NEURALGIAS All the authors who.have made a study of neuralgias agree that they are exceedingly rare in childhood. In a series of 150 cases observed by Remak, only one occurred during the first, and six during the second decade of life. The cases analyzed were undoubtedly cases of typical chronic ("stationary") neuralgias, with paroxysms of raging pain, which children fortunately escape. On the other hand, in my own experience the occurrence of attacks of mild, persistent pain lasting a few weeks is not infrequent among children. The nerves involved are chiefly the trifacial and occipital. The commonest causes of tbese neuralgias are influenza and coryza. Undoubtedly' a nervous disposition is an impor tant etiologic factor. The cases of neuralgia which have come under my observation were almost all in children with distinct neuropathic tendencies, in whom there appeared to be a disproportion in the inten sity of the attacks of pain and their complaints. Nevertheless, I am not willing to believe in a simple pseudoneuralgia or psycbalgia (Oppenheim) in these cases, or in other words, that the pain is purely psychical; the sudden onset of the disease, which usually lasts but a short time, dis tinctly points to a local lesion. It is possible that supraorbital neu ralgia and the rarer infraorbital form are caused by- inflammations in the accessory cavities of the nose. The distribution of the pain in facial and occipital neuralgia in the child, as in the adult, corresponds exactly to the nerve paths, and pain on pressure at the point of exit of the nerves is also observed. Other local symptoms due to vasomotor dis turbances or to pain I have never observed in the neuralgias of chil dren. In some cases, even when there is no suspicion of nialaria, the neuralgia COITICS on at a definite time of the day and lasts from a half hour to an hour. Occasionally- we observe periodical remissions and recurrences of these neuralgic stages; in these cases it is impossible to deny that the pain may rest on a purely psychic foundation.
The prognosis in facial and occipital neuralgia is therefore very favorable in childhood. Cases with persistently- recurring, uncon trollable attacks of pain, which belong to the most painful diseases that rnan is subject to, are fortunately unknown ainong children. Unless the neuralgic attacks depend on some other progressive disease, they disappear after a few days or weeks or rarely several months.
In the treatment of facial neuralgia in children we do not, therefore, need to resort to heroic operative procedures; laxatives, internal med ication and electric treatment are usually sufficient. Of the various nerve remedies quinine, antipyrin, aspirin and phenacetin, either alone or in combination, offer good results. Electric treatment consists in the use of the stabile anode and the faradic brush.
Neuralgias in other nerve territories are extremely rare in child hood. Thus sciatica, the most frequent form of isolated inflammation of nerves in adults, is unknown in the child. With regard to various painful conditions in the lower extremity which have recently been carefully studied in adults, such as achillodynia (pain in the tend° Achillis), metatarsalgia (pain in the region of the fourth metatarso phalangeal articulation) and coccycodynia (pain in the region of the coccy-x), but little attention has been paid to these things in children. In my experience they occasionally occur in older children.
The occurrence of typical Head's zones in children after the sixth year of age was proved by Bartenstein, who investigated a large series of eases. Picking up a fold of skin or stroking the skin with the head of a pin reveals the presence of painful areas on the trunk. They occur in connection with visceral diseases, and in their localization exhibit a certain constant relation to the various internal organs. The exist ence of these painful areas is explained by assuming that the irritation affects those spinal roots which give origin to the nerves of the corre sponding organ. This theory- explains many hitherto inexplicable pains occurring in the course of internal diseases, such as intercostal pain in pneumonia, and at the same time furnishes a theoretical foundation for the various procedures of counterirritation which have long been in use.
The peculiar relationship existing between swelling of the erectile tissue of the nose and uterine pain (Fliess, Schiff) is probably explain able in the same way-. In cases of severe dystuenorrhea occurring in girls near the age of puberty, cocainization of the nose, which often proves successful in such cases, may be considered.