Columbia ^nibersitp ^"^"^^ 
 in tfje Cit p of i^in ^ovk 
 
 CoUege of ^Ijpjiiciang anb burgeons! 
 
 i^eference I^ibrarp 
 
HEADACHES: 
 
 THEIR 
 
 CAUSES, NATURE, AND TREATMENT 
 
HEADACHES: 
 THEIR CAUSES, NATURE, AND TREATMENT. 
 
 OCTAVO SERIES OF STANDARD MEDICAL BOOKS. 
 Price, Strong Paper Covers, 75 Cents ; Cloth, $1.25. 
 
 By William Henry Day, M. D., 
 
 Author of "A Systematic Treatise on tlie Diseases of Children," Physician to the Samaritan Hospital for 
 
 Women and Children. 
 
 FOURTH EDITION,— ILLUSTRATED, 
 
 OPINIONS OF THE PRESS. 
 
 " Dr. Day gives an exceUent account of the nature and origin of bilious 
 headache, and the directions for treatment are full and clear. The chapter 
 on headaches in childhood and early life is worthy of careful perusal. Dr. 
 Day gives some excellent advice on the management of children during their 
 school life ; and this portion of his book might be read with advantage by 
 all intelligent persons. ' ' — Medical Examiner. 
 
 " The chief value of the work consists in the wealth of resources at the 
 command of the author, arid the practical value of his therapeutical sugges- 
 tions. ' ' — New York Medical Record. 
 
 ''Well worth reading. The remarks on treatment are very sensible." — 
 Boston Medical afid Surgical Journal. 
 
 " No practitioner could fail to read it without obtaining many a hint of 
 value to him in his daily work. ' ' — Westjninsfer Review. 
 
 " The best we have yet read on the subject. One of those works that will 
 be found very useful to the young practitioner. ' ' — Medical Press and Circidar. 
 
 ''Dr. Day's strongest sections are, perhaps, the large and important 
 division of nervous headaches, and the whole class of headaches incidental 
 to children, noting his cases with quick and keen intelligence of symptoms, 
 and with admirable perspicacity." — The London Quarterly Review. 
 
 "As a really useful manual for the practitioner it will take a high rank, 
 and will be found well worth diligent perusal." — Philadelphia Medical and 
 Surgical Reporter. 
 
 'The following books are also in the Octavo Series. Price, in paper 
 cover, 75 cents; cloth, $1.25. Beale on Slight Ailments ; Agnew, Female 
 Perineum ; Allingham on the Rectum ; Tilt, Change of Life ; Hewitt, Dis- 
 eases of Women, 2 parts in one. Send for circular with special rates. 
 
 R BLAKISTON, SON & CO., Publishers, 
 
 1012 Walnut Street, PMladelphia, Pa. 
 
HEADACHES : 
 
 NATURE, CAUSES, AND TREATMENT. 
 
 WILLIAM HENRY DAY, M. D., 
 
 MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON, PHYSICIAN TO THE SAMARI- 
 TAN HOSPITAL FOR WOMEN AND CHILDREN, AND AUTHOR OF A " SYSTEMATIC 
 
 TREATISE ON THE DISEASES OF CHILDREN." 
 
 ^^ The first requisite for success in life is to be a good animal.'''' 
 
 Herbert Spencer. 
 
 FOURTH EDITION. 
 
 WITH ILLUSTRATIONS 
 
 PHIDADELPHIA: 
 P. BLAKISTON, SON & CO., 1012 WALNUT STREET, 
 
 1883. 
 
BRAIN OF MAN. 
 I, 2, 3, frontal convolutions; 4, 5, 6, A and B, parietal convolutions; 7, 8, 9, temporo- 
 sphenoidal convolutions ; 10, 1 1, 12, occipital convolutions. A is the supramarginal lobule; 
 B is the postero-parietal lobule; and /3 on the bridging or annectent convolutions; R, fis- 
 sure of Rolando ; S, parieto-occipital fissure. 
 
PREFACE. 
 
 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 satisfactorily and to its full extent, unless we refreshed our ideas from 
 different increasing springs of knowledge, and thought the subject over and 
 over 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 continually 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. Tn 
 most of the cases which have formed the groundwork of the present task, I 
 have had ample opportunities of watching 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 adapted to meet the varieties and peculiarities of headache. 
 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 
 foundation 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 consequences, 
 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 practitioner. 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 and reconstruction of the nervous system, which is undergoing 
 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 without any 
 serious consequences ensuing. 
 
 The researches of physiologists heretofore had stopped short at the cere- 
 brum, and only comprised the deep-seated ganglia at its base; but the recent 
 investigations of Fritsch and Hitzig, and still more of our countryman, 
 
 (5) 
 
6 PREFACE. 
 
 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 researches justify us in 
 drawing certain definite conclusions, not only as confirmatory of the func- 
 tions of the deeper structures of the brain, but of the convolutions them- 
 selves. 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 hypercemia, increasing the quantity of blood and the size of the vessels ; 
 and, in the case of rabbits, he found that the repeated application of the 
 electrodes converted the cerebral substance into a condition resembling 
 fungus hcematodes. 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 by a hyperaemic state of the cortical 
 tissue. These experiments 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 irritability of the parts involved, while lessening the hypergemia 
 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 features which distinguish hypersemia 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 differ- 
 ence. As regards the origin of active hypersemia, 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 over-excited and stim- 
 ulated by increased cardiac action in the one case of hyperemia ; and in the 
 other, the hyperaemia is the consequence of relaxation of the vessels, and 
 vaso-motor paresis. All the states depend upon an enlargement of the cap- 
 illaries, either with increased activity 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 passive form of hjqoer- 
 aemia. A hvpersemic 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 hypersemia and passive congestion 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 condi- 
 tion of the vessels, and a greater tendency to serous exudation. 
 
 I must here express my indebtedness to Dr. Herbert Major, the Superin- 
 tendent of the West Riding Asylum, for permission to copy a plate of his, 
 which gives the microscopic appearances of the cerebral cells of the convo- 
 lutions. It is on these cells that cerebral activity depends. I also have to 
 thank Dr. Lauder Brunton, F. R. S., for a copy of a woodcut which renders 
 very intelligible the association of headache with disturbance in the abdom- 
 inal viscera. 
 
 I have made some additions to this edition, which I trust may be as favor- 
 ably received by the profession as the three previous editions. 
 
CONTENTS 
 
 PAGE. 
 
 General Introduction 9 
 
 CHAPTER I. 
 The Headache of Cerebral Anemia . 16 
 
 CHAPTER II. 
 The Headache of Cerebral Hyperemia 31 
 
 CHAPTER HI. 
 On Sympthetic Headache 44 
 
 CHAPTER IV. 
 On Dyspeptic or Bilious Headache 50 
 
 CHAPTER V. 
 On Congestive Headache 56 
 
 CHAPTER VI. 
 
 On Headache from Plethora and Increased Vascular Action . . 61 
 
 CHAPTER VII. 
 On Headache from Exhaustion, or from some Peculiar Change in 
 the Cerebral Tissue — Nervous Headache 64 
 
 CHAPTER VIII. 
 
 On Nervo-Hyper^mic Headache 82 
 
 CHAPTER IX. 
 
 On ToXiEMic Headache 85 
 
 CHAPTER X. 
 On Arthritic or Gouty Headache 94 
 
 CHAPTER XI. 
 On Rheumatic Headache 97 
 
 CHAPTER XII. 
 
 On Headache from Affections of the Periosteum 99 
 
 CHAPTER XIII. 
 On Organic or Structural Headache loi 
 
 CHAPTER XIV. 
 
 On Headaches of Advanced Life 105 
 
 CHAPTER XV. 
 On Neuralgic Headache 107 
 
 CHAPTER XVI. 
 Headaches OF Childhood AND Early Life 115 
 
 (vii) 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/headachestheirnaOOdayw 
 
DAY 
 
 ON 
 
 HEADACHES 
 
 GENERAL INTRODUCTION. 
 
 Preliminary Remarks on the Preponderance of Diseases of the Nervous System at the Pres- 
 ent Day — Source of the Pain in Headache, and its Common Dependence on the State of 
 the Brain and Nerves — Definition of the Term — Difficulties in Adapting Suitable Defini- 
 tions to Embrace all the Varieties of Headache — State of the Brain in Some Cases of 
 Apoplexy and Simple Concussion — 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 themselves in impaired func- 
 tional 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 alterated sensation which indicates a disturb- 
 ance in the sensorium. 
 
 The most typical diseases of the present day are those which affect the 
 nervous system, and we need not travel 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 unknovra 
 to our ancestors, and the young child is expected 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 enterprise and movements of other countries, are both powerful 
 factors in stimulating the brain of man to unusual activity ; the conflicting 
 theories and theological controversies 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 reas- 
 onably 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 irresist- 
 ibly drawn into the contest, 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 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, encamped themselves on earth. In our audacious age we are 
 
 I (9) 
 
lO HEADACHES. 
 
 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 com- 
 mon disorder we now find it, and physicians were nearly silent on the causes 
 which produced it. In whatever 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 professional 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 detail. If he does quit the field, failing to 
 discover some new stratum, he is followed by another, who digs up the hid- 
 den 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, Avhilst another set are 
 required to perform their lost functions; 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 and exhaustion of the 
 brain, if it could be adequately measured and carried out ; but the circum- 
 stances of life generally do not enable a man to avail himself of that change of 
 thought and occupation which would be a safeguard against the terrible evils 
 he is fostering. 
 
 If there be any truth in this argument, it is not surprising that the com- 
 plex 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 Avith an importance 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 suddenly or prematurely 
 give way, if it has to bear a load every day which at one time only emer- 
 gency 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 susceptibility 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 nervous 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, fol- 
 lowed by brief and broken periods of repose. 
 
 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 over-stimulation 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 pre- 
 ponderance 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 symptoms of disease in every texture of which the body 
 
 always stealing new fire, and swelling the cohort of fevers with new recruits." — Miscellan- 
 eous Prose Woi'ks, by Edward Bulwer, Lord Lytton, 1868, vol. iii., p. 108. 
 
GENERAL INTRODUCTION. II 
 
 is made up ; nor the rival sway it exerts in corrupting the machinery of the 
 whole body, and accomplishing the destruction of the vital parts. 
 
 In attempting to classify headaches into groups and varieties, some specu- 
 lations 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 investigation, 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 ascendency in the author's mind; and by 
 attaching undue importance 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 practical medicine. The mind is to be pitied that 
 extends the range of inquiry no further than the sphere of its own 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 headaches 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 cerebral cells, and pro- 
 duce 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 
 observation 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 
 condition by the statements of the sufferer ; in its functional derangement 
 it does not indicate by any reliable signs whether this or that part is at fault, 
 as in disorders of the abdominal or thoracic organs ; the source of the suffer- 
 ing cannot be fixed upon and removed, as a decaying 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 over- 
 loaded? These perplexing questions constantly present themselves for set- 
 tlement. The same symptoms arise when very opposite conditions prevail. 
 The delirium of scarlet fever is not the delirimn of typhus, although they 
 may present very similar features. There is the sleeplessness of anaemia and 
 of congestion ; and there is the coma of bloodlessness as well as of hyper- 
 semia. How can such dangerous conditions as these be treated with any 
 chance of success if we have erred in the interpretation 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 
 
1 2 HEADACHES. 
 
 circumstances that surround us, we approach the discussion of a disorder 
 which modern habits of life encourage and develop, and threaten to increase 
 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 interrupts 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 legit- 
 imate resources of our art. In clinging to any nostrum within his reach, he 
 increases the evil which is to render his life heavy and wearisome, and to 
 baffle his energies and labors to the end. 
 
 In no class of diseases do we observe better examples of sy77ipathetic 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 irrita- 
 bility 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 disease, the 
 pain in the knee from hip-joint disease, and the pain of the genito-crural 
 nerve from calculus in the kidney, 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 production 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 sympathetic 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 sud- 
 den shock of grief may occasion gastric pain, and it certainly awakens 
 fearful headache in some persons. "Putting aside," says Dr. Symonds, 
 "for the present, any reference to the patient's feelings, what do we learn 
 from anatomical considerations 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 hem- 
 ispheres, or of the cerebellum. No evidence of feeling has been obtained 
 by vivisectors 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 matter 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 vertebral 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 observe the large amount of these vessels, the brain and its membranes 
 being more liberally supplied with blood than any other organ (the quantity 
 being computed 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."* 
 
 *■ Gulstonian Lectures on Headache, Medical Times and Gazette, 1858. 
 
GENERAL INTRODUCTION. I 3 
 
 By the term headache, we mean to signify pain in the head, accompanied 
 with intolerance of light and sound, and incapability of mental exertion ; 
 a state, from whatever cause arising, in which the brain is temporarily pros- 
 trated and disturbed, in proportion to the cause and intensity of the suffer- 
 ing. Thus, many headaches depend primarily on a disturbance in the cere- 
 bral 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 sym- 
 pathetic disturbance in the digestive organs, which, reacting on the brain, 
 mcreases all the symptoms for a time; but soon, from the process having 
 advanced further, or from some change ensuing in the current of the circu- 
 lation, the morbid sensibility of the brain abates, and the headache vanishes. 
 
 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 breakfast ; that before the 
 close of the day they were unusually tired, and felt on going to bed some 
 flatulence and indigestion, with dryness of the mouth, and an extraordinary 
 degree of depression and weariness. During the night, or the following 
 morning, the nervous headache is developed, and after that the altered sen- 
 sibility of the brain and the arrest in the powers of digestion proceed to- 
 gether. Symptoms, therefore, which appear as primarily indicative of 
 disorder in the stomach and intestines, are really often secondary, or sym- 
 pathetic affections, resulting 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 compression. 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 movements 
 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 tumor 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 en- 
 croachment of disease ; 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 extensive, that it has pressed upon the 
 brain, so as to cause symptoms of rapid compression and death. It should, 
 however, be borne in mind that the phenomena of apoplexy have ensued 
 where nothing but a disproportionate amount of blood has been seen in the 
 
 * " The headache, a very frequent symptom in all cerebral diseases, 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 hemi- 
 spheres 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 im- 
 pressions on the senses depends on the increase of excitability, caused by the cerebral 
 hypersemia, on the hypersesthesia 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 ex- 
 cites 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." — Niemeyer'' s Practical Medici7ie,yo\. ii, page 159. 
 
14 HEADACHES. 
 
 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 tendency to relieve the sudden determination 
 within the head. The balance of the cerebral circulation is interrupted when 
 the arteries are nearly empty, for then the veins are full, and oppression is 
 the consequence. If arterial tension is increased, and the vessels are full a 
 state of exaltation and excitement then ensues, tending to delirium or mania. 
 There is no exact evidence of the actual change that takes place in the 
 cerebral mass, when a physical disturbance of the brain and nervous centres 
 is caused by simple concussion. A mere confusion of ideas, or a temporary 
 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 manifes- 
 tations of the mischief. I apprehend that in these slight cases of shock, 
 when recovery is early and permanent, 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 disturbed, being exces- 
 sive 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 inference to suppose that the same may occur 
 from functional disorder and preverted 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 pneumo- 
 gastric nerve are abundant, as they spring from the medulla oblongata. 
 Now, in concussion of the brain the enlightened surgeon, in his treatment, 
 relies more on rest and the exclusion of light and sound, than on any other 
 method of cure. He knows that any plan which does not include these in- 
 structions is futile to effect recovery, and to afford the brain a chance of re- 
 gaining its equilibrium. If it is not allowed a long season of repose, and strain 
 and exertion 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, in- 
 stead of subsiding, 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 framework 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- 
 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 manifestations 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 in- 
 stituted for our observance, she stays the progress of disease and injury, per- 
 mits 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 functional activity. 
 I have adopted the following classification of the varieties of headache:* 
 
 " 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. 
 
 15 
 
 Headaches depending on Causes within the Brain — Intracerebral Headaches. 
 
 1. The Headache of Cerebral Anemia. 
 
 2. The Headache of Cerebral Hyper^emia. 
 
 3. Sympathetic Headache. 
 
 4. Dyspeptic or Bilious Headache (known also as Sick Headache). 
 
 5. {a) Headache from Cerebral Congestion, or Congestive Headache. 
 \b\ Headache from Plethora and Increased Vascular Action, 
 
 6. Headache from Exhaustion, or from some Peculiar Change in the 
 
 Cerebral Tissue — Nervous Headache.* 
 
 7. Nervo-hyper^mic 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. RheuxMatic Headache. 
 
 2. Headache from Affection of tpie Periosteum. 
 
 3. Neuralgic Headache. 
 
 Headaches of Childhood and Early Life. 
 
 
 THE BASE OF THE BRAIN (fROM HIRSCHFIELD AND LEVEILLe). 
 
 I. 
 
 Longitudinal fissure. 
 
 12 
 
 Locus perforatus posticus. 
 
 23 
 
 Pneumogastric nerve. 
 
 2. 
 
 Anterior lobes of cerebrum. 
 
 13 
 
 Fifth nerve. 
 
 24 
 
 Lateral tract. 
 
 3 
 
 Olfactory bulb. 
 
 14 
 
 Crus cerebri. 
 
 25 
 
 Spinal accessory nerve. 
 
 4- 
 
 Lamina cinerea. 
 
 15 
 
 Sixth nerve. 
 
 26. 
 
 Digastric lobe. 
 
 S- 
 
 Fissure of Sylvius. 
 
 16 
 
 Pons Varolii. 
 
 27 
 
 Hypoglossal nerve. 
 
 6. 
 
 Locus perforatus anticus. 
 
 17- 
 
 Portio dura of seventh. 
 
 28 
 
 Cerebellum. 
 
 7- 
 
 Optic commissure. 
 
 18 
 
 Middle lobe of cerebrum. 
 
 29 
 
 Amygdala. 
 
 8. 
 
 Tuber cinereum and infundi- 
 
 19. 
 
 Portio mollis of seventh. 
 
 3°- 
 
 Slender lobe. 
 
 
 bulum. 
 
 20 
 
 Anterior pyramid. 
 
 31- 
 
 Posterior lobe of cerebrum. 
 
 9- 
 
 Third nerve. 
 
 21. 
 
 Glosso-pharyngeal nerve. 
 
 32. 
 
 Posterior inferior lobe. 
 
 10. 
 
 Corpus albicans. 
 
 22 
 
 Olivary body. 
 
 33- 
 
 Inferior vermiform process. 
 
 II. 
 
 Fourth nerve. 
 
 
 
 
 
 
 * This variety of headache is also familiarly known as sick headache, s^nd it is so termed 
 by some authors ; but the stomach here is only secondarily affected. 
 
CHAPTER I. 
 
 THE HEADACHE OF CEREBRAL ANAEMIA. 
 
 Physiology' of the Cerebral Circulation — Effect of the Cerebro-spinal Fluid in Influencing 
 the Circulation — Perivascular Spaces — Cerebral Ansemia and the Sources of Blood Supply 
 through the Circle of Willis — Relation of Anaemia to Coma — State of the Brain in Sleep 
 — Experiments of Mr. Durham — Physiological Considerations and Conclusions — Symp- 
 toms and Diagnosis — Prognosis and Treatment — Physiological Action of Alcohol in 
 Cerebral Anasmia, 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 relationship 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 atmos- 
 phere on the brain no longer exists, the variation in the contents of the 
 cerebral vessels is relatively diminished ; but the ventricles and subarach- 
 noidean fluid keep up a tolerably uniform pressure ; and where the cerebral 
 substance is diminished in volume from any cause, the fluids and 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 conse- 
 quently the pressure exerted on the nervous structure would be considerable 
 also if it were not for lym.ph arrangements within the encephalon. Dr. 
 Symonds and Mr. Mitchell Clarkef conducted some careful experiments 
 which confirmed those of Dr. Burrows, who proved that gravitation affected 
 the quantity of blood in the brain. These gentlemen 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 
 
 * " There can be no doubt that the most important influence modifying the amount of 
 blood in the brain is the fulness of the ventricles and other cavities of the subarachnoid 
 spaces, and of the l)'mphatic ' spaces ' or sheaths surrounding the cerebral bloodvessels, all 
 of which spaces contain a watery fluid identical with the cerebro-spinal fluid, and all com- 
 municate 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 Iseen established 'with regard to the 
 perivascular 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 hypersemic 
 conditions." — Jones e?= Sieveking's PatJiological 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 cdlidosus snbarachnoidealis con- 
 tain 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 collection of fluid in the ventricles, has contracted the space in the skull, do we find, 
 along with anaemia, dryness of the membranes and disappearance of the sulci between the 
 cerebral convolutions." — A'iemeye7''s Practical Medicine, vol. ii, p. 150. 
 
 f Symonds on Headache, Medical Times and Gazette, April 3d, 1858, p. 34. 
 
 (16) 
 
THE HEADACHE OF CEREBRAL ANEMIA. 1/ 
 
 suspended rabbits were poisoned with prussic acid after about half an hour, 
 their positions having been strictly maintained. The post-mortem exami- 
 nation 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 substance were numerous. The ventricles 
 contained no fluid, and there was none external to the convolutions. The 
 rabbit suspended by the ears and fore-legs 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 suspended, 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 fore-legs, 
 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 to 
 feed heartily. We see that the congestion of the brain and membranes pro- 
 duced no ill effects comparatively, whilst the opposite position was quick! y 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 experiment 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 cere- 
 bro-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 in- 
 tracranial vascularity and the cerebro-spinal fluid, but there are channels in 
 the substance of the brain, termed by Robin, His, and Obersteiner, "peri- 
 vascular spaces," along which the blood vessels travel ; and these are invested 
 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 compression 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. 
 
 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 howansemia 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 betokens 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.'j' In no 
 
 *rrey's Histology, by Barker, p. 577. 
 
 f " In the performance of an idea, as in the performance of a movement, there is a retro- 
 
lb HEADACHES. 
 
 organ of the body is it more essential that blood should be freely supplied 
 than to the brain, if its functions are to continue active and energetic. The 
 immense pre-eminence assigned to it as the mental organ seems naturally to 
 require an abundant vascular supply; for mental changes and nervous waste 
 are perpetually going on, and under the influence of strong emotion or ex- 
 citement, products are removed from the system by the skin and kidneys in 
 excess of what ordinarily occurs, especially in the amount of phosphates 
 excreted. I may mention, as bearing 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 over-fatigued ; but after rest and repose they disappear, and 
 the secretion becomes natural. 
 
 In the brain the demand for healthy blood is two-fold. 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 h^moglo- 
 bulin of the red corpuscles. Oxygen is absolutely necessary for the evolu- 
 tion 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 suf- 
 focation in three or four minutes ; and consequently it is plain that a defi- 
 ciency 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 capilliaries of the brain in sufficient number, we have 
 cerebral anaemia. This may be due to the state of the blood itself, as in 
 anasmia and cachexia, when the corpuscles counted by the method of Pro- 
 fessor Hayem, of Paris, may be reduced to less than half their proper pro- 
 portion. Or the blood itself may be of due composition, but virtual cere- 
 bral anaemia may arise from weak action of the heart, functional 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, menorrhagia, or 
 profuse leucorrhoea. 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 indicates dis- 
 order. 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 prolonged use of alkalies and mer- 
 curial pills, which some people take to excess because they fancy the liver is 
 disordered, and the brain confused in consequence. They may afford relief 
 for a time by relieving the torpor of the internal organs, to which an en- 
 feebled 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 
 corpuscles, and rob the blood of its chief vital properties. When the sup- 
 ply of healthy arterial blood is sufficient, and the cerebral circulation is 
 stimulated to activity, the thoughts are quick and bright, and the pleasure 
 
 grade 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 lower grade 
 of being; and the final retrograde products are, so far as is at present known, somewhat 
 similar in muscle and nerve." — Alaudsley. 
 
THE HEADACHE OF CEREBIiAL ANEMIA. 1 9 
 
 resulting therefrom is uniform and consistent ; but when the flow of blood 
 is unusually rapid, and the vessels are distended and throbbing, then mental 
 excitement ensues, and a disorderly succession of perverted thoughts and 
 exalted intentions arise, which are all created by a disturbance in the balance 
 of the circulation. 
 
 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 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 upou the common carotid, convulsions, 
 or anaemia of the brain, are more usual sequences than congestion or inflam- 
 mation 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 
 irritation induced, and the muscular relaxation is complete. With the con- 
 dition of pallor, arising from mere deficiency in the arterial blood supply, 
 there occur headache, loss of memory, petulance and irritability of manner, 
 and indifference to all those subjects which ordinarily possess interest. 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 sympa- 
 thetic 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, unreasonable, and 
 fidgety, and moves spasmodically from one part of the room to another, 
 like a man w^hose 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 mmd m proper working order involves other 
 considerations; it demands a discipline 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 re- 
 pose here on the rationality of a theory of ill health and disease, which, 
 beginning in ansemia and tardiness of circulation, ends by a series of conse- 
 cutive 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 
 
20 HEADACHES. 
 
 body, heaping upon them work which they cannot discharge, and leading 
 to morbid changes of structure. Recent microscopical research has fully 
 demonstrated the exactness and certainty of the lesions in paralysis, and an 
 endless variety of other forms of disease, when no alteration is visible to the 
 naked e)'e. When during life the symptoms appear to indicate a cerebral 
 lesion, no disorganization can be discovered after death — not more vascular- 
 ity 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 respiratory movements, and cause convulsions or delirium. 
 In what manner, or to what extent, disturbance is excited in the cerebral 
 functions by pressure, may yet be a question 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 uncomplicated 
 anaemia of the brain, involving nothing more than a meagre supply of blood 
 to an organ Avhich demands it in a large quantity, is a common and frequent 
 cause of headache. With this anaemic state there is in these cases a cachec- 
 tic condition of the blood circulating through the vessels, and this I appre- 
 hend is a constant accompaniment of headache. 
 
 As a cause of headache this pathological change is one of great import- 
 ance, though it is not easy to determine during life except through the 
 symptoms produced. The brain presents a pallid appearance, and is of 
 diminished consistence, whilst the red spots alluded to in congestion are 
 fewer in number. In some persons I have known a headache from this 
 cause to be of such a wearing 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 bloodvessels, the striking feature of this anaemic condition 
 is both an excess of fluid in the cavities of the brain, and an infiltration 
 through its substance, giving rise to the state known as oedema, and causing 
 actual enlargement and flattening out of the convolutions against the men- 
 inges. 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 path- 
 ologists 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 tct-uadsj to understand the subject of anemia and hyperaemia, 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, notwithstanding that a large vessel 
 might be obstructed altogether. I think the pain of occipital headache is 
 sometime, induced by the abundant blood-supply, for the basilar artery 
 formed by the union of the two vertebral arteries supplies half the encepha- 
 lon 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 posterior communicating artery. Now this 
 difference in the amount of blood-supply helps to explain the cause of fron- 
 
 * See the chapter on Organic Headache. 
 
THE HEADACHE OF CEREBRAL ANEMIA. 21 
 
 tal headache by the fact that the vertebral and carotid 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 hyper- 
 semia, 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 sometimes increased from dilata- 
 tion 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 be- 
 ing more full of blood than another. In cerebral anaemia there is the same un- 
 equal distribution 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 arteries have no communication one with another, and 
 the diff'erent vascular areas are distinct and independent. On a little reflec- 
 tion it becomes at once evident that the circulation may receive a check in 
 some part of its curious bendings, and proceed unhindered in others. The 
 different 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 melancholy 
 and suspicion, to distrust and apprehension. And it also fully explains the 
 effect of posture in relieving or aggravating cases of headache. There are 
 persons who, when suff"ering from agonizing headache, cannot rest their head 
 on a pillow, for even a moment, without the face becoming 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 supply 
 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 succeeded 
 to pain and suff"ering, through irritation of the membranes and nervous cen- 
 tres, is a natural one, particularly 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 eventually implicates the action of the cerebral cells, and by its 
 agency brings about irretrievable mischief in the structure of the brain, if 
 not disease of the bloodvessels themselves. 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 intellectual decay, and he readily 
 succumbs to the influences of intercurrent disease. Sleep is broken and 
 nutrition is further checked, for the unrested brain cannot fulfill its func- 
 tions, 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 func- 
 tions 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 
 
22 HEADACHES. 
 
 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 
 temporal 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 albumin- 
 ous matter takes place, separating the elements of nerve structure from the 
 capillary network, arresting nutrition, and accelerating decay. 
 
 Mr. Durham has conducted some interesting experiments to prove that in 
 sleep, when the brain is at rest, it is angemic, and no longer requires its ac- 
 customed 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 soundness of his conclu- 
 sions, and they have since received the testimony of other competent ob- 
 servers. Mr. Durham supports his views by the following experiment : 
 
 "A dog having been thoroughly chloroformed, a portion 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 dis- 
 tended, 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 con- 
 tinued, 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 be- 
 fore appeared congested, and full of dark blood, could scarcely be distin- 
 guished. After a time the animal was roused; a blush seemed to start over 
 the surface of the brain, which again rose into the opening through the 
 bone. As the animal was more and more excited, 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 visible, 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 distinguishable. After a short time the 
 animal was fed, and again allowed to sink into repose ; the blood vessels 
 gradually resumed 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 between 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 
 
THE HEADACHE OF CEREBRAL AN.EMIA. 23 
 
 by fancy, nor )^et by faulty memory, but that the difference was really great, 
 I operated on two animals, and kept them alternately in different 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 energetic it is freely sup- 
 plied with blood, and when it is sluggish and anemic it receives a small 
 amount of blood. But even this view is not altogether satisfactory, and v/e 
 are bound to concede some relationship between the blood and the tissues 
 themselves. There is an attractive force between them. Some organs draw 
 more blood towards them in disease than is the case with others, and this is 
 well shown in remittent fevers and ague, where the mere contraction or di- 
 latation of the bloodvessels through the vasomotor nerves cannot account 
 for it. 
 
 The diagnostic symptoms that belong to the cerebral ansemia are those we 
 might expect to arise from a weakened brain circulation. There are fits of 
 depression and lowness of spirits ; and yet these are not continual, for the 
 patient may be roused to a renewal of his accustomed efforts, and temporar- 
 ily forget his ailment altogether, if it has not assumed a serious aspect. 
 The patient is fearful and timid, and has a general dread of things and of 
 circumstances never likely to happen ; he is over-anxious 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 overrule 
 the liberty of his successors, and control the ever-changing events of life. 
 Sleeplessness is not an uncommon symptom, but many patients pass sound 
 nights, and in the day-time become drowsy and fall asleep in the chair, or 
 whilst traveling in a train ; and this, according to my experience, is most 
 frequent before the bxain has passed into the condition which produces ac- 
 tual 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 
 occipital, and present most of the characters of nervous headache. The 
 headache of intellectual strain, and severe gastric disorder from over-indul- 
 gence in alcohol and high living, is almost invariably frontal, and the veins 
 about the temples and forehead are full, and the face is flushed. In anemic 
 headache there are noises in the ears, dizziness, 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 muscles are also 
 common. f 
 
 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 exacting, and exhibits a 
 querulousness which is most trying 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 torpid 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 ver- 
 tical the pupils are oftener contracted, a symptom which I attribute to men- 
 
 * Physiology of Sleep, Guy's Hospital Reports, vol. vi., i860, p. 153. 
 
 f See Chapter XII., on Organic Headache, concerning the seat and character of the pain. 
 
24 HEADACHES. 
 
 ingeal irritation. The ophthalmoscopic signs reveal pallor of the optic disks 
 and dullness of the choroid. The blood vessels 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 anemic con- 
 ditions generally. The eyes are sunken in the orbits, and the pulse is slow, 
 labored, and languid. In a patient recently 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 ar- 
 teries, and the diminished quantity of blood throughout 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 habitually 
 rapid, and the heart's impulse weak and jerking against the thorax. In the 
 case of a parient who was drained from menorrhagia, the pulse averaged 120 
 for weeks together; the skin and mucous membranes were dreadfully 
 blanched, and )'et there was no headache to speak of, and no cardiac mur- 
 mur whatever. Occasionally 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 hsemorrhage became 
 sudden and profuse. 
 
 In the headache of cerebral anaemia, of which the nervous form in deli- 
 cate women is a good example, the feet and hands are cold, and the surface 
 of the skin generally 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 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 relief; but 
 when this effect has subsided the depression is all the greater, and the head- 
 ache is increased tenfold. 
 
 As to prognosis, recovery is certain if the pain is due to curable condi- 
 tions, and the system has not been reduced 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 leucor- 
 rhoea. 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 head- 
 ache gradually pass away, as the brain is better nourished. If the condition 
 is incurable and complicated with organic disease, the headache will persist ; 
 and instances of this kind are to be seen among the poor, where all the sur- 
 roundings are wretched and deplorable. 
 
 Treatment. — With respect to the treatment of the headache of cerebral 
 anaemia and exhaustion, it is obvious that this must depend on the peculi- 
 arities 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 consists in endeavoring to 
 restore the tone and quality of the blood, that the cerebral tissue may be 
 better nourished. The cause must be ascertained and removed if possible. 
 Where men have subjected themselves to great intellectual strain, rising 
 early and going to bed late, there will be no chance of recovery till these 
 
THE HEADACHE OF CEREBRAL ANEMIA. 25 
 
 habits are given up. Men so circumstanced only keep themselves going by 
 irregular living, and a too free use of stimulants. If with this high pres- 
 sure 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 moderation. Discharges of all kinds should receive prompt 
 attention, as in menorrhagia and leucorrhoea; and derangement in the 
 assimilative functions should never be overlooked. 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 serviceable which 
 increase vascular tension, and accelerate the flow of blood in the encepha- 
 lon. In gouty conditions, colchicum and the alkalies will be useful to 
 remove the mate7-ies 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 combination 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 depressing. 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 restricting the wear and tear of 
 tissue, it increases in some unexplained 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 rapidly acting stimulant. . . . When the 
 opium acts efficiently, 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 com- 
 bination with the bromides of potassium or ammonium, when it cannot be 
 safely administered alone (Form. 71). But the sudden filling of the cere- 
 bral vessels is always to be kept in mind, and regarded with apprehension. 
 
 Digitalis is another remedy to be relied on when the heart's action is 
 weak; it appears to strengthen the contractions of the ventricle, and to 
 render them more uniform 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 arterial 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. Digitalis is of no use in anaemic headache, 
 except for the eff"ect it may have on the circulation through the heart itself; 
 a slow pulse, which is commonly attendant on this condition, contraindi- 
 cates the use of digitalis. I do not think an irregular pulse altogether 
 demands its discontinuance if it does not depend on change of structure ; 
 but where there is decided intermission I should hesitate to employ it. I 
 
 * Anstie, On Stimulants and Narcotics, Philadelphia, Blakiston, 1864, 
 2 
 
26 HEADACHES. 
 
 believe that its good effects in these cases are often obtained by combina- 
 tion 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 
 eff"ect through the cardiac ganglia in increasing the force of the heart's con- 
 tractions, and causing arterial tension. In this way, the arteries becoming 
 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, headache, giddiness, and singing in the ears.* It therefore requires 
 to be used with caution, and I should not be disposed to include it among 
 the remedies for this condition. While strychnia dilates the spinal blood- 
 vessels, 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 -Jg-: Form. 89), daily after luncheon, whilst the hypophos- 
 phites of lime and soda have been given in calumba morning and evening 
 (Form. 28). 
 
 The headache of cerebral ansemia is said by Dr. Smith to be often mis- 
 taken 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 within one nostril, while the other 
 is held closed, "t When this headache is associated with nervous exhaustion, 
 as it very commonly is, he recommends a combination of strychnia, iron, 
 and gentian (Form. 33). 
 
 Vomiting, swooning, and faintness are common in cerebral anaemia, and 
 the patient, in a well-marked condition, 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 conse- 
 quently depressed. But even then there is another difficulty to be encoun- 
 
 * " 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 subsequent dilatation to the exhaustion resulting from the previous overstimulation."^ 
 
 I gave one grain of the extract to a patient who had dysmenorrhcea, 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 disturoed 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. Murrell, L. R. C. P., British 
 Medical Journal, January ist, 1876, p. 9. 
 
 f 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- 
 
THE HEADACHE OF CEREBRAL ANEMIA. 2/ 
 
 tered, 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.* 
 
 There are two means of acting on cerebral anaemia — (i) by raising the 
 blood-pressure generally, in which the 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 exhaustion are fre- 
 quently 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 feeling of fatigue and exhaustion, and increases 
 the tonicity of the vascular system; but when the habit is acquired of drink- 
 ing to excess it produces incalculable harm, by enfeebling the digestive 
 power, and aggravating the headache 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 alcohol on the tissues, the mucous mem- 
 brane becoming white and puckered up. Dr. Lauder Brunton says that in 
 common with hot metal, or corrosive sublimate, it coagulates albumen, and 
 that the white color of the mouth is "no doubt due to the precipitated 
 albumen on the surface 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 accompanies the dry hot mouth of a previous night's de- 
 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 membrane, as seen through a gastric fistula, is pale, and only 
 covered with a little mucus. If a little alcohol is now introduced, the blood- 
 vessels of the mucous membrane dilate, and it becomes of a rosy-red color; 
 its glands begin 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, "f The 
 very opposite condition follows a large dose ; the mucous membrane be- 
 comes 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 (alcoholism) is a formidable disease 01 
 
 the nervous system. In its early stages it is characterized by derangement 
 
 * 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 Anjemia " and 
 " Cerebral Hypersemia," 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. 
 
 f The Physiological Action of Alcohol, by T. Lauder Brunton, M. D., F. R. S., in The 
 Practitioner, January, 1876, p. 61. 
 
28 HEADACHES. 
 
 of the assimilative functions, as dyspepsia, nausea, and congestion of the 
 liver; and, later on, by failure of nutrition, 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 impregnation of the blood with a large percentage of the poison- 
 ous agent. " It may cause the corpuscles to run too closely together, and 
 to adhere in rolls," converting their clear outline into an "irregular or star- 
 like edge," and changing "the round corpuscle into the oval form." 
 These changes appear to be due to the action of the spirit in extricating the 
 water contamed 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, /. e., incapable of transmitting impressions 
 through its affected part ; while a very weak mixture of alcohol and water is 
 incapable of producing this affect. 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) para- 
 lyzed." | This experiment 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 various observers that the impregnation of 
 the blood with large quantities of alcohol interferes with its absorption of 
 oxygen," 1 1 and lessens the oxidizing power of the red corpuscles. § A mod- 
 erate amount of alcohol, by dilating the minute bloodvessels, and stimulat- 
 ing 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 assimilated, 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 control, and as 
 doing so is an indication of evil augury. The heart beats quicker, and as 
 it loses force in proportion, its power is too weakened and impaired for any 
 prolonged 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 dilatation of the vessels and the better supply of blood. 
 The slackened tide of the circulation has gained a new impetus and vigor, 
 and all the functions have derived additional stimulus to ward off threaten- 
 ing mischief; but taken immoderately, or on emergencies, the physical dan- 
 ger done to the animal economy is manifested in organic deterioration, and 
 in the shrinking and alteration of the nervous texture. To these succeed 
 
 * 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. 
 
 J Ibid. p. 46. 
 
 J Reynolds's System of Medicine, Alcoholism, vol. ii, p. 144, by F. E. Anstie, M. D., F. 
 R. C. P. 
 
 II Ibid. p. 145. 
 
 §The Physiological Action of Alcohol, by T. Lauder Brunton, M. D., F. R. S., in The 
 Practitioner, February, 1876, p. 122. 
 
THE HEADACHE OF CEREBRAL AN/EMIA. 29 
 
 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 a second time, 
 while failing speech is the harbinger of a general paralysis and a total wreck 
 of all that was formerly 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 cerebral anaemia, where the chief symptoms were kept up by 
 the injudicious use of alcohol. The deleterious consequences chiefly showed 
 themselves in disorder of the gastro-intestinal mucous membrane, while on 
 one occasion profuse haemorrhage from the stomach and bowels took place. 
 These symptoms were so severe that ulceration of the stomach was at one 
 period suspected, but abstinence from all stimulants, and a milk diet, rap- 
 idly improved 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, 
 indicating nerve degeneration ; a tremor of the lower limbs, and unsteadi- 
 ness of gait, similar to what is observed in delirium tremens.* The face was 
 generally pale and 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 comparatively well. 
 
 The amount of alcohol weighed by the standard of what a man takes to 
 health (when all the excreting organs are actively performing their func- 
 tions) is no criterion 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 nutriment 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 beerf is especially a compound which interferes 
 
 *" The worst sign of impending nervous change is muscular instability, irrespective of the 
 will; that is to say, an involuntary muscular movement whenever the will is off" guard. . . . 
 In the motor centres of the nervous organization the foreign agent is creating disturbance of 
 function. The fact is communicated to the muscles by the nervous fibres, and the active in- 
 voluntary 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 I ounce 
 
 Extractives, dextrin, sugar 1. 2 " (524 grains) 
 
 Free acid 25 grains 
 
 Salts 13 grains 
 
 — Practical Hygiene, by Dr. Parkes, Philadelphia, Blakiston,4th Edition, p. 257. 
 " One ounce of alcohol is equivalent to two fluid ounces of brandy (containing 50 per 
 
30 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 imperfect, but it may be 
 said to be absorbed into the system after its reception into the blood, escap- 
 ing 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 alco- 
 hol is very trifling through the kidneys. Although there is some difference 
 of opinion as to the amount excreted, most observers are tolerably agreed 
 that it is very small. The constant consumption of large quantities of alco- 
 hol leads to the accumulation of fat in the system, and produces degenera- 
 tive diseases of a fibroid and fatty nature. "The brain and its membranes, 
 and its vessels, suffer early and principally ; and Kremiansky has produced 
 haemorrhagic meningitis and pathological changes in the brain vessels and 
 membranes in dogs by giving them alcohol. There is no question that sev- 
 eral 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.)| Un- 
 fortunately there are many forms of bodily weakness and mental wretched- 
 ness which drive the sufferer to seek stimulants, not only from the gratifica- 
 tion he feels in the indulgence, but to drown his misery in excitement and 
 forgetfulness. Among the diseases which impel persons to drink, nervous 
 affections 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 car- 
 ried 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. 
 
 cent, of alcohol), or to five ounces of the strong wines (sherries, etc., 20 per cent, of alco- 
 hol), 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 increased one-half, 
 1% ounces of absolute alcohol will be taken, and the limit of moderation for strong men is 
 reached." — Ibid., p. 277. 
 
 * " ^Mlen 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 C. C.) and two fluid ounces 
 (= 56.8 C. C). The eff"ects which can then be detected are slight, but evident, narcosis, 
 lessening of appetite, increased rapidity of rise in the action of the heart, greater dilatation 
 of the small vessels as estimated by the sphygmograph, and the appearance 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. 277. 
 
 t " j\Iy friend. Dr. George Johnson, informs me that out of 200 patients with Bright's 
 disease, from all causes, he found no less than 53 were drunkards." — Quoted from Parkes's 
 Practical Hygietie, 4th edition, Philadelphia, Blakiston, p. 276. 
 
CHAPTER II. 
 
 THE HEADACHE OF CEREBRAL HYPEREMIA. 
 
 General and Local Causes — Active and Passive Hyperjemia of the Brain — Condition of the 
 Heart and Arterial System in some Cases of Surgical Pyrexia — Gouty Hyperasmia — 
 Active Hyperaemia sometimes due to Structural Delicacy in the Walls of the Blood- 
 vessels — Connective Tissue Overgrowth in the Brain — Nature and Causes of Passive 
 Hyperaemia or Congestion — Anatomical Changes in the Vessels and Meninges — Symp- 
 toms of Hyperaemia — Symptoms and Pathology of Sunstroke — Effect of Bloodletting and 
 Cold in reducing the Temperature of Hyperpyrexia— Hypersemia 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 Bromide 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 Effects of Cold, and its Mode of Action — Utility of the Ice Cap in con- 
 trolling Cerebral Hyperaemia and Vascular Excitement. 
 
 When an increased quantity of arterial blood passes through the enceph- 
 alic 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 a 
 state of venous congestion is established. If it continues, 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 physiological cerebral 
 hyperaemia of brain activity, contrasted with the anaemia which is an essen- 
 tial 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 indistinguishable. When consciousness returns in the act of awak- 
 ing, the process is reversed ; the brain fills, grows ruddier, and the vessels 
 which were lost sight of in sleep can again be distinguished by their enlarged 
 calibre. Such is the difference betwixt the conditions of sleeping and wak- 
 ing — so far as the blood-supply goes, but no further."* As the brains of 
 most persons are kept in a state of great activity 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 hypercBniia as a morbid state is a frequent cause of headache; 
 
 * Dr. J. Milner Fothergill on Cerebral Hyperaemia, in West Riding Lunatic Asylum Re- 
 ports, 1875, vol. v., p. 172. 
 
 (31) 
 
32 HEADACHES. 
 
 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 blood- 
 vessels, and in some hyperaemic 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 of meningitis, and this is attribu- 
 table more frequently to the same pathological change than to actual in- 
 flammation and the products that arise from it. This condition is, I believe, 
 a common exciting cause of headache. It leads to local congestion (partial 
 hypereemia), and often indicates the seat of suffering. When a change of 
 this character is present in a well-marked degree, and has come on rapidly, 
 death may take place from severe congestion without the occurrence of 
 actual hemorrhage, or comminution of the brain. 
 
 There is an active and a passive hypergemia of the brain — two opposite 
 conditions due to separate causes, and presenting a distinct set of symptoms. 
 
 In the active form 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 froni 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 happens that an excited action of the heart 
 from running, palpitation, or violent coughing in pulmonary disease, aggra- 
 vates the nervous suffering if long continued. But this by no means can be 
 accepted as a rule, for the exertion of wrestling, running, and active gym- 
 nastic 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 duration 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. Handheld Jones, who observes that the 
 effects produced by cerebral hyperemia vary according to the condition of 
 the nervous centres, and that when the organ is healthy, a moderate hyper- 
 aemia does not disorder their action, but that in weak and excitable subjects 
 the excitement may be very great.* 
 
 When febrile symptoms follow surgical operations, Ave 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 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 inde- 
 scribable 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; except in some cases where 
 venesection is so far to be credited 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 hyperemia is witnessed to perfection in the high inflamma- 
 tory fever which sometimes succeeds great surgical operations, more par- 
 
 *0n Functional Nervous Disorders, Hypergemia of the Brain, 1870, p. 88. 
 
THE HEADACHE OF CEREBRAL HYPEREMIA. 33 
 
 ticularly in young full-blooded persons, who are not emaciated or otherwise 
 reduced 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 conjunctivse 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 deposition of 
 fibrinous coagula in one in one or more of its chambers. With this state of 
 vascular excitement there are disturbances of sensibility, which partake more 
 of an irritating than of a painful character. There is throbbing 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 darkness to day- 
 light; sleep is broken and disturbed by restless dreams, till the head is 
 cooler and the temperature reduced. The constitutional symptoms are not 
 so alarming 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 
 compressible, 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 increases coagu- 
 lation 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 temperament suffer from active 
 hyperasmia, 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 quantity of blood in the body ; on the con- 
 trary, the predominance of the nervous over the vascular element renders it 
 probable that there is habitually an insufficient supply for the demands of an 
 ouerstrained nervous system. The brain in these cases is exposed suddenly 
 to a sort of deluge ; and two factors are concerned in the mischief. A dis- 
 turbed stomach transmits its irritation through the sympathetic system of the 
 brain, already overloaded with blood ; and as the vasomotor nerves become 
 relaxed, a further increase of blood overpowers the brain in consequence, 
 apart from the hyperasmia which the increased activity of the systemic cir- 
 culation induces. Persons whose digestive organs are weak and sensitive, 
 or v/ho sit down to a meal agitated and disturbed, soon experience discom- 
 fort and excitement ; the head aches violently, and 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 applied 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. 
 .When 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 con- 
 
34 HEADACHES. 
 
 gestion has disappeared. If no revulsive measures have been resorted to, or 
 the loss of blood has not occurred, the symptoms of active congestion and 
 intravascular pressure may be converted into those of effusion and fatal apo- 
 plexy. 
 
 Active hypersemia 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 conjunctivae are injected, and the pulse is firm and incom- 
 pressible. They easily tire and become breathless on exertion if they at- 
 tempt to walk at a moderate pace, or 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 di- 
 rection which, however detrimental to their health, is at least acceptable to 
 their feelings. The ordinary precautions 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 emi- 
 nently 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. Tri- 
 fling 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 over- 
 took 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 stimulating diet, and the patient's lethargy and inaction, effete mat- 
 ters accumulate in the blood, and throw upon the kidneys and other excre- 
 tory 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 kid- 
 ney from the excessive supply of blood, so that the organ is no longer able 
 to completely discharge its functions. Then follow spasm of the arterioles, 
 and that rise in blood-pressure which leads to hypertrophy of the left ventri- 
 cle, and the transmission of blood to the brain in greater force. As, there- 
 fore, 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 ves- 
 sels of the brain atheromatous and liable to rupture from the distension to 
 which they are subject. 
 
 The condition of cerebral hyperaemia is denoted in some persons (espec- 
 ially men of full or gouty habit who are approaching sixty years of age), by 
 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 enlargement. 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 arteries, and an increase in the growth of the tissues which 
 enter into their structure. The heart's sounds afford evidence of the mis- 
 chief which the arterial tension discloses : the impulse is frequently in- 
 
THE HEADACHE OF CEREBRAL HYPEREMIA, 35 
 
 creased, and the area of prsecordial dulness also ; whilst the aortic second 
 sound is accentuated. In a case which has furnished these remarks, the 
 patient was sixty-five years of age, and there stole on gradually a forgetful- 
 ness of passing events, and an indistinct utterance, which finally ended in 
 the rupture of some vessel near the base of the brain. 
 
 There is another form of active hypersemia 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 
 followed 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 nerv- 
 ous system is agitated and depressed, or if he exposes himself to the sun or 
 to noise and confusion after it, the mental excitement disturbs the process 
 of digestion, and provokes a hyper^mic state of the cerebral vessels. It is 
 not uncommon as a consequence of aortic insufficiency, the result of endo- 
 cardial inflammation. In these cases the carotids 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 hyper- 
 trophy 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 
 altered orifice. Now, what are the ultimate consequences of mitral valvu- 
 lar derangement on the cerebral circulation ? 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 paralyzing the left auricle. This induces en- 
 gorgement of the pulmonary veins, and, indeed, of the whole venous system, 
 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 insuf- 
 ficiency. 
 
 Again, any condition which arrests or interferes with the cutaneous circu- 
 lation 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 hyper- 
 aemia, there is developed a certain amount of pathological connective tissue, 
 which gradually contracts. 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 consequence of alcoholic 
 indulgence, has been pointed out by Schroeder Van der Kolk, and physio- 
 
 * Niemeyer, Practical Medicine, vol. ii, p. 247. 
 
30 HEADACHES. 
 
 logical 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 degeneration and disease.* 
 
 Passive hypercemia or congestion arises from any pressure 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 a bron- 
 chocele, aneurisms of the aorta, and hypertrophy of the thyroid ; in tricuspid 
 insufficiency; in the violent expiratory efforts produced by straining and 
 coughing, as in whooping-cough, when the blood accumulates in the general 
 circulation rather than in the pulmonary. The brain is overloaded, and 
 maintained in this unhealthy condition because the obstacle cannot be over- 
 come. 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, par- 
 ticularly when the right ventricle is diseased and acts imperfectly, the over- 
 fulness of the veins leads to capillary engorgement because the blood is ob- 
 structed in them, and this is a common cause of cerebral hypersemia. In 
 valvular disease of the right heart this aifection is far greater than when it 
 occurs on the left side, because the return of the blood is enormously im- 
 peded. f In cases of chronic bronchitis, with a weak and dilated right 
 heart, this state is also of common occurrence. In 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 proportionately 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 deepseated, and so continuous that the nerve-structure is gradually 
 brought to the verge of disease. It may continue for years, and end in apo- 
 plexy or rupture at last. The well-to-do rector, or the country squire who 
 has seen sixty summers, is the victim of this condition ; 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 commonly enlarge- 
 ment 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 aperients to maintain their 
 regular action. The patient cannot 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 ; and, if spoken to, or stopped on his 
 way, turns round so guardedly that his head seems to have no independent 
 motion from the rest of the body. The heart indicates commencing de- 
 generative change, and the aortic valves are the first to go wrong. Nearly 
 all his disagreeable sensations are referred to the head; and, when 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 nitro- 
 genous 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 deglee of uraemia. The patient's general demeanor is 
 
 * Effects of Alcohol on the Brain, Lancet, September 30th, 1876, p. 470. 
 -j- See Chapter V, on Congestive Headache, where this subject is continued. 
 
THE HEADACHE OF CEREBRAL HYPER.EMIA. 37 
 
 altered, and dejection of spirits and moroseness of manner are rather the 
 mental traits than excitement and irritability. Still, there is general rest- 
 lessness and a desire to be doing. The terrific headache and the morbid 
 sensations to which these persons 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 excite- 
 ment, 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 constant 
 in the amount of blood in the cerebral hemispheres and vessels, short of 
 actual rupture, which a post-mortem examination reveals. In the case of 
 children, often after death from head affections, the brain is only mode- 
 rately congested, and yet the symptoms have been alarming, and death 
 rapid, with insensibility and coma. The best examples of congestion and 
 hypergemia fail to account for the symptoms during life. But when the 
 continuance of active cerebral hypersemia 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 
 inflammatory action. 
 
 SymptojTis of Hypercemia. — x\lthough I have dwelt at some length on the 
 causes of congestion and hypercemia 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 dis- 
 turbance in fever arises from the high temperature and a change in the 
 quality of the blood, which is at variance with a healthy condition of the 
 nerve substance ; hence delirium and a comatose state in low fevers affecting 
 the brain are not infrequent, where the heart's action is feeble and the 
 blood-supply is also deficient. 
 
 In cases of severe sunstroke, where the patient is struck down suddenly, 
 the symptoms are rather due to a paralysis of the functions of the brain than 
 to a state of hypersemia. The nerve-centres are overheated and depressed, 
 and, until the temperature is lowered, they cannot recover their action. 
 These facts point out the rational treatment of the disease. " As the hyper- 
 pyrexia is due not only to the direct operation of heat on the nerve-centres 
 and tissues, but also to the fever set up by the disordered vasomotor arrange- 
 ments, remedies, such as may influence this disturbed condition, have been 
 suggested. The results have appeared in some cases to justify the theory ; 
 and the hypodermic injections of morphia and of quinine have both been 
 considered to produce good results by their influence on the vasomotor 
 nerves, and their power in retarding tissue change." * The plan of treating 
 
 *0n Sunstroke, British Medical Journal, August 12th, 1876, p. 224, by Sir Joseph 
 Fayrer, K. C. S. I. 
 
38 HEADACHES. 
 
 sunstroke by the subcutaneous injection of quinine, first introduced by Sur- 
 geon-Major A. R. Hall, has been found most successful. It is especially 
 serviceable for troops on the march where ice is unattainable (Form. 115); 
 There is excitement and cerebral irritation in some cases, but in the majority 
 of cases the patient falls down and gasps for breath, as in syncope. The 
 prduction of heat is increased by muscular exertion, and the body becomes 
 overheated, because perspiration takes place slowly through the high tem- 
 perature of the atmosphere ; and hence the overloading of the vessels of the 
 brain and the other organs of the body, but more particularly congestion of 
 the lungs, and distension of the right heart. Post-mortem examination ver- 
 ifies this in fatal cases of sunstroke, where the blood is fluid, as in death from 
 lightning and blows on the epigastrium. In mild cases prolonged head- 
 ache (which is not an early symptom), irritability, exhaustion, incapacity 
 for mental exertion and the concentration of ideas, are induced by it. For 
 it is important to remember that the shock of the seizure and the high tem- 
 perature together are highly injurious to the nerve-centres, over-loading the 
 brain with blood, and sometimes inducing severe meningitis. A brain 
 habitually charged with too much blood is just as likely to lay the founda- 
 tion of gradual tissue-change, as is the direct operation of heat and exposure 
 to the sun. In the management of these cases of hyperpyrexia Sir Joseph 
 Fayrer insists on reducing the temperature as quickly as possible by the use 
 of the cold douche to the head and body, mustard poultices, and purgative 
 enemata. He relies little on blood-letting, and records that of numbers of 
 soldiers who were struck down in the Burmese war in 1852 by the direct 
 action of the sun, all recovered except two, who were bled on the spot where 
 they fell. These remarks are in accordance with those of Dr. Wilson Fox,* 
 who says that cold is the only means of reducing the temperature in hyper- 
 pyrexia. He shows that venesection, in one case to twenty ounces, had no 
 effect in checking the rise of temperature in acute rheumatism ; whilst he 
 cites two cases of recovery under his own care, where the temperature in 
 one case reached 110°, and in the other 107.3°. He considers that vene- 
 section prejudicially interfered with the cold applications, and was the cause 
 of death in one case through the exhaustion induced. 
 
 In simple congestion the escape of venous blood is arrested, and the blood 
 passes slowly through the capillaries from this overfilling. Both in ansemia 
 and congestive venous hypersemia, the brain is not supplied with its due 
 amount of arterial blood, and so the cerebral symptoms are allied; and the 
 general condition bears a close resemblance in the two cases. 
 
 The pain and irritation induced by active hypereemia are not precisely 
 alike in all instances. At one time the functions of sensation are more 
 affected than those of motion, and at another time the mental faculties are 
 marked out for special implication. The thoughts are rapid, loose, and un- 
 connected, and the ideas are confused and false. Life is looked at through 
 a false medium. When the sensory functions are involved, there are head- 
 ache, excitability, and extreme sensitiveness to every impression that goes on 
 around, the slightest sound worrying the patient, and even quiet conversa- 
 tion being distasteful; the light of the sun causes a disagreeable and oppres- 
 sive feeling to the brain, scintillations of light appear before the eyes, and 
 there are noises in the ear. Some persons experience a condition of hyper- 
 sesthesia periodically; it comes on suddenly, and lasts a day or two, then 
 goes away as it came. 
 
 *0n Hyperpyrexia, 1871, pp.' i and 43. These views are supported in H. C. Wood's 
 work on Thermic Fever. 
 
THE HEADACHE OF CEREBRAL HYPER.EMIA. 39 
 
 There is a form of hyperaemia of the brain in men who tax their intellec- 
 tual efforts to the highest point, and who at the same time exert their bodily- 
 strength by other duties and calls on their attention. They scarcely allow 
 themselves time for their meals, or take them irregularly or hurriedly, and 
 perhaps indulge in stimulants to keep them up to the right mark. There is 
 headache with disturbed sleep, and pain at the back of the head, or a feeling 
 of blood rushing into the brain ; sometimes there is delirium. These per- 
 sons are nervous and apprehensive, yet they cannot stop the speed at which 
 they are pushed along the stream. Sometimes the pulse is quick, and there 
 is fever; or it is slow and labored, not more than sixty beats a minute, and 
 then the patient is depressed and more or less indifferent about himself. 
 The urine is very changeable; at one time it is high-colored and intensely 
 acid, or it is as pale as water, and contains phosphates in abundance. There 
 may be redness of the face, but often there is pallor and a worn, exhausted 
 look; the patient loses flesh and strength, and the excitement gives place to 
 lethargy and depression. If he indulges too freely in stimulants, melancholy 
 and even mania may result, or apoplexy and paralysis may be the termina- 
 tion. Suddenly the patient feels bewildered and giddy; he staggers or even 
 falls, or he rushes and takes wine or brandy to support his failing circulation. 
 His head is hot; he cannot engage in conversation, and is glad to resign 
 himself to rest and a recumbent posture. After a few hours' rest or sleep, 
 when the venous blood is better circulated, and the supply of a proper 
 amount of arterial blood stimulates the brain and nervous centres to healthy 
 excitability, the patient recovers and goes on again ; or if the condition 
 continues to recur from time to time, the nervous substance is structurally 
 altered, and loss of consciousness or convulsions are produced. 
 
 It is quite in accordance with clinical experience to have partial hyper- 
 semia of the brain, where certain spots are more congested than others. 
 This may be due to tumors, partial softening, and localized extravasation, as 
 in lobular pneumonia. An artery may be compressed, or the smaller vessels 
 and the collateral circulation take on congestive action, so that some portions 
 are anaemic and others hyperaemic ; and this is what we sometimes see in 
 other organs of the body. Unless there are local symptoms, the cause can- 
 not be found out. There are headaches limited and circumscribed — con- 
 traction of one or both pupils, noises in the ears, imperfect vision in one eye, 
 neuralgia of one eye, but never loss of sensibility in one spot, or paralysis 
 of one side. The treatment consists in relieving the local congestion.* 
 
 In discussing the question of hypergemia of organs there are two factors to 
 be included, the omission of either of which would greatly invalidate any 
 conclusion that might be drawn. The first is the relation of the tissues to 
 their blood-supply. This is seen in the increased blood-flow to an irritated 
 part, as a bat's wing, for instance. The other is the effect of an increased 
 blood-supply upon the growth of a part ; this is seen in the elongated limbs 
 of chronic joint mischief, and still more vividly in the growth of the cock's 
 spurs, Avhich John Hunter engrafted on the bird's comb ; or as happens in 
 the excessive growth of muscle and bone in a limb, from obstruction to the 
 lymphatic circulation. Thus we find that there may be much vascular hy- 
 pergemia in a maniacal patient, with but little general disturbance of the cir- 
 culation. Here the cerebral cells attract blood to themselves in too great a 
 quantity. In other cases of congestive headache, as in plethoric persons, 
 there is a hypertrophied heart, with throbbing distended carotid arteries, and 
 
 * " Local hypersemia, in fact, is not exactly local plethora; it simply implies that too much 
 blood is accumulated in the vessels of a part, without taking any account of the nature of 
 this blood." — Jones <2^ Sieveking's Pathological Anatomy, by Payne, Philadelphia, p. 44. 
 
40 HEADACHES. 
 
 an excessive blood-supply to the brain, which excites the cerebral cells and 
 causes exaltation of the special senses, producing the appearance of flashes 
 of light, the sound of ringing bells, and other ideal sensations. At times 
 these conditions are blended, as in the vivid sketch of "Preparing for the 
 House" in the diary of a late physician, where the stout country squire, 
 with a rubicund face, is in a condition of great excitement at the prospect of 
 delivering a speech which would defeat his assailants, and forthwith establish 
 his reputation as a politician. 
 
 Treatment. — The first indications that call for fulfilment are to lower the 
 vascular system, and to reduce the cerebral fulness. It is obvious, however, 
 that a separate line of treatment will be required to meet the special pecu- 
 liarities of each case. If the vascular element predominates, and other meas- 
 ures fail to control the more urgent symptoms, venesection may be demanded 
 to save the patient's life, and there can Idc no doubt that a full and effective 
 blood-letting has proved of great service. If the carotids beat violently and 
 fill the brain with blood, then leeching or cupping ought to be had recourse 
 to, as becomes advisable in some acute forms of febrile headache in young 
 subjects. In cases of active cerebral hypereemia, where the pulse is firm and 
 good, aconite, tartar emetic, and other depressants are to be selected (Form. 
 io6). Colchicum, in combination with the alkalies and iodide of potassium, 
 will also be of service (Form. 31-34), if it appears certain that the cerebral 
 vessels are distended, and the blood-pressure is too great. The bowels 
 should be freely evacuated by saline purgatives (Form. 19) in the early morn- 
 ing. An occasional pill containing mercury, with or without podophyllin, 
 will rouse the liver and intestines, and so bring great relief to the head symp- 
 toms, by tending to subdue vascular excitement and depress the circulation 
 generally (Form. Si-94). If the urine is scanty and acid, and aft''ords proof 
 of lithiasis, which is not uncommon, it will be advisable to take plenty of 
 diluents, and the salts of potash and lithia freely diluted with water. Fried- 
 richshalle, Pullna, and Hunyadi Janos waters on first rising in the morning 
 act quickly on the bowels, and produce no unpleasant effects afterwards ; 
 and the same may be said of the aerated waters of Vichy and Carlsbad, 
 which are favorite remedies with some persons of full and torpid habit. 
 
 In place of a heavy nitrogenous diet, fish, white meats, and fruits are to 
 be preferred, and fermented liquors and wines should be forbidden. 
 
 If the patient has strained his mind, or is advancing in years, venesection 
 on cupping will be of questionable service, for the veins of the brain and 
 s«iuses are too full and congested to be relieved by the attempt, and the 
 shock from the loss of arterial blood could not be borne. When, too, the 
 circulation is quiet, such remedies would be productive of harm rather than 
 good j and we must trust to a darkened room, general quiet, and remedies 
 havmg the sedative properties of hydrate of chloral. 
 
 In women the occurrence of the menses often brings relief, if the patient 
 is abstemious in diet and avoids stimulating food. In those forms of con- 
 gestive hypersemia from pressure'on the jugular veins, leeches may be used to 
 favor the escape of venous blood. When hypersemia results from overfeed- 
 ing and stimulants, lessening the diet, moderation in living, and walking 
 exercise will be necessary ; but no two cases are alike, and some modifica- 
 tion will be required. 
 
 In treatment it is of the highest importance to discriminate the two fac- 
 tors previously mentioned; the first is the relation of the tissues to their 
 blood-supply, and the second is the effect of an increased blood-supply upon 
 the growth of a part. The proportion of each factor in every individual 
 case must be carefully weighed, for in one the circulation needs depressing, 
 
THE HEADACHE OF CEREBRAL HYPER.EMIA. 4 1 
 
 and in the other sedatives and rest are the chief indications. In one the line 
 of treatment is to reduce the excessive blood-supply, which keeps up too 
 much excitement in the brain ; in the other the excited brain-cells are at- 
 tracting blood too freely, and the course to be adopted is to lessen activity 
 and their demand for blood. For this condition bromide of potassium, hy- 
 drate of chloral, and opium, are the chief remedies to rely upon. 
 
 With regard to the action of sedative remedies in hyperaemia of the brain, 
 bromide of potassium is one of the most remedial and curative agents we 
 possess in the treatment of nervous disorders. It has been clearly shown by 
 scientific observers that it is a most efficacious remedy in hypersemic forms 
 of headache, and also in those varieties of nervous headache where the cere- 
 bral cells are excited, and the emotional framework is highly strung. As 
 J bromide of potassium controls sexual excitement, it may be expected to sub- 
 ^ due cerebral excitement also, and dissipate those conflicting thoughts and 
 passions which stir us to anger, and aggravate the trifling incidents of daily 
 life. Our chief experience has been derived from its efficacy in the treat- 
 ment of epilepsy. As a calmative and narcotic, and as a remedy controlling 
 vascular excitement, it is usually admitted to occupy the first rank. By 
 reducing the irritability and lessening the fits, it controls the congestion on 
 which the headache depends. Clouston (Fothergillian Prize Essay) found 
 half-drachm doses of the bromide of potassium, of tincture of cannabis 
 indica, and of tincture of hyoscyamus, very useful in the sleeplessness of talk- 
 ative mania (Form. 63). I have often given the bromide and the cannabis 
 - indica together with great advange in smaller doses (Form. 64), and I have 
 known full doses of henbane with camphor, either in the shape of pill or 
 mixture, prove an excellent and reliable sedative (Form. 65-93). ^^ the 
 persistent headache which follows sunstroke, bromide of potassmm is the 
 most serviceable remedy.* Hydrate of chloral is sometimes given with ad- 
 vantage, either alone or in combination with the bromide (Form. 66-67). 
 When chloral is given alone it acts by depressing the heart's action and less- 
 ening blood-pressure, on which the cerebral excitement depends. Men 
 advanced in life, who have still active duties to perform which require 
 mental exertion, find their headaches relieved by a full dose of chloral on 
 retiring to bed. This indicates the hypersemia of vasomotor paresis. The 
 sleep is sometimes broken and disturbed in these subjects, and there is throb- 
 bing and a disagreeable sensation about the temples; but the next night, and 
 for many succeeding nights, the sleep is calm and peaceful, and the patient 
 goes about his work with renewed pleasure. This very action makes the drug 
 a seductive one, and it should never be taken except under medical super- 
 vision. It probably has a greater effect upon the vascular system than the 
 bromide, which would seem chiefly to have its action confined to the nerve- 
 ^ centres. Bromide of potassium with digitalis is serviceable if the pulse is fast 
 - and feeble and the patient has a weak heart, or has overdone himself in any way. 
 Ergot is a remedy highly spoken of by some authorities, but I have not 
 employed it, with so many more_rem.edies at hand. " I have found it almost 
 uniformly efficacious in reducing excitement, in shortening attacks, in wid- 
 ening the intervals between them, occasionally in altogether preventing the 
 recurrence, and in averting that perilous exhaustion by which excitement is 
 so often succeeded." Drs. Bucknill and Tuke add, " Dr. Browne explains 
 its beneficial action by its influence in contracting the vessels of the brain, 
 and administers the liquid extract of ergot in doses of from 3ss. to^j three 
 
 * Dr. Morehead, On Sunstroke, in A System of Medicine, edited by J. Russell Reynolds, 
 M. D., F. R. S., vol, ii., p. 142. 
 
 3 
 
42 HEADACHES. 
 
 times a day, or S] to 3ij of the pharmacopoeial tincture."* I do not like 
 these large doses, for the reasons given in another place. f 
 
 One of the most powerful agents we possess in the treatment of hypersemic 
 conditions is cold. Cold applied to the head is admitted to act in one of 
 three ways : 
 
 1. By exerting a direct action on the superficial vessels of the scalp, and 
 the parts within the cranium. 
 
 2. By diminishing the blood-supply, and contracting the vessels. 
 
 3. By exerting a sedative action on the nervous centres. 
 
 Some estimate of its power on the capillary circulation may be imagined 
 from the effect of immersion in a cold bath for a few minutes, where the 
 temperature, as in hj'perpyrexia, may be reduced several degrees in an in- 
 credibly short space of time. M. Marey has shown by a sphygmographic 
 tracing, that after exposure to a cold bath of one minute, there is consider- 
 able tension and hardness in the pulse in consequence of contraction in the 
 cutaneous capillaries, and an obstacle to the passage of blood from the ar- 
 teries. The effect of a hot-air bath, as we all know, is to relax the arterial 
 system, and to produce dilated vessels and general enlargement of the capil- 
 lary circulation. 
 
 The pulse is soft and full, and the increased frequency with which the 
 heart acts diminishes its force and power, enabling the blood to pass freely 
 into the veins. 
 
 When cold is applied to the head, one m.ode of action is considered to be 
 by abstracting heat from the scalp. There may not be a general agreement 
 on the subject, but it seems borne out by practical conclusions. Cold is so 
 powerful an agent that long exposure to it has resulted in the death of the 
 part to which it is applied ; and congestion of the internal organs, as the 
 brain and lungs, has been found after death, preceded by a tendency to 
 sleep and apoplectic coma. Here it is highly probable that a brief applica- 
 tion of cold may assist in the removal of the venous stasis, which a more 
 prolonged application tends to induce; and there is nothing adverse to the 
 physiological conclusion that cold, by contracting the vessels, may, by a seda- 
 tive action on the nerve-centres, diminish the flov/ of blood generally; and 
 it would appear to have this effect, as it will lower the pulse, and in control- 
 ling the action of the heart lessen the arterial supply to the brain. From a 
 series of carefully conducted experiments performed by Dr. Benham on the 
 dead subject, he ascertained "that as long as a fluid of a certain tempera- 
 ture is passing through the vessels of the intracranial tissues, the application 
 of even the most intense cold to the outside of the scalp has no effect in 
 lowering their temperature. "| Now this is what might be expected when 
 we consider the deep tissues through which the cold has to act. It may be 
 capable of abstracting a certain amount of heat from the scalp and superficial 
 tissues, but can it exert any physiological effect on the tissues, within the 
 rigid osseous skull? It seems unlikely that it can do so without causing con- 
 gestion, or even inflammation ; yet, moderately applied, it may, through the 
 influence of the nervous system, control the temperature to some extent. 
 Even in experiments performed on living dogs under the influence of chlor- 
 oform, although the temperature was temporarily lowered 2°, it did not con- 
 tinue to fall, but soon rose to the normal standard. This, therefore, was 
 
 * Psychological Medicine, 1874, p. 745. 
 ■j- See Chapter XIV., on Headaches of Advanced Life. 
 
 J On the Therapeutic Value of Cold to the Head, West Riding Lunatic Asylum ' Medical 
 Reports, vol. iv.,p. 157. 
 
THE HEADACHE OF CEREBRAL HYPER^.MIA. 
 
 43 
 
 rather due to some effect on the vessels through the nervous system and 
 sensory nerves, than to any effect on the blood temperature. 
 
 Mr. Knowsley Thornton* (to whom I am indebted for the engraving 
 here given), about four years ago, introduced into the Samaritan Hospital an 
 ice cap for the head, to be used as the easiest and best means of reducing the 
 high temperature and pyrexia which sometimes succeed ovariotomy. It has 
 received the sanction of Mr. Spencer Wells, and now forms one of his re- 
 liable remedies in the after-treatment of these cases. The apparatus is not 
 expensive, and is easy of application. It consists of india-rubber tubing 
 about the thickness of the little finger. This is coiled round so as to form a 
 closely-fitting cap for the head, communicating on one side, by means of the 
 tubing, with a pail of iced water, elevated about two feet, and placed on 
 one side of the patient's bed, and communicating on the other side Avith a 
 pail to receive the water which has passed through the cap. The two pieces 
 
 of tubing, in fact, — the 
 one conveying water to 
 the cap, and the other al- 
 lowing its escape from it, 
 — are the two strings of a 
 cap, so to speak. 
 
 The benefit of the ice 
 cap seems to me incalcu- 
 lable in cases of great vas- 
 cular fulness, for like cold 
 affusion it exerts a seda- 
 tive effect upon the heart, 
 and rather encourages the 
 free action of the skin, 
 which is one of the chief 
 means of lessening arter- 
 ial tension. 
 
 When the patient is 
 flushed and excited, and there are headache and confusion of the mind, im- 
 mediate relief follows the application of the ice cap in a large proportion 
 of cases; the high sthenic action is reduced, and the face loses its florid 
 appearance and becomes peaceful and calm. If bronchial irritation and 
 cough are threatening, they rapidly subside, and the excited action of the 
 heart gives way to a more steady and regular movement, whilst the pulse is 
 also reduced in force and frequency. If the temperature has been steadily 
 rising, it usually begins to fall perceptibly, and if not at once it does so in 
 the course of an hour or two, unless the elevation is due to septic causes : 
 and even in nearly all cases the ice cap may be said to check the rapidity 
 of the rise, at whatever stage of the pyrexia it is applied. When the cere- 
 bral symptoms are relieved, and the ice cap is hastily discontinued, the 
 head frequently becomes again hot and uncomfortable, until it is reapplied. 
 Patients are in the habit of begging for it during their recovery, whenever 
 they have once used it ; and in many other cases of cerebral hypersemia 
 which have been caused by alcoholic indulgence, and other causes of ner- 
 vous exhaustion, with high temperature and febrile disturbance, it is useful. 
 The headache of active cerebral congestion, and the nervo-hyperaemic head- 
 ache in the acute and early stages, yield more quickly to the ice cap than to 
 all the drugs in the pharmacopoeia; and when this is not obtainable. Dr. 
 Chapman's spinal ice bag is an excellent substitute. 
 
 * Improved Ice Water Cap for applying Cold to the Head in Hyperpyrexia, by J. Knows- 
 ley Thornton, M. B., M. C, in Medical Times and Gazette, May 27, 1876. 
 
CHAPTER III. 
 
 .=*?^^^ 
 
 SYMPATHETIC HEADACHE. 
 
 Extreme Frequency of this Variety of Headache, particularly in Women who suffer from 
 Menorrhagia and Uterine and Ovarian Irritation — Sympathetic Ganglia of the Uterus — Its 
 abundant Nerve-supply — Effects on the Cerebral Vessels of Section and Galvanization of 
 the Cervical Sympathetic — Researches of Dr. Brown-Sequard and Professor Bernard — 
 Examples of Headache attributable to Ovarian Irritation — Typical Specimen of Sympa- 
 thetic Headache from taking Ice into the Stomach, mentioned by Dr. Symonds. 
 
 Occipital Headache — Causes of Pain in this Locality frequently due to an Affection of the 
 Occipital Nerves — Its Significance vi'hen of Long Standing — Mr. Hilton's Opinion of Pain 
 at the Back of the Head as a Diagnostic Sign. 
 
 In well-marked examples of this headache, irritation proceeds at a distance 
 from the sensorium, as in the case of decayed 
 teeth, faulty or arrested digestion, and ovarian 
 excitement. The headache is dependent on these 
 eccentric sources of irritation, and the most per- 
 fect examples of it happen only when the ner- 
 vous system is already delicate or impaired. 
 
 Abundant instances might be adduced to prove 
 how impressions are conducted along the pneu- 
 mogastric nerve and the great sympathetic. 
 There is, so to speak, a sort of influence travel- 
 ling through many channels, and these two es- 
 pecially, till it reaches the brain, where it changes 
 the conditions of repose into heightened sensi- 
 bility and morbid exaltation. This influence, 
 when once excited, produces modifications in 
 the brain, by weakening its inherent strength. 
 The nature of these changes, and the relations 
 that exist between organs so remote and distinct, 
 must be recognized before we can ascertain their 
 mutual relation, and how an antagonism in their 
 functions is produced. 
 
 A nervous headache is as often sympathetic 
 as it it is idiopathic; that is, it is as much the 
 sequel of faulty action in a distant organ as it is 
 in the brain itself. Sympathetic headache is of 
 frequent occurence in women of excitable tem- 
 perament, and is periodically excited in them 
 when the uterine loss is natural, or scanty, or 
 excessive ; and hence we must seek for an expla- 
 nation in the cerebral functions themselves. 
 Women are often to be met with who suffer from 
 
 DIAGRAM SHOWING THE COURSE OF 
 THE VASOMOTOR NERVES OF THE 
 LIVER, ACCORDING TO CYON AND 
 ALADOFF. 
 
 These nerves are indicated by the 
 dotted line which accompanies them. 
 a. Vasomotor centre ; b. Trunk of 
 vagus ; c. Passage of the hepatic vas- 
 
 it at these times: and then the headache and omotor nerves froni the cord along the 
 
 ■' . vertebral artery; a. Fibres going on 
 
 sickness are both intense. Ihe sympathy be- each side of the subclavian artery, 
 
 tween the stomach and encephalon is so great, 
 that 
 
 and forming the annulus of Vieussens; 
 
 First dorsal ganglion ; _/". Gangh- 
 
 a little rich food, or noise, or a shock, or ated cord of the sympathetic ; ^. The 
 
 . . . 1 . . 1 1 • . • r spinal cord ; h. Splanchnic nerves ; 
 
 fatigue, or exertion during the digestion of a z. coeHac ganglion, from which vaso- 
 meal, will invite an attack. These people are C:°e's°ina^resLr;'°^.'VeTung',^"to 
 naturally nervous, and in many instances it will which fibres of the vagus are seen to 
 
 , ^ J • • ii, 4. 4-1 „ 4. „ be distributed ; /. The liver ; ?«. The 
 
 be found on inquiry that the parents on one or i„ustine- « The arch of the aorta. 
 
 C44) 
 
SYMPATHETIC HEADACHE. 45 
 
 both sides of the family have equally suffered ; or insanity or nervous disease 
 has carried off some members of it. They have perhaps led an anxious life 
 from an early period of their career, and have taxed the intellect inordi- 
 nately, when the growth of bone and muscle were most actively proceeding. 
 
 The patient who is eminently nervous asserts that her complaint is bilious; 
 and although in such a case as that just referred to, sickness begins immedi- 
 ately with the pain, it proves no more than this, that the extreme suscepti- 
 bility of the cranial nerves responded to the impression made upon the 
 gastric nerves by the food that was taken. Not, however, that the act of 
 digestion is necessary to originate the pain ; for too long fasting or a continued 
 train of unhappy thoughts will invite it. In a patient, aged thirty-nine, who 
 consults me from time to time, the pain begins as frequently in the left 
 temple as in the right, and as often in the occiput as in either of these places. 
 This sympathetic headache comes on sim.ultaneously with the catamenia, 
 although the function is regular. It is excited by ovarian irritation, and 
 differs in no respect from the nervous form except that there is a greater 
 chance of cure in these cases than in those we may designate as idiopathic ; 
 as with the cessation of the catamenia some physiological change may take 
 place in the constitution which modifies the whole functions of life, and the 
 head is no longer excited to morbid action. ' 
 
 Within the muscular walls of the uterus are imbbedded numerous sympa- 
 thetic ganglia, acting as originators of evil, alone or in concert with the 
 cerebro-spinal system. When; from the periodic nature of the menstrual 
 functions, more blood is determined to the uterus than in the intervals when 
 vascular energy is less marked, there is at the same time a greater evolution 
 of nerve-force, which involves it in irritation, and from thence the irritation 
 is conveyed to the sympathetic filaments which accompany the bloodvessels 
 of the brain. When these headaches are threatening, the sympathetic nerve 
 is engaged in regulating the supply of blood to the uterus, and its influence 
 is exerted in increasing or lessening the amount of secretion. The patient, 
 too, feels cold and shivering, as is the case during the cold stage of inter- 
 mittents, and there is a diminished supply of blood to the surface; the 
 secretions are scanty, the pulse feeble, and the extremities are cold. These 
 are striking manifestations of those conditions of headache over which the 
 sympathetic system presides, uniting distant organs in their sympathies, 
 acting as the conductors of impressions, and giving rise to the sensation of 
 pain, either alone or through the medium of the cerebro-spinal nerve-fibres, 
 which are closely united together in all parts of the body. 
 
 The lectures delivered by Dr. E. Brown-Sequard* a few years ago throw 
 much light on this interesting subject. Professor Bernard found, from ex- 
 periments he performed in 1851, that, when the cervical sympathetic nerve 
 was divided, a considerable afflux of blood in the head took place in those 
 parts beyond the point of section of the sympathetic. 
 
 Dr. Brown-Sequard (who afterwards repeated the same experiments with 
 like results) attributed this to the influence of the nerves on the walls of the 
 bloodvessels, the latter becoming paralyzed after section of the sympathetic. 
 He moreover found, as he anticipated, by another experiment, that galvani- 
 zation of the nerve led to the opposite effect, the bloodvessels contracting 
 and the temperature and the blood in the vessels diminishing. Apart from 
 any knowledge of Brown-Sequard's discovery. Professor Bernard soon after- 
 wards announced that he had seen galvanization of the sympathetic nerve 
 
 *0n the Physiology and Pathology of the Central Nervous System, Lancet, Lecture IX., 
 vol. ii, p. 441, October 30th, 1858. 
 
46 HEADACHES. 
 
 have precisely the same effect ; and this was corroborated by the researches 
 of some British physiologists ; so that it came to be acknowledged by differ- 
 ent investigators that, whilst galvanization of the sympathetic led to the 
 contraction of the bloodvessels, section of the same nerve produced the re- 
 verse effects. 
 
 Dr. Brown-Sequard smxis up the phenomena briefly under the following 
 heads : 
 
 Section of the Nerves. 
 
 1. Dilatation of bloodvessels. 
 
 2. Afflux of blood. 
 
 Increase of vital properties. 
 
 Galvanization of the Nerve. 
 
 1. Contraction of bloodvessels. 
 
 2. Diminution of blood. 
 
 3. Decrease of vital properties. 
 
 Dilatation of the bloodvessels, after section of the nerve, necessarily in- 
 creases the quantity of blood passing through these vessels in a given time, 
 and produces an excessive amount of cerebral congestion. "The hanging 
 down of an animal, by holding it by its hind-legs, in producing a conges- 
 tion in the head, produces very nearly all the effects of this section."* 
 
 From these experiments it is apparent that the action of the sympathetic 
 nerve exerts an extraordinary regulating effect on the condition of the 
 bloodvessels of the brain, and through them regenerates or impairs the 
 properties of the nervous matter. 
 
 "However, we are ready to acknowledge that there are other causes of 
 active circulation in the head, after the section of the cervical sympathetic, 
 besides the paral3'sis of the bloodvessels. The very fact that there is more 
 blood, producing an increase in nutrition and secretion — a fact which de- 
 pends chiefly, as we have said, upon the paralysis of bloodvessels — produces 
 an increase in the normal suction power of the capillaries. In other words, 
 the greater afflux of arterial blood is itself, through the increased chemical 
 changes of nutrition and secretion, a cause of .attraction of arterial blood. 
 To this cause another one of the same kind ought to be added : it is, that as 
 there is more blood the temperature is increased, and as the temperature is 
 augmented the chemical changes, v/hich are a cause of attraction of blood, 
 are also augmented. From this statement it may be concluded that the 
 primitive, and, I may say, by far the principal, cause of augmentation in 
 the afflux of blood is the absence of contraction of the bloodvessels, which 
 allows this liquid to pass easier there than elsewhere. "f 
 
 In any other persons who suffer from a sympathetic nervous headache, the 
 pain is of a continual shooting character, as though a nail was being driven 
 into the head. It is neuralgic, following the course of a particular nerve or 
 branch till it locates itself in the centre of the nervous system. It is more 
 severe in the morning and evening than during the rest of the day, and the 
 sight is confused and dim. The pain may commence over one ear, shoot 
 up to the top of the head, and then extend backwards to the occiput. The 
 pain is sometimes of a smarting character, and is attended with a sinking sen- 
 sation in the stomach. Any stimulant, as a little beer or wine in the middle 
 of the day, will bring it on. Although worry, hard work, and continual anx- 
 iety invite these headaches, the patient is not necessarily fidgety or irritable, 
 and the attacks are unattended with sickness. A patient, who suffered in the 
 way I have described, said: "I have two sons at sea, and if I could get 
 over the idea that I should not see them again, I am sure I should not suffer 
 so frequently." When with this anxiety of mind the catamenia are too 
 
 * Sur les Effets de la Section et de la Galvanisation du Grand Sympathique, Paris, 1854. 
 t On the Physiology and Pathology of the Central Nervous System, Lancet, Lecture IX, 
 vol. ii, p. 442, October 30th, 1858. 
 
SYMPATHETIC HEADACHE, 47 
 
 active, we have the best instance of sympathetic nervous headache. The 
 patient, being sleepless and unable to obtain rest, will pace the room all 
 night, and tell you that her senses are departing. 
 
 Anomalous sensations in the head, of various kinds, are complained of by 
 some persons. 
 
 An unmarried woman, thirty-three years of age, who was under my care 
 in June, 1876, with a sympathetic nervous headache, felt on lying down a 
 noise in her head like the ticking of a watch, which she never experienced 
 at any other time. It sometimes seized one temple, and then the other ; 
 sometimes it fixed itself in the forehead, and sometimes it was seated over 
 one ear (clavus) ; there was also the sensation of a heavy weight at the back 
 of her eyes, but there was no actual pain. The patient had been subject to 
 bilious headaches since she was a child, and the attacks, until a few years 
 ago, always ended in the bringing up of bile. Formerly, the headaches 
 came on at every catamenial period, and now they do not happen oftener 
 than once in three months. The tongue is furred, and there is some flatu- 
 lence after meals ; but there is no uterine ulceration or leucorrhoeal dis- 
 charge worth mentioning. Nothing is clearer than that this case owed its 
 origin to ovarian irritation ; but it is inexplicable why the pain should now 
 recur only once in three months, instead of at each catamenial period. The 
 patient derived great relief from the bromides of potassium and ammonium, 
 and for a time lost the ticking sensation altogether ; but when she was over- 
 fatigued, immediately she laid her head on the pillow there was a buzzing 
 sensation in the ears, and if she looked upwards she was giddy. When there 
 was pain at the back of the head there was always giddiness, and a queer 
 sensation which she was unable to define. 
 
 Here is another case in which ovarian irritation and uterine loss have pro- 
 duced a sympathetic headache, and I give it as an illustration of a group of 
 cases which are of common occurrence. The patient, E. S., thirty-one 
 years of age, thin and pallid, who has had one child, suffers from an excess 
 of catamenial loss. Her headache has now been continuous and severe for 
 six weeks, but she has suffered more or less since she was fourteen, and dates 
 the commencement of it from the time when the catamenia first appeared. 
 This has always been frequent and excessive in quantity, and she is scarcely 
 free from a headache, when the return of the catamenia brings it on again. 
 Between the periods there is a great deal of leucorrhoea and pain in the 
 back. The pain begins with the period, in the pit of the stomach (solar 
 plexus), with the sensation of a heavy and oppressive weight, which is speed- 
 ily followed by headache (generally in the left temple and side of the head), 
 as though something was being driven into it. If it lasts long the pain 
 extends over the whole head, particularly the occiput, which she constantly 
 throws back against the spine, or on one side, to obtain ease. When the 
 pain is severe, she is always sick and deaf, and there are noises in the ears 
 like the roar of the sea or the sound of a distant howling wind. At the 
 time of these headaches the bowels are obstinately costive, and she cannot 
 get relief until they have acted; the pulse is weak, and the hands and feet 
 are cold. When the pain is coming on, the pupils are contracted and sensi- 
 bility is increased, the head is hot and flushed, and the bowels are not free. 
 When they are, and no food has been swallowed for some time, her face is 
 as pallid as marble. 
 
 It can scarcely be contended that these cases were not due to uterine and 
 ovarian irritation. In one case we have seen that no headache was com- 
 plained of till the menstrual period was established, and from that time it 
 recurred periodically. In the last case to which I have referred, the patient 
 
48 HEADACHES. 
 
 had filled a hard and worrying situation for years, and the catamenial losses 
 were always considerable; so that the continuance of two depressing causes 
 fully accounted for the general tone of the nervous system being lowered, 
 and for a predisposition to headache. 
 
 But it is doubtful whether any excitement or disturbance of the uterine 
 functions would solely produce these headaches unless the nerves of the brain 
 were morbidly irritable; for I have known the general health greatly reduced 
 by losses of blood, and menorrhagia persist till the quality of the discharge 
 became almost colorless, and the patient blanched, without any headache 
 supervening. 
 
 Many diseases have a tendency to spread and extend from one part to 
 another. Whether the duodenum or any other portion of the intestinal tract 
 is the seat of offensive and irritating secretions, or whether the uterus and 
 ovaries are morbidly sensitive, the local disturbance is exceedingly prone to 
 increase, and involve contiguous and even remote organs in derangements. 
 Irritation arising from these and similar sources, travels by the sympathetic 
 to the brain. 
 
 In cases of true sympathetic headache the susceptibility to pain is far 
 greater from some causes than it is from others, according to the state of the 
 patient's health at the time the attack is provoked. If a person subject to 
 headache sits down exhausted to his dinner, he will probably pay the penalty 
 of an attack for taking into his stomach a meal when the gastric nerves are 
 oversensitive, and the secretion from its walls, instead of being clear and 
 acid, is tenacious and alkaline. But in another person such remote irritation 
 may not have this effect; Avhilst exposure to cold or the strong light of a 
 theatre would bring on an attack at once. 
 
 "A typical specimen of sympathetic headache is presented in that form, 
 more than once adverted to, which supervenes on taking ice into the stom- 
 ach. Within an hour or two, sometimes sooner, pain will come on in the 
 supraorbital ridge of the temple, attack the eye, dip down into the upper 
 jaw, or extend itself over one lateral half of the head, acquiring the violence 
 of a tic douloureux. The origin of this pain proves unquestionably how an 
 impression may be made on the nerves of a distant organ, which, without pro- 
 ducing any immediate inconvenience in that part, is conveyed to distant 
 organs, and lights upon some particular set of nerves ready to take offence 
 from such a cause, but which have shown their sensibility to disturbing 
 causes in no other manner. ' ' * 
 
 Occipital Headache. — It is a question of the gravest importance in ascer- 
 taining the cause of headache to trace the connection and distribution of the 
 affected nerves. How many persons give us a clue to the nature of their 
 pain by fixing upon the nerve from which it springs ! Headache, with 
 deepseated mischief going on within the head, may involve the third nerve 
 at its orgin, and produces such changes of the globe and eyelids as to enable 
 us to recognize with certainty the exact seat of the lesion. As the pain of 
 headache is referred to the forehead, the temples, or to one side of the head, 
 the fifth nerve may be taken as a tolerably accurate indication of the cause 
 of the pain ; so that, when there is pain at the back of the head, it must be 
 often due to an affection of the cervical nerves and their branches. " Thus 
 pain in the anterior part of the head would suggest that the cause must be 
 somewhere in the area of the distribution of the other portions of the fifth 
 nerve. So if the pain be expressed behind, the cause must as assuredly be 
 connected with the great or small occipital nerve, and in all probability 
 
 * Symonds on Headache. 
 
SYMPATHETIC HEADACHE. 49 
 
 depends on disease of the spine between the first and second cervical ver- 
 tebrae."* This is exactly the opinion we might expect to receive from a 
 surgeon ; for the pain at the back of the head is not of common occurrence 
 in the pure forms of idiopathic headache. When the nervous system has 
 become exhausted, and the patient is low and depressed, the occipital re- 
 gion is more frequently affected ; hence it is common in some cases of ner- 
 vous headache. It is not to be included as a symptom among the cases that 
 ordinarily present themselves for advice. Persons, however, may experience 
 periodic nervous headache for upwards of twenty years, and the pain on no 
 occasion extend behind. When pain is present in this locality, it will be 
 found to follow the track of the cervical nerves; and the neck, from the first 
 to the last cervical vertebra, is often tender and stiff. The pain extends 
 over the scalp at the back of the head, in the direction of the occipital 
 nerves and the free anastomoses which take place between it and the auricu- 
 lar and temporal branches of the fifth nerve. Now, I am of opinion that, 
 when the occiput is the seat of pain in headache, it may be considered to 
 arise from an affection of the cervical nerves and their occipital branches, if 
 the pain is superficial and the nervous sensibility is increased ; but pain in 
 the back of the head, as we have seen, may be owing to disease of the spine, 
 though I apprehend that it can over and over again be ascribed to no other 
 cause than a hypereemic state of the vessels at the posterior or under surface 
 of the brain (or of the cerebellum itself), where the veins and sinuses are also 
 too full of blood, and the nervous matter is deranged in consequence. 
 
 Occipital pain is sometimes present in the headache of acute congestion-, 
 and the patient will even cry out on any attempt being made to move him, 
 or examine the seat of suffering. In the case of a gentleman, aged twenty- 
 eight, who came under my care in 1876, the pain was described as like the 
 beating of a hammer over the greater portion of the head, which was hot. 
 The pain at the occiput was deepseated, and limited to the region of the 
 cerebellum; the muscles of the neck were also stiff, and the patient could 
 not rotate his head in the smallest degree. The chief additional symptoms 
 were constipation of the bowels, slight elevation of temperature, incessant 
 vomiting, and a large, slow, and laboring pulse, not exceeding fifty-two beats 
 per minute. I found free purgation by calomel, and an open blister at the 
 back of the neck, over the upper cervical vertebrae, gave much relief. The 
 first symptoms of improvement were a more frequent and natural pulse, and 
 the heavy, throbbing, deep-seated pain changing its character, and becoming 
 paroxysmal in the course of the right temporal and supraorbital branches of 
 the fifth nerve. 
 
 * Lectures on Pain and Therapeutic Influence of Mechanical and Physiological Rest, by 
 John Hilton, Esq., F. R. S,, in the Lancet, vol. ii., i860, p. 303. 
 
 As corroborative of the opinion of Mr Hilton, that pain at the back of the head is some- 
 times owing to organic disease, I may briefly mention the case of a consumptive patient who 
 came under my care in 1869. He suffered from the most excruciating pain at the back of 
 his head, which he could not move for weeks together. About two months before his death 
 the pain abated, and he then mentioned to me that his neck made a grating noise when he 
 slightly rotated his head, which he could now do without causing any pain. After death 
 the first and second cervical vertebrse were found carious. 
 
CHAPTER IV. 
 
 DYSPEPTIC OR BILIOUS HEADACHE. 
 
 Nature and Origin of — Effect of Sympathetic Action in Provoking Cerebral Disturbance — 
 Functions of Pneumogastric and Ganglionic Nerves — Relation of Vascular Excitement to 
 Nervous Exhaustion — Effects of Aperient Medicines — Stimulating Drinks and Suppers — 
 Use of Emetics in Cuttmg Short the Paroxysm — Alteratives — Alkalies — The Mineral 
 Acids — Quinine — Aconite — Pepsin. 
 
 This is also termed Sympathetic or Sick Headache by some authorities, and 
 I think rightly so, because vomiting often dispels the pain like magic, the 
 source of irritation being so removed. No headache, however, ought to be 
 termed bilious, unless there is so copious a secretion of bile that it either 
 accumulates in the duodenum or regurgitates into the stomach, or the skin is 
 yellow from its absorption into the blood. Dyspeptic headache has its 
 origin in imperfect digestion, and arises either in the stomach or duode- 
 num, from the irritating and disturbing of the nervous apparatus of the 
 alimentary canal by the resulting depraved secretion. Indigestion impresses 
 itself on the sensorium by sympathetic action, and originates pain in it ; but, 
 though this arises in a few persons only, and not in all whose habits are irreg- 
 ular in eating and drinking, it must still be accepted that there is a tendency 
 on the part of the nervous centres in the brain to be so impressed. A morbid 
 impression conveyed through the sympathetic nerve to the brain would 
 excite disturbance, and act as an agent of transmission. 
 
 All the processes of life must be carried on evenly and orderly to insure 
 health. The circulation cannot continue with regularity unless digestion and 
 respiration accord with it ; the one is dependent on the other, and the ner- 
 vous connections of the viscera, if arrested or deranged, propagate the dis- 
 turbing element to the cerebro-spinal system, through the ganglionic nerves. 
 Thus the unity of the whole is apparent through the intimacy of the physi- 
 ological relationships ; and when we consider for a moment how the action 
 of the heart is disturbed in its functions by derangement of the sympathetic 
 system, it shows clearly how inflammatory or other states may originate dis- 
 turbance, and produce painful sensations in a distant organ. 
 
 The facts which are proved concerning the functions of the par vagum do 
 not warrant the drawing of any exact or precise conclusions from them. 
 What we have to say, then, in reference to the part it plays in the digestive 
 process must be to a great extent uncertain and problematical. It consists of 
 a motor and a sensory tract, closely united together at their origin in the 
 brain, the one tract being destined for voluntary, and the other for involun- 
 tary motion and sensation. This gives a wider range of action, and its dis- 
 turbance is manifested by a variety of peculiar sensations, from severe pain 
 on the one hand to exalted sensibility on the other. Excitation of any 
 sensory branch of this compound nerve, after having reached the nervous 
 centre, may be reflected to any part of the periphery, or even to some part in 
 connection with it. So closely, then, is one part of this nerve associated 
 with other parts, that irritation experienced in any single branch may be 
 conveyed along it, and felt in the most distant portion of the nerve's peri- 
 phery. This kind of irritation, set up by some change or alteration in the 
 trunk or periphery of the various sensitive nerves, is analogous to those cases 
 of reflex paralysis mentioned by Dr. Brown-Sequard. Many paralytic affec- 
 
 (50) 
 
DYSPEPTIC OR BILIOUS HEADACHE. 5 I 
 
 tions (and especially paraplegia") are due, not to disease of the spinal cord or 
 its membranes, but simply to reflex irritation, starting from a sensory nerve 
 or its branches, which bave been irritated or excited ; and thus we have cases 
 recorded of paraplegia from the cutting of a molar tooth during the second 
 dentition (West, Kennedy, Brown-Sequard) from enlargement and displace- 
 ment of the uterus, or from ovarian excitement ; in hysterical paraplegia, 
 stricture of the urethra, and intestinal worms. These morbid states must 
 take place through the medium of the nervous system, and not through the 
 general circulation, or the paralysis would extend upwards. A case of pa- 
 ralysis of the lower limbs, due to synovitis, from the extension of irrita- 
 tion in the left knee-joint, is described by Brown-Sequard.* Now, all these 
 cases are caused by the excitation of an afferent nerve, and the reflex paraly- 
 sis continues so long as the excitation persists. The morbid effect on the 
 muscles is of a transient character, unlike the spasms, twitching, and anaes- 
 thesia which accompany the paraplegia of myelitis, where all parts are in- 
 volved, and the tendency of the disease is towards a fatal termination. Mr. 
 Hilton has also recorded the case of a boy who was lame in his right leg, 
 and could neither put it to the ground nor control its movements, yet the 
 real pathological cause was seated in the brain, and not in the limb; the 
 paralysis, in fact, being nothing more or less than a sympathetic disorder 
 occasioned by the febrile state. Mr. Hilton has also shown how the exact 
 seat of disease in the hip-joint may be indicated by the spot on the knee 
 where the pain is experienced. 
 
 The pneumogastric is no exception to this rule, and irritation in the stom- 
 ach will often occasion a cough — the well-known stomach cough. Sir 
 Thomas Watson relates the case of an epileptic, whose fits ceased with the 
 expulsion of a tape-worm. "I know that a physician of my acquaintance 
 cured a case of epilepsy in this way, somewhat to his own surprise. Without 
 having in his mind any notion of worms, he thought it might be well to purge 
 his patient, who had labored under epilepsy for some time, with the oleum 
 terebinth in se. The patient, who is the brother of a person holding at 
 present a high office in this country, was residing two or three miles out 
 of town. In the middle of the night the doctor was summoned to him in 
 a great hurry ; the messenger said he was supposed to be dying. He was 
 only intoxicated, however, by the free dose of turpentine that he had swal- 
 lowed. The next morning he voided into the close-stool a large tape-worm, 
 and he has hever had epilepsy since. A nobleman residing in Cambridge- 
 shire was long epileptic, and he too got rid of his epilepsy and of a worm at 
 the same time."f Irritation, then, at a portion of the periphery of the 
 pneumogastric may produce either centric or peripheral manifestations. 
 The headache of dyspepsia thus becomes intelligible. Seeing that the nerves 
 of the stomach are derived from the pneumogastric and the sympathetic, we 
 are in a position to understand the immense influence they must exert on the 
 secretions of the viscus. The branches of the pneumogastric, after perforat- 
 ing the muscular coat, ramify in the submucous areolar tissue, until they are 
 lost under the surface of the mucous membrane. " Each unites, not only 
 with large and small branches of its fellow, but with the sympathetic nerves 
 of the stomach, at all stages of their distribution visible to the naked eye — 
 from the solar plexus and semilunar ganglia to the secondary and tertiary 
 offshoots of those around the vessels, and even to their branches in the areolar 
 
 * Paralysis of the Lower Extremities, by C. E. Brown-Sequard, M. D., F. R. S., iS6i, 
 page 1 8. 
 
 f Principles and Practice of Physic (4th edition), vol. i., page 663. 
 
52 HEADACHES. 
 
 coat of the stomach. ' ' * The distribution of the sympathetic branches is much 
 the same, and, after perforating the muscular coat, the plexuses disappear in 
 the submucous tissue, like the gastric branches of the par vagum. The pneumo- 
 gastric gives off branches which have been traced into the plexus mesentericus, 
 and so brought in contact with the intestines. Any irritation, then, of the 
 stomach and intestines may produce headache by sympathetic disturbance. 
 
 The influence which the pneumogastric nerve exerts on the action and se- 
 cretions of the stomach is both interesting and important, and the subject 
 may well be considere'd in this place. The extensive distribution of the par 
 vagum, and its intimate connection with the sympathetic system, gives it a 
 wide and diversified action ; it changes local into general influences, and 
 possesses relations which involve distant organs in excitement and morbid 
 change. The pneumogastric nerve, both physiologically 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 communication 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 secretion 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, alcohol, wine and spirits, mustard, and a 
 host of other excitants, 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 cause the gastric vessels to dilate, and the mucous 
 membrane to become reddened, whilst Bernard found that section of the 
 vagi'caused pallor of the surface ; but it would appear " that the vagus con- 
 tains two sets of afferent fibres, one of which increases, whilst the other 
 dmiinishes, the degree of contraction of the gastric vessels, "f 
 
 The close connection of the par vagum with the sympathetic nerve of the 
 abdomen, uterus, and ovary, induces reflex irritation in the stomach, which 
 is so commonly observed in affections of these organs — as dysmenorrhcea, 
 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 spas- 
 modic action, retarded motion of the heart, or congestion or inflammation. 
 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 fthe 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 
 
 *Brinton on Diseases of the Stomach, 1864, p. 24. 
 
 f See The Action of the Vagus on the Stomach, by Dr. Lauder Brunton, in Handbook 
 for the Physiological Laboratory (Text 1873), page 493. 
 
DYSPEPTIC OR BILIOUS HEADACHE. 53 
 
 that state of irritability and supraorbital pain which we have seen to follow 
 the introduction of ice into the stomach.* 
 
 The alliance of the par vagum with the ganglionic supply to the stomach 
 enables us to judge of their continued effects upon the pulse and cardiac cir- 
 culation ; 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 and abdominal viscera produce their full 
 share in prostrating the vital powers, rendering the pulse imperceptible, 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 digestion fails, the nerve-power will frequently be found at fault. If the 
 strength of the constitution has been reduced from prolonged indulgence 
 in alcoholic stimulants, the nervous energy is the more exhausted, and as the 
 patient cannot assimilate sufficient food to keep the functions of life going 
 steadily, the way is paved for chronic dyspepsia and degenerative changes. 
 
 The secretion of gastric juice is affected by the state of the nervous sys- 
 tem, and sudden mental emotion is able to stop it altogether. The channel 
 by which this is conveyed clears up any doubt or mystery attaching ^to the 
 phenomena ; for the division of the trunk of the pneumogastric controls the 
 secretion of gastric juice and the movements of the stoinach. Though the 
 experiments of physiologists like Reid, Schiff, Budge, Longet, Bernard, 
 Ravitsch, etc., show that the stomach gradually recovers its lost tone after 
 division of the par vagum, the functions 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 con- 
 tinued disorder of one or other, or of both these nerves, apart from any ex- 
 perimental deduction, proves, I think, to demonstration, that when pain is 
 suddenly experienced at the pit of the stomach from the reception of bad 
 news, they are so affected as to exert a most important influence on the di- 
 gestive 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 oeso- 
 phageal opening or of the splanchnics in the abdomen of the lower animals 
 without palpable and permanent effect on the digestive powers, justifies us in 
 setting at naught the agency of the nervous system in man, and still more the 
 importance 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 
 
 *See Chaper III, on Sympathetic Headache. 
 
54 HEADACHES. 
 
 alleviation has departed, he suddenly and unexpectedly falls asleep, and 
 awakes next morning 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 digest it. After the 
 long continuance of severe gastric headaches, the vascular excitement gives 
 place to ner\'0us exhaustion, and as they become more frequent, the nervous 
 element preponderates, so that with the advance of years the bilious character 
 and the vomiting are exchanged for the type of headache which we shall 
 presently describe. But one form of headache during its continuance may 
 partake of the character of several types. That which begins as a purely 
 bilious may end as a nervous headache, and that which begms 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 
 accumulation 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, inasmuch as some persons of the most 
 irregular habits, with defective depurative organs, never have the sensation 
 of a headache. I once knew a gentleman who Avas 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 character 
 of the evacuations, high-colored urine, and foul tougue : 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 persons 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 stim- 
 ulating drinks, are common causes of this headache. A glass of beer, or a 
 teaspoonful 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. Sup- 
 pers, if persons are not accustomed to them, will cause disturbed sleep, fol- 
 lowed 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 indigestible food. Un- 
 wholesome food, which temporarily disturbs or arrests digestion, will occa- 
 sion acute dyspepsia in some persons, and such persons are extremely prone 
 to this form of headache ; uneasiness at the stomach, faintness, depression of 
 spirits, lassitude, and febrile excitement, are to be reckoned among the pro- 
 dromata. Then succeeds an oppressive frontal headache, with nausea and 
 inability to face the light, or bear the slightest noise. In some persons vom- 
 iting ensues, and the patient finds immediate 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 praecordia, dis- 
 like of food, high-colored urine, offensive 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 reflection. This headache may come on in a few hours after food, or 
 the patient may go to bed comfortably, and either have disturbed and rest- 
 
DYSPEPTIC OR BILIOUS HEADACHE. 55 
 
 less sleep, or wake up unrefreshed with a weight across the forehead, and 
 forthwith 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 apply- 
 ing 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 diges- 
 tions are weakened by sedentary employment, and who have a tendency to cos- 
 tiveness. It occurs, however, also in persons 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."* 
 
 Treat^nent. — In early life, when this headache is threatening, it can al- 
 ways be traced to some error in diet, and an emetic of sulphate of zinc or 
 ipecacuanha brings relief 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 alterative 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 excite 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 symptoms 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 indicated 
 (Form. 77-78). In some varieties of dyspeptic headache, Dr. Smith gives 
 one minim of the tincture of nux vomica every fifteen minutes for two or 
 three hours, and he has found it most effectual. Where the extremities 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 dilating the vessels and favoring perspiration it has wonderfully relieved 
 the aching brain. If the headache comes on soon after a meal from slow- 
 ness of digestion. Dr. Smith gives half a drachm of saccharated pepsin in a 
 wineglassful of sherry three times a day at meal-times. f I have given 
 Morson's pepsin wine with great advantage at meals, and it certainly 
 accelerates digestion and relieves nausea and gastric oppression. 
 
 * 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. 
 
 f The Therapeutics of Headache, by A. A. Smith, M. D. A Lecture deUvered at tlie 
 Bellevue Hospital Medical College, in Medical Record, September 15th, 1876, p. 390. 
 
CHAPTER V. 
 
 CONGESTIVE HEADACHE. 
 
 Physiological Distinctions between Congestion and H}-per8emia — 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 
 — Bronchits — Asthma^ — ^Yhooping- cough — Tight Stays and whatever impedes the Circula- 
 lation — Treatment consists in lessening the supply of Blood to the Brain when in excess, 
 and promoting its circulation through the Vessel when their Tonicity is impaired — Purga- 
 tives — Saline Waters — Occasional Advantage of Venesection — Spare Diet and Avoidance 
 of Stimulants in the Active Form — Counter-irritation — Walking Exercise — Change of Air 
 — Foreign Watering-places — Aconite — Bromides of Potassium and Ammonium — Strych- 
 nia — Nux Vomica — Mild Preparations of Iron in Ansemic Cases. 
 
 In the active variety this can scarcely be separated from the headache of 
 active hyperemia. It overlaps each of the other forms, active and passive 
 hypersemia ; 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 modification 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 tempera- 
 ture is higher, and the pulse quicker and stronger. The patient feels 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 increasing 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 hypersemia that does 
 not lead to inflammation. The sensibility is heightened in proportion to the 
 increased supply of blood. 
 
 Congestive headache occurs most frequently in plethoric persons, and 
 those of 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 aff"ection. In its true signification it is a passive congestive form of 
 headache, depending 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 be- 
 comes bloated, the eyes heavy, and the conjunctivae 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 suffeiing is rather limited 
 than general, and is sometimes referred to a particular part of the head, 
 which indicates congestion of one lobe or hemisphere of the brain ; the pa- 
 tient is apathetic and indifferent, and suffers from giddiness and noises in 
 the ears. If he stoop or turn round quicklv, he experiences the disagreeable 
 
 (56) 
 
CONGESTIVE HEADACHE. 57 
 
 sensation 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 symptoms are of common occurrence, and the nights are 
 restless and disturbed by frightful dreams. If the pain continues long, and 
 does not yield to treatment, the patient 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 torpid 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 head- 
 ache, during which the heart's action is violent, and the carotid and tem- 
 poral arteries throb ; but if congestion of the vessels of the brain exist, pain 
 comes on in paroxysms, from sudden noise or exertion, and is transitory in 
 its duration. An oversensitive condition of the nerves, by causing a hyper- 
 semic state of the vessels of the brain, analogous to the distension of the cap- 
 illaries in blushing, may induce it. 
 
 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 headache the circulation 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 inflamma- 
 tory lesion. Headache 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 conges- 
 tion can find "no other explanation. Now, this congestion seems to be borne 
 longer with impunity 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 altered (though it escapes injury), chiefly 
 through functional disturbance of the nerves themselves, which may or may 
 not produce an alteration in the vessels. The nerves in the form of head- 
 ache are first involved, and any mental excitement will cause their disturb- 
 ance; and as the bloodvessels are in close and intimate relation with them, 
 the capillary circulation quickly responds, and produces a state of hypersemia. 
 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 over- 
 loaded 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 circula 
 4 
 
58 HEADACHES. 
 
 tion, 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 con- 
 figuration 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 
 general redness of the skin and lips. The patient experiences 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 
 un frequently seen in young healthy womeix, whose catamenial losses have 
 been suddenly suppressed 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 wonien 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 instruments requiring prolonged ex;piratory 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 circulation. 
 
 Organic change may induce it, by disturbing the relations of the structures 
 of the brain, and causing congestion and interference with the circulation. 
 Congestive headache of a passive character is exemplified in hypertrophy 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 impossible to dissociate congestion of the vessels from any 
 form of headache in some stage of its progress. The purely nervous head- 
 ache in many persons, at its commencement, or shortly after, exhibits signs 
 of congestion in the frequency and fulness of the pulse, the warmth of 
 surface, the heat of the head and scalp, the tendency to vomit, in constipa- 
 tion, 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 
 
 * See Chapter VI., on Plethoric Headache. 
 
CONGESTIVE HEADACHE. 59 
 
 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 congestive headache. 
 The headache which happens to the intemperate and those addicted to 
 irregular habits is of the congestive and hypersemic 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 liver also, these latter organs being 
 first in fault. A hypersemic condition of the arteries of the brain, arising 
 from a diminution in the tonicity of the vessels, and causing severe head- 
 ache, is not uncommon in those persons who exhaust the brain by prolonged 
 study, and excessive 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 character 
 which they have not previously shown, and difficulty 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 uncomfortable 
 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 
 characterized 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 srruggles of professional life, hopes disappointed and plans 
 frustrated, will induce a state of congestion or hypersemia 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 vesicular 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 local as well as 
 the constitutional symptoms must be carefully 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 consideration, before we 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 exceedingly well in these cases. 
 
 The diet should be spare, and beer and spirits abandoned. 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 pre 
 ferable 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 young 
 
60 HEADACHES. 
 
 plethoric women I have known leeching the temples or groin prove advan- 
 tageous. There are instances occasionally to be met with, however, where 
 the patient is indolent and overfed, besides being too full o^ 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 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 bene- 
 fit was derived from an open blister at the back of the neck ; but no meas- 
 ures 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 
 paral)^zing the vasomotor system (Form. 26 a). Aconite depresses the 
 heart's action, and by reducing arterial excitement, and diminishing pres- 
 sure and tension in the vessels, it controls the amount of blood which circu- 
 lates 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 produc- 
 ing 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 traveling and the quiet amusements of the seaside. 
 Foreign watering places where the air is pure and 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 toorning light, and steady his nervous 
 system in a remarkable way. In the case of a gentleman who suffers period- 
 ically from a subacute 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 ammonia and lavender, 
 maybe 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 anemic 
 (Form. 22-24), but they must be cautiously given in the intervals between 
 the attacks, and the functions of digestion and assimilation should always 
 claim a large share of attention during their administration. 
 
CHAPTER VI. 
 
 HEADACHE FROM PLETHORA AND INCREASED VASCULAR ACTION. 
 
 Characters and Composition of the Blood in Plethoric States of the Constitution — Predispos- 
 ing and Exciting Causes — Variability of the Symptoms according as the Disorder is of a 
 Sthenic or Asthenic Type — Prevalence of the Headache at the Catamenial Periods and 
 during Pregnancy. 
 
 Treatment — Natural Cure by Spontaneous Hsemorrhage from the Bowels, Nose or Uterus — 
 Occasional Necessity for Venesection and Cupping or Leeching in Active Plethora — 
 Saline Aperients to Excite the Eliminative 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 sys- 
 tem, 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 con- 
 dition is essentially dependent on the cerebral vessels partaking of the gen- 
 eral fulness, and is not due to the determination of blood towards the head 
 in particular. The redundancy of blood in the brain excites 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, 
 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 exercise, and mental lethargy. Among 
 the exciting causes may be enumerated any circumstances that determine 
 blood to the brain and internal organs. The suppressson of any accustomed 
 discharge, as epistaxis or hsemorrhoids, 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 re- 
 lieved her came on.f There had been for some days previously singing in 
 the ears, and a throbbing and 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 
 
 * It is important to remember that the blood in plethora is different in its composition from 
 what it is even in active hyperjemia. 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 dimished from arterialization (Jones & Sieveking'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 coagulum is softer, be- 
 cause 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 consti- 
 tution ; but they are liable to congestion, especially of the brain, and to apoplexy or other 
 haemorrhage." — Carpenter' s Human Physiology, by Power, 8th edition, p. 264. 
 
 (61) 
 
62 HEADACHES. 
 
 overcrowded rooms and public assemblies, will excite this headache, if there 
 be a predisposition 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 
 instinctively 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 countenance 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 attempt 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 asthentic 
 type, the pulse is small and hard; and in some it is weak and scarcely dis- 
 cernible or intermittent, 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 ventricle 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 
 specific gravity, sometimes excessive, and at others containing a copious de- 
 posit of pink lithates and cayenne pepper crystals of uric acid. They eat 
 and drink immoderately, and fall into a heavy sleep after meals. The bow- 
 els 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 accumulates 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 exertion causes a rush of blood to the head, and heaviness 
 of breathing, with oppression about the praecordia, or labored action of the 
 heart. If a smart attack of diarrhoea supervene, the pain is partially re- 
 lieved ; but free hccmorrhage 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 severe at the catamenial 
 periods, when the secretion is suppressed, or during pregnancy ; they are not 
 always persistent, but occasional, and are excited by irritability of the 
 digestive organs and deficiency in the powers of assimilation. 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 accumulates in the capillary 
 vessels. 
 
 Treatment. — Nature endeavors to promote a cure by the occurrence of 
 haemorrhage from the bowels, nose, or uterus, and we must act upon this 
 hint if we would effectually 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 arterial tension and restored the functions of the sluggish organs. 
 But there are many persons (particularly women) who could not bear vene- 
 
HEADACHE FROM PLETHORA AND INCREASED VASCULAR ACTION. 63 
 
 section, 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 plethora; it is the accompaniment 
 of other forms of headache, and must not be sought for alone and unmixed 
 in all cases. Where, then, general bleeding is inadmissible, cupping at the 
 back of the neck, or a few leeches to the anus and peringeum, may be 
 resorted to. Saline aperients and those remedies that determine the force of 
 the circulation to the eliminative organs, must also be employed (Form. 18 
 -19-60-80). No relief can be obtained unless stimulating food and intoxi- 
 cating 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 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 regulate 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 consumption 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 re- 
 cumbent position encourages determination of blood to the head and con- 
 gestion of the vessels. The meals should be light, that sleep may not after- 
 wards ensue. Moderate and regular exercise should be taken in the open air, 
 and the mind kept as free from disturbance 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., Philadelphia, Blakiston. 
 
CHAPTER Vn. 
 
 NERVOUS HEADACHE. 
 
 Common to all Classes of Society, but more particularly to persons of Nervous Tempera- 
 ment and Delicate Organization — Pathology' of the AfTection — Probably dependent on 
 Ansemia and some peculiar Change in the Cerebral Tissue — Nerve Storms and supposed 
 Influence of Miasmatic Poisoning— Variation in the Seat of Pain and Mode of Com- 
 mencement and Teraiination — Want of Sleep, and Disturbance of the Mind — Disturb- 
 ance of Vision — Cases of Sir C. \'\Tieatstone and Sir J. Herschel — Distribution and 
 Functions of the Vasomotor Nerves — Cases in Illustration of Nen-ous Headache — Hered- 
 itary Tendencies — Peculiar Combination of Mental and Psychological Symptoms — Origin 
 of the Pain in Nervous Headache — Effects of Nervous Headache on the Moral Disposi- 
 tion — Falling oft 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 Zvledicine — Bromides of Potassium and Ammonium 
 — Guarana — Value of Hypodermic Injecdon, and Importance of Caution in employing it 
 — Ferruginous Tonics, and Strychnine, and Cod-liver Oil. 
 
 This variety of headache is not confined to any particular class of society, 
 but it is of most frequent occurrence in persons of nervous temperament 
 and delicate organization. No temperament can, however, claim exemption 
 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. 
 They feel it approaching as a certainty from which there is no escape, and 
 so placidly resign themselves to its torture. It is, to a certain extent, the 
 headache of ansemia, and yet not entirely so, because many persons are af- 
 fected with it whose blood is neither diminished nor impoverished, and 
 whose muscular development and robust appearance indicate the soundest 
 health. Amongst its victims it selects persons of high culture and vivid 
 imagination, and if at the same time they are deprived of their full allow- 
 ance 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 physical 
 state that a nervous headache originates ; for when the circulation is ener- 
 getic, 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 inclines toward a ner- 
 vous origin — to a morbid change in the nervous centres ; and this view can- 
 not be readily dismissed until the discoveries of experimental physiology are 
 proved to be inconclusive or erroneous. It is infinitely less probable that 
 the cerebral blood-supply should initiate the disturbance, whatever share it 
 may subsequently have in producing the pain. But clothe the arguments as 
 we may to support this or that opinion, reproduce 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 in- 
 dubitable may be far distant from ultimate truth. 
 
 Nervous headache comes on sometimes Avhen a patient dwells persistently 
 on anything unpleasant, or is unable to remove his thoughts from it ; when 
 be cannot be cheerful in repose, or see the faintest sunshine in the future. 
 This tries the brain, and disarranges the circulation within it ; for " the fact 
 
 (64) 
 
NERVOUS HEADACHE. 65 
 
 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 possi- 
 ible, to define the terms of the alliance." * 
 
 Persons know when this form of headache is threatening, 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 tnnes 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 perma- 
 nent 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,t for 
 it comes and goes suddenly, often when least expected, and without warn- 
 ing. But this is the character of nervous disorders generally, as facial neu- 
 ralgia, epilepsy, laryngismus stridulus, gastrodynia, angina pectoris, etc. 
 Dr. Edward Liveingt gives them the name of "nerve storms." As we 
 shall presently see, this type of headache is among the most hereditary of 
 diseases. 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 consciously or uncon- 
 sciously, 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 followed 
 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 exhaustion, fatigue, and losses of blood ; but more commonly to worry 
 and anxiety; in others, no cause can be assigned — it comes and goes with- . 
 out any satisfactory reason, and lays the robust and square-shouldered man 
 as prostrate as the overdrained sickly woman. In employing the term 
 " nerve storms," Dr. Liveing implies that there is an accumulation of ner- 
 vous 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 pre- 
 
 *Mind and Body, by Alexander Bain, L.L. D., 1873, p. 80. 
 
 f Remarks on some of the Paroxysmal Neuroses, Guy's Hospital Reports, vol. xxi., 
 1876, p. 376. 
 
 J " On this theory, then, the fundamental cause of all neuroses is to be found, not in any 
 irritation of the viscercal or cutaneous peripherj^, nor in any disorder or in-egularit}' of the 
 circulation, but in a primary and often hereditary vice or morbid disposition of the nervous 
 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 concentration 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 ner- 
 vous system more immediately concerned, while the paroxysm itself may be likened to a 
 storm, by which this condition is depressed, and equlibrium for the time restored." — On 
 Megrim and Sick Headache, 1873, V- 33^- 
 
^6 HEADACHES. 
 
 cede the outbreak. The period may vary from a few hours to many days. 
 In some confirmed suiferers I have repeatedly witnessed a series of symp- 
 toms Avhich have cuhninated 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 cere- 
 bral circulation 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 sug- 
 gested itself to my belief, for nervous headache is more common to residents 
 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 mischief. 
 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 unfre- 
 quently seizes upon one temple, or one eye, or one-half of the head, and 
 thus resembles the headache of neuralgia. A married lady, set. 30, consult- 
 ed me in May, 1876, for a nervous headache, 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 day, 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 plentifully that it became inflamed and sore, while the pain ex- 
 tended down the left side of the nose; also light and sound became intoler- 
 able 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 sometimes relieved the 
 pain, and at other times increased it. When 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 eructa- 
 tion. 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 persons, the passing of a large quantity of limpid 
 urine maybe the forerunner of an attack. In others, again, there is extreme 
 irritability and disquietude ; the patient cannot 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 exhausted and overcome. This headache is 
 most frequent among women who are approaching the middle period of life, 
 
NERVOUS HEADACHE. 6/ 
 
 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 
 occurrence. Oversuckling, menorrhagia, and profuse leucorrhoea are also 
 causes; dysmenorrhcfea, and even ordinary menstruation, will bring it on in 
 some persons. As regards 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 period, when the quantity of loss can- 
 not explain the occurrence 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 
 action ; 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, although they may have escaped it for many years of their 
 life, are persons whose constitution is originally weak. I have known per- 
 sons to reach the age of thirty-five before getting an attack, and then, cir- 
 cumstances 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 ansemic 
 girl, and the half-starved seamstress- — all are victims of this terrible form of 
 headache. Those who dwell in the fashionable world, and keep late hours, 
 are particularly subject to it ; for hot rooms, evening parties, and imperfect 
 ventilation are always likely to produce it. 
 
 But, in addition to the activity of the mind and the emotional sensibility 
 which are common to the sufferers of nervous headache, there is a state of 
 the bodily constitution which renders people liable to it. In a lowered con- 
 dition of the general health almost any cause will induce an attack. Pro- 
 longed study, the mind being kept bent on the accomplishment of a task in 
 a given time, pondering over figures that require much mathematical calcu- 
 lation, the jarring of vehicles over bad roads, the alarm and timidity at driv- 
 ing along crowded thoroughfares, and disagreeable 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 irritation, especially 
 in cases of meningeal mischief; consequently we find that darkened rooms 
 and absolute silence are excellent palliative measures. Moreover, depraved 
 secretions in the alimentary canal, or any morbid impression on the gastric 
 nerves, will bring it on. 
 
 Difficult as it is to fix upon exciting causes, we can hardly escape the con- 
 viction that derangement in the chylopoietic viscera has an important bear- 
 ing in the causation of the malady. The interruption to the process of 
 digestion caused by traveling on a full stomach invariably brings on a head- 
 ache with some persons. I have met with several cases, and one in particular, 
 where a gentleman alwa3^s suffers from headache if he goes a journey shortly 
 after taking food. There are persons of similar nervous organization, who 
 experience a sharp attack of diarrhoea at the prospect of traveling by rail, 
 or going a sea voyage. 
 
 *See Cliapter III., on Sympathetic Headaclie. 
 
68 HEADACHES. 
 
 Disturbance in the electrical states of the atmosphere will excite an attack 
 of nervous headache in some persons. By these persons the approach of a 
 thunderstorm can be calculated with an absolute certainty from the feeling 
 of weight over the forehead and a severe headache. ' Long before thunder 
 is heard, or the patient has any conception that a storm is coming on, he is 
 heavy and oppressed, 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 dryness in 
 the mouth. Abstinence from food and continuous 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 objects, and a misty or clouded appearance before the eyes, 
 or 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 Herschel, and other eminent 
 men, describe their own experience 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 fortification, with angles, bastions, 
 and ravelins, and faint lines of color between the dark lines, and the im- 
 pression was the same whether the eyes were closed or open. It lasted a 
 minute or two, and spread over the whole visual 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 of the cases, during this glimmering stage, there is 
 tingling in 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 aff'ected. "^ 
 The persons who suffer from ocular disturbance are, in my experience, most 
 frequently women of nervous temperament, who have active brains, and are 
 energetic and restless. They are often ansemic and subject to chronic 
 debility. Fatigue of all kinds and overexcitement will lead to it, and all 
 drains, leucorrhoea 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 contraction and 
 dilatation of the bloodvessels of the brain ; and we have seen that when the 
 cervical sympathetic was divided, there was an afflux of blood and a 
 dilatation of the vessels. When the vessels of the brain are contracted, the 
 supply of blood is diminished ; when they are dilated the quantity is in- 
 creased j and this is an explanation of the headache that results after the 
 
 *Dr. Latham, on Nervous or Sick Headache, p. 10. 
 
NERVOUS HEADACHE. 69 
 
 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— ^rst, 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 premature births, all in the course of seven years. After this 
 she had great and frequent catamenial losses, which compelled her to keep 
 her bed or to remain in a recumbent posture for days together. The head- 
 aches 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 con- 
 tracted, 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 ap- 
 peared 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 invariably 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 hypodermic injection of 
 
 *"That tliere is a vasomotor centre, and tliat 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 Owsjannikow, who have found by experiments that 
 it is limited towards the spinal cord by a line four or five millimeters above the calamus 
 scripto7-ms, and extends towards the brain to within a millimeter of the corpora qiiadrige- 
 mina. 
 
 " 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 centi'e were not constant, division could not produce arterial re- 
 laxation. In relation to this constancy of action, the word lomcs is used. Arterial tonus 
 means that degree of contraction of an artery which is constant and normal. It is main- 
 tained only so long as the artery is in communication with the vasomotor centre." — Hand- 
 book for the Physiological Laboratory, " Functions of Vasomotor Nerves," by Dr. Burdon- 
 Sanderson, Philadelphia, Blakiston. 
 
70 HEADACHES. 
 
 morphia was tried ; and then, after days of maddening pain, the patient 
 would turn aound 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 suf- 
 fered 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 conversation, 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 irrita- 
 ble 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 subside 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 outwards or inwards, caused acute suffering. 
 There was also frequent neuralgia of the right and left brow, and she had 
 great difficulty in reading, her sight seeming to go for a time when she made 
 the effort, the letters appearing clouded and misshapen. The light was so 
 trying to the e3'es 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 staying 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 diges- 
 tive powers to assimilate iron and arsenic (Form. 24 /5) and a glass of port 
 wine at her midday meal. She was also able to take brandy and egg mix- 
 ture, and a full dose of quinine when an attack ofhemicrania 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 ansemia of the tissues. 
 
 Note. — October, 1877. On returning to home duties, severe paroxysm 
 came on, and after three days of increasing agony and confinement to bed 
 without a monient's respite from pain, she suddenly became collapsed and 
 pulseless, with cold extremities, and her condition for a few manutes was 
 very alarming. She was unable to swallow for some time, till external 
 warmth and friction had restored her faltering circulation, and then the 
 effort was accomplished with the greatest difficulty, owing to a sense of suffo- 
 cation which the attempt excited. From 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 tem.ple, or both temples, and finally settling into 
 what she describes as "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 con- 
 tracted 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), followed soon afterwards by a glass of champagne, or brandy in soda- 
 water, has sometimes been found to shorten the attack, if given early enough; 
 
NERVOUS HEADACHE. 7 1 
 
 but more often the suffering has been prolonged over two days, notwith- 
 standing 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 indigestion, worry of mind, fatigue, excitement, and cold winds. 
 
 C. D., set. 40, m. ; three children, one miscarriage, active and energetic 
 temperament. When she first consulted 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 dur- 
 ing the flow of the catamenia; especially if she took extra exertion, or was 
 in any way excited. The patient had suffered from neuralgia of the face 
 for many years, but these attacks seldom recurred now. When these head- 
 aches were coming on, small things would worry and annoy her ; she could 
 not sleep, but would light a candle and read. They did not come on sud- 
 denly, 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 dysmenorrhoea. First, a 
 general sense of discomfort and confusion in the head was felt, trifles assum- 
 ing 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 affected, 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 headaches abated, sleep generally ensued for a considerable num- 
 ber of hours; and, on waking, the pain was gone, though the head was sore 
 and weak. If the attack Avas very acute, five or six days would elapse before 
 she recovered her usual strength. Formerly, when the headaches 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 addition to the 
 headache, when she first consulted me, there was great uterine loss and re- 
 laxation 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 con- 
 sisted in all possible rest, mental and physical, particularly at the menstrual 
 periods. A preparation 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 symptoms of relaxation had improved, and bromide of ammonium 
 
 * All states of nervous exhaustion, whether brought on by inordinate indulgence in drink, 
 or by the ordinary avocations of life, are capable of giving rise to subjective sensations of 
 the strangest character. They may be described as hallucinations — phantoms of the unreal 
 and imaginary. I have met with some sufferers from headache who, in their suspended 
 moments of agony, have told me that they have no power to give the aching brain rest. As 
 the pain lulled, the functions of the brain became unduly active, and the mind busy with 
 the miraculous ; tortured with the fear of death, or the dread of committing suicide. Emo- 
 tional excitement, and real or imaginary wrongs, will take possession of the sufferer, and he 
 can no more command himself and shake off the supernatural belief, than he can bid the 
 throbbing brain be still. This is the outcome partly of a disturbed circulation, 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. 
 
72 
 
 HEADACHES. 
 
 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- 
 mained in bed for days together in a darkened room, unable to eat a morsel 
 of food or to retain a drop of anything 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 now not only entirely free, but her activity and powers of en- 
 durance may well be envied by persons who are half her age. 
 
 The following is another example of nervous headache ; and it presents an 
 assemblage of symptoms, which prove unsteadiness in the brain-centre, and 
 a hypersemic 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 
 consequences and the train of symptoms are much the same in both in- 
 stances. And I must here insist on the fact that the true congestive head- 
 ache has features in common 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, fo"^ headache, to which he had been subject since i860. 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 essential 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 insensibility. 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 dyspepsia, 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 sensation of stuffiness and throbbing. Sometimes 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, rendering the muscles of 
 the neck stiff and painful to move from a fixed position. The headaches 
 were sometimes attended with nausea, and sometimes preceded by dizziness. 
 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, he was frantic and 
 
NERVOUS HEADACHE. 73 
 
 uncontrollable. In this respect he resembled his child, who also suffered 
 from a similar form of headache. When he was overtaken with these head- 
 aches he could not keep still or lie down, 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 dul- 
 ness and inactivity, and if he exerted himself it would return. 
 
 I ascertained in May, 1876, that this patient's headaches were less acute, 
 less frequent, and less inevitable than formerly, and that there was less per- 
 versity 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 treatment unless the occupation and habits of 
 life can be entirely changed. 
 
 S. B. T., set. 43, m., consulted me May 31st, 1877. Has served twenty- 
 seven years as an officer in the Indian army, and during this time experi- 
 enced good health except on two occasions. The patient was thin and 
 spare, of energetic habits, and nervous temperament. 
 
 In 1857 he had severe malarious fever, which compelled 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 expedi- 
 tion 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 recovered. 
 
 In 1872 he was subjected to severe mental distress, and about this time 
 continuous (as distinct from occasional^ 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, varying 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 distracting, 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 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 feeling 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. 
 
74 HEADACHES, 
 
 " But by degrees the periods of freedom from discomfort 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 growing better, but on 
 the whole worse, he was obliged to return 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 undulating pulsation. 
 
 There is often pain immediately over the eyebrows, great soreness of the 
 eyes, and unwillingness to face the 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 remain 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. Notwithstanding 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 improve- 
 ment than anything else. 
 
 " For the first eight months after returning from India, sleep Avas 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 i-est is the exception, and any feeling of wake- 
 fulness 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 sixteen days, and some- 
 times there is a feeling of weakness and pain in the limbs. On returning 
 from India I was examined, and the splee?i was found to be tender on pres- 
 sure, but the liver was free from disease. Took podophyllin, 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, with- 
 out 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 sin- 
 gularly free from them, being able to sav that he has never had a headache in 
 his life." 
 
 He has been constantly moving about to Scotland, to Wales, Folkstone, 
 
NERVOUS HEADACHE. 75 
 
 and Cornwall, without deriving benefit. Cannot ascertain v/hat 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 exhaustion, and a most 
 languid circulation. Arsenic, iron, and calumba were prescribed twice a 
 day (Form. 24 b) and bromide of ammonium on rising in the morning 
 (Form. 25). The diet was ordered to be plain and simple, stimulants to be 
 avoided, and no tea. 
 
 June 19th. He writes : " I think that, on the whole, 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 dullness still remain constant." 
 
 To continue cod-liver oil, or malt extract, and Carlowitz or claret. 
 
 From this 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 whist 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 quinine 
 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 sen- 
 sory tract. I must refer the reader to the different opinions held by Dr. 
 Broadbent, Dr. Ferrier, Dr. Bastian, and Dr. Crichton Browne.* The lat- 
 ter 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 distributed mostly to the sensory regions of the cerebrum. These 
 
 *Dr. Crichton Browne's paper on the Functions of the Thalarni Optici, in the West Rid- 
 ing Lunatic Asylum Medical Reports, 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 accom- 
 pany the arteries, whilst it manifests itself in the dilatation of these vessels, and in the com- 
 pression of the brain and other organs it produces. The treatment 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 gi'ain 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 Medirine, December, 1876.) — Quoted from the Practitiotier, 
 March, 1877, p. 197. 
 
^6 HEADACHES. 
 
 facts surely suggest the intimate association of tlie corpus striatum with 
 . motor, and of the optic thalamus with sensory functions." 
 
 In some few instances I have know the hair to fall off from continued ner- 
 vous headache, and when this happens the scalp becomes the seat of great 
 irritation, with troublesome pityriasis. Both Cazenave and Neligan have 
 observed the same.* Two cases are in my recollection where the scalp be- 
 came the seat of so much irritation that the patient could not summon up 
 sufficient fortitude to resist scratching her head incessantly. The itching, 
 tingling, and the abundant desquamation of white-brownish scales, are in- 
 variably increased after each paroxysm of headache. I have so often noticed 
 the co-existence of dandruff 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 con- 
 cerned, and the most frequent cases in my experience have been in women 
 about the middle period of life, who have suffered from catamenial disturb- 
 ance. 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. When 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 import- 
 ant to disting-uish the disease from eczema, which may generally be done 
 without difficult)^ ; true pityriasis being characterized by an absence of ex- 
 udation and albuniinous secretion. A weak ointment of nitric oxide of mer- 
 cury is an excellent application (Form. 114 a). 
 
 Another curious affection of the skin is sometimes observable 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 Palpebraj-um. " The patholog- 
 ical nature of this affection is an hypertrophy and altered color of the epithe- 
 lium of the sebiparous gland and of its execretory tubuli." f 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 canthus. They are variable in color, some- 
 times being of an orange or lemon tint, but that of chamois leather, or 
 nankeen, is a good resemblance. They are smooth and soft, and look like 
 caseous matter immediately beneath the skin. The patches are not attended 
 with pain or irritation, and they never ulcerate nor suppurate. 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. t 
 
 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; ab- 
 solute and binding rules are useless. A method of treatment which has an- 
 swered our expectations in one case is futile and barren of results in the 
 
 * 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. 
 
 J Diseases of the Skin, by Erasmus Wilson, F. R. S., 1S63, p. 619. 
 J Op. cit., 1863, p. 620. 
 
NERVOUS HEADACHE. 7/ 
 
 next ; the misery 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 expenditure, and sleep has readjusted the 
 tremulous circulation within the head. If we can induce the patient to alter 
 the habits of his life, we may hold out the prospect of arresting the fre- 
 quency of these headaches ; and, moreover, 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. We 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 
 forward with the throng, as feeble to oppose it as the stream of a gentle riv- 
 ulet is to reverse the course of the mountain 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 attack 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. 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. " The simple device effectually prevented 
 the frown, and there was at once an end to the mischief." The eyes were 
 afterwards gradually accustomed to light by being alternately covered and 
 uncovered by the card for two hours at a time, so as to regulate the ad- 
 mission 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 recumbent posture, and 
 taking a glass of wine or some other diffusible stim^ulant, 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 aff'ection. Now, I believe that 
 if a stimulant is to be of any service, it should be given at the onset of the 
 
 * The case is reported by Mr. Hilton in his lectures On Rest and Pain, 2d edition, 1877, 
 p. 147- 
 
78 ' HEADACHES. 
 
 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 irritation from the 
 splanchnic and gastric nerves to the nervous centres in the bram, 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 dark- 
 ened 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 increase 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 circula- 
 tion 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. io8), 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 alone (Form. 41), or with citrate of potash 
 in effervescence (Form. 42). A mustard poultice, or a small mustard 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 stimulant of this character aggravates 
 all the symptoms, and I now never resort to it unless the patient is pale and 
 exhausted. An active aperient pill given the night before the attack is threat- 
 ening, 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 efferves- 
 cence'(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, 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 subduing 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 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 phy- 
 siological effect on the nervous centres. It may be given alone in the form 
 of a pill, or with quinine or rhubarb (Form. 87). If the headache is asso- 
 
NERVOUS HEADACHE. 79 
 
 ciated with ansemia, 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. Liveing 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 hyoscy- 
 amus in a pill at bedtime, effectually removed an obstinate nervous headache 
 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 de- 
 serving 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. 110-113), and quinine persevered with, as 
 in the neuralgic variety of the affection. When quinine causes headache, 
 it is well to combine it with hydrobromic acidj (Form. 14). I am in the 
 habit of prescribing, with much advantage in these cases, the bromide of 
 potassium and tincture of quinine together (Form. 13), and I am fully satis- 
 fied 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 meal times. 
 
 The inhalation of chloroform in acute nervous headache sometimes con- 
 trols the severity of the paroxysm, and induces sleep ; but if there is any 
 nausea it is rarely of service, and usually provokes vomiting, which distresses 
 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 re- 
 peated 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. II Dr. Wilks also gives testimony in favor of it.§ As 
 it appears to stimulate the vasomotor nerves, and so to diminish the supply 
 of blood to the brain, it would have no good effect, probably, in the early 
 or premonitory stage, when there was disturbance of the vision ; but at a 
 later stage, if the headache is severe and attended with throbbing of the 
 temporal arteries, it may succeed when the bromides and other remedies fail. 
 This remedy is also of service in the genuine neuralgic headaches (hemi- 
 crania). 
 
 When, in a case of this character, the face is pallid and the pulse weak 
 and slow, and the patient is beginning to feel the want of sleep, there is no 
 remedy equal to the hypodermic injection of morphia.^ It may be always 
 
 * Gulstonian Lectures on Headache, in Medical Times and Gazette, 1858, vol. xvi., p. 496. 
 
 f On Megrim and Sick Headache, 1873, p. 448. 
 
 % The formula for preparing the hydrobromic acid is given in a short paper by Dr. J. Mil- 
 ner Fothergill in the British Medical Journal, July 8th, 1876, p. 40. 
 
 II Dr. Latham, on Nervous or Sick Headache, p. 69. 
 \ Medical Times and Gazette, January 2, 1869. 
 
 ^ " 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 con- 
 stantly passing from the tissues into the blood; the blood being, of course, the vehicle by 
 
80 HEADACHES, 
 
 used with the greatest safety if the quantity is small to begin with, and the 
 patient needs sleep. Nothing 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 susceptibility 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 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 8oth 
 to the 40th of a grain of atropia will exert an antagonistic effect, and com- 
 bat the tendeney 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 
 injection of the drug. On one occasion I found that, after a few hours' rest 
 and repose (during which time the surface 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 parox- 
 ysm short, and recovery has been much more rapid ; the terrible confusion 
 of ideas and nervous excitability have been prevented, and the prostration 
 after the attack has not been so tedious and lingering. I consider, however, 
 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 sympathetic 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 accelerate the 
 
 which the absorbed 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. R. S., in British Medical Journal, January ist, 
 1876, p. 7. 
 
 *0n the Treatment of Different Forms of Headache, in The Lancet, vol. i, 1875, June 
 19th, p. 854. 
 
NERVOUS HEADACHE. 8 I 
 
 capillary circulation (Form. 46). In the case of women, where the men- 
 strual functions are deficient and the bowels sluggish, five grains of the iron 
 and aloetic pill of the British Pharmacopoeia (Form. 85) will answer well, 
 whilst the the nitro-muriatic acid in infusion 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). 
 
 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 wine, air, exercise, and relaxation of mind and body, are 
 the chief remedies on which to rely. 
 
CHAPTER VIII. 
 
 NERVO-HYPER^MIC 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 indicate 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 vessels of the brain are overloaded and in a 
 state of vascular irritation. It is by far the most common form of conges- 
 tion, 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 exciteuient or 
 noise, hot rooms, or eating and drinking. There is not the same amount of 
 prostration and helplessness, which are the striking features of the nervous 
 headache. It belongs to persons whose circulation is excitable, and to those 
 who are impulsive and undisciplined, or who, from the force of circum- 
 stances, have no alternative but to work on and abide the consequences. It 
 is met with in men whose brains are overworked, and whose meals are hur- 
 riedly 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, unpleas- 
 ant taste in the mouth ; the breath is hot and offensive, and there is thirst 
 and a total loss of appetite. 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 al- 
 together, they have no power of moderation. Control is gone. This con- 
 dition 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 surrender, and the whole 
 aspect of the man's manner and life is changed. 
 
 With this exhaustion, and partial or general congestion 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 unrefreshed and eats his breakfast in 
 a hurry. If he is vexed or annoyed, he can scarcely prevent himself from 
 going into great passion and rage. He feels a rush of blood to the head, 
 and a passing sensation of momentary unconsciousness. His scalp is hot, 
 the capillaries of the face injected, and the eyelids are wearied and tremu- 
 lous. 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 
 
 (82) 
 
NERVO-HYPER^MIC HEADACHE. 83 
 
 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, especially 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 phos- 
 phates, 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 returning period there has been headache 
 across the forehead, and weight over the eyes. The patient complains of 
 flushes of heat, and the head and scalp are hot. Any allusion to her condi- 
 tion drives the blood to her cheeks, and a dry skin is succeeded by a hot 
 oppressive perspiration, 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 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 cerebral hypersemia 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 indigestion. 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), ^^'^ more serviceable than depletion, 
 which, by weakening the nerve-force, would further increase the excitability 
 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 relieving the acidity of the 
 bowels. It is a good plan to get the bowels to act promptly, and this may 
 be promoted 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 
 no food in the stomach whatever, the effort of vomiting relieves the conges- 
 tion 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, 
 depressants 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 extremities. 
 
 During the acute attacks we are powerless to do more than this, and when 
 they pass away, and the patient resumes his ordinary habits, he feels as well 
 as at any time of his life. In cases where the headache lingers, or returns 
 
84 HEADACHES. 
 
 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 ammo- 
 nium, 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 combination 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 frequency, I have known a few drops of ne- 
 phene (Form. 69), given with bromide of potassium or hydrate of chloral, 
 tranquillize the patient and promote refreshing sleep. As long as the head- 
 ache persists, a non-nitrogenous diet and abstinence from stimulants ought 
 to be observed. 
 
 I know an unmarried lady, thirty years of age, who 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 
 hypodermic injection of morphia, I find the effects of the two agents very- 
 similar in the comfort 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 ence- 
 phalon 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 defective 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 eft'ects, 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. Wood). In non-lethal doses, 
 chloral by its double action 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 followed from depression of the circu- 
 lation 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 irritability, which lays the foundation of perverted nutri- 
 tion, and such changes in the nerve-centres as in the long run encourage 
 serous effusion, and the waste of brain-structure. In those cases where 
 chloral furnishes great relief during the acute attack, it is well to give nerv- 
 ine tonics during the intervals by means of quinine, stiychnia, phosphorus, 
 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 duting the inter\'al is in no way incompatible 
 with the use of chloral during the acute attack. 
 
CHAPTER IX. 
 
 TOXEMIC HEADACHE. 
 
 Headache of Fever OAving 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 Head- 
 ache — Headache from Gas-poisoning — Symptoms 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 Constitutional Effects in continued Doses — Phosphorus — Cod-liver Oil. 
 
 It will be well in the first place to consider under this category the head- 
 ache 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 membranes 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 con- 
 stant 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 abundant secretion. It is a strik- 
 ing symptom in influenza 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 Sympathe- 
 tic Headache, I have already alluded to this extensive nerve communication, 
 along which morbid impressions are so readily conveyed. 
 
 In acute fevers headache is rarely absent. With respect to its relative 
 freqency. Dr. Murcliison has noted that, of ninety-two cases of typhus, 
 headache was complained of in all but six. Dr. Henderson found it in 150 
 out of 159, and Dr. Stewart in a large number of cases. f The pain gener- 
 ally 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 overlooked 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. ;{; In typhoid fever, headache is also 
 a frequent symptom, both in adults and children. Dr. Murchison ascer- 
 tained that it existed in seventy-seven out of eighty-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 
 
 * See Diseases of Children, and Chapter XVI. Philadelphia, Blakiston. 
 f Murchison, On Continued Fevers, 1862, p. 150. 
 J Murchison, On Fever, 1862, p. 345. 
 II Ibid., p. 487. 
 
 (85) 
 
86 HEADACHES. 
 
 forehead ; but the mental faculties are rarely impaired, and delirium is ex- 
 ceptional. 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 intense, 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), poster- 
 iorly (occipital), or on either side (hemicrania). We meet with headache, 
 again, in whooping-cough and scarlatina, in variola, measles, etc. ; in fact, 
 in all those diseases 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 cerebral cells become irritated and disturbed, till the inflam- 
 matory aff"ection passes away."]" 
 
 I might reasonably have included the headaches of gout, rheumatism, and 
 syphilis under this name, seeing that the accumulation of morbid products 
 
 * Murchison, On Fever, 1862, p. 600. 
 
 f It does not appear that the intensity of the cerebral symptoms in typhoid fever in adults, 
 or in extreme cerebral congestion and tubercular menmgitis in children, bear any relation to 
 the morbid appearances found after death. In some fatal cases, when the head symptoms 
 have been trivial, extreme vascularity of the membranes has been discovered, and the ves- 
 sels 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 delirum and even 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 mem- 
 branes of the brain may be detected after death. In both these diseases the cerebral con- 
 gestion 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 inflam- 
 mation, and the congestion is of a passive rather than of an active character. The transpar- 
 ent and often colorless serum which is found in the ventricles, and beneath the arachnoid, is 
 ratlier 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 inliammatory. The subarach- 
 noidean 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 explain- 
 ing the severity of the cerebral symptoms during life. In young children of rickety constitu- 
 tion, w'hen the head is growing unusually large, the convulsions and comatose condition 
 have, in my experience, 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 elevatoin of its temperature in the cerebral vessels. In 
 relapsing fever the same remarks apply without exception ; there is no constant relation be- 
 tween 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 symp- 
 toms 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 essentially dependent on the presence of the specific poison in the blood, and the 
 accumulation in it also of the products of tissue change, which are not eliminated by the 
 proper channels. The nutrition of the brain suffers in consequence of this detention, not- 
 withstanding 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 para- 
 lyzed. 
 
 As a matter of clinical experience, I am informed by Dr. Broadbent that protracted head- 
 ache in the early stages of enteric fever denotes unusually severe affection of Peyer's patches, 
 and is often followed by hsemorrhage at a later period. 
 
TOXEMIC HEADACHE. 8/ 
 
 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 toxsemic change {tir(zmic 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 energetically for a time, but 
 at length the morbid material in the blood ceases to exert a diuretic in- 
 fluence, and degeneration 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 continuing for days together. When the local con- 
 gestion 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 headache by still further impairing the functions of 
 the eliminative organs, and causing on two or three occasions severe 
 h^ematuria. 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 Bright's 
 disease, the frontal headache was insupportable, and lasted, without inter- 
 mission, 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 restricted and careful diet, with purgatives and stimu- 
 lating 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 in- 
 gredients. 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 excessive amount of urea from the system. 
 Put the patient on a milk diet, and give no animal food or stimulants of any 
 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 excite the action of the renal organs, as well as 
 freely open the bowels, and unload any obstruction of the portal system. 
 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 convulsions, with a scanty discharge of concentrated urine, vene- 
 section or cupping over the loins may be demanded to save the patient's 
 life. If anasarca comes on, and there are indications of cerebral oedema or 
 effusion into the ventricles, 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 relieves renal congestion by favoring the 
 
88 HEADACHES. 
 
 escape of exudative products from the urinary tubules, and in this way it in- 
 creases 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 atmos- 
 phere is vitiated by crowded assemblies or the imperfect ventilation of apart- 
 ments. I believe that the accumulation of carbonic acid and expired air in 
 school and lecture rooms is to be reckoned among the chief exciting causes of 
 headache in young persons, and still more in adults, when the nervous system 
 becomes more susceptible with the advance of years. 
 
 "The normal quantity of carbonic acid being .4 volumes per 1000, it pro- 
 duces fatal results when the amount reaches from 50 to 100 per 1000 volu- 
 mes; and, at an amount much below this, 15 or 20 per 1000, it produces 
 in some persons, at any rate, severe headache. Other persons 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 produced when the amount of car- 
 bonic 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. Well-sinkers, when not actually disabled from 
 continuing their work by carbonic 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 breathing an atmosphere 
 vitiated and overcharged with carbonic acid. The dangerous consequences 
 are first made manifest 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 is large, the requi- 
 site elimination of it from the lungs does not take place, and the blood, be- 
 coming more venous 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 replaced 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-pois- 
 oning, i. e., gas generated by putrefaction, 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 
 dullnes 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 evening, unless relieved 
 by treatment. 
 
 Li the head there is a sense of heat, weight, and dullness, and nervous 
 prostration, and inability to apply the mind to work, or to make any physi- 
 cal 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 
 
 . * Practical Hygiene, by Dr. Parkes, 1873, 4th edition, Philadelphia, Blakiston, p. 112. 
 
 ■j- 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. 
 
TOXyEMIC HEADACHE. 89 
 
 has the thick yellow fur at the back and sides, always present in the bilious 
 headache. 
 
 Treat7nent. — The only remedy is a gastric 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 useless, as they fail to bring away the offensive gas, and only pro- 
 duce 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 de- 
 cidedly injurious. 
 
 This form of headache with gas-poisoning very much resembles the head- 
 ache 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 examina- 
 tions 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 stom- 
 ach of the body when bent. If a body-snatcher should •' get a gulp,'-' as he 
 expressed it, he knew it would be followed by headache and nervous de- 
 pression 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 relia- 
 ble means of curing the headache and depression produced by gas-poison- 
 
 In the treatment of the forms of headache arising from specific fever, care- 
 ful judgment will be required. When the brain is oppressed by the high 
 temperature of the blood, and the accumulation of effete and j^oisonous mat- 
 ters within it, there is imminent danger to life, if this state of things is per- 
 mitted to go on unchecked. The local abstraction of blood is a measure to 
 be held in recollection, seeing that it has sometimes averted the most threat- 
 ening 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 manner, 
 and relieve the patient more completely and quickly than any 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. Graves, and sanctioned by 
 Dr. Murchison.* It must be understood, however, that there is the head- 
 ache of exhaustion which succeds 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 
 
 * Loc. cit., p, 274. 
 6 
 
90 HEADACHES. 
 
 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 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., ^t. 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 (186S), when he got headache diffused over the forehead. Two 
 daj^s later, he had a bilious attack — violent spasms, retching and bringing 
 up large quantities of bile, passing it by the bowels as well. The attacks 
 came on once or twice a Aveek, and the doctors ascribed them to malaria. 
 There were new drainage works going on, v/hich 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 headache. 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 in the 
 right eye, and insupportable depression of spirits accompanied it. 
 
 In 1875 he came to England again for three months, and derived consid- 
 erable benefit ; returned in November, and after being a month in Bombay 
 the spasms, vomiting, 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 be- 
 gin at 3 a. m. and last until 7 p. m., when he fell asleep, and woke up re- 
 lieved in a few hours ; a cup of tea or coffee would sometimes relieve the 
 pain quickly. Heavy sleep and snoring were invariable precursors of an at- 
 tack. During the last year, his memory, which was formerly acute, has be- 
 come very defective. 
 
 There is no disease of the heart, liver, or spleen; abdomen very large and 
 flabby ; he is now fidgety and irritable, 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 -albuminous. 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 mixutre, 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 ago, which he considers a sufficient 
 cause. The bowels not having acted satisfactorily, he was ordered to take 
 two "oills of aloes and myrrh, with half a grain of sulphate of iron (Form. 
 86).^ 
 
TOXEMIC HEADACHE. 9 1 
 
 July 1 2th. He is much better, and has had no headache since the last 
 visit. Two pills acted well, and produced 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 animated. 
 
 July 17th. On the 15th, i6th, 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 or- 
 dered a pill containing agrain of calomel at bed time, 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 last- 
 ing 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 cer- 
 tainly improved in all respects. A mixture of citrate of iron and arsenic 
 was now ordered to be taken twice a day after food, when free from head- 
 ache, and the bromide mixture when an attack was threatening (Form. 26). 
 July 30th. His head had been better, but two mornings 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 loth, when it began in 
 a moment at 4 p. m., and continued all day and night. On the nth the 
 pain was better in the early morning, then it returned at i 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 period- 
 icity in the headache suggests the use of quinine in large doses, and there- 
 fore the previous medicines were discontinued, and two pills, each contain- 
 ing three grains of quinine, were prescribed twice a day. 
 
 September 26th. A month's residence at the seaside improved his gen- 
 eral 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. sV daily) and quinine and iron in a mixture; in addition, as the patient 
 was corpulent, a Turkish bath was ordered once in ten days, and a dose of 
 Friedrichshalle water twice a week. 
 
 December nth. 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 intelligence and vigor ; he took long walks with- 
 out 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, increas- 
 
92 HEADACHES. 
 
 ing the arsenical solution one drop each day (Form. 6 to 9). It may be 
 advisable to persevere with this combination if phosphorus and quinine 
 should fail. " I have witnessed the postponement and ultimate cessation of 
 a periodic headache, through the influence of arsenic, before the prickling 
 eyelid or silvered tongue demonstrated its agency " (Begbie). Arsenic is a 
 remedy of the greatest possible value in nervous cases, if it is given judi- 
 ciously 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 circum- 
 stances it should be suspended for a time, and then cautiously resumed. 
 Every practitioner should make himself familiarly acquainted 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 
 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 unoxidized 
 state, capable of being readily assimilated. No remedy requires more care 
 in prescribing than this, for whilst in small doses it is a 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. ^l, but I have seen no 
 ill effects from gr. J^ ; 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 con- 
 sider it an excellent combination, as the virtue of the phosphorus is retained, 
 while in this form it is taken up readily by the stomach. 
 
 * " 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 inflamed, 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 silveiy film, resembling that produced by touching its surface with a 
 weak solution of the lunar caustic. . . . The throat becomes diy and sore, the gums swollen 
 and tender; and, if the medicine is still further persisted in, salivation ensues." — " On the 
 Physiological and Therapeutical Effects of Arsenic," by James Begbie, M. D., F. R. S. E., 
 in Contributions to Practical Medicine, 1862, p. 270. 
 
TOXEMIC HEADACHE. 93 
 
 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 containing 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 chemi- 
 cal combihation and become a hypophosphite. Hypophosphites are made 
 by boiling phosphorus 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 
 som^e cases of gastralgia, cod-liver oil brings relief when ferruginous tonics 
 and the most careful diet fail, so will it frequently ward off attacks of neu- 
 ralgic headache by improving general nutrition, and strengthening the tone 
 of the nervous system. 
 
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 Sup- 
 pressed Gout — Character of the Pulse and Heart's Sounds — Importance of exciting Action 
 in the Eliminative Organs — Mercurials — Podophyllin — Alkalies — Salts of Lithia — Car- 
 bonate of Ammonia. 
 
 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 fortu- 
 nate. I should say from my OAvn 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 accompanied 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 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 suff"ering from his fifteenth 
 attack of acute gout in May, 1876, consulted me for headache, which was a 
 new symptom of his conriplaint. The right great toe was vividly inflamed 
 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 headache 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.* 
 
 The influence of the gouty diathesis in exciting severe headache is well 
 
 ■^On Gout and Rheumatic Gout, by A. B. GaiTod, M. D., F, R. S., 1862, p. 515. 
 
 (94) 
 
ARTHRITIC OR GOUTY HEADACHE. 95 
 
 illustrated in the following case recorded by Dr. Begbie.* For the limita- 
 tion of space at my disposal, I shall make no apology for abridging the 
 details. A lady, aged thirty-five, of full habit and florid complexion, 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 congestive ; it was not anemic ; it was not dyspeptic. It 
 could not be traced to cerebral disease; it was not of neuralgic or rheumatic 
 character ; it was not periostitic ; it was not periodic. As the urinary secre- 
 tion from time to time presented alternately oxalates and lithates in great 
 excess, and the hands of the patient's father presented 'the little knobs of 
 Heberden,' some light at length arose to reveal the true character of the per- 
 plexing 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 regu- 
 lations 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 persons 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 membranes 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 regular attack of gout ever showed itself. The symptoms were 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 sen- 
 sation 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 
 
 * 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 lengthened periods of intermission may best per- 
 haps be noted liere. 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, 1 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 excretory organs most concerned in giving relief in these 
 cases, and principally by an increased separation of the lithic acid or its compounds. 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. 
 
96 HEADACHES. 
 
 the urine threw down a thick reddish sediment. It was noticeable that the 
 headache was often relieved when the urinary secretion became thus changed. 
 An active mercurial medicine would generally, I found, relieve the headache 
 after the secretions were rectified ; but occasionally the symptoms would con- 
 tinue for days, accompanied with extreme flatulence, disordered digestion, 
 and irritability of temper. On some occasions there were fearful attacks of 
 painful colic ; but vv^hen these were present the head was free from dis- 
 comfort. 
 
 When effete products accumulate in the blood, the vasomotor centre 
 becomes damaged, and the minute arterioles are thrown into a state of spas- 
 modic 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 cere- 
 bral arteries are atheromatous and thickened, and the calibre being dimin- 
 ished, the blood-supply to the brain is insufficient to nourish it. The emo- 
 tional conditions to which this important change gives rise are shown in 
 outbursts of passion, and fits of 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 be- 
 comes slowly developed and superimposed upon the gouty condition, the 
 characteristics of cerebral anemia 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 structurally 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 sys- 
 tem, and damaging the nervous centres, instead of seeking elimination 
 through the joints in the form of articular inflammation. The treatment, 
 therefore, is much the same as for gout, modified according to the peculiari- 
 ties and exigencies 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 head- 
 ache. And this is liable to occur periodically with those persons whose con- 
 stitution is not vigorous enough to throw off" the poison through the joints. 
 It is, in fact, an internal 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 sedatives, and particularly of colchi- 
 cum. When the urine is loaded, and the evacuations dark or clay-colored, 
 mercurials, podophyllum, alkalies, and salts of lithia may be needed (Form. 
 79-80-81-31-33-94). Carbonate of ammonia will relieve the head, and 
 minute doses of colchicum 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. • 
 
 * On Cerebral Aneemia, by Dr. J. Milner Fothergill, West Riding Lunatic Asylum Medi- 
 cal Reports, vol. iv., p. 104. 
 
CHAPTER XL 
 
 RHEUMATIC HEADACHE. 
 
 Its Seat — Causes— Symptoms — Importance of Diet and Attention to the Digestive Functions 
 — Iodide of Potassium — Bark— Colchicum — Baths and Waters. 
 
 This is occasionally met with in rheumatic subjects. It affects the apo- 
 neurosis of the scalp, and the occipito-frontalis and temporal muscles. It 
 comes on from exposure to cold in railway traveling, and 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 con- 
 tinuous ; there is an aching too of the teeth and gums (which are often ex- 
 quisitely 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 toward morning. Dr. Sieveking points out that, according 
 to Romberg, the pain is of paroxysmal and hemicranial character, especially 
 affecting the forehead and vertex, from which it radiates in various direc- 
 tions, a description which does not completely accord with the majority of 
 cases which have come under my own observation. "I do not," he con- 
 tinues, "find that authors allude to the possibility of an intracranial rheu- 
 matic affection ; but I have repeatedly met with cases of cephalalgia in 
 which no such external 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 concides with my view of the affection, for 
 the dura mater might with as much show of reasoning be expected to sympa- 
 thize in rheumatic headache, as that the fibro-serous pericardium should 
 sometimes be involved in acute articular rheumatism. 
 
 Treatment. — For the treatment of this headache, attention to diet is of 
 primary importance, in order to counteract the rheumatic tendency. Vege- 
 tables, milk, and tapioca are preferable to animal food, and a little dry wine 
 to beer and spirits. Any derangement in the digestive organs must be over- 
 come 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 neuralgia, then iodide of potassium, 
 bark, the alkaline carbonates, and small doses of colchicum will be servicea- 
 ble (Form. 36-34-35). " I think it almost certain that some kinds of head- 
 ache are produced by the same morbid 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 
 
 *0n Chronic and Periodical Headache, by E. H. Sieveking, M. D., F. R. C. P., in Med- 
 ical Times and Gazette, 1854, p. 209. 
 
 (97) 
 
98 HEADACHES. 
 
 habit, and particularly to their connection 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 efficient 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 gentle- 
 man 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 procure 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 Reflections, by Sir H. Hol- 
 land, Bart., M. D., F. R. S., 3d edition, 1855, p. 267. 
 
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 Mercury — Small Doses of Calomel — Quinine — Ar- 
 senic. 
 
 This is met with m 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 sur- 
 face of the dura mater and the bone are often involved in syphilitic inflam- 
 mation, leading 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 intra- 
 cranial disease, in which there were found either fibrinous (gummatous) 
 tumors in the brain, or the results of internal periostitis or inflammation of 
 the membranes, besides more or less marked indications of syphilis in the 
 liver, inguinal glands, or other parts. "f 
 
 Dr. Symonds alludes, in his remarks on the headache of secondary syphi- 
 lis, 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 
 S)'Stem saturated with the syphilitic poison, the specific inflammation may 
 extend to the membranes, and involve the brain itself. 
 
 One of the most marked instances of this type of headache 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 manifesta- 
 tions of the syphilitic poison, and were the chief cause of his quitting the 
 service. The natural placidity and cheerfulness of his disposition were ex- 
 changed 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 nucontrollable 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 beneath the bed- 
 clothes. 
 
 Iodide of potassium in large doses, with tonic bitters and bark, were or- 
 dered, 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. Gradually the worst symptoms returned ; he became more 
 and more exhausted, probably from obstruction in the cerebral vessels, or 
 
 * Pathological Anatomy, by Wilks and Moxon, 2d edition, Philadelphia, Blakiston, 1875, 
 p. 198. 
 
 fNew Sydenham Society, article Nervous System, 1862, p. 79. 
 
 (99)- 
 
100 HEADACHES. 
 
 lesion in one or more of the membranes, 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 perios- 
 teum, which I have known to be the case among soldiers who have had 
 syphilis in a bad form. 
 
 The treatment is the same as was employed in this case, iodide of potas- 
 sium being the chief medicinal agent. It should be given in full and con- 
 tinuous 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 re- 
 peatedly seen relapses, 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 attendant, 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 potas- 
 sium produced great depression and other injurious effects ; in these one- 
 quarter or half a grain may do all the good, or iodide of sodium or of am- 
 monium maybe tolerated."* It occasionally happens that small doses of 
 calomel (gr. to) 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 process. Severe secondary 
 symptoms ensued, with nodes on the cranium and tibise, which produced 
 foul suppurating sores, and caries of the affected bones. Alarming epileptic 
 seizures followed, accompanied by great irritation of the brain and mem- 
 branes, 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 consid- 
 erably modified the cerebral symptoms. The treatment consisted in strict 
 attention to hygienic rules, the fresh, pure air of the country, and a gener- 
 ous diet. The remedies prescribed in the shape of drugs were iodide of po- 
 tassium, quinine, and arsenic (Form. 38). Under their separate and com- 
 bined use, and that great power which nature, if allowed time, possesses to 
 remove morbid products, when the inernal 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 cachetic conditions mercury may be given with advantage, and without 
 detriment to the patient, if combined with iron (Form. 4). 
 
 *0n Syphilitic Affections of the Brain, by W. H. Broadbent, M. D., in the Lancet, Nov. 
 25th, 1876. 
 
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 Ather- 
 omatous Degeneration in the Cerebral Vessels — Terminations in Apoplexy and Paralysis 
 —Usual Causes of Organic Pleadache — Cysts — Hydatids — Exostoses — Syphilis — Value 
 of Large Doses of Iodide of Potassium in all Cases of Cerebral Tumor, whether due to 
 Syphilis or not — Rest to be Procured by Bromide of Potassium and Hydrate of Chloral 
 — If all Hypnotics fail, the Hypodermic Injection of Morphia to be Employed. 
 
 Organic headache (^Cephalalgia organica) is called "Structural Head- 
 ache ' ' 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 
 tuberculous, cancerous, or syphilitic tumors, hydatids, ossific formations 
 within the cranium, softening of the brain, adhesion of the membranes, ar- 
 terial degeneration, aneurism, obstruction of the sinuses, and so forth. But 
 disease of the brain from any of these causes iTiay be present without our 
 being able to recognize its nature or its extent, as in the case of the late 
 Professor J. Plughes Bennett. A tumor may exist and cause neither head- 
 ache 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 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 adjustment of the circulation, and balance of the various structures 
 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 
 organic headacne ; 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 sen- 
 sation, 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 re- 
 ferred to one particular spot, some organic lesion may be suspected. The 
 headache which never yields for a moment to any treatment 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 ; it is impossible to distract his 
 attention in such a way as to convince one that he is ever entirely 
 free from pain. " Dr. Hughlings Jackson remarks that frontal head- 
 ache is generally referable to abdominal affections, vertical headache to 
 cerebral disturbance, and occipital pains to disorders of the circulation, 
 
 (lOl) 
 
102 HEADACHES. 
 
 and more especially to anEemia. However that may be, it is certain 
 that the pain due to cerebral disease may, especially in the case of cere- 
 bral 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, continuous 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 intra- 
 cranial tumors or abscesses upon sensory nerves."* Dr. Walshe's experience 
 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 tumor exists within the cranium are : the existence for a con- 
 siderable period of intense cephalalgia, especially if limited to a fixed point, 
 or even to one side of the head, and if attended with repeated vomiting; of 
 convulsive movements without paralysis, but followed by mere weakness, or 
 actual paralysis of the affected parts ; of different affections of the organs of 
 sense, especially alteration of sight, and of disturbance of intellect, while the 
 general health does not very materially suffer, "f 
 
 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 magnitude 
 before it causes pain or inflammation, the subject of diagnosis is confessedly 
 obscure. Dr. Abercrombie relates a class of cases, which are often mistaken 
 for periodical or sick headache, the pain not being urgent enough to invite 
 attention to the head as the origin of the mischief, but to the stomach as the 
 supposed offender. After death the chief morbid appearances are found in 
 the cerebellum. 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 degen- 
 erative 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 continuance of the suffer- 
 ing, which either extends over the entire brain, or is deeply seated in one 
 spot. It occasionally 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 re- 
 spite, and his agony was so acute that he longed for death. Though there 
 was at no time of his early illness any symptom of paralysis, or loss of mem- 
 ory 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 stomach. These symptoms continued, and he fell 
 into a comatose condition and died. After death a cancerous tumor was 
 found in the left hemisphere, extending posteriorly and downwards to the 
 
 *The Tlieory and Practice of Medicine, by Dr. Bristowe, 1876, p. 942. 
 
 f The Nature and Treatment of Cancer, by W. H. Walshe, M. D., 1S46, p, 495. 
 
ORGANIC HEADACHE. IO3 
 
 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 forma- 
 tion 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 generally does follow if the headache be due to gastric 
 disorder. It comes on suddenly, and the patient may be able and willing to 
 take food immediately after the contents of the stomach have been expelled. 
 
 This headache is witnessed in softening of the brain, where the blood- 
 vessels are diseased from atheromatous deposit. In a female patient, aged 
 seventy, who was under my care in 1875 f^^ 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 paralytic 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 head- 
 ache, 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 indications of hardness and tortuosity; 
 depression of spirits and irritability of mind and manner were also noticeable 
 features of his changed condition. After dinner the headache was generally 
 relieved by a larger quantity of wine than was allowable, and next morning 
 the pain and confusion 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 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 rela- 
 
 *Dr. Moxon, On the Treatment of Headache from Intracranial Disease, in Lancet, May 
 29th, 1875, P- 750- 
 
I04 HEADACHES. 
 
 tion, except in the instance of the cerebellum, 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 I ; while by eliminating the apoplectic cases, we obtain the still higher 
 ratio of 74 to 15, or nearly 5 to i."* "In twenty cases of fungus of the 
 dura mater, published by Louis (Mem. de V Acad. Roy. de Chir., t. 5), 
 there were only three with cerebral symptoms of any kind; and chronic 
 abscesses, cysts, hydatids, exostoses, etc. , have often arrived at an enormous 
 size without having produced any serious alteration in the functions of the 
 brain, "f 
 
 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 persons, who have derived no advantage from the drug; on the con- 
 trary, the pain has increased under its use. In one case of syphilitic head- 
 ache, 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 con- 
 tinuous. Dr. Smith recommends iodide of potassium in all cases of head- 
 ache due 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 induced 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; bet if these remedies 
 fail, with other suitable hypnotics, then the subcutaneous injection of mor- 
 phia may be tried, and the observations I have elsewhere made are also 
 applicable here. J Dr. Moxon found that gr. \ of morphia, used hypoder- 
 mically, 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. 
 
 *On Chronic and Periodical Headache, by E. H. Sieveking, M. D., F. R. C. P., in 
 Medical Times and Gazette, 1854, p. 181. 
 
 f Tweedie's Practical Medicine, article Cephalalgia, 1840, vol. ii., p. 154. 
 
 % See Chapter VII, on Nervous Headache. 
 
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 atheromatous, and the circulation through the brain is impeded 
 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 congestive type, and therefore any 
 excitement of the circulation, 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 softening change through the 
 failure of nutrition, the withdrawing of this support renders the vessels ex- 
 ceedingly 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 demonstrates that the 
 large nerve-cells are in a state of granular degeneration in senile atrophy of 
 the brain, and that 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 headaches which we ascribe to organic change. We cannot 
 expect that we shall find anything at all constant in character with the various 
 morbid conditions of the brain. 
 
 Treatmeiit. — 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 morn- 
 ing will be found serviceable (Form. 8i). 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 excitement, promoted sleep, and refreshed the 
 patient, so that he was able to walk a short distance with comparative com- 
 fort after it. When cold is thus locally applied, it has a tonic and invigorat- 
 ing 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 thirty minims of the liq. extract ergot, in 
 water, with a few drops of spirit of chloroform, three times a day, is a fair 
 
 * Observations on the Histology of the Morbid Brain, in West Riding Lunatic Asylum 
 Reports, 1874, vol. iv., p. 223. 
 
 7 (105) 
 
I06 HEADACHES. 
 
 dose (Form. 57), but Dr. Smith* recommends much large 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 ex- 
 haustion 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 cannot 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 conversa^ 
 tion ; 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 H., on theHeadache of Cerebral 
 Hypersemia. 
 
CHAPTER XV. ' 
 
 NEURALGIC HEADACHE. 
 
 Relation to Nervous Headache — Its Origin traceable to Decayed Teeth and other Local 
 Causes of In-itation, as Changes of Weather and Uterine and Intestinal Disturbance — Its 
 Origin in the Special Poison of Ague — Pain precedes Sickness, and is not relieved by 
 Vomiting, as in the Dyspeptic or Bilious Headache — Acute Hearing a premonitory Symp- 
 tom — Hard Work a common 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 Aconitina Ointments — Hypodermic Injection of Morphia — Valerianate of 
 Zinc — Phosphorus — Strychnia — Cannabis Indica — Arsenic — Iron — Cod-liver Oil. 
 
 This is really one form of nervous headache. It affects one side of the 
 head and face (hemicrania,) or it fixes on one particular spot, causing a 
 sensation as though a nail Vv^ere being driven through the head (clavus hys- 
 tericus).* It frequently proceeds from decayed teeth, or some other local 
 cause of irritation, which may depress the nervous system and weaken the 
 appetite and digestive functions. f It is one form of neuralgia like tic doulou- 
 
 * With regard to these definite and tender spots having their origin in the fifth nerve, Dr. 
 Anstie thus writes: "Ever since the time of Valleix, most authors have disposed of this 
 question summarily, 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 affected wiih universal and equally violent neuralgia 
 of all the principal 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 : i. 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 exquisitely 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. 
 
 f "A gentleman had for many years been liable to attacks of headache on the slightest 
 provocation. Long- continued intellectual exertion, 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 tlrat time he has been almost exempt from pain in the head. In other re- 
 spects 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 par- 
 took 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 explana- 
 tion cannot be accepted, there is no alternative but the supposition that morbid inrpressions 
 on the dental nerves (not creating pain in those parts), arriving at the central exremities of 
 the nerves, are passed on to that part of the sensorinm which is related with the sensory 
 fibres of the ganglionic nerves of the brain, and maintain in that part of the sensorium a 
 morbidly susceptible condition ; and that this condition is brought into such action as con- 
 
 (107) 
 
I08 HEADACHES. 
 
 reux, and the paroxysm may come on after regular and short intervals of 
 ease, or after irregular and long intervals. 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 exhaustion, as severe leucorrhoea, or other 
 uterine loss, will bring it on in subjects who are predisposed to it. Women 
 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 trouble- 
 some; 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 experi- 
 ence I should say that neuralgia of malarial origin is very rare, at least in 
 London practice. The improved dwellings of the poor throughout 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 physical and elevating the moral nature of man — have reduced 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 
 sickness or vomiting, unless the attack has lasted long and is very severe. I 
 should limit its strict definition to the intensity 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 engaged 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 vomiting of dyspeptic head- 
 ache, or from indulgence in alcoholic drinks, the nausea and vomiting pre- 
 cede the headache, and afford relief from the removal of the cause. 
 
 Extreme sensibility to sound of any kind, or a distressing acuteness of 
 hearing, is an occasional accompaniment 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 can- 
 not even hear it strike when she is free from headache. The ticking of her 
 
 stitutes 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 lias received like disturbing impressions from the nerves 
 of other parts of the ganglionic system." — Symonds, on Headache, in Medical Times and 
 Gazette, April 3d, 1858, p. 339. 
 
NEURALGIC HEADACHE. IO9 
 
 own watch, and that of any other person in the same apartment, is quite 
 annoying, if not ahnost 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 suddenly acute, and when the attack is likely to 
 pass off, by a declme in its sensibility. 
 
 Excitement of all kinds will bring this headache on, as the noise of railway 
 travelling, and any bustle or confusion; but it is more frequently attributable 
 to disordered 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 children ; * 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 gastralgia. 
 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 followed 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 who are subject to it. 
 
 With regard to decayed teeth as a cause of nenralgia, 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 3'ears 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 violent and exhausting 
 exertion of mind or body. And, conversely, I am sure that a generous diet 
 would often relieve the agony arising from sheer involvement of nerves in a 
 cancerous deposit, "f 
 
 When a person who has a solitary decayed tooth is suffering from contin- 
 uous 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 de- 
 cayed 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 ar- 
 resting further decay. Women who stand for hours together over a wash- 
 tub, or a laundress's table, are frequent victims to this form of headache. 
 Household servants, who work hard and are over-anxious to discharge their 
 duties creditably, are sometimes great sufferers. In confirmed cases, if the 
 
 *See Chapter XVI, on Neuralgic Headache in Children. 
 
 f 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. 
 
no HEADACHES. 
 
 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 situa- 
 tion has to be given up, and pure air and complete rest obtained. The fol- 
 lowing is a case in illustration : 
 
 M. A. S., set. 33, s., a female servant, and a resident in London, con- 
 sulted me May 2 2d, 1877. She has been subject to sick headache all her 
 life, but has become much worse during the last nine months, which she at- 
 tributes to hard work and fatigue ; extra work increases the pain, and going 
 up-stairs tires her exceedingly. The house iu 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 temperament. 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 any- 
 where, and she is afraid of returning with the pain. She feels very^ low- 
 spirited with it, but not hysterical, and is inclined 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 difficulty 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 im- 
 pulse 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 ex- 
 citement causes palpitation and discomfort over the praecordial region, while 
 she experiences 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 assafoetid., gr. x, in pil. ij, at bedtime, 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 F). 
 
 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 difficulty 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 v/eeks. She 
 can take a long walk Avithout any fatigue, and she looks quite well. She has 
 taken the arsenic and iron mixture twice a day since it was prescribed, and 
 
NEURALGIC HEADACHE. Ill 
 
 a pill occasionally. The right eye is still puffed, and pain will always bring 
 on this oedematous 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. 
 
 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 experience : 
 
 "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, 
 hit 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 production 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 metallic probes has been adopted from time to 
 time, with great temporary relief, but the obstruction has always recurred, 
 and, as a consequence of it, the discharge of tears from the gland is incon- 
 tinently 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 
 useful, "f 
 
 The condition of the renal organs has much to do with headache, and I 
 have seen very persistent forms of it (see page 87, Uraemic 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 excessively severe hemi- 
 crania 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 paroxysms may last for several 
 days. In one case of this kind I noticed almost complete anaesthesia of the 
 skin of the face and of the fingers upon the affected side during the continu- 
 
 *A neuralgic headache is sometimes caused by gastric irritation and acidity, and a full 
 dose of an alkali, as half a teaspoonful of bicarbonate of potash in a wineglassful of water, 
 will liberate carbonic acid in the stomach, and speedily remove the pain. 
 
 f On Stimulants and Narcotics, by F. E. Anstie, M. D., 1864, p. 83, Philadelphia, 
 Blakiston. 
 
112 HEADACHES. 
 
 ance of the attack. This patient had an attack of the kind nearly every 
 week; and, finally, during the intermissions, normal sensation did not quite 
 return to the face or fingers, but a feeling of numbness and formication re- 
 mained. 
 
 "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 anaemic, 
 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 im.mediate 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 sometimes give ease after friction for a few minutes. A little 
 extract of belladonna rubbed into the affected temple will be useful in some 
 cases (Form, no), and an ointment of aconitina (Form. 113) or of veratria 
 (Form, in) will prove efficacious in some obstinate cases. Internally, the 
 carbonate of ammonia will sometimes be of service (Form. 16). The chlo- 
 ride 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 gss. 
 doses (Form. 27), and if no relief follow the administration of three or four 
 doses, it is not Avell 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 trou- 
 blesome 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 qui- 
 nine, strychnia and iron (Form 21-22-22 a-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 symp- 
 toms of constitutional irritation becoming manifest, and when its alterative 
 effects on the blood are about to be secured (Form. 8-9). Under these cir- 
 cumstances it should be discontinued 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 nausea and depression, as to render the contin- 
 uance of the remedy unadvisable. 
 
 "I have witnessed the postponement and ultimate cessation of a periodic 
 
 * Cyclopoedia of ]Medicine, by Dr. H. von Ziemssen, Diseases of Kidneys, vol. xv., p. 
 421. 
 
NEURALGIC HEADACHE. I I 3 
 
 headache through the influence of arsenic before the pricking eyelid or sil- 
 vered tongue demonstrated 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 afternoon. 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 promised 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 grati- 
 fied 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 disappointment. We return to quinine, which has sel- 
 dom failed on former occasions, but without success. We betake ourselves 
 to bebeerin, and supplement its powers with the alternative efi''ects of depur- 
 ants, diuretics and laxatives, but all to no avail. We try a combination of 
 arsenic and quinine, and in a short time the wished-for cure is obtained, "f 
 
 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 por- 
 tal circulation have been drained (Form. 29). After this, full doses of qui- 
 nine, and a little brandy and water during the day, have aided the cure. 
 Such persons have gone on comfortably for weeks and months, notwith- 
 standing inattention to decayed teeth, and a drain from the system of var- 
 ious kinds. 
 
 When the subjects are excitable and hysterical, and the pain is persistent, 
 bromide of ammonium or potassium with valerian will be advisable (Form. 
 72), and if anaemia 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 camphor, 
 henbane, and cannabis indica (Form. 92-93) will be found of service, and 
 it will have a most tranquilizing effect ; but all drugs will fail to remove the 
 pain, unless air, exercise, rest, and good food be prescribed. 
 
 Gelseminum sempervirens has been employed successfully in neuralgic 
 affections, and the neuralgia arising from decayed teeth. In hemicrania and 
 supraorbital 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 tincture 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, set. 39, I found that one grain of 
 the powder made into a pill with glycerin and given every night at bedtime 
 acted marvelously, inducing sleep, and warding off a paroxysm when taken 
 
 *0n the Physiological and Therapeutical Effects of Arsenic, by James Begbie, M. D., 
 1862, p. 272. 
 
 ■j- Ibid., p. 276. 
 
114 HEADACHES. 
 
 as the seizure was threatening. In large doses it appears to cause frontal 
 headache, contraction of the pupils, and weakness of the legs.* From the 
 observations of M. Emery-Heroguelle it acts favorably as an anti-neuralgic 
 in neuralgia of the fifth pair, dental neuralgia, the brachial plexus and inter- 
 costal nerves, f 
 
 Croton chloral has been recommended by Dr. Liebreich, 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 in- 
 duce 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 glycerin, and then add the required quantity of 
 cinnamon-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 headache. There has been sickness and 
 prostration. A teaspoonful of brandy in a little soda-water, and quinine 
 with spirits of chloroform (Form. 12), have been retained on the stomach, 
 and the pain has gradually departed. Twenty grains of bromide of potas- 
 sium 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 neuralgic 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 employed for improv- 
 ing the quality of the blood, and restoring 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 nervous tissues. 
 
 *"A girl nine years old was killed in two hours by a dose of two drachms of the tincture." 
 — Squire' s Pharmacopaeia, iithedit., 1877, p. '^\^- 
 f Medical Examiner, Dec. 27th, 1877, p. 1067, 
 
CHAPTER XVI. 
 
 HEADACHES OF CHILDHOOD AND EARLY LIFE. 
 
 Preliminary Remarks on the Significance of Headache in Children — Their Insidious Course 
 and Character — Hereditary 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 Physical Growth — Their Relationship and Bearing on Health — Effects of Illness on 
 the Functions of the Brain — Parents entail Disastrous Evils on their Offspring by Forced 
 Mental Discipline — Difference among Children in the Power of Memory, and Acquire- 
 ment of Knowledge — Case of Arithmetical Power related by Carpenter — Evil Conse- 
 quences of the Forcing System — Hypertrophy of the Brain — School Board Legislation — 
 Weight and Size of the Human Brain at Different Ages in Both Sexes — Popular Tradi- 
 tion of Delayed Mental Training — Professor Lay cock's Opinion that Precocious Children 
 are generally Strumous. 
 
 The Chief Varieties of Headache in Children : i. Cerebral Headache. 2. Gastric Head- 
 ache. 3. Epileptic Headache. 4. Febrile Headache. 5. Headache from Anaemia, 
 Neuralgia, etc., constituting Nervous Headache. 6. Headache depending on some In- 
 tricate Change in the Cerebral Membranes or Tissues of the Brain. 7. Organic Head- 
 ache. 
 
 Headaches hold such a prominent position in the diseases of childhood 
 as to constitute them worthy of special notice and consideration. There 
 are few practitioners of any experience who have not had reason to 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 convulsion, 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 
 iBoment than the vigorous growth of the body and the stability of the frame. 
 The influences which develop the general strength, and produce strong mus- 
 cles 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 to induce disorders from which they suf- 
 fer themselves. The resemblance which a child bears to the parent in out- 
 
 *The Building of a Brain, by E. H. Clarke, M. D., 1875, P- 21. 
 
Il6 HEADACHES. 
 
 ward form and feature, ought to teach us how transmissible 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 regimen and appropriate 
 management, as we have seen exemplified in some members of a family who 
 have been reared differently to the rest. But asthma, emphysema, the heem- 
 orrhagic diathesis, tuberculous diseases, cancer, gout, and affections of the 
 skin, have a congential 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 disorders of the brain and nervous system, there are few 
 sensible parents who will not admit that headache is an affection more fre- 
 quently hereditary than almost any other. The nervous habits, and the ex- 
 citable 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 pre- 
 sumably vary in different instances. Sometimes, and especially 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, again, some peculi- 
 arity in the nervous system itself." * These considerations should counsel 
 prudence, and control the agencies at work which threaten domestic peace. 
 Surely the cautious parent ought to consider the cheerful or melancholy tem- 
 perament of his child, his mental as well as his bodily strength, and be 
 guided in his management accordingly. The gains and losses in life, the 
 competition and the struggles, should not be obtrusively thrust before him, 
 for the mind will realize early enough the bitter lessons of material exist- 
 ence. 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 in- 
 stant. 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 sorrow- 
 ful 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 are induced which years may never over- 
 come, even if the defective nutrition of the brain does not lead to those 
 pathological changes which affect the blood-vessels 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 im- 
 pedes the harmony of its actions, and henceforth invites those changes, 
 
 * Medical Notes and Reflections, Hereditary Disease, by Sir H. Holland, Bart., M. D., 
 F. R. S., i8S5,p. 37. 
 
 I " Children are heedless alike of the past and the future ; the present is enough for them." 
 — La Bruyere. 
 
HEADACHES OF CHILDHOOD AND EARLY LIFE. 11/ 
 
 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 constitutions in the springtide of life. When a child is fast growing 
 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 de- 
 fined 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. Cerebra- 
 tion is brain-exercise ; and brain-exercise strengthens and develops the 
 brain. But the brain is evolved from the organization, and, unless the lat- 
 ter is normal, the evolution is imperfect. Moreover, physiology informs us 
 that conscious, or, more properly speaking, volitional cerebration, should 
 not be attempted too early in life. In nature's order, the nervous system of 
 an individual is the last to attain its full development ; and, of the nervous 
 system, the cerebial ganglia reach maturity later than any other part. Ob- 
 viously the latter should not be put to work till they are capable of labor. 
 Without 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 appropriate 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 acquired 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 resem- 
 blance of the present to the past, the past coming back to him when a sim- 
 ilar subject is again presented to his mind, however remote the connection 
 may be. The power of acquiring knowledge or of forming habits is partic- 
 ularly strong in childhood, when the mind is flexible and plastic. Of all 
 periods of life, then, this is the one when impressions are most likely to be- 
 come 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 disuse. 
 
 The development of the human brain, like the wonderful organization of 
 the whole animal kingdom, is a subject of peculiar interest, proceeding on 
 that grand and harmonious design which the Almighty has instituted through- 
 out 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 dependence 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 
 
 *The Building of a Brain, by E. H. Clarke, M. D., 1875, P- 44- 
 
1 1 8 HEADACHES. 
 
 and posterior ganglia of the cord are sunk amid the substance of the hemi- 
 spheres (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 certain. We 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 education is neglected or imperfect. The 
 y brain requires exercise or it will waste, and the moral strength will decline 
 also if intellectual culture is abandoned. Take 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 re- 
 sponsibilities of his situation ; whilst the actions of the other are governed by 
 V selfish and ungenerous motives, or the ruling principle of his life is caprice. 
 No human being is so constituted as to be above physical 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 depressing 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 digestive 
 system is strong enough to assimilate sufficient nourishment to restore the 
 exhausted energies of the brain. We know his mental condition as he ap- 
 proaches convalescence. 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 men-^ 
 tal faculties have sustained a shock by the illness, and the disease has im- 
 paired or temporarily suspended the powers of memory, and obliterated 
 recent impressions. What he does 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 recovered from meningitis after many 
 months of shattered health. When 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 idleness 
 and inattention, but it was soon found that perseverance 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 
 
 * " The brain is clearer in \dgorous health than it can be in the gloom and miseiy of sick- 
 ness ; 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 perfonnance. Health sustained for many years is so use- 
 ful 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. 
 
HEADACHES OF CHILDHOOD AND EARLY LIFE. II9 
 
 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 knowl- 
 edge." At length, when his health was restored, "his lost impressions 
 suddenly returned to his mind, and he found himself at once in possession of 
 all his former acquirements."* I have seen some of the worst forms of 
 headache 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 cerebral symptoms were considerable), always suffered 
 from severe headache when he attempted to resume his studies ; and the in- 
 ference 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 irretrievably 
 damaged, and that he would possibly pass into a state bordering on idiocy. 
 
 The privation of active exercise and light amusements for children, by 
 enfeebling the digestive and assimilative functions, impairs the quality of 
 the blood, and thus disturbs and lowers the cerebral functions. The ntrv- 
 ous symptoms shown in petulance and irritability should be serious warn- 
 ings, 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 over-cultivation of the intellect, and in every instance where it arises 
 the studies should be cast aside and recreation 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 ener- 
 gies, and win back sleep to their worn-out intellect and wearied body. 
 "There appears 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. "f 
 
 Moderate occupation of the mind is healthy and beneficial ; excessive 
 work is nothing less than a curse. Both independent and prudential con- 
 siderations impress us with the conviction that no plausible reasoning can 
 support 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 common fault to be laid at the threshold of most ambitious 
 people is that they take it for granted that all their children have equal nat- 
 ural endowments, and that what the one acquires readily the other can 
 equally well accomplish. 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 con- 
 
 * On the Intellectual Powers, by J. Abercrombie, M. D. 
 
 I Hermann's Human Physiology, by Arthur Gamgee, M. D., F. R. S., 1875, P- 324- 
 
120 HEADACHES. 
 
 sider the advice 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 easily to him as the digestion of the daily meal which is provided 
 for his bodily support. Mathematical problems are solved with incredible 
 quickness, and geometrical principles are mastered in such a surprising man- 
 ner that the knowledge seems almost intuitive.* 
 
 Another child of the same parents, who is equally anxious and persever- 
 ing, may not have the same aptitude; he may have a feeble mind, and no 
 amount of culture and drudgery can ever place him in the front rank oi 
 scholars, or enable him to acquire more than commonplace facts. Books 
 are not the delight of his eyes ; the bent of his inclination is not in this di- 
 rection. He sees nothing to grasp at and acquire. His restless struggles to 
 overcome this inherent deficiency of mental endowment impair the structure 
 of a brain already weak, and too often end in miserable failure and disap- 
 pointment. We may awaken the child's interest and understanding in the 
 work he is set to accomplish, and render abstruse points clear by familiar il- 
 lustration ; but unless his natural powers are considerable, no plan of instruc- 
 tion can ever make him a great scholar. 
 
 The power of memory depends greatly on sound physical health; but also 
 on original difference of constitution, which ought to be taken into account, 
 some children being much more remarkable for the faculty of acquirement 
 than others. This does not appear to be invariably connected with super- 
 iority of intellectual endowments, for the facts thus readily acquired are not 
 seldom rapidly forgotten ; the memory is local, so to speak, and is not ac- 
 companied by a full perception of the facts, as where the attention is com- 
 plete, 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 manner, 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 listless 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 natnre, and the attention being aroused 
 by a pleasurable excitement, there is much less effort required to master the 
 subject. Some persons are gifted with reflecting minds, and they have the 
 habit of intense attention and correct association. They may be taciturn in 
 society, and be considered stupid and dull ; but they carry away a knowl- 
 edge 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. 
 
 * A case is mentioned by Dr. Carpenter of extraordinary mathematical 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. 
 
HEADACHES OF CHILDHOOD AND EARLY LIFE, 121 
 
 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 
 Avide one, continually before his mind. When any subject of inquiry is ex- 
 tensive and complex, it requires logical proof to enunciate the facts, and in- 
 volves protracted and laborious 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 incident 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 attainments, I am 
 convinced that a premature decay of the mental powers has been invited, 
 and decrepitude established years before such a calamity would have befallen 
 them in the ordinary course of nature. f What 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. | 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 obliterated the 
 bloodvessels. On making a horizontal section, the gray matter is not seen 
 altered, and the naked-eye view displays an increase in the amount of white 
 matter ; this, according to Rokitansky, is owing, not to an augmentation in 
 the number of nerve tubes, or their dimensions, but to the excessive develop- 
 
 * On the Intellectual Powers, by J. Abercrombie, M. D., 1871, 19th edition, p. 99. 
 
 ■j- " 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. 
 
 \ " There can be no doubt that many a child has been sacrificed in early life to the pride 
 of parents, who, delighted with the intellectual 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 been the cause of either a fatal issue or of 
 subsequent mental imbecility." — Solly, On the Brain, 2d edition, 1847, p. 662. 
 
1 22 HEADACHES. 
 
 ment of the intervening and nucleated substance or neuroglia."* Wilks and 
 Moxon, after stating that they have no special experience of this condition, 
 say that in the cases that have lately occurred, the hypertrophy was un- 
 accompanied 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 between the fibres. "f In adult life, as we have 
 previously seen,| when the ossification of the cranial bones is complete, the 
 cerebral contents are not liable to the same degree 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 conclusively 
 established that this disease is nwst 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 exhausting 
 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 smallness of the chest, and the large 
 size of the joints.; and the waste of whose nervous tissue, from over-anxiety 
 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 prose- 
 cution 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 keep- 
 ing their children 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 in- 
 struction, 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 daytime, headache, and loss of appetite are the 
 usual train of 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 anemic, the blood is poor and impoverished, and there is a 
 taint of consumption or scrofula in some of its forms. Some parents, in 
 seeking advice for a child, tell me that their children are so anxious and in- 
 terested in their school-work, that it is painful to keep them at home, but 
 the effects of allowing 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 
 
 * Jones and Sieveking's Pathological Anatomy, by Payne, 2d edition, Philadelphia, 
 Blakiston, 1875, p. 272. 
 
 •j- Pathological Anatomy, 2d edition, Philadelphia, Blakiston, 1875, P- ^i^- 
 J See Chapter I., on the Headache of Cerebral Anaemia. 
 
 II 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 filteen causes, and exceeded the deaths from old age by upwards of 2000, 
 which comes next on the list. Nervous diseases are also fearfully on the increase, and are 
 fifth in order. Convulsions, nearly all among children, realize the high figure of 27,139, 
 and is fourth on the list. It exceeded the deaths from epidemic and zymotic diseases, as 
 scarlet fever, measles, whooping-cough, and diarrhoea, which strike down such a large pro- 
 portion of our juvenile population. 
 
HEADACHES OF CHILDHOOD AND EARLY LIFE. 1 23 
 
 doubt, the girls, from the fact that they are girls, are more liable to suffer 
 than boys."* Now this in many cases is caused by the physical health be- 
 ing 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 gen- 
 eral health had received a full share of attention, and the culture 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 disastrous. When the health is robust, the 
 brain tolerates sustained attention with impunity, particularly if the exercise 
 goes on unconsciously (as in the pursuit of pleasure), for then the brain 
 escapes the fatigue which is the certain accompaniment of effort. The men- 
 tal 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 property of the brain to feel every debilitat- 
 ing power in the smallest degree, and to call into active operation the excit- 
 ability of the whole vital system. Impressions made upon the brain by 
 over-exertion, when the body as a whole is in a state of debility or exhaus- 
 tion, invite a degree of excitement or stimulation, which proportionately 
 distresses and weakens it. In consequence of the presence of irritation in 
 distant and overtaxed organs, the brain is affected, and its functions are 
 suspended or excited according to the amount of mischief which determines 
 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 alter- 
 ations which take place in nerves during exhaustion have not yet been made 
 out" (Hermann). The separate functions of life cannot long be main- 
 tained in health, under any degree of excitement, without exhaustion being 
 sooner or later felt in the entire organism. Every disturbance 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 compli- 
 cated 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 tradition 
 
 * School Hygiene, by Dr. Frederick Winsor, Winchester, Massachusetts. 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 increases from one year old up to twenty. Be- 
 tween 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 distinguished themselves by their talent is often large. The brain of Cuvier weighed 
 4 lbs. II oz. 4 dr. 30 grains, troy weight. The brain of an idiot, fifty years of age, weighed 
 but I lb. II oz. 4 dr. The female bi-ain usually is lighter than the male. It varies between 
 2 lbs. 6 oz. and 3 lbs. 1 1 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 perceptible in the new-born child." — Solly, O71 the B7-ain, 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 Euro- 
 pean 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 (Jour- 
 nal of Medical 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 
 Physiology, by Power, 8th edition, 1876, p. 786. 
 
1 24 HEADACHES. 
 
 is not a mere fancy or superstition, but is founded on the every-day exper- 
 ience of people who have seen the facts for themselves, and who are not 
 simply bent on propounding a theory. Parents may equally take warning 
 from the fact that mental strain encouraged to excess in delicate children is 
 almost certain to entail disastrous consequences. If such children are ab- 
 surdly pressed by 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 afterwards rises above the level of mediocrity. 
 
 According to Professor Laycock, precocious children are usually of the 
 strumous type, which he terms an approach 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 engaged in education : 
 When 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 adop- 
 tion 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 imfolded, 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 may be 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 pressure may 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 between the strong vigorous child 
 who can bear the pressure, and the weak excitable child who is probably of 
 the two the more willing and anxious to learn. Looking at the physical 
 health of a child as a means of judging 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 facul- 
 tses, 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. When it does commence the nervous system is dis- 
 turbed, and convulsive affections not unfrequently ensue. Now, if convul- 
 sions 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 point of view, the most important 
 period of childhood — the period when educational training should be cau- 
 
HEADACHES OF CHILDHOOD AND EARLY LIFE. 1 25 
 
 tiously proceeded with, because then the physical growth is very active, and 
 the animal functions are proceeding 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 subjects 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 {Carpenter'' s Hinna?i Physiology, page 1105). 
 During childhood the digestive organs are very active, and derangements 
 which are brought about by perverted nutrition are especially common. If 
 disorders of the digestive organs become chronic, any trifling cold may pro- 
 voke an inflammatory attack, and hence tuberculous diseases are frequent, a 
 latent strumous diathesis being called into activity. Any immoderate intel- 
 lectual training at a time when the digestive organs are enfeebled, and the 
 appetite 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 physi- 
 cal health in both cases had not reached that standard of strength, or perhaps 
 could not reach it, which admitted of any tension or concentrated employ- 
 ment 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 ex- 
 pense, and at the possible risk of a complete breakdown. 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 compara- 
 tively quiescent. How frequently does it happen that a long and trying ill- 
 ness 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 headaches: 
 (i) Cerebral headache, attributable to injury, or to acute or chronic 
 inflammation. 
 
 (2) Gastric headache, from intestinal and hepatic derangement, known 
 as bilious headache {sympathetic headache'). 
 
 (3) Epileptic headache {congestive headache). 
 
 (4) Febrile headache {active hyperce7fiia or active congestion). 
 
 (5) Headache from ansemia, neuralgia, etc., constituting nervous head- 
 ache. 
 
 (6) Headache depending on some intricate change in the cerebral mem- 
 branes or tissues of the brain. 
 
 (7) Organic headache. 
 
 (i) 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, 
 
126 HEADACHES. 
 
 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 en- 
 feebled 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 exclusively in this situation, 
 and when it has been severe, the pain in the forehead has been less intense 
 and overpowering. No degree of pain in the back of the head, according 
 to my experience, produces such vital prostration 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 expression ; the eyes 
 are sunken in the orbits, and move sluggishly ; 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 constipation. 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 Avill doze in the daytime and sleep soundly at night. Petulance 
 and irritability are not features of this condition, the nerve-centres not being 
 so much involved Tat 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 careful and guarded. Trifling excitement may set up inflamma- 
 tory action, or renew the congestion, which it is so necessary to remove 
 before the brain has sustained irreparable injury. For this congestion, be- 
 coming localized, may lay the foundation of a tumor or morbid growth, and 
 our attention in after years is not directed to the injury till continuous or 
 paroxysmal pain in the head, loss of power in the limbs, defective vision, or 
 obstinate vomiting, indicates the presence', of serious mischief in the brain. 
 If the case goes on, the general weakness increases, and the child is laid up, 
 giving every one the idea, by his looks and manner, that he is laboring 
 under disease of the brain. Any indiscretion in diet causes flushing 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 tendons, 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 convulsions or coma usher in death. 
 After death, in such cases as these, there may be presented on a post-mortem 
 examination 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 
 
HEADACHES OF CHILDHOOD AND EARLY LIFE. 12/ 
 
 excessive congestion. When the symptoms of meningitis are well marked 
 in young children, they may generally be assigned to tubercle. If there i.s 
 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 excitement or after food ; the limbs waste ar.d 
 become powerless, 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 injury has been so slight as to provoke into ac- 
 tion a slumbering 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 symp- 
 toms 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 appreciative 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 occi- 
 put and the muscles are stiff. If the child is not old enough to complain, he 
 will often raise his hand teethe back of his head to indicate the seat of mis- 
 chief. 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 con- 
 vulsion six months previously. About three months before I saw him he 
 struck his head ; and, although no bad consequences 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 unconscioness passing into deep coma. 
 
 (2) Gastric Headache (Sympathetic Headache). — This is not uncom- 
 mon in children, from errors in diet and over-feeding; 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 in- 
 stance, 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. Where the brain is affected vomiting is a constant 
 symptom, and in those who die the mucous membrane and its larger ex- 
 tremity is found digested, or dissolved by the gastric juice — a proof that 
 the irritation of the brain excites, at least in many cases, untimely secretion 
 of gastric acid (Budd, 07i 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 epigastriumi, there 
 is in most cases severe pain in the head. This disease also occurs in chil- 
 dren from tubercular disease of the lungs, and it is not uncommon during 
 the first dentition, at the time of weaning, if they have been reduced by the 
 eruptive fevers, or by improper food and impure air. They are thirsty and 
 fretful, the vomited matters are sour, and the bowels loose and the motions 
 greenish. Exhaustion may set in with coldness of the surface, and death. 
 In infants the gums should be lanced, and a diet of milk given, or a wet- 
 nurse procured, as the case may be ; and bismuth, magnesia, logwood, and 
 
128 HEADACHES, 
 
 krameria given, with aromatic spirits of ammonia, hydrocyanic acid, 
 morphia, etc. It is most common in children who are reduced by previous 
 ilhiess, and who are fragile and excitable. In many cases of this sympathetic 
 disorder, there is no remedy that will give relief till the irritatioa of the blood 
 and brain subsides. The stomach secretes unhealthy mucus, which causes 
 fermentation in the starchy principles of the food, and lactic acid is formed, 
 which disturbs both stomach and bowels. The gases generated by the 
 stomach where flatulence exists are carbonic acid, nitrogen, and sulphuretted 
 hydrogen ; and there is nearly always headache in these cases. 
 
 These headaches in children are constantly due to the choice of food and 
 drink, and to preserve health and strength it is obvious that the supply 
 should be in suitable proportions, according to age, sex, and occupation. 
 " Thus we may estimate that a child of eight or nine years of age, as con- 
 trasted with a full-grown adult, actually gives off, relatively to the weight of 
 its body, one and a half times as much carbonic acid ; and the same rule 
 probably applies to its urea."* It stores up in its body a larger portion of 
 the constitutents of its food, and a smaller quantity of effete matter is 
 dismissed from its body by the various emunctory functions ; and it con- 
 sequently becomes apparent why the food in the case of children should be 
 purer and easier of assimilation than in adults, whose powers of assimilation 
 are so much stronger, and are capable of chemically converting into the 
 textures of the body ingredients which the feeble power of digestion in 
 young children is incapable of transforming. "The morphological and 
 chemical changes, for example, which transform the cartilaginous femur of 
 the infant into the bone bearing the same name in the adult, imply such 
 large and incessant demands on the part of its organism for lime, magnesia, 
 and phosphoric acid, as may well suggest the possible magnitude of the 
 contrast in the proportions of these inorganic substances required to be 
 present in its food. Nor does the circumstance that such a contrast is 
 probably only quantitative, much affect the deducible result. "f 
 
 (3) Epileptic Headache (Congestive). — The headache that accompanies 
 epilepsy is deserving of some consideration ; and to those who are the un- 
 fortunate subjects of it, it will be found a frequent and distressing symptom. 
 Drowsiness, lethargy, heavy sleep, disturbed dreams, and want of animation, 
 are premonitory symptoms of the attack, so frequent as not to be disregarded. 
 But headache is more commonly a consequence of the attack, and as such it 
 chiefly concerns us at present. Of fifty-six cases recorded by Dr. Sieveking 
 in which headache occurred, it was constant or frequent in twenty-eight 
 cases; it occurred before the fits in four cases only, after the fits only in 
 twenty-two cases, and it occurred both immediately before and after the 
 seizure in three cases. | These headaches are of a congestive character, and 
 they present a different class of symptoms in some cases to what they do in 
 others. If the epileptic is of the sanguine temperament, and of full habit, 
 the headache is accompanied by heat of surface, throbbing of the temporal 
 vessels, and fulness of the veins about the scalp; the face is some- 
 times flushed and the eyes suffused, the patient cannot bear the ap- 
 proach of light, and if he sleeps he wanders and is disturbed and restless. 
 This condition, in fact, is an acute form of congestion or hypersemia of the 
 vessels, such as we get in the headache which attends the early periods of 
 
 *On Food and its Digestion, by W. Brinton, M. D., 1861, p. 426. 
 f On Food and its Digestion, p. 427. 
 \ On Epilepsy, 2d edition, p. 59. 
 
HEADACHES OF CHILDHOOD AND EARLY LIFE. 1 29 
 
 some acute diseases, as pneumonia, whooping-cough, and that which I shall 
 next describe as feb7'ile headache. In other cases, again, the congestive 
 headache is more passive. It is better described as passive hypersemia, on 
 which we have dwelt in an earlier chapter. The effect of the epileptic par- 
 oxysm is to disturb the equilibrium of the circulation, and to induce relaxa- 
 tion in the vessels, while a tardiness of the circulation springing from the 
 central organ of life — the heart — favors a blood stasis in the sinuses and ves- 
 sels of the brain. That epilepsy should induce severe headaches when the 
 attacks are frequent is just what we might reasonably anticipate, seeing that 
 the effect of repeated paroxysms is to damage the nervous substance of the 
 brain, to impair the memory, and to lead in some instances to idiocy, or 
 even dementia. 
 
 I have met Avith most agonizing cases of headache in children the subjects 
 mitral regurgitation or insufficiency. In one case which was under my care 
 at intervals for upwards of three years, the suffering was acute and unremit- 
 ting ; the poor girl presented the appearance of a much older person, the 
 cheeks had a dusky crimson flush on them, and the brain was habitually 
 overloaded with venous blood. The superficial veins of the neck and scalp 
 were distended, and the temporal arteries throbbed violently, for the oc- 
 casional epistaxis, which had brought relief from time to time, had long 
 since ceased to recur. Active purgation, by means of a grain of calomel at 
 night, and a febrifuge and saline aperient, failed on some occasions to give 
 relief, and I was compelled to leech the temples, which for a time lessened 
 the tumultuous action of the heart, and alleviated the headache. 
 
 Treatnwnt. — This must be regulated according to the strength and consti- 
 tution of the patient. If the child is of a nervous disposition, the surface 
 pale, and the circulation languid, small doses of strychnia with a mild prep- 
 aration of iron will be useful, by increasing the tone of the system generally, 
 and a stimulating liniment at the back of the neck will relieve the headache. 
 The extremities should be kept warm, and moderate exercise encouraged. 
 Sponging the body with Tidman's sea salt will be beneficial ; it improves 
 the force and character of the capillary circulation, and in some degree re- 
 moves the liability to headache and cerebral congestion. In the case of 
 stronger children a calomel purge, followed by a saline aperient in the early 
 morning, will be necessary, if the bowels are disordered, or worms are sus- 
 pected. Sulphate of zinc, in a bitter infusion, is a remedy worth trying in 
 some cases : it improves the appetite, and imparts a degree of vigor to the 
 digestive functions which relieves the oppressive headache. If, however, 
 the headache is continuous and acute, bromide of potassium alone, or com; 
 bined with bark, ammonia, or valerian, will be advisable till its severity is 
 mitigated ; and when the pulse is quick and unsteady, or anaemia is present, 
 digitalis with iron may have a beneficial effect, by reducing the venous ful- 
 ness and promoting the force of the arterial current. 
 
 (4) Febrile Headache. — I speak of this variety of headache because the 
 brain is active and susceptible in young persons, and the circulation being 
 additionally excited by the fever process, the vessels convey a larger quan- 
 tity of blood to the brain than they do in health. If the subjects of fever 
 are robust and strong, the hyperemia of the vessels is all the greater. In 
 typhus fever the headache is frequently most intense — dull and heavy across 
 the forehead and in both temporal regions. Sometimes the pain extends 
 over the whole head, and is not confined to the vertex or occiput; nor is it 
 so throbbing, darting, or bursting as in relapsing fever or the headache of 
 some other febrile disorders. In the typhoid fever of children there is usu- 
 ally dull frontal headache, and the mental faculties are disturbed ; some- 
 
1 30 ' HEADACHES. 
 
 times delirium or convulsions ensue, but more frequently there is a moder- 
 ate degree of headache during convalescence, if the patients have exerted 
 theinselves too much, or have been awake too long, or without food. In all 
 acute diseases we should be on the lookout for headache, as it is of common 
 occurrence in pneumonia, bronchitis, whooping-cough, and the various 
 exanthemata. I have observed it extremely severe in scarlet fever and 
 measles, particularly before the eruptive stage is fully developed. 
 
 In the treatment of headaches complicating these febrile affections, a few 
 leeches to the head, cold affusion, or the ice-cap, will sometimes be advis- 
 able to control the vascular excitement within the head, and reduce the 
 activity of the cerebral circulation; whilst the specific diseases on which 
 they depend must receive proper attention. 
 
 (5) The headache of ancemia, neuralgia, etc., may be classified as nervous 
 headache, and the description given in the first and. seventh chapters will be 
 found to include all that is important under this variety in children. 
 Neuralgic headache ■as.Mally aS^acis those of a timid and delicate constitution, 
 and if they have been reduced by acute or chronic disease, it is readily 
 excited in them. I have met with it in boys and girls whose intellects have 
 been overtaxed during study and confinement to long and wearisome lessons. 
 It is also induced by indoor confinement and bad air, though it is not so 
 common from these causes as the congestive form of headache, in which the 
 vessels are over-distended. Dr. West says: "It does not by any means 
 depend on overstudy, though I do not ever remember meeting with it in 
 children who have not yet gone into the schoolroom ; and I have frequently 
 found it dependent on too continuous application, though the number of 
 hours devoted to study in the course of the day may not have been by any 
 means excessive."*- From my own experience I have certainly observed it 
 quite as often among children whose intellect has not been overtried, or even 
 exerted at all ; and I am inclined to the view that any depressing causes, or 
 unhealthy surroundings, are capable of exciting it into action. I have seen 
 a bad attack in a boy, aged fifteen, whose nervous system was reduced by a 
 long, and trying local disorder. Neuralgia of the ophthalmic and temporal 
 branches of the fifth nerve, succeeding lymphatic obstruction and painful 
 muscular spasms in one lower limb, were experienced on several occasions. 
 He was often kept awake at night, and had become so nervous, that sleep 
 could not be obtained till he took some brandy and water, and the attack 
 was only removed by a generous diet, and full doses of quinine three times 
 a day. Whenever at his best time he took a longer walk than he was able 
 to accomplish with comfort, he was liable to headache. I have known fear- 
 ful neuralgia to come on in delicate girls of thirteen or fourteen, who are 
 approaching the catamenial period, but in whom it has not appeared, or is 
 delayed, particularly if the intellect has been strained, especially where the 
 temperament is over-anxious. These patients are more frequently seen in 
 the out-patient department of our hospitals than in private practice, for poor 
 living is a great determining cause. They are pale and anaemic, and some 
 of them have been thrust into situations of hard work, which they have not 
 the strength to fill ; and if there is cough and loss of appetite, a consumptive 
 tendency can be frequently detected. 
 
 A case of supraorbital neuralgia is recorded by Mr. Nunn in a young lady 
 about eleven, which yielded to lancing of the second molar tooth. f A 
 
 *0n Some Disorders of the Nervous System in Childhood (Lumleian Lectures, 1871), 
 P- 15- 
 
 f See a paper on Irrritation of the Dental Nerve, in British Medical Journal, May 5th, 
 1877. 
 
HEADACHES OF CHILDHOOD AND EARLY LIFE. 1 3 I 
 
 similar case also came under my own notice in a girl of ten, who had suffered 
 very severe headache for many weeks. The first molar tooth on the left side 
 was extracted, and from that time the patient began to recover. Headache 
 from dental caries is more rare in children than adults. 
 
 In one case that came under my care in October, 1876, pleurodynia was 
 added to the acute supraorbital and temporal pain, and there was a fearful 
 degree of apprehension and nervousness. This assemblage of symptoms was 
 mainly brought about by the ordinary causes which induce anaemia. In the 
 case of a little girl, eight years of age, who first came under my care in 
 November, 1876, with cardiac spasm (angina pectoris), there was pallor of 
 the face, weak pulse, and headache of a neuralgic character supervening. If 
 the second dentition is delayed, and the teeth are slow in appearing, 
 neuralgic headache, involving the branches of the fifth nerve as they ramify 
 over the brow and temple, is oftentimes very acute in boys and girls. The 
 symptoms which denote neuralgic headache are localized pain in one temple, 
 or half of the forehead, coming on in paroxysms; very frequently it is situ- 
 ated over the brow, or supraorbital ridge, and the ball of the eye is tender. 
 The pain seldom extends across the forehead, but remains limited to one 
 side of the head, and either passes superficially beneath the muscles of the 
 scalp to the occiput, or in stabbing paroxysms through the eye itself, in the 
 same direction. Vomiting is not a frequent symiptom, nor yet the disposi- 
 tion to refuse food ; but when the attack is severe, and one eye is much 
 affected, there will be nausea and sickness, tears will course down the cheek, 
 and light and sound will increase the suffering. Sometimes this is so violent 
 that the patient has fainted away, and the timidity of the child's nature has 
 been so nurtured by it, that it could not sleep alone, or be left in the room 
 at night without a candle. Sometimes the pain will come on in the morn- 
 ing, and depart after a good meal, or it will occur in the evening when the 
 child is exhausted, and ought to be in bed. The pulse is usually small, 
 excitable, and quick, or even intermittent, and the emotions are so sensitive 
 that the child will cry at the expression of any word that savors of the least 
 harshness. When the pain is of such continuance as to reduce the child's 
 health, the intestinal secretions are disordered, and the urinary secretion is 
 excessive, or it abounds in lithates. The whole expression is one of languor 
 and exhaustion, and the child is incapable of any mental exertion. In the 
 intervals of pain there may be a full display of cheerfulness, and the stupor 
 and indifference which betoken organic disease of the brain are absent. The 
 attacks are not of long continuance, and they pass away entirely, leaving the 
 patient quite cheerful, to return again in a week or fortnight. 
 
 I do not think we ought to make a mistake in diagnosis, though in some 
 cases it is perplexing, where the symptoms are not so marked as I have 
 described, and especially in very young children about the period of their 
 first dentition, in whom neuralgia is sometimes met with. Nervous affections 
 and general increase of sensibility are common enough in young children 
 about this time, or in older children after a long and exhausting illness, as 
 chronic diarrhoea or typhoid fever. We should be cautious to ascertain 
 whether the pain in the head is continuous and unremitting, before we com- 
 mit ourselves to an opinion, or carry out any plan of treatment. Having 
 made out our diagnosis, and satisfied ourselves that the cerebral tissue is not 
 implicated, we do not in any way become anxious about a neuralgic seizure, 
 for though it robs life of much enjoyment, it does not tend to shorten it, 
 and in these cases it passes off as the health improves. Severe pain, local 
 and either continuous or recurrent, if attended with nausea, vomiting, or 
 constipation, ought to put us on our guard against meningitis or cerebral 
 
132 HEADACHES. 
 
 tubercle; nor should these symptoms delude us if they pass off, for they may, 
 notwithstanding, be due to lurking organic mischief, and have a fatal termi- 
 nation at no distant period. Many years ago I met with an instance of 
 headache in a girl fourteen years of age, chiefly frontal, which had continued 
 on and off for months, and caused, as headaches often do, no anxiety among 
 the parents. When the head was very painful, the child was kept from 
 school, and when the suffering passed away, school-work was resumed, the 
 health of the child being at all times delicate. After the headache had 
 troubled her more or less for a year, inflammation of the meninges accom- 
 panied by convulsions set in, and the child lost her life. There were no 
 gastric symptoms present to attract attention to the stomach, and the head- 
 ache, undoubtedly due to cerebral exhaustion in the first instance, was 
 followed by inflammatory action which could not be traced to tubercle. 
 
 Treatment. — This consists in enforcing rest, if educational zeal has been 
 carried too far, and getting the general health amended in every possible way, 
 that the nervous tissue, may be improved, and degenerative changes pre- 
 vented. Quinine, cod-liver oil, fresh air, and absolute rest of mind and 
 body, are important at this early period of life. For the medical treatment, 
 the plan to be adopted is much the same as that recommended in the chapter 
 on neuralgic headache in adults, and the formulae in doses suitable to the 
 age of the child will be equally appropriate.* Dialyzed iron, either in the 
 character of syrup, or an aqueous solution, is an excellent preparation where 
 it is sought to improve the quality of the blood, and to remove the anaemia 
 (Form. 24 a). As it is almost tasteless, no child will refuse to take it, and, 
 unlike many other preparations of iron, it is readily absorbed, causing 
 neither indigestion nor constipation. 
 
 (6) Headache depe7iding on some intricate Change in the Cerebral Mem- 
 branes or Tissues of the Brain. 
 This condition I have oftener observed among hospital out-patients than 
 in private practice. The children are generally from three to eight years of 
 age ; they gradually fall into a delicate state of health, and cause anxiety in 
 the minds of their parents. In some cases there is the hereditary tendency 
 to struma and consumption, nervous disease, or syphilis; in other instances, 
 irregular and drunken habits on the part of the father have implanted a lia- 
 bility in his child's constitution to take on nervous disorder. Frontal head- 
 ache is the first symptom of which any complaint is made; the child is 
 lethargic and indisposed for exertion, the mind strays and wanders from any 
 pursuit or occupation, and the intelligence is dull and totally incapable of 
 strain or concentration. The child's disposition is much changed ; if he has 
 been bright and cheerful before the illness overtook him, he is now listless 
 and dull, or he is so excitable that, if thwarted in his plans or wishes, he 
 becomes exceedingly fretful and quarrelsome. When playing with his com- 
 panions, he is liable to outbursts of passion, and goes into such a state of 
 frenzy that he may inflict bodily harm on those about him. After a fit of 
 temper, or looking over a book, the child will suddenly become drowsy, and 
 rest his head on a table or chair, and fall off to sleep. It is the sleep of 
 exhaustion, but quiet and profound; the skin and head are often perspiring, 
 and when he awakes he is unrefreshed. At night he is restless, tossing off 
 the clothes, and in the morning is fretful and irritable, as though the sleep 
 had done him no good. The pulse is soft and quiet, occasionally intermit- 
 tent, but there is an absence of cardiac disease; there is no sickness and no 
 
 * See Chapter XV., on Neuralgic Headache. 
 
HEADACHES OF CHILDHOOD AND EARLY LIFE. 1 33 
 
 elevation of temperature ; the tongue is clean, and the bowels regular, or 
 disposed to constipation. In fact, it is not a condition of meningitis, though 
 there is no reason whatever why such cases in pursuing a downward course 
 should not lead to inflammatory mischief in the brain or membranes. Rather, 
 the tendency is to cause an ansemic state of the blood and tissues, and an 
 increase of serum in the lateral ventricles, and beneath the arachnoid, or 
 between the sulci of the convolutions. If this goes on, the head occasion- 
 ally gets larger at the sides and more prominent at the forehead, and this 
 appears all the more obvious as the child loses flesh and the face shrinks. In 
 rickety children this headache is not uncommon, and recovery is the more 
 slow and tedious. I have observed it among boys who are fond of school 
 and books, particularly if they are of a nervous or sensitive temperament, 
 when they become overanxious with their studies, and this worry is very pre- 
 judicial to the nervous system. If the health is naturally delicate, and the 
 food unwholesome, and the boys are deprived of air and exercise, they are 
 the more likely to be victims to this form of suffering. As to the pathology 
 of this affection, there can be no doubt of its being one of exhaustion, and 
 the cerebral texture is more exsanguine and less firm than in health. I 
 think there is nothing incompatible with recovery, if the blood improves in 
 quality, and the brain is better nourished. Pure air, wholesome food, and 
 proper medicine will be required. Whilst the pain lasts, and the excitabil- 
 ity of the nervous centres is great, there is no remedy like bromide of potas- 
 sium, combined with small doses of belladonna, and, in some cases, with 
 iodide of potassium. If bark or quinine is ventured on too soon, the head- 
 ache returns with its former violence ; and the same will happen if iron or 
 strychnine is had recourse to before the brain is strong enough to bear a 
 sudden influx of blood into its vessels. 
 
 (7) Organic headache in children arises from the same set of causes as in 
 adults. Any morbid growths from the bone or membranes, or from the 
 white or gray substance of the brain itself, usually induce severe pain in the 
 head, and such physiological symptoms as serve to indicate with tolerable 
 accuracy the situation of the mischief. Unfortunately, the condition in too 
 many instances defies all treatment from medicine, and surgery is equally 
 powerless. Cancerous or fungoid growths may spring from the dura mater, 
 and in extending outwards cause absorption of the bone, and elevation of 
 the tissues of the scalp, resembling an encysted tumor. When interfered 
 with, they cause convulsions and death. These growths rarely implicate the 
 bones, which often present obstruction to their progress, but at times the 
 hardest structures do not oppose the direction which they take. Tumors 
 having this perforating tendency may also grow from the diploe, and even 
 from the cellular tissue beneath the arachnoid and pia mater, and from the 
 cerebral substance itself. It is a curious fact connected with these tumors, 
 that they often attain considerable size before they produce any disturbance 
 in the functions of the brain ; and post-mortem examination has occasionally 
 revealed their presence in the substance of the brain, when no symptoms to 
 attract attention to the brain have been observed during life. This de- 
 pends in a great measure on the situation of the tumor, for one which is im- 
 bedded in the substance of either hemisphere, and does not press on the 
 sinuses, or falx, or tentorium, is less likely to cause pain or uneasiness.* 
 
 * A case is related by Andral where an osteo-fibroid tumor was attached to the tentorium, 
 and this caused such pressure on the cerebellum as to diminish its volume, and change its 
 texture into one of extraordinary hardness. The tumor was traced to a fall four years be- 
 fore death, and the leading symptoms were no uneasiness at the time of the accident, but 
 later on a dull pain at the left part of the occipital bone; giddiness from time to time, and 
 
1 34 HEADACHES. 
 
 Even a cancerous tumor may arise as a primary disease in the brain of a 
 child, and pursue a slow and tedious course, setting up no disturbance, un- 
 less by increasing growth or pressure it should involve the membrane and 
 excite inflammation. A case of this kind is related by Mr. Solly, in a child 
 only four years of age.* The chief symptoms Avere drowsiness and inactivity 
 for some months, followed by an epileptic seizure. Under the use of mer- 
 curials and purgatives, the child apparently got well, but after a time he " 
 became again sleeply and forgetful ; his intellect was impaired, and he died 
 at the end of six months from the time of the epilepsy. After death a tu- 
 mor was found in the posterior lobe of the left hemisphere, the size of a 
 hen's egg. Neither the membranes 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 fre- 
 quently 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,, continuous 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 convolutions, 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, f severe headache with 
 vomiting, constipation, impairment of intellect, convulsive movements, paral- 
 ysis or coma, disturbance of vision, etc., are the prominent symptoms of 
 headache due to organic change. 
 
 occasional loss of consciousness for a few moments. Later on, the upper extremity of the 
 right side was attacked with a painful tetanic shock. Five or six of these shocks followed 
 each other rapidly, and then intervals of months elapsed ; then they became more frequent, 
 limited to the nght arm, and paralysis of this limb came on, at first transient, and afterwards 
 more complete. The right lower extremity also lost the power of motion, but there was no 
 convulsive movement. — Solly, On the Brain, p. 647. 
 
 * Solly, On the Brain, p. 648. 
 
 •j- See Chapter XIV., on Organic Headache. 
 
FORMULA. 
 
 (i) R. Potass. Citrat., 9j. 
 Inf. Digitalis, 
 Inf. Buchu, aa ^ss. 
 Misce. — To be taken three 
 times a day. 
 In ursemic headache, with deficient 
 renal action. 
 
 (2) R. Potass. Citrat., Qj. 
 
 Spt. Juniperi, 33. 
 
 ^ther. Nitr., n^^xx. 
 Decoct. Scoparii, §j. 
 Misce. 
 In the same cases as the above. 
 
 (3) R. Potass. Bitart., ^ss. 
 
 Syr. Limonis, §ss. 
 Aquje 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 purse, 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 ansemia, where the 
 headache is due to renal congestion, 
 and in some forms of syphilitic head- 
 ache when the cachetic state is well 
 marked. 
 
 (5) R- Quinise Disulph., gr. x-gr. 
 
 XV. 
 
 Acid. Sulph. Dil., n\_x. 
 Syrupi , gij. 
 
 Aquae, ad gjss. 
 Misce. 
 
 (I 
 
 To be taken in headache from ma 
 larial poisoning, two or three hours 
 before the expected paroxysm. Af- 
 terwards, a third part three times a 
 day till cinchonism is produced. (Dr. 
 Smith.) 
 
 (6) R. Liquor. Fowleri, 
 
 Tinct. Belladonnae, aa^j. 
 Aquae purae, ad §jss. 
 M. Sig. — A teaspoonful in a 
 wineglassful of 
 water three times 
 a day. 
 In the same cases, where the head- 
 ache recurs from time to time. 
 
 (7) R- Quiniae Disulph., gss. 
 
 Acid. Arseniosi, gr. j. 
 Nitric. Dil., 3J. 
 Aquae purse, ad §j. 
 M. Sig. — Thirty drops in a 
 wineglassful of 
 water three times 
 a day after food. 
 In similar cases to the above. (Dr. 
 Routh's formula for giving Arsenic.) 
 
 (8) R. Liquor. Cinchonae, tt|^xx. 
 
 Fowleri, rr^v. 
 Aquae purae, ad 5J. 
 M. Sig. — To be taken three 
 times a day after 
 food. 
 In neuralgic headache and cerebral 
 anaemia. 
 
 (9) R. Liquor. Fowleri, 3J. 
 
 Tinct. Quinis, 3jss. 
 Mist. Camph., ad §vj. 
 M. Sig. — §ss three times a day 
 in a little water 
 after food. 
 In neuralgic and periodic headache. 
 
 35) 
 
136 
 
 FORMULA. 
 
 (10) R. Liquor. Potass. Ars., 5J. 
 Tinct. Quinice, 5Jss. 
 Hydr. Bichlor., gr. ss. 
 Aquas, ad §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) B. Liquor. Potass., Ars., 
 Potass^, aa 3]. 
 Tinct. Colchici, ^ij. 
 
 Lavand. Co., ^iij. 
 Aqu« purse, ad gvj. 
 Misce. — A tablespoonful in 
 a wineglassful of 
 water twice a day 
 after food. 
 In neuralgic headache associated 
 with the gouty diathesis. 
 
 (12) B. Tinct. QuiniEe, 3xiv. 
 
 Spt. Chloroformi, gij, 
 
 Misce. — A teaspoonful in 
 
 a wineglassful of 
 
 water twice or 
 
 three times a day. 
 
 In neuralgic and nervous headache. 
 
 (13) B. Tinct. Quinise, ^vj. 
 
 Potass. Bromid., oJ^SU- 
 Glycerini, ^ij. 
 Mist. Camphorae, ad §vj. 
 Misce. — A sixth part twice or 
 three times a day. 
 In neuralgic and nervous headache. 
 
 (14) B. Acid. Hydrobromici, ^vj. 
 Quinise Disulph., gr. xij. 
 Inf. Gent. Comp., ad gxij. 
 J^Iisce. — Two tablespoonfuls 
 twice or three times 
 a day. 
 In neuralgic and nervous headache, 
 where Quinme alone disagrees. 
 
 (15) B. Sodse Bicarb., 
 
 Bismuth. Subcarb., 
 Pulv. Acacise, aa jj. 
 Spt. Amm. Arom., gij. 
 Syr. Zingib., ^iij. _ 
 Aquae purae, ad gviij. 
 Misce. — Two tablespoonfuls 
 three times a day 
 half an hour before 
 food. 
 In dyspeptic headache with flatu- 
 lence, acidity, and pyrosis. 
 
 (16) B. Amm. Carb., gr. iv. 
 
 Aquae, gj. 
 Misce. — To be taken every 
 three or four hours. 
 In dyspeptic, neuralgic, and nerv- 
 ous headache, and in some forms of 
 gouty headache. 
 
 (17) B. Spt. Amm. Arom., ttlxI. 
 
 Chloroformi, rrLx. 
 Aquae, ad ^j. 
 Misce. — To be taken every 
 three hours. 
 In dyspeptic and^nervous headache. 
 
 (18) B. Sodae Citro-Tart. Efferv., 
 
 3j-3ij. (B. P.) 
 To be taken whilst effervesc- 
 ing 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) B. Magnes. Sulphat., 3vj. 
 
 Carb., 5j. 
 Tinct. Lavand. Co., giij. 
 Aquae Menth. Pip., ad gviij. 
 Misce. — A sixth part to be 
 taken early in the 
 morning, and re- 
 peated as may be 
 necessary. 
 In dyspeptic and bilious headache 
 with flatulence. 
 
FORMUL/E. 
 
 137 
 
 (20) R. Quinise Disulph., gr. xij. 
 Acid. Sulp. Dil., gss. 
 T. Ferri Perchlor., .^^ij. 
 Spt. Chloroformi, jij. 
 Magnes. Sulph., gjss. 
 Syr. Zingib.,^j. 
 Aquae, ad ^xij. 
 Misce. — Two tablespoonfuls 
 three times a day. 
 In neuralgic headache with consti- 
 pation. 
 
 (21) R. Syr. Ferri Phosph. et Quin. 
 
 ise et Strychniae, 5Jss. 
 
 Misce. — A teaspoonful in a 
 
 wineglassful of 
 
 water three times a 
 
 day after food. 
 
 In neuralgic and nervous headache. 
 
 (22) R. Syr. Ferri Hypophos., gjss. 
 
 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. 
 
 (22a) R. Syr. Ferri et Calcii Lacto- 
 phosph., §ij. 
 Misce. — One or two teaspoon- 
 fuls in a wineglass- 
 ful of water twice 
 a day after food. 
 Fifteen or twenty 
 grains of bromide 
 of potassium or 
 ammonium may 
 sometimes be add- 
 ed to each dose. 
 In similar cases to the preceding 
 marked by general debility and de- 
 fective nutrition. 
 
 (23) R. Calcis Hypophos., gr. Ixxx. 
 Tinct. Ferri Perchl., giij. 
 Quinise Disulph., gr. xvj. 
 Strychnise, gr. ss.-gr. j. 
 Spt. Chloroformi, gij. 
 
 Syrupi, §jss. 
 Aquae purae, ad gviij. 
 Misce. — A tablespoonful to be 
 taken three times a 
 day in a wineglass- 
 ful of water. 
 In similar cases to the above. 
 
 (24) R. Ferri. Citr. et Quinis, 353. 
 Spt. Chloroformi, 3J. 
 Syr. Aurant., giij. 
 Aquae purae, ad |vj. 
 Misce. — A sixth part three 
 times a day after 
 food. 
 In neuralgic and nervous headache, 
 with anaemia and depression, and in 
 some congestive headaches.* 
 
 (24a) R. Liquor. Ferri Dialysati, 51. 
 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 head- 
 ache of children. 
 
 (24^^) R. Ferri Amm. Citr., gij. 
 Liq. Potass. Ars., n^xl. 
 Syr. Zingib., gss. 
 Inf. Calumbae, ad gviij. 
 Misce. — Two tablespoonfuls 
 twice a day after 
 food. 
 In nervous and neuralgic headache 
 with anaemia. 
 
 (25) R. Amm. Bromid., gj. 
 
 Spt. Amm. Arom., gss. 
 Aquae purae, ad 3Jss. 
 Misce. — To be taken on ris- 
 ing in the early 
 morning. 
 In some forms of nervous and con- 
 gestive headache. 
 
 * Three to five drops of the Liquor. Strych- 
 niae, and half an ounce of the Tincture of 
 Calumba, may he sometimes added to this 
 prescription -with advantage. 
 
I -.8 
 
 FORMUL.'E. 
 
 (25^;) R. Potass. Bromid., 3J. 
 
 Spt. iVmm. Arom, gij. 
 Amm. Carb., 
 Sodse Bicarb., aa 9ij. 
 Syr. Aurant, ^iij. 
 Aquae purse, ad ^viij. 
 Misce. — A sixth part to be 
 taken every four 
 hours whilst effer- 
 vescing 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. 
 
 (26) R. Potass. Bromid., sij. 
 
 Spt. Amm. Arom., giij. 
 Mist. Camph., ad ^vj. 
 Misce. — A sixth part three 
 times a day. 
 In nervous and neuralgic head- 
 aches, and where there is excitement 
 and irritability. 
 
 (26c) R. Tinct. Aconiti, ^ss. 
 Aquae purse, ad giv. 
 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 pur^, ad sjss. 
 Misce. — To be taken three 
 times a day. 
 In neuralgic and nervous headache, 
 where migraine and clavus are spe- 
 cially marked. 
 
 (28) R. Sodse PI yphophosphitis,3ss. 
 
 Inf. Calumbse, ad gvj. 
 Misce. — A sixth part to be 
 taken three times 
 a day. 
 In neuralgic, nervous, and anaemic 
 headache. 
 
 (29) R. Magnes. Sulphat., 5J. 
 
 Quiniae Disulph., gr. viij. 
 Acid. Sulph. Dil., n^^x. 
 Inf. Rosae Co., ad 5viij. 
 Misce. — Two tablespoonfuls 
 twice or three times 
 a day after food. 
 In neuralgic and congestive head- 
 ache, with constipation and full habit. 
 
 (30) R. Tinct. Quiniae, 5vj. 
 
 Spt. Chloroformi, 3J. 
 Mist. Camph., ad 5VJ. 
 Misce. — A sixth part three 
 times a day. 
 In gouty and nervous headache, 
 where Quinine is necessary. 
 
 (31) R. Potass. Bicarb., 
 
 Sodae Bicarb., aa 3Jss. 
 Vin. Sem. Colch., 3J-3ij. 
 Syr. Zingib., §ss. 
 Aquae, ad 3viij. 
 Misce. — Two tablespoonfuls 
 three times a day, 
 with one table- 
 spoonful of lemon- 
 juice, whilst effer- 
 vescing. 
 In gouty headache, and the head- 
 ache of cerebral hyperemia. 
 
 (32) R. Amm. Carb., ^ss. 
 
 Vin. Sem. Colch., gss. 
 Tinct. Aurant., gss. 
 Aquae, ad §jss. 
 Misce. — A teaspoonful in half 
 a tumblerful of 
 Apollinaris or 
 Vichy water three 
 times a day. 
 In gouty headache. 
 
 (33) R. Lithiae Citrat., 9ij. 
 
 Potass. Bicarb., sijss. 
 Tinct. Aurant., §ss. 
 Aquae, ad §iv. 
 Misce. — A tablespoonful in 
 half a tumblerful of 
 water three times 
 a day. 
 In gouty headache, where the urine 
 is turbid, and contains lithic acid in 
 excess. 
 
FORMUL/E. 
 
 139 
 
 (34) R. Potass. lodidi, ^ss-.^j. 
 
 Bicarb., gij. 
 Vin. Sem. Colch., Ti^xl. 
 Amm. Carb., gr. xxiv. 
 Syr. Zingib., §ss. 
 Aquae, ad sviij. 
 Two tablespoonfuls three 
 times a day. 
 In rheumatic headache. 
 
 (35) R. Potass. lodidi, 
 
 Amm. Hydrochlor.,aa3Jss. 
 Inf. Humuli. ^vj. . 
 Misce. — A tablespoonful 
 three or four times 
 a day in a wine- 
 glassful of water. 
 In rheumatic headache. (Dr. 
 Smith.) 
 
 (^6) R. Potass. lodidi, 3J. 
 
 Tinct. Cinch. Co., §j. 
 
 Colch., 3j._ 
 Aquae Cinnamomi, ad §xij. 
 Misce. — Two tablespoonfuls 
 three times a day. 
 In rheumatic headache. 
 
 (37) R. Potass. lodidi, gij. 
 
 * Liquor. Hydr. Bichlor. , 
 
 pvj-gjss. 
 
 Tinct. Gent. Comp., ^jss. 
 
 Aquae Cinnamomi, ad gxij. 
 
 Misce. — Two tablespoonfuls 
 
 three times a day 
 
 in a wineglassful 
 
 of water after food. 
 
 In syphilitic and organic headache. 
 
 (38) R. Potass. lodidi, gj. 
 
 Liq. Arsenicalis, gj. 
 Tinct. Quinis, ad 5iij. 
 Misce. — A teaspoonful in 
 a wineglassful of 
 water three times 
 a day after food. 
 In syphilitic headache. 
 
 (39) R. Tinct. Ferri Perchlor, gijss. 
 
 Acid. Sulph. Dil. vel'Spt. 
 Chloroformi, .5J. 
 
 * The mercury may be omitted according 
 to circumstances. 
 
 Tinct. Lavand. Co., gvj. 
 Syr. Aurant., 3SS. 
 Mist. Camph., ad giv. 
 Misce. — Two teaspoonfuls 
 three times a day 
 in a wineglassful of 
 water. 
 In nervous headache from menor- 
 rhagia.* 
 
 (40) R. Potass. Bromid., 9j. 
 
 Syr. Tolutani, gj. 
 Aquae, ad gjss. 
 Misce. — To be taken every 
 night at bedtime. 
 As a sedative in the pain and sleep- 
 lessness of nervous and neuralgic 
 headache. 
 
 (41) R. Acid. Hydrocy. Dil., gss. 
 
 Aquae, ad 5Jss. 
 Misce. — A teaspoonful in 
 a tablespoonful of 
 water every two or 
 three hours. 
 In the sickness and nausea of nerv- 
 ous headache. 
 
 (42) R. Acid. Hydrocy. Dil., 
 
 ni^xxiv. 
 Potass. Bicarb., 3J. 
 Aquae, ad §vj. 
 Misce. — Take a sixth part, 
 with eight grains 
 of Acid. Citric, dis- 
 solved in a table- 
 spoonful 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, n^iv. 
 Decoct. Aloes Comp., ad 
 3jss. 
 Misce. — To be taken early 
 every 'morning. 
 In the constipation of nervous 
 headache. 
 
 '■• One of the prescriptions containing Arse- 
 nic or Ergot may be necessary, according to 
 the discretion of the practitioner, or either of 
 these remedies mav be added to the Formula. 
 
I40 
 
 FORMULA. 
 
 (44) R. Acid. Citric, gijss. 
 
 Quinice Dis., gr. xij. 
 Syr. Aurant., ^jss. 
 Aquae purse, ad gvj. 
 Misce. 
 
 R. Potass. Bicarb, vel. Sodse 
 Bicarb., giij. 
 Amm. Carb., 9ij. 
 in pulveres xij. 
 Signetur. — One powder to be 
 dissolved in a 
 claretglassful of 
 water, then 
 mixed with a 
 tablespoonful of 
 the mixture, and 
 taken three times 
 a day whilst ef- 
 fervescing. 
 In some forms of nervous headache 
 where there is nausea and depression. 
 
 (45) R. Sodse Bicarb., gjss. 
 
 Spt. Amm. Arom., gij. 
 Tinct. Gent. Comp., gss. 
 Syr. Aurant., §ss. 
 Inf. Gent. Co., ad gviij. 
 Misce. — Two tabiespoonfuls 
 three times a day. 
 In nervous headache with dyspep- 
 sia, furred tongue, and acidity. j 
 
 ! Liquor Strychniae,n|^xxxvj. 
 
 j Inf. Quassise, ad gxij. 
 
 I Misce. — Two tabiespoonfuls 
 
 j three times a day. 
 
 j In nervous headache with a clean 
 tongue and slow digestion. 
 
 (48) R. Tinct. Nuc. A^om., jj. 
 I Acid. Nitr. Dil., 3J. 
 
 ! Hydrochl. Dil., jij. 
 
 Tinct. Aurant., 3vj. 
 Aquse pur^e, ad gvj. 
 Misce. — A tablespoonful in 
 a wineglassful of 
 water three times a 
 day. 
 In nervous headache where the 
 Strychnia does not agree. The 
 Liquor Strychnine sometimes causes 
 nervous depression, sickness, and 
 muscular tremors, which I have occa- 
 sionally noticed as the effect of the 
 Ferri Citr. et Strychnise in gastralgia. 
 
 (49) R. Tinct. Digitalis, ^ss.-gij. 
 
 Mist. Camphorse, ad ^vj. 
 Misce. — A sixth part to be 
 taken three times 
 a day. 
 In the headache of cerebral antemia 
 as a cardiac tonic, when the pulse is 
 small and frequent, or there is palpi- 
 tation. 
 
 (46) R. * Ferri Amm. Citr., ^ss. 
 
 Acid. Citric, jj. 
 
 Quinine Sulph., gr. vj. 
 
 Aquce purse, ad §vj. 
 Misce. — A sixth part to be 
 taken three times 
 a day in efferves- 
 cence, with Sodse 
 Bicarb., gr. x, pre- 
 viously dissolved 
 in a tablespoonful 
 of water. 
 
 (47) R. Acid. Nitric. Dil., ^j. 
 
 Hydrochlor.Dil.,5ij. 
 
 * Three to five minims of the Liquor 
 Strychnise may be added in some cases. 
 
 (50) R. Tinct. Digitalis, jss.-jij. 
 
 Spt. Chloroformi, 5J. 
 Syr. Aurant. Flor., 3;iij. 
 Aqute, ad svj. 
 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, |vj. 
 
 Misce. — Two teaspoonfuls to 
 be taken three 
 times a day. 
 In similar cases to the preceding, 
 especially if accompanied v/ith dilata- 
 tion, or fattv chana^e of the heart. 
 
FORMULA. 
 
 141 
 
 (52) B. Tinct. Bel]adonn3e,3ij-3iij. 
 
 Nuc. Vom., 3j. 
 Syr. Zingib., §ss. 
 Aquae, ad ^vj. 
 Misce. — A tablespoonful in 
 a wineglassful of 
 water three times a 
 day. 
 In some forms of anaemic headache. 
 
 (53) B. Strychnise Sulph., gr. ss. 
 
 Tinct. Ferri Chlorid., gij. 
 Glycerini, gss. 
 *Inf. Gent. Comp., ad ^vj. 
 (Dr. Smith.) 
 Misce. — A tablespoonful in a 
 wineglassful of wa- 
 ter three times a 
 day after meals. 
 In the headache of cerebral ane- 
 mia with nervous exhaustion. • 
 
 (54) R. Amm. Carb., ^ss. 
 
 Tinct. Calumbs. 
 Syr. Aurant., aa giij. 
 Aquse. purse, ad gvj. 
 Misce. — A sixth part to be 
 taken twice a day. 
 In the headache of cerebral soft- 
 ening. 
 
 (55) R. Amm. Carb., ^ss. 
 
 Tinct. Lavand. Comp., ^ss. 
 
 Calumbse, giij. 
 Mist. Camph., ad §viij. 
 Misce. — Two tablespoonfuls 
 to be taken three 
 times a day. 
 In the headache of cerebral soften- 
 ing with irritability and depression, 
 and in some congestive headaches. 
 
 (56) R. Potass. Bicarb., 3J. 
 
 lodidi, gr. xviij. 
 Spt. Amm. Arom., giij. 
 Mist. Camph., ad §viij. 
 Misce. — A sixth part three 
 
 times a -day after 
 
 food. 
 
 * The infusion of Quassia or Calumba is 
 preferable to Gentian, in consequence of the 
 decomposition of the iron in the latter prep- 
 aration. 
 
 In organic headache due to syphi- 
 
 lis. 
 
 (57) R. Spt. Chloroformi, rriv. 
 
 Liq. Ergot. Ext., n^xx-gss. 
 Aqu^ purae, ad gj. 
 Misce.— To be taken three 
 times a day. 
 In the congestive and organic forms 
 of headache in advanced life. 
 
 (58) R. Liq. Ergot. Ext., ^iij. 
 
 Aquse, ad gvj. 
 Misce. — Two teaspoonfuls, to 
 be gradually in- 
 creased to two ta- 
 blespoonfuls, three 
 times a day. 
 In congestive headaches from or- 
 ganic disease. 
 
 (59) R. Sodae Pot. Tart., gij. 
 
 Potass. Bicarb., 9j. 
 Syr. Aurant., gjss. 
 Aquse, ad gjss. 
 Misce. — The draught to be 
 taken in efferves- 
 cence with Acid. 
 Citric, gr. xv, dis- 
 solved in a table- 
 spoonful of water, 
 early in the morn- 
 ing. 
 In dyspeptic and plethoric head- 
 ache. 
 
 (60) R. Magnes. Sulph., giij. 
 
 Sodse Bicarb., giij. 
 
 Liquor Taraxaci, ^vj. 
 
 Tinct. Zingib., .^j. 
 
 Aquse pur«, ad .^vj. 
 Misce. — A sixth part to be 
 mixed with Acid. 
 Tart., 9j, previ- 
 ously dissolved in 
 a tablespoonful of 
 water, and taken 
 early in the morn- 
 ing whilst efferves- 
 cing. 
 In dyspeptic and plethoric head- 
 aches with sluggish liver. 
 
142 
 
 FORMUL/E. 
 
 (6i) R. Quiniae Sulph., gr. viij. 
 Acid. Citric, gij. 
 Aquae purs, ad ^iv. 
 Misce. Sig. — No. i Mistura. 
 
 R. Sodae Bicarb., ^iij. 
 Liquor. Taraxaci, 
 Syr. Aurant., aa gss. 
 Aquse purae, ad 5viij. 
 Misce. Sig. — No. 2 Mistura. 
 One tablespoonful of 
 No. I to be mixed 
 with two table- 
 spoonfuls of No. 
 2, and taken whilst 
 effervescing three 
 times a day. 
 In similar cases to the above, where 
 Quinine is admissible. 
 
 (62) R. Tinct. Cinch. Comp., gj. 
 Spt. Amm. Arom., §ss. 
 Misce. — A teaspoonful in a 
 wineglass ful of 
 water three times 
 a day. 
 In some passive congestive head- 
 aches, where a tonic and stimulant 
 are required. 
 
 (63) R. Potass. Bromid., 53s. 
 Tinct. Cannabis Ind., 
 
 Hyoscyami, aa, gss. 
 Aquas purse, ad ^j. 
 (Clouston.) 
 Misce. — To be taken at bed- 
 time. 
 In the sleeplessness of hyperaemic 
 headache. 
 
 (64) R. Tinct. Cannabis Ind., n]^x. 
 Potass. Bromid., 9j. 
 Aqus purae, ad 3J5S. 
 Misce. — To be taken at bed- 
 time. 
 In the sleeplessness of hypersmic 
 headache. 
 
 (65) R. Tinct. Hyoscyami, gss. 
 Mist. Camph., ad §j. 
 
 Misce. — To be taken every 
 
 night at bedtime. 
 
 In the sleeplessness of nervous and 
 
 hyper aemic headache. 
 
 (66) R. Hydrat. Chloral., 9j. 
 
 Aqus purae, ad gjss. 
 Misce. — To be taken at bed- 
 time. 
 In the headache of cerebral hyper- 
 emia and vascular excitement. 
 
 (67) R. Hydrat. Chloral., 
 
 Potass. Bromid., aa gr. x. 
 Syr. Rhoeados, 3J. 
 Aque purae, ad ^jss. 
 Misce. — To be taken at bed- 
 time. 
 In the headache of cerebral hyper- 
 emia and nervo-hyperaemic headache 
 with nervous excitement. 
 
 (68) R. Potass. Bromid., gij. 
 
 Syr. Aurant., ^ss. 
 Inf. Gent. Comp., §iv. 
 Aquae purae, ad gvj. 
 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, tt^^x. 
 Aquae purae, ad gjss. 
 Misce. — To be taken at bed- 
 time. 
 In the sleeplessness of nervo-hyper- 
 emic headache. 
 
 (70) R. Syr. Hydrat. Chloral., §jss. 
 
 Misce. — One teaspoonful in a 
 wineglassful of wa- 
 ter in the nervo- 
 hypersmic form of 
 headache at bed- 
 time, or in the day- 
 time, when the 
 pain is severe, till 
 sleep comes on. 
 
FORMULAE. 
 
 143 
 
 (71) B. Ferri Amm. Citr., .5J. 
 Potass. Bromid., giij. 
 vel Amm. Bromid., giij. 
 Syr. Zingib., §ss. 
 Aquae purae, ad gvj. 
 Misce. — A tablespoonful in a 
 wineglassful of wa- 
 ter twice a day, at 
 II A. M. and 4 P. M. 
 In the headache of cerebral anse- 
 
 (72) R. Potass. Bromid., 9j. 
 
 vel Amm. Bromid., 5j. 
 Tinct. Valerian. Co., gj. 
 Syr. Aurant. Flor., gj. 
 Aquae Cinnamomi, ad §jss. 
 Misce. — To be taken twice or 
 three times a day. 
 In some forms of neuralgic head- 
 ache. 
 
 (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., aa gr. vj. 
 Ext. Aloes Aquos., 
 Quinise 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 anae- 
 mia and neuralgia, where the bowels 
 are sluggish. 
 
 (77) R. Ext. Aloes Barb., gr. i^. 
 
 Pulv. Ipecac, gr. j. 
 Pil. Rhei Comp., gr. iij. 
 Misce et fiat pilula. — To be 
 taken daily before 
 dinner. 
 In the headache of cerebral anae- 
 mia and dyspeptic headache, where 
 intestinal action is sluggish. 
 
 (7S) R. Quinis 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. y^. 
 Misce et fiat pilula. — To be 
 taken daily at 12 
 o'clock. (Samari- 
 tan Hospital.) 
 An excellent pill to keep the bow- 
 els regular in nervous headache, where 
 the muscular fibre of the intestines 
 requires stimulation. 
 
 (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 dys- 
 peptic, bilious, and gouty headache. 
 
 (80) R. Pulv. Scammonii, 9j. 
 
 Ext. Coloc. Co., 5j. 
 
 Hydr. Subchlorid., gr. xij. 
 
 01. Carui, tt^x. 
 Misce et divide in pilulas 
 xviij. — One or two 
 occasionally at 
 bedtime, in similar 
 cases to the pre- 
 ceding. 
 
 (81) R. Pil. Hydrarg., gr. xij. 
 
 Rhei Comp., gss. 
 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 
 
144 
 
 FORMULA. 
 
 (82) B. Hyd. c. Creta, gr. xij. 
 
 Ext. Hyoscyami, gr. x. 
 Pil. Rliei Comp., Qij. 
 Misce et divide in pilulas xij. 
 — One or two occa- 
 sionally at bedtime. 
 As an alterative in dyspeptic head- 
 ache. 
 
 (83) R. Ferri Sulphat., 
 
 Quinise Sulph., aa gr. xij. 
 Pulv. Rhei, gr. ix. 
 Zingib.,_gr._vj. 
 Misce et divide in pilulas xij. 
 — Take one three 
 times a day. 
 In neuralgic headache and atonic 
 dyspepsia with flatulence. 
 
 (84) B. Pil. Aloes etAsafoetid.j^ij. 
 
 In pilulas xij. — One or two at 
 bedtime every 
 night. 
 In nervous headache with flatulence 
 and constipation. 
 
 (85) B. Pil. Aloes et Ferri, ^j. 
 
 In pilulas xij. — One or two 
 at bedtime every 
 night. • 
 In neuralgic and nervous headache 
 with constipation. 
 
 (86) R. Pil. Aloes et Myrrhse, 3J. 
 
 Ferri Sulphat., gr. vj. 
 Misce et divide in pilulas xij. 
 — Two occasionally 
 at bedtime. 
 In nervous or ansemic 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., 
 
 Strychnice, aa gr. j. 
 Conf. Rosse, q. s. 
 
 Ut fiant pilute 1. — Take one 
 three times a day. 
 In some forms of neuralgic head- 
 ache. 
 
 (89) R. Phosph. Pur., gr. j. 
 
 Conf. Rosae, q. s. 
 Ut fiant plulse xxxvj. — Take 
 one three times a 
 day. 
 In similar cases to the preceding.* 
 
 (90) B. Phosph. Pur., gr. j^. 
 
 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, f 
 
 (91) R. Phosph. Pur., gr. j. 
 
 Quiniae Sulph., 
 Ferri Sulph., aa gr. xvj. 
 Ext. Rhei, 5j. 
 In pilulas xxxvj. — One to be 
 
 taken three times a 
 
 day. 
 
 (92) B. Ext. Cannabis Ind., gr. y( 
 
 -gr- j- 
 Conf. Rosse, 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. 
 
 * Perles of Phosphorus are manufactured 
 by Messrs. Corbyn, Stacey & Co., of London, 
 each Perle containing gr. J^, gr. J^ , gr. yi^. 
 They are hermetically closed in a covering of 
 gelatin, and the dose and effect of the rem- 
 edy may be relied upon. ^Vllen Phosphorus 
 is prescribed alone, the Perle is the best 
 method of administering it. 
 
 ■j- These prescriptions may be varied accord- 
 ing to the state of the patient; Valerianate of 
 Zinc and Cannabis Indica may sometimes be 
 added, 
 
FORMULAE. 
 
 145 
 
 (94) B. 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 occasion- 
 ally. 
 In nervous headache, when an ac- 
 tive aperient is required. 
 
 (96) R. Ext. Colocynth, ^ij. 
 Rhei, 
 Pulv. Scammonii, aa gr. x. 
 In pilulas xij. — Take one oc- 
 casionally at bed- 
 time. 
 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. Rosse, q. s. 
 Ut fiat pilula. — To be taken 
 twice a day. 
 In nervous headache. 
 
 (98) R. Zinci Oxyd., gr. ij. 
 Conf. Ros^, q. s. 
 Ut fiat pilula. — To be taken 
 three times a day. 
 In nervous headache. 
 
 (99) R. Pil. Rhei Comp., gj. 
 
 In pilulas xij. — Take one ev- 
 ery night. 
 
 As a mild aperient in nervous and 
 dyspeptic headache. 
 
 xij. 
 
 (100) R. Pulv. Ipecac, gr. vj. 
 Ext. Aloes Barb., gr. 
 
 Taraxaci, ^ss. 
 Saponis, gr. x. 
 Misce et divide in pilulas 
 xij. — Take one ev- 
 ery night, or before 
 dinner daily. 
 As a laxative in nervous headache 
 to assist digestion. 
 
 (loi) R. Pulv. Myrrhse, 
 
 Rhei, aa gr. xvj. 
 Pil. Aloes Barb., gr. xij. 
 Ext. Anthemidis, ^ss. 
 01. Caryophylli, itlv. 
 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 digestion. 
 
 (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 an- 
 aemia, where Digitalis is required. 
 Where there is unsteadiness of the 
 heart's action after food, and there is 
 flatulence, the iron may be advan- 
 tageously omitted, and Pulv. Zingib. 
 substituted for Pulv. Cinnamomi. 
 
146 
 
 FORMULAE. 
 
 (104) R. Ext. Belladonnje, gr. vj- 
 
 gr. xij. _ 
 
 Ext.Glycyrrhizse, 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. 
 
 (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 
 hypersemia, where depressants are re- 
 quired. 
 
 (107) R. Bismuth. Subcarb., 9j. 
 
 To be taken in a wineglass- 
 
 ful of water twice 
 
 a day before meals. 
 
 In subacute congestive headache, 
 
 with flatulence and discomfort after 
 
 food. 
 
 (108) R. Zinci Sulph., gr. v. 
 
 Aquge purse, gjss. 
 Fiat haustus. — To be taken 
 as an emetic, fol- 
 lowed by drinking 
 freely of warm 
 water till vomiting 
 ensues. 
 In some forms of bilious and nerv- 
 ous headache. 
 
 * See the effects of an overdose in Chapter 
 I., on the Headache of Cerebral Anaemia. 
 
 (109) R. Pulv. Ipecac, 9j. 
 Aquae puree, §jss. 
 Fiat haustus. 
 In the same cases as the preceding. 
 
 (no) R. Ext. Belladonna, gr. v. 
 To be rubbed into the af- 
 fected temple every 
 night. 
 In nervous headache, migraine, 
 clavus, etc. 
 
 (in) R . Ung. Veratria;, 3J. (B. P.) 
 A little to be rubbed into 
 the affected temple 
 till the pain is re- 
 lieved. 
 In neuralgic and some forms of 
 nervous headache, where the pain is 
 localized. 
 
 (112) R. Ung. Aconiti^, 3J. (B. P.) 
 
 To be used in the same way, 
 and for the same 
 cases as the pre- 
 ceding. 
 Ung. Aconitinse (Flem- 
 ing). 
 
 (113) R. Aconitinse, gr. xvj, 
 
 Spt. Vini Rect., ttlxvj. 
 Rub together, and then add 
 carefully one ounce 
 of lard. It may be 
 used in the same 
 cases as the preced- 
 ing. (A very ex- 
 pensive applica- 
 tion.^ 
 
 (114) R. Ext. Aconiti Alcohol., 3j. 
 
 Adipis, gij. 
 Misce et fiat unguentum. — 
 To be used in the 
 same cases as the 
 preceding. {Much 
 less expensive. '^^ 
 
 *In using all these ointments, care is re- 
 quired to apply very small quantities, and 
 never to the broken skin. A tingling sensa- 
 tion commonly precedes the cessation of the 
 pain. 
 
FORMULA. 
 
 147 
 
 (ii4<a!) R. Ung.Hyd.Nit.0xyd.,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. Quinise Sulph., gr. x. 
 Acid. Sulph. Dil. n^x. 
 Aquae, ad ni^c. 
 Misce. — To be injected in 
 severe cases.* 
 
 * The acid in this gives rise to pain and in- 
 flammation, sometimes even to a troublesome 
 boil or abscess. The neutral sulphate is sol- 
 uble without acid, and does not produce 
 local irritation. 
 
 (Surgeon-Major A. R. Hall's for- 
 mula for the subcutaneous injection of 
 Quinine in the hyperpyrexia of sun- 
 stroke.) 
 
 (116) R. Morph. Acet., gr. x. 
 Atropi^ Sulph., gr. j. 
 Aquse destill., gij. 
 Misce. 
 Formula for the hypodermic injec- 
 tion of Morphia. Twelve minims 
 contain one grain of Morphia. 
 
 Many of the preceding Formula 
 are suitable for children in diminished 
 doses proportioned to age. 
 
INDEX. • 
 
 Aconitina ointment in nervous and neuralgic headache, 
 
 79) i^t^. 
 Aconite in congestive headache, 60. 
 
 cerebral hyperaemia, 40. 
 Active hyperaemia, 33. 
 Advanced life, headache of, 105. 
 
 treatment of, 105. 
 Alcohol in cerebral anaemia, 27. 
 
 Aloes, compound decoction of, in nervous headache, 78. 
 Ammonia, carbonate of, in nervous headache, 96, 103. 
 Ammonium, bromide of, in congestive and nervous 
 headache, 60. 
 
 chloride of, in neuralgic headache, 112. 
 Anaemia, cerebral, 16. 
 
 vascular conditions in, 18. 
 
 symptoms of, 23. 
 
 prognosis of, 24. 
 
 treatment of, 24. 
 
 chronic, 21. 
 Antimony m hyperaemic headache, 40. 
 Arsenic in malarial and neuralgic headache, 92, 112. 
 Arthritic headache. See Gouty Headache, 94. 
 Atheromatous change, headache in, 103. 
 
 Bebeerin, 113. 
 Belladonna, 25. 
 
 Bernard, Professor, experiments of, 45, 46. 
 Bilious Headache. See Dyspeptic Headache, 50. 
 Blood-letting in congestive headache, 59. 
 Blood-supply, relation of tissues to their, 39. 
 Body-snatcher's headache, 89. 
 Brain, concussion of, 125. 
 
 vascular supply of, 17. 
 Bromide of potassium in congestive headache, 60. 
 
 nervous headache, 77. 
 Brown-Sequard's experiments, 45, 46. 
 Burrows, Sir G., experiments of, 16. 
 
 Cannabis Indica, 41. 
 
 Causes of increased activity of the nervous system, 9. 
 Cerebral circulation, 16. 
 anaemia, 17- 
 
 experiments to produce, 16, 17. 
 vascular condition of, 18. 
 symptoms of, 23. 
 prognosis of, 24. 
 treatment of, 24. 
 alcohol in, 27. 
 hyperaemia, 31. 
 forms of, 32. 
 
 with inflammatory fever, 32. 
 active, 34. 
 in the gouty, 34. 
 
 from weakness of cerebral vessels, 35. 
 passive, 36. 
 symptoms of, 37. 
 treatment of, 40. 
 Cerebro-spinal fluid, 17. 
 Chapman's, Dr., spinal ice-bag, 43. 
 Childhood, headaches of, 115. 
 cerebral headache in, 125. 
 treatment of, 127. 
 Childhood, gastric headache in, 127. 
 epileptic headache in, 128. 
 
 treatment of, 129. 
 febrile headache in, 129. 
 neuralgic headache in, 130. 
 Childhood, neuralgic headache in, treatment of, 132. 
 headache due to tissue change in, 132. 
 organic headache in, 133. 
 Children, training of, 115. 
 overtaxation of, 116. 
 
 Chloral hydrate, cautions as to use of, 84. 
 Chronic cerebral anaemia, 21. 
 Cod-liver oil in nervous headache, 81. 
 Cold, use of, in cerebral hyperaemia, 42. 
 Congestive headache, 56. 
 in plethoric persons, 56. 
 due to acute congestion, 57. 
 from mental causes, 57. 
 
 asthma, whooping-cough, bronchitis, 58. 
 hypertrophy and valvular diseses of heart, 58. 
 . organic changes, 58. 
 epilepsy, 59. 
 effects of, upon the disposition, S9- 
 treatment of, 59. 
 Cranium, anatomical peculiarities of, 44. 
 Croton-chloral, 114. 
 
 Depressant remedies, 40. 
 
 Determination of blood to the head, 33. 
 
 Diet in plethoric headache, 63. 
 
 Digitalis, 25. 
 
 Disturbances of vision in nervous headache, 68. 
 
 Dysmenorrhaea, a cause of headache, 67. 
 
 in nervous headache, 70. 
 Dyspeptic headache, 50. 
 
 action of the vagus in, 50. 
 
 commencement of, 53. 
 
 causes of, 54. 
 
 treatment of, 55. 
 
 emetics in, 55. 
 
 calomel in, 55. 
 
 alkalies in, 55. 
 Dyspeptic headache, bismuth and nux vomica in, 55. 
 
 aconite in, 55. 
 
 Early life, headaches of, 115. 
 
 brain repose in, 119. 
 
 hypertrophy of brain in, 121. 
 
 attendance at school in, 122. 
 Emotion, effects of, upon the gastric juice, 53. 
 Epilepsy from tapeworms, 51. 
 Epileptic headache in children, 128. 
 Ergot in headache, 41, 106. 
 Experiments of Mr. Durham, 22. 
 Eye, pain in the, 70. 
 
 Febrile headache in children, 129. 
 
 treatment of, 130. 
 Fecal fermentation, headache from, 88. 
 Fever, imflammatory, 52. 
 Fevers, headache in, 85. 
 Friedrichshalle water, 40. 
 
 Gas-poisoning, headache from, 88. 
 Gastric headache in children, 127. 
 Gelseminum, tincture of, 113. 
 Gouty, cerebral hyperaemia in the, 34. 
 
 hyperaemia, state of vessels in, 34, 35. 
 
 or arthritic headache, 94. 
 
 physical symptoms of, 94. 
 in the cachectic, 95. 
 
 headache, treatment of, 96. 
 Guarana in nervous headache, 79. 
 
 action of, on vasomotor nerves, 79. 
 
 Hair affected in nervous headache, 76. 
 Headache, causes of, 9. 
 
 from tissue change in children, 132. 
 Headache from disorder of liver, 50. 
 Hearing, acuteness of, in neuralgic headache, 108. 
 Hemicrania in renal cirrhosis, iii. 
 Hunyadi Janos water, 40. 
 
 (148) 
 
INDEX. 
 
 149 
 
 Hydrate of chloral, 84. 
 
 cautions as to the use of, 84. 
 Hydrocyanic acid in nervous and sick headache, 78. 
 Hypersemia, cerebral, 31. 
 
 forms of, 32. 
 
 with inflammatory fever, 32. 
 
 active, 34. 
 
 in the gouty, 34. 
 
 passive, 36. 
 
 symptoms of, 37. 
 
 treatment of, 40. 
 
 use of cold in, 42. 
 
 from intellectual strain, 39. 
 
 irritability in, 34. 
 Hyperpyrexia, with headache, 37. 
 Hypertrophy of brain in children, 121. 
 Hypodermic injections in nervous headache, 80. 
 Hypophosphite of soda in neuralgic headache, 112. 
 Hypophosphites of quinine, strychnia, and iron in 
 neuralgic headache, 112. 
 
 Ice-cap in hyperaemia, 43. 
 
 Iodide of potassium in syphilitic headache, 100. 
 
 Iron, dialyzed solution of, 132. 
 
 Lactophosphites of iron and lime, 112, 137. 
 
 Leucorrhoea a cause of neuralgic headache, 108. 
 
 Lithia, salts of, 40, 96. 
 
 Liver, disorder of, headache in, 50. 
 
 Local hyperaemia of the brain, 20. 
 
 Malarial headache, treatment of, 90. 
 Menorrhagia as a cause of headache, 67, 108. 
 Mental causes of congestive headache, 57. 
 Mercury, bichloride of, in syphilitic headache, 100. 
 Migraine, 75. 
 
 Morson's pepsin wine in nervous headache, 81. 
 Mustard poultice in nervous headache, 78. 
 
 Nervo-hyperasmic headache, 82. 
 symptoms of, 82. 
 at the menopause, 83. 
 treatment of, 83. 
 chloral in, 84. 
 Nervous headache, 64. 
 means to avert, 65. 
 causes of, 65. 
 malaria, 66. 
 symptoms of, 66. 
 constipation in, 67. 
 disturbance of vision in, 68 . 
 cases of, 6g, 71, 72, 73. 
 occasional, 73. 
 continuous, 73. 
 effects of, on scalp, 76. 
 treatment of, 76. 
 
 preventive, 77. 
 
 palliative, 77, 78. 
 belladonna and aconitina ointment in, 79. 
 Neuralgic headache, 107. 
 
 oversensibility to sound in, 108. 
 menorrhagia as a cause of, 108. 
 causes of, 108. 
 cases of toothache in, 109. 
 Dr. Anstie's case of, iii. 
 treatment of, 112. 
 
 belladonna and aconitina ointment in, 112. 
 chloride of ammonium in, 112. 
 quinine and arsenic in, 113. 
 in children, r3o. 
 Nux vomica in nervous headache, 81. 
 
 Occipital headache, 49. 
 
 Opium, 25. 
 
 Organic or structural headache, loi . 
 
 lack of symptoms in, 101. 
 
 symptoms of, 102. 
 
 causes- of, 103, 104. 
 
 treatment of, 104. 
 
 in children, 133. 
 Ovarian irritation, 67. 
 
 Oversuckling, a cause of nervous headache, 67. 
 Overtaxation of children, 116. 
 Oxide of zinc, 79. 
 
 silver, 79. 
 
 Pain, sympathetic, 12. 
 
 Periosteum, headache in disease of the, 99. 
 
 treatment of, 100. 
 Perivascular spaces, 17. 
 Phosphorus, 92. 
 Phosphorus, paries of, 144. 
 
 in neuralgic headache, 113. 
 Plethoric headache, 61. 
 
 symptoms of, 62. 
 
 treatment of, 62. 
 Podophyllin, 96. 
 Potash, salts of, 40. 
 Potassium, iodide of, 25. 
 
 in syphilitic periostitis, 99. 
 
 bromide of, in congestive and nervous headache 
 60, 78. 
 Prodromata of headache, 13. 
 Psychical symptoms in gouty headache, 95. 
 Pullna water, 40. 
 
 Quinine, 37. 
 
 subcutaneous injection of, in sunstroke, 37. 
 large doses of, in malarial headache, 90. 
 and arsenic combined, 113. 
 
 Relapsing fever, headache in, 85. 
 Relation of tissues to thetr blood-supply, 39. 
 Renal cirrhosis, headache in, iii. 
 Rest in brain affections, 14. 
 Rheumatic headache, 97. 
 treatment of, 97. 
 
 Saline aperients in plethora, 63. 
 
 School attendance of children, 122. 
 
 Sedative remedies in cerebral hyperaemia, 41. 
 
 Senna, 89. 
 
 Sleep, state of the brain in, 22. 
 
 Soda-water and champagne in nervous and sick head-- 
 
 ache, 78. 
 Structural headache. See Organic Headache, loi. 
 Strychnia, 80. 
 Sulphate of zinc, 145. 
 Sunstroke, severe symptoms due to, 37. 
 Supraorbital neuralgia, 70. 
 
 in children, 130. 
 Symonds, Dr., experiments of, 16. 
 Sympathetic headache, 44. 
 
 vasomotor nerves, relation of, to, 44. 
 
 visceral relations of, 44. 
 
 from ovarian irritation, 47. 
 
 pain, 12. 
 Symptoms of cerebral anaemia, 23. 
 
 hyperaemia, 37. 
 Syphihs as a cause of headache, 99. 
 Syrup of buckthorn, 89. 
 
 Tamar-Indien, 89. 
 
 Teeth, diseased, as a cause of headache, 109. 
 
 Thalami optici, functions of, 10. 
 
 Tissues, relation of, to blood-supply, 39. 
 
 Toxaemic headache, 85. 
 
 in acute fever, 85. 
 
 from uraemia, 87. 
 
 carbonic acid poisoning, 88. 
 
 treatment of, 89. 
 Training of children, i-is. 
 Tumors of the brain, 102, 134, 
 
 Uraemic headache, 87. 
 
 treatment of, 8-7. 
 Urine, limpid, in nervous headache, 66. 
 
 Vagus, action of, on stomach, 52-. 
 
 Varieties of headache, 15. 
 
 Vasomotor nerves of viscera, 44. 
 
 Vertical headache, 23. 
 
 Vision, disturbances of, in nervous headache, 68. 
 
 Waters, mineral, in congestive headache, 41. 
 
 Xanthelasma palpebrarum, 76. 
 
 Zinc, oxide of, 79. 
 
 valerianate of, in nervous headache, 78, 113. 
 sulphate of, 78. 
 
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 " In the multitudinous collection of works devoted to the propagation of human beings, and to the 
 details of parturition, none, in our estimation, bears any comparison to the work of Cazeaux, in itf 
 entire perfectnesa : and if we were called upon to rely alone on one work on accouchments, our choioi 
 would fall upon the book before us without any kind of hesitation." — West. Jour, of Med. and Surgery 
 
 "We do not hesitate to say, that it is now the most complete and best treatise on the subject in th* 
 English language." — Buffalo Medical Journal. 
 
 "We know of no work on this all-important branch of our profession that we can recommend to th« 
 undent or practitioner as a safe guide before this." — Chicago Medical Journal. 
 
yUST PUBLISHED. 
 
 ■ A PRACTICAL TREATISE 
 
 ON THE 
 
 Diseases of the Uterus^ 
 
 OVARIES, AND FALLOPIAN TUBES. 
 
 By A. COURTY, M.D., 
 
 Professor of Clinical Surgery, Montpellier. 
 
 TRANSLATED FROM THE THIRD EDITION, BY HIS PUPIL AND ASSISTANT, 
 
 AGNES M'LAREN, M.D., M.K.Q.C.P.I., 
 
 WITH A PREFACE BY 
 
 MATTHEWS DUNCAN, M.D., LL.D., F.R.S.E., 
 
 Obstetric Physician to Saint Bartholonnew's Hospital, London. 
 
 WITH FOUR HUNDRED AND THIRTY-ONE ILLUSTRATIONS 
 
 ONE VOLUME, OCTAVO. 
 
 Price, handsome cloth, $6.00; full sheep, raised bands, $7.00. 
 
 EXTRACT FROM PREFACE. 
 
 Among books devoted to diseases of women, none has been, or is, more important 
 than that of Professor Courty, of Montpellier. It is the carefully elaborated and 
 repeatedly revised work of a man at once imbued with the science and immersed in 
 the practice of gynecology; of one who has long lived in a centre of general science 
 and* learning, amidst an abounding population, and who enjoys the great advantage ol 
 combining in his sphere of practical activity both hospital and private patients — two 
 classes which differ in their circumstances, and in their aspects for observation, favor- 
 able and unfavorable to the student. 
 
 This translation of a work on women has been, with striking appropriateness, 
 executed by a woman doctor. I have had the privilege of her friendship since her 
 childhood, and know her excellent qualities. She has already, by original work, shown 
 her competence, in an important respect, for this now completed task of translation. 
 But she is, in addition, specially qualified, having studied in the University of Mont- 
 pellier, under Dr. Courty, among others, and having, subsequently to her graduation, 
 been for a considerable time his assistant in practice. Moreover, since she settled in 
 Edinburgh, Dr. M'Laren has, in her own practice, maintained her familiarity with the 
 diseases treated of in this book. 
 
 Courty's work has, since its first publication, been recognized everywhere. In 
 France its position is attested by the sale of two editions, numbering, I am told, ten 
 thousand copies, and by the appearance of another, the third edition. It is from this 
 third edition that this translation has been made. As it now appears, it is a treatise on 
 the diseases of the Uterus, Fallopian Tubes and Ovaries, with an introductory chapter on 
 the anatomy, physiology and teratology of the organs of generation. I recommend to 
 the careful study of my professional brethren a book which has already been crowned 
 by the Institute of France. J. Matthews Duncan. 
 
 OUTLINE OF CONTKNTS. 
 
 Introduction. — On the Anatomy, Physiology, and Teratology of the Organs of Generation. Part i. — Geheral 
 Survey of Uterine Diseases. Diagnosis of Uterine Diseases in General ; Treatment of Uterine Diseases in 
 General; General Characteristics of Uterine Diseases. Part, ii — Uterine Diseases in Detail. Functional 
 Disorders; Changes of Position; Morbid States without Neoplasm; Organic Alterations; Diseases of the 
 Uterine Appendages ; Pelvic Hemorrhages and Peri-uterine Haematocele ; Cyst of the Ovary and Genito-pelvic 
 Tumor; Sterility, etc., etc Index. 
 
 *^* This work is now ready. It may be obtained from the booksellers, or will be 
 sent by mail, postage prepaid by the publishers, upon receipt of the 
 
 PBICE, CLOTH, $6.00; LEATHER, $7.00. 
 
 P. BLAKISTON, SON & CO., 1012 Walnut Street, Philadelphia. 
 
THE CHANGE OF LIFE 
 
 IN HEALTH AND DISEASE. 
 
 BY EDWARD JOHN TILT, M.D. 
 FOTJETH EEVISED EDITION. 
 
 COMPLETE IN ONE OCTAVO VOLUME. 
 
 PRICE, CLOTH, $1.25. PAPER COVERS, 75 cts. 
 
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 and handles it accordingly. No recent researches in physiology or pathology which 
 have any bearing are overlooked by him', and, as a result of his method, a completeness 
 attaches to each of the subjects treated which greatly increases the value of the work. 
 It will be seen the subjects are of a kind most cursorily, if at all, elsewhere discussed, 
 and the work, therefore, contains information nowhere else to be obtained. Few books 
 are issued which are more indispensable to the general practitioner; none of which he 
 will be less likely to regret the purchase." — PMladelpMa Medical Times. 
 
 " Dr. Tilt has now fairly occupied the field with a work which, if it does not include 
 all that is known upon the diseases of the climacteric period, is at all events a repertory 
 of information upon a subject not very generally understood. The work is divided into 
 twelve chapters ; the first five are, an introductory one on the physiology of the change 
 of life, one on its pathology, one on its therapeutics, and one on its hygienics. Then 
 follow chapters which treat consecutively of the diseases of the reproductive organs at 
 this period of life, of the diseases of the digestive organs, and of the skin ; the tenth 
 treats of the diseases of the ganglionic nervous system, and the eleventh of the cerebro- 
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 climacteric derangements is pretty nearly exhausted, and additional value is given to 
 the volume by numerous interesting tables, which exhibit various physiological and 
 pathological facts in a clear and definite manner. 
 
 "There is a fund of practical matter in Dr. Tilt's book, and no small share of 
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 "Additional value is given to the volume by numerous interesting tables, which 
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 a work containing a large amount of valuable practical information upon a subject 
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 " Dr. Tilt's clear and concise style makes the book at once a pleasant one to read 
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 HANDBOOK OF MIDWIFERY. By D. Lloyd Kobeuts, m.d. 95 Illlustrations. 317 pages. 
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 published on the subject. — London Lancet. 
 
 MEADOWS' MANUAL OF OBSTETRICS. 
 
 THE THIED EEYISED AND ENLAEGED EDITION, NOW EEADY., . 
 
 WITH ONE HUNDRED AND FORTY-FIVE ILLUSTRATIONS. 
 
 INCLUDING THE SIGNS AND SYMPTOMS OF PREGNANCY, 
 Obstetric Operations, Diseases of the Puerperal State, Sec, &c. By 
 Alfred ISIeadows, M. D., Physician to the Hospital for Women, to 
 the General Lying-in Hospital, &c., &c. Revised and Enlarged Edi- 
 tion. With numerous Illustrations. Price ;^2.oo 
 
 In this new edition, .. .not merely is the practical treatment of Labor, and also of the Dis- 
 eases and Accidents of Preguaucy, well and clearly taught, but the anatomical machinerj), 
 of parturition is more effectively explained than in any other treatise that we remember ; 
 besides this, the book is honorably distinguished among manuals of Midwifery by the ful* 
 ness with which it goes into the subject of the strticture and develojjment of the ovum. Oa 
 all questions of treatment, whether by medicines, by hygienic regimen, or by mechanical oif 
 operative appliances, this treatise is as satisfactoiy as a work of manual size could be ; student* 
 and practitioners can hardly do better than adopt it as their vade-mecum. — The Practitioner. 
 
 Upwards of ninety new engravings have been inserted in this edition, and, with a view to 
 facilitate reference, the author has furnished it with a very full and complete table of contents 
 and index. "We can cordially recommend this manual as accurate and practical, and as con- 
 taining in a small compass a large amount of the kind of information suitable alike to the 
 student and practitioner. — London Lancet. 
 
 It is concise, well arranged, and remarkably complete, as a guide to the student during his 
 lecture term ; and as a ready reference to the Physician, no work of similar character equals 
 it iu value. — Buffalo Medical Journal. 
 
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 of contents and index renders it easily accessible as a work of reference. — Chicago Medical 
 Examiner. 
 
 There can be no doubt that this manual will be generally accepted as a brief, convenient, 
 and compendious guide to the study and practice of the Obstetric Art. — Richmond and 
 Louisville Medical Journal. 
 
 We cannot btit feel that every teacher of obstetrics has good cause to con,gratulate himself 
 on being able to put in the hands of the student a book which contains so much valuable 
 and reliable information in so condensed a form. — Philadelphia Medical Times. 
 
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 most recent knowledge of the day. — British and Foreign Medical Review. 
 
 A work which embodies a larger amount of practical information than any other book on 
 the subject. — Pacific 3Ledical and Surgical Journal. 
 
 It is with great gratification that we are enabled to class Dr. Meadows' Manual as a rare 
 exception, and to pronotince it an accurate, practical, and creditable work, and to unhesi- 
 tatingly recommend it to both student and practitioner. — American Journal of Obstetrics. 
 
 It is a book of decided merit : every pasre teems with sound, practical common sense, advice 
 and suggestions. — Kansas City Medical Journal. 
 
GRAILY HEWITTS 
 
 DISEASES OF WOMEN. 
 
 FOURTH AMERICAN, FROM THE LAST REVISED AND ENLARGED LONDON EDITION. 
 WITH NUMEROUS BEAUTIFULLY EXECUTED ILLUSTRATIONS. 
 
 This Edition of Gi^aily Hewitt' s Celebrated Woi^k on The Dis- 
 eases of. Women, as now issued in two parts in P. Blakiston, Son & 
 Co.'s Octavo Series of Standard Medical Works, the two 
 
 paints containing 750 large octavo pages, cleaidy printed fT-om small 
 pica type, leaded, with all the Illustrations of the English Edition, 
 is published by special arrangement with the author, made through 
 his publishers, Messrs. Longmans & Co., of Londojt, to who7n a 
 large amount ivas paid for an advance copy. 
 
 THE TWO PARTS IN ONE VOLUME. 
 Handsomely bound in Cloth, Price, - - $2.50 
 
 Strongly bound in Paper Covers, Price, - - 1.50 
 
 The Pathology, Diagnosis, and Treatment of Diseases of Women, including the 
 Diagnosis of Pregnancy. Founded on a Course of Lectures Delivered at St. 
 Mary's Hospital Medical School. By Graily Hewitt, m.d., Lond., m.r.c.p.. 
 Physician to the British Lying-in Hospital ; Professor of Midwifery and Diseases 
 of Women, University College, and Obstetric Physician to the Hospital, etc. 
 The Fourth American from the Last London Edition. Revised and Enlarged, 
 with many New Illustrations. Octavo. 
 
 The author, in his preface to this edition, says : — ■ i 
 
 "This new edition of my treatise on The Diseases of Women is substantially a new work. 
 It has been made more systematic, from a pathological point of view; many new illustrations have 
 been added, the greater part of them being carefully prepared representations of cases coming 
 under my own observation." 
 
 " Readers of the former editions will not require to be I "The excellent work of Dr. Hewitt presents — in a 
 told that the additions now made are of the highest ] form well adapted to conduct the student to a knowledge 
 
 possible excellence." — Thnes and Gazette. 
 - " It is one of the most useful, practical, and compre- 
 hensive works upon the subject in the English language, 
 a true guide to the student, and an invaluable means of 
 reference for the teacher." — iV. I'. Medical Record. 
 
 of the Diseases of Women, and to assist the young prac- 
 titioner in his study of these diseases at the bf-dside cf 
 the patient — a very full and clear exposition of the views 
 entertained by the most authoritative teachers as to their 
 pathological treatment and their correct Diagnosis." — 
 Ainer. Med. Journal. 
 
 ALSO, NOW READY, 
 
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 COLORED PLATES, AND WOOD ENGRAVINGS; 318 PAGES. 
 
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 The Nature, Varieties, and Treatment of Sore Throat, including the Connection 
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 One volume, i2mo, 318 pages. 
 
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NOW READY, THE SEVENTH REVISED EDITION. 
 
 MEIGS AND PEPPER, ON CHILDREN. 
 
 THE MOST THOROUGH, COMPLETE AND PRACTICAL WORK 
 ON THE SUBJECT NOW BEFORE THE PROFESSION. ■ 
 
 A PRACTICAL TREATISE ON THE DISEASES OF CHILD- 
 REN. By J. Forsyth Meigs, m.d., one of the Physicians to the Pennsylvania 
 Hospital, Consulting Physician to the Children's Hospital, etc., and Willlam 
 Pepper, m.d., Professor of Clinical Medicine, University of Pennsylvania, Provost 
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 value unequaled, probably, by any other on the subject now before the profession. 
 
 The entire work has been now again subjected to an entire and thorough revision, 
 some articles have been rewritten, many additions made, and great care observed by 
 the authors, that it should be most effectually brought up to the light, pathological 
 and therapeutical, of the present day. 
 
 The publishers have very many favorable notices of the previous editions, re- 
 ceived from numerous sources, foreign and domestic. They append a few from lead- 
 ing journals, which will give a general idea of the value placed upon it, both as a 
 Text-Book for the Student and a work of reference for the Ge7ieral Practitioner. 
 
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 and agreeable diction are appreciated." — American yournal of Obstetrics. 
 
 " It is only three years since we had the pleasure of recommending the Fifth Edition of this excellent work. 
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 and practice, with evidence throughout of good personal judgment, knowledge, and experience. The book also 
 abounds in exposition of American experience and observation in all that relates to the diseases of children. We 
 are glad to add it to our library. There are few diseases of children which it does not treat of fully and wisely, in 
 the light of the latest physiological, pathological, and therapeutical science." — London Lancet. 
 
 R BLAKISTON, SON & CO., Publishers, 
 
 Successors to LINDSAY & BLAKISTON, 
 
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