Supra-orbital neuralgia or neuritis (with or without symptoms of migraine *) is a nerve disease which often gives pronounced phenomena on palpation. Such cases require very careful examination on the lines spoken of above, as small swellings over the nerve trunk after it emerges from the supra-orbital foramen, as well as painful points with or without palpable changes, are often found over the whole extent of the nerve. The separate nerve trunks near the supra-orbital foramen can often be felt thickened, and one finds tender cord-like swellings (which occasionally can be seen on account of their prominent position on the forehead).

* I group together supra-orbital neuralgia and migraine, as most English, American, and French medical men do. The Germans are still generally of another opinion, since Du Bois-Reymond in 1860 described migraine as a primary vasometer neurosis. Professor Henschen, who carefully analysed 140 cases, remarks upon and demonstrates in detail in his useful book ("Studier ofver hufvudets neuralgier" : Upsala, 1881) the impossibility of distinguishing different forms of the disease, an opinion which is accepted not only by Scandinavian but also by German authors. For my part I believe that those who are accustomed to treat these cases by massage, and therefore are accustomed at the same time to lay more stress on palpation, would be the least inclined to make a separate class of those forms in which the vasomotor and eye symptoms are most prominent.

In all examinations of supra-orbital neuralgia it is important not only to examine that nerve, but also the other cutaneous nerves of the head. Supra-orbital neuralgia is often due to rheumatism,* which also affects other nerves, commonly the facial, occipital, and auriculo-temporal. Although changes in these nerves are seldom palpable, the nerve trunk may be more or less tender and must be treated in the whole of its course. Both the inferior branches of trigeminus, with their smaller branches, must be examined, although they are less often affected than the above-named nerves. One must also further examine other parts than nerves, observe if the skin, as is often the case after lengthy processes, is thickened and oedematous (it is best to lift a fold of skin on either side and compare them), and notice also if there is infiltration in the neighbouring muscles.+ Finally one must ascertain if there is pain on pressure on the same side of the neck over the two superior sympathetic ganglia; if present, this must be treated by fairly strong frictions. ++

* Of Henschen's 140 cases 106 had rheumatic symptoms in other parts of the body, three had absolutely none; in the 31 remaining cases such symptoms were at least not noticeable. Henschen points out that supra-orbital neuralgia is more often combined with neuralgia in the occipital nerves than in the two lower branches of trigeminus, and he therefore considers the spread of the disease peripherally through chronic rheumatic inflammation to be more common than its spread through central irritation. It is certain that supra-orbital neuralgia, with or without the special symptoms of migraine, is often found in persons who are thoroughly rheumatic, and where palpation gives reason to diagnose the existence of rheumatic infiltrations in the nerves, muscles, and subcutaneous connective tissue in various parts of the head, and in whom the trouble is of a rheumatic kind, since they are affected more by changes of weather than by anything else. It is just in these cases that one may expect beneficial results from massage. However, as always, one ought in these cases to consider the possibility of several co-operating causes, and not forget the effect that poisons (mercury, lead), infections (malaria), dyscrasiae (syphilis, chlorosis, gout, diabetes), or by reflex action diseases of the digestive organs or uro-genital apparatus, may have in causing supra-orbital pains, and then use not only massage, but also other means indicated by the causal disease. Also it is necessary to remember aneurism periostitis, etc., in the head, and before massage is begun it is necessary to exclude the possibility of purulent and tubercular processes, etc. I know of one case where a little Swedish girl was treated with strong massage almost up to the day of her death from intracranial abscess by a professor and doctor of medicine, whose mind was preoccupied by the idea of peripheral irritation of the branches of trigeminus by rheumatic infiltrations.

+ Since the soft tissues on the head are so thin, it is quite impossible to make what is in any case rather a difficult diagnosis between subcutaneous infiltrations in the connective tissue and in the muscles. They are often found combined; each may exist alone, and both are common, although infiltrations in the connective tissue are often taken for the more troublesome myositis (very fashionable now among masseurs). Infiltrations in the head, if at all extensive, invade the various tissues in their neighbourhood. They are treated best by performing small frictions or kneading with the pads of the three fingers close together at right angles over the affected and oedematous area, so that they reach the muscles, nerves, and connective tissue (Fig. 6, p. 2(5).

++ Henschen, in his work described above, has spoken of the tenderness to pressure over the cervical ganglia in cases of supra-orbital neuralgia remarked upon by many authors as very common, and he found this present in 91 cases out of 112 (?).

There is little to add to the above concerning massage for supraorbital neuritis (or neuralgia). One massages first and foremost all those parts where changes are found on examination, viz., the nerve trunks, by all three manipulations already mentioned, as well as the other parts (muscles, skin, and subcutaneous tissue) by friction and effleurage. In cases where no palpable changes have been found it is best to work according to the above rule as if they had been found, laying greatest stress on the work in the places where they are most common, i.e., of course near the supra-orbital foramen.* It ought not to be necessary to remind my readers that effleurage ought always to be given in the same direction as the venous blood flow (frontal vein), that is, from the frontal and temporal regions towards the root of the nose. My only reason for calling attention to this is the fact that I have often seen masseurs work in the opposite direction.

The treatment must often be given for a long time, weeks or months. Henschen was successful in twenty-four out of twenty-nine cases in obtaining either improvement or cure. My own experience has given improvement as the general result; complete recovery has only been effected in the minority of cases. Pain, tenderness on pressure, the pure symptoms of migraine (viz., vomiting, nausea, ocular phenomena, etc.), and muscular tremors are sometimes quite unaffected by massage treatment. In one case of a well-known German Wagner singer, who from time to time alarmed his enthusiastic audience by horrible involuntary grimaces, I treated him without being able to ascertain the cause, with almost or quite a negative result, by massage over both the facial nerve and the branches of the trigeminal for several weeks. In other cases one often performs "miracles" with the utmost ease and in a very short time.