks after, he called again, the pain having returned with 
increased violence. I injected, at the same point as before, fifteen 
drops of my strongest solution. The same phenomena were ob- 
served, and the same results followed. Having cautioned my pa- 
tient in regard to his dress and over-exertion, and having prescrib- 
ed some stimulating anodyne liniment, to be used in case pain 
should be only slight in future, I sent him home. This happened 
in March, 1859. From that time to the present he has had, in 
cold, wet and damp weather, occasional and very slight pains, which 
he says are not worth noticing when compared with his former suf- 
fering. Is now working at his trade, perhaps more assiduously 
than ever. 
Case YII.—Neuralgia of Twenty Years' standing, seated in the Fes 
Anserinus of the Portio Dura of the seventh, or facial Nerve, and 
the third union of the Portio Dura with the Trifacial; Injection at 
the Temporo-Maxillary point ; relief 
The following case was placed in my hands by my esteemed 
friend, George Bartlett, M.D., of this city, in October, 1859, 
Mrs. , of Boston, widow, 48 years old, mother of three 
children, of nervo-sanguineous temperament, has been subject to 
neuralgia for the last twenty-six years. Her father was healthy; 
but her mother, who is still alive, and 74 years old, suffered from 
early youth, for many years, from the same complaint. Her two 
sisters have never had neuralgia. She has been delicate and sickly 
from childhood, but has never been subject to rheumatism, or any 
kindred malady. 
Twenty-six years ago the patient experienced, for the first time, 
a very severe paroxysm of pain in the superior maxillary and ma- 
lar bone, without being able to assign any cause for it. It thence 
travelled upwards to the vertex, never crossing the median line, 26 
Subcutaneous Injections in Neuralgia. 
but now and then a sudden, sharp pain would dart down the left 
side of the face. It continued generally from one to three or five 
days, and then would be superseded by a severe nervous headache, 
occurring about once in a continuing for three days 
without abating, and leaving her, at the end of that period, in an 
extremely exhausted condition. Had some teeth extracted in the 
hope of getting relief, but all in vain. About six months ago, the 
pain changed its seat suddenly, and appeared at a point directly 
in front of the right ear, where the portio dura of the facial gives 
off its ascending, transverse and descending branches. Since that 
time, the neuralgia has been entirely confined to the ear itself, 
and a small space in front and behind it. Complains of a con- 
stant noise going on within the ear—similar to the humming of a 
swarm of bees—which keeps her awake all night. Her general 
health has suffered much within the last few years; her appetite, 
however, is good, and the digestive functions are in tolerably good 
condition. 
As every possible remedy had been perseveringly tried with 
only temporary relief, on taking charge of the patient I tried at 
once subcutaneous injection. 
Oct. 11th, 9, P.M.—Suffers excruciating pain in and about the 
ear. I injected ten drops of the solution between the temporo-max- 
illary and the auriculo-temporal point. Experienced a little nausea. 
After ten minutes she felt more comfortable, and almost free from 
pain. Noise in the ear still perceptible and annoying. 
Oct. 12th, 9, A.M.—Patient had a comfortable night. Com- 
plains of no pain, and declares she had never tried any thing 
which gave her such prompt relief. Feels weak and nervous. 
R. Infus. gentianse, § iii.; extr. valerian., fl § i. M. Sumat. coch., 
amp. ter in die. 
14th, 9|, P.M.—Patient sent for me. Has great pain in and 
around the ear. Injected fifteen drops of the strong solution at 
the auriculo-temporal point, with decided relief to the pain. She 
slept for an hour, and was then troubled with nausea. 
15th.—Passed the night free from pain. Ordered her to try, in 
case the pain should return, the valerianate of ammonia. 
16th.—No pain. Pulse weak. Advised her to drink wine. 
17th, 18th, and 19th.—Had one of her periodical headaches, but 
no pain in or about the ear. 
21st. Has some pain, but not violent. Injected once more as 
before. Slept well that night. Subcutaneous Injections in Neuralgia. 
27 
Nov. 14th.—The patient to-day is free from pain. The noise 
in the ear has not returned. Persevered in taking tonics, and par- 
ticularly Rhine wine, with her principal meal; her general health 
has in consequence much improved. Appetite good: strength 
returning. I have seen this patient a number of times since the 
above date, and find her doing well, continuing free from pain. 
Case YIII.—Sciatica of three and a half years' standing ; Injection 
in the course of the Sciatic Nerve ; relief 
Mrs. , aged 26 years, of nervous temperament,but strong con- 
stitution, aborted some six years ago. Since that time her health 
has been impaired. About a year after the above mentioned event, 
she was treated for prolapsus uteri by the most eminent physicians, 
but never recovered her former health. Three years ago, she was 
attacked with severe pain in the right sciatic nerve, starting from the 
ilium and shooting down the thigh to the knee. The least damp, 
cold or wet weather, the wearing of thin stockings and shoes, ex- 
citement of any kind, or a long walk, would bring on a paroxysm. 
Warmth and friction generally relieves the pain. In November, 
1859, this lady consulted me in regard to her sciatica. Examina- 
tion revealed tenderness of the whole right hip, and a distinct 
painful point was felt upon pressure, near the posterior superior 
spinous process of the ilium, and another farther down, a little be- 
low the middle of the thigh. 
I had previously advised her to apply ten leeches in the course 
of the sciatic nerve, to be followed promptly and assiduously by 
warm fomentations, and Dover’s powder, in five grain doses, once 
or twice during the night. An active cathartic was also given, and 
followed by good effects. 
Nov. 22d.—Pain returned with much exasperation, being very 
severe and lancinating in the middle of the thigh and around the 
head of the fibula. I introduced the syringe at the painful point in 
the middle of the thigh, this point not being larger than a three-cent 
piece, and ten drops of the narcotic solution were injected without 
any pain, only producing a slight smarting at the seat of the punc- 
ture. In a little more than an hour the pain ceased and the patient 
fell into a sound sleep. Slept for more than two hours, and, on 
awaking, declared herself free from pain. 
The state of this patient’s general health required considerable 
attention. She is. now much better than before, but still far from 28 
Subcutaneous Injections in Neuralgia. 
being well. She has also had two slight returns of the sciatica, ow- 
ing chiefly to her own imprudence in exposing herself to a cold and 
damp atmosphere in the evening. At her own request, she has 
been treated by opiate injections twice, with decided benefit. Con- 
tinues doing well; has, however, now and then, slight attacks of 
pain. 
Case IX.—Case of Rheumatic Neuralgia of four years' standing; 
Injection at the Supra-Orbital Point; use of the Valerianate of 
Ammonia and Tonics ; partial relief 
January 18th, 1860, I was requested to see Mrs. , of Bos- 
ton; mother of five children, of feeble constitution, inclined to 
consumption, and of a very nervous temperament. For about ten 
years she has been subject to rheumatism, and is still a victim to 
it. This malady first attacked her knees, next the articulations of 
the forearms and fingers. Her family is subject to the same affec- 
tion. Her heart has never been affected by the disease. Pulse 
78. Lungs not in a good condition. Suffers much from sore 
throat. In fact, ask her what you please, and she will have some 
complaint or other to make. 
About four years ago she was attacked with severe neuralgic 
pain over the left eye, which at times disappeared and again re- 
turned with increased violence. Being very careless in regard to 
her health, even trying to indulge in the pleasure of skating, and 
shunning no weather in the evening when the occasion offered, she 
often suffered from an aggravation of the pain. 
I directed my attention first to her general health. In case of 
pain I tried, with tolerable success, valerianate of ammonia; at 
other times, the valerianate of zinc, with hyoscyamus, in the form 
of pills, and vegetable bitters were also given. Having laid down 
strict rules as to her manner of living, and particularly as to her 
leaving the house, &c., I had the satisfaction of seeing this patient’s 
health improved, and her pain mitigated. 
Feb. 3d.—The pain over the eye is more severe than ever. 
Pressure at the supra-orbital foramen gives great pain. I inject- 
ed at the supra-orbital point, therefore, ten drops of the usual so- 
lution. In a few minutes patient was nauseated. Felt like an in- 
toxicated person. This feeling soon passed off, and she declared 
herself free from pain. A little oedema at the point of injection, 
but no rash. Subcutaneous Injections in Neuralgia. 
29 
4th.—Is very comfortable. Feels weak and without energy. 
Continues the tonic treatment. 
9th.—Sent for me in the night. Had severe pain in the left 
temple and over the eye. Had been out in a rain, to a party, the 
evening before, notwithstanding my directions to the contrary. 
Upon examination, pressure pointed still to the supra-orbital point 
as the proper place for the injection. I introduced eight drops of 
solution No. 4, with good effect. Pain soon ceased. No nausea 
or vomiting followed the injection. 
5th.—Rested well the whole night. Is free from pain. Di- 
rected her to continue the tonic treatment. 
From the above date to the present, my patient has had but lit- 
tle pain, except in damp and unpleasant weather. Uses still the 
valerianate, in solution and in pills, with good results. 
Five other cases have come under my observation, besides the 
nine already detailed, but I shall report for the present only the 
above, and give the history and result of the remaining at some 
future day. 
In no case have I observed any injurious effects to follow the 
operation, although in most cases I have injected more than once, 
and in some at more than six different times. In those not unfre- 
quent cases where the disease has a central, not a centripetal origin, 
I maintain that the treatment is quite useless, except in giving mo- 
mentary relief to the suffering patient. In two cases, the punc- 
ture was, in a few minutes, surrounded by a blush of urticaria. 
Lastly, I shall briefly consider the modus operandi of this new 
method of applying remedial agents. 
But let me here state, plainly and unreservedly, that I approach 
this question of the modus operandi with great diffidence. I have 
no new principles or discoveries in the domain of physiology to 
advance. All I claim is, to bring into notice those facts scattered 
through the best works of our modern physiologists, bearing upon 
this point. These theories, supported by facts, have been collect- 
ed by Prof. Wood in his little treatise already quoted by me, and 
this question of the modus operandi has been discussed by him at 
some length. I have repeatedly and carefully studied the treatise of 
Dr. Wood. I have sought for and read the authors quoted by him, 
with reference to this question. I shall therefore do little else 
than chiefly to restate his principal arguments. I may not always 30 
Subcutaneous Injections in Neuralgia. 
quote him literally, and shall incorporate, when necessary, extracts 
from the authors quoted by him. The reader will judge, from the 
actual cases given in these researches, how far the principles laid 
down by physiologists are borne out by actual experiments and 
the treatment of the disease known as neuralgia. 
Our point of inquiry is, then, have we any means of introduc- 
ing medicinal agents very rapidly into the body, in a situation 
where they will not be readily decomposed, and where, in certain 
cases, we can secure at once their local and their remote effects ? 
In neuralgia we have usually a general and a local affection, a 
morbid state of the system, arising from many causes, displaying 
various symptoms, requiring varied treatment, and existing in 
states of the body the most opposite; a local affection, occurring 
in paroxysms of violent pain, either regular or irregular, follow- 
ing, like the electric current, the course of the affected nerve, ceas- 
ing, either to be suspended for a time, or immediately to recur 
with still more unbearable violence. An affection presenting cha- 
racters such as have been described, would appear to demand at 
once a local and a general treatment; a local treatment intended to 
mitigate the fearful anguish, under which the patient is well nigh 
driven to despair,* a general treatment intended to correct the 
“ habitus neuralgicus ” on which it depends, and having reference 
to the causes from which it has arisen, the state of the system in 
which it exists, and the diseases with which it may be associated.* 
Let us first consider the local treatment and its effect. Many cir- 
cumstances in the history of neuralgia seem to point at, and give 
peculiar facilities to, local treatment. All observers admit that 
the superficial nerves are of all others the most liable to the dis- 
ease. Hence various methods of applying narcotic and other 
remedies more directly to the seat of the disease have been intro- 
duced. Prof. Wood classifies them thus: 
1st. The enepidermic method, in which the agent is simply applied 
to the surface of the skin. 
2d. The iatralcptic method, in which the absorbents are stimulated 
by friction to take up the agents which are presented to them in 
solution or in a minute state of division. 
3d. The endermic method, proposed by MM. Lembert and Lesieur, 
in which the obstacle which the epidermis offers to the entrance 
of the remedy is overcome by previously removing it. 
* Wood on Neuralgia, p. 19. Subcutaneous Injections in Neuralgia. 
31 
4th. Inoculation, which, largely practised for the introduction of 
smallpox and cowpox into the system, has been proposed by M. 
Lefergue St. Emilion, to be extended so as to secure the applica- 
tion of remedies. Dr. Bureaud* does not seem to have been very 
successful in the application of inoculation with morphine. It was 
also found, by M. Martin Solon, that the effect produced was very 
much the same, whether the patient was inoculated with belladonna, 
or strychnia, or gastric juice, or chyme.f 
5th. There ought to be added the plan of local treatment pro- 
posed by M. Yalleix,:}: which consists in the application of a suc- 
cession of small blisters over the points in the course of the 
nerves which are painful on pressure. In all his cases it seemed 
to alleviate the symptoms. This plan of blistering is not new, 
but for the application of it to the tender points we are indebted 
to M. Yalleix. He has clearly shown that some points in the 
course of the nerve are more liable to be affected than others, and 
that these points are frequently the very ones where the nerve is 
most superficial. Moreover, these points can in most cases be de- 
tected in the course of the disease by their extreme tenderness on 
pressure. Even in the intervals between the paroxysms, very 
slight pressure on these points is sufficient in many cases to excite 
severe suffering, although, in some exceptional cases, firm pres- 
sure may be applied without causing any complaint. We are 
therefore greatly indebted to M. Yalleix for the immense improve- 
ment in practice, by showing where our local treatment, whatever 
that may be, ought to be applied. Dr. Wood’s own experience 
has not confirmed the value of simple blisters, and he prefers fol- 
lowing them up by the endermic application of morphia. Two 
strong objections are, however, raised by Dr. Wood against the 
blistering, or the endermic application of narcotics in this dis- 
ease—first, the painful nature of the remedy; and, secondly, the 
mark which it often leaves, which is very objectionable, particu- 
larly when the disease is seated in the nerves of the face.§ 
Thus it is evident that we were still in want of a method of di- 
rectly applying sedatives to the affected part: but such a method 
has been suggested by Prof. Wood, and supported by many suc- 
cessful experiments; a method whi&li is almost painless, and calcu- 
* Lancet, 1837, p. 826. f Bullet, de l’Acad. Roy. de Med., 1836. 
Trait6 des ou Affections Doloureuses des Nerfs; par L. L. S. Vallpix. Paris, 
1841. § Wood on Neuralgia, pp. 19-20. 32 
Subcutaneous Injections in Neuralgia. 
lated not only to diminish the local pain, but, at the same time, 
powerfully and rapidly to affect the general system. 
Moreover, the experiments instituted by Muller* clearly show 
that, to quote his own words, “ narcotic poisons, when applied lo- 
cally to nerves, have only a local effect.” “ I held,” he continues, 
“ the nerve of a frog’s leg, which was separated from the body in 
a watery solution of opium, for a short time, and that portion of 
the nerve lost its irritability, but below the part that the poison 
had touched, the nerve still retained this function; opium, therefore, 
produces a change in the nervous matter itself \ but the influence is 
local.” 
The advantages, therefore, secured by this mode of administer- 
ing narcotics and sedatives are: 
1st. A local effect, produced directly upon the affected nerve. 
2d. A remote effect, ensuing almost instantaneously, on the appli- 
cation of the remedial agents. 
The first of the above propositions is amply proved by the al- 
most immediate cessation of the pain after the opiate was injected, 
in all the cases reported by Dr. Wood and many other experi- 
menters, as well as by the cases which I have myself given, and 
others which have come under my observation. The acute and 
agonizing pain may, in some cases, have returned, as indeed it did 
in most of my own, yet still the pain was mitigated and subsided 
for a time, after the injection, and in some it never returned. 
In regard to the second proposition—the remote effect pro- 
duced by the injection—it is well known that opiates, administered 
through the ordinary channels, are usually some hours in taking 
effect; whilst most of the cases which I detailed show with what 
rapidity narcotics take effect when introduced into the system in 
this manner. In one case, the patient felt as if she was seasick; 
in another, immediately after the injection, a drowsy state follow- 
ed, and the patient saw beautiful visions; a third could not de- 
scribe her feelings, it was a sort of crawling sensation all over the 
body, and so on. In a case where Dr. Wood tried injection, the 
man, who was not at all aware of what was being done, told him 
that he felt as if he was drunk within a few minutes after the in- 
troduction of the narcotic. 
We are now led to the second point of our inquiry, namely, how 
is this remote effect produced ? 
* Muller's Physiology, by Baly, vol. i., p. 246. Subcutaneous Injections in Neuralgia. 
33 
Medicines, remarks Dr. Wood, page 14, when exhibited, have 
usually two effects :—1st, the local effect or topical—the particular 
effect of a medicine on the tissue to which it is applied ; 2d, the 
remote effects—being physical, chemical or vital changes, produced 
on parts at a distance from those to which the medicine is directly 
applied, or on the system at large. 
The manner in which the local effect is produced is compara- 
tively simple, and depends on the relation of the medicine to the 
tissue to which it is applied. Thus some applications simply 
stimulate or irritate the tissue, the effect varying from the least 
powerful, which merely redden, to the strongest, which produce 
ulceration, or even gangrene. Others, again, form compounds with 
the elements of the tissue, thus chemically decomposing or cor- 
roding it; while a third class, according to Dr. Christison,* “ nei- 
ther corrode or irritate, but make a peculiar impression on the sen- 
tient extremities of the nerves, unaccompanied by any visible change of 
structure.” 
Considerable difference of opinion prevails, continues Prof. 
Wood, as to the manner in which the remote effects are produced. 
Magendief and his supporters contended strongly that they were 
conveyed by absorption from the part to which they arc first ap- 
plied, while Messrs. Morgan and AddisonJ are of opinion that the 
remote effects are exclusively due to sympathy, or an impression 
transmitted through the nerves. Other observers, however, among 
whom may be mentioned Sir Benjamin Brodie and Dr. Christison, 
unable to adopt either view exclusively, admit this double mode of 
operation; “ a conclusion,” which Messrs. Morgan and Addison 
agree, “ that all fair analogy forbids; because it is contrary to 
Nature’s rule,” they say, “ to adopt two ways of attaining the 
same end.” Absorption is admitted, by all European and Ameri- 
can authors, to be the most usual channel by means of which medi- 
cinal agents are conveyed from the part to which they are directly 
applied, so as to affect remote organs, or the system at large. 
The principal agents by which absorption is effected are the veins, 
though the lacteals and absorbents take up certain agents, but 
their operation is both limited and slow. Much depends upon the 
absorbent power of different tissues. M. Vcrniere§ has shown 
that the mucous membrane of the intestinal canal absorbs less 
* Christison, Treatise on Poisons, p. 1. f Magendie, Annales de Cliimie et de Physique, 
t Essay on the Operation of Poisonous Agents, &.c. § Journal des Progres, 1827. 34 
Subcutaneous Injections in Neuralgia. 
rapidly than the serous membranes, and they, in their turn, are less 
powerful channels of absorption than a vein or an open wound. 
Hence this difference of the absorbent power of different tis- 
sues must modify to a great extent the action of remedies. Thus, 
the stomach and intestines, which are the tissues to which medi- 
cines are generally applied, possess a considerable power of ab- 
sorption, as we might expect from their office; nevertheless, we 
find, from the experiments of Christison* and Coindet,+ that when 
oxalic acid is introduced under the same circumstances into the 
stomach of one dog and the peritoneum of another, the dose may 
be so apportioned that the amount which does not prove fatal to 
the former kills the latter in fourteen minutes. M. Segalas found, 
that half a grain of the solution of extract of nux vomica, inject- 
ed into the windpipe, proved fatal; while two grains might be in- 
jected into the stomach, peritoneum or chest, without any fatal 
effect, thus showing the power of absorption of the pulmonary 
membrane. 
The skin, which has at various times been employed as a medi- 
um for the introduction of medicines into the system, would ap- 
pear to possess no very active power of absorption, at least, unless 
it be denuded of its cuticle. “Accordingly,” says Dr. Christison, + 
M many active poisons are quite inert when applied to the unbroken 
skin, or even to the skin deprived of its cuticle. Hydrocyanic 
acid, perhaps the most subtle of all poisons, was found by Coullon 
to have no effect when dropped on the skin of a dog.” On the 
other hand, Dr. Madden, in his work on Cutaneous Absorption,§ 
has shown, from carefully-conducted experiments, the power which 
the healthy skin possesses of absorbing from a gaseous and from 
an aqueous medium, and has collected, from various authors, proofs 
of its power to absorb medicinal substances. Both solids and 
fluids have been thus absorbed by the skin. Kellie found saliva- 
tion follow the use of mercurial plaster. Arsenic employed to 
destroy lice, has been known to produce violent inflammation. Sa- 
livation has been produced by the absorption of a solution of cor- 
rosive sublimate. Iodine has been detected by Dr. Wadden in his 
urine, after immersing his hands in a solution of hydriodatc of po- 
tassa, and he also succeeded in purging himself, by applying to his 
;skin infusions of rhubarb, jalap and gamboge. “ Some poisons,” 
* Christison on Poisons, p. 29. 
t On Poisons, p. 28. 
t Journal dcs Progres. 
§ Edinburgh, 1838. Subcutaneous Injections in Neuralgia. 
35 
says Dr. Christison, u which act slowly through the stomach, cause 
instant death when injected into a vein.” 
With regard to the cellular tissue, the same author further 
states :—“ that it is a ready medium for introducing poisons into 
the blood, especially if an artificial cavity be made where the tis- 
sue is loose, but that its power as a medium of absorption has 
not been, and cannot easily be ascertained. On the one hand, it 
is difficult to apply poisons to it, without also applying them to 
the mouths of divided vessels; and, on the other hand, it is difficult 
to make a set of experiments for comparison with others, on the 
stomach, pleura or peritoneum, as the cellular tissue does not form 
an expanded cavity, and consequently the extent of surface to 
which a poison is applied cannot be made the same in each expe- 
riment of a series.”* Sir Benjamin Brodie reported in the Philo- 
sophical Transactions of 1811-12, some experiments which ap- 
proach the most nearly to direct injection of the cellular tissue, 
in which experiments various poisons were introduced into wounds, 
and were found to produce very speedy results; but in all these 
cases, the great division of parts exposed so many blood-vessels, 
that it is not easy to say how much of the effect was due to the 
cellular tissue, and how much to the action of the divided vessels. 
The preceding, being quoted from Prof. Wood’s - Treatise, he 
adds:—u I am at present engaged in some experiments on this 
subject, in which, by means of an improved apparatus, various sub- 
stances have been introduced into the cellular tissue with compa- 
ratively little injury to the adjacent vessels, and, as far as these 
have gone, they would lead to our ascribing great absorbent power 
to the cellular tissue.”t What has been stated proves satisfac- 
torily :— 
1st. That medicines are more rapidly absorbed by some tissues 
than by others. 
2d. That the stomach is by no means the most rapid way of in- 
troducing medicines into the system. 
3d. That the cellular tissue has a great power of absorption. 
From the cases which I have submitted at some length in this 
paper, I think it may be safe to arrive at the following important 
* Christison on Poisons, p. 30. 
f I know that Prof. Wood is at present engaged in writing a treatise on the subject of Neural- 
gia, and I have no doubt, when all his experiments and cases are given to the profession, with refe- 
rence to subcutaneous injection particularly, he will throw much light on the subject, and the book, 
being not only of practical value, will also be a most valuable addition to medical literature. 36 
Subcutaneous Injections in Neuralgia. 
conclusions, with which Prof. Wood concludes his consideration of 
the modus operandi. 
1st. That narcotics, injected into the neighborhood of the pain- 
ful point of a nerve affected with neuralgia, will diminish the 
sensibility of that nerve, and, in proportion, diminish or remove 
pain. 
2d. That the elfect of narcotics, so applied, is not confined to 
their local action, but that they reach the brain through the venous 
circulation, and there produce their remote effects. 
3d. That in all probability what is true in regard to narcotics, 
would be found to be true in regard to other classes of reme- 
dies. 
4th. That the small syringe affords a safe, easy, and almost pain- 
less method of exhibition. 
5th. That, destitute as we are of any precise experiments as to 
the applicability of the cellular tissue as a medium for the recep- 
tion of medicinal agents, the experiments made with the syringe 
show that it seems to offer an excellent surface for the operation 
of the absorbent action of the venous system. 
6th. That the method now detailed seems as extensively appli- 
cable as any of the methods of applying remedies to the skin, 
whether enepidermic, iatraleptic, cndermic, or by inoculation. 
Finally, the above conclusions, arrived at after the considera- 
tions of the modus operandi, may not be entirely satisfactory and 
conclusive to some of the readers of this paper. Such, however, 
need not be apprised of the existence of many phenomena pre- 
senting themselves in health, and particularly in disease, the causes 
of which cannot be ascertained. Too often we have, indeed, to 
content ourselves with the maxim of Cicero—“ Sufficit si quid fiat 
intelligamus, etiamsi quomodo quidque fiat ignoramus.”