Quinine, which in large doses is so very useful in the treatment of neuralgia, in small doses is of very little value.

To rely upon small doses of quinine, iron and strychnine, prescribed in combination, for the relief of the sufferings of a patient with neuralgia, is a species of therapeutic cruelty almost Hahnemannian in its respectability and childlike simplicity.

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Cod-liver oil and phosphorus and its compounds, on account of their special tonic influence upon nervous system, are of especial value in neurasthenic conditions.

The use of laxatives and bitter tonics has already been referred to while speaking of the regulation of the digestive organs.

Indispensable as are the tonics, it will generally be found that while their effect possesses to a considerable degree the element of permanency, it is nevertheless very desirable to prescribe something which will afford more prompt relief to the pain. Of course no drug is more reliable for this purpose than morphine, of which more will be said. subsequently. But morphine may produce very unpleasant effects, and should not be used habitually. Better adapted for more constant use are a class of drugs which are known as neurotics, on account of their peculiar action upon the nervous system. The most important members of this group are aconite, belladonna and gelsemisum.

Aconite has been used in the treatment of neuralgia for over half a century. More recently its alkaloid -aconitia-has obtained considerable popularity in the treatment of certain forms of the disease. Both are of unquestionable value, as might be inferred from a knowledge of their physiological action.

Belladonna also has some, but less positive reputation as an anodyne.'

Of unmistakable value is gelsemisum.

It will generally be found unwise to depend upon any one of these drugs singly. A better result will be obtained by combining several of them in one prescription, and administering them simultaneously.

Several years ago Dr. John T. Metcalfe, of New York, published in the Boston Medical and Surgical Fournal an account of a remedy which he had used with considerable satisfaction in the treatment of sciatica. It consists of equal quantities of the tinctures of aconite root, belladonna leaves, colchicum seeds and cimicifuga racemosa (black snakcroot). Of this three or four drops may be taken every three or four hours. This combination was placed upon the market in the form of tablet triturates, each containing three-fourths of a minim of each of the tinctures. These tablets I have used rather extensively for several years, and am able to testify that they are of considerable value in the treatment of different forms of neuralgia, although I am not prepared to commend them quite so enthusiastically as did Dr. Metcalfe in the communication referred to.

After becoming convinced of the value of this combination, it occurred to me that its utility might be increased by substituting gelsemisum for the colchicum and cimicifuga, and that fluid extracts might, with advantage, be substituted for the tinctures. After repeated trials I adopted the following formula:

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Ex. belladonna fluidi, zss. Ex. aconiti fluidi, 3jss. Ex. gelsemii fluidi, ad zvi. M. Sig., take six drops every four hours.

A simple calculation shows that each dose of six drops contains onehalf drop of fluid extract of belladonna, one and one-half drops of fluid extract of aconite, and four

drops of fluid extract of gelsemisum. This dose can generally be prescribed with safety for an adult of average size, whose heart is normal and who is not confined to the bed. It is, however, wise to watch the effect of the remedy rather carefully lest the vision of the patient be interfered with, an occurrence which always causes considerable alarm. In many cases a dose of eight drops can be taken without unpleasant results. Tablet triturates have been made for me, each of which contains one minim of the mixture. One or two of these may be given every two hours. This combination will be found especially useful, if used in connection with tonics, in subacute and chronic cases of moderate severity.

With the neurotics should perhaps also be mentioned the newer analgesics, of which the most widely known are antipyrine, acetanilide or antifebrin, and phenacetine. These all possess some value in relieving neuralgic pain, but in my opinion their efficiency has been somewhat overestimated. Antipyrine has the great advantage over the others that it is soluble in water, and therefore is more readily taken by many patients. It has seemed to me to possess greater efficiency than either of the other remedies which were mentioned. When small doses are used it rarely, if ever, produces any unpleasant effects. Acetanilide and phenacetine sometimes act very favorably. They are generally believed to cause less depression of the heart, and consequently to be safer for ordinary use.

Turning now from the drugs which are prescribed internally, it remains to speak of remedies which are used locally and externally.

Among the most important of these are several drugs which are injected subcutaneously. They are morphine, atropine, cocaine, theine and osmic acid.

When a patient is suffering excruciating pain from neuralgia, it is necessary that something should be done at once which will afford prompt relief. At such a time nothing is more useful than a hypodermatic injection of morphine. A sufficient dose should be administered to, if possible, entirely relieve the pain. The unpleasant effects may in some cases be partially or entirely obviated by combining a little atropine with the morphine. Ordinarily one-quarter or one-half grain of sulphate of morphine, with one one hundred and fiftieth, one one hundredth, or one seventy-fifth grain of sulphate of atropine, will produce the desired result, and can be used without danger.

Cocaine, from which so much was expected when its wonderful power of destroying peripheral sensation was first established, has not proved to be a very great addition to our resources in the treatment of neuralgia. Its effects are so transient, and the danger of establishing an uncontrollable appetite for the drug are so great, that it is seldom used in this disease, and should be employed, if at all, with great caution.

The demonstration of the physiological action of theine seemed to indicate that it would be a very useful local remedy in neuralgia. Injected into the neighborhood of the affected nerve, in doses of one-quarter or onehalf grain, it will often afford considerable relief. Its action is, however, neither so prompt nor so satisfactory in relieving pain as is that of morphine.

Osmic acid, the use of which seems to have been suggested from its peculiar action upon nervous when used in the preparation of specimens for microscopic examination, is disagreeable to use, causes considerable pain at the seat of injection, does not always benefit the disease, and there is reason to believe is not always safe.