ON OCCIPITAL HEADACHE AS A SYMPTOM 
-'cv'v. 
OF UREMIA. I " 
I have recently met with two cases in which occipital headache 
was so localized and persistent as to give rise to a strong suspicion 
of organic disease of the cerebellum, and in one of them a posi- 
tive conclusion was only reached by means of a post mortem ex- 
amination. These cases both now appear to have been cases of 
contracted kidneys and uraemia. 
I shall first relate the cases as they are in my case-book. 
Case i.—Lieut. X., U. S. A., aged 36 years, consulted me on 
November 5, 1879, and gave the following history ; Until the 
time of his graduation from West Point, he had suffered from 
frequent general headaches ; but that since leaving the school in 
1867 he had had several severe attacks of occipital headache. 
These at first occurred two or three times a year, but in the last 
few years much more often, the attacks lasting from twenty-four 
to forty-eight hours, accompanied by vomiting and sometimes by 
delirium. These paroxysms were often relieved by bromide of 
potassium. In 1876, during Centennial times, he had one of his 
headaches, and with it an epileptiform convulsion, in which he did 
not bite his tongue. In February, 1879, at the same time with a 
headache, he had another convulsion, in which the tongue was 
bitten. He has noticed that while in the Northern States he has 
but few headaches, whereas when in Texas he has had a great 
many. He often has a feeling'of soreness and fulness in the back 
of the neck, and is very nervous after the attacks ; has been in 
the North since March. In August had a severe attack and an- 
other on October 26, aborted by bromide of potassium. This 
last headache was accompanied by stiffness and fulness in the 
Reprinted from the Archives of Medicine, Vol. iv, No. 1. August, 1880. 2 
E. C. SEGUIN. 
back part of the neck. There are no special ocular symptoms 
during the attacks, and he considers his eyesight normal. Dur- 
ing the paroxysms the face is flushed, the head feels full and 
pulsating. The father and the grandfather of the patient had 
sick-headache. 
Mr. X. has abstained from the use of intoxicating drinks since 
1876 ; he has never been injured about the head, and has never 
had syphilis. 
Examination.—Eyesight normal to all ordinary tests ; no astig- 
matism ; no lesion seen with the ophthalmoscope. Cervical spine 
not tender ; no symptoms of dyspepsia ; heart normal. The gen- 
eral appearance is that of health. November 6th, looks puffy 
under the eyes. Three specimens of urine are examined with 
the following results : Their specific gravity is low, ranging from 
1018 to 1020 ; they all contain albumen—from 1 per cent, to .5 
per cent., and hyaline casts. The retinae are reexamined with neg- 
ative results. Subsequently, numerous examinations of the urine 
were made by Dr. Alexander, Surgeon U. S. A. at West Point, 
and evidences of chronic Bright’s disease were invariably found, 
such as low specific gravity, hyaline and granular casts; the 
amount of urea in one period of twenty-four hours was about 
twelve grammes. 
Case 2.—Mr. J. W., a merchant, aged 47 years, was seen by 
me at Passaic, N. J., in consultation with Dr. J. C. Herrick, on 
December 21, 1879. I obtained the following hisotry of the case : 
The patient had formerly enjoyed good health ; had never re- 
ceived any injury to the head ;no syphilis. During all his adult 
life he has suffered from headaches, more or less periodical, per- 
haps one in three weeks, each attack accompanied by nausea, and 
usually lasting one day. Of late years he has had much less of 
this headache ; it was evidently migraine. About twelve years 
ago, in the streets of New York, during hot weather, he had an 
attack which was called “sunstroke.” The symptoms of this at- 
tack are unknown. Mr. W. consulted me in 1874, but I have no 
notes of his case except a memorandum of my examination of 
the urine. This appears to have been perfectly normal. 
In the last two years he has been almost constantly suffering 
‘from some headache, a little every morning, and more and more 
often of late he has had severe attacks. In the past two months 
very severe headaches, with nausea and vomiting several times a 
week. During the last two weeks has been confined to his bed. 
The patient and his wife clearly distinguish this pain from the 0 CCIPITA L HE ADA CHE - UREMIA. 
3 
former headaches by several characteristics; the pain is more vio- 
lent, it is distinctly occipital, and lately has been cervical as well ; 
it appears in paroxysms at any time, chiefly during the day, and 
the pain itself is of a different character. After a migraine Mr. 
W. felt very well; but now after a severe headache he is pros- 
trated and dull. The nausea always comes on after the pain ; he 
has no nausea between the paroxysms. He has not had much 
frontal headache, but the pain has extended from the occiput into 
the vertex and the whole top of the head. Movements aggravate 
the pain. There is no affection of sight or hearing ;no dizziness. 
Of late has needed morphia ; Paullinia seemed effectual for a few 
days only. During the last week he has taken about 4 gm. of 
bromide of potassium a day, and on the day before yesterday he 
had 15 gm. in twenty-four hours. The attending physician has 
examined one specimen of urine, but found no albumen. 
Examination.—Patient feeble ; lies relaxed in bed ; voice faint, 
but articulation is distinct ; mind clear ; the head is not tender. 
The right eyelid is in partial ptosis ; no strabismus ; the ophthal- 
moscope shows no lesion of the fundus (atropine used). The 
right side of the face is ra’ther inert, but the tongue (heavily coat- 
ed) points straight. The hands are of due proportionate strength ; 
in walking the right foot is dragged after a few turns in the room. 
No incontinence of urine ; morphia affects patient very readily ; 
he has had none in twenty-three hours, yet he is dull, and his pu- 
pils are small and fixed. The heart is normal, but the pulse is 
quite irregular ; beating 23 and 29 in successive thirds of a min- 
ute ; twice in the minute an acceleration is noticed. There is a 
trace of oedema on the tibias. Patient denies that his neck is 
really stiff, though he carries his head on one side, and keeps it 
quite still; no opisthotonus. To-day the pain extends to the 
sixth cervical vertebra. 
I declined to give a positive diagnosis until after the urine had 
been thoroughly examined. At the same time I saw that the pa- 
tient was in great danger from exhaustion and a tendency to 
stupor ; and that many of the symptoms of tumor in the cerebel- 
lum were present. One was lacking, viz : neuro-retinitis. I also 
thought he was brominized. 
On December 23, three specimens of urine were received, and 
were at once examined by Dr. R. W. Amidon. The specific 
gravity was found to vary between 1024 and 1025 ; there was al- 
bumen in all, varying in amount from 3 to 10 per cent.; there 
were also in all specimens numerous hyaline and granular casts. 4 
E. C. SEGUIN'. 
Mr. W. died on December 27th, in a comatose state ; no con- 
vulsions or further paralytic symptoms having shown themselves. 
The autopsy made on the 28th, showed that the cerebellum and 
the other parts of the encephalic mass were normal ; while both 
kidneys were extensively diseased. The left kidney was found 
completely diseased, granular and hard in places ; its membranes 
peeling off with difficulty. It had a reddened congested appear- 
ance, and showed some evidences of not only a chronic trouble, 
but of a more recent acute inflammatory action. The right kid- 
ney was found to be only partially affected ; somewhat congested, 
and with the same type of lesion. 
Dr. Herrick, to whose courtesy I am indebted for the above ac- 
count of the autopsy, adds : “ The results of our examination go 
to show evidently that, after all, the patient’s symptoms may have 
originated from a kidney disease, although we cannot explain yet 
why his headaches so many years should have been from such a 
cause. He had never complained of backache or of any of the 
usual symptoms of Bright’s disease, except the head pain.” 
The following is a summary of the symptomatology of the two 
cases: 
Both patients were adults ; both had suffered from chronic 
headache more or less of the migraine type ; at a given period the 
headache became transformed into a localized occipital pain, very 
different from that of the former attacks. 
In Case 2, the pain extended down the cervical spine, and was 
so much aggravated by movement as to suggest a rigid state of 
the neck. In Case 1, there was once stiffness of the neck in an 
attack. 
This peculiar headache was distinctly paroxysmal, but not at 
all periodical or influenced by any apparent outward circumstance. 
In both cases nausea accompanied the headaches, and in Case 2 
it is clearly stated that the nausea was secondary in point of 
time. 
Case 1 was made relatively clearer by the previous history of 
convulsions, and by the fact (not stated in the notes, but quite 
clear in ray recollection) that the surgeons in attendance then 
(in 1876) found albumen in the urine. 
Case 2 was greatly complicated by the presence of symp- 
toms of slight paralysis, partial ptosis and a weak right leg. 
I am now disposed to think that these phenomena, together 
with the astonishing debility, staggering gait, and the sluggish 
state of the mind which I observed in this patient, were due OCCIPITAL HEADACHE—URAEMIA. 
5 
to brominism : a condition to which I have called attention as a 
possible serious complication in the diagnosis of disease.* 
I would also remark that the symptoms of renal disease were 
not marked ; in one case there was no oedema, in the other a mere 
trace ; neither patient had the dyspeptic symptoms or the frontal 
headache which often suggest renal disease, and neither patient 
has the “ Brighty look ” which is so well known. 
It is to be observed that the occipital sensation in these cases was 
true pain, not the painful paraesthesise which are sometimes due 
to lithaemia and oxaluria, and sometimes to eye-strain, and which 
are erroneously (or rather insufficiently) designated as cerebral 
hypersemia. 
In some respects the story of these cases is imperfect, and I 
particularly regret the lack of observations upon the quantity of 
urine passed, and upon the state of the arterial tension. 
Still I am inclined to believe that the publication of these cases 
may serve to render more accurate the diagnosis of occipital 
headache, and to illustrate the utility of critically examining the 
urine in cases of any degree of obscurity ; more especially as oc- 
cipital headache is scarcely mentioned as a symptom of uraemia.