»t*:-':^.'i:^ :'•:'- iff ww 3NOIQ3W jo Aavaan wnomvw NLM 00551643 7 f!\ 3NiDia3w jo Aavaan ivnoiivn TIONAL LIBRARY OF MEDICINE NATIONAL LIBRAI —*^ o' " ~^ 3NOIQ3W jo Aavaan ivnoiivn snidiqsw jo aj ek/" i 7 NATIONAL LIBRARY OF MEDICINE n NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRA ^S?\ I J^sptf 3NiDia3w jo Aavaan ivnoiivn snidiqsw jo Aavaan ivnoiivn snidiqsw jo aj ,/ NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRA V t V I 3NIDI03W JO Aava8ll IVNOIIVN NATIONAL LIBRARY OF MEDICINE / /-^.' o? V-^v x a..- i 3NIDIQ3W JO Aavaan IVNOIIVN 3NIDI03W JO A $ n NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRA i 3Nma3w jo Aavaan ivnoiivn NLM005598437 oiasw jo Aava8n ivnoiivn snidiosw i /I :ine NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE S "'■iTi^Tv'.r /^ — -v lis?" n £/ \ /. u%&? * HEADACHES: THEIR NATURE, CAUSES AND TREATMENT. WILLIAM HENRY DAY, M.D., AUTHOR OF A SYSTEMATIC TREATISE ON DISEASES OF CHILDREN ; MITMIiEK OF THE ROYAL COLLEGE OF PHYSICIANS, LONDON. THIRD EDITION, ENLARGED. ILLUSTRATED. PHILADELPHIA : P. BLAKISTON, SON & CO. 1012 WALNUT STREET. BRAIN OF MAX. 1,2,3, frontal convolutions; 4,5, 6, A and B, parietal convolutions; 7,8,9, temporo- sphenoidal convolutions; 10,11,12, occipital convolutions. A is the supra-marginal lobule; B is the postero-parietal lobule; and /? on the bridging or anneetent con- volutions; It, fissure of Rolando; S. parietooccipital fissure. CONTENTS. PAGE General Introduction,.......17 CHAPTEE I The Headache of Cerebral Anemia, .... 33 CHAPTER II. The Headache of Cerebral Hyperemia, ... 66 CHAPTEE III. On Sympathetic Headache,......95 CHAPTER IV. On Dyspeptic or Bilious Headache, . . . .109 CHAPTER V. On Congestive Headache,.......123 CHAPTER VI. On Headache from Plethora and Increased Vascu- lar Action,.........134 CHAPTER VII. On Headache from Exhaustion, or from some Pecu- liar Change in the Cerebral Tissue—Nervous Headache,......... 140 vi CONTENTS. CHAPTER VIII. 179 On Nervo-Hyper-emic Headache,..... CHAPTER IX. On Toxemic Headache, ...-••• 186 CHAPTER X. On Arthritic or Gouty Headache,.....205 CHAPTER XL On Rheumatic Headache,.......212 CHAPTER XII. On Headache from Affections of the Periosteum, . 215 CHAPTER XIII. On Organic or Structural Headache, .... 219 CHAPTER XIV. On Headaches of Advanced Life,.....228 CHAPTER XV. On Neuralgic Headache,.......231 CHAPTER XVI. Headaches of Childhood and Early Life, . . . 248 PREFACE TO THE FIRST EDITION. In the present day there are so many investigators in every field of study, that it would be impossible to keep pace with any branch of it, if worked out satis- factorily and to its full extent, unless we refreshed our ideas from different increasing springs of knowledge, and thought the subject over again and again from every point of view. This applies, perhaps, more to medi- cine than to any other subject; for as we inquire into the origin of human maladies, new features continually present themselves, and new mysteries to be solved con- tinually arise. The views I have here advanced are the results of notes and observations carefully recorded by me, and extending over a period of many years. In most of the cases which have formed the groundwork of the present task, I have had ample opportunities of watch- ing their course and progress. I have, moreover, rather relied on the investigation of facts, as presented by the record of cases, than trusted to plausible theories. It is on actual facts I have attempted to lay the basis of the treatment and management which appear to me best vm PREFACE. adapted to meet the varieties and peculiarities of head- ache. In all search for truth facts must be recognized, however they appear to contradict an apparently secure and well-established principle. To grasp the general conception and meaning of any subject in which the operations of nature are concerned, and from which a reasonable solution is expected, we must establish the conclusions which lead up to principles on the sure foun- dation of fact, and not, like the French philosopher, think it so much the worse for the facts if they are not included in our theory. If theory is unsupported by fact, our views and opinions entail disastrous conse- quences, and any line of argument we may have adopted is rendered utterly futile. I may here remark that several works have recently issued from the medical press on the subject of headache, teeming with interest both to the patient and practi- tioner. Headache has always been carefully studied in its clinical aspect, but the recent advance of physiological knowledge, as derived from experiment, has given a new and powerful stimulus to the study of the diseases of the nervous system. Not only has it furnished a stimulus, but it has tended much to clear up our impressions as to the pathology of diseased conditions. The recognition of perivascular spaces has enabled us to comprehend how the blood supply of the brain may vary from time to time. These modifications in its physical consistency do not impair its functional activity, but promote the growth PREFACE. IX and reconstruction of the nervous system, which is under- going incessant change and regeneration. By means of these spaces the vessels dilate without compressing the brain, and when they again contract the soft structures of the brain are sustained by the effusion of lymph with- out any serious consequences ensuing. . The researches of physiologists heretofore had stopped short at the cerebrum, and only comprised the deep- seated ganglia at its base; but the recent investigations of Fritsch and Hitzig, and still more of our countryman Ferrier, have demonstrated that the different portions of each convolution possess special functions. Some are motor-centres, and others are centres of sensation. The vast additions which have been recently made to our previous knowledge by Dr. Ferrier's experimental re- searches justify us in drawing certain definite conclu- sions, not only as confirmatory of the functions of the deeper structures of the brain, but of the convolutions themselves. By applying electricity in the form of local faradization to the cortical substance of the brain, he could produce at will an intense amount of hyperemia, increasing the quantity of blood and the size of the ves- sels ; and, in the case of rabbits, he found that the re- peated application of the electrodes converted the cerebral substance into a condition resembling fungus hwmatodes. By irritating the different portions of the hemispheres in some of the lower animals, he could excite partial or general convulsions, and these were invariably preceded l* x PREFACE. by a hyperemic state of the cortical tissue. These ex- periments bear most strikingly on that state of nerve- tension, which Dr. Liveing describes as leading to "nerve- storms," when an explosive discharge takes place from the ganglionic centres, reducing the tension and irrita- bility of the parts involved, while lessening the hyper- emia on which they depend. A recognition of these facts is essential to a rightful comprehension of headache. They help in no small degree to explain the intimate relation of the nerve force to the blood supply. My earnest endeavor throughout the book has been to make it practically useful. I have adopted the division of headaches into several varieties, which may possibly seem to some readers to involve too great a refinement; but on full consideration, I think they will find it neither unnecessary nor frivolous. The diagnostic fea- tures which distinguish' hyperemia in some of its forms from congestion and plethora, are somewhat difficult to lay down, but we are most likely right in assuming that there is a physiological difference. As regards the origin of active hyperemia, if we see the subject dimly, we are sure that its active form does not always depend upon the same pathological conditions. The cerebral tissue is overexcited and stimulated by increased cardiac action in the one case of hyperemia; and in the other, the hy- peremia is the consequence of relaxation of the vessels and vaso-motor paresis. All the states depend upon an en- largement of the capillaries, either with increased activity PREFACE. XI of the general circulation, or with obstructed or .retarded motion of the blood through them. Congestion, in the strict sense of the word, would seem to be the excessive attraction of blood by the tissues, rather than either the active or the passive form of hyperemia. A hyperemic state of the brain, when long kept up, leaves the organ weaker, and disposes it to an asthenic form of congestion. I have described passive hyperemia and passive conges- tion under separate headings, and although they are in many points identical, I wish to imply by the latter a decrease in the circulating power of longer standing, a more relaxed condition of the vessels, and a greater tendency to serous exudation. I must here express my indebtedness to Dr. Herbert. Major, the Superintendent of the West Riding Asylum, for permission to copy a plate of his, which gives the microscopic appearances of the cerebral cells of the con- volutions. It is on these cells that cerebral activity de- pends. I also have to thank Dr. Lauder Brunton, F.R.S., for a copy of a woodcut, which renders very in- telligible the association of headache with disturbance in the abdominal viscera. 10 Manchester Square, March, 1877. I have added a few pages to this book, which I trust may be as favorably received by the , profession as the two previous editions. December, 1879. DAY on HEADACHES. GENERAL INTRODUCTION. Preliminary Remarks on the Preponderance of Diseases of the Ner- vous System at the Present Day—Source of the Pain in Head- ache, and its Common Dependence on the State of the Brain and Nerves—Definition of the Term—Difficulties in adapting Suit- able Definitions to embrace all the Varieties of Headache— State of the Brain in some Cases of Apoplexy and Simple Con- cussion—Importance of Rest in the Treatment of Headaches at all Periods of Life, and more particularly in the Young, when the Growth of Mind and Body is in Active Progress. Many affections of the brain rather manifest them- selves in impaired functional activity than in actual pain and suffering. Almost any change in the circulating fluid, whether it be degraded from the absorption of noxious ingredients, or impoverished by a diminution of its normal constituents, will give rise to irritation and that altered sensation which indicates a disturbance in the sensorium. The most typical diseases of the present day are those which affect the nervous system, and we need not travel 2 18 HEADACHFX. far to ascertain the causes which produce them. The strain to which the nervous system is subjected through the requirements of modern times, renders it far more liable to disease than formerly, and men break down prematurely from overwork and the want of rest. Every branch of study is now pushed forward with a vigor unknown to our ancestors, and the young child is ex- pected to grapple with abstruse questions, which a few years ago were only intended for the advanced scholar and those who made philosophy their peculiar study. The microscope with its revelations, the electric telegraph which brings us in immediate contact with the enter- prise and movements of other countries, are both power- ful factors in stimulating the brain of man to unusual activity; the conflicting theories and theological contro- versies that have sprung out of the discoveries which geological science has called forth, and the generally increased pace at which we live, have all tended to excite and exhaust the brain. The tide, having once set in, rolls with resistless force, and the question may be reasonably asked, Where will the waves of destruction stop? The diseases of the nervous system threaten to be the diseases of the future, as they are of the present day, in spite of any restraint which men can put upon themselves. However desirous they may be to prevent it, they are helplessly and irresistibly drawn into the con- test, to struggle on and survive, or to fall early in the combat.* * This matter has not escaped the attention of observant laymen. " The politician, the professional man, the merchant, the speculator__ all must experience that strain of special faculties in the direction towards special objects, out of which comes nervous exhaustion with GENERAL INTRODUCTION. 19 Before civilization had arrived at its present high state, the overwrought brain was confined to men of letters and laborious students in the solitary contemplation of human knowledge. Nervous exhaustion was not the common disorder we now find it, and physicians were nearly silent on the causes which produced it. In what- ever direction a man now turns his attention, he is sure to see competitors who are striving for the same prizes. In trade, in commerce, in literature, and in art, it is ever the same—no man has the field to himself. But the pro- fessional man may perhaps be singled out as the chief example of overstrained exertion. He must strain every faculty toward the special object he is studying, and dare not leave it till he has worked it out to the minutest de- tail. If he does quit the field, failing to discover some new stratum, he is followed by another, who digs up the hidden treasure which gives a name or builds up a future. His thoughts are ever active and at work, and the brain will not rest, unless other occupations are found, and a new set of organs are called into play. In the physical disorders of man a certain set of muscles require rest, whilst another set are required to perform their lost func- tions, and disease imitates this in the activity of certain organs, to allow the worn-out ones to recruit themselves. Rest from thought would obviate much of the fatigue the maladies consequent on overstimulus and prolonged fatigue. Horace is a sound pathologist, when he tells us that after Prometheus had stolen fire from heaven, a cohort of fevers, unknown before, en- camped themselves on earth. In our audacious age we are always stealing new fire, and swelling the cohort of fevers with new recruits." —Miscellaneous Prose Works, by Edward Bulwer, Lord Lytton, 1868, vol. iii, p. 108. 20 HEADACHES. and exhaustion of the brain, if it could be adequately measured and carried out; but the circumstances of life generally do not enable a man to avail himself of that change of thought and occupation which would be a safe- guard against the terrible evils he is fostering. If there be any truth in this argument, it is not sur- prising that the complex and delicate structure of the brain, and nerves, should fail under the continued strain and this struggle for existence in the battle of life. Every emotion, every perception, and every action operate through this vast machinery, and invest it with an im- portance which did not belong to it forty years ago, when the atmosphere of thought was more serene and tranquil. What wonder, then, if the nervous system should sud- denly or prematurely give way, if it has to bear a load every day, which at one time only emergency or accident put upon it! Added to the altered circumstances of modern times, care and anxiety bring their oppressive burden to bear in greater force, increasing the suscepti- bility of the nervous framework, and robbing it of much of its power of resistance. Then, too, the luxuries of a larger portion of mankind have increased, and in a corresponding ratio; and ner- vous prostration is the penalty we pay for our indulgence. The sensual pleasures of life, which make such inroads on our strength and powers of endurance, are alarming to contemplate, in the varied forms of suffering which they produce in return for a passing gratification or an idle enjoyment. Sustained and steady work are not the prevalent features of our present life, but laborious strain and tension, followed by brief and broken periods of re- pose. GENERAL INTRODUCTION. 21 A continuity of causes oftentimes produces the same results; and we see this exemplified in headache, as well as in many other diseases. There is first the influence of excitement, and overstimulation to the brain, and then the influence of exhaustion. When both act in concert, how rapid is the downfall! I hold with unshaken fidelity to the conviction of a nerve preponderance in these headaches, which eclipses every other. We cannot set aside its attractive power to implicate the vascular tissues, and to change and modify the signs and symp- toms of disease in every texture of which the body is made up; nor the rival sway it exerts in corrupting the machinery of the whole body, and accomplishing the de- struction of the vital parts. In attempting to classify headaches into groups and varieties, some speculations are necessarily indulged in to establish conclusions and to support principles; but I have endeavored to place fairly before the reader the chief aspects of the question, and to weigh carefully in the scale of calculation every collateral sign of investiga- tion, that fallacy may be reduced to a minimum, if not wholly got rid of, and that conviction of some sort may be gained. It has been my desire to consider this matter in a broad light. Devotion to any view or idea gives it an ascen- dency in the author's mind ; and by attaching undue im- portance to it, he may be led into error. We are all, in fact, more or less disposed to incline to one side or the other, and so to entertain a prejudiced view of things, which has a cramping effect in the pursuit of a study like prac- tical medicine. The mind is to be pitied that extends the range of inquiry no further than the sphere of its own 22 HEADACHES. special study, for in this way knowledge is improperly applied. "Men's thoughts," says Lord Bacon, "are much according to their inclination, and they speak as they have learned." In the disorders we are about to consider we shall deal chiefly with those that are functional, for curable head- aches cannot be strictly classified with morbid states of the brain. And yet the difficulty is as real as it is hypo- thetical. Molecular changes may take place in the cere- bral cells, and produce symptoms allied to organic lesions, having no show of difference except in their transient duration. The subject of headache is of manifest importance, because it claims so many sufferers and is surrounded by so many difficulties—the pathology is obscure, the diagnosis perplexing, the remedies uncertain. Headache is a disorder of the utmost frequency, and yet there is none which more taxes the experience and scientific knowledge of the physician, or requires closer observa- tion in elucidating its nature and removing its obscurity. The habitual sufferer from headache allows no other pain to compete with it. Whether he is prostrated by its agony, or has recovered from a recent attack, he is persistent in his statement, that a continuance of the pain would rob him of all pleasure in existence, and make him sigh for escape by death. The aching cerebral mass shut up in its bony cavity only reveals its morbid condi- tion by the statements of the sufferer; in its functional derangement it does not indicate by any reliable sio-ns whether this or that part is at fault, as in disorders of the abdominal or thoracic organs; the source of the suf- fering cannot be fixed upon and removed, as a decaying GENERAL INTRODUCTION. 23 tooth, or a calculus in the bladder ; but it goes on, and we are too often left in doubt whether the suffering has originated in the brain itself, or in some other organ of the body from reflex irritation and sympathy. Are the brain and its vessels deficient in the supply of blood ? Is the circulation contributing its due supply of arterial nourishment? Or is it in excess, and are its vessels overloaded ? These perplexing questions constantly present themselves for settlement. The same symptoms arise when very opposite conditions prevail. The de- lirium of scarlet fever is not the delirium of typhus, although they may present very similar features. There is the sleeplessness of anemia and of congestion; and there is the coma of bloodlessness as well as of hyperemia. How can such dangerous conditions as these be treated with any chance of success if we have erred in the interpre- tation of their pathological associations, or ascribed the phenomena to a state of the brain and general system which does not exist? Bearing in mind, then, the intricacy of the subject, and the ever-changing circumstances that surround us, we approach the discussion of a disorder which modern habits of life encourage and develop, and threaten to in- crease tenfold. Our system of railway travelling has no small share in producing that aching of nerves within the brain, which robs existence of enjoyment, and inter- rupts the serenity of social life; and which too often drives the pitiable sufferer to the brink of despair, when he finds no relief in the legitimate resources of our art. In clinging to any nostrum within his reach, he increases the evil which is to render his live heavy and wearisome, and to baffle his energies and labors to the end. 24 HEADACHES. In no class of diseases do we observe better examples of sympathetic pain than in headache. Pain originating in one part may be transferred to another and weaker part, or to one ready to take on the morbid impression of pain. This communication is regulated to a great extent by the irritability or nervous susceptibility of the patient. The mere idea of pain is enough to bring on actual pain in some persons ; and the mind can so vivify or exaggerate it, as to give it a reality through sensation. The sympathetic pain of the shoulder from hepatic dis- ease, the pain in the knee from hip-joint disease, and the pain of the genito-crural nerve from calculus in the kid- ney, or the severe pain down the thigh after the removal of ovarian tumors, are all instances of reflected pain. The transference of pain beyond the seat of its produc- tion is an interesting fact in physiology, and where the impressions can be traced along a set of nerves the explanation is forthcoming. It is this communication which refers painful sensations to a distant part from which the irritation has sprung, till it finally appears to have its origin in that part, whilst the original seat of mischief is lost sight of altogether. If, then, the cause of some headaches is traceable to a morbid sensation conveyed along a nerve by sympa- thetic action, it is explanatory of some painful feelings in the head and face, through the contact of certain articles of food, and intense cold on the terminal nerves of the stomach. Any sudden shock of grief may occa- sion gastric pain, and it certainly awakens fearful head- ache in some persons. " Putting aside," says Dr. Sy- monds, " for the present, any reference to the patient's feelings, what do we learn from anatomical considerations GENERAL INTRODUCTION. 25 as to the probable source of pain within the cranium when the person is the subject of headache? It does not appear to be in the nervous matter, whether vesicular or tubular, of the cerebral hemispheres, or of the cerebel- lum. No evidence of feeling has been obtained by vivi- sectors till they approached the sensory ganglia—the thalami optici and corpora quadrigemina. But these are the centres of sensation to all parts of the body as well as to the head. All analogy must further look for the nerves as the source of pain (though some writers are hardy enough to doubt the necessity of nervous mat- ter as instrumental in sensation). And what are the nerves ? Numerous as are the nerves which come out of the cranium, there are on a superficial view very few that go into it. A branch of the suboccipital accompanies the vetebral artery, but a large majority of the other nerves, destined for intracranial purposes, are derived from the sympathetic. These, then, are the nerves which are of the chief interest to our present inquiry. Nerves of this class accompany bloodvessels, and when we ob- serve the large amount of these vessels, the brain and its membranes being more liberally supplied with blood than any other organ (the quantity being com- puted as one-fifth of the blood of the whole body), we might, without searching further, feel convinced that there must be a correspondent supply of ganglionic nerves; but the minute examination of modern anato- mists has tracked them in great abundance."* By the term headache, we mean to signify pain in the * Gulstonian Lectures on Headache, Medical Times and Gazette, 1858. 26 HEADACHES. head, accompanied with intolerance of light and sound, and incapability of mental exertion ; a state, from what- ever cause arising, in which the brain is temporarily prostrated and disturbed, in proportion to the cause and intensity of the suffering. Thus, many headaches de- pend primarily on a disturbance in the cerebral structure, on a loss of balance in the relations of the nervous force and vascular supply, or on some intricate phenomena of the mind, which increase the sensibility of the brain, and disturb its functions.* Then follows sympathetic dis- turbance in the digestive organs, which, reacting on the brain, increases all the symptoms for a time; but soon, from the process having advanced further, or from some change ensuing in the current of the circulation, the morbid sensibility of the brain abates, and the headache vanishes. * " The headache, a very frequent symptom in all cerebral dis- eases, is very difficult to explain; we do not even know if it is of central origin (that is, if it originates in the parts of the brain where irritation causes symptoms of pain after the insensible greater hem- ispheres have been removed), or whether, as I think is more probable, it depends on irritation of the filaments of the trigeminus going to the dura mater. The great sensitiveness to impressions on the senses depends on the increase of excitability, caused by the cerebral hy- peremia, on the hyperesthesia of those portions of the brain through which peripheral irritations are perceived. The patients do not exactly feel, see, and hear more sharply than ordinarily, but they are annoyed by irritations far weaker than such as usually annoy them. Light troubles them; a slight sound or an insignificant irritation of the nerves of touch excites disagreeable feelings. Morbid excitation (which must not be identified with increased excitability) of the same central parts causes the dazzling before the eyes, seeing sparks, roaring and buzzing in the ears, the sensation of formication or of undefined pain, which are not induced by peripheral irritation."— Nietneyer's Practical Medicine, vol. ii, page 159. GENERAL INTRODUCTION. 27 For some days before the development of a nervous headache, patients will admit, on close examination, that they felt easily fatigued without any real cause; that they awoke unrefreshed in the morning, with a feeling of weight over the eyes, which passed away after break- fast ; that before the close of the day they were unusually tired, and felt on going to bed some flatulence and indi- gestion, with dryness of the mouth, and an extraordi- nary degree of depression and weariness. During the night, or the following morning, the nervous headache is developed, and after that the altered sensibility of the brain and the arrest in the powers of digestion proceed together. Symptoms, therefore, which appear as prima- rily indicative of disorder in the stomach and intestines, are really often secondary, or sympathetic affections, re- sulting from the pre-existent disorder within the brain; and when we come to consider the varieties of headache, we shall see how this disturbance is effected. The conditions which produce some forms of headache are wrapped in mystery, and we are carried into the realms of speculation to explain them. The cranium of the adult is air-tight and unyielding. In a healthy state the brain probably undergoes neither dilation nor com- pression. Neither the contents of the thorax, nor the abdomen, sustain the same amount of pressure for one second ; the elasticity of their walls through the move- ments of respiration keeps them in perpetual activity, and the blood-pressure is continually changing ; but the case of the cranium is altogether different. Where a tu- mor is present, or lymph or blood is effused into the brain, there is an alteration in pressure, and the brain substance is displaced by the encroachment of disease; 28 HEADACHES. but if pressure arises gradually, the brain sometimes adapts itself to the changes which are going on. In some cases of apoplexy the effusion has been so rapid and ex- tensive, that it has pressed upon the brain, sq as to cause symptoms of rapid compression and death. It should, however, be borne in mind that the phenomena of apo- plexy have ensued where nothing but a disproportionate amount of blood has been seen in the vessels and sinuses after death, without any rupture; but then the vascular connection that exists between the vessels of the brain and those that ramify over the face and scalp has a ten- dency to relieve the sudden determination within the head. The balance of the cerebral circulation is inter- rupted when the arteries are nearly empty, for then the veins are full, and oppression is the consequence. If ar- terial tension is increased, and the vessels are full, a state of exaltation and excitement then ensues, tending to de- lirium or mania. There is no exact evidence of the actual change that takes place in the cerebral mass, when a physical dis- turbance of the brain and nervous centres is caused by simple concussion. A mere confusion of ideas, or a tem- porary lull in the mental process, as though the sufferer had just awoke from sleep, and had not yet realized the external world around him, are all the manifestations of the mischief. I apprehend that in these slight cases of shock, when recovery is early and permanemt, there is no structural or molecular lesion; but when headache and congestion of the cerebral vessels creep on after a time then we may calculate with almost absolute certainty that the force of the circulation through the bruised organ is GENERAL INTRODUCTION. 29 disturbed, being excessive in some parts, and scanty in others. If the delicate structure of the brain is susceptible of molecular disturbance from injury, it is a rational in- ference to suppose that the same may occur from func- tional disorder and perverted nutrition, when they have been of long standing. A structural lesion at the base of the brain is possible where the vascular supply is the greatest, and the minute filaments of the pneumogastric nerve are abundant, as they spring from the medulla ob- longata. Now, in concussion of the brain the enlightened surgeon, in his treatment, relies more on rest and the ex- clusion of light and sound, than on any other method of cure. He knows that any plan which does not include these instructions is futile to effect recovery, and to afford the brain a chance of regaining its equilibrium. If it is not allowed a long season of repose, and strain and exer- tion are put upon it at a time when the utmost quietude is demanded, then softening, inflammation, and gradual degeneration are established. The brain cannot stand still like a monument, and maintain its integrity. If there is no repair, then there is degeneration ; the morbid condition, instead of subsid- ing, slowly advances, and the rest, of which sleep is the most perfect form, cannot bring its restorative influence into operation ; the nights are disturbed and restless, and dismal dreams announce that the morbid changes are still in progress. Repair proceeds with activity in persons of adult life, when growth has ceased and the bodily frame- work is stationary ; but in children, when the tissues are building up, and the changes are rapid in all the organic functions, recovery is often tedious, defective, and uncer- 30 HEADACHES. tain. In these young patients a shaking of the cerebral mass has laid the foundation of confirmed headache, and subsequently of organic change in the structure of the brain, sometimes leading to exudative products and mor- bid growths. Repair is one of the most beneficent man- ifestations of the goodness of the Creator: by the sorrow and pain which nature inflicts for the disobedience of our acts, and the violation of the laws which she has insti- tuted for our observance, she stays the progress of disease and injury, permits the restoration of the wasted tissues, and, by a period of calm repose, evokes that growth and repair which obviates permanent harm, and furnishes the conditions requisite for the restoration of perfect func- tional activity. I have adopted the following classification of the va- rieties of headache :* Headaches depending on Causes within the Brain— Intracerebral Headaches. 1. The Headache of Cerebral Anemia. 2. The Headache of Cerebral Hyperemia. 3. Sympathetic Headache. 4. Dyspeptic or Bilious Headache (known also as Sick Head- ache). 5. (a) Headache from Cerebral Congestion, or Congestive Headache. (6) Headache from Plethora and Increased Vascular Action. * This classification differs from that which I have adopted for the headaches of children, because adults are liable to some forms of headache which do not belong to early life. GENERAL INTRODUCTION. 31 6. Headache from Exhaustion, or from some Peculiar Change in the Cerebral Tissue—Nervous Head- ache.* 7. Nervo-hyper^emic Headache. 8. Arthritic or Gouty Headache. 9. Toxemic Headache. 10. Organic or Structural Headache. 11. Headaches of Advanced Life. Headaches depending on Causes external to the Brain— Extracerebral. 1. Rheumatic Headache. 2. Headache from Affection of the Periosteum. 3. Neuralgic Headache. Headaches of Childhood and Early Life. * This variety of headache is also familiarly known as sick head- ache, and it is so termed by some authors; but the stomach here is only secondarily affected. 32 HEADACHES. THE BASE OF THE BRAIN (FROM HIRSCHFIELD AND LEVEILLE). 1. Longitudinal fissure. 18. Middle lobe of cerebrum. 2. Anterior lobes of cerebrum. 19. Portio mollis of seventh. 3. Olfactory bulb. 20. Anterior pj ramid. 4. Lamina cinerea. 21. Glosso-pharyngeal nerve. 5. Fissure of Sylvius. 22. Olivary body. 6. Locus perforatus anticus. 23. Pneumogastric nerve. 7. Optic commissure. 24. Lateral tract. 8. Tuber cinereum and infundibulum. 25. Spinal accessory nerve. 9. Third nerve. 26. Digastric lobe. 10. Corpus albicans. 27. Hypoglossal nerve. 11. Fourth nerve. 28. Cerebellum. 12. Locus perforatus posticus. 29. Amygdala. 13. Fifth nerve. 30. Slender lobe. 14. Crus cerebri. 31. Posterior lobe of cerebrum. 15 Sixth nerve. 32. Posterior inferior lobe. 16 Pons Varolii. 33. Inferior vermiform process. 17. Portio dura of seventh. THE HEADACHE OF CEREBRAL ANAEMIA. 33 CHAPTER I. THE HEADACHE OF CEREBKAL ANAEMIA. Physiology of the Cerebral Circulation—Effect of the Cerebro-spinal Fluid in Influencing the Circulation—Perivascular Spaces—Cer- ebral Anaemia and the Sources of Blood Supply through the Cir- cle of Willis—Eelation of Anaemia to Coma—State of the Brain in Sleep—Experiments of Mr. Durham—Physiological Consider- ations and Conclusions—Symptoms and Diagnosis—Prognosis and Treatment—Physiological Action of Alcohol in Cerebral Anaemia, and its general Effects and Consequences on the Animal Economy. Cerebral Circulation. — Before we can comprehend fairly what is nervous pain, it behooves us to glance at the peculiarities of the cerebral circulation, and the rela- tionship existing between the nerves and bloodvessels. In a young child, with its open and elastic fontanels, the amount of blood within the cranium is subject to great variation, because the skull is not quite closed by bone, and the cerebral circulation is obedient to the same laws as regulate the circulation in the rest of the body. In adults, as we have seen, when the ossification of the skull is complete, and the pressure of the atmosphere on the brain no longer exists, the variation in the contents of the cerebral vessels is relatively diminished; but the ventricles and subarachnoidean fluid keep up a tolerably uniform pressure; and where the cerebral substance is diminished in volume from any cause, the fluids and 3 34 HEADACHES. blood in the vessels prevent that difference from taking place which is so common in the other great cavities of the body.* The experiments of Dr. Burrows and others prove that the quantity of blood within the cranium is subject to considerable variation, and consequently the pressure exerted on the nervous structure would be considerable also if it were not for lymph arrangements within the encephalon. Dr. Symonds and Mr Mitchell Clarkef conducted some careful experiments which confirmed * " There can be no doubt that the most important influence mod- ifying the amount of blood in the brain is the fulness of the ven- tricles and other cavities of the subarachnoid spaces, and of the lym- phatic ' spaces' or sheaths surrounding the cerebral bloodvessels, all of which spaces contain a watery fluid identical with the cerebro-spinal fluid, and all communicate with one another. Their fulness, as said above, holds a precisely converse relation to the amount of blood in the brain, a fact which has been established with regard to the peri- vascular spaces by exact measurements, it having been found by Golgi that they are larger in all conditions of the brain accompanied by anaemia, and smaller in hyperaemic conditions."—Jones & Sieve- king's Pathological Anatomy, by Dr. Payne, p. 254. " In almost all autopsies it may be seen that the amount of blood contained in the vessels and the amount of cerebro-spinal fluid are in inverse proportion ; that a distension of the vessels of the meninges is accompanied by a decrease of arachnoid fluid, and conversely that when the vessels are less full, the meshes of the textus cellulosus suba- rachnoidealis contain a greater amount of serum. Only when the brain is atrophied do we find oedema of the membranes with overfilling of the vessels; and only when an effusion of blood, a tumor, or a collec- tion of fluid in the ventricles has contracted the space in the skull, do we find, along with anaemia, dryness of the membranes and disap- pearance of the sulci between the cerebral convolutions."—Niemeyer's Practical Medicine, vol. ii, p. 150. f Symonds on Headache, Medical Times and Gazette, April 3d 1858, p. 34. THE HEADACHE OF CEREBRAL ANvEMIA. 35 those of Dr. Burrows, who proved that gravitation af- fected the quantity of blood in the brain. These gentle- men selected three rabbits—one rabbit was suspended by the hind-legs, another was suspended by the ears and forelegs, and a third was kept in a horizontal position. " The two suspended rabbits were poisoned with prussic acid after about half an hour, their positions having been strictly maintained. The post-mortem examination was made immediately, and with the bodies kept steadily in the same position." The rabbit suspended by its hind-legs was found to have its eyes congested, and the tissues of the head and neck gorged with blood; but the substance of the spinal cord, and the lumbar and dorsal regions were pallid, the bony tissue of the cranium and the meninges were highly congested, and the puncta vasculosa in the cerebral sub- stance were numerous. The ventricles contained no fluid, and there was none external to the convolutions. The rabbit suspended by the ears and forelegs was found to have its head, neck, and back exsanguine, whilst the lumbar region was full of blood. No serous fluid was found in the ventricles, or between the convolutions. The brain and membranes were as blanched as those of an animal bled to death. In the third rabbit, not sus- pended, also poisoned by prussic acid, and examined in the horizontal position, there was an equal distribution of blood, and nothing remarkable beyond the absence of cerebro-spinal fluid in the cranial or vertebral cavity. In a full-grown and strong rabbit, suspended by the ears and forelegs, death occurred in an hour; another strong middle-sized rabbit, hung up by its hind-legs for four hours, recovered itself almost immediately, and began 36 HEADACHES. to feed heartily. We see that the congestion of the brain and membranes produced no ill effects comparatively, whilst the opposite position was quickly fatal. These experiments corroborate what we know of the rapid congestion of dependent parts after death, and of the tendency to hypostatic congestion of the lungs and brain in fever and other exhausting diseases. It has been satisfactorily demonstrated by the experi- ment of Dr. Burrows, A. Durham, Hilton, Kussmaul, and Tenner, and other observers, that there is vascularity of the encephalon during excitement and mental strain; while during sleep and exhaustion the vessels lose their turgidity, and the brain is pale and bloodless. These changes are owing to the presence of the cerebro-spinal fluid, on which Mr. Hilton has laid so much stress. When it is in excess the vascularity is slight, and when it is diminished the turgescence is increased (Rest and Pain). Not only is there a relation between the intra- cranial vascularity and the cerebro-spinal fluid, but there are channels in the substance of the brain, termed by Robin, His, and Obersteiner, "perivascular spaces," along which the bloodvessels travel; and these are in- vested with a loose sheath of connective tissue, within which is found a watery fluid, regarded by some as lymph,* When the brain is active the vessels dilate, and the fluid is absorbed, without causing any compres- sion of the nervous structure; but when this activity has subsided the vessels undergo contraction, and the space between them and the perivascular space is again filled with fluid. * Frey's Histology, by Barker, p. 577. THE HEADACHE OF CEREBRAL ANiEMIA. 37 Cerebral Ancemia.—In order to approach anything like an explanation of the different forms of headache, we must arrive at some definite conclusions regarding the quantity of blood within the brain, and how anaemia is brought about when the supply is deficient and its quality altered. It is computed, as we have before noticed, that the brain receives fully one-fifth of the whole blood in the body (Haller), a circumstance which irresistibly be- tokens its immense vigor and activity, and connects it with consciousness, and thought, and feeling—in fact, with all the higher attributes of the mind of man.* In no organ of the body is it more essential that blood should be freely supplied than to the brain7 if its functions are to continue active and energetic. The immense pre- eminence assigned to it as the mental organ seems natu- rally to require an abundant vascular supply} for mental changes and nervous waste are perpetually going on, and under the influence of strong emotion or excitement, pro- ducts are removed from the system by the skin and kid- neys in excess of what ordinarily occurs, especially in the amount of phosphates excreted. I may mention, as bear- ing on the point, the case of a gentleman sixty years of age, in whom the symptoms of cerebral anaemia are well marked. The urine is loaded with phosphates when the head is confused, and the brain is overfatigued; but after * " In the performance of an idea, as in the performance of a move- ment, there is a retrograde metamorphosis of organic elements; the display of energy is at the cost of highly organized matter, which undergoes degeneration or passes from a higher to a dower grade of being ; and the final retrograde products are, so far as is at present known, somewhat similar in muscle and nerve."—Maudsley. 38 HEADACHES. rest and repose they disappear, and the secretion becomes natural. In the brain the demand for healthy blood is twofold. In common with all the tissues of the body, it requires a due supply of nutrient material for the maintenance of its structural integrity and functional efficiency, but a more urgent demand is for the oxygen which is conveyed by the haemoglobulin of the red corpuscles. Oxygen is absolutely necessary for the evolution of nerve-force in all its forms. It is the absence of oxygen from the blood in the cerebral capillaries which causes death to occur in cases of suffocation in three or four minutes; and conse- quently it is plain that a deficiency of it must impair the activity of the nerve-elements of the brain. Whenever the red corpuscles with their constant supply of oxygen are not passing through the capillaries of the brain in sufficient number we have cerebral anaemia. This may be due to the state of the blood itself, as in anaemia and cachexia, when the corpuscles counted by the method of Professor Hayem, of Paris, may be reduced to less than half their proper proportion. Or the blood itself may be of due composition, but virtual cerebral anaemia may arise from weak action of the heart, func- tional or organic in origin, through the slow transmission of blood along the vessels. Or, again, the cerebral blood- vessels may be diseased, and obstruct the passage of the blood by loss of elasticity, or actual narrowing. This is the great cause of the cerebral anaemia of advanced life. Deficiency in the circulation of the brain will gradually enfeeble the mind, and lower all the functions of the body. We may witness this when there is any drain going on from the system, as in haemorrhoids, menor- THE HEADACHE OF CEREBRAL AN7EMIA. 39 rhagia, or profuse leucorrhcea. If the blood is wanting in certain constituents, or is contaminated by the presence of others which it ought not to possess, then the mental faculties are clouded and depressed, and the brain indi- cates disorder. This is remarkably well exemplified in the cachexia of syphilis, and in blood-poisoning from lead, copper, or mercury. The persistent use of alkalies has an equally injurious effect. I am sure I have seen the disposition to cerebral anaemia accelerated by the pro- longed use of alkalies and mercurial pills, which some people take to excess because they fancy the liver is dis- ordered, and the brain confused in consequence. They may afford relief for a time by relieving the torpor of the internal organs, to which an enfeebled circulation tends, but the system invariably fails in the long run. The same happens in the acute fevers, which break up and destroy the red corpfiscles, and rob the blood of its chief vital properties. When the supply of healthy arterial blood is sufficient, and the cerebral circulation is stimu- lated to activity, the thoughts are quick and bright, and the pleasure resulting therefrom is uniform and consist- ent; but when the flow of blood is unusually rapid, and the vessels are distended and throbbing, then mental ex- citement ensues, and a disorderly succession of perverted thoughts and exalted intentions arise, which are all created by a disturbance in the balance of the circula- tion. The rush of blood to the head, which some people feel when they are the subjects of cerebral anaemia, is to be thus explained: Emotion or sudden excitement causes the arterial circulation to become quicker, and this fills the cerebral vessels too suddenly with blood for the 40 HEADACHES. brain substance to bear it with composure; besides, the venous circulation is slow, and unable to respond to the call at once. The unconsciousness which accompanies syncope, or fainting, takes place when the heart's action is failing or feeble, and the cerebral functions are no longer stimulated by the usual flow of arterial blood. When animals are bled to death, or a ligature is placed upon the common carotid, convulsions, or anaemia of the brain, are more usual sequences than congestion or inflammation of the lungs. It is obvious that this shutting off of the arterial current from the brain, resembles in the effects produced the symptoms of an apoplectic clot, or the obstruction due to embolism. The surface is pallid, the pulse quick and small, the temperature occasionally rises from the irrita- tion induced, and the muscular relaxation is complete. With the condition of pallor, arising- from mere deficiency in the arterial blood supply, there occur headache, loss of memory, petulance and irritability of manner, and indif- ference to all those subjects which ordinarily possess in- terest. The brain is badly nourished, and it refuses to respond, for the nerve-centres have lost their tone. The patient lies exhausted in his bed, with slow and feeble respiration, and dilated pupils. If the veins are full, and there is fear or terror, the features may be livid and cold from the effect on the sympathetic system, and, through it, on the ventricular contractions of the heart. The pallor of the eye and its dead calm present a striking contrast to the red and eager eye of hyperaemia. There is often the blank waxen look of despair, with the angles of the mouth drawn down, as though the patient had passed days together in solitary grief. He is restless THE HEADACHE OF CEREBRAL ANAEMIA. 41 unreasonable, and fidgety, and moves spasmodically from one part of the room to another, like a man whose mind is ill at ease, and stricken with remorse. Now he feels his pulse, now he consults his tongue, and if he has the sensation of numbness or cramp in his legs he dreads the approach of paralysis. If his attention is directed to his head, as the possible cause of his discomfort, he fears the approach of a fit of apoplexy, and is afraid to be alone. In women the condition is more passive. To keep the brain and the mind in proper working order involves other considerations : it demands a disci- pline of life which few persons can or will carry out. Their ordinary habits are provocative of change in the nervous tissue, through the stimulants they daily consume, or the laborious life they are compelled to lead. Mental effort is incompatible with muscular strain, and if both are attempted at the same time the supply of blood to the brain will not be maintained, and the tissue will suffer from innutrition. Local congestions overloading some portions of the cerebral mass, and obstructing the free current of blood to other portions, may be the beginning of that anaemia which is so frequently the starting-point of some headaches. I repose here on the rationality of a theory of ill health and disease, which, beginning in anaemia and tardiness of circulation, ends by a series of consecutive changes in impurity of the blood itself. A vital fluid so contaminated destroys at length the vigorous action of the various excretory organs of the body, heap- ing upon them work which they cannot discharge, and leadino- to morbid changes of structure. Recent micro- scopical research has fully demonstrated the exactness and certainty of the lesions in paralysis, and an endless variety 4 42 HEADACHES. of other forms of disease, when no alteration is visible to the naked eye. When during life the symptoms appear to indicate a cerebral lesion, no disorganization can be dis- covered after death—not more vascularity or congestion, we are sure, than is constantly present in many degrees of headache; yet the influence of the circulation upon the functions of the brain demonstrates that a deficiency or excess of blood does not interfere with or arrest the re- spiratory movements, and cause convulsions or delirium. In what manner, or to what extent, disturbance is excited in the cerebral functions by preasure, may yet be a ques- tion to determine; but it is certain that a deficient supply of blood, or a state of anaemia, will disorder the brain and cause derangement, as in epilepsy, when the arteries are so affected as to lead to their contraction; while their thickening and diminution, as in atheroma, also render the supply of blood deficient, and by robbing the brain of its proper nourishment lead to disease. Hence uncom- plicated anaemia of the brain, involving nothing more than a meagre supply of blood to an organ which de- mands it in a large quantity, is a common and frequent cause of headache. With this anaemic state there is in these cases a cachectic condition of the blood circulating through the vessels, and this I apprehend is a constant accompaniment of headache. As a cause of headache this pathological change is one of great importance, though it is not easy to deter- mine during life except through the symptoms produced. The brain presents a pallid appearance, and is of dimin- ished consistence, whilst the red spots alluded to in con- gestion are fewer in number. In some persons I have known a headache from this cause to be of such a wear- THE HEADACHE OF CEREBRAL ASLEMIA. 43 ing character, and so continuous, that symptoms allied to insanity have been present, and alarm has arisen in the minds of those who have witnessed the sufferer. Now, as congestion results from the overloading of the bloodves- sels, the striking feature of this anaemic condition is both an excess of fluid in the cavities of the brain, and an in- filtration through its substance, giving rise to the state known as oedema, and causing actual enlargement and flattening out of the convolutions against the meninges. This is by no means an uncommon cause of irritation of the brain and severe headache. And here I may observe in passing, that some pathologists are of opinion that pain in the head is a positive indication that the meninges are involved, and that when they are free there is an absence of suffering.* In order to understand the subject of anaemia and hy- peraemia, it is important to glance at the circulation of the vessels at the base of the brain, and see how freely they are united at their sides and in the middle line. The vascular supply is enormous, and nature has provided a free circulation of blood through the brain, notwithstand- ing that a large vessel might be obstructed altogether. I think the pain of occipital headache is sometimes induced by the abundant blood-supply, for the basilar artery formed by the union of the two vertebral arteries sup- plies half the encephalon with blood, viz., the medulla oblongata, the pons, the cerebellum, and the posterior third of the cerebrum (Ellis). The anterior portion of the cerebrum is supplied by the internal carotid, which divides into the anterior and middle cerebral, and the * See the chapter on Organic Headache. 44 HEAD ACHES. posterior communicating artery. Now this difference in the amount of blood-supply helps to explain the cause of frontal headache by the fact that the vertebral and caro- tid circulations are independent, and because they are regulated by different vasomotor influences. Of the state of the circulation generally in cerebral anaemia we may observe that the very opposite conditions exist to those present in hypenemia, where the vascular supply is well maintained and the cerebral cells are active. In anaemia the heart's impulse is weak, and the sounds are short and indistinct—the area of dulness being some- times increased from dilatation of the ventricles; or there may be fatty degeneration of its muscular structure ; the pulse is feeble and easily compressible from the unfilled state of the arteries, and the general diminution of blood in the vascular system. I shall allude further on to local hyperaemia—to one part of the brain being more full of blood than another. In cerebral anaemia there is the same unequal distribu- tion of blood, one portion being more exsanguine than another (except at the base of the brain in the so-called circle of Willis just described), because the cerebral ar- teries have no communication one with another, and the different vascular areas are distinct and independent. On a little reflection it becomes at once evident that the cir- culation may receive a check in some part of its curious bendings, and proceed unhindered in others. The dif- ferent areas of the brain being irregularly supplied with blood, it is clear that the unequal distribution not only causes headache of a nervous type, but gives rise to a perverted or morbid condition of the emotions—to mel- ancholy and suspicion, to distrust and apprehension. And THE HEADACHE OF CEREBRAL AN.EMIA. 45 it also fully explains the effect of posture in relieving or aggravating cases of headache. There are persons who, when suffering from agonizing headache, cannot rest their head on a pillow for even a moment without the face be- coming flushed, and the brain throbbing to the verge of delirium ; because the egress of blood from, the overloaded vessels is not aided by gravitation, and an excessive sup- ply is maintained by the recumbent posture. Chronic cerebral anaemia, and the headaches that result from it, are to be regarded with anxiety in those persons whose nervous system is hereditarily weak, and whose minds are vacillating and unsteady. A headache of thirty years' continuance is apt to produce permanent change in the temper and feelings, and to diminish the powers of the mind. The fear that organic disease should be developed after a period of depression which has suc- ceeded to pain and suffering, through irritation of the membranes and nervous centres, is a natural one, partic- ularly if hallucinations are present, and the patient has a fixed idea that he has sustained injury or wrong. It would be an error past redemption not to connect physical disease with mental disease. How often does not the first induce the last ? Perverted sensation even- tually implicates the action of the cerebral cells, and by its agency brings about irretrievable mischief in the struc- ture of the brain, if not disease of the bloodvessels them- selves. The brain assumes an altered appearance; it becomes atrophied and sodden, and the convolutions shrunken and undeveloped. The patient's gait and wasting motor power in the lower extremities accompany the in- tellectual decay, and he readily succumbs to the influences of intercurrent disease. Sleep is broken and nutrition is 46 HEADACHES. further checked, for the unrestcd brain cannot fulfil its functions, or repair the waste of its tissue. Disturbed dreams supplant repose, and morbid changes pursue their downward progress. In hyperaemia the head is hot and the cerebral vessels full, and the functions of the brain are slow and torpid; in anaemia the cerebral organs are irritable and excitable, and the face is pale and the pulse weak; in both the functional activity of the brain is disturbed. In the first case there are sensorial disturbances with exaltation, such as ringing in the ears, or flashes of light; in the latter, diminution of sensorial power. Commonly, however, there is noise in the ears, arising either from some peculiar condition of the nervous apparatus, allied to debility, or to neuralgia; or it may possibly be explained from the partially filled carotid on the petrous portion of the tem- poral bone. Long-continued congestion, in which inflammation has taken no part, deranges the connection existing between the nervous and vascular systems, and induces minute degenerative changes in the coats of the smaller cerebral vessels. If these vessels become blocked up or lose their elasticity, the relationship between the brain and the tissues is destroyed, and there ensues degraded nutrition in the proper structure of the brain. In congestion, as well as in inflammation, the exudation of serum or the effusion of albuminous matter takes place, separating the elements of nerve structure from the capillary network, arresting nutrition, and accelerating decay. Mr. Durham has conducted some interesting experi- ments to prove that in sleep, when the brain is at rest, it THE HEADACHE OF CEREBRAL ANJEMIA. 47 is anaemic, and no longer requires its accustomed arterial stimulus. Hitherto it had been generally supposed that the brain was lulled into quietude during sleep by an overcharged state of the cerebral vessels—that congestion and a large blood-supply were most favorable for repose and rest; but the facts adduced by Mr. Durham proved the sound- ness of his conclusions, and they have since received the testimony of other competent observers. Mr. Durham supports his views by the following experiment: " A dog having been thoroughly chloroformed, a por- tion of bone about as large as a shilling was removed from the parietal region of the skull by means of the trephine, and the subjacent dura mater partially cut away. The portion of brain thus exposed seemed inclined to rise into the opening through the bone. The large veins over the surface were somewhat distended, and the smaller vessels of the pia mater seemed full of dark-colored blood; no manifest difference in color between the arteries and veins could be perceived. The longer the administration of the chloroform was continued the more distended did the veins become. As the effects of the chloroform passed off the animal sank into a comparatively natural and healthy sleep. Corresponding changes took place in the appearance of the brain ; its surface became pale and sank down rather below the level of the bone; the veins were no longer distended ; a few small vessels, containing blood of arterial hue, could be distinctly seen ; and many which had -before appeared congested, and full of dark blood, could scarcely be distinguished. After a time the animal was roused ; a blush seemed to start over the surface of the brain, which again rose into the opening 48 HEADACHES. through the bone. As the animal was more and more ex- cited, the pia mater became more and more injected, and the brain substance more and more turgid with blood. The surface was of a bright-red color; innumerable vessels, unseen while sleep continued, were now everywhere visi- ble, and the blood seemed to be coursing through them very rapidly; the veins, like the arteries and capillaries, were full and distended, but their difference of color, as well as their size, rendered them clearly distinguish- able. After a short time the animal was fed, and again allowed tosink into repose; the bloodvessels gradually re- sumed their former dimensions and appearance, and the surface of the brain became pale as before. The animal slept in a perfectly natural manner. The contrast be- tween the appearances of the brain during its period of functional activity, and during its state of repose or sleep, was most remarkable. In order, however, to be quite sure that I was not misled by fancy, nor yet by faulty memory, but that the difference was really great, I oper- ated on two animals, and kept them alternately in dif- ferent states. The animals being placed side by side, the appearance in the two cases could be satisfactorily compared."* When the functions of an organ are active and ener- getic it is freely supplied with blood, and when it is slug- gish and anaemic it receives a small amount of blood. But even this view is not altogether satisfactory, and we are bound to concede some relationship between the blood and the tissues themselves. There is an attractive * Physiology of Sleep, Guy's Hospital Reports, vol. vi. 1860, p. 153. THE HEADACHE OF CEREBRAL ANAEMIA. 49 force between them. Some organs draw more blood to- wards them in disease than is the case with others, and this is well shown in remittent fevers and ague, where the mere contraction or dilatation of the bloodvessels through the vasomotor nerves cannot account for it. The diagnostic symptoms that belong to cerebral anae- mia are those we might expect to arise from a weakened brain circulation. There are fits of depression and low- ness of spirits; and yet these are not continual, for the patient may be roused to a renewal of his accustomed efforts, and temporarily forget his ailment altogether, if it has not assumed a serious aspect. The patient is fear- ful and timid, and has a general dread of things and of circumstances never likely to happen; he is overanxious to put his worldly affairs in the best possible security, lest illness should overtake him suddenly; and he would like to make such stipulations for the future as shall over- rule the liberty of his successors, and control the ever- changing events of life. Sleeplessness is not an uncom- mon symptom, but many patients pass sound nights, and in the daytime become drowsy and fall asleep in the chair, or whilst travelling in a train; and this, according to my experience, is most frequent before the brain has passed into the condition which produces actual headache and overpowers the reason. The pain is most frequently vertical; it occupies the top of the head, which feels hot and burning to the hand. The pain is not throbbing, or bursting, but of a gnawing, scraping character. It may be also frontal, or occasionally occipital, and present most of the characters of nervous headache. The headache of intellectual strain, and severe gastric disorder from overindulgence in alcohol and high 50 HEADACHES. living, is almost invariably frontal, and the veins about the temples and forehead are full, and the face is flushed. In anaemic headache there are noises in the ears, dizzi- ness, and flashes of light before the eyes, especially where losses of blood have taken place, and there is pallor of the skin and lips. Swooning and twitching of the mus- cles are also common.* The patient does not resign himself so completely to his misery in this variety of headache ; and in the earlier stages of the attack, at least, he is more anxious about his fate, and when he is likely to be well again. When the attack is threatening he is unusually fidgety and ex- acting, and exhibits a querulousness which is most try- ing to contend with. The tongue is furred at the back, if the pain has been of any considerable duration, and there is flatulence, nausea, and constipation. The colon is loaded and tor- pid from deficient muscular contraction, which is common in all forms of impaired functional activity of the brain ; indeed, the one often induces the other. The pupils are sometimes dilated, but frequently they are of medium size, and, according to my experience, when the pain is vertical the pupils are oftener contracted, a symptom which I attribute to meningeal irritation. The ophthal- moscopic signs reveal pallor of the optic disks and dul- ness of the choroid. The bloodvessels of the retina are generally thin and few, and the optic disk is of a pale and waxy-white hue, which is common to an impeded circulation through the brain, and to anaemic conditions * See Chapter XIII, on Organic Headache, concerning the seat and character of the pain- THE HEADACHE OF CEREBRAL AN.EMIA. 51 generally. The eyes are sunken in the orbits, and the pulse is slow, labored, and languid. In a patient re- cently under my care the pulse did not exceed fifty-four beats per minute during the continuance of the headache and exhaustion. In this case there was some dilatation of the left ventricle and enlargement of the heart chiefly due to fatty change. In the majority of cases the pulse is weak and small, owing to the unfilled state of the arteries, and the diminished quantity of blood through- out the vascular system. Slight pressure obliterates the pulse altogether, and sometimes it can scarcely be felt. In other cases the pulse, in addition to being small, is habit- ually rapid, and the heart's impulse weak and jerking against the thorax. In the case of a patient who was drained from menorrhagia, the pulse averaged 120 for weeks together; the skin and mucous membranes were dreadfully blanched, and yet there was no headache to speak of, and no cardiac murmur whatever. Occasion- ally a shooting neuralgic pain was referred to the right eye and temple, but it was never vertical, and the severity was greatest some months before admission into hospital, when the haemorrhage became sudden and profuse. In the headache of cerebral anaemia, of which the nervous form in delicate women is a good example, the feet and hands are cold, and the surface of the skin gen- erally is dry and often gelid. The gloomy thoughts and wretchedness incident to this anaemic state, too frequently induce a desire for alcoholic stimulants, which slowly steals on, and the patient, who through life may have been most temperate, may resort to this indulgence till it merges into a miserable habit, and destroys the power of digestion by taking away every remnant of appetite. It 52 HEADACHES. is a passion hard to overcome, because it gives temporary relief by dilating the vessels of the brain, and increasing the force of the heart's contraction. So far there is re- lief; but when this effect has subsided the depression is all the greater, and the headache is increased tenfold. As to prognosis, recovery is certain if the pain is due to curable conditions, and the system has not been re- duced too low. We observe this over and over again in young women who are exhausted by prolonged lactation and hard work, or who have had miscarriages, or been drained by leucorrhcea. When the habits of life can be changed, and the patient is able to avail herself of rest and proper hygienic measures, her debility and headache gradually pass away, as the brain is better nourished. If the condition is incurable, and complicated with or- ganic disease, the headache will persist; and instancas of this kind are to be seen among the poor, where all the surroundings are wretched and deplorable. Treatment.—With respect to the treatment of the head- ache of cerebral anaemia and exhaustion, it is obvious that this must depend on the peculiarities and special symptoms of each individual case. In addition to the distraction and pleasant society by which the current of gloomy thoughts should be turned aside, and in order that gleams of joy may break upon the patient's path, and disperse those heavy clouds of sadness which add to the depression of the disease, the medical treatment con- sists in endeavoring to restore the tone and quality of the blood, that the cerebral tissue may he better nourished. The cause must be ascertained and removed if possible. Where men have subjected themselves to great intellec- tual strain, rising early and going to bed late, there will THE HEADACHE OF CEREBRAL ANAEMIA. 53 be no chance of recovery till these habits are given up. Men so circumstanced only keep themselves going by ir- regular living, and a too free use of stimulants. If with this high pressure there are pecuniary anxieties and heavy responsibilities, and the patient has no alternative but to remain at his post he is certain to break down. Entire cessation from work, and absolute repose and quiet for a few months or a year, have restored the brain and enabled the patient to resume his duties in modera- tion. Discharges of all kinds should receive prompt at- tention, as in menorrhagia and leucorrhoea ; and derange- ment in the assimilative functions should never be over- looked. The tonic effects of arsenic are invaluable (Form. 7-8), and iodide of potassium is indicated if there is a syphilitic taint; in fact those remedies will be service- able which increase vascular tension, and accelerate the flow of blood in the encephalon. In gouty conditions, colchicum and the alkalies will be useful to remove the materies morbi and the product of tissue metamorphosis. If depression should threaten, the addition of carbonate of ammonia will be found useful (Form. 31-32). Opium is a remedy which, when given in small doses, increases the force of the heart, and produces a soothing influence on the system generally. If employed in com- bination with a stomachic or aperient, I have never known it to do harm; but if pushed to narcotism, it loses its sustaining powers, locks up secretion, and becomes de- pressing. I have given it with advantage in half-grain doses, with three grains of powdered rhubarb, at bedtime, in the form of a pill (Form. 102). It has composed the patient and relieved the cerebral discomfort. By restrict- ing the wear and tear of tissue, it increases in some unex- 54 HEADACHES. plained manner the nutritive processes, and is of service in allaying the extreme restlessness and disquietude which are attendant on the anaemic condition. Dr. Anstie remarks that the soporific effects of opium are not the most remarkable on the system. " In the countries where opium is indigenous, it is an article in daily use with the great majority of the population, by whom it is employed for a very different purpose than that of procuring sleep ; in fact, as a powerful and rap- idly acting stimulant. . . . When the opium acts effi- ciently, not a trace of narcosis can be perceived; on the contrary, the vital powers are distinctly raised."* The ammonio-citrate of iron is one of the best haematics and blood-restorers in the whole Pharmacopoeia, and is a very valuable drug in combination with the bromides of potassium or ammonium, when it cannot be safely ad- ministered alone (Form. 71). But the sudden filling of the cerebral vessels is always to be kept in mind, and re- garded with apprehension. Digitalis is another remedv to be relied on when the heart's action is weak; it appears to strengthen the con- tractions of the ventricle, and to render them more uni- form and regular; hence it is of value in weakness or dilatation from any cause, when given in small doses. In anaemia, where the blood-supply to the brain is not enough for the purpose of nourishment, it increases ar- terial tension, and thus it becomes of as great service here as it is detrimental in hyperaemic conditions and where the arteries are changed from atheromatous disease. Digi- * Anstie, On Stimulants and Narcotics, 1864, pp. 147-150. THE HEADACHE OF CEREBRAL ANAEMIA. 55 talis is of no use in anaemic headache, except for the effect it may have on the circulation through the heart itself; a slow pulse, which is commonly attendant on this condi- tion, contraindicates the use of digitalis. I do not think an irregular pulse altogether demands its discontinu- ance if it does not depend on change of structure; but where there is decided intermission I should hesitate to employ it. I believe that its good effects in these cases are often obtained by combination with a few drops of spt. chloroform (Form. 49-50). The fresh infusion is the best preparation (Form. 51), and next to this I prefer the powder, with a grain of sulphate of iron (Form. 103). In giving the tincture in these cases, it is well to commence with five-minim doses, and gradually increase it to one drachm. Both experiment and observation go far to prove that reduction in the frequency of the heart's action takes place through the influence it exerts on the pneumogastric, whilst it also has some effect through the cardiac ganglia in increasing the force of the heart's contractions, and causing arterial tension. In this way, the arteries be- coming fuller and acting with increased energy, the blood is propelled with greater vigor into the veins. Tea, coffee, and quinine act in a similar way. Belladonna, according to Dr. J. Harley, is another heart tonic, though it is said to weaken the muscular power generally, and to cause confusion of ideas, head- ache, giddiness, and singing in the ears.* It therefore * " Harley has found that after the administration of a moderate dose of belladonna the arteries are contracted ; but that when a large dose is given, the contraction is replaced by dilatation. The primary contraction is due to stimulation of the sympathetic system, and the 56 • HEADACHES. requires to be used with caution, and I should not be disposed to include it among the remedies for this condi- tion. While strychnia dilates the spinal bloodvessels, belladonna does the same for the cerebral vessels ; but it seems to me that as it increases the force of the arterial current, it may be profitably employed in some cases (Form. 52-104). I have seen good effects follow the use of phosphorus in doses (varying from gr. ^ to ^2 : Form. 89), daily after luncheon, whilst the hypophosphites of lime and soda have been given in calumba morning and evening (Form. 28). The headache of cerebral anaemia is said by Dr. Smith to be often mistaken for the passive congestive form, and to occur in enfeebled heart power, and enlargement with dilatation and fatty degeneration. " Nitrite of amyl will relieve the intermediate headache. Let the patient inhale three to five drops of it on a piece of cotton, placed subsequent dilatation to the exhaustion resulting from the previous overstimulation."1 I gave one grain of the extract to a patient who had dysmenorrhea, in the form of a pill three times a day, and it produced severe frontal headache and dimness of vision, so that she could not see ordinary- sized print; the face was hot and flushed of a crimson hue, and the pupils widely dilated, which gave her a squint and a strange staring look. There was loss of appetite, and difficulty in swallowing from contraction of the pharynx ; the girl was very tremulous and agitated, and her sleep was disturbed and broken by horrible dreams. Although she only took three pills altogether (one daily for the first three days), the toxic symptoms did not pass off completely till the ninth day. 1 On a Case of Diabetes Insipidus treated by Belladonna and Ergot, by W. Mur- rell, L.R.C.P., British Medical Journal, January 1st, 1876, p. 9. THE HEADACHE OF CEREBRAL ANAEMIA. 57 within one nostril, while the other is held closed."* When this headache is associated with nervous exhaustion, as it very commonly is, he recommends a combination of strychnia, iron, and gentian (Form. 53). Vomiting, swooning, and faintness are common in cerebral anaemia, and the patient, in a well-marked con- dition, cannot remain in an upright posture without risk of syncope; for the blood falls away from the vessels, and the elasticity of the arteries not being brought into play, favors venous stasis, because the vasomotor system is relaxed, and the heart's action is consequently de- pressed. But even then there is another difficulty to be encountered, and this is, that if the cerebral vessels are too excited, and filled with blood, the nerve-centres are excited also, and headache, heat of scalp, and extreme discomfort ensue. I have known the pulse run up from 50 to 84 in the course of a few hours when tonics have been attempted too soon, or the patient has brought on acute indigestion by eating a heavy meal.f There are two means of acting on cerebral anaemia,— (1) by raising the blood-pressure generally, in which the * The Therapeutic Effects of Headache, by A. A. Smith, M.D. A Lecture delivered at the Bellevue Hospital Medical College. London Medical Record, September 15th, 1876, p. 392. f I would here express my obligation to Dr. J. Milner Fothergill for much information derived from reading his two instructive and valuable papers on " Cerebral Anaemia " and " Cerebral Hyperemia," in the fourth and fifth volumes of the West Riding Lunatic Asylum Medical Reports. In the treatment of these affections I have freely availed myself of many hints and suggestions. These papers will amply repay attentive study, from the orderly manner in which the facts are marshalled, and the physiological reasoning which supports the views set forth. 5 58 HEADACHES. brain profits; and (2) by acting on the cerebral vessels, and dilating them especially. These two measures may be combined with advantage in many cases. Alcohol.—Headaches due to cerebral anaemia and ex- haustion are frequently relieved by the moderate use of stimulants. A little champagne or claret, or weak brandy and water, may be taken with the meals (but not at odd times) so as to prop up the system with artificial strength. When taken in moderation it dispels the feel- ing of fatigue and exhaustion, and increases the tonicity of the vascular system; but when the habit is acquired of drinking to excess it produces incalculable harm, by enfeebling the digestive power, and aggravating the head- ache and confusion. The gastric juice, which is poured out in additional quantity, becomes less responsive to the stimulus which invited its secretion, and in place of it viscid mucus and fermentative products arise. The more concentrated the stimulant the more injurious are the consequences on the mucous membrane. The hot and burning sensation which is experienced on swallowing a full potation of brandy is due to the action of the alco- hol on the tissues, the mucous membrane becoming white and puckered up. Dr. Lauder Brunton says that in common with hot metal, or corrosive sublimate, it coagu- lates albumen, and that the white color of the mouth is " no doubt due to the precipitated albumen on the sur- face obscuring the red color which the circulating blood imparts to the tissues beneath." The influence which alcohol exerts on the mucous membrane of the stomach is precisely similar. We are so well acquainted with the gastric uneasiness which ac- companies the dry hot mouth of a previous night's de- THE HEADACHE OF CEREBRAL AXJEMIA. 59 bauch, that a general conviction among the public has arisen that the state of the one organ is the index of the other. " When the stomach is empty its mucous mem- brane, as seen through a gastric fistula, is pale, and only covered with a little mucus. If a little alcohol is now introduced, the bloodvessels of the mucous membrane di- late, and it becomes of a rosy-red color ; its glands beo-in to secrete copiously, beads of gastric juice stand upon its surface, become larger and larger, until they can no longer preserve their form, when they coalesce and run down together in a little stream."* The very opposite condition follows a large dose; the mucous membrane becomes pale, and the secretion of irritative mucus takes the place of the gastric juice. This leads me briefly to consider the utility of alcohol as a therapeutic agent. Overindulgence in alcohol (al- coholism) is a formidable disease of the nervous system. In its early stages it is characterized by derangement of the assimilative functions, as dyspepsia, nausea, and con- gestion of the liver; and, later on, by failure of nutri- tion, muscular weakness, diminished intellectual force, and gradual degeneration of the nerve-centres and tissues of the body. When alcohol is habitually resorted to in excess, its action resembles an overdose of opium, chloroform, or ether, and these direful consequences are due to the im- pregnation of the blood with a large percentage of the poisonous agent. " It may cause the corpuscles to run * The Physiological Action of Alcohol, by T. Lauder Brunton, M.D., F.R.S., in The Practitioner, January, 1876, p. 61. 60 HEADACHES. too closely together, and to adhere in rolls," converting their clear outline into an " irregular or starlike edge," and changing " the round corpuscle into the oval form." These changes appear to be due to the action of the spirit in extracting the water contained in the corpuscles.* " It may fix the water with the fibrin, and thus destroy the- power of coagulation, or it may extract the water so de- terminately as to produce coagulation."f Experimental physiology has aided us immensely in explaining the action of alcohol on the nervous system. " If we surround a living nerve (partially dissected from its connections) with alcohol of a certain strength, we find that it becomes paralyzed, i. e., incapable of trans- mitting impressions through its affected part; while a very weak mixture of alcohol and water is incapable of producing this effect. Similarly, if an animal absorb into his circulation a certain quantity of alcohol within a given time, the nerve-centres and the peripheral nerves become (though in less degree) paralyzed."^ This ex- periment forcibly teaches us that blood so charged with alcohol is totally unfitted to support the nervous tissue in health; " there is, however, a co-operative cause of no small importance, namely, it has been ascertained by the researches of varions observers that the impregnation of the blood with large quantities of alcohol interferes with its absorption of oxygen,"§ and lessens the oxidizing * On Alcohol, a course of six Cantor Lectures, delivered before the Society of Arts, by B. W.Richardson, M.D., F.R.S., 1875, p. 45. f Ibid. p. 46. % Reynolds's System of Medicine, Alcoholism, vol. ii, p. 144, by F. E. Anstie, M.D , F.R.CP. \ Ibid. p. 145. THE HEADACHE OF CEREBRAL AN.EMIA. 61 power of the red corpuscles.* A moderate amount of alcohol, by dilating the minute bloodvessels, and stimu- lating the action of the heart, is a remedy in cerebral anaemia not to be lightly set aside, when the circulation is reduced below its normal activity ; for, by improving digestion through its action upon the gastric nerves, it enables food to be digested which cannot otherwise be as- similated, whilst it furnishes in itself a certain amount of oxidizable material, and is in so far a form of food ; but carried beyond a certain point, it reduces nervous con- trol, and as doing so is an indication of evil augury. The heart beats quicker, and as it loses force in propor- tion, its power is too weakened and impaired for any pro- longed effort or exertion. Some cases of cerebral anaemia, in which headache is the most prominent symptom, have yielded to a moderate use of stimulants, from the dilata- tion of the vessels and the better supply of blood. The slackened tide of the circulation has gained a new im- petus and vigor, and all the functions have derived ad- ditional stimulus to ward off threatening mischief; but taken immoderately, or on emergencies, the physical danger done to the animal economy is manifested in or- ganic deterioration, and in the shrinking and alteration of the nervous texture. To these succeed muscular weariness, confusion of thought, looseness of ideas, and irresolution of purpose. Heavy dreams and restless sleep increase the headache. As the prostration of vital energy creeps on, the mind loses its grasp of recent events, as in childhood, into which it may be said to pass * The Physiological Action of Alcohol, by T. Lauder Brunton, M.D., F.R.S., in The Practitioner, February, 1876, p 122. 62 HEADACHES. a second time, while failing speech is the harbinger of a general paralysis and a total wreck of all that was for- merly so compact and powerful. If in cerebral anaemia drink is too much indulged in, the sufferer wakes with a diffused headache, vertigo, and flashes of light before the eyes. He has many of the symptoms which herald the approach of intoxication ; a mental disquietude takes possession of him, and he is painfully apprehensive of danger in open daylight, and exceedingly nervous about his state of health. His whole character is changed; tears are shed and dried up in a moment; his face becomes blank and expressionless, and his eyes watery and inflamed. For some years past I have had under observation a case of headache from cer- ebral anaemia, where the chief symptoms were kept up by the injudicious use of alcohol. The deleterious con- sequences chiefly showed themselves in disorder of the gastro-intestinal mucous membrane, while on one occa- sion profuse haemorrhage from the stomach and bowels took place. These symptoms were so severe that ulcera- tion of the stomach was at one period suspected, but ab- stinence from all stimulants, and a milk diet, rapidly im- proved the condition. It was followed, however, by a relapse on two separate occasions, when the old habits were resumed, and nausea and bilious attacks were of common occurrence. Other symptoms supervened, indi- cating nerve degeneration ; a tremor of the lower limbs, and unsteadiness of gait, similar to what is observed in delirium tremens.* The face was generally pale and * " The worst sign of impending nervous change is muscular in- stability, irrespective of the will; that is to say, an involuntary mus- cular movement whenever the will is off guard. ... In the motor centres of the nervous organization the foreign agent is creatine dis* THE HEADACHE OF CEREBRAL AX.EMIA. 63 sallow, but it would flush under ordinary conversation, and the pulse, which was habitually small and slow, would become quick and tremulous. Then ensued the most painful headache and confusion of ideas—to use the patient's own phrase, " his head went all wrong," and he only obtained relief by assuming a recumbent posture in a dark and quiet room, and sleeping for three or four hours. After this rest he would sometimes wake up com- paratively well. The amount of alcohol weighed by the standard of what a man takes in health (when all the excreting or- gans are actively performing their functions) is no crite- rion of his capability to tolerate it in disease. In the latter case elimination is repressed, and his nerve-centres are the special organs to bear the brunt of the evil. When the appetite is poor, and an insufficient amount of nutri- ment is consumed, the alcohol is rapidly absorbed from the walls of the stomach, and the liver is the first organ to undergo structural change. All remedies containing alcohol in excess lessen the excretion of urea and carbonic acid, and beer* is especially a compound which interferes turbance of function. The fact is communicated to the muscles by the nervous fibres, and the active involuntary start of the lower limbs rouses the sleeper in alarm; Ignorant of the import of these messages of danger, the habituated alcoholic continues too frequently his way, until he finds the agitated limbs unsteady, wanting in power of co-ordinated movement."—Diseases of Modern Life, by B. W. Richardson, M.D., F.R.S., p. 265. * One pint of beer (20 ounces) will contain— Alcohol,.....1 ounce Extractives, dextrin, sugar, . . 1.2 " (524 grains) Free acid,.....25 grains Salts,......13 grains —Practical Hygiene, by Dr. Parkes, 4th Edition? p. 257. "One ounce of alcohol is equivalent to two fluid ounces of brandy 64 HEADACHES. with the elimination of fatty and nitrogenous matters, heaping upon the system partially oxidized products, which provoke gout and liver disorder. Our knowledge of the action of alcohol is very imper- fect, but it may be said to be absorbed into the system after its reception into the blood, escaping in very small quantities by the lungs, the skin, the kidneys, and the bowels; so that it is now a generally received opinion that a considerable quantity disappears in the body.* The experiments of the late Dr. Anstie, Thudichum, Dupre, Baudot, and others, show that the elimination of alcohol is very trifling through the kidneys. Although there is some difference of opinion as to the amount ex- creted, most observers are tolerably agreed that it is very small. The constant consumption of large quantities of alcohol leads to the accumulation of fat in the system, and produces degenerative diseases of a fibroid and fatty (containing 50 per cent, of alcohol), or to five ounces of the strong wines (sherries, etc., 20 per cent, of alcohol), or to ten ounces of the weaker wines (claret and hocks, 10 per cent, of alcohol), or to 20 ounces of beer (5 per cent, of alcohol). If these quantities are in- creased one-half, \\ ounces of absolute alcohol will be taken, and the limit of moderation for strong men is reached."—Ibid. p. 277. * '*' When only one fluid ounce of absolute alcohol was given, none could be detected in the urine. We found that in a strong healthy man, accustomed to alcohol in moderation, the quantity given in twenty-four hours that begins to produce effects which can be consid- ered injurious is something between one fluid ounce (= 28.4 O C) and two fluid ounces (= 56.8 C C). The effects which can then be detected are slight, but evident, narcosis, lessening of appetite, in. creased rapidity of rise in the action of the heart, greater dilatation of the small vessels as estimated by the sphygmograph, and the ap- pearance of alcohol in the urine. These effects manifestly mark the entrance of that stage in the greater degrees of which the poisonous effects of alcohol become manifest to all."—Ibid. p. 'A77. THE HEADACHE OF CEREBRAL ASLEMIA. 65 nature. " The brain and its membranes, and its vessels, suffer early and principally; and Kremiansky has pro- duced haemorrhagic meningitis and pathological changes in the brain vessels and membranes in dogs by giving them alcohol. There is no question that several brain diseases, including some cases of insanity, are produced by excess of alcohol. So, also, degenerative changes in the stomach, liver, lungs, and probably in the kidneys, result from immoderate use."—(Parkes.)* Unfortunately there are many forms of bodily weakness and mental wretched- ness which drive the sufferer to seek stimulants, not only from the gratification he feels in the indulgence, but to drown his misery in excitement and forgetfulness. Among the diseases which impel persons to drink nervous affec- tions and periodical losses of blood are the most frequent, and the dose which at first restores the nervous system to its healthy standard is soon carried beyond reasonable limits. The relief furnished by alcohol in the misery of cerebral anaemia is one of the most fertile sources of drinking habits, especially among women. * " My friend, Dr George Johnson, informs me. that out of 200 patients with Briglit's disease, from all causes, he found no less than 53 were drunkards."—Quoted from Parkes's Practical Hygiene, 4th edition, p. 276. G 66 HEADACHES. CHAPTER II. THE HEADACHE OF CEREBRAL HYPEREMIA. General and Local Causes—Active and Passive Hyperemia of the Brain—Condition of the Heart and Arterial System in some Cases of Surgical Pyrexia—Gouty Hyperemia—Active Hyper- emia sometimes due to Structural Delicacy in the Walls of the Bloodvessels—Connective Tissue Overgrowth in the Brain— Nature and Causes of Passive Hyperemia or Congestion—Ana- tomical Changes in the Vessels and Meninges—Symptoms of Hyperemia— Symptoms and Pathology of Sunstroke—Effect of Bloodletting and Cold in reducing the Temperature of Hyper- pyrexia—Hyperemia due to Intellectual Strain and Bodily Exertion—Relation of the Tissues to their Blood-supply, and the Effect of an increased Blood-supply upon the Growth of a Part. Treatment—Occasional Utility of Venesection—Value of Aconite, Tartar Emetic, and Saline Purgatives—Friedrichshalle and Hunyadi Janos Waters—Moderation in Diet and Avoidance of Stimulants—Importance of Walking Exercise—Effects of Brom- ide of Potassium, Opium, and Hydrate of Chloral in diminishing Cerebral Excitement and relieving Headache—Action of these Sedatives on the Nerve-cells—Ergot of Rye—Therapeutic Eflects of Cold, and its Mode of Action—Utility of the Ice Cap in controlling Cerebral Hyperemia and Vascular Excite- ment. When an increased quantity of arterial blood passes through the encephalic mass it constitutes the condition known as cerebral hyperaemia. It is obvious that the veins at the same time are full and distended, and hence THE HEADACHE OF CEREBRAL HYPEREMIA. 67 a state of venous congestion is established. If it contin- ues, the dilatation is attended with a retardation of the blood-current through the veins, to which succeeds a diminished flow through the arteries also. It will be pointed out in another chapter that there are no more common causes of congestive or hyperaemic headache than overprolonged thought and too great mental occupation. When the mind is attentively engaged on any special line of abstruse reasoning, or taken up with care and anxiety about worldly affairs, the effect of this concentrated attention is to dilate the arterial vessels, and to admit a larger quantity of blood than usual to the cerebral cells, by which they are overwhelmed. " The activity of an organ is in strict relation to its blood-supply, and the capacity of each brain from time to time, not as compared with other brains, depends upon the amount of arterial blood passing into it. Such is the true physio- logical cerebral hyperemia of brain activity, contrasted with the anaemia which is an essential factor of sleep. As sleep comes on the brain falls, becomes paler, and many of its bloodvessels that could be recognized during the waking state become undistinguishable. When con- sciousness returns in the act of awaking, the process is reversed; the brain fills, grows ruddier, and the vessels which were lost sight of in sleep can again be distin- guished by their enlarged calibre. Such is the difference betwixt the conditions of sleeping and waking—so far as the blood-supply goes, but no further."* As the brains of most persons are kept in a state of great activity * Dr. J. Milner Fothergill on Cerebral Hyperemia, in West Riding Lunatic Asylum Reports, 1875, vol. v, p. 172. 68 HEADACHES. at the present day, the vessels are habitually full, and the tissue is increased in vascularity. This is proved to be essential for the maintenance of their healthy functions, and they would even be arrested if the supply of arterial blood was deficient. Cerebral hypcramia as a morbid state is a frequent cause of headache; especially of that variety in which the nervous substance and the bloodvessels are both concerned. The brain is increased in volume, and presents a turgid appearance when it is superficially examined. The small red points which are observed when the brain is sliced are the mouths of open bloodvessels, and in some hyper- aemic states of the brain they exude a good deal of dark blood, as where death has resulted from bronchitis and whooping-cough, or from fever, and organic disease of the heart and kidneys, which have induced coma and stagnation in the contents of the venous vessels. A faint reddish or pinkish tint of the cerebral substance is not uncommon in the case of children who die of convulsions or meningitis, and this is attributable more frequently to the same pathological change than to actual inflammation and the products that arise from it. This condition is, I believe, a common exciting cause of headache. It leads to local congestion (partial hyperaemia), and often indicates the seat of suffering. When a change of this character is present in a well-marked degree, and has come on rap- idly, death may take place from severe congestion without the occurrence of actual haemorrhage, or comminution of the brain. There is an active and a passive hyperaemia of the brain—two opposite conditions due to separate causes, and presenting a distinct set of symptoms. In the active form THE HEADACHE OF CEREBRAL HYPEREMIA. 69 the arteries contain a larger quantity of blood than usual. Active hyperaemia of the brain occurs with violent action of the heart, or excitement of the circulation, from fever and so forth, as we have already seen. If the nerves are healthy, they may undergo some degree of pressure from distended vessels without causing pain or disturbance; but if they are oversensitive, any change in the force of the circulation at once distresses them ; and hence it hap- pens that an excited action of the heart from running, palpitation, or violent coughing in pulmonary disease, aggravates the nervous suffering if long continued. But this by no means can be accepted as a rule, for the exer- tion of wrestling, running, and active gymnastic sports, which subject the cerebral vessels to extreme pressure from the accumulation of blood within them, does not cause pain and suffering; and we can only infer that this exemption arises from a healthy condition of the nerves, unless the fulness and congestion have been of such dura- tion that a change has taken place in them. I am glad to be supported in this view by so able an authority as that of Dr. Handfield Jones, who observes that the effects produced by cerebral hyperaemia vary according to the condition of the nervous centres, and that when the organ is healthy, a moderate hyperaemia does not disorder their action, but that in weak and excitable subjects the excite- ment may be very great.* When febrile symptoms follow surgical operations, we may sometimes witness high temperature, and intense excitement of the arterial system. There is tension in the pulse, a tumultuous and rolling action of the heart, and * On Functional Nervous Disorders, Hyperaemia of the Brain, 1870, p. 88." 70 HEADACHES. an exaggeration or modification of its sounds, followed in some fatal cases by the deposition of fibrin in one or more of its chambers. An indescribable weight and confusion in the brain, with headache and dizziness, are experienced, which are more rapidly relieved by cold to the head than by any other measure with which I am acquainted ; ex- cept in some cases where venesection is so far to be cred- ited with reducing the temperature, that it has been known to refuse to fall till bloodletting was practiced. I shall consider this more fully when we come to speak of the treatment. This form of hyperaemia is witnessed to perfection in the high inflammatory fever which sometimes succeeds great surgical operations, more particularly in young full- blooded persons, who are not emaciated or otherwise re- duced by the disease; or who have not lost sufficient blood at the time of operation to control excessive reaction. If at the commencement of these symptoms the skin is dry and pungent, the pulse is generally hard, tense, and rapid; the conjunctivae are reddened, the carotid arteries beat violently, and the jugular veins are likewise full and pulsating; the heart's action is tumultuous, and strikes vehemently against the walls of the thorax; the sounds are muffled and run together, or the first sound is soft and prolonged, both at apex and base—just what might be expected from the alteration in the relative proportions of the blood-corpuscles, and the rapidity with which the organ has to deal with the obstruction offered by the dep- osition of fibrinous coagula in one or more of its cham- bers. AVith this state of vascular excitement there are disturbances of sensibility, which partake more of an irri- tating than of a painful character. There is throbbing THE HEADACHE OF CEREBRAL HYPEREMIA. 71 over the forehead and vertex of the head, and a feeling sometimes of contraction, and at others of bursting—I have heard it also described as a disagreeable- or nasty sensation ; the sight is dim, and the patient prefers dark- ness to daylight; sleep is broken and disturbed by rest- less dreams, till the head is cooler and the temperature reduced. The constitutional symptoms are not so alarm- ing when the skin is bathed in sweat and the kidneys are acting freely, for then the tension is to a great extent taken off the arterial system, and the determination of blood to the brain is lessened ; the pulse is more compres- sible, the confusion of ideas is mitigated, but the face may assume a purplish flush, and the lips become of a dark- livid red. In cases of this character the injudicious use of stimulants, even in the shape of hot tea or coffee, aggravates the symptoms of cerebral excitement, and in- creases coagulation in the vessels, till they are on the point of rupture, or so distended that they cannot propel their contents; and at last induces effusion in the neighborhood of the large vessels at the base of the brain, with a torpid and comatose condition. Some persons of a sanguine and excitable tempera- ment suffer from active hyperaemia, or determination of blood to the head. They experience sound health till something ruffles them, or opposes their plans, and then it is readily induced by alcoholic stimulants and high feeding. It cannot be said that there is too large a quan- tity of blood in the body ; on the contrary, the predomi- nance of the nervous over the vascular element renders it probable that there is habitually an insufficient supply for the demands of an overstrained nervous system. The brain in these cases is exposed suddenly to a sort of del- 72 HEADACHES. uge ; and two factors are concerned in the mischief. A disturbed stomach transmits its irritation through the sympathetic system to the brain, already overloaded with blood; and as the vasomotor nerves become relaxed, a further increase of blood overpowers the brain in conse- quence, apart from the hyperaemia which the increased activity of the systemic circulation induces. Persons whose digestive organs are weak and sensitive, or who sit down to a meal agitated and disturbed, soon experi- ence discomfort and excitement; the head aches violently, the face flushes scarlet, and no ease can be obtained; the temporal arteries throb, and the pulse is full and frequent. Everything that is taken causes nausea and vomiting, and no relief is forthcoming till a few leeches are ap- plied to the head, or the contents of the intestine are washed out by active purgation. Instances of this kind occasionally present themselves in the practice of our profession. \Vhen the headache continues severe, and the intelligence becomes blunted, so that the patient can scarcely stand or walk, a moderate bloodletting or a free epistaxis has been followed by immediate relief, and the cerebral congestion has disappeared. If no revulsive measures have been resorted to, or the loss of blood has not occurred, the symptoms of active congestion and in- travascular pressure may be converted into those of effu- sion and fatal apoplexy. Active hyperaemia is very commonly seen among men who have passed the meridian of life. They are of stout configuration, and the face is full and florid ; the con- junctivae are injected, and the pulse is firm and incom- pressible. They easily tire and become breathless on ex- ertion if they attempt to walk at a moderate pace, or THE HEADACHE OF CEREBRAL HYPEREMIA. 73 ascend a hill, which is one reason why sedentary pursuits or actual idleness are more congenial to them than out- door occupation. Such men as these need be endowed with immense energy and force of character to willingly encounter fatigue and determine to live abstemiously, when the constitutional diathesis impels them in a direc- tion which, however detrimental to their health, is at least acceptable to their feelings. The ordinary precau- tions against illness are disregarded and set aside, and the patient never pauses to consider that his mode of living is injurious, but goes on in the same course. His mental condition is eminently characteristic. However amiable he may be by nature, irritability becomes a new and striking feature in his character, surprising his most in- timate associates, and those who have known him best through life. Trifling annoyances vex him and put him out, and he bursts into fits of passion and violence, which would not disturb the mind of a man in health. As soon as these outbursts of passion are over, the mind is restored to reason and reflection; and, as he finds relief, so he admits the weakness that overtook him. He is what is called low at times, and suffers acutely from throbbing headache. These persons have lived too well from their early manhood, and indulged in food of a nitrogenous character. In consequence of this stimulat- ing diet, and the patient's lethargy and inaction, effete matters accumulate in the blood, and throw upon the kidneys and other excretory organs an amount of labor which provokes structural change. A gouty element is the disturbing foe when more visible indications are wanting; and one of the first morbid changes to arise is a hyperaemic state of the kidney from the excessive sup- 74 HEADACHES. ply of blood, so that the organ is no longer able to com- pletely discharge its functions. Then follow spasm of the arterioles, and that rise in blood-pressure which leads to hypertrophy of the left ventricle, and the transmission of blood to the brain in greater force. As therefore the heart increases in size from the additional duty it is called upon to discharge, so the natural tissues of the kidney become diseased, and the vessels of the brain atheroma- tous and liable to rupture from the distension to which they are subject. The condition of cerebral hyperaemia is denoted in some persons (especially men of full or gouty habit who are approaching sixty years of age), the face being florid, and the capillaries full and distended. Not unfrequently the nose is marked with acne rosacea, from the too free use of stimulants and overindulgence. There are noises in the ears, and the head is confused and aches fearfully —it is a deepseated pain, as though a nail was being driven into it; and the pulse is full, tense, and hard— it is often to be felt rigid from atheromatous degeneration ; and the bladder is sometimes irritable from prostatic en- largement. Structural change may begin in the kidneys, and, by causing a rise in blood-pressure, propel the blood with greater force through the encephalic arteries; thus is brought about an overloaded state of the cerebral ar- teries, and an increase in the growth of the tissues which enter into their structure. The heart's sounds afford evi- dence of the mischief which the arterial tension discloses; the impulse is frequently increased, and the area of pre- cordial dulness also; whilst the aortic second sound is ac- centuated. In a case which has furnished these remarks, the patient was sixty-five years of age, and there stole on THE HEADACHE OF CEREBRAL HYPEREMIA. 75 gradually a forgetfulness of passing events, and an indis- tinct utterance, which finally ended in the rupture of some vessel near the base of the brain. There is another form of active hyperaemia due to structural delicacy in the walls of the bloodvessels, and their feeble resistance. In consequence of their thinness they yield to the pressure of the blood-current when the heart's action is increased, and too much pressure is put upon them; the capillaries become injected and bright, and the patient feels the rush of blood to the head. These patients have most likely dilated vessels also, through paralysis of the vasomotor nerves, and consequently they all the more readily yield to an increased pressure of blood. Some persons suffer from this congestion after running or engaging in active exertion; and it is fol- lowed by symptoms of sickness and severe headache. It is observed in many acute pulmonary diseases, and is the chief cause of fatal exhaustion in these cases. If a meal has been recently taken by a person whose nervous sys- tem is agitated and depressed, or if he exposes himself to the sun or to noise and confusion after it, the mental ex- citement disturbs the process of digestion, and provokes a hyperaemic state of the cerebral vessels. It is not un- common as a consequence of aortic insufficiency, the re- sult of endocardial inflammation. In these eases the ca- rotids are too full of blood, and their tension and impulse are strikingly apparent. The undue pressure to which the left ventricle has been exposed has led to dilatation and hypertrophy of its structure, from the augmented effort it is called upon to make, and it sends onward an increased volume of blood through the diseased and al- tered orifice. Now, what are the ultimate consequences 76 HEADACHES. of mitral valvular derangement on the cerebral circula- tion? Every time the ventricle contracts a smaller quantity of blood is discharged, and some portions dur- ing the systole flow back again, further crippling the auriculo-ventricular valve, and disabling or half paralyz- ing the left auricle. This induces engorgement of the pulmonary veins, and, indeed, of the whole venous sys- tem, so that headache and dizziness are common, and death from congestion or embolism becomes intelligible. In aortic stenosis the arteries are scantily filled, and there are no signs of venous engorgement; pallor of the face, syncope, and anaemia of the brain are the characteristic symptoms, just as hyperaemia of the cerebral circulation is associated with valvular insufficiency. Again, any condition which arrests or interferes with the cutaneous circulation will cause active hyperaemia, as severe exposure to cold, or the cold stage of intermittent fever; and then there is also paralysis of the vasomotor nerves accompanying the cerebral bloodvessels. In the brain, as in other organs, when it has long been subject to hyperaemia, there is developed a certain amount of pathological connective tissue, which gradually con- tracts. In the liver and kidney this pathological pro- cess is accompanied by reduction in the bulk of the organ. The brain being in an unyielding bony case, its contraction is accompanied by the effusion of fluid. This is a condition known as the water-logged brain, common in some forms of insanity. Niemeyer has given it the name of Hydrocephalus ex vacuo.* Connective tissue overgrowth in the brain, as a conse- * Niemeyer, Practical Medicine, vol. ii, p. 247. THE HEADACHE OF CEREBRAL HYPEREMIA. 77 quence of alcoholic indulgence, has been pointed out by Schroeder Van der Kolk, and physiological investigation would seem to establish the fact that the absorption of alcohol into the cerebral tissue causes the nerve-cells to undergo important physical changes, producing degenera- tion and disease.* Passive hypoxemia or congestion arises from any pres- sure on the jugular veins interfering with the free return of the blood to the heart. We have examples of it in cases of glandular enlargement of the neck, as in bron- chocele, aneurisms of the aorta, and hypertrophy of the thyroid ; in tricuspid insufficiency ; in the violent expi- ratory efforts produced by straining and coughing, as in whooping-cough, when the blood accumulates in the gen- eral circulation rather than in the pulmonary. The brain is overloaded, and maintained in this unhealthy condition because the obstacle cannot be overcome. This does not apply to the circulation through the lower organs of the body, where it is much less impeded. In all diseases of the heart, particularly when the right ventricle is diseased and acts imperfectly, the overfulness of the veins leads to capillary engorgement because the blood is obstructed in them, and this is a common cause of cerebral hyper- aemia. In valvular disease of the right heart this affec- tion is far greater than when it occurs on the left side, because the return of the blood is enormously impeded.f In cases of chronic bronchitis, with a weak and, dilated right heart, this state is also of common occurrence. In * Effects of Alcohol on the Brain, Lancet, September 30th, 1876, p. 470. f See Chapter V, on Congestive Headache, where this subject is continued. 78 HEADACHES. pleuritic effusion and compression of the thoracic viscera, in emphysema and chronic diseases of the lungs, there is congestion of the brain from the overloading of the sys- temic circulation, when the right heart is not proportion- ately enlarged to overcome the impediment. But I must not omit another important phase of the gouty diathesis, which I shall briefly allude to here, as it is rather of a passive than of an active character. Headache is the prevailing symptom of this condition, frontal and deepscated, and so continuous that the nerve- structure is gradually brought to the verge of disease. It may continue for years, and end in apoplexy or rupture at last. The well-to-do rector, or the country squire who has seen sixty summers, is the victim of this con- dition ; they are prone to gouty bronchitis on any change of weather, and there is vesical irritability with an abundance of lithic acid in the urine, and very com- monly enlargement of the prostate gland. The digestive functions are constantly getting wrong, and there is a foul tongue, with much flatulence and discomfort after food ; the bowels are habitually costive, and need ape- rients to maintain their regular action. The patient can- not exert himself to his accustomed duty, and is too nervous to seek society. He has confused sensations in the head, and noises in the ears; he moves along slowly and carefully, rather than walks, but with a faltering step withal i and, if spoken to, or stopped on his way, turns round so guardedly that his head seems to have no inde- pendent motion from the rest of the body. The heart indicates commencing degenerative change, and the aortic valves are the first to go wrong. Nearly all his dis- agreeable sensations are referred to the head; and, when THE HEADACHE OF CEREBRAL HYPEREMIA. 79 not actually painful, it is too disordered to admit of any exertion. When there is no need for worldly anxiety, he conjures up ideas of impending ruin, and is hysterical or so nervous that life is irksome to himself, and his presence unendurable to others. The blood is here also contaminated with nitrogenous waste, and the cerebral vessels are habitually overloaded from this poisonous source of irritation, to the risk of threatening rupture, particularly also if there is any degree of uraemia. The patient's general demeanor is altered, and dejection of spirits and moroseness of manner are rather the mental traits than excitement and irritability. Still, there is general restlessness and a desire to be doing. The terrific headache and the morbid sensations to which these per- sons are liable depend on excitement of the cerebral cells, scarcely to be accounted for by any additional supply of arterial blood, but more to venous fulness and stagnation. The relation which this cell activity holds to the blood- supply, and their dependence on one another, have yet to be determined. With this headache and increased local vascularity there is not necessarily associated a general arterial excitement, for the pulse may be soft and quiet, and the face pallid. These latter cases are often the consequence of mental anxiety or overstrain, and the evidences of exhaustion and low blood-pressure are to be observed. When we reflect on the anatomical changes in the vessels and meninges of the brain, it is no easy question to decide on the appearances they may be expected to present after death. I am not aware of anything con- stant in the amount of blood in the cerebral hemispheres and vessels, short of actual rupture, which a post-mortem 80 HEADACHES. examination reveals. In the case of children, often after death from head affections, the brain is only moderately congested, and yet the symptoms have been alarming, and death rapid, with insensibility and coma.^ The best examples of congestion and hyperaemia fail to account for the symptoms during life. But when the continu- ance of active cerebral hyperaemia has induced pain in the head, disturbances of the mind, and a severe degree of cerebral congestion, it may result in delirium and meningitis. This is by no means of rare occurrence in malarious fevers, which are so common in tropical climates. After death in such cases, the minutest vessels of the brain have been found injected, and the arachnoid thickened and of a deep-red color. Extravasation of blood beneath the scalp and between the dura mater and the skull is found in some cases of this sort. The other internal organs, also, as the liver, stomach, and spleen, undergo enlargement and softening as the result of in- flammatory action. Symptoms of Hyperemia.—Although I have dwelt at some length on the causes of congestion and hyperaemia of the brain, it would be a deeply rooted error to infer that disturbance in its functions necessarily originates in either state, if actual change of structure is excluded. The brain disturbance in fever arises from the hi. 24. 10 114 HEADACHES. morbid change. The pneumogastric nerve, both physio- logically and pathologically, is never lost sight of in any organic or functional disorder, and least of all should it be so in an affection like headache, when its communica- tion with the brain and stomach is so closely united, and the derangement of all parts which it supplies becomes evident in the painful sensations we experience when it is irritated or inflamed. The mucous membrane of the stomach in a healthy condition is of a pale color when at rest, but immediately an irritant, in the shape of food, comes in contact with it, the mechanical action induced by the friction and motion causes the vessels to dilate, and the surface to become red. The thin, acid, transparent, gastric secre- tion is poured out even after the nervous supply is cut off from without, though it is largely concerned in the secretion, as we shall see in considering the action of the pneumogastric nerve on the walls of the stomach itself. During fasting, when the stomach is at rest, there is another secretion furnished by its walls, which is thick, ropy, and alkaline. The various stimulants, as ether, al- cohol, wine and spirits, mustard, and a host of other ex- citants, cause the gastric juice to issue forth in abundance and to perform a necessary part in the digestive process. Irritation of the afferent sensory fibres causes the gastric vessels to dilate, and the mucous membrane to become reddened, whilst Bernard found that section of the vao-i caused pallor of the surface ; but it would appear " that the vagus contains two sets of afferent fibres, one of which increases, whilst the other diminishes, the degree of con- traction of the gastric vessels."* * See The Action of the Vagus on the Stomach, by Dr. Lauder DYSPEPTIC OR BILIOUS HEADACHE. 115 The close connection of the par vagum with the sym- pathetic nerve of the abdomen, uterus, and ovary, in- duces reflex irritation in the stomach, which is so com- monly observed in affections of these organs—as dys- menorrhoea, ovaritis, and uterine contraction. When the nerve is divided or injured, any of the parts to which it is supplied may be affected, as violent or spasmodic ac- tion, retarded motion of the heart, or congestion or in- flammation. Irritation of the gastric branches induces vomiting, but section arrests it, and causes distension of the viscus. As the par vagum is in immediate relationship with the chief cerebral nerves (the glosso-pharyngeal, the fifth, the seventh, the third, the ninth, and spinal accessory), we may in a great measure realize how its sympathetic disturbance may involve organs which own a different nerve-supply, and are only brought into relation with it through nerve inosculations. The union of the par vagum, therefore, with other nerves may set up far away reflex irritation, as we have seen, but more particularly with the fifth, and with that state of irritability and su- praorbital pain which we have seen to follow the intro- duction of ice into the stomach.f The alliance of the par vagum with the ganglionic sup- ply to the stomach enables us to judge of their continued effects upon the pulse and cardiac circulation ; in many acute diseases the cardiac plexus and the solar plexus are brought into close and immediate sympathy, which is inseparable between them. The diseases of the stomach Brunton, in Handbook for the Physiological Laboratory (Text 1873), page 493. f See Chapter III, on Sympathetic Headache. 116 HEADACHES. and abdominal viscera produce their full share in pros- trating the vital powers, rendering the pulse impercepti- ble, and causing coldness of the surface and syncope. No better illustration can be found than the effect which a disturbed stomach or a severe bilious attack has on the cardiac circulation, when the nervous power is exhausted and the vessels are weak and dilated. Hence it is that the healthy action of this nerve is essential for the steady performance of the digestive process; and, when diges- tion fails, the nerve-power will frequently be found at fault. If the strength of the constitution has been re- duced from prolonged indulgence in alcoholic stimulants, the nervous energy is the more exhausted, and as the patient cannot assimilate sufficient food to keep the func- tions of life going steadily, the way is paved for chronic dyspepsia and degenerative changes. The secretion of gastric juice is effected by the state of the nervous system, and sudden mental emotion is able to stop it altogether. The channel by which this is con- veyed clears up any doubt or mystery attaching to the phenomena; for the division of the trunk of the pneu- mogastric controls the secretion of gastric juice and the movements of the stomach. Though the experiments of physiologists like Reid, Schiff, Budge, Longet, Bernard, Ravitseh, etc., show that the stomach gradually recovers its lost tone after division of the par vagum, the func- tions of absorption and assimilation are enfeebled for a considerable length of time. The division of the sym- pathetic nerves, also, does not arrest the functions of this organ. But continued disorder of one or other, or of both these nerves, apart from any experimental deduction, proves, I think, to demonstration, that when pain is sud- DYSPEPTIC OR BILIOUS HEADACHE. 117 denly experienced at the pit of the stomach from the re- ception of bad news, they are so affected as to exert a most important influence on the digestive apparatus. The failure of nervous power is obvious enough in the fearful gastralgia and feeble digestion that render the life of some people a burden, and I do not think that even the division of the par vagum at the oesophageal opening or of the splanchnics in the abdomen of the lower ani- mals without palpable and permanent effect on the di- gestive powers, justifies us in setting at nought the agency of the nervous system in man, and still more the impor- tance of the pneumogastric in the production of reflex phenomena. A genuine bilious headache is less common among women than men, who commit greater excesses in eating and drinking. Young people of both sexes are, however, liable to it. The pain comes on in the morning after a heavy meal the night before, or after drinking too much wine; or it succeeds a heavy midday meal, if the person is not accustomed to it; or if the food is hurriedly eaten, and exertion and fatigue follow it. The pain occupies the whole forehead and top of the head, which feel hot and sometimes burning. The face is flushed, and the temporal arteries throb. A heated room, or stooping, brings on extreme nausea, and aggravates the suffering. If the patient avoid taking food he may manage to get through the business of the day, but when evening arrives if he attempts to eat the pallid face is exchanged for one of vascular excitement, and the throbbing headache often culminates in a violent attack of vomiting, after which, when the hope of alleviation has departed, he suddenly and unexpectedly falls asleep and awakes next morning 118 HEADACHES. well. An attack of severe retching, with or without the discharge of frothy mucus and bile from the stomach, will sometimes remove the fit of suffering. Its duration varies from a few hours to three or four days. In some patients it frequently continues a week, and the first sign of amendment is a desire for food with the power to di- gest it. After the long continuance of severe gastric headaches, the vascular excitement gives place to nervous exhaustion, and as they become more frequent, the ner- vous element preponderates, so that with the advance of years the bilious character and the vomiting are ex- changed for the type of headache which we shall pres- ently describe. But one form of headache during its con- tinuance may partake of the character of several types. That which begins as a purely bilious may end as a ner- vous headache, and that which begins as a nervous may terminate as a bilious headache, so great is the sympathy between the stomach and the brain. Where the urine is turbid and high-colored, and the complexion sallow, the cause may be traced in many instances to an accumula- tion of bile in the duodenum or the blood, and a fit of vomiting will sometimes cause a large quantity to be ejected by the stomach. Whatever the exact cause and nature of the headache may be, the nervous system has largely to do with it, in- asmuch as some persons of the most irregular habits, with defective depurative organs, never have the sensa- tion of a headache. I once knew a gentleman who was a martyr to gout, and had attacks which confined him to bed for six weeks at a time, and whose secretions were much deranged, as was shown by the dark bilious char- acter of the evacuations, high-colored urine, and foul DYSPEPTIC OR BILIOUS HEADACHE. 119 tongue; yet this patient, who freely indulged in the pleasures of the table, and drank largely of wine, never within his knowledge felt the sensation of a headache. He was, however, one of the most nervously timid per- sons I ever met with, shunning the society of ordinary visitors, and at times he could not summon up sufficient courage to meet his oldest friends. Causes.—The habit of continually taking aperient medicines by which the powers of digestion are enfeebled, indulgence in indigestible food and stimulating drinks, are common causes of this headache. A glass of beer, or a tablespoonful of brandy, will bring it on at any time in those persons who are predisposed to it, and where the digestive organs are easily deranged. Suppers, if per- sons are not accustomed to them, will cause disturbed sleep, followed by heat of the head, extreme nausea, and headache on awaking. Some of the worst forms of this headache have followed the excitement of evening parties, and the overloading of the stomach with indi- gestible food. Unwholesome food, which temporarily disturbs or arrests digestion, will occasion acute dyspepsia in some persons, and such persons are extremely prone to this form of headache ; uneasiness at the stomach, faint- ness, depression of spirits, lassitude, and febrile excite- ment are to be reckoned among the prodromata. Then succeeds an oppressive frontal headache, with nausea and inability to face the light, or bear the slightest noise. In some persons vomiting ensues, and the patient finds im- mediate relief; and in others colicky pains and diarrhoea expel the irritating matters from the intestines, and the patient loses the headache more gradually ; weight about the prsecordia, dislike of food, high-colored urine, offen- 120 HEADACHES. sive evacuations, and a creamy fur on the tongue may remain for days after, during which the nervous system is more or less implicated, and confusion of ideas and vertigo, with a return of throbbing headache, follow any employment of the mind requiring thought and reflec- tion. This headache may come on in a few hours after food, or the patient may go to bed comfortably, and either have disturbed and restless sleep, or wake up tin- refreshed with a weight across the forehead, and forth- with the affection begins in earnest. A sense of cold and chilliness is felt about the scalp and face for a few hours, particularly if nothing is put into the stomach; but if such be the case, or as the day advances, the face becomes hot and flushed, and the patient is continually employed in applying cold wetted rags to the head for relief. " The headache which appears in the course of the slighter attacks of this nature, often assumes a form with somewhat characteristic features, and which is familiarly known as the 'sick headache.' It is most common when acute exacerbations are superadded to the ordinary forms of atonic dyspepsia; and hence it is most liable to affect those who are out of health, and whose digestions are weakened by sedentary employment, and who have a tendency to costiveness. It occurs, however, also in per- sons of apparently vigorous health, sometimes without apparent cause, but most usually after some indiscretion in diet, or after some of the causes most likely to arrest the digestive process."* Treatment.—In early life, when this headache is threat- * On Acute Gastric Catarrh, by Wilson Fox, M.D., F.R.S.; A System of Medicine, edited by J. Russell Reynolds, M.D., F.R.S., vol. ii, 1872, p. 869. DYSPEPTIC OR BILIOUS HEADACHE. 121 ening, it can always be traced to some error in diet, and an emetic of sulphate of zinc or ipecacuanha brings re- lief in a couple of hours (Form. 108-109); or one grain of calomel, or three grains of blue pill taken on an empty stomach will mitigate the suffering in the head, though it may increase the nausea and loathing of food. With the advance of years these headaches become less acute, but more exhausting and tedious in their recovery. Rest in bed, cold applications to the head, and an altera- tive pill, followed by an alkaline purge in the morning, suffice for their cure (Form. 81-19). When patients are very bilious, and the conjunctivae yellow, a good cholagogue purgative (Form. 79) will ex- cite the action of the liver, and drain away a copious quantity of bile. A mixture of soda and bismuth with sal volatile will be useful to relieve flatulency and acidity (Form. 15). Where the bowels are irritable, a full dose of bismuth twice a day before meals is good (Form. 107). In the case of persons who are not strong, a few grains of carbonate of ammonia in water (Form. 16), or sal volatile, and chloric ether will sometimes arrest the symp- toms at once (Form. 17). If the headache is accompanied with atonic dyspepsia, and there is a clean tongue with weight and oppression at the epigastrium, the nitro-muriatic acid will be found serviceable before meals twice or three times a day (Form. 48). If flatulence is very troublesome, bismuth with nux vomica, and if there is constipation, a morning pill of aloes, nux vomica, and belladonna, or one consisting of aloes, capsicum, quinine, and ipecacuanha are indi- cated (Form. 77-78). In some varieties of dyspeptic headache Dr. Smith gives one minim of the tincture of 122 HEADACHES. nux vomica every fifteen minutes for two or three hours, and he has found it most effectual. Where the extremi- ties have been cold, and the pulse small and hard, a drop of tincture of aconite in a teaspoonful of water has fully answered my expectations in many instances. By dilat- ing the vessels and favoring perspiration it has wonder- fully relieved the aching brain. If the headache comes on soon after a meal from slowness of digestion, Dr. Smith gives half a drachm of saccharated pepsin in a wineglassful of sherry three times a day at meal-times.* I have given Morson's pepsin wine with great advan- tage at meals, and it certainly accelerates digestion and relieves nausea and gastric oppression. * The Therapeutics of Headache, by A. A. Smith, M.D. A Lec- ture delivered at the Bellevue Hospital Medical College, in Medical Record, September 15th, 1876, p. 390. CONGESTIVE HEADACHE. 123 CHAPTER Y. CONGESTIVE HEADACHE. Physiological Distinctions between Congestion and Hyperaemia— Definition of the two States—True Congestive Headache is of a Passive Character—Seat of Pain and General Symptoms—Causes that invite Congestive Headache—Good Living — Sedentary Habits—Bronchitis — Asthma—Whooping-cough—Tight Stays and whatever impedes the Circulation—Treatment consists in lessening the Supply of Blood to the Brain when in excess, and promoting its Circulation through the Vessels when their Tonic- ity is impaired—Purgatives—Saline "Waters—Occasional Ad- vantage of Venesection—Spare Diet and Avoidance of Stimu- lants in the Active Form—Counter-irritation—"Walking Exercise —Change of Air—Foreign Watering-places—Aconite—Bromides of Potassium and Ammonium—Strychnia—Nux Vomica—Mild Preparations of Iron in Anaemic Cases. Ix the active variety this can scarcely be separated from the headache of active hyperseniia. It overlaps each of the other forms, active and passive hyperaemia; yet it is not absolutely either. Congestion seems rather to be a dilated condition of the minute vessels, arterioles, capillaries, and venules, owing probably to some modifi- cation of the textures of the brain, by which they attract more blood to themselves than they do in health. In active hyperaemia, or one form of it, the determination of blood is more sudden and energetic, and the symptoms violent for the time it lasts; the temperature is higher, and the pulse quicker and stronger. The patient feels 124 HEADACHES. the whole arterial system throb and pulsate. As another and marked distinction from any form of congestion, the nervous centres are more susceptible, and this has a very determining influence on the vascular system, rousing the circulation more violently than in congestion, and increas- ing the functional activity of the affected part. Vital power and action are increased, with a less tendency to produce inflammation. It is a form of hyperaemia that does not lead to inflammation. The sensibility is height- ened in proportion to the increased supply of blood. Congestive headache occurs most frequently in plethoric persons, and those of a full habit of body ; but it may happen to those who have a sluggish brain circulation, and in whom the vessels are habitually loaded. It is the form of headache that occurs at the commencement of febrile disorders, acute hydrocephalus, and threatening apoplexy ; but in these latter cases it attracts less notice and consideration than the primary disease on which it depends, and is therefore to be considered as a secondary rather than as a primary affection. In its true significa- tion it is a passive congestive form of headache, depend- ing on fulness of the vessels of the brain, and there is no better example than that which follows an epileptic seizure. I have met with it in country people who lead an active life and are of regular habits. Bilious and lymphatic temperaments are liable to this affection ; the face becomes bloated, the eyes heavy, and the conjunc- tivae injected; the expression is heavy and sad, and the pulse full and soft, or weak, small, and accelerated. The symptoms are a dull and severe pain, extending from the forehead to the occiput, and great heaviness and stupor ; the suffering is rather limited than general, and is some- CONGESTIVE HEADACHE. 125 times referred to a particular part of the head, which indicates congestion of one lobe or hemisphere of the brain ; the patient is apathetic and indifferent, and suffers from giddiness and noises in the ears. If he stoop or turn round quickly, he experiences the disagreeable sen- sation of vertigo; his walk is apt to be overcautious, and his nervous system is tremulous and susceptible. In persons who are advancing in life, hypochondriacal symp- toms are of common occurrence, and the nights are rest- less and disturbed by frightful dreams. If the pain continues long, and does not yield to treatment, the pa- tient loses strength, is depressed, and easily fatigued ; the pulse is irregular in force and frequency, and there may be palpitation and shortness of breath. The appetite is generally good, and the tongue clean and red, but the bowels are disposed to be costive, and the urine turbid and high-colored. This form of headache is said by some writers to occur in irritable and anaemic subjects, but I cannot say that I have frequently observed it in this class of persons. When it does occur in these states of constitution, the pulse is weak and frequent; there are flashes of light before the eyes, the skin is pale, and the tongue generally clean and bloodless. Sometimes weakly persons suffer from a dull continuous headache, during which the heart's action is violent, and the carotid and temporal arteries throb; but if congestion of the vessels of the brain exist, pain comes on in paroxysms, from stidden noise or exertion, and is transitory in its dura- tion. An oversensitive condition of the nerves, by caus- ing a hyperaemic state of the vessels of the brain, analo- gous to the distension of the capillaries in blushing, may induce it. 126 HEADACHES. The true headache of active congestion belongs to a general hyperaemic condition, and there is an excess of blood in the system, or it is propelled with an increased activity, which overexcites the cerebral tissues and causes pain. But in passive congestive headaches the circula- tion is at fault, and the tone of the system is deficient. Cases are often seen where the patient is nervous and weak, the expression heavy, and the face sallow and bloodless. The spirits are dejected, and the drooping eyes bespeak a sad and sorrowful condition of the mind. The blood is not propelled through the cerebral vessels with sufficient activity or force, in consequence of their imperfect contractility, and hence they become overloaded without any extra power to propel their contents onwards. In malarial poison, congestion of the brain is common, like that of the spleen and liver; the blood moves slowly, and the vessels are enlarged and distended in consequence of a loss of tone. Cases of meningitis are recorded which prove that there is no necessary connection between the locality and degree of headache and the inflammatory lesion. Head- ache must therefore have an independent existence, and owe little to actual disorganization of structure. For organic change may cause congestion—a condition brought about by very opposite causes, as overexertion, mental distress, and debility of the vessels through which the blood is conveyed. Many cases of headache attributable to cerebral congestion can find no other explanation. Now, this congestion seems to be borne longer with im- punity by a sensitive organ, like the brain, than by any other tissue, where it would lead to excess of secretion or alteration of structure. The functions of the brain are CONGESTIVE HEADACHE. 127 altered (though it escapes injury), chiefly through func- tional disturbance of the nerves themselves, which may or may not produce an alteration in the vessels. The nerves in the form of headache are first involved, and any mental excitement will cause their disturbance; and as the bloodvessels are in close and intimate relation with them, the capillary circulation quickly responds, and produces a state of hyperaemia. Under any degree of emotion these headaches are common enough, and the flushing of the vessels of the face and neck indicates how they become overloaded under passion, or any kind of mental disturbance. The vehemence, again, of invective oratory, under a strain of deep thought and reasoning, excites the action of the heart, and forces the blood to the cerebral circulation, where it is detained, and keeps up the cerebral excitement. There are many persons (and it is especially so with nervous and irritable children) in whom intellectual exertion brings on a state of active congestion, which prevents them from following their work; and if it is persisted in, changes may then ensue in the vesicular structure of the brain, which permanently damage or impair it. I possess notes of cases of fatal congestion of the brain and meningitis in children after a few days' illness. In each instance the attacks were preceded by slight headache and sickness; but setting aside this significant symptom of brain mischief in early life, the other indications of failing health were too trivial to have given warning of the grave results to follow. Causes.—The causes that invite congestive headache are a peculiar configuration of the body, such as when the chest is capacious, the shoulders high, and the neck short; or again when, as with many persons, there is a 128 HEADACHES. general redness of the skin and lips. The patient ex- periences shortness of breath in going upstairs, and is distressed with exertion. He is fond of good diet and stimulating drinks, and prefers sleep and sedentary habits to active exertion and scanty fare. This headache in its active form is not unfrequently seen in young healthy women, whose catamenial losses have been suddenly sup- pressed through taking cold* Whatever depresses the bodily powers and reduces the general strength, exhausts the system and induces debility of the vessels, favors congestion, and relaxes their tonicity and contractility. It is seen in both sexes when the constitution is broken down and shattered by indulgence, and in stout heavy persons, who have had attacks of bronchitis and asthma; in women who have borne large families, and whose nervous power is exhausted. During or after whooping- cough it is not uncommon when the attacks of spasm are violent, and the pulmonary complication is tedious and irksome. Persons who play the cornet, and other in- struments requiring prolonged expiratory efforts, and the suspension of the breath for some seconds, are frequent sufferers. The now happily discarded stock worn by our soldiers a few years ago induced this variety of headache; and any constriction about the neck, or the use of tight stays to compress the figure into a fashionable shape, will bring about the same evil by impeding the circu- lation. Organic change may induce it, by disturbing the rela- tions of the structures of the brain, and causing conges- tion and interference with the circulation. Congestive headache of a passive character is exemplified in hyper- * See Chapter VI, on Plethoric Headache. CONGESTIVE HEADACHE. 129 trophy and valvular disease of the heart, where we may frequently witness lividity of the features, distension of the jugular veins, coldness of the skin, and fulness of the temporal vessels. In a little girl, aged ten years, who was under my care with this form of heart affection, the headache was nearly unceasing, and the poor child only got relief by a free purgative and the lightest diet. The brain was overloaded with blood from passive congestion, and the blood interrupted in its return by the condition of the heart. Indeed, it appears to me that it is impossi- ble to dissociate congestion of the vessels from any form of headache in some stage of its progress. The purely nervous headache in many persons, at its commencement, or shortly after, exhibits signs of congestion in the fre- quency and fulness of the pulse, the warmth of surface, the heat of the head and scalp, the tendency to vomit, in constipation, and in a greater or less degree of paralysis of all the functions. As the circulation of the brain is active, and the amount of blood within it is at all times great, even in health, we may reason from analogy that the nerves are exceedingly liable to disturbance in those who are subject to headache, because it is possible, and not uncommon, for persons to have habitually a congested and sluggish circulation through the brain and other cavities of the body, without experiencing the sensation of a headache. Repeated epileptic seizures will also induce severe con- gestive headache. The headache which happens to the intemperate and those addicted to irregular habits is of the congestive and hyperaemic variety. The vessels of the brain are overloaded by the entrance of alcohol into the blood; there is congestion of the stomach and of the 11 130 HEADACHES. liver also, these latter organs being first in fault. A hyperaemic condition of the arteries of the brain, arising from a diminution in the tonicity of the vessels, and causing severe headache, is not uncommon in those per- sons who exhaust the brain by prolonged study, and ex- cessive intellectual exertion. The brain is fagged, and never rested long enough for the vessels to recover their tone and vigor. Men of the strongest intellect and the most placid natures, when afflicted with this headache, become dejected and irritable, and exhibit traits of char- acter which they have not previously shown, and a diffi- culty is felt in concentrating the mind on work; while the patient, if accustomed to walk vigorously, now finds that short distances tire him. He first has an uncomfort- able feeling of pressure along the front and top of his head—an uneasy sensation, similar to what is felt from extreme heat or cold. Later on, the headache is charac- terized by a heavy pain across the frontal region, dull and continuous. This is often succeeded by faintness and inability to walk. When talking, there is a sensation of weight over the brain, and numbness of the scalp. In short, the brain is being worn out; and if this continues, there is certainty of the patient sooner or later breaking down altogether. Long-continued anxiety and the strug- gles of professional life, hopes disappointed and plans frustrated, will induce a state of congestion or hyperaemia of the brain and headache, which may become permanent, if the warning is not taken in time; for when the brain is constantly overcharged with blood, changes in the vesic- ular structure of the nervous matter are not unlikely to occur, which sometimes end in weakness of intellect. Treatment.—In managing this variety of headache, the CONGESTIVE HEADACHE. 131 local as well as the constitutional symptoms must be care- fully estimated. It will be necessary to inquire into the condition of the capillaries of the brain, and whether the blood is impeded in its passage through the circuitous veins and sinuses of the cranium. The age of the patient and the habits of his life will also demand careful con- sideration, before Ave can submit him to treatment with any prospect of relief. In the plethoric and robust, the quantity of blood circulating through the brain may be lessened by exciting the action of the secreting organs. A full dose of calomel and colocynth should be given at bedtime occasionally and a saline aperient during the day (Form. 80). A tumblerful of Apollinaris water, on going to bed, will stimulate the bowels to act more freely on the following morning, and cool and refresh the system. About twice a week, according to the circumstances of the case, two-thirds of a tumblerful of Friedrichshalle water, in a little lukewarm water, taken on rising, will prove a mild and efficient purgative, and it answers ex- ceedingly well in these cases. The diet should be spare, and beer and spirits aban- doned. Active exercise in the fresh air, and habits of early rising should be enforced; and these measures, when rigorously carried out, afford the best promise of relief. Bloodletting, either general or local, is rarely if ever needed ; it being preferable to trust to abstinence, mild or active exercise in the open air, and due attention to the action of the liver and bowels. In the case of voung plethoric women I have known leeching the temples or groin prove advantageous. There are instances occasion- ally to be met with, however, where the patient is indo- 132 HEADACHES. lent and overfed, besides being too full of blood already. He is about the middle period of life, and is much averse to exertion or active employment of any kind. His habits of life having become more sedentary, it happens probably that the bowels no longer act so freely, the liver being habitually congested, and the circulation through it to some extent obstructed. Cases of this character may possibly be benefited by the abstraction of blood, but even here brisk cathartic and alterative medicines are most to be relied on (Form. 79-80-29). In one case that came under my notice, much benefit was derived from an open blister at the back of the neck ; but jio measures will be availing unless the diet is restricted, and exercise is regularly taken in the open air. In some cases of acute congestive headache, where the face is hot and flushed, the pulse firm, and the skin dry, the antiphlogistic effects of aconite prove of signal service, by inducing diaphoresis, and relaxing or partially para- lyzing the vasomotor system (Form. 26 a). Aconite depresses the heart's action, and by reducing arterial ex- citement, and diminishing pressure and tension in the vessels, it controls the amount of blood which circulates through the cerebral mass. The patient should lay his head on a hard and elevated pillow, and either the ice- cap, or some other means of producing cold, should be continually applied to it, till the pain becomes less severe. When this headache is the result of overwork of the brain and prolonged study, change of place and scene will be desirable. The mind must have entire relaxation by easy travelling and the quiet amusements of the sea- side. Foreign watering-places, where the air is pure and CONGESTIVE HEADACHE. 133 the waters are adapted to promote the digestive functions, will amply compensate for a long visit. It is in such cases as these, and especially in nervous and irritable subjects, that the bromides of potassium and ammonium are of such signal value. If the patient is sleepless at night, the bromide of potassium will be of great service if taken just before going to bed (Form. 40); and if he is unsteady on rising in the morning, and dreads the fatigue and business of the day that is before him, the bromide of ammonium (Form. 25) will avert the headache which threatens with the morning light, and steady his nervous system in a remarkable way. In the case of a gentleman who suffers periodically from a sub- acute congestive headache, and who is also troubled at these times with flatulent dyspepsia, a full dose of the subcarbonate of bismuth in plain water twice a day, before the two chief meals, always controls the headache and general discomfort and flushing of the face (Form. 107). When tonics are required, bark and ammonia, or am- monia and lavender, may be first ventured on (Form. 55 -62), and in some cases they answer well. The mild preparations of iron are suitable if the patient is weak and anaemic (Form. 22-24), but they must be cautiously given in the intervals between the attacks, and the func- tions of digestion and assimilation should always claim a large share of attention during their administration. 5 134 HEADACHES. CHAPTER VI. HEADACHE FROM PLETHORA AND INCREASED VASCULAR ACTION. Characters and Composition of the Blood in Plethoric States of the Constitution—Predisposing and Exciting Causes—Variability of the Symptoms according as the Disorder is of a Sthenic or an Asthenic Type—Prevalence of the Headaches at the Catamenial Periods and during Pregnancy. Treatment—Natural Cure by Spontaneous Haemorrhage from the Bowels, Nose, or Uterus—Occasional Necessity for Venesection and Cupping or Leeching in Active Plethora—Saline Aperients to Excite the Fliminative Organs—Importance of Abstemious Habits and a Limited Indulgence in Animal Food—Fish and Vegetables, and the Influence of Diet on the Composition of the Blood. In this variety of headache there is an excess of blood in the whole system, and throughout every organ of the body. It is allied to the congestive form; but here there is an increased quantity of blood in the brain, without any corresponding repletion of the rest of the vessels of the body. The condition is essentially dependent on the cerebral vessels partaking of the general fulness, and is not due to the determination of blood towards the head in particular. The redundancy of blood in the brain ex- cites morbid action of the nerves and causes headache, whilst the general plethoric state leads to indolence and insufficient exercise; and with defective action of the skin, HEADACHE FROM PLETHORA. 135 liver, and bowels, the fulness of the vessels is continually kept up. When the capillaries are too full they favor congestion, by the exudation of their contents through their thin membranous walls.* The predisposing causes are overindulgence of every kind, stimulating foods and drinks, want of regular ex- ercise, and mental lethargy. Among the exciting causes mav be enumerated any circumstances that determine blood to the brain and internal organs. The suppression of any accustomed discharge, as epistaxis or haemor- rhoids, will induce it. I knew a lady, forty years of age, short, stout, and of full florid habit, who only obtained relief from violent throbbing headache by a great uterine loss, or profuse bleeding from the nose, till she was blanched and faint. On more than one occasion she was on the verge of apoplexy, when the haemorrhage which relieved her came on.f There had been for some days previously singing in the ears, and a throbbing and * It is important to remember that the blood in plethora is different in its composition from what it is even in active hyperaemia. With the increase in the general mass, there is also a larger number of red corpuscles and fibrin. According to Dr. Payne, however, the fibrin is somewhat diminished from deficient arterialization (Jones & Sieve- king's Pathological Anatomy, page 42). The quantity of water is very considerably less, so that after venesection the coagulum is large, and the serum scanty. In the asthenic form of plethora the coagu- lum is softer, because the tendency to an approximation of the red particles is decreased, and they are more easily drawn asunder, by the loss of attractive force and the want of cohesion between the solid and fluid parts. f "Plethoric persons are not more prone to inflammation than are those of weaker constitution; but they are liable to congestion, espe- cially of the brain, and to apoplexy or other haemorrhage."— Carpen- ter's 'Human Physiology, by Power, 8th edition, p. 264. 136 HEADACHES. bursting sensation in the head. Purging and low diet kept the symptoms in abeyance, but never brought so much relief as this unloading of the general circulation. A fit of passion in a sanguine person, or exposure to the heat of the sun, or overcrowded rooms and public assemblies, will excite this headache, if there be a pre- disposition to it. Persons who suffer from this sort of headache look well and strong; they are usually stout and of short stature, and any exertion from which they are instinc- tively averse, causes a throbbing of the temples and a rush of blood to the head. The symptoms vary in different individuals. In the more sthenic forms of plethora the pulse is full and strong, the eyes are bloated and suffused, and the counte- nance is flushed and hot; the veins about the temple and forehead are distended, and the patient experiences so much discomfort and confusion in his head on any at- tempt at movement, that he encourages his complaint from a disinclination to exert himself. In other persons, where there is less arterial excitement, and the symptoms approach an asthenic type, the pulse is small and hard; and in some it is weak and scarcely discernible or inter- mittent, as when the heart is flabby and weak, or there is a tendency to the deposition of fat around the heart and in the subcutaneous areolar tissue. The right ven- tricle is habitually too full, and the chief veins of the neck are large and prominent. Dyspnoea on exertion, and a stifling cough with pulmonary congestion, are also common in these subjects. I have met with persons of this constitution who pass urine at one time of low spe- cific gravity, sometimes excessive, and at others contain- HEADACHE FROM PLETHORA. 137 ing a copious deposit of pink lithates and cayenne pepper crystals of uric acid. They eat and drink immoderately, and fall into a heavy sleep after meals. The bowels are not always costive, but sometimes loose and relaxed, and continue so without any diminution of headache. In some persons the extremities are cold, and the face has a more dusky hue, from the plethora being of a less active character. The headache is heavy and throbbing, chiefly across the forehead or the occiput, where the blood accu- mulates in the occipital lobes. This form of headache may precede congestion of the brain, or even effusion and apoplexy, for the whole capillary system is too full. In milder cases there is dizziness and confusion of ideas, with a mist before the eyes ; and any excitement or exer- tion causes a rush of blood to the head, and heaviness of breathing, with oppression about the pnecordia, or labored action of the heart. If a smart attack of diarrhoea super- vene, the pain is partially relieved ; but free haemorrhage from the nose or bowels will cause it to depart, even after a steady continuance of some weeks. These headaches are common in women, and are se- vere at the catamenial periods, when the secretion is sup- pressed, or during pregnancy; they are not always per- sistent, but occasional, and are excited by irritability of the digestive organs and deficiency in the powers of as- similation. When the latter condition exists, the fulness of habit is not so marked, and the venous system is not so loaded; the circulation is more active, and the arteries are less disposed to relaxation, while the blood accumu- lates in the capillary vessels. Treatment.—Nature endeavors to promote a cure by the occurrence of haemorrhage from the bowels, nose, or 12 138 HEADACHES. uterus, and we must act upon this hint if we would ef- fectually relieve the headache. I knew a young man residing in the country who was periodically bled, and in this way the strain was taken off the cerebral circulation, and" his symptoms relieved. Some years ago I met with a stout plethoric female, twenty-five years of age, who was about to give up her situation from this form of headache. There was a full hard pulse, and scarcely any menstrual flow, till a free bloodletting reduced the arte- rial tension and restored the functions of the sluggish organs. But there are many persons (particularly women) who could not bear venesection, and who, nevertheless, are only relieved by the loss of blood from the nose or uterus. These belong to the luxurious classes, and the brain is as much in a state of passive as of active pleth- ora; it is the accompaniment of other forms of head- ache, and must not be sought for alone and unmixed in all cases. WThere, then, general bleeding is inadmissible, cupping at the back of the neck, or a few leeches to the anus and perinaeum, may be resorted to. Saline aperients and those remedies that determine the force of the circu- lation to the eliminative organs, must also be employed (Form. 18-19-60-80). No relief can be obtained unless stimulating food and intoxicating drinks are given up, and the sufferers resolve to change their habits of life by early rising and regular exercise, that as much blood as possible may be diverted from the internal organs, and pulmonary and cutaneous exhalation encouraged. The sufferer, however (who is usually a bon-vivant), cannot endure much depletion, and demands vigilance and judg- ment in prescribing for him. Meat should be taken not oftener than once a day, and fish and vegetables are HEADACHE FROM PLETHORA. 139 highly to be commended. Many persons, from peculiarity of constitution and temperament, cannot maintain their health for any considerable time if they consume animal food oftener than once a day. Diet has a great influence on the composition of the blood, and we may so regelate it as to diminish the tendency to the formation of solid matter, and to increase the watery constituents. Many persons are stronger and more elastic when the consump- tion of azotized food is small; and in cases of this class, there is no probability of cure unless they are willing to submit to a careful regimen. Plethoric persons make blood abudantly from an innate disposition in the system to corpuscular growth, and sedentary habits and high living will encourage the predisposition. The patient should lie on a hard bed with an elevated pillow, as the recumbent position encourages determina- tion of blood to the head and .congestion of the vessels. The meals should be light, that sleep may not afterwards ensue. Moderate and regular exercise should be taken in the open air, and the mind kept as free from disturb- ance as possible. " The hair should be kept short. It has been observed that monks who neglect shaving their heads after having once habituated themselves to do so suffer severely from headache."* * Headaches: their Causes and Cure, by Henry S. Wright, M.D., London. 140 HEADACHES. CHAPTER VII. NERVOUS HEADACHE. Common to all Classes of Society, but more particularly to persons of Nervous Temperament and Delicate Organization—Pathology of the Affection—Probably dependent on Anaemia and some pecu- liar Change in the Cerebral Tissue—Nerve Storms and supposed Influence of Miasmatic Poisoning—Variation in the Scat of Pain and Mode of Commencement and Termination—Want of Sleep, and Disturbance of the Mind—Disturbance of Vision—Cases of Sir C. Wheatstone and Sir J. Herschel—Distribution and Func- tions of the Vasomotor Nerves—Cases in Illustration of Nervous Headache—Hereditary Tendencies—Peculiar Combination of Mental and Psychological Symptoms—Origin of the Pain in Nervous Headache—Effects of Nervous Headache on the Moral Disposition—Falling off of the Hair, and Pityriasis of the Scalp —Xanthelasma Palpebrarum—Importance of Rest and Quiet— Cold to the Head and Warmth to the Feet—Effects of Quinine, and Aperient and Sedative Medicine—Bromides of Potassium and Ammonium—Guarana—Value of Hypodermic Injection, and Importance of Caution in employing it—Ferruginous Tonics, Strychnine, and Cod-liver Oil. This variety of headache is not confined to any par- ticular class of society, but it is of most frequent occur- rence in persons of nervous temperament and delicate organization. No temperament can, however, claim ex- emption from it, and no habit of body is proof against it. Throughout a long life it periodically attacks those who are susceptible to it, and they surrender themselves to the irresistible evil without comment and without murmur. NERVOUS HEADACHE. 141 They feel it approaching as a certainty from which there is no escape, and so placidly resign themselves to its tor- ture. It is, to a certain extent, the headache of anaemia, and yet not entirely so, because many persons are affected with it whose blood is neither diminished nor impov- erished, and whose muscular development and robust ap- pearance indicate the soundest health. Amongst its vic- tims it selects persons of high culture and vivid imagi- nation, and if at the same time they are deprived of their full allowance of sleep, it all the more readily seizes upon them. When the brain is highly developed and the physical organization delicate, it is always likely to occur. It is in the want of balance between the mental and phys- ical state that a nervous headache originates; for when the circulation is energetic, and the digestive organs are in sound working order, the mind may be exerted to the utmost without the risk of incurring it. All investigation concerning this form of headache in- clines towards a nervous origin—to a morbid change in the nervous centres; and this view cannot be readily dis- missed until the discoveries of experimental physiology are proved to be inconclusive or erroneous. It is infi- nitely less probable that the cerebral blood-supply should initiate the disturbance, whatever share it may subse- quently have in producing the pain. But clothe the ar- guments as we may to support this or that opinion, re- produce them as we will to the proof of conviction, we are still in the infancy of knowledge concerning the causes of many diseased processes, and the evidence which now appears indubitable may be far distant from ultimate truth. Nervous headache comes on sometimes when a patient 142 HEADACHES. dwells persistently on anything unpleasant, or is unable to remove his thoughts from it; when he cannot be cheerful in repose, or see the faintest sunshine in the future. This tries the brain, and disarranges the circu- lation within it; for " the fact is now generally admitted that thought exhausts the nervous substance, as surely as walking exhausts the muscles. Our physical framework is involved with thought no less decidedly than with feeling, and it is requisite, if possible, to define the terms of the alliance."* Persons know when this form of headache is threat- ening, and by rest and extreme care they may ward it off altogether. Thus at an early stage, its full force may be averted by going to bed and falling asleep; if it threatens before the accustomed time of taking food, a moderate meal will prevent it, or a full dose of bromide of potassium. Sometimes the routine duty of the day can be got through, and the misery endured; at other times the pain reaches such a degree of severity that there is no standing up against it, and the patient is compelled to give in. This peculiar functional disorder of the nervous centres is neither permanent nor continuous, and in the interval of the seizures the patient is as well as though it had not happened. This disease has been very appropriately, I think, classed among the paroxysmal neuroses by Dr. Hilton Fagge,f for it comes and goes suddenly, often when least expected, and without warning. But this is the character of nervous disorders generally, as facial * Mind and Body, by Alexander Bain, LL.D., 1873, p. 80. f Remarks on some of the Paroxysmal Neuroses, Guy's Hospital Reports, vol. xxi, 1876, p. 376. NERVOUS HEADACHE. 143 neuralgia, epilepsy, laryngismus stridulus, gastrodynia, angina pectoris, etc. Dr. Edward Liveing* gives them the name of " nerve storms." As we shall presently see, this type of headache is among the most hereditary of dis- eases. From the mode and habits of life, when the nervous system has been subjected to great strain, it may break out anew in a single member of a family, when no other member of it suffers from any neurotic disorder. The occupation of each one's life exercises, either con- sciously or unconsciously, an important influence on the bodily and mental state, and each calling may have a large share in determining our susceptibilities. In some persons the headache, which I would designate as strictly nervous, begins with an affection of vision, the sight being clouded and dim on that side of the head where the pain commences (as in one temple), afterwards fol- lowed by the usual phenomena of sickness and confusion of ideas independent of any excess or diminution in the blood-supply. It is traceable in some cases to exhaus- * " On this theory, then, the fundamental cause of all neuroses is to be found, not in any irritation of the visceral or cutaneous periph- ery, nor in any disorder or irregularity of the circulation, but in a primary and often hereditary vice or morbid disposition of the ner- vous system itself. This consists in a tendency on the part of the nervous centres to the irregular accumulation and discharge of nerve- force—to disruptive and uncoordinated action, in fact; and the con- centration of this tendency in particular localities, or about particular foci, will mainly determine the neurosis in question. The immediate antecedent of an attack is a condition of unstable equilibrium and gradually accumulating tension in the parts of the nervous system more immediately concerned, while the paroxysm itself may be likened to a storm, by which this condition is dispersed, and equi- librium for the time restored."—On Megrim and Sick Headache, 1873, p. 336. 144 HEADACHES. tion, fatigue, and losses of blood; but more commonly to worry and anxiety; in others, no cause can be as- signed—it comes and goes without any satisfactory reason, and lays the robust and square-shouldered man as pros- trate as the overdrained sickly woman. In employing the term " nerve storms," Dr. Liveing implies that there is an accumulation of nervous force which explodes in the shape of headache; and it is certain that all who have carefully observed the phenomena leading up to an attack must have been struck with the excitement of manner and irritability which precede the outbreak. The period may vary from a few hours to many days. In some confirmed sufferers I have repeatedly witnessed a series of symptoms which have culminated in an attack, and no ease has been obtained till the affection has worked up to its height. There is a period during which disease obtains the mastery, and all remedies are unavailing to keep it in check. If the general health is reduced, the attacks are more frequent, and recur with no precise regularity; but when the health is stronger, the intervals are also greater. Worry is a common exciting cause in both men and women, especially if they are sensitive and given up to society and excitement. A mind ill at ease becomes exalted or depressed, and the cerebral circula- tion being unsteady deranges the nervous structure. Overwork of the brain is another cause in those persons who live in towns and large cities, and pursue sedentary occupations. When the paroxysms recur with regularity, miasmatic poisoning requires to be taken into consideration; but I must say that this cause has rarely suggested itself to my belief, for nervous headache is more common to residents NERVOUS HEADACHE. 145 in large and populous towns, where marsh poison does not prevail, whilst it is questionable whether the disease is especially frequent in aguish districts. When a nervous headache, having all the characters of true migraine, follows certain articles of diet, as pork, butter, fatty articles of food, and alcohol, it is beyond doubt that these have had a large share in provoking the mis- chief. We are Repeatedly told by patients that, unless they observe the greatest care, they will suffer the penalty of a headache for indiscretion. The pain most usually attacks the forehead and vertex, but sometimes the occiput and back of the neck. After it has lasted some time, it not unfrequently seizes upon one temple, or one eye, or one half of the head, and thus resembles the headache of neuralgia. A married lady, aet. 30, consulted me in May, 1876, for a nervous head- ache, to which she had long been subject. It began over the forehead, and in the course of an hour or two would seize on the left eye, where it would continue for a whole dav, and then leave her after a night's rest. The feeling she described to be as though something was forcing out the left eye, the tears running over the cheek so plenti- fully that it became inflamed and sore, while the pain extended down the left side of the nose; also light and sound became intolerable to her. The patient stated that through life she had been subject at times to " bilious attacks" and, though still she often would feel nausea, she never actually vomited. With this condition of the brain the hands and feet were always cold, and, if the pain had continued long, the head grew hot, as if full of blood, and the face became flushed. However severe the suffering, she could always eat her dinner, which some- 146 HEADACHES. times relieved the pain, and at other times increased it. W7hen the pain was coming on, she told me that she was always inclined to cry at the slightest thing. The approach of headache in some persons may be foretold by the sluggish action of the bowels, a loathing of food, together with flatulency and eructation. In the same class of persons, at other times, I have known a state of chilliness and a very scanty and turbid secretion of urine to precede the headache; while with other per- sons, the passing of a large quantity of limpid urine may be the forerunner of an attack. In others, again, there is extreme irritability and disquietude; the patient can- not keep quiet for an instant, and no efforts avail to calm or appease her; all things are wrong—nothing goes right. The pupils are contracted, the eyes sunken, the pulse feeble, and the extremities cold. Then succeeds a period of calm and surrender, and the patient is completely ex- hausted and overcome. This headache is most frequent among women who are approaching the middle period of life, and who are exhausted by the strain of maternal duties. If they have borne children rapidly, and the uterine functions are active, then it is of common occur- rence. Oversuckling, menorrhagia, and profuse leucor- rhoea are also causes; dysmenorrheas, and even ordinary menstruation, will bring it on in some persons. As re- gards menstruation as an exciting cause, the quantity of loss affords no explanation, for nervous headache is as common where the catamenia are deficient, as where they are in excess. The ovarian irritation which prevails at these periods, induces a painful condition of the cerebral nerves through sympathetic action ; and there are women who invariably suffer in this way at every menstrual NERVOUS HEADACHE. 147 period, when the quantity of loss cannot explain the oc- currence of the pain. The real disorder is in the nerve- fibres of the brain, which become deranged from distant sources of irritation acting through the sympathetic system.* Constipation is sometimes held to be a cause of nervous headache, when, in reality, it is an effect. If, when the attack comes on, the bowels happen to be costive, the pain in the head is increased from the greater sympathetic ac- tion ; but if they happen to be relaxed, the pain is the same, and mere looseness of the bowels does not relieve it. Those who are subject to this form of headache, al- though they may have escaped it for many years of their life, are persons whose constitution is originally weak. I have known persons to reach the age of thirty-five before getting an attack, and then, circumstances having arisen to lower the standard of health, the consequent excessive waste of nervous matter has rendered them liable to the complaint. The hard-worked physician, the laborious scholar, the anxious merchant, who toil hard and late, and neglect the ordinary precautions of health ; the corrupted youth, who has sacrificed himself to vicious habits; the anaemic girl, and the half-starved seamstress—all are vic- tims to this terrible form of headache. Those who dwell in the fashionable world, and keep late hours, are partic- ularly subject to it; for hot rooms, evening parties, and imperfect ventilation are always likely to produce it. But, in addition to the activity of mind and the emo- tional sensibility which are common to the sufferers of nervous headache, there is a state of the bodily constitu- * See Chapter III, on Sympathetic Headache. 148 HEADACHES. tion which renders people liable to it. In a lowered con- dition of the general health almost any cause will induce an attack. I'rolonged study, the mind being kept bent on the accomplishment of a task in a given time, ponder- ing over figures that require much mathematical calcula- tion, the jarring of vehicles over bad roads, the alarm and timidity at driving along crowded thoroughfares, and dis- agreeable odors of all kinds, will be sufficient to invite it in some cases. All forms of peripheral irritation of the senses of sight and hearing excite increased central irrita- tion, especially in cases of meningeal mischief; conse- quently we find that darkened rooms and absolute silence are excellent palliative measures. Moreover, depraved secretions in the alimentary canal, or any morbid impres- sion on the gastric nerves, will bring it on. Difficult as it is to fix upon exciting causes, we can hardly escape the conviction that derangement in the chylopoietic viscera has an important bearing in the cau- sation of the malady. The interruption to the process of digestion caused by travelling on a full stomach invari- ably brings on a headache with some persons. I have met with several cases, and one in particular, where a gentleman always suffers from headache if he goes a jour- ney shortly after taking food. There are persons of simi- lar nervous organization, who experience a sharp attack of diarrhoea at the prospect of travelling -by rail, or going a sea voyage. Disturbance in the electrical states of the atmosphere will excite an attack of nervous headache in some per- sons. By these persons the approach of a thunderstorm can be calculated with an absolute certainty from the feel- ing of weight over the forehead and a severe headache. NERVOUS HEADACHE. 149 Long before thunder is heard, or the patient has any con- ception that a storm is coming on, he is heavy and op- pressed, or restless and timid; there is a weight across the forehead, and he is unable to exert himself in mind or body. If he attempts to read, his temples beat and his forehead aches, his face flushes, and his last meal has probably caused flatulence, and a sense of heat and dry- ness in the mouth. Abstinence from food and continu- ous effort may keep the pain in abeyance, but still it clings to him more or less, and he gets through the day's work miserably enough. As regards disturbances of vision, all the patients who have complained to me of this symptom have described a painful sensation on attempting to read or look at ob- jects, and a misty or clouded appearance before the eyes, of flashes of light and dazzling sparks in the field of vision. One 'female patient assured me that a dim and clouded appearance before the left eye announced the commencement of the attack for some hours before the head began to ache. Sir C. Wheatstone, Sir John Her- schel, and other eminent men describe their own experi- ence of it, and for another interesting account, I would refer to the Philosophical Transactions for 1870, "On a Distinct Form of Transient Hemiopsia," by Dr. Airy. Sir J. Herschel describes a singular shadowy appearance at the outside corner of the field of vision in the left eye, coming on when he was doing nothing and thinking of nothing. It gradually assumed the drawing of a forti- fication, with angles, bastions, and ravelins, and faint lines of color between the dark lines, and the impression was the same whether the eyes were closed or open. It lasted a minute or two, and spread over the whole visual 150 HEADACHES. area, and was not followed by headache as it was in another case. The account given by Dr. Airy of the phenomena is very interesting, and will repay careful consideration. "Another very important point about these attacks is, that in perhaps from one-fourth to one- third o"*1" ' cases, during this glimmering stage, there is tingling some portion of the body—the part is asleep. In a young female that I saw, the tingling affected one arm and the side of the tongue, and, curiously enough, both her sister and her father were affected in precisely the same way. The tingling was on the same side as that on which the glimmering in the eye began. In another case, the patient complained of a feeling of pricking and scratching on that side of the face corresponding with the glimmering. In others, speech or hearing may be af- fected."* The persons who suffer from ocular disturb- ance are, in my experience, most frequently women of nervous temperament, who have active brains, and are energetic and restless. They are often anaemic and sub- ject to chronic debility. Fatigue of all kinds and over- excitement will lead to it, and all drains, leucorrheea or menorrhagia, which exhaust the system and lower the bodily tone, are common causes. Under " Sympathetic Headache" I have described how this state is brought about, and I may here mention that the vasomotor branches of the sympathetic nerve regulate the contrac- tion and dilatation of the bloodvessels of the brain ; and we have seen that when the cervical sympathetic was di- vided, there was an afflux of blood and a dilatation of the vessels. When the vessels of the brain are contracted, * Dr. Latham, on Nervous or Sick Headache, p. 10. NERVOUS HEADACHE. 151 the supply of blood is diminished; when they are dilated the quantity is increased, and this is an explanation of the headache that results after the stage of excitement has passed, when the systemic circulation is heightened and increased.* The following case is one carefully studied, and may be regarded as a type of nervous headache. Each attack seemed to divide itself into two distinct periods,—-first, the stage of irritation, where the brain is first at fault, and the stomach secondarily affected ; secondly, the neuralgic stage. This will be best explained by the sufferer's own account, as communicated to me from time to time: A. B., aet. 49, began to suffer from severe headache twelve years ago, being then the mother of four children which she had had in rapid succession, besides two prema- * "That there is a vasomotor centre, and that it is intracranial, we learn by observing, first, that if the medulla is divided immediately below the cerebellum, all the arteries are relaxed, and that a similar effect is produced if certain afferent nerve-fibres which lead to the intracranial part of the cord are excited. Its position has been lately determined with great precision in the rabbit by Ludwig and Ows- jannikow, who have found by experiments that it is limited towards the spinal cord by a line four or five millimeters above the calamus scriptorius, and extends towards the brain to within a millimeter of the corpora qvadrigemina. " That the vasomotor centre is in constant automatic action is shown by the paralyzing effect of section, whether of the spinal cord, or of any nerve known to contain vascular fibres. If the action of the centre were not constant, division could not produce arterial relaxa- tion. In relation to this constancy of action, the word tonus is used. Arterial tonus means that degree of contraction of an artery which is constant and normal. It is maintained only so long as the artery is in communication with the vasomotor centre."—Handbook for the Physiological Laboratory, " Functions of Vasomotor Nerves," by Dr. Burdon-Sanderson (Text 1873), p. 235. 152 HEADACHES. ture births, all in the course of seven years. After this she had great and frequent catamenial losses, which com- pelled her to keep her bed or to remain in a recumbent posture for days together. The headaches generally came on the third day of the loss, though occasionally at other times, and then they were always traceable to fatigue or worry. At the onset of each attack she complained of violent pain on the top of her head (which was always very hot), extending over the occiput to the neck. The eyes were sunken in the orbits, and the pupils were small and contracted, and there was a feeling as though they were being pulled back into the head; light and sound were intolerable; the feet and hands cold ; the pulse slow and feeble, sometimes not exceeding fifty beats in a minute. The bowels refused to respond to medicine. Sometimes she obtained partial relief from ice on her head, while at other times she could not lie still, but kept pacing up and down the room, with her mind much disquieted, and a wish to die. When the suffering was acute, the patient could not rest her head on the pillow, nor could she open her eyes or engage in conversation. She was continually tossing and turning from one position to another, while her mind indulged in the most melancholy forebodings, and renewed the fancied grievances of a lifetime. She could not escape from the toils of calculation ; her mind kept running in a narrow groove, and all things appeared distorted. This stage would last as long as thirty-six hours, being sometimes accompanied by sickness, and sometimes not, but no food could be borne, and her sleep, which was broken, seldom brought any relief, for she continually awoke groaning with pain. Very gradually, however, a change in the character of the headache in- NERVOUS HEADACHE. 153 variably ensued ; acute neuralgic pain, coming and going over one or both brows, would set in, and occupy the place of the other, which now slowly decreased. From this moment she was able to take plenty of soup, champagne, and quinine. This case baffled all attempts at relief till the hypo- dermic injection of morphia was tried; and then, after days of maddening pain, the patient would turn round at once and sleep tranquilly for twenty-four hours. She awoke with the neuralgic period to ensue, but fortified to bear it, and after a few days' weakness and exhaustion, during which the eye retained the drawn-back feeling, she regained her usual health. Note.—February, 1877. During the last six months the patient has suffered less from the variety of headache she formerly complained of, but her general health has sensibly declined, and she is fatigued after the slightest mental or physical exertion; the noise of the street, the sound of music, or the excitement of ordinary conversa- tion are all too much for her, and she has the manner and appearance of a confirmed invalid. Her blood shows indications of great impoverishment and anaemia, as evidenced by an irritable and red eruption on the nose and face, troublesome pityriasis of the scalp, and purple patches of ecchymosis at the inner angles of the upper eyelids, which are always increased during and just after a seizure of headache. When the eruption began to sub- side she complained of pain in and about her eyes, of a very distressing character ; she could not bear the light, and to move the eyes (especially the left), either out- wards or inwards, caused acute suffering. There was also frequent neuralgia of the right and left brow, and 13 154 HEADACHES. she had great difficulty in reading, her sight seeming to go for a time when she made the effort, the letters ap- pearing clouded and misshapen. The light was so try- ing to the eyes that she always preferred a darkened room, and when able to venture out of doors she wore blue spectacles with advantage. There was no optic neuritis. Six months' absence from home life and stay- ing at different quiet places where the air was pure, and getting plenty of rest, restored her general health in a remarkable manner, and enabled her digestive powers to assimilate iron and arsenic (Form. 24 b) and a glass of port wine at her midday meal. She was also able to take brandy and egg mixture, and a full dose of quinine when an attack of hemicrania was threatening. Bromide of potassium at night, and aconitina ointment (Form. 112-113), applied over the brow, often cut short the paroxysm, and procured sleep. Moderate exercise, short of fatigue, was of advantage, but the least worry or anxiety invariably threw her back for several days. All chance of success depended upon the power to improve the quality of the blood, and to remove the anaemia of the tissues. Note.—October, 1877. On returning to home duties a severe paroxysm came on, and after three days of in- creasing agony and confinement to bed without a mo- ment's respite from pain, she suddenly became collapsed and pulseless, with cold extremities, and her condition for a few minutes was very alarming. She was unable to swallow for some time, till external warmth and fric- tion had restored her faltering circulation, and then the effort was accomplished with the greatest difficulty, owing to a sense of suffocation which the attempt excited. From NERVOUS HEADACHE. 155 this time " the nerve storm " abated in severity, leaving the patient very prostrate, but free from pain. Note.—April, 1879. Since the above report the general state of health has improved, but the headaches have assumed a more neuralgic type, the pain seizing the right or left temple, or both temples, and finally settling into what she describes as " the back of the eyeballs." It is of so severe a character that she cannot bear the light, or even lie still for many minutes together. There is generally coldness of the extremities, shivering, pallor, small contracted pulse, and a sense of indescribable misery and exhaustion. A full dose of quinine (five grains, with a few drops of spirit of chloroform and water), fol- lowed soon afterwards by a glass of champagne, or brandy in soda-water, has sometimes been found to shorten the attack, if given early enough; but more often the suffering has been prolonged over two days, notwithstanding that the quinine has been repeated every two or three hours, with various kinds of nourishment given in the intervals. The pain is traceable to indi- gestion, worry of mind, fatigue, excitement, and cold winds. C. D., aet. 40, m.; three children, one miscarriage, ac- tive and energetic temperament. When she first con- sulted me in November, 1874, she had been complaining of headaches for five months previously. Any exertion would bring these headaches on, and they generally came either after or during the flow of the catamenia; espe- cially if she took extra exertion, or was in any way ex- cited. The patient had suffered from neuralgia of the face for many years, but these attacks seldom recurred now. When these headaches were coming on, small 156 HEADACHES. things would worry and annoy her; she could not sleep, but would light a candle and read. They did not come on suddenly, but the patient was aware of their approach, and could ward them off altogether by rest and quiet. The bowels were always inclined to act too freely, and before marriage there had been great dysmenorrhea. First, a general sense of discomfort and confusion in the head was felt, trifles assuming undue importance, one idea running persistently in her head, while the patient lost all sense of proportion.* If the pain increased, it became localized in the temples and the top of the head, and there was a feeling as if something were being driven into them. " It seems, however," said the patient, " as if my spine must be in some degree Ttffected, for I am obliged to lie with my chin raised, so as to rest the back of my neck." The intense pain varied considerably in duration —from about six hours to twenty-four. When the head- * All states of nervous exhaustion, whether brought on by inordi- nate indulgence in drink, or by the ordinary avocations of life, are capable of giving rise to subjective sensations of the strangest charac- ter. They may be described as hallucinations—phantoms of the un- real and imaginary. I have met with some sufferers from headache who, in their suspended moments of agony, have told me that they had no power to give the aching brain rest. As the pain lulled, th« functions of the brain became unduly active, and the mind busy with the miraculous ; tortured with the fear of death, or the dread of com- mitting suicide. Emotional excitement, and real or imaginary wrongs, will take possession of the sufferer, and he can no more command him- self and shake off the supernatural belief, than he can bid the throb- bing brain be still. Tins is the outcome partly of a disturbed circu- lation, causing, it may be, some arrest or interference with the passage of the blood through the vessels which supply the brain and nourish its delicate tissue, and still more of an irritable and exhausted state of the cerebral cells. Irritability is the forerunner of exhaustion in nerve-matter. NERVOUS HEADACHE. 157 aches abated, sleep generally ensued for a considerable number of hours; and, on waking, the pain was gone, though the head was sore and weak. If the attack was very acute, five or six days would elapse before she re- covered her usual strength. Formerly, when the head- aches were very severe, she had slept badly for six months; now she had quite recovered her sleep, except just before an attack of headache. The patient writes (April, 1876) that she followed medical advice for six months. In ad- dition to the headache, when she first consulted me, there was great uterine loss and relaxation of the bowels. Both these functions are right now, but if she happens to get a return of the one, she also has a return of the other. The headaches are far less frequent than they were eighteen months ago, and as a rule much less severe. At the time of consultation (November, 1874), the pulse was weak, and only sixty beats per minute; the tongue was clean, the eyes were energetic, but her looks showed exhaustion. The treatment consisted in all possible rest, mental and physical, particularly at the menstrual periods. A prep- aration of iron (Form. 39) was to be taken twice a day after food, and bromide of potassium at night (Form. 40). A month later all the sumptoms of relaxation had im- proved, and bromide of ammonium was substituted for the previous medicines (Form. 25). At the close of De- cember, 1874, the bowels were more regular, and there was less headache and irritability; the pulse was firmer, and the beats were seventy-two per minute. It may be interesting to note that the mother of these two patients, who were sisters, suffered in the same way, and that she was for years under the late Dr. Todd. She suffered from extreme meningeal irritation, and re- 158 HEADACHES. mained in bed for days together in a darkened room, unable to eat a morsel of food or to retain a drop of any- thing on her stomach. During a period of twenty years, whilst these headaches lasted, fears were entertained that she would lose her intellect. After the age of sixty she ceased to suffer from them, and is bow not only entirely free, but her activity and p.owers of endurance may well be envied by persons who are half her age. The following is another example of nervous head- ache; and it presents an assemblage of symptoms, which prove unsteadiness in the brain-centre, and a hyperaemic state of the cerebral vessels from partial paralysis and dilatation. It is a matter of no great importance whether the cause is attributable to overindulgence in spirituous liquors, or to excessive mental activity. The conse- quences and the train of symptoms are much the same in both instances. And I must here insist on the fact that the true congestive headache has features in com- mon with the nervous form in some stage or degree of the attack. F. H. B., aet. 31, married, first consulted me on December 5th, 1873, for headache, to which he had been subject since 1860. He is tall, slender, pale, and dark, and leads a life full of intellectual activity, exerting his physical and mental strength to the utmost, and seldom taking that allowance of rest which is essen- tial to the enjoyment of moderate health. Eighteen years ago he had scarlet fever, succeeded by congestion of the kidneys and dropsy. At this time he had agonizing headache, leading to effusion of the brain and insensi- bility. There is little doubt that these symptoms were due to the retention of urea in the blood. When he re- covered from this illness he suffered from irritative dys- NERVOUS HEADACHE. 159 pepsia, which lasted for a year or two. The attack of headache in question came on from dining in the middle of the day, and walking afterwards. The pain grew worse and worse, and at length he became sleepy and retired to bed, when he seemed a little better. He awoke at 10 p.m. with a kind of muddling pain, and a dreadful feeling as though his head was filled with lead, and then followed a sensatien of stuffiness and throbbing:. Some- times there was a pain as if the head was opening and shutting. The headache began in one or the other temple (formerly in the left temple); it passed through to the occiput, and extended down the cervical vertebrae, render- ing the muscles of the neck stiff and painful to move from a fixed position. The headaches were sometimes attended with nausea, and sometimes preceded bv dizzi- ness. They usually came on in the morning, with a dull oppressive weight and pain; but this time he was attacked later in the day, and, as the pain grew bad, he became cold and shivering. The urine was clear and free from albumen, the bowels regular, the tongue slightly coated; the pulse 72, small, weak, and regular. The heart was healthy, and free from any organic or functional bruit. The psychological symptoms were peculiar. He would feel he ought to do a particular thing, but could not bring his mind to do it; he was playing at cross purposes, and contending between reason and obstinacy. He would not allow his wife, whom he loved, to come near him; but he would allow the nurse, whom he hated. He was irritable, and knew intuitively the remedy of three which would abate the headache; but unless his attendants could find out which it was, he was so perverse that he would not tell them ; and if they brought the wrong one, 160 HEADACHES. he was frantic and uncontrollable. In this respect he resembled his child, who also suffered from a similar form of headache. When he was overtaken with these headaches he could not keep still or lie dewn, but was perpetually walking about. As to remedies, an emetic was one of the most speedy and effectual; but the quickest remedy of all was a mustard poultice applied to the back of the neck, the feet being immersed in warm water This sent him soundly to sleep in half an hour. The day after the headache was simply one of dulness and inactivity, and if he exerted himself it would return. I ascertained in May, 1876, that this patient's head- aches were less acute, less frequent, and less inevitable than formerly, and that there was less perversity and violence of manner. A dull heavy feeling frequently threatens, but gives way to rest or treatment. Hot water to the feet, and rest, are still the two chief remedies he relies upon. He still uses a mustard poultice to the neck when the pain is very bad, but this now very rarely happens. Brandy never gives the slightest relief; and music, which at one time seemed to arrest the headaches magically, has no effect at all now. The following is an example of nervous headache of the severe type, not promising great benefit from treat- ment unless the occupation and habits of life can be entirely changed. S. B. T., aet, 43, m., consulted me May 31st, 1877. Has served twenty-seven years as an officer in the Indian army, and during this time experienced good health except on two occasions. The patient was thin and spare, of energetic habits, and nervous temperament. NERVOUS HEADACHE. 161 In 1857 he had severe malarious fever, which com- pelled him to return to England for eighteen months. In 1867—8 he held a responsible and anxious post during the Abyssinian war; the strain of mind and body was so great, that at the end of the expedition he was compelled to return to England, when he suffered chiefly from sleeplessness and disinclination for mental work. Two years' residence in this country completely set him up, and he returned to India in July, 1870, quite re- covered. In 1872 he was subjected to severe mental distress, and about this time continuous (as distinct from occa- sional) headaches commenced, and from these he is still suffering. He thus writes : " I appear to suffer from two distinct headaches; the one occurs only at distant intervals, vary- ing from one to three months; the other is continuous. The occasional headache gives some notice of its ap- proach, feeling out of sorts for a day or two previously. It commences soon after awaking in the morning, and increases in intensity during the day; the pain is dis- tracting, head hot, with sense of fulness, extremities cold, and nervous twitching. Cannot bear a reclining position for a moment, but compelled to keep constantly walking up and down, till sometimes ready to drop from fatigue; when pain moderates sufficiently to make sleep possible, still obliged to avoid a recumbent posture, and get my first sleep either in a chair, or propped up with pillows in bed. These attacks leave no trace behind, except a little shakiness next day. A strong saline draught some- times shortens their duration, and in unusually severe attacks, an ice-bag'to the head, and occasionally (though 14 162 HEADACHES. seldom) I inhale a little chloroform to deaden pain, but not sufficient to cause insensibility. "The continuous headache first commenced about five years ago, shortly after the mental strain in 1872. At first symptoms slight; would wake in the morning feel- ing unrefreshed, and with a most uncomfortable sense of giddiness and weight in the head; this would generally go off at ten or eleven o'clock. "But by degrees the periods of freedom from dis- comfort became shorter; there was difficulty in getting sleep; would constantly go to rest and sleep well for an hour or so, and then awake and be unable to sleep for several hours, generally getting up and reading in the intervals. There was great disinclination for mental work, and a putting off from day to day of business or duties, which, when circumstances compelled to be taken in hand, were transacted on the spur of the moment with satisfaction." As he continued in this state for four years, not grow- ing better, but on the whole worse, he was obliged to re- turn to England—in May, 1876* He has derived no benefit at present from being in England, as he suffers continually from this headache. The symptoms are so variable that it is difficult to describe them with precision. As a rule, there is a dull heavy pain in the head, accompanied with giddiness and with throbbing, which is sometimes so intense that the beats are distinctly felt in both ears, whilst at other times the pain is slight, and less of a throb than a sort of un- dulating pulsation. There is often pain immediately over the eyebrows, great soreness of the eyes, and unwillingness to face the NERVOUS HEADACHE. 163 light. The headache is sometimes in the brow, when it is generally accompanied with heat of surface; at other times it is confined to one spot (about the size of the palm of the hand) in the centre of the top of the head, and at others it is over the occiput and nape of the neck. Again he writes: "When very bad, every noise seems to go through the brain ; the sound of talking in the room is so unbearable that I am compelled to go away and re- main in a room by myself. Occasionally there is very great irritability, and a sort of weary restlessness, inducing a constant desire to travel about from place to place. There is unwillingness to exert the mind, in any way ; reading is taken up as a distraction, and as the memory is affected the subject is speedily forgotten. Notwith- standing disinclination for exertion, the want of regular occupation (to which I have been long accustomed) is 'severely felt, and has, I think, done more to prevent im- provement than anything else. " For the first eight months after returning from India, sleep was most irregular; night after night lying awake till two or three in the morning; but during the past few months there has been an improvement in this respect, and a broken night's rest is the exception, and any feeling of wakefulness yields to tincture of cannabis indica in twenty-minim doses, leaving no unpleasant effects next day. " My appetite is better than on my first return from India; digestion good. I am temperate, but smoke freely, and the inclination is greatest when irritable. For the last four months the headaches seem to increase in intensity at regular intervals of from fourteen to six- teen days, and sometimes there is a feeling of weakness 164 HEADACHES. and pain in the limbs. On returning from India I was examined, and the spleen was found to be tender on pressure, but the liver was free from disease. Took podo- phyllin, hydrochloric acid, and taraxacum; later on, took bromide of potassium three times a day for a month without benefit; neither the sleeplessness nor headache had diminished. Then a blister was applied to the neck, and arsenic taken, without benefit; after this, strychnine # failed. Recently quinine in gr. v doses was prescribed, and failed, and gr. x doses gave no relief. "The headaches are not hereditary.in our family, and my brother is singularly free from them, being able to say that he has never had a headache in his life." He has been constantly moving about to Scotland, to Wales, Folkestone, and Cornwall, without deriving benefit. Cannot ascertain what causes the headaches; they appear to become more intense, and to moderate without special cause; no medicine has any effect. May 31st. (His first visit.) Had intense weight this morning over head; giddiness up to 10 a.m., which has left only the feeling of weight: the pain moves about from one part of the head to another. Tongue bluish and furred ; pulse 64; pretty good ; very regular; urine pale-straw color, sp. gr. 1020, and non-albuminous; liver healthy; heart weak. N.B. The great feature of this case is nervous exhaus- tion, and a most languid circulation*. Arsenic, iron, and calumba were prescribed twice a day (Form. 24 6), and bromide of ammonium on rising in the morning (Form. 25). The diet was ordered to be plain and simple, stim- ulants to be avoided, and no tea. June 19th. He writes : " I think that, on the whole, NERVOUS HEADACHE. 165 I can fairly say that I am better; the periodical attack is somewhat less severe, and I have not suffered quite so much either from giddiness or headaches; but the sense of heaviness and dulness still remain constant." To continue cod-liver oil, or malt extract, and Car- lowitz or claret. From his account he had evidently taken too much exertion, and fatigued himself. September 30th. Benefited and improved for two months in Wales, but when out in the garden one day picking strawberries, the sun was powerful, and beating fiercely down his back whilst stooping. In the afternoon one of his severe headaches came on, and he has never been well since. The weather after this was damp and depressing for six weeks; he felt weak and depressed; the chief new symptom was aching pain in the small of the back, which he has never lost. Frequently he felt feverish, and on one occasion, soon after the " sunning," had a distinct but mild attack of ague. Giving up smoking did no good ; the pain in the back gives more uneasiness than the headache itself. As he was obliged to return to India, he was advised to avoid the heat of the sun, and as much as possible to live quietly. A simple plaster was ordered to the back, and hydrobromic acid and qui- nine twice a day (Form. 14). The origin of the pain in migraine is supposed by some authorities to reside in the optic thalami, and the visual defects to originate in the organ of the affected side, and then to extend downwards in the course of the sensory tract. I must refer the reader to the different opinions held by Dr. Broadbent, Dr. Ferrier, Dr. Bastian, and 166 HEADACHES. Dr. Crichton Browne.* The latter writer, in speaking of the blood-supply to the great ganglia of the corpus striatum and thalamus opticus, thus writes: " But the middle cerebral, the chief artery of the corpus striatum, is distributed to the motor regions of the cerebrum, while the posterior cerebral, the chief artery of the optic thala- mus, is distributee! mostly to the sensory regions of the cerebrum. These facts surely suggest the intimate asso- ciation of the corpus striatum with motor, and of the optic thalamus with sensory functions." In some few instances I have known the hair to fall off from continued nervous headache, and when this hap- pens the scalp becomes the seat of great irritation, with troublesome pityriasis. Both Cazenave and Neligan have observed the same.f Two cases are in my recollection where the scalp became the seat of so much irritation that * Dr. Crichton Browne's paper on The Functions of the Thalami Optici, in the West Biding Lunatic Asylum Medical Beports, vol. v, 1875, p. 129. " According to M. Hervez, of Chegoin, migraine is an arterial neurosis which takes its origin in the great sympathetic nerve, and its seat is in the nervous filaments which accompany the arteries, whilst it manifests itself in the dilatation of these vessels, and in the compression of the brain and other organs it produces. The treat- ment of migraine consists in combating the tendency to periodicity, the pain and the arterial dilatation. M. Hervez finds the following prescription of essential value in fulfilling those indications. He gives every day one pill containing about one grain of sulphate of quinine, one grain of tannic acid, and a seventy-fifth of a grain of aconitina. The dose may easily be increased to three or four such pills daily." (Journal de Medecine, December, 1876.)—Quoted from the Practi- tioner, March, 1877, p. 197. f Neligan, On Diseases of the Skin, 1852, p. 250. The late Dr. Anstie after each attack went gray over the temple which was subject to neuralgia. NERVOUS HEADACHE. 167 the patient could not summon up sufficient fortitude to resist scratching her head incessantly. The itching, tingling, and the abundant desquamation of white-brown- ish scales, are invariably increased after each paroxysm of headache. I have so often noticed the coexistence of dandriff with imbricated scales in those who have suffered from confirmed nervous headache, that it must be more than accidental. It is a constitutional affection, in which the nervous system is largely concerned, and the most frequent cases in my experience have been in women about the middle period of life, who have suffered from catamenial disturbance. It is not improbable that a local irritation may be induced through the branches of the fifth nerve, as they ramify over the scalp, and so lead to an excessive secretion from the sebaceous glands. Wlien the greasy scales so formed are allowed to remain, they become dry and brown, and in some few cases the scalp underneath is tender and reddened. But it is important to distinguish the disease from eczema, which may gen- erally be done without difficulty ; true pityriasis being characterized by an absence of exudation and albuminous secretion. A weak ointment of nitric oxide of mercury is an excellent application (Form. 114 a). Another curious affection of the skin is sometimes ob- servable in women about the middle period of life, who are great sufferers from nervous and neuralgic headache, patients who have endured severe pain for years, and who are much exhausted in consequence. Their dark shrivelled eyelids and blank expression of the face attest the fact beyond doubt. The complaint to which I allude is known as Xanthelasma Palpebrarum. " The patholog- ical nature of this affection is an hypertrophy and altered 168 HEADACHES. color of the epithelium of the sebiparous gland and of its exccretory tubuli."* It is a new growth of connective tissue infiltrated with an oily material which imparts to the discolored integument the buff or yellow color. The disease consists in defined patches of discolored skin, of irregular outline, occupying the upper and lower eyelids at the inner eanthus. They are variable in color, some- times being of an orange or lemon tint, but that of cha- mois leather, or nankeen, is a good resemblance. They are smooth and soft, and look like caseous matter imme- diately beneath the skin. The patches are not attended with pain or irritation, and they never ulcerate nor sup- purate. They are generally looked upon as permanent and incurable, but Professor Erasmus Wilson says he succeeded in removing the disorder in one patient by the application of compound tincture of iodine, and by the internal exhibition of arsenic.f Treatment.—Here a task of exceeding difficulty lies before any writer, and no amount of experience enables him to lay down any uniform plan for adoption and guidance. Every case must be treated on its own merits; absolute and binding rules are useless. A method of treatment which has answered our expectations in one case is futile and barren of results in the next; the mis- ery pursues a determined progress till the attack is over. Practically, then, the patient resigns himself to his fate, till the nerve-storm has worn itself out by excessive ex- penditure, and sleep has readjusted the tremulous circu- lation within the head. If we can induce the patient to * Diseases of the Skin, by Erasmus Wilson, F.R.S., 1863, p. 619. t Op. cit., 1863, p. 620. NERVOUS HEADACHE. 169 alter the habits of his life, we may hold out the prospect of arresting the frequency of these headaches ; and, more- over, we shall bestow some ease and comfort, if we can fortify the general health to resist them, till increasing years and physiological changes in the different organs of the body, render the patient no longer susceptible to them. In one instance constant change of scene and place, by occupying the patient's mind with new ideas and pleasant thoughts, kept the disease at bay. AVe may lay down golden rules, but the circumstances of life seldom admit of their being observed faithfully or consistently. A man is obliged to live in a large town, and from bad air and want of exercise he gets severe headaches ; if he resides in the country he loses them. But he has no choice of residence; his lot has fallen among the noise and crowd, where all is hurry and excitement, and he is driven for- ward with the throng, as feeble to oppose it as the stream of a gentle rivulet is to reverse the course of the moun- tain torrent into which it falls. When a nervous headache is threatening, the patient should lie down and observe the strictest seclusion and rest; and if this be done at an early stage, a severe at- tack may sometimes be averted altogether. The sudden influx of light when the curtains are drawn up of a morning in a dark bedroom, may instantaneously cause the return of a bad attack, previously stopped by a good night's rest. Mr. May, of Reading, once had under his care a most remarkable case of a lady subject for years to " intense headache and intolerance of light, commencing on first awaking in the morning, and persisting more or less all day." The immediate effect of the first influx of light was to cause a severe frown, followed by headache. 170 HEADACHES. Mr. May cured the patient by covering one eye with a card to which was attached an elastic tape, and this was passed around the head, so as to slightly compress the occipito-frontalis and corrugators. " This simple device effectually prevented the frown, and there was at once an end to the mischief." The eyes were afterwards gradu- ally accustomed to light by being alternately covered and uncovered by the card for two hours at a time, so as to regulate the admission of light. The patient completely recovered, and remained free from headache till her death about eighteen years later.* When persons derive benefit from lying in a recum- bent posture, and taking a glass of wine or some other diffusible stimulant, at the beginning of the attack, the cerebral vessels are insufficiently supplied with blood ; and hence, by stimulating the heart's action, the blood is propelled to the cranium with increased force, and relief is obtained. This is the stage and form of headache where people (especially fashionable ladies) overfatigued from driving and excitement in the London season lose their headaches as the dinner advances, and they consume more wine than is advisable. The feet and hands are often cold at this stage, the skin is shrivelled and dry, and the pulse is slow and weak ; there are in some cases glimmering flashes of light before one or both eyes, and the patient is depressed, prostrate and helpless. She both feels and looks wretchedly miserable. When altered sensation has not entirely merged into pain irritability, agitation, and disquietude are the prevailing features of the affection. Now, I believe that if a stimulant is to * The case is reported by Mr. Hilton in his lectures On Kcst and Pain, 2d edition, 1877, p. 147. NERVOUS HEADACHE. 171 be of any service, it should be given at the onset of the symptoms; and if there exist nausea, or more certain derangement of the digestive organs, we shall certainly increase the evil by the exhibition of a stimulant. And why ? Because the ganglia of the sympathetic nervous system, being exceedingly impressible, transfer the irrita- tion from the splanchnic and gastric nerves to the ner- vous centres in the brain, causing the vessels to become unduly dilated through the action of the vasomotor nerves, and so the headache becomes more violent and throbbing than when the encephalic supply of blood is diminished. During the acute stage of a severe nervous headache there is so little to be done that it is the best plan to leave the patient, alone and quiet, in a darkened room. Beyond applying cold to the head by means of a sponge wrung out of cold water, or the ice-cap previously spoken of, there is nothing to be done. Interference is cruelty. If we put anything into the stomach, we shall incsease the nausea and aggravate the pain. I have sometimes known a warm bath, and afterwards a bottle of hot water to the extremities afford relief, by dilating the systemic vessels, and in some way altering the circu- lation within the head. If the pulse is good, and the face is at all flushed, an emetic of mustard, or a scruple of sulphate of zinc (Form. 108), will rid the stomach of any offensive matters, and give immediate ease. But it often happens that the nausea is extreme when the stomach is empty, or after vomiting has continued some time. In these cases it is best to try and relieve the sickness, and for this purpose hydrocyanic acid may be given 172 HEADACHES. alone (Form. 41), or with citrate of potash in efferves- cence (Form. 42). A mustard poultice, or a small mus- tard leaf to the epigastrium, or at the back of the neck, and a piece of ice to suck, are also worth trying. Soda- water and a little dry champagne or brandy sometimes answer well, and the patient may at once feel relief and fall asleep afterwards; but very frequently any stimu- lant of this character aggravates all the symptoms, and I now never resort to it unless the patient is pale and ex- hausted. An active aperient pill given the night before the attack is threatening, or an ounce of the compound decoction of aloes, will often avert the pain altogether after two or three actions of the bowels (Form. 43), if the patient will remain perfectly quiet in her room the next day, and take the lightest diet, and carbonate of ammonia, potash, and quinine in effervescence (Form. 44); but if she persists in getting up and resuming her duties, the mind is put upon the stretch too early, and headache returns in its worst forms. When the headache is coming on, and the patient is irritable and can obtain no sleep, a mixture of bromide of potassium, sal volatile, and camphor-water may be given with great advantage (Form. 26). If the patient too is in any way excited, as the attack threatens, and there are transient flushings of the face, and a sense of overpowering heat and faintness (by no means uncommon in women at the climacteric period), a full dose of bromide of potassium will be extremely beneficial by allaying the mental disquietude and subdu- ing the excitement on which the distressing symptoms depend. If it is given at the right moment, before the headache has set in completely, it will frequently arrest NERVOUS HEADACHE. 173 the approaching paroxysm altogether; the patient will fall into calm sleep, and wake up well, provided she will aid the cure by absolute repose. Valerianate of zinc is a remedy which often proves serviceable in nervous headache, if there is no sickness, and if the pain is chiefly on one side of the head. It is a powerful nervine tonic, and may possibly exert some physiological effect on the nervous centres. It may be given alone in the form of a pill, or with quinine or rhu- barb (Form. 87). If the headache is associated with anaemia, it may be ordered in combination with sulphate of iron (Form. 97). The late Dr. Symonds was in the habit of prescribing oxide of zinc, extract of valerian, and extract of hyoscyamus together; * and Dr. E. Live- ing quotes a case of paroxysmal headache completely cured after the administration of twenty-four grains of valerianate of zinc.f Oxide of zinc alone has been found of use in a few cases (Form. 98). Oxide of silver in half-grain doses, with two grains of extract of hyoscyamus in a pill at bedtime, effectually removed an obstinate-nervous head- ache due to irritation of the sympathetic nerve, after the failure of other remedies. Full doses of hydrochlorate of ammonia are also to be mentioned as deserving a trial in these cases, when the physician is driven to his wits' end (Form. 27). If the pain is chiefly confined to a spot or small space on one side of the head, belladonna or aconitina ointment may be rubbed into the temple at the same time (Form. 110- * Gulstonian Lectures on Headache, in Medical Times and Gazette, 1858, vol. xvi, p. 496. f On Megrim and Sick Headache, 1873, p. 448. 174 HEADACHES. 113), and quinine persevered with, as in the neuralgic variety of the affection. AVhen quinine causes headache, it is well to combine it with hydrobromic acid* (Form. 14). I am in the habit of prescribing, with much ad- vantage in these cases, the bromide of potassium and tincture of quinine together (Form. 13), and I am fully satisfied that the headache and nervous excitability would have increased by the employment of the quinine alone. I knew, many years ago, a young lady who obtained relief from a nervous headache by drinking a tumblerful of warm water twice or three times a day, and this she sometimes did with equally good effect at mealtimes. The inhalation of chloroform in acute nervous head- ache sometimes controls the severity of the paroxysm, and induces sleep; but if there is any nausea it is rarely of service, and usually provokes vomiting, which dis- tresses the patient and increases the suffering. Guarana has not proved a successful remedy in the few cases in which I have employed it, but many medical men have borne testimony to its efficacy on the first symptoms of headache making their appearance. It may be given in doses of 15 or 20 grains in water with an equal quantity of sugar, and repeated in half an hour if it does not afford relief. Dr. Latham speaks well of it when there is glimmering in the field of vision, pain in one temple, and nausea or vomiting.f Dr. Wilks also gives testimony in favor of it.| As it appears to stimu- * The formula for preparing the hydrobromic acid is given in a short paper by Dr. J. Milner Fothergill in the British Medical Jour- nal, July 8th, 1876, p. 40. f Dr. Latham, on Nervous or Sick Headache, p. 69. % Medical Times and Gazette, January 2d, 1869. NERVOUS HEADACHE. 175 late the vasomotor nerves, and so to diminish the supply of blood to the brain, it would have no good effect, prob- ably, in the early or premonitory stage, when there was disturbance of vision; but at a later stage, if the head- ache is severe and attended with throbbing of the tem- poral arteries, it may succeed when the bromides and other remedies fail. This remedy is also of service in the genuine neuralgic headaches (hemicrania). When, in a case of this character, the face is pallid and the pulse weak and slow, and the patient is begin- ning to feel the want of sleep, there is no remedy equal to the hypodermic injection of morphia.* It may be always used with the greatest safety if the quantity is small to begin with, and the patient needs sleep. Noth- ing has so realized my expectations in those pure forms of nervous headache, where I think it more likely that the nervous centres are in a state of extreme suscepti- bility than that the calibre of the vessels is changed. If it does not completely remove the pain, it induces sleep, or gives that amount of repose which renders the patient indifferent to all that goes on around him; and in this way the brain gets rest from those harassing thoughts and miserable speculations which haunt the poor sufferer, and from which there is no escape. I repeat what I have elsewhere written, as it bears on * " The quick and powerful action of morphia and other narcotics, when injected beneath the skin, affords a familiar illustration of the fact that a current of liquid is constantly passing from the tissues into the blood; the blood being, of course, the vehicle by which the ab- sorbed morphia reaches and acts upon the nervous centres."—"On Certain Physiological Phenomena connected with the Circulation, Respiration, Secretion, and Nutrition," by George Johnson, M.D., F.E.S., in British Medical Journal, January 1st, 1876, p. 7. 176 HEADACHES. some points under consideration.* When the sickness and prostration are extreme, and nothing can be retained on the stomach, not so much as a little iced water; when the extremities are cold and the pulse feeble ; when there is intolerance of light and sound, and the patient has been days without getting any relief; the one-sixth of a grain of acetate of morphia for an adult will be sufficient to insure sleep, and the patient will wake up without headache, if not well. Sometimes the addition of the 80th to the 40th of a grain of atropia will exert an antagonistic effect, and combat the tendency to sickness which morphia alone frequently excites (Form. 116). In cases of nervous headache I have lately used the hypodermic injection at once, without waiting for the effects of other remedies, and seen immediate relief follow. I would urge the employment of the remedy when the patient is distracted with agony, though the pulse be slow and weak, and the features collapsed. There will be no risk of employing it at this stage of depression, if the sufferer has been accustomed to the subcutaneous in- jection of the drug. On one occasion I found that, after a few hours' rest and repose (during which time the sur- face becomes warmer and the pulse improves), the pain and sickness returned, but with less intensity; then, after retching had continued some few minutes, the stomach was able to retain a teaspoonful of brandy and two ounces of soda-water, after which the patient fell asleep for several hours. This treatment has cut the paroxysm short, and recovery has been much more rapid ; the terrible confusion of ideas and nervous excitability * On the Treatment of Different Forms of Headache, in The Lancet, vol. i, 1875, June 19th, p. 854. NERVOUS HEADACHE. 177 have been prevented, and the prostration after the attack has not been so tedious and lingering. I consider, how- ever, that the system tolerates the injection better at a more advanced stage, when the excitement is abated, and the patient is worn out for want of sleep. In the intervals of the suffering we may reasonably expect to mitigate the severity and frequency of the paroxysms, provided the patient can and will carry out our instructions. When a severe headache has passed off, the stomach is often deranged from the remedies employed or the sym- pathetic disturbance set up in the various organs. Here an alkali, with the aromatic spirit of ammonia and a vegetable bitter, has a good effect (Form. 45), and a mild aperient pill at bedtime (Form. 99), particularly a small quantity of iron with aloes and myrrh, to empty the large bowel (Form. 85-86). When the tongue is clean and the secretions are in proper order, iron in effervescence is a valuable remedy twice or three times a day after food, and sometimes strychnia may be added to improve digestion and ac- celerate the capillary circulation (Form. 46). In the case of women, where the menstrual functions are de- ficient and the bowels sluggish, five grains of the iron and aloetic pill of the British Pharmacopoeia (Form. 85) will answer well, whilst the nitromuriatic acid in in- fusion of quassia, with small doses of strychnia, may be employed during the day, or the tincture of nux vomica, which answers better with some persons (Form. 47-48)- A dinner pill, given daily before luncheon, will sometimes prove of great service (Form. 77), or one or other of the formulae (78-100-101). 15 178 HEADACHES. In cold weather, if the nutrition of the body is much impaired, cod-liver oil will be found of great service, and a teaspoonful may be given, after the two chief meals of the day, in a little of Morson's pepsin wine or orange wine. But fresh air, exercise, and relaxation of mind and body are the chief remedies on which to rely. NERVO-HYPE1CEMIC HEADACHE. 179 CHAPTER VIII. NERVO-HYPER.EMIC HEADACHE. Condition of the Cerebral Vessels, and Diagnosis from Nervous Headache—Most common in Men who indulge in Stimulants and whose Brain is overworked at the same Time—Symptoms indi- cate Nervous Exhaustion, with Depression of Spirits and Loss of Appetite—Excitability of Manner and Annoyance from Trivial Causes—Frequently met with in Young Persons of both Sexes— Use of an Emetic—Aperients—Alkalies—Occasional Utility of Opium—Bromide of Potassium and Chloral. I intend by this term to imply a form of headache in which the nervous element is concerned, and the ves- sels of the brain are overloaded and in a state of vascular irritation. It is by far the most common form of con- gestion, and fully one-half the cases that seek relief are to be classified under this head ; at least this holds good with male subjects. At one stage or another the nervous headache indicates that the vessels of the brain are con- gested, because it is liable to paroxysms of severity from any excitement or noise, hot rooms, or eating and drink- ing. There is not the same amount of prostration and helplessness, which are the striking features of the ner- vous headache. It belongs to persons whose circulation is excitable, and to those who are impulsive and undis- ciplined, or who, from the force of circumstances, have no alternative but to work on and abide the consequences. 180 HEADACHES. It is met with in men whose brains are overworked, and whose meals are hurriedly taken, especially if at the same time they indulge freely in wine and spirits, and do not get a full allowance of sleep. These persons are liable to flatulence; they have a coated tongue in the morning, and a dry unpleasant taste in the mouth ; the breath is hot and offensive, and there is thirst and a total loss of appe- tite. Such persons go on working against time with an ardor and zeal which they feel to be irresistible. They appear to know that the speed with which they are carried along is detrimental, and that soon they must yield in the contest; and yet, unless they give up work altogether, they have no power of moderation. Control is gone. This condition of the brain makes men really nervous ; if they can be convinced of the mischief that may come, they slacken the speed for a time, and in some instances when they find the weight of the symptoms pressing upon them the reckless fortitude is abandoned for complete surren- der, and the whole aspect of the man's manner and life is changed. With this exhaustion, and partial or general conges- tion of the brain, there is great nervousness, with lowness of spirits and depression. The appetite, however, in many cases is natural, and the sleep may be good, or, what is more common, the patient feels inclined to sleep after dinner, but when he gets to bed is wakeful and restless, turning about from side to side ; his mind is busy with strange ideas, or he is morbidly solicitous about himself or others. Then in the morning he wakes unre- freshed and eats his breakfast in a hurry. If he is vexed or annoyed, he can scarcely prevent himself from goino- into great passion and rage. He feels a rush of blood NERV0-HYPER.EM1C HEADACHE. 181 to the head, and a passing sensation of momentary uncon- sciousness. His scalp is hot, the capillaries of the face injected, and the eyelids are wearied and tremulous. For the rest of the day (and for some time afterwards, it may be) his legs and knees feel as if they would give way under him, and he does not walk securely. If he has been in the habit of riding, he has no confidence in the saddle, and any sudden movement of the horse drives the blood to the face and head. Such a patient as this may pass an excessive quantity of lithic acid in the urine, es- pecially if he is of gouty or rheumatic diathesis; but it more frequently happens that the urine is copious and clear, of acid reaction, and of low specific gravity. In one patient, whose case chiefly furnished these remarks, the urine contained a copious quantity of phosphates, when the headache and nervousness were severe; and I never noted their absence with this state of the head. A good example of this headache is also seen in women at the change of life, whose constitution till this time has been sound and good, and the mind properly balanced. The catamenia have been regular up to the age of forty- five or thereabouts, and then somewhat suddenly they have become sluggish, or irregular and scanty. At each re- turning period there has been headache across the fore- head, and weight over the eyes. The patient complains of flushes of heat, and the head and scalp are hot. Any allusion to her condition drives the blood to her cheeks, and a dry skin is succeeded by a hot oppressive perspira- tion, with faintness and languor. She sleeps badly, and sees dark spots before her eyes; she cannot concentrate her attention on her household duties; and her children vex her, and easily put her out. She is made jealous and 182 HEADACHES. excitable without reason and magnifies into questions of great moment trifling circumstances, to which at other times she would not pay any attention. There are many cases of mixed headache, happening to young persons of both sexes, and due as much to cer- ebral hyperaemia as to nervous disturbance. The cheeks are flushed, the eyes suffused, and the patient is compelled to lie down and discontinue the duties of the day. The symptoms cannot be attributed to a gastric origin, for the tongue is clean, the pulse is quiet, and there is no indi- gestion. Here the vasomotor system is at fault, and the cerebral vessels are relaxed. Remedies like strychnia and gentian, the mineral acids, and iron (Form. 47-53) are more serviceable than depletion, which, by weaken- ing the nerve-force, would further increase the excitabil- ity of the cerebral tissue. A careful discrimination of these cases, which may well baffle a shrewd observer, is very necessary, and successful treatment depends on a correct diagnosis. As regards treatment, a mercurial pill followed by an effervescing aperient saline, will often cut short the attack (Form. 18-81-61). Three grains of blue pill when the headache is threatening will sometimes get rid of the misery in a few hours, and the fixed alkalies, as bicarbonate of soda or bicarbonate of potash, will also be of service, by re- lieving the acidity of the bowels. It is a good plan to get the bowels to act promptly, and this may be pro- moted by soap and water enemata. Where there is much throbbing of the temporal arteries, and the patient feels nausea on turning round, or going into a warm room, an emetic of ipecacuanha or sulphate of zinc (Form. 108- 109) will act in a marvellous manner; and even if there is NERVO-HYPER.EMIC HEADACHE. 183 no food in the stomach whatever, the effort of vomiting relieves the congestion of the liver and duodenum, and the headache departs. In this class of cases, where there is hot burning headache, with cold hands and feet, de- pressants of the circulation are valuable remedies, and among them aconite (Form. 106) may be selected, from its power in dilating the contracted vessels of the ex- tremities. During the acute attacks we are powerless to do more than this, and when they pass away and the patient re- sumes his ordinary habits, he feels as well as at any time of his life. In cases where the headache lingers, or re- turns from slight excitement or fatigue, the ordinary treatment would consist of bromide of potassium with laxatives or a bitter stomachic twice a day (Form. 68), and if there is acidity and flatulence,, the subcarbonate of bismuth, in full doses half an hour before meals (Form. 107), will be found of value. I have often seen great benefit derived from bromide of potassium or ammonium, with small doses of sal volatile, taken on first getting out of bed. As a sedative at night, where the patient rests badly, bromide of potassium alone (Form. 40).or in com- bination with hydrate of chloral, is the best (Form. 67). I do not think tincture of opium should be ventured on in these cases, particularly if the pulse is at all hard or incompressible; but where it is soft, and of average fre- quency, I have known a few drops of nepenthe (Form. 69), given with bromide of potassium or hydrate of chlo- ral, tranquillize the patient and promote refreshing sleep. As long as the headache persists, a non-nitrogenous diet and abstinence from stimulants ought to be observed. I know an unmarried lady, thirty years of age, who 184 HEADACHES. v thinks she would lose her senses if she did not take a full dose of chloral (Form. 70) when the headache is severe. It relieves the pain quickly, and on comparing this case with that of a patient (much her senior in years) who gets relief from the hypodermio injection of morphia, I find the effects of the two agents very similar in the com- fort and undisturbed sleep that ensue. But the two head- aches are due to different pathological conditions,—in the one the maddening pain is as much owing to increased vascularity of the contents of the encephalon as to a morbid excitability of the nerve-centres; in the other the nervous system is primarily and chiefly at fault, and hydrate of chloral would further rob the brain of its de- fective blood-supply. The action of chloral is not always to be explained in these complicated cases. A young person who enjoys good health in the intervals of the attacks of headache, suffers no continued inconvenience from an occasional dose. The system soon rallies from any depression it might induce, but persons should be warned not to fly too frequently to this nerve-depressant, nor to take it at random without any regard to preventive treatment in the intervals of suffering. Chloral is taken for all kinds of headache by many, who get relief in the stupor and drowsiness which follow, and although they may resort to it from time to time, without experiencing any immediate ill effects, they are nevertheless, in many cases, injuring their nervous tissue where it is frequently resorted to. The action of chloral is double: in the first place, it acts directly upon the nerve-tissues themselves, lowering their activity; in the second place, it depresses the circulation and the respiration. Chloral kills by paralyzing the respiration and the circulation (H. C. NERVO-HYPER.EMIC HEADACHE. 185 Wood). In non-lethal doses, chloral by its double ac- tion produces chronic starvation of the brain-tissues ; not only that, but there is danger in its continued use, as not rarely, under these circumstances, a fatal result has fol- lowed from depression of the circulation and respiration produced by the ordinary doses. The condition of the brain becomes more and more debilitated under frequent resort to it, and the excitement gives place to a state of mental lethargy and inaptitude, accompanied by irrita- bility, which lays the foundation of perverted nutrition, and such changes in the nerve-centres as in the long run encourage serous effusion, and the waste of brain-struc- ture. In those cases where chloral furnishes great relief during the acute attack, it is well to give nervine tonics during the intervals by means of quinine, strychnia, phos- phorus, and iron (Form. 14-21-24); taken regularly at these times, the nutrition of the brain-tissues is improved and the attacks are rendered less frequent and less severe. Such treatment during the interval is in no way incom- patible with the use of chloral during the acute attack. 16 186 HEADACHES. CHAPTER IN. TOXiEMIC HEADACHE. Headache of Fever owing to the Action of Poisoned Blood on the Nerve-centres — Character of Headache in Acute Fevers — Relapsing—Typhus—Simple continued—Enteric—Whooping- cough—Measles—Scarlet Fever—Variola—Malarial Poisoning —Ursemic Headache—Headache from Gas-poisoning—Symp- toms and Treatment — "Body-snatchers' Headache" — Local Abstraction of Blood—Leeches—Cold Affusion to the Scalp— Ice-cap—Quinine — Ammonia — Antimony— Opium — Case of Headache from Malarial Poisoning—Arsenic and its Constitu- tional Effects in continued Doses—Phosphorus—Cod-liver Oil. It will be well in the first place to consider under this category the headache of fever, which I have elsewhere termed febrile headache.* The pain is attributable to an alteration in the constitution of the blood and its com- ponent parts; this causes a morbid sensibility of the nerve- centres, and induces congestion of the vessels and mem- branes of the brain. When the absorption of the fever poison into the system has taken place, every tissue through which the blood passes is impressed by it, and one of the most constant indications of its pernicious effects is headache. Headache is present in the simple fever of common catarrh, when the frontal sinuses are congested, and the lachrymal glands pour out an abun- dant secretion. It is a striking symptom in influenza * See Diseases of Children, and Chapter XVI. TOX.EMIO HEADACHE. 187 and frequently recurring colds, when there is prostration of the strength, and the nervous power is reduced. The sudden impression of cold or atmospheric poison may exert an influence on the fifth nerve, at its origin in the brain, through the branches of the ophthalmic nerve, springing from the Gasserian ganglion. In the chapter on Sympathetic Headache, I have already alluded to this extensive nerve communication, along which morbid im- pressions are so readily conveyed. In acute fevers headache is rarely absent. With re- spect to its relative frequency, Dr. Murchison has noted that, of ninety-two cases of typhus, headache was com- plained of in all but six. Dr. Henderson found it in 150 out of 159, and Dr. Stewart in a large number of cases.* The pain generally occupies the forehead and temples; it is of a dull heavy character, and is attended with giddiness and confusion of ideas. In young and strong children the pain is intense, and frequently forms the most prominent and leading feature of the disease. When it is acute and distressing, it is often associated with great restlessness, flushing of the countenance, and injection of the conjunctival vessels. If this state is over- looked or neglected, it may lead to delirium and profound somnolence, from which the patient cannot be roused. In relapsing fever, headache is a common and early symptom, and is more darting and throbbing than in typhus.f In typhoid fever, headache is also a frequent symptom, both in adults and children. Dr. Murchison ascertained that it existed in seventy-seven out of eighty- * Murchison, On Continued Fevers, 1862, p. 150. f Murchison, On Fever, 1862, p. 345. 188 HEADACHES. two cases, and M. Louis in all but seven out of 133 cases.* The pain resembles the headache of typhus in its dull continuous character, and in its usual limitation to the forehead; but the mental faculties are rarely impaired, and delirium is exceptional. In simple continued fever, and that variety known as ephemera, headache is more or less present; and in some forms of the same disease, where the duration of the fever is longer and more in- tense, it is relatively more acute than in either typhus or enteric fever. | The poison of malaria gives rise to a severe type of headache, either anteriorly (frontal), pos- teriorly (occipital), or on either side (hemicrania). We meet with headache, again, in whooping-cough and scar- latina, in variola, measles, ete.; in fact, in all those dis- eases in which a toxaemic condition of the blood exists. Headache is also frequently found in some acute local inflammations, as pneumonia and pericarditis, and the treatment should be determined by these respective lesions. There is no specific febrile or inflammatory disorder which does not create some morbid impression on the brain, and in many instances, as we have seen, the cere- bral cells become irritated and disturbed, till the inflam- matory affection passes away 4 * Ibid., p. 487. f Ibid., p. 600. X It does not appear that the intensity of the cerebral symptoms in typhoid fever in adults, or in extreme cerebral congestion and tuber- cular meningitis in children, bear any relation to the morbid ap- pearances found after death. In some fatal cases, when the head symptoms have been trivial, extreme vascularity of the membranes has been discovered, and the vessels and sinuses of the brain have been gorged with dark blood ; whilst in other cases, when the head symptoms have been severe, and there has been delirium and even TOXEMIC HEADACHE. 189 I might reasonably have included the headaches of gout, rheumatism, and syphilis under this name, seeing convulsions in children, no sign of inflammation could be detected, but considerable effusion of serous fluid into the lateral ventricles and beneath the arachnoid. A large quantity of intracranial fluid is not infrequent in typhoid, and as regards the substance of the brain itself it is more frequently found normal than otherwise. In typhus fever the same rule obtains, viz.,| that in the absence of severe cerebral symptoms during life, abnormal vascularity of the membranes of the brain may be detected after death. In both these diseases the cere- bral congestion is not greater than may be found to exist in cases of severe pneumonia or bronchitis, or any disease which has impeded the pulmonary circulation. There is no sign of inflammation, and the congestion is of a passive rather than of an active character. The transparent and often colorless serum which is found in the ventricles, and beneath the arachnoid, is rather more common among the morbid appearances in typhus than it is in typhoid. A few albuminous flakes are occasionally present in both diseases, but there is no genuine lymph or exudation corpuscles in either—no products we can term inflammatory. The subarachnoidean serosity and the fluid between the convolutions and the sulci are well marked, and this large amount of fluid, although not indicating any inflammation, does assist in ex- plaining the severity of the cerebral symptoms during life. In young children of rickety constitution, when the head is growing unusually large, the convulsions and comatose condition have, in my experi- ence, borne a close relation to this excessive secretion of fluid. Yet most physicians will declare that, when the amount of fluid is trifling, the cerebral symptoms are as great as when the quantity is excessive. The symptoms are chiefly attributable to the altered quality of the blood," and the elevation of its temperature in the cerebral vessels. In relapsing fever the same remarks apply without exception ; there is no constant relation between the cerebral symptoms and the state of the brain and its vessels. The vascularity of the membranes and the serosity in the ventricles do not in any way explain the head symptoms during life, and there is no proof whatever that the brain or its membranes are liable to be inflamed in consequence of the fever process. The inference is that the headache of fever is essen- tially dependent on the presence of the specific poison in the blood, and the accumulation in it also of the products of tissue change, 190 HEADACHES. that the accumulation of morbid products in the blood impairs the nutrition of the nervous tissue, and originates pain and suffering; but although these headaches are sympathetic, and secondary to the constitutional state which calls them forth, I think a separate classification is advisable for the varieties depending on the special affections to which I have alluded. A form of headache due to toxaemic change (urannic headache) now and then occurs in connection with disease of the kidneys, when their secreting tissues are impaired, and they are no longer able to separate the excremen- titious matters from the blood. They may act energeti- cally for a time, but at length the morbid material in the blood ceases to exert a diuretic influence, and degenera- tion in their structure takes place. In a little girl, aged ten years, who came under my care in 1875 with acute desquamative nephritis and anasarca, the headache was most inveterate, occupying the entire forehead, and con- tinuing for days together. When the local congestion had subsided, and the urinary secretion had increased in quantity, she obtained relief; but if any animal food was taken, even in the shape of beef tea, it renewed the head- ache by still further impairing the functions of the elimi- native organs, and causing on two or three occasions which are not eliminated by the proper channels. The nutrition of the brain suffers inconsequence of this detention, Tio(\vi;hstanding the wide difference in the nature of the respective fever poisons. Hence it is that the nervous system generally becomes oppressed, and the sympathetic partially paralyzed. As a matter of clinical experience I am informed by Dr. Bro ulbent that protracted headache in the early stages of enteric fever denotes unusually severe affection of Peyer's patches, and is often followed by haemorrhage at a later period. TOXyEMIC headache. 191 severe haematuria. Active aperients from time to time, and a diet consisting exclusively of milk, were the chief remedies trusted to. In the case of a man, 64 years of age, who came under my care in 1864 with chronic Briglit's disease, the frontal headache was insupportable, and lasted, without intermission, from the day of its commencement to his death, a period of many months. The slow accumulation of urea in the blood (uraemic poisoning), from gradual degeneration in the kidneys, rendered all attempts at relief abortive. The most re- stricted and careful diet, with purgatives and stimulating diaphoretics, only produced temporary benefit. Where the cause cannot be removed there is little to be gained from any plan of treatment. When he became anaemic, a few drops of the tincture of the perchloride of iron were tried ; but no relief was obtained, because the blood became more and more contaminated, in consequence of the increasing destruction in the secreting apparatus of the kidney and the absorption of the urinary ingredients. As usually happens in these cases, drowsiness and stupor came on, and the patient died comatose from uraemic poisoning. The headache may be the first sign that the kidneys are damaged, and the indications are to remove the ex- cessive amount of urea from the system. Put the patient on a milk diet, and give no animal food or stimulants of anv kind whatever, or the congestion of the kidneys will increase, and blood appear in the urine. The action of the kidneys will be promoted by giving acetate or citrate of potash and digitalis (Form. 1-2), or the same salt with spirit of juniper and decoction of broom. Cream of tartar drink (tartrate of potash, Form. 3) will mildly ex- 192 headaches. cite the action of the renal organs, as well as freely open the bowels, and unload any obstruction of the portal sys- tem. Diaphoretics, hot-air baths, etc., are useful at the proper time, by assisting the elimination of urea through the skin. If the headache is severe, and there are con- vulsions, with a scanty discharge of concentrated urine, venesection or cupping over the loins may be demanded to save the patient's life. If anasarca conies on, and there are indications of cerebral oedema or effusion into the ven- tricles, then the digitalis and citrate of potash mixture will be required to rouse the flagging action of the heart and kidneys. Where anaemia has been complicated with the anasarca at this stage, and the blood gets gradually thinner and more impoverished, I have found minute doses of the bichloride of mercury, with the tincture of perchloride of iron, of great service (Form. 4). It re- lieves renal congestion by favoring the escape of exuda- tive products from the urinary tubules, and in this way it increases the diuretic action of the kidneys, and improves the vitiated state of the blood at the same time. Under this treatment I have witnessed every trace of anasarca disappear, and the headache depart entirely. I cannot dismiss this character of headache without considering the effect which toxic agents have on the blood and nervous system, when the atmosphere is viti- ated by crowded assemblies or the imperfect ventilation of apartments. I believe that the accumulation of car- bonic acid and expired air in school and lecture-rooms is to be reckoned among the chief exciting causes of head- ache in young persons, and still more in adults when the nervous system becomes more susceptible with the ad- vance of years. TOXEMIC HEADACHE. 193 " The normal quantity of carbonic acid being .4 vol- umes per 1000, it produces fatal results when the amount reaches from 50 to 100 per 1000 volumes; and, at an amount much below this, 15 or 20 per 1000, it produces in some persons, at any rate, severe headache. Other per- sons can inhale, for a brief period, considerable quantities of carbonic acid without injury; and animals can be kept for a long time in an atmosphere highly charged with it, provided the amount of oxygen be also increased. In the air of respiration, headache and vertigo are pro- duced when the amount of carbonic acid is not more than 1.5 to 3 volumes per 1000; but then organic matters, and possibly other gases, are present in the air, and the amount of oxygen is also lessened. Wrell-sinkers, when not actually disabled from continuing their work by car- bonic acid, are often affected by headache, sickness, and loss of appetite, but the amount of carbonic acid has never been determined."* Facts like these attest the danger of continually breath- ing an atmosphere vitiated and overcharged with carbonic acid. The dangerous consequences are first made mani- fest in the reduction of the force and frequency of the heart's action,f and in the enfeeblement of the whole capillary circulation, which causes the brain gradually to become exhausted from the diminished quantity of blood it receives, and then follow headache, languor, and inca- pacity for sustained mental exertion. When the amount of carbonic acid in the atmosphere * Practical Hygiene, by Dr. Parkes, 1873, 4th edition, p. 112. f Cyon brought a frog's heart to a standstill by passing through it serum charged with carbonic acid ; on removing the carbonic acid from the serum the heart began to beat again. 194 HEADACHES. is large, the requisite elimination of it from the lungs does not take place, and the blood, becoming more ve- nous and impure, fails to impart its accustomed stimulus to the cerebral vessels, which now fall into an atonic state; while the normal amount of oxygen in the blood is re- placed by the retention of the gas, and a diminution of vascular pressure. In one form of headache the symptoms appear to have arisen from gas-poisoning, i. e., gas generated by putre- faction, fecal fermentation absorbed into the blood, and thus producing its effects upon the brain and spinal cord. This form of headache often commences with a feeling of heaviness and dulness the first thing in the morning, and gradually increases till the middle of the day, when it may be temporarily relieved by luncheon ; but it soon reappears and increases through the afternoon and even- ing, unless relieved by treatment. In the head there is a sense of heat, weight, and dul- ness, and nervous prostration and inability to apply the mind to work, or to make any physical exertion—the legs seem to lose their power more or less. The tongue may be quite clean, or have a little white coating; but it never has the thick yellow fur at the back and sides, always present in the bilious headache. Treatment.—The only remedy is a drastic purge, in a fluid form to insure rapidity of action. This brings away a fetid evacuation, with the escape of extremely offensive gas, generated by the putrefactive fermentation which has taken place instead of healthy digestion. Senna, aloes, Tamar-Indien, syrup of buckthorn are amongst the most useful remedies. Saline aperients are utterly use- less, as they fail to bring away the offensive gas, and TOXEMIC HEADACHE. 195 only produce watery evacuations—a little saline may be usefully combined with the drastic, as quickening its action and allaying any feverish condition, but the drastic must be relied upon and its effect obtained. Stimulants are decidedly injurious. This form of headache with gas-poisoning very much resembles the headache from gas-poisoning by sewer gas, from decomposed bodies in the dead-house and dissecting- room. The old " Body-snatchers " were quite familiar with it. My friend, Mr. W. Adams, informs me that in the year 1842, and for some few years afterwards, when he used to make the post-mortem examinations at St. Thomas's Hospital, he had as a dead-house assistant a well-known man who had been one of the leading body-snatchers for many years, and he told him that when doubling up a body and putting it into a sack, the body-snatchers always turned their heads away, and were extremely careful not to inhale any of the gas which generally escaped from the stomach of the body when bent. If a body-snatcher should " get a gnlph," as he expressed it, he knew it would be followed by headache and nervous depression from gas-poisoning, and he had learnt from experience that these symptoms would be increased by gin or brandy, to which he would naturally resort. This man told Mr. Adams that on these occasions he always avoided spirits, and took two strong pills as soon as he got home. Thus he had learned that the eliminative treatment by a drastic purge was the only reliable means of curing the headache and depression produced by gas-poisoning. In the treatment of the forms of headache arising from specific fever, careful judgment will be required. When 196 HEADACHES. the brain is oppressed by the high temperature of the blood, and the accumulation of effete and poisonous mat- ters within it, there is imminent danger to life, if this state of things is permitted to go on unchecked. The local abstraction of blood is a measure to be held in recol- lection, seeing that it has sometimes averted the most threatening cerebral symptoms. It removes the extreme venous tension, and, by promoting a free action of the skin, brings down the temperature. Three or four leeches applied to the temples will act in a most efficacious man- ner, and relieve the patient more completely and quickly than anv other remedy at our command. Cold affusion to the scalp, or the application of the ice-cap, may, in ordinary cases, render their employment unnecessary, but the abstraction of blood is sometimes the only chance of subduing the pain, and amending the patient's general condition. In the headache of aged and feeble persons, who are struck down by fever, warm fomentations appear to be of service. They were used by the late Dr. Craves, and sanctioned by Dr. Murchison.* It must be understood, however, that there is the headache of exhaus- tion which succeeds sleeplessness, and is independent of any inflammatory condition of the brain or membranes. For this state, quinine, ammonia, opium, and antimony may be demanded to restore the equilibrium of the brain, and to mitigate the nervous agitation which is associated with it. In the headache due to malarial poisoning a full dose of quinine will be advisable, if it is periodical in character. As large a dose as gr. x or gr. xv has been recommended * Loc. cit., p. 274. TOXEMIC HEADACHE. 197 before the attack, and it may be necessary to push it to cinchonism in divided doses, and then gradually diminish the dose (Form. 5). The following is a severe case of malarial poisoning and hemicrania. J. R., aet. 49, m., sallow, tall, and corpulent, consulted me July 3d, 1877. Has lived in Bombay for twenty- five years, and had good health till nine years ago (1868), when he got headache diffused over the forehead. Two days later, he had a bilious attack—violent spasms, retch- ing and bringing up large quantities of bile, passing it by the bowels as well. The attacks came on once or twice a week, and the doctors ascribed them to malaria. There were new drainage works going on, which his duties called upon him to superintend. After suffering more or less for fourteen months he went to Australia, and there lost his headache; but on his return to Bombay he suf- fered again, within six or eight weeks. In 1870 he was ill again, and, in consequence, came to England, and lost his bilious attacks, but not his head- ache. His wife, who was with him in India at the time, became subject to similar attacks, and it is only recently that they have abated in severity. In November, 1872, he returned to Bombay, and was as bad as ever ; then he suffered from 1872 to July, 1877, and for some time took forty-five grains of quinine in three doses daily for one month; the effect was to keep off the headache for one year, during which time he felt well; the urine was clear, and the motions healthy. When the headache was bad, heat or cold applied over the eye would give relief; occasionally there was pain 198 HEADACHES. in the right eye, and insupportable depression of spirits accompanied it. In 1875 he came to England again for three months, and derived considerable benefit; returned in November, and after being a month in Bombay the spasms, vomit- ing, and headache returned in all their former severity. He took ipecacuanha, which made him sick and ill; and since then he has had no vomiting, but severe headache, extending through the left eye and temple, which would find its escape through the left shoulder. He was worst at noon, when the sun was at its height; generally the pain would begin at 3 a.m. and last until 7 p.m., when he fell asleep, and woke up relieved in a few hours; a cup of tea or coffee would sometimes relieve the pain quickly. Heavy sleep and snoring were invariable pre- cursors of an attack. During the last year, his memory, which was formerly acute, has become very defective. There is no disease of the heart, liver, or spleen ; ab- domen very large and flabby ; he is now fidgety and irri- table^ and cannot bear the least noise or excitement; he looks pallid and sallow; pulse 96 ; tongue clean ; bowels free; urine clear, reaction acid, sp. gr. 1020, non-albu- minous. He has taken tincture of gelseminum, croton chloral, and bromides, without benefit. He was now ordered arsenic, quinine, and bromide of potassium twice a day in a mixture, and a dose of Friedrichshalle water in the morning, twice a week. The diet was to be plain and simple, with a little claret and water with his meals ; cheese, pastry, and tea to be avoided. July 9th. Has had some headache over the left eye, but not so piercing or severe; he caught cold a few days TOXEMIC HEADACHE. 199 ago, which he considers a sufficient cause. The bowels not having acted satisfactorily, he was ordered to take two pills of aloes and myrrh, with half a grain of sul- phate of iron (Form. 86). July 12th. He is much better, and has had no head- ache since the last visit. Two pills acted well, and pro- duced two motions ; urine clear; he feels stronger and not worried with anything or anybody; pulse 84 ; free from pain entirely. His aspect is now clear and ani- mated. July 17th. On the 15th, 16th, and 17th headache began at 3 and 4 a.m., and lasted till 8 and 9 A.m., each morning. It commenced over the entire brow, forehead, and eyes; now it has extended to the left side of the head, and he has pain and tightness in the right side over the liver. The pain makes him emotional; he can scarcely avoid crying or being excited, and he often sheds tears when reading. The region of the liver is tender and its area slightly increased ; the urine is turbid and high-colored. He was ordered a pill containing a grain of calomel at bedtime, a sulphate of magnesia draught in the morning, and citrate of potash with quinine in an effervescing mixture during the day. July 25th. On the 22d he went to church, and there felt pain ; on the following day it recurred ; then on the succeeding evening had attacks lasting for some hours. This occurred for three evenings, and on the 23d did not get up till 6 p.m. The pain begins in the left eye, and then extends over the head, but he has had no shivering ; he sleeps better, and is certainly improved in all respects. A mixture of citrate of iron and arsenic 200 HEADACHES. was now ordered to be taken twice a day, after food, when free from headache, and the bromide mixture when an attack was threatening (Form. 26). July 30th. His head had been better, but two morn- ings since he had acute pain over the liver, sudden and piercing, and this he has experienced in Bombay. There are no physical signs of hepatic congestion; the urine is clear, and the bowels free. The iron mixture seems to exert a slightly aperient effect. • August 14th. He had no attack whatever till the 10th, when it began in a moment at 4 p.m., and continued all day and night. On the 11th the pain was better in the early morning, then it returned at 1 p.m. and lasted all night. Before the attack of headache comes on the urine is always cloudy and thick, and when it passes away it becomes clear. This periodicity in the headache suggests the use of quinine in large doses, and therefore the previous medicines were, discontinued, and two pills, each containing three grains of quinine, were prescribed twice a day. September 26th. A month's residence at the seaside improved his general condition, but he had three attacks, two mild and one severe. He took quinine only when the pain was on him. October 6th. On returning to town a few days since he got an attack of headache, which seized the forehead at 3 a.m., and then settling in the right temple and eye, gradually passed up to the top of the head, where, as a heavy weight, it would last for hours. I now gave a phosphorus capsule (gr. JG daily) and quinine and iron in a mixture ; in addition, as the patient was corpulent, TOXJEMIC HEADACHE. 201 a Turkish bath was ordered once in ten days, and a dose of Friedrichshalle water twice a week. December 11th. The patient reported himself quite well in health, and his general appearance and manner fully bore out his testimony, for he was now active and energetic, and most desirous to return to his duties in India. He had in a great measure exchanged his sallow aspect for a fresh color, and his eyes sparkled with intel- ligence and vigor; he took long walks without fatigue, and went into society without experiencing any after ill effects. In February, 1878, he returned to Bombay quite well in health. If the pain continue to recur in these cases, Fowler's solution and tincture of belladonna, in five-drop doses, are recommended by Dr. Smith, increasing the arsenical solution one drop each day (Form. 6 to 9). It may be advisable to persevere with this combination if phospho- rus and quinine should fail. "I have witnessed the postponement and ultimate cessation of a periodic head- ache, through the influence of arsenic, before the prick- ling evelid or silvered tongue demonstrated its agency" (Begbie). Arsenic is a remedy of the greatest possible value in nervous cases, if it is given judiciously and watched carefully, but it is too generally abandoned on the first symptoms of constitutional irritation becoming manifest, and when its alterative effects on the blood are about to be secured. Under these circumstances it should be suspended for a time, and then cautiously resumed. Every practitioner should make himself familiarly ac- quainted with the physiological signs of arsenical action, for the exhibition of small doses long together, in some persons of peculiar idiosyncrasy, is accompanied with so 17 202 H SADACHES. much nausea and nervous depression, as to render the continuance of the remedy inadmissible.* Phosphorus is another good remedy in nervous and neuralgic headache, and also in that form arising from the poison of malaria, as we have just seen, where the nerve-centres are depressed and exhaustion is the conse- quence of it. Its action is not unlike that of iron and cod-liver oil, and it is a constituent of many of the tissues, especially the nervous. I have now and then observed its beneficial effects after the failure of other well-known remedies, and therefore, in all obstinate cases, it should have a fair trial, as its general tonic effects in repairing the waste of nervous tissue are very marked, and in my experience it has occasionally produced the happiest re- sults. Phosphorus is one of the most important agents we possess in nervous exhaustion, and its efficacy is undoubted when administered in an unoxidizcd state, capable of being readily assimilated. No remedy requires more care in prescribing than this, for whilst in small doses it is a * " Arsenic, when given continuously in moderate doses—say, five drops of the liquor arsenicalis, diluted largely with water, twice or thrice a day—will, sooner or later, generally within eight or ten days, produce increase of heat and dryness of skin, together with accelera- tion of pulse, followed by a sense of heat and itching of the eyelids, to which succeed swelling and tenderness ; the conjunctiva becomes in- flamed, the eye sensitive to light, and the orbits surrounded by a dark discoloration. The tongue at this time will be found finely coated with a white silvery film, resembling that produced by touching its surface with a weak solution of the lunar caustic. . . . The throat becomes dry and sore, the gums swollen and tender; and, if the med- icine is still further persisted in, salivation ensues."—"On the Phvs- iological and Therapeutical Effects of Arsenic," by James Begbie, MD., F.R.S.E., in Contributions to Practical Medicine, 1862, p. 270. TOXEMIC HEADACHE. 203 gentle stimulant and tonic, in large doses it depresses the heart's action like chloral, and is not free from danger. It may be well to begin with gr. g'¥, but I have seen no ill effects from gr. ^; and thus, after a time, may be taken twice a day. I never exceed this quantity. Then as to the best mode of giving it. The Pil. Phosphori of the British Pharmacopoeia is seldom ordered, as it is open to objections, which are now overcome by more recent modes of prescribing phosphorus in such a form as shall insure its activity. The Pharmacopoeia pill, when made, is kept in water, and after a time it becomes extremely hard, and resists absorption in the stomach, passing through the intestines in an unchanged state. As an excellent solvent of phosphorus, cocoa butter and Castile soap have been recommended (Yearbook of Pharmacy, 1876), to form into pills which will keep well, and retain their properties. Messrs. Squire recom- mend a formula composed of mutton suet, liquorice, and mastic. They consider it an excellent combination, as the virtue of the phosphorus is retained, while in this form it is taken up readily by the stomach. The perles of phosphorus are an excellent form for administration. They appear to retain the virtues of the drug for an indefinite time, and to be readily digested and absorbed. This leads me to say that the sugar-coated pills con- taining phosphorus are unreliable. I am told, on good authority, that the phosphorus is oxidized or volatilized by the necessary heat employed in the process. If there is a base such as oxide or carbonate of iron, or strychnia, it will form a chemical combination and become a hypo- 204 HEADACHES. phosphite. Hypophosphites are made by boiling phos- phorus with lime or soda. Cod-liver oil, as in all forms of neuralgia, is sometimes of great service in hemicrania and neuralgic headache, if the opportunity is seized of giving it in the intervals of suffering, when the patient is free from pain. As in some cases of gastralgia, cod-liver oil brings relief, when fer- ruginous tonics and the most careful diet fail, so will it frequently ward off attacks of neuralgic headache by im- proving general nutrition, and strengthening the tone of the nervous system. ARTHRITIC OR GOUTY HEADACHE. 205 CHAPTER X. ARTHRITIC OR GOUTY HEADACHE. Sometimes, though not frequently, the Accompaniment of Acute Articular Gout—Illustrative Cases — Influence of the Gouty Diathesis—Affection of the Brain and Membranes in Suppressed Gout—Character of the Pulse and Heart's Sounds—Importance of exciting Action in the Eliminative Organs—Mercurials— Podophvllin— Alkalies—Salts of Lithia—Carbonate of Am- monia. When the febrile disturbance is considerable, and the secretions vitiated, acute gout is now and then attended with severe frontal headache, and weight across the eyes. Many persons who experience periodical attacks of acute articular gout escape headache altogether; but others are not so fortunate. I should say from my own experience that headache is not a frequent accompaniment of gout, and that, whenever it is present, it is generally in those persons whose general health has been shaken by many previous attacks, and whose nervous system has suffered in consequence. One gentleman, who consulted me in 1867, stated that for upwards of twenty years he had been a martyr to gout, but that the last attacks had alarmed him from the severe headache which accom- panied them, although the foot was swelled and inflamed, and the urine copious and free from albumen. The pain was frontal, obstinate, and depressing, and it continued for some days after the local inflammation had subsided. Carbonate of ammonia proved a reliable remedy; and 206 headaches. sometimes a stimulating draught, consisting of quinine, chloric ether, and camphor, was of great use in relieving the pain (Form. 16-30). A gentleman, thirty-five years of age, who was suffer- ing from his fifteenth attack of acute gout in May, 1876, consulted me for headache, which was a new symptom of his complaint. The right great toe was vividly in- flamed and tender, and had been so for some days before I saw him. His nights were disturbed and restless (as they had been on many former occasions), but he was reluctant to attribute the headache to pain in the joint, or to want of sleep. As the urine was abundant and clear, and the bowels thoroughly open, I attributed the headache to the local pain and general weakness; and I prescribed the carbonates of ammonia and potash in effervescence, with small doses of colchicum. Under this treatment the local disorder soon subsided, and the head- ache departed. Dr. Garrod mentions a very interesting case of gouty headache in a lady, sixty years of age, who consulted him for intense headache, from which she had suffered about seventeen days. The pain chiefly occupied the vertex and back of the head, and was somewhat periodic in character. There was heat and tenderness of the painful part. The affection was considered hysterical at first, but on the next evening the pain suddenly left the head, and the ball of the great toe became acutely painful and tender, swollen, red, and shining. It was a severe attack of acute gout. The occurrence of a second fit after some months was not preceded by headache.* * On Gout and Rheumatic Gout, by A. B. Garrod, M.D., F.R.S. 1862, p. 515. ARTHRITIC OR GOUTY HEADACHE. 207 The influence of the gouty diathesis in exciting severe headache is well illustrated in the following case recorded bv Dr. Begbie.* For the limitation of space at my dis- posal, I shall make no apology for abridging the details. A lady, aged thirty-five, of full habit and florid com- plexion, had suffered for many years from severe and lasting headache, which had defied the power of many and divers remedies. It was difficult to fix upon any variety of headache which had been observed to answer to the character of that which she presented. " It was not nervous or hysteric; it was not inflammatory or con- * On Gout and the Gouty Diathesis in Contributions to Practical Medicine, 1862, p. 29, case xvi. " It is somewhat difficult to class the several forms of intermittent headache with other affections of this kind ; but those having length- ened periods of intermission may best perhaps be noted here. The equality of time often observed, even where the intervals extend to two or three weeks, or yet longer, is a very remarkable feature in these cases, and denotes a cause specific in its nature and uniform in its operation. I know instances where such intermittent headaches have occurred during the greater part of a protracted life. More frequently, however, it happens that they affect especially certain periods of life; in this, as in many other circumstances, showing singular relation to the disordered actions of the gouty constitution, with which, as I have stated in a former chapter, I cannot doubt their close kindred and dependence on the same causes. In conformity with this view there is reason to believe that the kidneys are the ex- cretory organs most concerned in giving relief in these cases, and principally by an increased separation of the lithic acid or its com- pounds. Such action may readily escape notice, where the attention is directed by the presence of pain to another part; but I infer it from close observation of many intermittent headaches, and think the remark likely to be confirmed by others."—" On Morbid Actions of an Intermittent Kind," in Medical Notes and Reflections, by Sir H. Holland, Bart., M.D., F.R.S., 1855, p. 288. 208 HEADACHES. gestive; it was not anaemic; it was not dyspeptic. It could not be traced to cerebral disease j it was not of neuralgic or rheumatic character; it was not periostitic; it was not periodic. As the urinary secretion from time to time presented alternately oxalates and lithates in great excess, and the hands of the patient's father pre- sented 'the little knobs of Heberden,' some light at length arose to reveal the true character of the perplex- ing headache. The paternal grandfather was the victim of gout, and died of heart disease. Under the persistent employment of a combination of colchicum with the nitrate and carbonate of potash, aided by those regula- tions of diet and exercise which are suitable to the gouty habit, the severe headaches were relieved and ultimately removed." There is another form of headache occurring to per- sons subject to irregular gout, and who are sallow and cachectic in appearance. This form is far more important than the varieties we have been considering, because it denotes a more serious affection of the brain or mem- branes by the gouty poison, due to the latter not finding its proper vent through the joints and cutaneous surface. Some years ago I attended a gentleman who suffered from this form of headache. He was nearly sixty years of age when he first came under treatment, and remained under my observation for upwards of twelve years. The character of the urine and evacuations from the bowels indicated great disorder in the functions of digestion and assimilation; and, although there were pains and obscure swellings in the knuckles, wrist, and feet, no reo-ular attack of gout ever showed itself. The symptoms were ARTHRITIC OR GOUTY HEADACHE. 209 due to the retention of the gouty poison. The patient was liable to be seized with giddiness in walking, and could only be saved from falling by being supported. He experienced at the same time noises in the ears, and a sensation as of something giving way in the head. His complexion was sallow, his sight dim, his face bedewed with perspiration, and his pulse weak and slow. His tongue was generally clean, or only very slightly furred; while the motions were always either clay-colored or dark and bilious, and the urine threw down a thick red- dish sediment. It was noticeable that the headache was often relieved when the urinary secretion became thus changed. An active mercurial medicine would gonerally, I found, relieve the headache after the secretions were rectified; but occasionally the symptoms would continue for days, accompanied with extreme flatulence, disor- dered digestion, and irritability of temper. On some occasions there were fearful attacks of painful colic; but when these were present the head was free from dis- comfort. When effete products accumulate in the blood, the vaso- motor centre becomes damaged, and the minute arterioles are thrown into a state of spasmodic contraction. This is proved by the increased tension in the pulse, and the reduplicate and accentuated sounds of the heart, as in the case of albuminuria. In the confirmed gouty headache of advancing years the cerebral arteries are atheromatous and thickened, and the calibre being diminished, the blood-supply to the brain is insufficient to nourish it. The emotional conditions to which this important change gives rise are shown in outbursts of passion, and fits of 18 210 HEADACHES. melancholy depression. " Irascibility is the characteristic par excellence of a brain fed with blood laden with gout- poison, and hastiness is habitual; but as the condition of heart-failure becomes slowly developed and superimposed upon the gouty condition, the characteristics of cerebral anaemia are blended with those of lithiasis."* For this variety of gouty headache, absolute repose, light diet, and careful attention to the liver and bowels, are of paramount importance. If the kidneys are struc- turally unsound, the patient is in constant danger of his life from the accumulation of the gouty poison; but if they act well, relief may be obtained. This headache, in fact, is due to gout pent up in the system, and, dam- aging the nervous centres, instead of seeking elimination through the joints in the form of articular inflamma- tion. The treatment, therefore, is much the same as for gout, modified according to the peculiarities and exigen- cies of each particular case. The gouty diathesis may affect in turn all the internal organs, as is shown by the character of the intestinal disorder, the palpitation, the syncope, the dyspnoea, the vomiting, and headache. And this is liable to occur periodically with those persons whose constitution is not vigorous enough to throw off the poison through the joints. It is, in fact, an inter- nal fit of gout, and the treatment must be conducted on general principles; always bearing in mind the liability of the brain to be depressed by the incautious use of sed- atives, and particularly of colchicum. W^hen the urine is loaded, and the evacuations dark or clay-colored, mer- * On Cerebral Anaemia, by Dr. J. Milner Fothergill, West Riding Lunatic Asylum Medical Reports, vol. iv, p. 104. ARTHRITIC OR GOUTY HEADACHE. 211 curials, podophyllum, alkalies, and salts of lithia may be needed (Form. 79-80-81-31-33-94). Carbonate of am- monia will relieve the head, and minute doses of colchi- cum may be tried with it to act as an alterative on the blood (Form. 16-32). Of course the same precautions are necessary as in gout, viz., abstinence in eating and drinking, and taking regular exercise. 212 HEADACHES. CHAPTER XL RHEUMATIC HEADACHE. Its Seat—Causes—Symptoms—Importance of Diet and Attention to the Digestive Functions—Iodide of Potassium—Bark—Colchi- cum—Baths and Waters. This is occasionally met with in rheumatic subjects. It affects the aponeurosis of the scalp, and the occipito- frontalis and temporal muscles. It comes on from expo- sure to cold in railway travelling, from the head being uncovered (especially when heated or perspiring), or by sudden changes in the temperature, when north or east winds prevail. But even then it is probable that there has been some predisposing derangement of the general health, or some stomach or liver disorder. The pain is marked by an aching and a tenderness of the scalp and jaws, severe, heavy and continuous; there is an aching too of the teeth and gums (which are often exquisitely tender), and mastication becomes painful. There is no throbbing of the temporal arteries, nor elevation in the temperature of the scalp, but the face is sometimes flushed, the eyes are injected, and the vessels of the head and face are loaded and excited, so that if the patient is of full habit he gets a somewhat bloated appearance. The pain increases in the evening, and grows less towards morning. Dr. Sieveking points out that, according to Romberg, the RHEUMATIC HEADACHE. 213 pain is of paroxysmal and hemicranial character, espe- cially affecting the forehead and vertex, from which it radiates in various directions, a description which does not completely accord with the majority of cases which have come under my own observation. " I do not," he continues, " find that authors allude to the possibility of an intracranial rheumatic affection ; but I have repeatedly met with cases of cephalalgia in which no such exter- nal indications presented themselves, and in which the concomitant symptoms, though but feebly marked, the history of the case, and the anti-rheumatic treatment adopted, appear to justify the conclusion that the dura mater, the fibrous envelope of the brain, was the seat of the disease."* This remark quite coincides with my view of the affection, for the dura mater might with as much show of reasoning be expected to sympathize in rheumatic headache, as that the fibro-serous pericar- dium should sometimes be involved in acute articular rheumatism. Treatment.—For the treatment of this headache atten- tion to diet is of primary importance, in order to counter- act the rheumatic tendency. Vegetables, milk, and tapioca are preferable to animal food, and a little dry wine to beer and spirits. Any derangement in the diges- tive organs must be overcome by suitable remedies, in order to restore the functions of the bowels, skin, and kidneys (Form. 3-19); and where the local disorder has followed a general attack or is complicated with neural- gia, then iodide of potassium, bark, the alkaline carbon- ates, and small doses of colchicum will be serviceable * On Chronic and Periodical Headache, by E. II. Sieveking, M.D., F.R.C.P., in Medical Times and Gazette, 1854, p. 209. 214 HEADACHES. (Form. 36-34-35). "I think it almost certain that some kinds of headache are produced by the same mor- bid cause in the circulation, which brings on, in other persons, or at other times, true gouty affections of the joints. With due attention to the family temperament, to the individual habit, and particularly to their connec- tion with certain states of the urine, it is for the most part easy to discriminate them ; and where thus attested, colchicum will generally be found to act as a safe and effi- cient remedy."* A sudorific at bedtime, and a liniment to the temples or nape of the neck (Form. 73), will often relieve the wearing pain; and I know of one gentleman who obtains most relief from wrapping up his head in flannel. Warm clothing is very essential; and if the case is obstinate, and the patient has the means to pro- cure change, he may with advantage go to Vichy, Ems, or Homburg, and take the baths and waters there. * On Gout as a Constitutional Disease, in Medical Notes and Re- flections, by Sir H. Holland, Bart., M.D., F.R.S., 3d edition, 1855, p. 267. HEADACHE FROM AFFECTION OF PERIOSTEUM. 215 CHAPTER XII. HEADACHE FROM AFFECTION OF THE PERIOSTEUM. Headache attacking the Periosteum—Its Symptoms and Treatment- Large Doses of Iodide of Potassium—Bark—Bichloride of Mer- cury—Small Doses of Calomel—Quinine—Arsenic. This is met with in the subjects of secondary syphilis. It is limited to spots on the scalp, which are tender on pressure; they occasionally present some swelling, as is seen on the skin and sternum when these parts are af- fected with nodes. The pain is always aggravated at night. The outer surface of the dura mater and the bone are often involved ill syphilitic inflammation, lead- ing to adhesion of the brain to the affected spot, and even suppurative phlebitis. A pink or red swelling from congestion takes place, with a caseous patch in the centre.* " Meyer relates eight cases of intracranial dis- ease, in which there were found either fibrinous (gumma- tous) tumors in the brain, or the results of internal peri- ostitis or inflammation of the membranes, besides more or less marked indications of syphilis in the liver, in- guinal glands, or other parts."f Dr. Symonds alludes, in his remarks on the headache * Pathological Anatomy, by AVilks and Moxon, 2d edition, 1875 p. 198. f New Sydenham Society, article, Nervous System, 1862, p. 79. 216 HEADACHES. of secondary syphilis, to the experience of Mr. Spencer Wells, who has noticed a very striking symptom, pain across the forehead where the brim of the hat presses. The pain is due to subacute frontal periostitis; and, if the case is bad, and the system saturated with the syphilitic poison, the specific inflammation may extend to the mem- branes, and involve the brain itself. One of the most marked instances of this type of head- ache came under my notice nearly twenty years ago. The subject of it was a young officer twenty-five years of age, in whom the syphilitic cachexia was strongly marked. The pains in the head (chiefly frontal) were the latest manifestations of the syphilitic poison, and Mere the chief cause of his quitting the service. The natural placidity and cheerfulness of his disposition were exchanged for irritability of temper and fits of passion. The attempt to alter his position in bed, or to give food at the wrong moment, threw him into an uncontrollable fury. To this succeeded great exhaustion, a feeble pulse, and a clammy skin; and sometimes nausea and vomiting were also present. For some days he would continue in a state of heavy stupor, from which it was as difficult to rouse him as to rouse a drunken man. He would turn his face from the light, knit his brows, and conceal his head be- neath the bedclothes. Iodide of potassium in large doses, with tonic bitters and bark, were ordered, together with small doses of the bichloride of mercury, from which he derived partial benefit (Form. 37). But eventually the condition grew worse, the cachexia increased, and the brain fell into a state of syphilitic degeneration, producing hemiplegia from which he partially recovered for a few months. HEADACHE FROM AFFECTION OF PERIOSTEUM. 217 Gradually the worst symptoms returned ; he became more and more exhausted, probably from obstruction in the cerebral vessels, or lesion in one or more of the mem- branes, and died at the end of a year after the head was first affected. Until the paralytic symptoms came on the external surface of the head was always tender, and at times exceedingly painful. No fluctuation or signs of matter were found beneath the periosteum, which I-have known to be the case among soldiers who have had syph- ilis in a bad form. The treatment is the same as was employed in this case, iodide of potassium being the chief medicinal agent. It should be given in full and continuous doses, and not abandoned till forty or sixty grains have been taken during the day, freely diluted with water, and after the principal meals. If it is hastily given up the case may end fatally, when large and repeated doses may cure. " The average dose of iodide of potassium is from twenty to thirty grains three times a day, which is reached by rapid steps, from six to eight grains given at first. The larger doses are necessary. I have repeatedly seen re- lapses, when the dose has been at ten or twelve grains, checked and cured by a rise to twenty-four or thirty-six grains. I have given a drachm every four hours for a short time, and one patient came to me who had for two or three months taken this quantity three times a day with advantage, under the direction of his family medical at- tendant, who had ' bettered' my advice after a previous consultation with me. On the other hand, I have met with cases in which a single grain of iodide of potassium produced great depression and other injurious effects ; in these one-quarter or half a grain may do all the good, or 218 HEADACHES. iodide of sodium or of ammonium may be tolerated."* It occasionally happens that small doses of calomel (gr. T\) every two or three hours relieve the pain, and prepare the way for the iodide. Another remarkable case of syphilitic headache in a young man fell under my notice some years ago. The patient, who was strong and healthy at the time when he contracted syphilis, took an abundance of mercury, which greatly reduced him, and encouraged the ulcerative pro- cess. Severe secondary symptoms ensued, with nodes on the cranium and tibia?, which produced foul suppurating sores, and caries of the affected bones. Alarming epilep- tic seizures followed, accompanied by great irritation of the brain and membranes, and his life was often despaired of. When a sore on the leg or foot discharged freely, it favored the escape of the syphilitic poison, and consider- ably modified the cerebral symptoms. The treatment consisted in strict attention to hygienic rules, the fresh, pure air of the country, and a generous diet. The rem- edies prescribed in the shape of drugs were iodide of po- tassium, quinine, and arsenic (Form. 38). Under their separate and combined use, and that great power which nature, if allowed time, possesses to remove morbid pro- ducts, when the internal organs have escaped structural mischief, the patient perfectly recovered, and is now in as good a state of health as any person of his age could expect to be. In cachectic conditions mercury may be given with ad- vantage, and without detriment to the patient, if com- bined with iron (Form. 4). * On Syphilitic Affections of the Brain, by AV. II. Broadbent M.D., in The Lancet, Nov. 25th, 1876, ORGANIC HEADACHE. 219 CHAPTER XIII. ORGANIC HEADACHE. Character of the Pain in Organic Headache, Continuous, Limited, or Paroxysmal—The General Symptoms assist in the Diagnosis of the Cerebral Changes—Often due to Atheromatous Degenera- tion in the Cerebral Vessels—Terminations in Apoplexy and Paralysis—Usual Causes of Organic Headache—Cysts—Hydat- ids—Exostoses—Syphilis—\Talue of Large Doses of Iodide of Potassium in all Cases of Cerebral Tumor, whether due to Syph- ilis or not—Rest to be procured by Bromide of Potassium and Hydrate of Chloral—If all Hypnotics fail, the Hypodermic In- jection of Morphia to be employed. Organic headache (Cephalalgia organica) is called "Structural Headache" by Dr. Symonds, but I prefer the term organic, because it is more clearly expressive of the grave morbid changes which provoke it, such as tu- berculous, cancerous, or syphilitic tumors, hydatids, os- sific formations within the cranium, softening of the brain, adhesion of the membranes, arterial degeneration, aneurism, obstruction of the sinuses, and so forth. But disease of the brain from any of these causes may be present without our being able to recognize its nature or its extent, as in the case of the late Professor J. Hughes Bennett. A tumor may exist and cause neither headache nor any cerebral disturbance, if the membranes are not stretched, and inflammation does not ensue. When either of these results follows, then symptoms, which till then 220 HEADACHES. have been obscure and perplexing, are occasionally cleared up. The brain accommodates itself to pressure when it is gradual and brought about slowly, and thus the encroachment is not resented, owing to a new adjust- ment of the circulation, and balance of the various struc- tures within the cranium. Before pain is complained of, there is sometimes impairment of function, as in the case of a small tumor, or softening at the origin of the third nerve, by no means an uncommon accompaniment of or- ganic headache; and we derive important and conclusive evidence of the situation of the lesion, when the patient does not complain of the sensation of headache, and is able to follow his usual duties. Yet on the other hand, a tumor has been found to occupy the centre of one of the hemispheres of the brain, or ventricles, and to cause no disorder of motion or special sensation, no failing sight, no impairment of intellect, no threatening palsy. Pain in the head has been the one single and constant symptom, sometimes even intermitting, and coming on in paroxysms. This depends on some varied condition of the circulation. Paroxysmal pain is often observed in structural disease of the brain, from the liability of all nervous pain to take on this peculiar feature ; but if pain is intense and continuous, and is referred to one particu- lar spot, some organic lesion may be suspected. The headache which never yields for a moment to any treat- ment may be safely put down as organic. The pain of organic headache is an abiding and continuous agony ; it enters into every thought, and the patient lies in some obscure corner of the house, or in bed, silently enduring the maddening pain, with the saddest and most pitiable expression. He can do nothing, and think of nothing • ORGANIC headache. 221 it is impossible to distract his attention in such a way as to convince one that he is ever entirely free from paiu. "Dr. Hughlings Jackson remarks that frontal headache is generally referable to abdominal affections, vertical headache to cerebral disturbance, and occipital pains to disorders of the circulation, and more especially to anse- mia. However that may be, it is certain that the pain due to cerebral disease may, especially in the case of cer- ebral tumors, be referred to all parts of the head, and that this pain may exactly simulate those which are of no less serious origin. It may be slight or intense, con- tinuous or paroxysmal; may be attended with tenderness of the scalp, or with several of the symptoms which have been already referred to as frequent accompaniments of headache. When the pain is intense, and especially if it be paroxysmal, it frequently causes the patient to scream out, and to support his head with his hands. The most intense pain, which is then usually very limited as to its seat, is induced by the pressure of intracranial tumors or abscesses upon sensory nerves."* Dr. Walshe's experi- ence concerning the diagnosis of a cerebral tumor is much to the same effect. He says, " The circumstances most distinctly permitting the physician to affirm that a tu- mor exists within the cranium are: the existence for a con- siderable period of intense cephalalgia, especially if lim- ited to a fixed point, or even to one side of the head, and if attended with repeated vomiting ; of convulsive move- ments without paralysis, but followed by mere weakness, or actual paralysis of the affected parts; of different af- fections of the organs of sense, especially alteration of * The Theory and Practice of Medicine, by Dr. Bristowe, 1876, p. 942. 222 HEADACHES. sight, and of disturbance of intellect, while the general health does not very materially suffer."* It is obvious that the pain, as a rule, varies according to the size and seat of the tumor, and the pressure to which the several nerves are subjected ; but when it is remembered that a tumor may attain considerable magni- tude before it causes pain or inflammation, the subject of diagnosis is confessedly obscure. Dr. Abercrombie re- lates a class of cases, which are often mistaken for peri- odical or sick headache, the pain not being urgent enough to invite attention to the head as the origin of the mis- chief, but to the stomach as the supposed offender. After death the chief morbid appearances are found in the cere- bellum. There are cases, too, in which giddiness, failing muscular power, loss of sight and recollection, are the chief features; but there is no headache whatever, and exemption from it may be possibly owing to degenerative changes in the nervous tissue, rather than to pressure on membranous structures, and congestion of the cerebral vessels. Organic headache, then, is distinguished by the con- tinuance of the suffering, which either extends over the entire brain, or is deeply seated in one spot. It occasion- ally resembles the congestive form of headache from over- distension of vessels, which is so frequently present; though some cases exhibit pallor and anaemia, with much pain. Some years ago a man, aged forty, came under my care, who suffered the most excruciating agony in the vertex and left side of the head, from which he never had a moment's respite, and his agony was so acute that he * The Nature and Treatment of Cancer, by W. H. Walshe, M.D., 1846, p. 495. ORGANIC HEADACHE. 223 longed for death. Though there was at no time of his early illness any symptom of paralysis, or loss of memory or sensation, it was conjectured that he was suffering from disease of the brain, because the pain was continuous and fixed, and his expression vacant and desponding. His forehead was wrinkled, his brows drooping, and his eyes had lost all animation. In the course of a few weeks, whilst under observation, delirium came on, accompanied by vomiting, and inability to retain any food on his stom- ach. These symptoms continued, and he fell into a coma- tose condition and died. After death a cancerous tumor Mas found in the left hemisphere, extending posteriorly and downwards to the margin of the left lateral ventricle, but not to the deeper structures at the base of the brain. The presence of febrile symptoms, with rigors and high temperature, where there is pain in the head, would help us to the diagnosis of the organic change within the cranium, as in tubercular mischief, or the formation of an abscess. When headache in a young adult man comes on with symptoms approaching convulsion, or epileptic seizure, and there is any amount of facial paralysis or thickening of speech, it is suggestive of organic origin, and more especially so if there is a history of syphilis. If vomiting be added to the list of symptoms, it is all the more likely, particularly if no relief follows, which gen- erally does follow if the headache be due to gastric dis- order. It comes on suddenly, and the patient may be able and willing to take food immediately after the con- tents of the stomach have been expelled. This headache is witnessed in softening of the brain, where the bloodvessels are diseased from atheromatous deposit. In a female patient, aged seventy, who was 224 HEADACHKS. under my care in 1875 for this headache (which she de- scribed as unceasing and occupying the whole frontal region), there were present most of the symptoms which accompany disease of the brain, such as depression of spirits, the apprehension of some impending calamity, and the gradual failure of the intellectual powers. No treatment was available in removing the headache, and it is probable the termination is not far distant in a par- alytic or apoplectic seizure. In this case, as in many similar cases, there was more confusion of ideas than pain. In 1867 a gentleman, aged seventy-four, consulted me for frontal headache, which was so overpowering, that in my presence he often wished for deliverance by death. He had had two slight apoplectic seizures in 1866, due to cerebral haemorrhage. There was atheromatous change in this case, and the radial and temporal arteries gave in- dications of hardness and tortuosity; depression of spirits and irritability of mind and manner were also noticeable features of his changed condition. After dinner the head- ache was generally relieved by a larger quantity of wine than was allowable, and next morning the pain and con- fusion of ideas were increased. In this case much relief was obtained by carbonate of ammonia and calumba (Form. 54), and by valerianate of zinc and hop in the form of a pill (Form. 105), and ammonia and tincture of lavender (Form. 55). A few months before his death, in August,. 1868, from sudden apoplexy and hemiplegia, he had quite lost his headache, and the condition of the brain did not appear worse until the time of his fatal illness. Among the causes of organic headache, a blow on the head, received at an early period of life, may eventually provoke a change in the vessels which leads on to organic ORGANIC HEADACHE. 225 disease. A slow insidious congestion or inflammation may end in mischief by causing a local pressure, impeding the circulation in some parts, and increasing it in others. Dr. Moxon says: " The organic causes of great headache are never diseases of the proper nervous tissue, but always diseases of its enveloping textures."* Here it is right to state that this view is open to some question. " It may be well briefly to advert to the ratio in which cephalalgia occurs in organic affections of the intracranial contents, determined by cadaveric inspection. We shall find that it is a symptom of less frequent occurrence than we might have anticipated, a fact which negatively demonstrates the necessity of additional care in attending to other signs indicating disturbance of the nerve-centres. The analysis of authentic cases of this description also shows that there is no definite relation, except in the instance of the cere- bellum, between the site of the lesion and the site of the previous pain." Taking the diseases of the cerebrum and cerebellum together (apoplectic and non-apoplectic cases), furnished by Andral and Dr. Abercrombie, " we find that the ratio in which headache is a concomitant of organic disease of the brain is as 92 to 38, or nearly as 3 to 1; while by eliminating the apoplectic cases, we obtain the still higher ratio of 74 to 15, or nearly 5 to l."f " In twenty cases of fungus of the dura mater, published by Louis (Mem. de HAcad. Roy. de Chir., t. 5), there were only three with cerebral symptoms of any kind; and chronic abscesses, cysts, hydatids, exostoses, etc., have * Dr. Moxon, On the Treatment of Headache from Intracranial Disease, in Lancet, May 29th, 1875, p. 750. f On Chronic and Periodical Headache, by E. H. Sieveking, M.D., F.R.C.P., in Medical Times and Gazette, 1854, p. 181. 19 226 HEADACHES. often arrived at an enormous size without having pro- duced any serious alteration in \he functions of the brain."* Treatment.—Here our first steps are to ascertain what is the cause of the headache, and in what way we ought to proceed to arrest the inflammation or the pain which has been set up. Dr. Moxon considers that organic headache occurring in the earlier decades of adult age demands large doses of iodide of potassium, and that it even yields to this drug when not of a syphilitic nature. It must be evident, as he says, to most observers, that syphilis may affect the system without our being able to trace any hereditary history of it, or to find any evidence of it on the skin or bones of the body. When the iodide does afford relief to the suffering, I am strongly inclined to think there is some undiscovered syphilitic taint, for I have seen many cases of confirmed headache, supposed to be due to organic change, both in young and old per- sons, who have derived no advantage from the drug ; on the contrary, the pain has increased under its use. In one case of syphilitic headache, the iodide, which gave relief at first, failed altogether in the latter period of the patient's life; and in another case the drug made the patient much worse at first, but better afterwards. It may be given in small doses, sometimes combined with the bicarbonate of potash and small doses of sal volatile (Form. 56); but as many as forty or sixty grains should be given in the course of the day, if there be a suspicion of syphilis and the pain is continuous. Dr. Smith rec- ommends iodide of potassium in all cases of headache due * Tweedie's Practical Medicine, article Cephalalgia, 1840 vol ii p. 154. ORGANIC HEADACHE. 227 to cerebral tumor. If the growth depends on syphilis, it may cure the condition entirely; and, if not, it has been known to relieve the pain and local congestion in- duced by other swellings, so that the remedy is worth a trial in all cases that appear obstinate. Bromide of potassium and hydrate of chloral will be necessary to procure rest if the patient is wakeful and can obtain no sleep ; but if these remedies fail, with other suitable hypnotics, then the subcutaneous injection of morphia may be tried, and the observations I have elsewhere made are also applicable here.* Dr. Moxon found that gr. £ of morphia, used hypodermically, gave relief in a syphilitic case after the iodide failed; but he urges caution, from its liability to produce insensibility; and, apart from the possibility of this contingency, it does induce very serious depression and mental disturbance in some persons, even when the operation is carefully performed and the quantity used very small. When the pain is severe and yields to nothing else, it ought to be tried. * See Chapter VII, on Nervous Headache. 228 HEADACHES. CHAPTER XIV. HEADACHES OF ADVANCED LIFE. These can scarcely be separated from the headaches of organic disease, there being in all likelihood some change of structure ; the vessels become brittle and ather- omatous, and the circulation through the brain is im- peded and deficient. There are many of the changes that may be looked for in the decline of life, when the physical frame grows feebler and weaker, and the tissues are but slowly renovated. In some persons of full habit, who are advanced in life, the headaches are of a conges- tive type, and therefore any excitement of the circula- tion, as overeating, or too great indulgence in stimulants, may cause the vessels to rupture, and so an apoplectic seizure be induced ; for, the brain having undergone soft- ening change through the failure of nutrition, the with- drawing of this support renders the vessels exceedingly liable to rupture from any sudden strain which may be put upon them. In cases of headache dependent upon cerebral softening, the suffering is less acute than in most other of the organic varieties, and irritability and fits of depression are more common. Dr. Herbert Major dem- onstrates that the large nerve-cells are in a state of granu- lar degeneration in senile atrophy of the brain, and that HEADACHES OF ADVANCED LIFE. 229 the smaller cells are simply atrophied without degenera- tion.* It is highly probable that many of the morbid changes found in senile atrophy of the brain are the cause of the headaches of advanced life, and also those head- aches which we ascribe to organic change. We cannot expect that we shall find anything at all constant in char- acter with the various morbid conditions of the brain. Treatment.—If there is a tendency to congestion about the head, it should be controlled by those remedies which naturally suggest themselves to the practitioner. A mild aperient and cold sponging the head night and morning will be found serviceable (Form. 81). In the case of one patient who had confirmed headache from cerebral degeneration, I found that a large sponge filled with water, and allowed gradually to empty itself over the top of the head night and morning, gave more relief than any other remedy that was tried; it calmed the excite- ment, promoted sleep, and refreshed the patient, so that he was able to walk a short distance with comparative comfort after it. When cold is thus locally applied, it has a tonic and invigorating effect. By contracting the vessels and lessening the supply of blood to the brain, it retards the cell growth and other degenerative changes in the tissues. Ergot of rye is a useful remedy, and has been given with benefit in these cases. It causes contraction of the vessels through its influence on the sympathetic system, and our experience of its efficacy in the treatment of uterine haemorrhage and haemoptysis entitles it to a most prominent position among styptic agents. Twenty to * Observations on the Histology of the Morbid Brain, in-West Riding Lunatic Asylum Reports, 1874, vol. iv, p. 223. 230 HEADACHES. thirty minims of the liq. extract ergot, in water, with a few drops of spirit of chloroform, three times a day, is a fair dose (Form. 57), but Dr. Smith* recommends much larger doses. He begins with one drachm of the same preparation, and increases it to half an ounce three times a day (Form. 58). If the theory is correct regarding the action of ergot, these large doses are not advisable. In small doses it is known to contract the arterioles very considerably, but in large doses it leads to exhaustion and subsequent dilatation. Judging from the headache which it sometimes induces when used in menorrhagia, smaller doses are preferable, and in most cases will be found equally effectual. If these measures fail to afford relief, and the patient is in so much pain that sleep can- not be obtained, opium alone, or the bromide and chloral mixture must be resorted to, and in doses full enough, and as often repeated as the urgency of the case appears to warrant. The treatment also comprises fresh air, light food, and cheerful conversation; for there is a risk in confirmed cases of the mind becoming so weak, that the patient may end his days in a lunatic asylum. * Therapeutics of Headache, by A. A. Smith, M.D., a lecture delivered at Bellevue Hospital Medical College, in Medical Record, September 15th, 1876. The action of ergot is further alluded to in Chapter II, on the Headache of Cerebral Hyperaemia. NEURALGIC HEADACHE. 231 CHAPTER XV. NEURALGIC HEADACHE. Relation to Nervous Headache—Its Origin traceable to Decayed Teeth and other Local Causes of Irritation, as Changes of Weather and Uterine and Intestinal Disturbance—Its Origin in the Special Poison of Ague—Pain precedes Sickness, and is not re- lieved by Vomiting, as in the Dyspeptic or Bilious Headache— Acute Hearing a premonitory Symptom—Hard Work a com- mon Cause—Cases in Illustration—Renal Cirrhosis a cause of Hemicrania. Treatment—Nutritious Diet—Local and General Stimulants—Bitter Ale—Brandy and Water—Rest and Full Doses of Quinine— Carbonate and Hydrochlorate of Ammonia—Veratria and Aco- nitina Ointments—Hypodermic Injection of Morphia— Valeri- anate of Zinc—Phosphorus—Strychnia—Cannabis Indica—Ar- senic—Iron—Cod-liver Oil. This is really one form of nervous headache. It af- fects one side of the head and face (hemicrania), or it fixes on one particular spot, causing a sensation as though a nail were being driven through the head (clavus hys- tericus).* It frequently proceeds from decayed teeth, or * With regard to these definite and tender spots having their ori- gin in the fifth nerve, Dr. Anstie thus writes : " Ever since the time of Valleix, most authors have disposed of this question gummarijy, by inquiring as to the existence or non-existence of certain tender points at particular situations in the course of various branches of the fifth nerve. Supposing it were possible that a patient should be af- fected with universal and equally violent neuralgia of all the princi- 232 HEADACHES. some other local cause of irritation, which may depress the nervous system and weaken the appetite and digestive functions.* It is one form of neuralgia like tic doulou- pal branches of the nerve, the situations in which the most important of these painful points would be developed are such as you see marked on the diagram: 1. The parietal point. 2. The supraorbital. 3. The trochlear. 4. The palpebral. 5. The ocular. 6. The nasal. 7. The infraorbital. 8. The malar. 9. The superior labial. 10. The mental. 11. The auriculo-temporal. Pressure on any of these points, even in the intervals of the neuralgic attacks, causes an ex- quisitely acute pain to dart along to the terminal branches which lie external (peripheral) to the tender spot."—" Lettsomian Lectures on Certain Painful Affections of the Fifth Nerve," by F. E. Anstie, M.D., in The Lancet, August, 25th, 1866, p. 200. * " A gentleman had for many years been liable to attacks of head- ache on the slightest provocation. Long-continued intellectual exer- tion, the excitement of an agreeable party, a journey, any error of diet, would inevitably lead to an attack of headache. During the same period he suffered at different times from pain in his teeth, which decayed rapidly, and at last were removed and replaced by false ones. This change happened more than a year ago, and since that time he has been almost exempt from pain in the head. In other respects his health and mode of life have been unaltered. What was the connection between the diseased teeth and the headache? The morbid impressions on the ganglionic fibres of the fifth pair might, without any stretch of hypothesis, be reasonably presumed to induce a morbid state of the Gasserian ganglion, whether the impressions on the sensory fibres did or did not reach the sensorium, and induce a painful sensation referred to the teeth. The Gasserian ganglion is connected by marked fibres with the cephalic ganglion, from which a large number of nerves pass to the cerebral arteries. The cephalic ganglion probably partook of the morbid condition of the Gasserian, and hence might have arisen so susceptible a state of the ganglionic nerves of the brain that they may have become disposed to ache under the influence of impressions which, without the predisposition in the nerves, produced in the manner I have described, would have no effect. It seems to me that if this explanation cannot be ac- cepted, there is no alternative but the supposition that morbid im- NEURALGIC HEADACHE. 233 reux, and the paroxysm may come on after regular and short intervals of ease, or after irregular and long inter- vals. I have often met with it in women out-patients who come periodically to get relief after hard work or poor living ; and this they find in full doses of quinine, and in rest. Any causes that induce excitement or ex- haustion, as severe leucorrhcea, or other uterine loss, will bring it on in subjects who are predisposed to it. WTomen drained from menorrhagia are as common victims to this variety as they are to any form of nervous headache. I could enumerate many examples of acute suffering from this cause, in which the periods of intermission were very short, and the local mischief that followed was obstinate and troublesome; impaired motion of the affected eyelid, conjunctivitis, and excessive secretion from the lachrymal gland may all be looked for in severe cases. Sometimes the disease is distinctly intermittent, like an attack of ague, and it is commonly traceable to the same exciting causes. From my own experience I should say that neu- ralgia of malarial origin is very rare, at least in London practice. The improved dwellings of the poor through- pressions on the dental nerves (not creating pain in those parts), ar- riving at the central extremities of the nerves, are passed on to that part of the sensorium which is related with the sensory fibres of the ganglionic nerves of the brain, and maintain in that part of the sen- sorium a morbidly susceptible condition ; and that this condition is brought into such action as constitutes pain, whenever the said part of the sensorium receives impressions transmitted from nerves which have been offended by causes acting directly upon them in the brain itself, as in overstudy or anxiety, or when it has received like dis- turbing impressions from the nerves of other parts of the ganglionic system."—Symonds, on Headache, in Medical Times and Gazette^ April 3d, 1858, p. 339. 20 234 HEADACHES. out the country, and the better drainage of the soil, which has rendered the ground more productive and easier of cultivation,—two powerful means of improving the phys- ical and elevating the moral nature of man,—have re- duced this cause very considerably. With these changes in human progress, the spread of malaria and fevers of all kinds have greatly diminished. When neuralgia is present from this cause, it affects the fifth nerve, or some of its branches, and the periodicity may be as regular as a quotidian or tertian ague. The true neuralgic headache seldom extends over the whole head, or produces sick- ness or vomiting, unless the attack has lasted long and is very severe. I should limit its strict definition to the in- tensity of the suffering, and its superficial seat; to the paroxysmal character of the pain, and its extension in the course of the superior branch of the fifth nerve, and those filaments which supply the orbit, inner angle of the eye, and forehead. I would here say, however, that the pain in some cases appears to enter the eye or the brow, to pierce through the centre of the head and to escape at the occiput, or to find its way out through the neck, arms, and legs. The pain in the limbs resembles a pricking or numbness, and the patient suddenly finds, whilst en- gaged in writing, that he cannot hold or control his pen, and he then becomes apprehensive of paralysis. I have met with several instances of the kind. Phosphates are frequently present in the urine. In this headache, as in the nervous variety, the pain precedes the sickness, and is not relieved by vomiting. The patient vomits incessantly, till almost torn in two by the violence of the retching, and only brings up some frothy watery mucus—not a vestige of bile; but in the NEURALGIC HEADACHE. 235 vomiting of dyspeptic headache, or from indulgence in alcoholic drinks, the nausea and vomiting precede the headache, and afford relief from the removal of the cause. Extreme sensibility to sound of any kind, or a dis- tressing acuteness of hearing, is an occasional accompani- ment of neuralgic headache. I am acquainted with the case of a married lady who has long been in delicate health from spinal weakness, and whose decayed teeth have partly induced the attacks of neuralgia in the head. When she is suffering from hemicrania she can hear the ticking of a clock in an adjoining room, in which she cannot even hear it strike when she is free from headache. The ticking of her own watch, and that of any other person in the same apartmant, is quite annoying, if not almost unendurable to her. Another peculiar feature of the case is, that the patient knows when an attack of headache is threatening by her hearing becoming sud- denly acute, and when the attack is likely to pass off, by a decline in its sensibility. Excitement of all kinds will bring this headache on, as the noise of railway travelling, and any bustle or con- fusion ; but it is more frequently attributable to dis- ordered digestion, and to changes in the weather, than to causes operating on the brain itself. It is most frequent in adult or middle life, and is far less common in chil- dren ;* but if it happens to those advanced in years, when degenerative changes are established, it is often severe, protracted, and obstinate. It may be noticed that other neuralgias are equally common at this period of life, as sciatica, pleurodynia, angina pectoris, and gas- * See Chapter XVI, on Neuralgic Headache in Children. 236 HEADACHES. tralgia. I consider oversuckling a most fertile cause in women, and among hospital patients it is common enough, when they have to contend with the cares and privations of a miserable home, and the common necessaries of life are not to be obtained. Hunger and fatigue are fol- lowed by sleeplessness, and the various causes of nerve starvation invite the malady, or set light to a pre-existing local distress. A northeast wind, or a cold harsh day, will frequently invite an attack of neuralgic headache in those persons M'ho are subject to it. With regard to decayed teeth as a cause of neuralgia, it is important that they be not hastily removed. Many young persons have had tooth after tooth extracted, and still the pain has continued. I remember a nervous and delicate young lady, twenty years of age, who, having lost three teeth at the hands of a dentist, and finding the neuralgia of the head and face as bad as ever, gave up the idea of ever submitting again to a similar operation. She took quinine, arsenic, and cod-liver oil, and the pain gradually left her, notwithstanding she had many stumps and carious teeth. For months together she was free from all pain; but it returned from time to time when the health was lowered, and again yielded to the same measures. " There are plenty of facts which suggest that lesions of nerves not necessarily painful may become so from causes originally by no means local. Thus, I believe that there are hundreds of people walking about London this minute, the diseased nerves of whose carious teeth would be speedily roused into severe neuralgia by two or three nights of sleepless watching and anxiety, or by two or three days of insufficient nourishment or of NEURALGIC HEADACHE. 237 violent and exhausting exertion of mind or bod v. And, conversely, I am sure that a generous diet will often re- lieve the agony arising from sheer involvement of nerves in a cancerous deposit."* When a person who has a solitary decayed tooth is suffering from continuous neuralgia of recent duration, and the general health is not reduced, I should advise its extraction, if constitutional remedies have failed. In most cases this will be found a good rule to carry out; but if there are several decayed teeth, and the patient is weak and delicate, then I should prescribe rest, good diet, and nervine tonics, and trust to the dentist's powers of arresting further decay. Women who stand for hours together over a washtub, or a laundress's table, are fre- quent victims to this form of headache. Household servants who work hard and are overanxious to dis- charge their duties creditably, are sometimes great suf- ferers. In confirmed cases, if the general health is much impaired, the hours of labor must be diminished, or there will be no prospect of recovery; indeed, in many instances the situation has to be given up, and pure air and complete rest obtained. The following is a case in illustration : M. A. S., set. 33, s., a female servant, and a resident in London, consulted me May 22d, 1877. She has been subject to sick headache all her life, but has become much worse during the last nine months, which she attributes to hard work and fatigue; extra work increases the pain, and going upstairs tires her exceedingly. The * Dr. Brinton, on Anomalous Intussusception of the Intestines, in Lancet, April 11, 1863, p. 411. Quoted from Dr. Handfield Jones, On Functional Nervous Disorders, 1870, p. 499. 238 HEADACHES. house in which she resides has been much altered in its arrangements, and this vexes and worries her. History and Present Condition.—The patient is thin and weak, and bears all the evidences of a nervous tem- perament. Never had any illness except indigestion two years ago, which lasted six weeks. Catamenia regular, but scanty; slight leucorrhcea; bowels regular; appetite capricious, sometimes ravenous; has slept badly of late. Her mother suffered periodically from headache. The patient's early headaches were always relieved by sleep, and if she could get a nap she was certain to be better, or if she went to bed a good night's rest would set her up. Now she cannot trust herself to go out anywhere, and she is afraid of returning with the pain. She feels very low-spirited with it, but not hysterical, and is in- clined to shut herself up, and keep quiet. Character of Headache.—The situation of the pain is entirely unilateral; it begins over the right eye, above the brow, as a heavy pressure, which works through the centre of the right half of the brain to the occiput (one- half of head), the neck becomes stiff, and there is diffi- culty in rotating the head ; then the pain extends down the right arm, and the fingers of the same side feel stiff and the right leg is weak, as if asleep. She is very flushed when the pain is on her, and the right eye is red, injected, and watery, and the lower eyelid is rather puffed and quivering. Sometimes she feels irritable before the pain comes on, and nothing goes right. The impulse of the heart against the sternum is weak, sudden, and short, and the first sound is rather blowing, as in ansemic states of the blood ; the least excitement causes palpitation and discomfort over the precordial region, whileshe experiences NEURALGIC HEADACHE. 239 feelings of breathlessness and anxiety ; the pulse is weak and tremulous, and the hands and feet are inclined to be cold. She was ordered cocoa instead of tea, and to take as much milk as she could digest. White fish, fowl, and mutton were to be the chief forms of food ; pastry and stimulants were rigorously forbidden. In the shape of medicine, pil. aloes et assafcetid., gr. x, in pib ij, at bed- time, were prescribed occasionally. Bromide of potassium and ammonia when the attacks of headache threatened (Form. 26), and a mixture of iron and arsenic twice a day (Form. 24 6). May 29th. On the two days following her visit she had severe headache, but the last three days she has been easier, and has slept better; the right eyelid is puffed to- day, and there is pain over the orbit, from the corner of the nose to the temple of the same side. She has some diffi- culty in walking up and down stairs; both the right leg and right hand are cold, stiff", painful, and rather swelled, but she is on the whole better, though nervous about her state. August 2d. The queer sensation in her right hand and leg has departed for three weeks, and she has had no headache whatever for five weeks. She can take a long walk without any fatigue, and she looks quite well. She has taken the arsenic and iron mixture twice a day since it was prescribed, and a pill occasionally. The right eye is still puffed, and pain will always bring on this cedematous condition. In September the patient had gained flesh and strength, and there was no return of the headache. She was in all respects well, and the recovery was due to her better nutrition, and improved quality of blood. 240 HEADACHES. Neuralgia points to a lowered state of vitality in the track of a nerve, and to combat this nutrition must be improved. Dr. Anstie thus gives his own personal ex- perience : " I have been subject, ever since childhood, to severe attacks of neuralgia of the brow, entirely independent of digestive derangement; although liable, as this affection usually is,»to be aggravated by any coincident stomach disorder.* The pain always follows accurately the course of those branches of the fifth nerve which are distributed to the forehead, the internal angle of the eye, and the nose, more rarely extending also to the branches derived from the second division of the fifth nerve, and distributed to the cheek, but always on the right side only. This kind of headache began to trouble me at about the age of fourteen, and for two or three years was of frequent occurrence ; for many years past, however, it has been an unfrequent visitor. One circumstance ought to be mentioned, although I cannot pretend to estimate its exact relation to the pro- duction of the neuralgic pain, viz., that about the time when the headache first occurred with any severity I began to suffer from an obstruction of the lachrymal duct on the same side. This obstruction has been ascertained to depend upon a light stricture of the upper end of the nasal duct, close to the lachrymal sac, and is apparently caused by a tough fibrous cicatrix, probably the relic of some past ulceration. Treatment by the passing of me- tallic probes has been adopted from time to time, with * A neuralgic headache is sometimes caused by gastric irritation and acidity, and a full dose of an alkali, as half a teaspoonful of bicar- bonate of potash in a wineglassful of water, will liberate carbonic acid in the stomach, and speedily remove the pain. NEURALGIC HEADACHE. 241 great temporary relief, but the obstruction has always recurred, and, as a consequence of it, the discharge of tears from the gland is incontinently profuse. The attacks of pain are invariably caused by fatigue of body or mind, and are preceded and accompanied by pallor of the face, weak pulse, and a general sense of depression. The only remedies which are of the slightest value are sal volatile, hot tea, and occasionally quinine in a full dose, or a glass of wine. Ammonia and hot tea are most frequently use- ful."* The condition of the renal organs has much to do with headache, and I have seen very persistent forms of it (see page 190, Uremic Headache), when the kidneys have sustained mischief from scarlet fever and desquama- tive nephritis. The cases I have generally observed have been marked by continuous frontal headache, heavy and oppressive, less at one time than at another, but rarely if ever completely absent for a single moment. Dr. Barthels has witnessed severe hemicrania in connection with renal cirrhosis, and I shall therefore quote his own words on the subject. " In other cases, the first evidence of the disease consists in frequent and severe attacks of headache, sometimes occurring under the form of exces- sively severe hemicrania of remarkably long duration ; indeed, I have observed this form a number of times. The pain, too, may extend down the neck, and even to the brachial plexus of the affected side. Such parox- ysms may last for several days. In one case of this kind I noticed almost complete anesthesia of the skin of the face and of the fingers upon the affected side during the continuance of the attack. This patient had an attack of * On Stimulants and Narcotics, by F. E. Anstie, M.D., 1864, p. 83. 242 HEADACHES. the kind nearly every week ; and, finally, during the in- termissions, normal sensation did not quite return to the face or fingers, but a feeling of numbness and formication remained. " In any case of migraine occurring after middle life in an apparently robust individual, it is well to consider the possibility of the nerve affection being dependent upon contracting kidneys. Neuralgic pains in the track of other nerves have, in my own experience, proved far less common than headache, so that I am still doubtful whether I can properly connect these isolated attacks of neuralgia with this renal disease as cause and effect. But the terrible itching of the skin, which I shall advert to hereafter, may be reckoned belongs indisputably among the results of the renal affection, and it is likely enough that a more or less extensive muscular pain that sets in toward the end of life and is usually satisfactorily but fancifully explained under the name of rheumatism, owns a similar origin."* Treatment.—The subjects of this variety of headache being usually anemic, the first indications are to improve the general conditions by nutritious diet, and enforcing mental and bodily rest. I have known a full dose of brandy and water give almost immediate relief when the attack was limited to one side of the head and face. A lady who was under my care some years ago was able to ward off a neuralgic headache, which came on late at night, by taking a slice of bread and butter, and a glass of Bass's ale, or good bitter beer, before getting into bed. A local stimulant of chloroform and aconite liniment will * Cyclopaedia of Medicine, by Dr. H. von Ziemssen, Diseases of Kidneys, vol. xv, p. 421. NEURA LGIC HEADACHE. 243 sometimes give ease after friction for a few minutes. A » little extract of belladonna rubbed into the affected tem- ple will be useful in some cases (Form. 110), and an oint- ment of aconitina (Form. 113) or of veratria (Form. Ill) will prove efficacious in some obstinate cases. Internally, the carbonate of ammonia will sometimes be of service (Form. 16). The chloride of ammonium is another good remedy in these cases, particularly if the pain extends to the face (facial neuralgia). It should be given in 9j or 5ss. doses (Form. 27), and if no relief follow the admin- istration of three or four doses, it is not well to continue it. It diminishes congestion of the vessels, and promotes cutaneous action and diaphoresis. When the pain is very severe the hypodermic injection of morphia (gr. ^) may be tried, and it is necessary to conduct the operation carefully, as troublesome boils, and even sloughing, may follow; and on this account I should be reluctant to employ it for the face. The hypophosphite of soda in infusion of calumba (Form. 28) is a good remedy, or the hypophosphoric acid may be given in combination with quinine, strychnia, and iron (Form. 21-22-22 «-23). Arsenic is a remedy of the greatest possible value, if it is given judiciously and watched carefully; but it is too generally abandoned on the first symptoms of constitu- tional irritation becoming manifest, and when its altera- tive effects on the blood are about to be secured (Form. 8-9). Under these circumstances it should be discon- tinued for a time, and then resumed again. It is well to be acquainted with the physiological signs of arsenical action, for the exhibition of small doses in some persons of peculiar idiosyncrasy is accompanied with so much 244 HEADACHES. nausea and depression, as to render the continuance of the remedy unadvisable. " I have witnessed the postponement and ultimate ces- sation of a periodic headache through the influence of arsenic before the pricking eyelid or silvered tongue de- monstrated its agency."* When we are disappointed with the effects of arsenic, there is often a taint of gout, or syphilis, or mercury, and when combined according to these circumstances we may often succeed. " We are called to one laboring under excruciating headache, which attacks him at an early hour in the day, and regularly takes its departure in the after- noon. Day after day the attack is renewed, and the same hours witness the return and departure of the paroxysm. It has defied all ordinary methods of treating headache; the physician has pronounced it brow ague, and has prom- ised that it shall yield to quinine or bebeerin. He is disappointed ; it has resisted both ; he betakes himself to Fowler's solution, and after two or three days the attack is postponed, or it comes in a less severe form, and takes its leave at an earlier hour. After another day or two it ceases altogether. We are gratified by this exhibition of the power of arsenic over periodic headache, and resolve to test it again on the first opportunity. The occasion arrives; with confidence we prescribe our remedy; we persist day after day in its use, but we are doomed to dis- appointment. We return to quinine, which has seldom failed on former occasions, but without success. We betake ourselves to bebeerin and supplement its powers with the alternative effects of depurants, diuretics, and laxa- * On the Physiological and Therapeutical Effects of Arsenic, by James Begbie,M.D.,1862, p. 272. NEURALGIC HEADACHE. 245 tives, but all to no avail. We try a combination of ar- senic and quinine, and in a short time the wished-for cure is obtained."* It is well to bear in mind that neuralgic headache sometimes occurs in plethoric-looking persons; but they have not the blood belonging to this condition, and the florid countenance is more strictly due to relaxation and debility of the capillary circulation. In subjects of this kind I have found a mixture of sulphate of magnesia and quinine useful till the liver and portal circulation have been drained (Form. 29). After this, full doses of quinine, and a little brandy and water during the day, have aided the cure. Such persons have gone on com- fortably for weeks and months, notwithstanding inatten- tion to decayed teeth, and a drain from the system of various kinds. When the subjects are excitable and hysterical, and the pain is persistent, bromide of ammonium or potas- sium with valerian will be advisable (Form. 72), and if anemia is a marked symptom, iron with quinine (Form. 20 to 24), or valerianate of zinc and a stomachic (Form. 87); phosphorus and small doses of strychnia, if the nervous system is harassed by mental toil and anxiety (Form. 88-89). If there is sleeplessness, a pill of cam- phor, henbane, and cannabis indica (Form. 92-93) will be found of service, and it will have a most tranquillizing effect; but all drugs will fail to remove the pain, unless air, exercise, rest, and good food be prescribed. Gelseminum sempcrvirens has been employed suc- cessfully in neuralgic affections, and the neuralgia arising from decayed teeth. In hemicrania and supraorbital * Ibid., p. 276. 246 HEADACHES. neuralgia it has been found exceedingly useful, but at present it is impossible to say what those cases are which will be most benefited by it. The powder and the tinc- ture are the two forms for administration ; the dose of the former is from one to two grains, and of the latter from ten to twenty minims. In the case of a lady, et. 39, I found that one grain of the powder made into a pill with glycerin and given every night at bedtime acted marvellously, inducing sleep, and warding off a paroxysm when taken as the seizure was threatening. In large doses it appears to cause frontal headache, con- traction of the pupils, and weakness of the legs.* From the observations of M. Emery-Heroguelle it acts favor- ably as an antineuralgic, in neuralgia of the fifth pair, dental neuralgia, the brachial plexus and intercostal nerves.f Croton chloral has been recommended by Dr. Liebrich of Berlin as possessing a special action on the sensory branches of the fifth nerve. It is of most benefit in facial neuralgia, relieving pain and producing sleep. I have known it prove very serviceable in some cases of nervous headache in which the disorder has chiefly occupied one temple, the occiput and neck, or one parietal bone, and in other cases not only to utterly fail, but to induce sickness and nausea, if they did not previously exist. I generally give gr. x for a dose in plain water, though it has been advised to dissolve the remedy in a few drops of glyc- erin, and then add the required quantity of cinnamon- * " A girl nine years old was killed in two hours by a dose of two drachms of the tincture."— Squire's Pharmacopoeia, 11th edit., 1877 p. 148. f Medical Examiner, Dec. 27th, 1877, p. 1067. NEURALGIC HEADACHE. 247 water, which to some extent disguises the bitter nauseous taste. On this account it may be given in the form of a pill, beginning with two grains, and increasing the dose according to the urgency of the symptoms. I have known terrible neuralgia over one eye and side of the face follow immediately on a diffused nervous head- ache. There has been sickness and prostration. A tea- spoonful Of brandy in a little soda-water, and quinine with spirits of chloroform (Form. 12), have been re- tained on the stomach, and the pain has gradually de- parted. Twenty grains of bromide of potassium in a wineglassful of water will sometimes have the same beneficial effect. A middle-aged lady, recently under my care, derived great benefit, and repeatedly warded off an attack of neu- ralgic headache, by taking, as soon as she awoke in the morning, one or two teaspoonfuls of tincture of quinia in a small cup of milk. In the intervals of the headache remedies must be em- ployed for improving the quality of the blood, and re- storing the general health. Quinine and arsenic together are very valuable remedies (Form. 8-9), and so are cod- liver oil and fatty matters for restoring the wasted ner- vous tissues. 248 HEADACHES. CHAPTER XVI. HEADACHES OF CHILDHOOD AND EARLY LIFE. Preliminary Remarks on the Significance of Headache in Children —Their Insidious Course and Character—Hereditar}7 Disease— The Resemblance in Physical Form and Features to the Parent are not more Constant than Mental Peculiarities—Importance of checking the Transmission of Disease—The Life of Childhood contrasted with that of the Adult—Brain of Childhood^compared to that of Maturity—Mental Development compared with Physi- cal Growth—Their Relationship and Bearing on Health—Effects of Illness on the Functions of the Brain—Parents entail Disas- trous Evils on their Offspring by forced Mental Discipline—Dif- ference among Children in the Power of Memory, and Acquire- ment of Knowledge—Case of Arithmetical Power related by Carpenter—Evil Consequences of the Forcing System—Hyper- trophy of the Brain—School Board Legislation—Weight and Size of the Human Brain at different Ages in both Sexes—Pop- ular Tradition of delayed Mental Training—Professor Laycock's Opinion that Precocious Children are generally Strumous. The Chief Varieties of Headache in Children: 1. Cerebral Head- ache. 2. Gastric Headache. 3. Epileptic Headache. 4. Feb- rile Headache. 5. Headache from Anaemia, Neuralgia, etc., constituting Nervous Headache. 6. Headache depending on some Intricate Change in the Cerebral Membranes or Tissues of the Brain. 7. Organic Headache. Headaches hold such a prominent position in the diseases of childhood as to constitute them worthy of special notice and consideration. There are few prac- titioners of any experience who have not had reason to HEADACHES OF CHILDHOOD AND EARLY LIFE. 249 lament the overlooking of the first symptoms of brain mischief in a young child. No fever, no vomiting, no thirst, may have been present to arrest attention ; the symptoms may have been entirely subjective, and yet in a few hours the child has been struck down by a convul- sion, and forthwith meningitis has followed. No parent should neglect a headache in any child under thirteen or fourteen years of age, especially in girls about this period of life, when physiological changes are in active progress. The conventional usages of modern life, in regulating the education of children, have a tendency to push them forward without sufficient regard to physical training, the acquisition of knowledge being considered of more moment than the vigorous growth of the body and the stability of the frame. The influences which develop the general strength, and produce strong muscles and sound limbs, are counteracted in their good effects by the undue pressure which is put upon the brain when it is least able to bear the tension, and nature is thus thwarted and her wise counsels are defiantly ignored and set aside. " No perfect brain ever crowns an imperfectly developed body. When Michael Angelo reared St. Peter's dome in the air, he made every stone beneath contribute, not only to the use and beauty of the part he put it in, but to the support and power of the dome. The brain must be built up in connection with the building of the rest of the body, remembering constantly that the imperfections of the latter reflect themselves upon the former."* Parents incur a heavy responsibility in enforcing a course of study, or a system of training, which is likely * The Building of a Brain, by E. H. Clarke, M.D., 1875, p. 21. 21 250 HEADACHES. to induce disorders from which they suffer themselves. The resemblance which a child bears to the parent in outward form and feature, ought to teach us how trans- missible is every taint and peculiarity, which it should be our constant desire to avoid and to arrest. Some faulty conditions of the blood, and of the different fluids of the body, may be nearly stamped out by careful regi- men and appropriate management, as we have seen ex- emplified in some members of a family who have been reared differently to the rest. But asthma, emphysema, the hemorrhagic diathesis, tuberculous diseases, cancer, gout, and affections of the skin have a congenital origin, and here structural disease is as frequently owing to a transmitted tendency, and to a peculiar state of the blood and bodily temperament, as the family outline of the figure and face. When we consider the disorde&s of the brain and nervous system, there are few sensible parents who will not admit that headache is an affection more frequently hereditary than almost any other. The ner- vous habits, and the excitable manner of the parents, stand out in a remarkable manner where the children even have been brought up at a distance from home, and when their surroundings have been entirely changed. " There is much that is curious in the tendency to headaches thus transmitted by descent, and often going through whole families with similar character. The causes here presum- ably vary in different instances. Sometimes, and espe- cially perhaps where they are periodical, the affection may belong to the gouty habit, and to the matter of gout in the circulation. In other cases abnormal structure of the vessels of the head may be concerned; in others, HEADACHES OF CHILDHOOD AND EARLY LIFE. 251 again, some peculiarity in the nervous system itself."* These considerations should counsel prudence, and con- trol the agencies at work which threaten domestic peace. Surely the cautious parent ought to consider the cheerful or melancholy temperament of his child, his mental as well as his bodily strength, and be guided in his manage- ment accordingly. The gains and losses in life, the com- petition and the struggles, should not be obtrusively thrust before him, for the mind will realize early enough the bitter lessons of material existence. How different is the life of childhood from that of the adult! It is the existence, as it were, of another creation ; life is wrapt up in the present, and not in the future, f A child lives for himself, and not for others; his keen sensibilities move him to sorrow and to pain with great quickness; his weak reasoning power is counteracted by the activity of his imagination. He feels intuitively the approach of a friend, and knows his foe in an instant. His life is not one of mingled sorrow and pleasure ; it is all one, or it is all the other—the past lights up no remorse, the future has no sorrowful forebodings. How fruitful of evil is the tyrannical oppression of the unsympathizing parent or guardian of a child, who exacts from him thought and conduct beyond his years, and, with restless caprice, despotically moulds his actions. The weakening more and more of the overtaxed brain lays the foundation of nerve-exhaustion, and disorders * Medical Notes and Reflections, Hereditary Disease, by Sir H. Holland, Bart., M.D., F.R.S., 1855, p. 37. f " Children are heedless alike of the past and the future ; the pres- ent is enough for them."—La Bruyb-e. 252 HEADACHES. are induced which years may never overcome, even if the defective nutrition of the brain does not lead to those pathological changes which affect the bloodvessels and cerebral cells. The symptoms which announce these alarming evils are fits of recurring mental excitement, evidencing; exhaustion in the functions of the brain. The amount of exercise which ordinarily maintains this organ in health now impedes the harmony of its actions, and henceforth invites those changes, which the naked eye too plainly detects in some cases, while scientific methods of research are alone capable of revealing them in others. If, in ignorance of ensuing evil, children are pushed forward too much, fretfulness of mind is implanted, and general debility takes the firmest hold of their constitu- tions in the springtide of life. When a child is fast grow- ing it needs fostering care, and all its reserve of energy, in order to approach completeness of development. If at this time it sustains damage, or injury of any kind, and one link is broken in that mysterious chain of vital forces which keeps the whole fabric in order, then the health in too many instances is appreciably undermined, and life is absolutely shortened. A closely defined plan of study carried out in defiance of the laws of health often leads to a delicate manhood. " Study and student-work aid this evolution; but, as we have seen, they are not the only factors of brain-building. Cerebration is brain- exercise ; and brain-exercise strengthens and develops the brain. But the brain is evolved from the organization, and, unless the latter is normal, the evolution is imper- fect. Moreover, physiology informs us that conscious, or, more properly speaking, volitional cerebration, should not be attempted too early in life. In nature's order HEADACHES OF CHILDHOOD AND EARLY LIFE. 253 the nervous system of an individual is the last to attain its full development; and, of the nervous system, the cerebral ganglia reach maturity later than any other part. Obviously the latter should not be put to work till they are capable of labor. AVithout exercise an organ will attain little or no development; excessive or premature exercise will monstrously develop it—in either case to the injury of the rest of the organism."* But it is worthy of consideration that the judicious culture (within appro- priate limits) of the mind in early life, gives the child so trained an immense advantage over another less fortunate. He retains more after a lapse of time, because his previous knowledge calls up something familiar and already ac- quired which bears on the subject in hand. This holds good through life, and it is only necessary to furnish him with fresh facts, and new combinations and impressions will be easily engrafted upon the recollection. Every skilled workman from his previous training is rendered capable of acquiring an increase of knowledge from the resemblance of the present to the past, the past coming back to him when a similar subject is again presented to his mind, however remote the connection may be. The power of acquiring knowledge or of forming habits is particularly strong in childhood, when the mind is flexible and plastic. Of all periods of life, then, this is the one when impres- sions are most likely to become enduring, and the habit of concentration to be acquired—a period when the capacity of the brain should be carefully estimated, and the organ not pushed to dangerous excitement, which in the growing stage is more pernicious than complete dis- use. * The Building of a Brain, by E. H. Clarke, M.D., 1875, p. 44. 254 HEADACHES. The development of the human brain, like the won- derful organization of the whole animal kingdom, is a subject of peculiar interest, proceeding on that grand and harmonious design which the Almighty has instituted throughout the universe. If the facts which spring from a study of vital phenomena are carefully searched and scrutinized, we shall trace the connecting link between the physical and the intellectual parts of our nature, and be in a better position to understand their mutual de- pendence on one another. In the earliest periods of foetal existence, when life is just beginning to dawn, there is nothing like nervous matter, those parts corresponding to the head consisting of merely a limpid colorless fluid. The corpora olivaria are not formed till the seventh month, and at the period of birth the optic thalami and posterior ganglia of the cord are sunk amid the sub- stance of the hemispheres (Solly). The complicated structure of the nervous system reaches perfection in the adult brain only. An adult brain may stand an excessive amount of overwork if the physical strength is robust, but a child cannot endure immoderate exercise of the mental powers without soon breaking down, unless there is strong bodily health also. Even if the attempt is made, failure is cer- tain. \\fe are willing to admit the force of an argument held by those philosophers who have closely analyzed the subtle powers of mind, and have examined what it is capable of achieving. It is unquestionable that the reasoning powers are never completely developed if edu- cation is neglected or imperfect. The brain requires exercise or it will waste, and the moral strength will decline also if intellectual culture- is abandoned. Take HEADACHES OF CHILDHOOD AND EARLY LIFE. 255 the case of two members of the same family starting in life with an equal capacity of mind. The exercise of one brain, let us suppose, is complete and methodical, that of the other is entirely neglected. The first youth will grow up strong and vigorous in intellect, and be anxious to carry out with justice and honor the respon- sibilities of his situation; whilst the actions of the other are governed by selfish and ungenerous motives, or the ruling principle of his life is caprice. No human being is so constituted as to be above phys- ical considerations; the closeness of the connection must be apparent to all who reflect on the question for a single moment. The brain of a person whose bodily health is hereditarily weak, or who has been subjected to depress- ing influences, will evince earlier and greater indications of weariness than it would do if the physical conditions had been different, and the brain supplied with healthy blood.* Can a child who has recovered from fever, or an exhausting illness, prosecute his studies at once with the same delight and ease he did before the attack ? A considerable length of time must elapse before his diges- tive system is strong enough to assimilate sufficient nour- ishment to restore the exhausted energies of the brain. We know his mental condition as he approaches conva- * " The brain is clearer in vigorous health than it can be in the gloom and misery of sickness ; and although health may last for a while without renewal from exercise, so that if you are working under pressure for a month the time given to exercise is so much deducted from the result, it is not so for the life's performance. Health sus- tained for many years is so useful to the realization of all considerable intellectual undertakings, that the sacrifice to the bodily well-being is the best of all possible investments."—The Intellectual Life, by P. G. Hamerton, 1873, p. 28. 256 HEADACHES. lescence. He wakes in the morning after refreshing sleep, and is lively with his toys and amusements; then suddenly he becomes petulant and irritable over them, throwing them on one side in anger and disgust, till he falls off to sleep, and the jaded brain is restored. The mental faculties have sustained a shock by the illness, and the disease has impaired or temporarily suspended the powers of memory, and obliterated recent impressions. AVhat he docs acquire is easily forgotten, till the brain is restored to its former strength. Some years ago I had under my care a little boy, aged two years, who re- covered from meningitis after many months of shattered health. AVhen he reached the age of seven, and was strong in his limbs, an attempt was made to teach him to read and write; and it was found that he could give his attention for about ten minutes at a time, and that then he began to tire. At first this was ascribed to idle- ness and inattention, but it was soon found that perse- verance in the attempt caused headache, pallor of the face, and disinclination for food ; his nights were restless, and it was obvious that the continuance of the plan would be fraught with danger. His memory was not retentive, and it was more than probable that were the system continued in years to come, the brain would never be able to master more than the most ordinary details of elementary knowledge. The shock sustained at the time of the illness had impaired the cerebral tissue, and damaged the mental powers. " Dr. Pritchard, on the authority of the late Dr. Rush, of Philadelphia, mentions an American student, a person of considerable attainments, who, on recovering from a fever, was found to have lost all his acquired knowledge." HEADACHES OF CHILDHOOD AND EARLY LIFE. 257 At length, when his health was restored, " his lost im- pressions suddenly returned to his mind, and he found himself at once in possession of all his former acquire- ments."* I have seen some of tKe worst forms of head- ache supervene on acute illness, and continue when the attempt to resume study was made. A boy aged thirteen, who had a tedious attack of typhoid (in which the cere- bral symptoms were considerable), always suffered from severe headache when he attempted to resume his studies, and the inference I drew from the protracted stupor and heaviness was, that the brain tissue had undergone some permanent change, and that if the course of study was continued after this warning, his memory would be irre- trievably damaged, and that he would possibly pass into a state bordering on idiocy. The privation of active exercise, and light amuse- ments for children, by enfeebling the digestive and as- similative functions, impairs the quality of the blood, and thus disturbs and lowers the cerebral functions. The nervous symptoms shown in petulance and irritability should be serious warnings, though they are too frequently overlooked, or attributed to a wrong cause. A headache traced to confinement and study is a familiar example of this overcultivation of the intellect, and in every instance where it arises the studies should be cast aside and recre- ation substituted. Absolute brain repose is an urgent necessity in these cases, and the greatest literary workers in all times have sought hours of indolence to recruit their exhausted energies, and win back sleep to their wornout intellect and wearied body. " There appears * On the Intellectual Powers, by J. Abercrombie, M.D. 92 258 HEADACHES. to be a kind of sleep in which no mental action whatever takes place, so that the only central organs in operation are those of an automatic and reflex nature. The functions depending upon the central organs of this character, viz., circulation, respiration, secretion, digestion, etc., go on as usual."* Moderate occupation of the mind is healthy and bene- ficial ; excessive work is nothing less than a curse. Both independent and prudential considerations impress us with the conviction that no plausible reasoning can sup- port the views of abstruse thinkers, who delude society by the advocacy of schemes for education, which press so hard upon the intellect of youth. They indicate a grievous lack of capacity to comprehend the fragility of a structure which is incapable of bearing any additional burden, when the struggle to support life alone is great, and conservative action is urgently needed to sustain the workmanship. Some restraint ought to be placed on the hazardous attempts of parents to force their children in the prosecution of intellectual pursuits, when the mind betrays any symptom of fatigue or weariness. The com- mon fault to be laid at the threshold of most ambitious people is, that they take it for granted that all their children have equal natural endowments, and that what the one acquires readily, the other can equally well ac- complish. No greater delusion can take possession of the understanding, and parents should be warned not to steer in a direction whence they may drift blindly into peril and danger. If they calmly consider the advice * Hermann's Human Physiologv, by Arthur Gamgee, M.D., F.R S 1875, p. 324. HEADACHES OF CHILDHOOD AND EARLY LIFE. 259 not to expose all their children to the same ordeal, they will avoid the current which is carrying them only to the ocean of sorrow. One child is born with prodigious capabilities, and the acquirement of knowledge comes as easy to him as the digestion of the daily meal which is provided for his bodily support. Mathematical prob- lems are solved with incredible quickness and geometri- cal principles are mastered in such a surprising manner that the knowledge seems almost intuitive.* Another child of the same parents, who is equally anxious and persevering, may not have the same apti- tude ; he may have a feeble mind, and no amount of cul- ture and drudgery can ever place him in the front rank of scholars, or enable him to acquire more than common- place facts. Books are not the delight of his eyes ; the bent of his inclination is not in this direction. He sees nothing to grasp at and acquire. His restless struggles to overcome this inherent deficiency of mental endow- ment impair the structure of a brain already weak, and too often end in miserable failure and disappointment. AVe may awaken the child's interest and understanding in the work he is set to accomplish, and render abstruse points clear by familiar illustration, but unless his natu- * A case is mentioned by Dr. Carpenter, of extraordinary mathe- matical ability in a boy, the son of an American peasant, who had received very little instruction in either reading or arithmetic, and yet he surprised every one by solving the most difficult arithmetical questions that were proposed to him, with ease and accuracy, at the age of six years. The immortal author of the " Messiah," at nine years of age, composed the church service for voices and instruments, and at fourteen far excelled many of the most eminent musicians of his time. 260 HEADACHES. ral powers are considerable, no plan of instruction can ever make him a great scholar. The power of memory depends greatly on sound physi- cal health; but also on original difference of constitu- tion, which ought to be taken into account, some chil- dren being much more remarkable for the faculty of acquirement than others. This does not appear to be invariably connected with superiority of intellectual en- dowments, for the facts thus readily acquired are not seldom rapidly forgotten ; the memory is local, so to speak, and is not accompanied by a full perception of the facts, as where the attention is complete, and the mind grasps the whole subject, and conceives it fully from every point of view. If close attention and pondering over a subject enable a child to master it in a given space of time, a habit of quick appreciation may be acquired, but the result is not usually so fixed or permanent, as where information is obtained in a more deliberate man- ner, and by slow and careful preparation. In reading or studying a book there are certain passages which strike the memory, and arrest it more deeply than others, which take a less abiding form in the recollection ; again, there are other portions which lull the mind into a list- less and inactive condition, from which it cannot be roused to engage the feelings, or awaken an interest. This is of deep importance in the training of children ; for that study which comes easy and pleasant to them is the least exhausting and wearisome. A child will become tired over an uninteresting book, whilst one which amuses and pleases him is easily understood, and the facts remembered. One thought suggests another of kindred nature, and the attention being aroused by a HEADACHES OF CHILDHOOD AND EARLY LIFE. 261 pleasurable excitement, there is much less effort required to master the subject. Some persons are gifted with re- flecting minds, and they have the habit of intense atten- tion and correct association. They may be taciturn in society, and be considered stupid and dull; but they carry away a knowledge of all they see and hear, and can reproduce much of the discussion, if it happens to be worth remembering. " The mental power which, in some cases, is acquired by constant and intense exercise, is indeed astonishing. Bloomfield, the poet, relates of himself that nearly one-half of his poem, ' The Farmer's Boy,' was composed, revised, and corrected, without writing a word of it, whilst he was at work with other shoemakers in a garret."* This was acquired by the power of keeping the subject, which was not a wide one, continually before his mind. When any subject of in- quiry is extensive and complex, it requires logical proof to enunciate the facts, and involves protracted and labori- ous study. If the subject also demands great exactness and precision, the intellect is much more taxed by this nicety of detail than by a more simple generalization. Intellectual strain and even hours of labor are to be carefully measured out according to the capacity of a child. So profound is my conviction of the danger in- cident on indiscriminate taxation of the mental powers, and that even children with high intellectual endowments have had their general health damaged by this forcing process, that, notwithstanding that they have in after life greatly distinguished themselves in scholastic attain- ments, I am convinced that a premature decay of the * On the Intellectual Powers, by J. Abercrombie, M.D., 1871, 19th edition, p. 99. 262 HEADACHES. mental powers has been invited, and decrepitude estab- lished years before such a calamity would have befallen them in the ordinary course of nature.* AYhat greater error could possibly be conceived than to enforce close attention and drudgery over lessons when the brain feels a sense of weariness, and the bodily strength is weak ? The application is imperfect, and attention cannot be given for any length of time, because the vigor of the brain is failing, and the intellectual functions are being spoiled. It is considered certain by some pathologists that the brain of childhood may become hypertrophied, but from what causes we are not in a position to speak with any degree of certainty; beyond this, that it has generally been observed in those cases of bright children, who have given evidence of intellectual precocity; and this being so, it is obvious that the undue employment of the brain (especially if the general health is in any way defective) may lead to inflammation of the membranes, or at least to severe congestion, or serous effusion into the ventricles.f * " The forcing system has been by many given up ; and precocity is discouraged. People are beginning to see that the first requisite for success in life is to be a good animal. The best brain is found of little service if there be not enough vital energy to work it; and hence to obtain the one by sacrificing the source of the other is now considered a folly—a folly which the eventual failure of juvenile prodigies constantly illustrates."—Education, Intellectual, Moral, and Physical, by Herbert Spencer, p. 60. f " There can be no doubt that many a child has been sacrificed in early life to the pride of parents, who, delighted with the intellec- tual activity of their children, have striven to make them prodigies of learning. But in these cases of early and undue employment of the brain, inflammation of the hemispherical ganglion, or of the lining membrane of the ventricles with serous effusion, has usually HEADACHES OF CHILDHOOD AND EARLY LIFE. 263 The anatomical changes after death are extreme elasticity and compressibility, so that the brain is too large for the cavity which contains it; the upper portion of the skull rises immediately, and the dura mater bulges out at the sides from the expansion beneath, as soon as the bone is separated from the rest of the cranium. The brain is said to be hard and pallid, owing to pressure having ob- literated the bloodvessels. On making a horizontal sec- tion, the gray matter is not seen altered, and the naked- eye view displays an increase in the amount of white matter; this, according to Pokitansky, is owing, not to an augmentation in the number of nerve tubes, or their dimensions, but to the excessive development of the in- tervening and nucleated substance or neuroglia."* AVilks and Moxon, after stating that they have no special ex- perience of this condition, say that in the cases that have lately occurred, the hypertrophy was unaccompanied by effusion into the ventricles, which were small, and that the actual growth of the cerebral structure " was found to be due to increase of the neurilemma, or cement be- tween the fibres."f In adult life, as we have previously seen,| when the ossification of the cranial bones is com- plete, the cerebral contents are not liable to the same de- gree of variation as in children, where the brain often attains considerable size and weight. From the evidence which has been obtained by scientific research, it seems been the cause of either a fatal issue or of subsequent mental imbecil- ity."—Solly, On the Brain, 2d edition, 1847, p. 662. * Jones and Sieveking's Pathological Anatomy, by Payne, 2d edi- tion, 1875, p. 272. f Pathological Anatomy, 2d edition, 1875, p. 218. X See Chapter I, on the Headache of Cerebral Anaemia. 264 HEADACHES. conclusively established that this disease is .most likely to attack delicate and active-minded children, just as atrophy of the brain is sometimes witnessed in young subjects, when they have been struck down by chronic and ex- hausting illness. It would appear, then, that this and some other morbid conditions of the brain may attack children of fragile frame and intellectual energy—those in whom the senses are acute, and the imagination lively; whose constitutional debility is apparent in the small- ness of the chest, and the large size of the joints; and the waste of whose nervous tissue, from overanxiety or mental excitement, is out of all proportion to the means of restoring it. I think our school boards have something to answer for in the measure they deal out to those parents who omit sending their children regularly to school when they are not in a fitting state to exert themselves in the prosecution of their studies. There may be much to be said in extenuation of these severe measures from the ready excuses which the poor offer for keeping their chil- dren at home ; but they have reason sometimes on their side, and it is only requisite to take a glance at many of the cases brought before us, to see how opposed it is to common-sense and reason to expect that such children should be supposed capable of grasping the most simple facts with health so shaken. I am frequently asked by sensible mothers who bring their children for hospital advice, and fully realize the importance of instruction, to sign a certificate recommending absence from school which they may present to the board. I find that sleepless nights, irritability of manner, drowsiness in the day- time, headache, and loss of appetite are the usual train of HEADACHES OF CHILDHOOD AND EARLY LIFE. 265 symptoms, and they are just what we might anticipate when children are imperfectly fed and clothed. In nine cases out of ten, the children are anaemic, the blood is poor and impoverished, and there is a taint of consump- tion or scrofula in some of its forms. Some parents, in seeking advice for a child, tell me that their children are so anxious and interested in their school-work, that it is painful to keep them at home, but the effects of allow- ing them to go to school are debility, headache, languor, depression, and loss of appetite, till they finally break down altogether,* and this applies in a far greater ratio to girls than to boys. " Beyond doubt, the girls, from the fact that they are girls, are more liable to suffer than boys."f Now this in many cases is caused by the phys- * The returns of the registrar-general in England for the year 1874 show that 30,995 deaths, chiefly among children, were due to atrophy and debility. It was the third on the list of deaths from fifteen causes, and exceeded the deaths from okf age by upwards of 2000, which comes next on the list. Nervous diseases are also fear- fully on the increase, and are the fifth in order. Convulsions, nearly all among children, realize the high figure of 27,139, and is the fourth on the list. It exceeded the deaths from epidemic and zymotic dis- eases, as scarlet fever, measles, whooping-cough, and diarrhoea, which strike down such a large proportion of our juvenile population. f School Hygiene, by Dr. Frederick Winsor, Winchester, Massa- chusetts. Quoted from The Building of a Brain, p. 72. The size of the brain may have something to do with this. " The average weight of the human adult male brain is about 3 lbs. It in- creases from one year old up to twenty. Between twenty and thirty there is a slight decrease on the average ; afterwards it increases and arrives at its maximum between forty and fifty; after fifty to old age the brain gradually decreases in weight. Tiedemann, in his paper on the brain of the negro, states that the brain of the adult male varies between 3 lbs. 2 oz. and 4 lbs. 6 oz. The brain of men who have dis- tinguished themselves by their talents is often large. The brain of 266 HEADACHES. ical health being so delicate that the mind will not bear the strain. There is no reserve force to draw upon. How different might this have been, supposing the general health had received a full share of attention, and the cul- ture of the mind had been neglected till a later period. The aptitude and great desire for learning in young children physically weak and delicate is oftentimes dis- astrous. AVhen the health is robust, the brain tolerates sustained attention with impunity, particularly if the ex- ercise goes on unconsciously (as in the pursuit of pleasure), for then the brain escapes the fatigue which is the certain accompaniment of effort. The mental development of an individual is inseparably united with the growth of the physical frame, and the two should be looked at side by side in all their relationship. It is an essential prop- erty of the brain to feel every debilitating power in the smallest degree, and to call into active operation the ex- citability of the^whole vital system. Impressions made Cuvier weighed 4 lbs. 11 oz. 4 dr. 30 grains, troy weight. The brain of an idiot, fifty years of age, weighed but 1 lb. 11 oz. 4 dr. The fe- male brain usually is lighter than the male. It varies between 2 lbs. 6 oz. and 3 lbs. 11 oz. Tiedemann never met with a female brain that weighed 4 lbs. The female brain weighs on an average from 4 to 6 oz. less than that of the male, and this difference is already percepti- ble in the new-born child."—Solly, On the Brain, 1847, p. 162. " The average of both sexes differs, however, in the various races of mankind. Dr. Davis (Proceedings of the Royal Society, January 23d, 1868) found the mean of the European series to be 46.87 oz.; of the Asiatic series, 44.62 oz.; of the American series, 44.73 oz.; of the African series, 44.3 oz.; and of the Australian series, 41.38 oz. Dr. Thurnam (Journal of Mental Science, April, 1866) gives 49 oz. as the average weight of the European brain, whilst in distinguished men it amounts to 54.6 oz."—Quoted from Carpenter's Human Phys- iology, by Power, 8th edition, 1876, p. 786. HEADACHES OF CHILDHOOD AND EARLY LIFE. 267 upon the brain by overexertion, when the bod}' as a » whole is in a state of debility or exhaustion, invite a de- gree of excitement or stimulation, which proportionately distresses and weakens it. In consequence of the pres- ence of irritation in distant and overtaxed organs, the brain is affected, and its functions are suspended or ex- cited according to the amount of mischief which deter- mines the irritability. "Continued activity of a nerve diminishes its irritability in proportion to the time, and may destroy it altogether (exhaustion). In the former case rest restores the nerve to its original condition. The alterations which take place in nerves during exhaustion have not yet been made out" (Hermann). The separate functions of life cannot long be maintained in health, under any degree of excitement, without exhaustion being sooner or later felt in the entire organism. Every dis- turbance, from the most accidental cause, is quickly responded to, and in consequence of the influence of sympathy the affections of each are felt, till disease is complicated or incurable, through the bond of connection between the vascular and the nervous systems. Parents may take comfort from the fact that a popular tradition is held as sound by many people, that the boy who may appear somewhat heavy and backward at first, may turn out a distinguished man at last. This tradi- tion is not a mere fancy or superstition, but is founded on the every-day experience of people who have seen the facts for themselves, and who are not simply bent on propounding a theory. Parents may equally take warn- ing from the fact, that mental strain encouraged to excess in delicate children is almost certain to entail disastrous consequences. If such children are absurdly pressed by 268 HEADACHES. the vanity of parents, or the mistaken views of teachers, the extreme point of tension is not generally discovered till it is exceeded, and the result of early forcing is too often to produce a state of brain which, at its best, never after- wards rises above the level of mediocrity. According to Professor Layeoek, precocious children are usually of the strumous type, which he terms an ap- proach to a " lower ethnic form," and which is more or less incompatible with high intellectual development; hence the common phrase, that "some children are too clever to live." The question will be asked by parents, and those en- gaged in education : AA7hen may we put pressure on with safety? The age of the child is not a criterion, and I can conceive of no greater error than to attempt the adoption of any general rule which shall be applicable to all cases, for children differ widely from each other in a hundred ways, and what will prove a healthy stimulus to- some will exhaust and overthrow others. If a child has had his intellect carefully and slowly unfolded, he will be in a very different position at six or seven years of age to one whose culture has been neglected up to that time; the memory maybe exercised with safety, and the gift of imitation so strong in childhood made use of from a very tender age. The mind, like the body, is amenable to rational management, and when this is gradual, and not premature or forced, the facility of acquirement will be all the more ready. The process of additional pres- sure must be conducted with a full appreciation of what the child can accomplish with pleasure, and must not cause weariness. This appears to be about the only rule we are justified in suggesting, and we must discriminate HEADACHES OF CHILDHOOD AND EARLY LIFE. 269 between the strong vigorous child who can bear the pres- sure, and the weak excitable child who is probably of the two the more willing and anxious to learn. Look- ing at the physical health of a child, as a means of judg- ing of its mental strength, I think the commencement of the second dentition is the earliest period when instruc- tion requiring brainwork can be safely pushed. Even then the knowledge should be of a kind which accords with the evolution of the different faculties, or the mind will become disgusted with the difficulties placed before it, and not having mastered simple subjects, it will be unfit to receive more complex ones; hence precise methods of instruction, and exact definitions, if attempted too soon, will be fraught with evil, and the child will languish under the accumulation of facts with which its mind is weighted. Let us, then, consider the question of dentition in its relation to the physical and mental growth of childhood. The eruption of the first set of teeth is determined by the state of the nervous system, the quality of the food that is supplied, and the surrounding conditions of pure air and water; it is much more delayed in some children than in others, and notably in those who are weakly and delicate, or whose development is retarded by a rickety constitution. AVhen it does commence the nervous system is disturbed, and convulsive affections not un- frequently ensue. Now, if convulsions happen from time to time the nerve-centres are rendered still more excitable, and the brain is weakened, which weakness may show'itself at the time of the second dentition. The period of the second dentition, which begins about the seventh or eighth year, must be reckoned, from this 270 HEADACHES. point of view, the most important period of child- hood—the period when educational training should be cautiously proceeded with, because then the physical growth is very active, and the animal functions are pro- ceeding with extraordinary rapidity, and a large amount of rest and sleep are required for the building up of the tissues. This period in some children is of much longer duration than in others, lasting in weakly, rickety sub- jects till thirteen or fourteen. The rule of the Factory Laws does not allow a child to work before the age of nine, and at thirteen only nine hours a day, the gradual development of the teeth being taken as the best standard of physical capability, and a more reliable test of age than height, because it is very well known that the tallest children are generally the most weak and fragile (Car- j)cnterx Human Physiology, page 1105). During child- hood the digestive organs are very active, and derange- ments which are brought about by perverted nutrition are especially common. If disorders of the digestive organs become chronic, any trifling cold may provoke an in- flammatory attack, and hence tuberculous diseases are frequent, a latent strumous diathesis being called into activity. Any immoderate intellectual training at a time when the digestive organs are enfeebled, and the appe- tite poor, may so impoverish the quality of the blood as to increase the irritability of the nervous centres. Two instances of this kind have come under my observation, where delicacy of the general health, with ordinary mental exertion, was followed by tubercular disease of the brain in young, bright, clever lads, aged respectively eight and eleven years. In neither instance could any blame be attached to the mental training; but the physical health HEADACHES OF CHILDHOOD AND EARLY LIFE. 271 in both cases had not reached that standard of strength, or perhaps could not reach it, which admitted of any tension or concentrated employment of the faculties. Some children are naturally quick and active-minded, and they will make rapid progress in their studies, and achieve with ease what is unattainable by others; or, at least, if it is accomplished by another child, it is at great expense, and at the possible risk of a complete break- down. It is undesirable to make a great demand upon the intellectual powers till the completion of growth, when the demands upon the system are distinctly lessened ; all the functions of life cannot bear severe strain at the same time, and therefore advantage should be taken of the intervals of growth when it is comparatively quiescent. How frequently does it happen that a long and trying illness has kept a boy from school, and he has lost so much time that it seems impossible that he can make it up again; yet, on recovery, the period of inactivity has had a most salutary effect, and he is not long in coming up to the level of his competitors and rivals. I have adopted the following classification of head- aches : (1.) Cerebral headache, attributable to injury, or to acute or chronic inflammation. (2.) Gastric headache, from intestinal and hepatic de- rangement, known as bilious headache (sympa- thetic headache). (3.) Epileptic headache (congestive headache). (4.) Febrile headache (active hyperamia or active con- gestion). 272 HEADACHES. (o.) Headache from ameraia, neuralgia, etc., constitu- ting nervous headache. (6.) Headache depending on some intricate change in the cerebral membranes or tissues of the brain. (7.) Organic headache. (1.) Cerebral headache seems to me an appropriate term for a variety of headache, which has supervened on a blow or injury to the head. The slight concussion so induced has interrupted the functions of the brain, and disturbed the circulation. No notice is taken at the time of the accident, although there may have been disturbance of sensation, or voluntary motion, giddiness, and even nausea may have been the evidence of disturbance ; but, passing off quickly, neither the patient (if old enough to reflect on the cause) nor the friends have a notion that so slight an injury could be associated with the oppressive headache which ensues. The circumstances under which the brain usually reveals its weakness are the exercise of the intellect, chronic illness, deficient food, and imperfect ventilation. The brain cannot tolerate any ordinary strain without becoming exhausted, and the intellect is so enfeebled that in many cases all attempts at education have to be given up. The headache is almost invariably frontal, and I would go so far as to hazard the opinion that the anterior lobes never escape. In some cases the pain is also occipital, but I have seldom observed it ex- clusively in this situation, and when it has been severe, the pain in the forehead has been less intense and over- powering. No degree of pain in the back of the head, according to my experience, produces such vital prostra- HEADACHES OF CHILDHOOD AND EARLY LIFE. 273 tion and loss of energy, as a less degree of suffering will occasion in the frontal region. The patient has a dull and languid look; there is no animation in the expres- sion ; the eyes are sunken in the orbits, and move slug- gishly ; the lower eyelids are dark, and the face is pallid and drawn ; the skin is cool, and the extremities cold or chilly, because there is a disinclination to exertion ; the pulse is soft and slow, and the bowels disposed to consti- pation. The psychological symptoms are an alteration in ordinary manner and character, so much so that the friends tell us that he is not like the same child. He takes no interest in anything, and lies about in one corner of the room, as though depressed or unhappy; he will doze in the daytime and sleep soundly at night. Petu- lance and irritability are not features of this condition, the nerve-centres not being so much involved (at least primarily)as the vascular system, which, being overloaded, the want of contractility in the vessels favors congestion and serous exudation into the brain-structure itself. Cases with a history of this character cannot receive too much attention, and the prognosis should always be care- ful and guarded. Trifling excitement may set up in- flammatory action, or renew the congestion, which it is so necessary to remove before the brain has sustained irreparable injury. For this congestion, becoming local- ized, may lay the foundation of a tumor or morbid growth, and our attention in after years is not directed to the in- jury till continuous or paroxysmal pain in the head, loss of power in the limbs, defective vision, or obstinate vom- iting indicates the presence of serious mischief in the brain. If the case goes on, the general weakness in- creases, and the child is laid up, giving every one the idea, 23 274 HEADACHES. by his looks and manner, that he is laboring under dis- ease of the brain. Any indiscretion in diet causes flush- ing of the face, accelerated pulse, and often vomiting. Not unfrequently the symptoms increase in severity, and meningitis ensues ; there is rigidity of the arms and legs, the head is thrown back against the spine, the thumbs are hidden in the palms of the hands by the flexor ten- dons, the cheeks are flushed, the temperature rises, and the bladder is paralyzed. Now the respiration becomes sighing and irregular, the bowels act involuntarily, the child cannot be roused to swallow anything, and convul- sions or coma usher in death. After death, in such cases as these, there may be presented on a post-mortem exam- ination the evidences of extreme congestion in the veins, ramifying over the dura mater, and in the sinuses and base of the brain; the,lateral ventricles may contain serous fluid in excess, and when the brain is sliced, the puncta vasculosa are everywhere turgid with blood, which oozes out gradually from their open mouths after section. It is important not to ascribe too hastily to inflammatory action what in reality may be due to excessive congestion. AVhen the symptoms of meningitis are well marked in young children, they may generally be assigned to tuber- cle. If there is much elevation of temperature, and fever, we need have no hesitation on the subject. But a more slow and insidious form of meningitis may arise. In these cases the temperature is normal or nearly so, the pulse is habitually slow, but rises rapidly on any excite- ment or after food; the limbs waste and become power- less, the child is irritable and fretful; he sleeps badly at night, and is so restless that the clothes cannot be kept over him. These are the most favorable cases. The in- HEADACHES OF CHILDHOOD AND EARLY LIFE. 275 jury has been so slight as to provoke into action a slumber- ing strumous diathesis, or a delicacy of constitution, which but for the accident may never have been developed, or certainly not till a later period, when the intellect has been subjected to extra exertion, or the child has been struck down by an eruptive fever or exhausting diarrhoea. The treatment consists in subduing any congestive or inflammatory symptoms that arise, by careful diet and the observance of strict hygienic rules, the avoidance of all excitement, and everything that tends to disturb the equanimity of the mind; for children become quickly alive to surrounding circumstances, and mentally appre- ciative of all that goes on around them. In some cases that have fallen under my notice, counter-irritation at the back of the neck has answered well, especially if there has been pain in the occiput, and the muscles are stiff. If the child is not old enough to complain, he will often raise his hand to the back of his head to indicate the seat of mischief. I saw a male child in November, 1876, aged fourteen months, who had cut most of his teeth with comparative ease, except with one slight convulsion six months previously. About three months before I saw him, he struck his head; and although no bad conse- quences ensued till the present illness, when I saw him in consultation with the ordinary medical attendant of the family, I have no doubt of the accident having laid the foundation of the congestion and meningitis, which carried him off after four days, from gradual unconscious- ness passing into deep coma. (2.) Gastric Headache (Sympathetic Headache).—This is not uncommon in children, from errors in diet, and 276 HEADACHES. overfeeding; but it is less frequent with them than with adults, who are more prone to irregularity in eating and drinking. It is to be understood, however, that gastric disorder, or sympathetic dyspepsia, is often met with from irritation elsewhere; for instance, it may be the result of ascarides in the rectum, or worms in the bowels; but we must not forget that the real cause of the disturbance may be inflammation of the brain or its membranes in children. Irritability, peevishness, languor, may give rise to reflex irritation, as we have seen in the previous chapter. AY here the brain is affected, vomiting is a constant symp- tom, and in those who die, the mucous membrane and its larger extremity is found digested, or dissolved by the gastric juice,—a proof that the irritation of the brain ex- cites, at-least in many cases, untimely secretion of gastric acid (Budd, On the Stomach, p. 193). Andral has pointed out that these patients often throw up a large quantity of greenish bile with painful efforts. In addition to pain and tenderness at the epigastrium, there is in most cases severe pain in the head. This disease also occurs in children from tubercular disease of the lun4s. HEADACHES OF CHILDHOOD AND EARLY LIFE. 291 end of six months from the time of the epilepsy. After death a tumor was found in the posterior lobe of the left hemisphere, the size of a hen's egg. Neither the mem- branes nor the substance of the brain were more vascular than usual. Tubercular tumors of the brain are far more common in the case of children than the other varieties, and they more frequently involve the substance of the hemispheres and cerebellum than the membranes which are liable to inflammation; in fact, tubercle of the brain is very prone to induce inflammation and effusion into the ventricles. The symptoms are severe headache, con- tinuous or paroxysmal: then passing off to recur again with convulsions, insensibility, and coma. After death it is not uncommon to meet with flattening of the convo- lutions, effusion into the ventricles, and a hard portion of yellow tubercle, varying in size from a marble to an egg. As I have previously mentioned,* severe headache with vomiting, constipation, impairment of intellect, convulsive movements, paralysis or coma, disturbance of vision, etc., are the prominent symptoms of headache due to organic change. See Chapter XIV, on Organic Headache. FORMULA. (1) R. Potass. Citrat., 9j. Inf. Digitalis, Inf. Buchu, aa gss. Misce.—To be taken three times a day. In uraemic headache, with deficient renal action. (2) R. Potass. Citrat., 9j. Spt. Juniperi, 3j. ^Ether. Nitr., "Kxx. Decoct. Scoparii, %j. Misce. In the same cases as the above. (3) R. Potass. Bitart., £ss. Syr. Limonis, §ss. Aquae ferventis, Oij. Misce. To be taken during the day and night in the same cases, where the urine is scanty and the bowels sluggish. (4) R. Hydrarg. Bichlorid., gr. j. Tinct. Ferri Perchlor., Glycerini, aa gss. Aquae purae, ad §xij. Misce.—A tablespoonful in an equal quantity of water, or one ounce of Infusion of Quassia, three times a day. In anasarca and anaemia, where the headache is due to renal con- gestion, and in some forms of syphilitic headache when the cachectic state is well marked. 294 FORMULAE. (5) R. Quiniae Disulph., gr. x-gr. xv. Acid. Sulph. Dil., "Kx. Syrupi----, ^ij. Aquae, ad §jss. Misce. To be taken in headache from malarial poisoning, two or three hours before the expected paroxysm. Afterwards, a third part three times a day till cinchonism is produced. (Dr. Smith.) (6) R. Liquor. Fowleri, Tinct. Belladonna?, aa gj. Aquae purae, ad 3Jss. M. Sig.—A teaspoonful in a wineglassful of water three times a day. In the same cases, where the headache recurs from time to time. (7) R. Quiniae Disulph., ^ss. Acid. Arseniosi, gr. j. Nitric. Dil., 3j. Aquas purae, ad 3j. M. Sig,—Thirty drops in a wineglassful of water three times a day after food. In similar cases to the above. (Dr.' Eouth's formula for giving Arsenic.) (8) R. Liquor. Cinchona?, ii£xx. Fowleri, ffP.v. Aquae purae, ad ,^j. M. Sig.—To be taken three times a day after food. In neuralgic headache and cerebral anaemia. (9) R. Liquor. Fowleri, ^j. Tinct. Quiniae, ^jss. Mist. Camph., ad ^vj. M. Sig.—^ss three times a day in a little water after food. In neuralgic and periodic headache. FORMULAE. 295 (10) R. Liquor. Potass. Ars., 3j. Tinct. Quiniae, 3*jss. Hydr. Bichlor., gr. ss. Aquae, ad 3 vj. Misce.—A tablespoonful in a wineglassful of water three times a day after food. In neuralgic headache, where a mercurial is desirable, and there is the history of syphilis. (11) R. Liquor. Potass. Ars., Potassae, aa 3j. Tinct. Colchici, ^ij. Lavand. Co., giij. Aquae purae, ad 3*yj. Misce.—A tablespoonful in a wineglassful of water twice a day after food. In neuralgic headache associated with the gouty diathesis. (12) R. Tinct. Quiniae, £xiv. Spt. Chloroformi, ^ij. Misce.—A teaspoonful in a wineglassful of water twice or three times a day. In neuralgic and nervous headache. (13) R. Tinct. Quiniae, 3yj. Potass. Bromid., 3j—^ij. Glycerini, ^ij. Mist. Camphoras, ad 3*yj. Misce.—A sixth part twice or three times a day. In neuralgic and nervous headache. (14) R. Acid. Hydrobromici, JJvj. Quiniae Disulph., gr. xij. Inf. Gent. Comp., ad 3*xij. Misce.—Two tablespoonfuls twice or three times a day. In neuralgic and nervous headache, where Quinine alone disagrees. 296 FORMUL.E. (15) R. Sodae Bicarb., Bismuth. Subcarb., Pulv. Aeaciae, aa 3J. Spt. Amm. Arom., ^ij. Syr. Zingib., ^iij. Aquae purae, ad ,^viij. Misce.—Two tablespoonfuls three times a day half an hour before food. In dyspeptic headache with flatulence, acidity, and pyrosis. (16) R. Amm. Carb., gr. iv. Aquae, gj. Misce.—To be taken every three or four hours. In dyspeptic, neuralgic, and nervous headache, and in some forms of gouty headache. (17) R. Spt. Amm. Arom., ntf.xl. Chloroformi, "£x. Aquae, ad 3*j. Misce.—To be taken every three hours. In dyspeptic and nervous headache. (18) R. Sodae Citro-Tart. Efferv., 3j-3ij. (B. P.) To be taken whilst effervescing in the third of a tumblerful of cold water early in the morning. As a mild aperient in dyspeptic or bilious headache, with nausea and sickness, and in plethoric headache. (19) R. Magnes. Sulphat., 3yj. Carb., 3j. Tinct. Lavand. Co., ^iij. Aquae Menth. Pip., ad 3*viij. Misce.—A sixth part to be taken early in the morn- ing, and repeated as may be necessary. In dyspeptic and bilious headache with flatulence. FORMULA. 297 (20) R. Quiniae Disulph., gr. xij. Acid. Sulph. Dil., gss. T. Ferri Perchlor., ^ij. Spt. Chloroformi, 31J. Magnes. Sulph-., 3*jss. Syr. Zingib., 3*j. Aquae, ad 3* xij. Misce.—Two tablespoonfuls three times a day. In neuralgic headache with constipation. (21) R. Syr. Ferri Phosph. et Quiniae et Strychniae, 3*jss. Misce.—A teaspoonful in a wineglassful of water three times a day after food. In neuralgic and nervous headache. (22) R. Syr. Ferri Hypophos., 3*jss. Misce.—A teaspoonful in a wineglassful of water three times a day after food. In neuralgic and nervous headache, where the hypophosphites are useful, and in some congestive headaches. (22 a) R. Syr. Ferri et Calcii Lactophosph., 3*ij. Misce.—One or two teaspoonfuls in a wineglassful of water twice a day after food. Fifteen or twenty grains of bromide of potassium or ammonium may sometimes be added to each dose. In similar cases to the preceding marked by general debility and defective nutrition. (23) R. Calcis Hypophos., gr. lxxx. Tinct. Ferri Perchl., giij. Quiniae Disulph., gr. xvj. Strychniae, gr. ss.-gr. j. Spt. Chloroformi, ^ij. Syrupi, 3>s. Aquae purae, ad 3*viij. Misce.—A tablespoonful to be taken three times a day in a wineglassful of water. In similar cases to the above. 25 298 FORMULAE. (21) R. Ferri. Citr. et. Quiniae, v^ss. Spt. Chloroformi, 3j. Syr. Aurant., 3iij. Aquae purae, ad 3*vj. Misce.—A sixth part three times a day after food. In neuralgic and nervous headache, with anafmia and depression, and in some congestive headaches.* (24 a) R. Liquor. Ferri Dialysati, %j. Misce.—Ten to thirty minims in a wineglassful of water twice or three times a day. In similar cases to the preceding, and especially in the anaemic headache of children. (24 b) R. Ferri Amm. Citr., 9ij. Liq. Potass. Ars., "Kxl. Syr. Zingib., 3*ss. Inf. Calumbae, ad 3*viij. Misce.—Two tablespoonfuls twice a day after food. In nervous and neuralgic headache with anaemia. (25; R. Amm. Bromid., 3j. Spt. Amm. Arom., t^ss. Aquae purae, ad 3*jss. Misce.—To be taken on rising in the early morn- ing. In some forms of nervous and congestive headache. (25 a) R. Potass. Bromid., 3j. Spt. Amm. Arom., gij. Amm. Carb., Sodae Bicarb., aa Qij. Syr. Aurant., giij. Aquae purae, ad 3*viij. Misce.—A sixth part to be taken every four hours whilst effervescing with Acid. Citric, gr. xiv, dissolved in one tablespoonful of water. In the early stage of nervous and neuralgic headache when there is nausea, and the tongue is coated. * Three to five drops of the Liquor. Strychniae, and half an ounce of the Tinc- ture of Calumba, may be sometimes added to this prescription with advantage. FORMULAE. 299 (26) R. Potass. Bromid., 31 j. Spt. Amm. Arom., 3iij. Mist. Camph., ad 3*vj. Misce.—A sixth part three times a day. In nervous and- neuralgic headaches, and where there is excite- ment and irritability. • (26 a) R. Tinct. Aconiti, 3ss. " . Aquae purae, ad §iv. Misce.—A teaspoonful in a tablespoonful of water every half-hour till the pain is relieved. In acute congestive headache, with flushed face and full pulse. (27) R. Amm. Chlorid., gr. x~9j. Aquae purae, ad ^jss. Misce.—To be taken three times a day. In neuralgic and nervous headache, where migraine and clavus are specially marked. (28) R. Sodae Hypophosphitis, 3ss. Inf. Calumbae, ad 3*vj. Misce.—A sixth part to be taken three times a day. In neuralgic, nervous, and anaemic headache. (29) R. Magnes. Sulphat., gj. Quiniae Disulph., gr. viij. Acid. Sulph. Dil., nXx. Inf. Kosae Co., ad 3"viij. Misce.—Two tablespoonfuls twice or three times a day after food. In neuralgic and congestive headache, with constipation and full habit. (30) R. Tinct. Quiniae, 3vj. Spt. Chloroformi, 3J. Mist. Camph., ad 5yj. Misce.—A sixth part three times a day. In gouty and nervous headache, where Quinine is necessary. 300 FORMULAE. (31) R. Potass. Bicarb., Sodae Bicarb., aa 3jss. Vin. Sem. Colch., 3J-31J. Syr. Zingib., 33s. Aquae, ad § viij. Misce.—Two tablespoonfuls three times a day, with one tablespoonful of lemon-juice, whilst effervescing. In gouty headache, and the headache of cerebral hyperaemia. (32) R. Amm. Carb., 3ss. Vin. Sem. Colch., 3*s. Tinct. Aurant., 3*ss. Aquae, ad 3jss. Misce.—A teaspoonful in half a tumberful of Apollinaris or Vichy water three times a day. In gouty headache. (33) R. Lithiae Citrat., 9ij. Potass. Bicarb., 31JSS. Tinct. Aurant., 3*ss. Aquae, ad 3*iv. Misce.—A tablespoonful in half a tumblerful of water three times a day. In gouty headache, where the urine is turbid, or contains lithic acid in excess. (34) R. Potass. Iodidi, 3SS.-3J. Bicarb., 31J. Vin. Sem. Colch., "Kxl. Amm. Carb!, gr. xxiv. Syr. Zingib., 3*ss. Aquae, ad 3"viij. Two tablespoonfuls three times a day. In rheumatic headache. FORMULAE. 301 (35) R. Potass. Iodidi, Amm. Hydrochlor., aa 3jss. Inf. Humuli, 3*vj. Misce.—A tablespoonful three or four times a day in a wineglassful of water. In rheumatic headache. (Dr. Smith.) (36) R. Potass. Iodidi, 3j. Tinct. Cinch. Co., 3*j. Colch., 3j. Aquae Cinnamomi, ad 3*xij. Misce.—Two tablespoonfuls three times a day. In rheumatic headache. (37) R. Potass. Iodidi, 3ij. *Liquor. Hydr. Bichlor., 3yj-3*jss. Tinct. Gent. Comp., §jss. Aquae Cinnamomi, ad 3"xij. Misce.—Two tablespoonfuls three times a day in a wineglassful of water after food. In syphilitic and organic headache. (38) R. Potass. Iodidi, 3j. Liq. Arsenicalis, 3j- Tinct. Quiniae, ad §iij. Misce.—A teaspoonful in a wineglassful of water three times a day after food. In syphilitic headache. (39) R. Tinct. Ferri Perchlor., 3ijss. Acid. Sulph. Dil. vel Spt. Chloroformi, 3J. Tinct. Lavand. Co., 3yj. Syr. Aurant., ^ss. Mist. Camph., ad giv. Misce.—Two teaspoonfuls three times a day in a wineglassful of water. In nervous headache from menorrhagia.f * The mercury maybe omitted according to circumstances. t One of the prescriptions containing Arsenic or Ergot may be necessary ac- cording to the discretion of the practitioner, or either of these remedies may be added to the Formula. 302 FORMULAE. (40) R. Potass. Bromid., 9j. Syr. Tolutani, 3j. Aqua?, ad ^jss. Misce.—To be taken every night at bedtime. As a sedative in the pain and sleeplessness of nervous and neuralgic headache. (41) R. Acid. Hydrocy. Dil., 3ss. Aquae, ad 3*jss. Misce.—A teaspoonful in a tablespoonful of water every two or three hours. In the sickness and nausea of nervous headache. (42) R. Acid. Hydrocy. Dil., "JUxiv. Potass. Bicarb., 3j. Aquae, ad 3*vj. Misce.—Take a sixth part, with eight grains of Acid. Citric dissolved in a tablespoonful of water, whilst effervescing. In similar cases to the preceding, and in the sickness and acidity of dyspeptic headache. (43) R. Spt. Chloroformi, n^x. Liquor. Strychniae, nj;iv. Decoct. Aloes Comp., ad 3*jss. Misce.—To be taken early every morning. In the constipation of nervous headache. (44) R. Acid. Citric, 3ijss. Quiniae Dis., gr. xij. Syr. Aurant., 3*jss. Aquae purae, ad 3*vj. Misce. FORMULAE. 303 R. Potass. Bicarb, vel Sodae Bicarb., 3iij. Amm. Carb., Qij. in pulveres xij. Signetur.—One powder to be dissolved in a claret- glassful of water, then mixed with a tablespoonful of the mixture, and taken three times a day whilst effer- vescing. In some forms of nervous headache where there is nausea and de- pression. (45) R. Sodae Bicarb., 3jss. Spt. Amm. Arom., 31J. Tinct. Gent. Comp., 3*ss. Syr. Aurant., 3*ss. Inf. Gent. Co., ad 3*viij. Misce.—Two tablespoonfuls three times a day. In nervous headache with dyspepsia, furred tongue, and acidity. (46) R. *Ferri Amm. Citr., 3ss. Acid. Citric, 3J. Quiniae Sulph., gr. vj. Aquae puree, ad 3*vj. Misce.—A sixth part to be taken three times a day in effervescence, with Sodae Bicarb., gr. x, previously dissolved in a table- spoonful of water. (47) R. Acid. Nitric. Dil., 3j. Hydrochlor. Dil., 3ij. Liquor. Strychniae, "Kxxxvj. Inf. Quassiae, ad 3*xij. Misce.—Two tablespoonfuls three times a day. In nervous headache with a clean tongue and slow digestion. * Three to five minims of the Liquor. Strychnife may be added in some cases. 304 FORMULAE. (48) R. Tinct. Nuc. Vom., 3j. Acid. Nitr. Dil., 3j. Hydrochl. Dil., 3ij. Tinct. Aurant., 3vj. Aquae purae, ad 3*yj. Misce.—A tablespoonful in a wineglassful of water three times a day. In nervous headache where the Strychnia does not agree. The Liquor. Strychniae sometimes causes nervous depression, sickness, and muscular tremors, which I have occasionally noticed as the effect of the Ferri Citr. et Strychniae in gastralgia. (49) R. Tinct. Digitalis, 3ss.-3ij. Mist. Camphorse, ad 3*vj. Misce.—A sixth part to be taken three times a day. In the headache of cerebral anaemia as a cardiac tonic, when the pulse is small and frequent, or there is palpitation. (50) R. Tinct. Digitalis, 3ss.-3ij. Spt. Chloroformi, 3j. Syr. Aurant. Flor., 3iij. Aquae, ad 3*vj. Misce.—A sixth part to be taken three times a day. In the headache of cerebral anaemia, where depression is to be guarded against. (51) R. Inf. Digitalis, gvj. Misce.—Two teaspoonfuls to be taken three times a day. In similar cases to the preceding, especially if accompanied with dilatation, or fatty change of the heart. (52) R. Tinct. Belladonnae, 3ij~3iij. Nuc. Vom., 3j. Syr. Zingib., gss. Aquae, ad gvj. Misce.—A tablespoonful in a wineglassful of water three times a day. In some forms of anaemic headache. FORMULAE. 305 (53) R. Strychniae Sulph., gr. ss. Tinct. Ferri Chlorid., 31J. Glycerini, 3~ss. *Inf. Gent. Comp., ad 3*vj. (Dr. Smith.) Misce.—A tablespoonful in a wineglassful of water three times a day after meals. In the headache of cerebral anaemia with nervous exhaustion. (54) R. Amm. Carb., 3ss. Tinct. Calumbae, Syr. Aurant., aa 3iij. Aquae purae, ad 3*vj. Misce.—A sixth part to be taken twice a day. In the headache of cerebral softening. (55) R. Amm. Carb., 3ss. Tinct. Lavand. Comp., 3*ss. Calumbae, 3iij. Mist. Camph., ad 3 viij. Misce.—Two tablespoonfuls to be taken three times a day. In the headache of cerebral softening with irritability and depres- sion, and in some congestive headaches. (56) R. Potass. Bicarb., 3j. Iodidi, gr. xviij. Spt. Amm. Arom., 3iij. Mist. Camph., ad ^ viij. Misce.—A sixth part three times a day after food. In organic headache due to syphilis. (57) R. Spt. Chloroformi, n^v. Liq. Ergot. Ext., n^xx-3ss. Aquae purae, ad 3*j. Misce.—To be taken three times a day. In the congestive and organic forms of headache in advanced life. * The infusion of Quassia or Calumba is preferable to Gentian, in consequence of the decomposition of the iron in the latter preparation. 26 306 FORMULAE. (58) R. Liq. Ergot. Ext., giij. Aquae, ad gvj. Misce.—Two teaspoonfuls, to be gradually in- creased to two tablespoonfuls, three times a day. In congestive headaches from organic disease. (59) R. Sodae Pot. Tart., gij. Potass. Bicarb., 9j. Syr. Aurant., 3jss. Aquae, ad gjss. Misce.—The draught to be taken in effervescence with Acid. Citric, gr. xv, dissolved in a tablespoonful of water, early in the morning. In dyspeptic and plethoric headache. (60) R. Magnes. Sulph., 3iij. Sodae Bicarb., 3iij. Liquor. Taraxaci, 3vj. Tinct. Zingib., 3j. Aquae purae, ad t^vj. Misce.—A sixth part to be mixed with Acid. Tart., 9j, previously dissolved in a tablespoon- ful of water, and taken early in the morning whilst effervescing. In dyspeptic and plethoric headaches with sluggish liver. (61) R. Quiniae Sulph., gr. viij. Acid. Citric, Jjij. Aquae purae, ad 3*iv. Misce. Sig.—No. 1 Mistura. R. Sodae Bicarb., 3iij. Liquor. Taraxaci, Syr. Aurant., aa 3*ss. Aquae purae, ad 3* viij. Misce, Sig.—No. 2 Mistura. One tablespoonful of No. 1 to be mixed with two tablespoonfuls of No. 2, and taken whilst effervescing three times a day. In similar cases to the above, where Quinine is admissible. FORMULAE. 307 (62) R. Tinct. Cinch. Comp., gj. Spt. Amm. Arom., 3*ss. Misce.—A teaspoonful in a wineglassful of water three times a day. In some passive congestive headaches, where a tonic and stimulant are required. (63) R. Potass. Bromid., 3ss. Tinct. Cannabis Ind., Hyoscyami, a a 3ss. Aquae purae, ad 3*j. (Clouston.) Misce.—To be taken at bedtime. In the sleeplessness of hyperaemic headache. (64) R. Tinct. Cannabis Ind., "Kx. Potass. Bromid., 9j. Aquae purae, ad 3*jss. Misce.—To be taken at bedtime. In the sleeplessness of hyperaemic headache. (65) R. Tinct. Hyoscyami, 3ss. Mist. Camph., ad 3*j. Misce.—To be taken every night at bedtime. In the sleeplessness of nervous and hyperaemic headache. (66) R. Hydrat. Chloral., 9j. Aquae purae, ad 3*jss. Misce.—To be taken at bedtime. In the headache of cerebral hyperaemia and vascular excitement. (67) R. Hydrat. Chloral., Potass. Bromid., aa gr. x. Syr. Rhoeados, 3J. Aquae purae, ad ^jss. Misce.—To be taken at bedtime. In the headache of cerebral hyperaemia and nervo-hyperaemic headache with nervous excitement. 308 FORMULAE. (68) R. Potass. Bromid., 3ij. Syr. Aurant., ^ss- Inf. Gent. Comp., %\v. Aquae purse, ad 3vj. Misce.—A sixth part to be taken three times a day. In nervo-hyperaemic headache with loss of appetite and debility. (69) R. Potass. Bromid. vel Hydr. Chloral., gr. x. Nepenthe, ^x. Aquae purae, ad jfjss. Misce.—To be taken at bedtime. In the sleeplessness of nervo-hyperaemic headache. (70) R. Syr. Hydrat. Chloral., gjss. Misce.—One teaspoonful in a wineglassful of water in the nervo-hyperaemic form of head- ache at bedtime, or in the daytime, when the pain is severe, till sleep comes on. (71) R. Ferri Amm. Citr., 3j. Potass. Bromid., 3iij. vel Amm. Bromid., 3iij. Syr. Zingib., 3*ss. Aquae purae, ad 3*vj. Misce.—A tablespoonful in a wineglassful of water twice a day, at 11 a.m. and 4 p.m. In the headache of cerebral anaemia. (72) R. Potass. Bromid., 9j. vel Amm. Bromid., 9j. Tinct. Valerian. Co., 3j. Syr. Aurant. Flor., 3j. Aquae Cinnamomi, ad 3*jss. Misce.—To be taken twice or three times a day. In some forms of neuralgic headache. FORMULAE. 309 (73) R. Pulv. Ipecac. Comp., gr. x-gr. xv. Fiat pulvis.—To be taken at bedtime in gruel. In rheumatic headache. (76) R. Ferri Sulphat., Pulv. Zingib., a a, gr. vj. Ext. Aloes Aquos, Quiniae Sulph., Saponis, aa gr. xij. Misce et divide in pilulas xij.—One to be taken twice a day after food. In the headaches of cerebral anaemia and neuralgia, where the bowels are sluggish. (77) R. Ext. Aloes Barb., gr. J. Pulv. Ipecac, gr. j. Pil. Bhei Comp., gr. iij. Misce et fiat pilula.—To be taken daily before dinner. In the headache of cerebral anaemia and dyspeptic headache, where intestinal action is sluggish. (78) R. Quiniae Sulph., Ext. Aloes Aquos, aa gr. xij. Pulv. Capsici, Ipecac, aa gr. vj. Glycerini, q. s. Ut fiant pilulae xij.—One to be taken daily before food, at midday. In similar cases to the preceding, and especially in women with small assimilative power. Vel. R. Ext. Nuc Vom., gr. ss. Pil. Rhei Comp., gr. iij. Pulv. Capsici, gr. \. Misce et fiat pilula.—To be taken daily at 12 o'clock. (Samaritan Hospital.) An excellent pill to keep the bowels regular in nervous headache, where the muscular fibre of the intestines requires stimulation. 310 FORMULAE. (79) R. Hydr. Subchlorid., gr. iij. Pil. Coloc. Co., gr. vj. Ext. Hyoscyami, gr. ij. Misce et divide in pilulas ij.—To be taken at bed- time occasionally. As a cholagogue cathartic in dyspeptic, bilious, and gouty head- ache. (80) R. Pulv. Scammonii, 9j. Ext. Coloc. Co., 3j. Hydr. Subchlorid., gr. xij. 01. Carui, "£x. Misce et divide in pilulas xviij.—One or two occa- sionally at bedtime, in similar cases to the preceding. (81) R. Pil. Hydrarg., gr. xij. Rhei Comp., 3ss. Ext. Hyoscyami, gr. x. Misce et divide in pilulas xij.—One or two at bed- time twice a week. In dyspeptic headache, and in the headaches of advanced life with a sluggish liver. (82) R. Hyd. c. Creta, gr. xij. Ext. Hyoscyami, gr. x. Pil. Rhei Comp., Qij. Misce et divide in pilulas xij.—One or two occa- sionally at bedtime. As an alterative in dyspeptic headache. (83) R. Ferri Sulphat., Quiniae Sulph., aa gr. xij. Pulv. Rhei, gr. ix. Zingiber, vj. Misce et divide in pilulas xij.—Take one three times a day. In neuralgic headache and atonic dyspepsia with flatulence. FORMULAE. 311 (84) R. Pil. Aloes et Asafcetid., 3j. In pilulas xij.—One or two at bedtime every night. In nervous headache with flatulence and constipation. (85) R. Pil. Aloes et Ferri, 3j. In pilulas xij.—One or two at bedtime every night. In neuralgic and nervous headache with constipation. (86) R. Pil. Aloes et Myrrhae, 3j. Ferri Sulphat., gr. vj. Misce et divide in pilulas xij.—Two occasionally at bedtime. In nervous or anaemic headache with torpid colon. (87) R. Zinci Valerian., gr. xij. Pulv. Rhei, gr. xx. Zingib., gr. vj. Ext. Gentian, gr. xij. Misce et divide in pilulas xij.—One to be taken three times a day. In neuralgic headache. (88) R. Phosph. Pur., Strychniae, aa gr. j. Conf. Rosae, q. s. Ut fiant pilulae 1.—Take one three times a day. In some forms of neuralgic headache. (89) R. Phosph. Pur., gr. j. Conf. Rosae, q. s. Ut fiant pilulae xxxyj.—Take one three times a day. In similar cases to the preceding,* * Perles of Phosphorus are manufactured by Messrs. Corbyn, Stacey & Co., each Perle containing gr. ■£$, gr. ■$■$, gr. y-g-g-. They are hermetically closed in a covering of gelatin, and the dose and effect of the remedy may be relied upon. When Phosphorus is prescribed alone, the Perle is the best method of administer- ing it. 312 FORMULAE. (90) R. Phosph. Pur., gr. \. Ferri Redact., gr. xx. Ext. Nuc. Vom., gr. ij. Misce et divide in pilulas viij.—One to be taken twice a day. In neuralgic headache.* (91) R. Phosph. Pur., gr.j. . Quiniae Sulph., Ferri Sulph., aa gr. xvj. Ext. Rhei, £j. In pilulas xxxvj.—One to be taken three times a day. (92) R. Ext. Cannabis Ind., gr. }-gr. j. Conf. Rosae, q. s. Ut fiat pilula.—To be taken at bedtime. In the sleeplessness of neuralgic headache. (93) R. Pulv. Camphor., gr. ij. Ext. Hyoscyami, gr. ij. Misce et fiat pilula.—To be taken at bedtime. In the sleeplessness of nervous and neuralgic headache. (94) R. Podophyllin, gr. iv. Pil. Hydrarg, gr. viij. Ext. Hyoscyami, gr. xvj. Misce et divide in pilulas viij.—Take one every night. In gouty headache. (95) R. Pil. Coloc c Hyos., 3j. In pilulas xij.—One or two at bedtime occasionally. In nervous headache, when an active aperient is required. * These prescriptions may be varied according to the state of the patient; Valerianate of Zinc and Cannabis Indica may sometimes be added. FORMULAE. 313 (96) R. Ext. Colocynth., 9ij. Rhei, Pulv. Scammonii, 5a gr. x. In pilulas xij.—Take one occasionally at bedtime. In nervous or dyspeptic headache as an active aperient. (97) R. Zinci Valerian., Ferri Sulph., Ext. Rhei, aa gr. xvj. Misce et divide in pilulas xvj.—One to be taken three times a day. In nervous headache. (97a) R. Zinci Sulph., gr.j. Ext. Nuc. Vom., gr. ss. Conf. Rosae, q. s. Ut fiat pilula.—To be taken twice a day. In nervous headache. (98) R. Zinci Oxyd., gr. ij. Conf. Rosae, q. s. Ut fiat pilula.—To be taken three times a day. In nervous headache. (99) R. Pil. Rhei Comp., 3j. In pilulas xij.—Take one every night. As a mild aperient in nervous and dyspeptic headache. (100) R. Pulv. Ipecac, gr. vj. Ext. Aloes Barb., gr. xij. Taraxaci, 3SS- Saponis, gr. x. Misce et divide in pilulas xij.—Take one every night, or before dinner daily. As a laxative in nervous headache to assist digestion. 26* 314 FORMULAE. (101) R. Pulv. Myrrhse, Rhei, aa gr. xvj. Pil. Aloes Barb., gr. xij. Ext. Anthemidis, 3ss. 01. Caryophylli, "Xv. Misce et divide in pilulas xx.—One or two daily before the midday meal. As a dinner pill in nervous and dyspeptic headache to assist di- gestion. (102) R. Ext. Opii, Pulv. Rhei, aa gr. j. Pil. Coloc. Co., gr. jss. Misce et fiat pilula.—To be taken every night. In the sleeplessness of anaemic headache. (103) R. Ext. Gentian., Ferri Sulph., Pulv. Digitalis, aa gr. xij. Cinnamomi, gr. vj. Misce et divide in pilulas xij.—Take one three times a day. In the headache of cerebral anaemia, where Digitalis is required. Where there is unsteadiness of the heart's action after food, and there is flatulence, the iron may be advantageously omitted, and Pulv. Zingib. substituted for Pulv. Cinnamomi. (104) R. Ext. Belladonnae, gr. vj-gr. xij. Glycyrrhizae, gr. xxiv. Misce et divide in pilulas xij.—Take one every night, or night and morning, but the remedy must be carefully watched.* In the headache of cerebral anaemia. * See the effects of^n overdose in Chapter I, on the Headache of Cerebral Anaemia. FORMULAE. 315 (105) R. Zinci Valerian, gr. viij. Ext. Humuli, gr. xx. Rhei, gr. viij. Misce et divide in pilulas viij.—Take one every night. In some forms of organic headache and cerebral softening, where there is irritability and sleeplessness. (106) R. Ext. Aconiti, gr.vj. Hyoscyami, gr. xviij. Ant. Pot, Tart., gr. j. Misce et divide in pilulas vj.—Take one every night. In the headache of active cerebral hyperaemia, where depressants are required. (107) R. Bismuth. Subcarb., 9j. To be taken in a wineglassful of water twice a day before meals. In subacute congestive headache, with flatulence and discomfort after food. (108) R. Zinci Sulph., Aquae purae, 3*jss. Fiat haustus.—To be taken as an emetic, followed by drinking freely of warm water till vomiting ensues. In some forms of bilious and nervous headache. (109) R. Pulv. Ipecac, 9j. Aquae purae, 3*jss. Fiat haustus. In the same cases as the preceding. (110) R. Ext. Belladonna?, gr. v. To be rubbed into the affected temple every night. In nervous headache, migraine, clavus, etc 316 FORMULAE. (Ill) R. Ung. Veratriae, 3j. (B. P.) A little to be rubbed into the affected temple till the pain is relieved. In neuralgic and some forms of nervous headache, where «the pain is localized. (112) R. Ung. Aconithe, 3J. (B. P.) To be used in the same way, and for the same cases as the preceding. Ung. Aconitinae (Fleming). (113) R. Aconitinae, gr. xvj, Spt. Vini Rect., "Kxvj. Rub together, and then add carefully one ounce of lard. It may be used in the same cases as the preceding. (A very expensive ap- plication.) (114) R. Ext. Aconiti Alcohol., 3j. Adipis, 3ij. Misce et fiat unguentum.—To be used in the same cases as the preceding. {Much less ex- pensive.)* (114 a) R. Ung. Hyd. Nit. Oxyd., 3jss. Adipis Benz., 3ijss. Misce.—A piece the size of a small nut to be rubbed into the scalp night and morning. In pityriasis of the scalp. (115) R. Quiniae Sulph., gr. x. Acid. Sulph. Dil., "Ex. Aquae, ad nj>c Misce.—To be injected in severe cases.f (Surgeon-Major A. R. Hall's formula for the subcutaneous injec- tion of Quinine in the hyperpyrexia of sunstroke.) * In using all these ointments care is required to apply very small quantities, and never to the broken skin. A tingling sensation commonly precedes the cessation of the pain. 0 t The acid in this ^ive* rise to pain and inflammation, sometimes even to a troublesome boil or abscess. The neutral sulphate is soluble without acid, and does not produce local irritation. FORMULAE. 317 (116) R. Morph. Acet.; gr. x. Atropiae Sulph., gr. j. Aquae destill., 31J. Misce. Formula for the hypodermic injection of Morphia. Twelve minims contain one grain of Morphia. Many of the preceding Formulae are suitable for children in dimin- ished doses proportioned to age. 27 INDEX. Aconitina ointment in nervous and neuralgic headache, 174, 24 2 Aconite in congestive headache, 132 cerebral hypera?nuia, 86 Active hyperaemia, 71 Advanced life, headache of, 228 treatment of, 229 Alcohol in cerebral anaemia, 58 Aloes, compound decoction of, in nervous headache, 172. Ammonia, carbonate of, in nervous headilche, 210, 224 Ammonium, bromide of, in conges- tive and nervous headache, 132 chloride of, in neuralgic head- ache, 242 Anaemia, cerebral, 33 vascular conditions in, 38 symptoms of, 48 prognosis of, 52 treatment of, 52 chronic, 45 Antimony in hyperasmic headache, 86 Arsenic in malarial and neuralgic headache, 201, 243 Arthritic headache. See Gouty Headache, 205 Atheromatous change, headache in, 224 Bebeerin, 244 Belladonna, 55 Bernard. Professor, experiments of, 99, 100 Bilious headache. See Dyspeptic Headache, 109 Bloodletting in congestive headache, 131 Blood-supply, relation of tissues to their, 85 Body-snatcher's headache, 195 Brain, concussion of, 271 vascular supply of, 36 Bromide of potassium in congestive headache, 132 nervous headache, 172 Brown Sequard's experiments, 99, 100 Burrows, Sir G., experiments of, 34, 35 Cannabis Indica, 89 Causes of increased activity of the nervous system, 18 Cerebral circulation, 33 anaemia, 36 experiments to produce, 34, 35 vascular condition of, 38 symptoms of, 48 prognosis of, 52 treatment of, 52 alcohol in, 58 hyperaemia, 66 forms of, 69 with inflammatory fever, 70 active, 72 in the gouty, 74 from weakness of cerebral vessels, 75 passive, 77 symptoms of, 80 treatment of, 86 Cerebro-spinal fluid, 36 Chapman's, Dr., spinal ice-bag, 94 Childhood, headaches of, 248 cerebral headache in, 271 treatment of, 275 320 INDEX. Childhood, gastric headache in, 275 epileptic headache in. 278 treatment of, 280 febrile headache in, 281 neuralgic headache in, 281 Childhood, neuralgic headache in, treatment of, 286 headache due to tissue change in, 286 organic headache in, 289 Children, training of. 249 overtaxation of, 251 Chloral hydrate, cautions as to use of, 186 Chronic cerebral anaemia, 45 Cod-liver oil in nervous headache, 178 Cold, use of, in cerebral hyperaemia, 91 Congestive headache, 123 in plethoric persons. 124 due toacute congestion, 125 from mental causes, 126 asthma, whooping- cough, bronchitis, 127 hypertrophy and val- vular diseases of he.-irt, 129 organic changes, 129 epilepsy, 130 effects of, upon the dispo- sition, 13(1 treatment of, 131 Cranium, anatomical peculiarities of, 97 Croton-chloral, 246. Depressant remedies, 86 Determination of blood to the head, 71 Diet in plethoric headache, 139 Digitalis, 64 Disturbances of vision in nervous headache, 149 Dysmenorrhoea, a cause of headache, 146 in nervous headache, 155 Dyspeptic headache, 109 action of the vagus in, 110 commencement of, 117 causes of, 118 treatment of, 121 emetics in, 121 calomel in, 121 alkalies in, 121 Dyspeptic headache, bismuth and nux vomica in, 122 aconite in, 122 Early life, headaches of, 248 brain repose in, 257 hypertrophy of brain in, 262 attendance at school in, 264 Emotion, effects of, upon the gastric juice, 116 Epilepsy from tapeworm?. 112 Epileptic headache in children, 278 E.gol in headache, 90. 230 Experiments of Mr. Durham, 47, 48 Eye, pain in the, 155 Febrile headache in children, 281 treatment of, 281 j Fecal fermentation, headache from, 194 Fever, inflimmatory, 70 Fevers, headache in, 187 Friedrichshalle water, 86 Gas-poisoning, headache from. 195 Gastric headache in children, 275 Gelseminum, tincture of, 246 Gouty, cerebral hyperaemia in the, 74 hyperaemia, state of vessels in 74, 75 or arthritic headache, 205 psychical symptoms of, 206 in the cachectic, 208 headache, treatment of, 209, 210 Guarana in nervous headache, 174 action of, on vasomotor nerve9, 174 Hair affected in nervous headache, 166 Headache, causes of. 18 from tissue change in children, 286 Headache from disorder of liver, 109 Hearing, acuteness of, in neuralgic headache, 235 Iletnicrani.i in renal cirrhosis, 241 llunyadi Janos wnter, 86 Hvdrate of chloral, 181 cautions as to the use of, 185 Hydrocyanic acid in nervous and sick headache, 172 INDEX. 321 Hyperaemia, cerebral, 66 forms of, 69 with inflammatory fever, 70 active, 72 in the gouty, 73 passive, 77 symptoms of, 80 treatment of, 86 use of cold in, 90 from intellectual strain, 83 irritability in, 73 Hyperpyrexia, with headache, 80 Hypertrophy of brain in children, 262 Hypodermic injections in nervous headache, 175 Hypophosphite of soda in neuralgic headache, 243 Hypophosphites of quinine, strych- nia, and iron in neuralgic head- ache, 243 Ice-cap in hyperaemia, 92 Iodide of potassium in syphilitic headache, 217 Iron, dialyzed solution of, 286 Lactophosphites of iron and lime, 243, 297 Leucorrhcea a cause of neuralgic headache, 233 Lithia, salts of, 86, 210 Liver, disorder of, headache in, 109 Local hyperaemia of the brain, 43 Malarial headache, treatment of. 197 Menorrhagia as a cause of headache, 146, 233 Mental causes of congestive head- ache, 126 Mercury, bichloride of, in syphilitic headache, 217 Migraine, 166 Morson's pepsin wine in nervous headache, 178 Mustard poultice in nervous head- ache, 172 Nervo-hyperaemic headache, 179 symptoms of, 180 at the menopause, 182 treatment of, 182 chloral in, 184, 185 I Nervous headaehe, 140 means to avert, 142 causes of, 143 malaria. 144 symptoms of, 144 constipation in, 147 disturbance of vision in, 148 cases of, 152, 155, 158, 161 occasional, 161 continuous, 161 effects ■'', on scalp, 167 treatment of, 168 preventive, 169 palliative, 170, 172 belladonna and aconitina ointment in, 173 Neuralgic headache. 231 oversensibility to sound in, 235 menorrhagia as a cause of, 233 causes of, 235 cases of toothache in, 236 Dr. Anstie's case of, 240 treatment of, 242 belladonna and aconitina ointment in, 242 chloride of ammoniu i in, 242 quinine and arsenic i ., 244 in children, 281 Nux vomica in nervous headache, 177 Occipital headache, 107 Opium, 53 Organic or structural headache, 219 lack of symptoms in, 220 symptoms of, 222 causes of, 224, 225 treatment of, 226 in children, 289 Ovarian irritation, 147 Oversuckling, a cause of nervous headache, 146 Overtaxation of children, 251 Oxide of zinc, 173 silver, 174 Pain, sympathetic, 24 Periosteum, headache in disease of the, 215 treatment of, 217 Perivascular spaces, 36 Phosphorus, 202 322 INDEX. Phosphorus, perles of, 337 in neuralgic headache, 248 Plethoric headache, 134 symptoms of, 136 treatment of, 137 Podophyllin, 210 Potash, salts of, 86 Potassium, iodide of, 53 in syphilitic periostitis, 217 bromide of, in congestive and nervous headache, 132, 171 Prodromata of headache, 27 Psychical symptoms in gouty head- ache. 208 Pullna water, 86 Quinine, 80 subcutaneous injection of, in sunstroke, 81 large doses of, in malarial head- ache, 196 and arsenic combined, 245 Relapsing fever, headache in, 188 Relation of tissues to their blood- supply, 85 Renal cirrhosis, headache in, 241 Rest in brain affections, 29 Rheumatic headache, 212 treatment of, 212 Saline aperients in plethora, 138 School attendance of children, 264 Sedative remedies in cerebral hy- peraemia, 88 Senna, 195 Sleep, state of the brain in, 47 Soda-water and champagne in ner- vous and sick headache. 170 Structural headache. See Organic Headache, 219 Strychnia, 177 Sulphate of zinc, 313 Sunstroke, severe symptoms due to, : 81 Supraorbital neuralgia, 154 in children, 283 Symonds, Dr., experiments of, 35 | Sympathetic headache, 95 vasomotor nerves, relation of, to, 96 visceral relations of, 96 from ovarian irritation, 102 pain, 24 Symptoms of cerebral anosmia, 48 hyperaemia, 80 Syphilis as a cause of headache, 215 Syrup of buckthorn, 195 Tamar-Indien, 195 | Teeth, diseased, as a cause of head- ache, 236 Thalami optici, functions of, 20 Tissues, relation of, to blood-supply, 85 Toxaemic headache, 185 in acute fever, 187 from uraemia, 190 carbonic acid poison ing, 193 treatment of, 194 Training of children, 249 Tumors of the brain, 222, 291 Uraemic headache, 190 treatment of, 192 Urine, limpid, in nervous head- ache, 146 Vagus, action of, on stomach, 113 Varieties of headache, 30 Vasomotor nerves of viscera, 96 Vertical headache, 49 Vision, disturbances of, in nervous headache, 148 Waters, mineral, in congestive head- ache, 86 Xanthelasma palpebrarum, 168 Zinc, oxide of, 173 valerianate of, in nervous head- ache, 173, 245 sulphate of, 171 ^7\«5; r NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBR, i /\# 8 %/' N r W P P 3NIDIQ3W JO AMVMfln IVNOIIVN 3NIDIQ3W JO Aavaflll IVNOIIVN 3NIDIQ3W JO iM^AsM \ ? 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