LIBRARY OF CONGRESS. @^3p Goiiijnghi :^o, Shelf ^-.r. '^ UNITED STATES OF AMERICA. A TREATISE ON HEADACHE AND NEURALGIA, INCLUDING SPINAL IRRITATION AND A DISQUISITION ON NORMAL AND MORBID SLEEP. / BY J. LEONAED COmsriNG, M.A., M.D., Consultant in Nervous Diseases to St. Francis Hospital ; FeUow of the New York Acaderav of Medicine ; Member of the New York Neurological Society ; etc. AUTHOR OF "A Treatise on Hysteria and Epilepsy,'^ " Local Anaesthesia^^ " Brain Rest," etc. WITH AN APPENDIX. Eye Strain, a Cause of Headache, By DAYID WEDSTEE, M.D., Prof of Ophthalmology in the New York Polyclinic ; Surgeon to the Manhat- tan Eye and Ear Hospital, etc., etc. ILLUSTRATED. THIRD ^Z)/r/OA'.(*>|v|^R19l894'^. Of WASH^^ / NEW YORK : ^-^-^^Ij::^ ^ ^ ^ E. B. TREAT, 5 COOPER UNION, / ^ ^/ London : H. K. Lewis, 136 Grower Street. 1894:. Price, $2.75. f^:\ty Copyright, By E. B. TREAT, N. Y. 1888-1894:. PREFACE, The affections treated of in the following pages have ever shown a decided predilection for the neurotic portion of our population. For the great towns of the Atlantic seaboard, headaches and neuralgias exhibit a special preference. To the nervous exhaustion and strain incident to the irregular mode of life and com- petition of the great cities are due. in no small degree, these head -pains so often the precursors of impending nervous bankruptcy. The same causes, in conjunction with one of the most trying climates to be found in the whole world, serve also to give rise to a thousand aches and pains, the most excruciating of which are those neuralgias of the face that not infrequently drive the victim to suicide or the madhouse. For several years past I have devoted much time to the careful study of these prolific sources of human misery. I have not done this in a spirit of mere path- ological analysis; but I can truly say that my endeav- ors have been of a practical kind, every thought being directed to the rehef and cm-e of these distressing affections. As insomnia is one of the most constant and dis- 8 PREFACE. tressing accompaniments of pain, I have added a chap- ter on sleep and its derangements, which I trust will lend completeness to the general argument. When to personal experience I add the fact, that many of the principles herein formulated have already- been extensively promulgated and kindly received by my professional brethren on both sides of the Atlan- tic, I may perhaps claim extenuation for confidence placed in my own undertakings. PEEFACE TO THE SECOND EDITION. The kind reception which the first edition of this work received at the hands of the profession has been an agreeable surprise to the author. As regards the second edition, I may state that the value of the work has been materially enhanced by the addition of an appendix on the relation of eye strain to headache, contributed by my distinguished friend, Dr. David Webster, of New York. Dr. Webster's reputation as an accomplished oph- thalmologist is a sufficient guarantee of the soundness of his opinions. J. L. Corning. New York, September 1st, 1889. PEEFACE TO THE THIED EDITION. To this, the third edition, I have added a chapter on the "Localization of the Action of Eemedies upon the Brain," which I trust may prove suggestive as well as useful. J. L. Corning. New York, January 1st, 1894. CONTENTS, PART I.— HEADACHE. Pains which owe their Origin to Intra-Cranial Causes. PAGE. I. General Considerations on the Mechanism of Head- Pains ; Classification of Head-Pains 15 II. Anaemic Headache 22 , III. Hyperagmic or Congestive Headache 26 lY. Nervous or Cerebral Headache 38 (a) Cerebro-Hypertemic Headache, (b) Cerebro- Anaemic Headache. V. Toxic Headache 44 VI. Sympathetic Headache ; Bilious Headaclie 47 VII. Organic Headache, or that which is dependent upon profound Changes in the Constitution of the Brain or its Membranes 52 VIII. Cases Illustrative of Various Phases of Headache ... 56 PART II.— NEURALGIA. ains which owe their Origin to Extra-Cranial Causes. IX. General Considerations 63 X. Classification of Neuralgia — (1) Trigeminal (Facial) Neuralgia 66 XI. Trigeminal Neuralgia continued. Modification in the Symptoms of Facial Neuralgia, consequent upon the Restriction of the Pain to one or more Branches of the Nerve ; (2) Cervico-Occipital Neuralgia ; (3) Cer- vico-Brachial Neuralgia 69 Xn. Other Varieties of Neuralgia 73 (4) Crural Neuralgia. (5) Lumbar Neuralgia. (6) Lumbo-Abdominal Neuralgia. (7) Dorso-Intercostal Neuralgia. (8) Sciatic Neuralgia. 10 CONTENTS. , (9) Plantar Neuralgia. (10) Coccygodynia. (11) Mastodj'nia. (12) Muscular Neuralgia. p^oe XIII. Causation 79 XIV. Diagnosis 83 XV. Pathology 84 XVI. Prognosis 86 XVII. Treatment in General 88 XVIII, Local Medication of Nerves, Authors Method 93 XIX. Local Medication of Nerves continued. The Prolonga- tion of the Local Action of the Remedy, Author s Method ; Cases Illustrative of various Phases of Neuralgia ; The Endermic Use of Remedies in Neu- ralgia 97 PART III.— HISTORICAL. CONSIDERATIOX OF METHODS OF TREATMENT HERETOFORE PROPOSED. XX. Methods Involving the Use of Electricity 119 XXI. Electric Methods continued. Simultaneous Applica- tion of Pressure and Galvanism 121 XXII. Narcotics and Sedatives 125 XXin. Other Remedies which have been Recommended ; Treatment by Freezing 132 XXIV. Surgical Exped'ients 138 XXV. Some Concluding Observations on Rheumatic, Osteal and Periosteal Head-Pains 140 PART IV.— IRRITATIVE CONDITIONS OF THE SPINE. XXVI. Spinal Irritation 145 XXVII. Spinal Irritation and other Painful Symptoms conse- quent upon Slight Local Injurj^ or General Shock. . 169 PART v.— NORMAL AND MORBID SLEEP. XXVIII. Considerations on the Physiolog}' of Sleep 187 XXIX. Idiopathic Insomnia 201 XXX. Secondary Insomnia 206 XXXI. Considerations on Dreams 209 XXXIL The Difference between Dreams and Waking Thought. 215 XXXm. Morbid Somnolence 219 XXXIV. General Observations on the Treatment of Insomnia 222 XXXV. Localization of the Action of Remedies upon tlie Brain . . 228 Appendix : Eye Strain, a Cause of Headache 245 Index 273 PART I. HEADACHE PAINS WHICH OWE THEIR ORIGIN TO INTRA- CRANIAL CAUSES. CHAPTER I. INTEODUCTORY AND RETROSPECTIVE. GENERAL CONSIDERATIONS ON THE MECHANISM OF HEAD- PAINS.— CLASSIFICATION OF HEAD -PAINS. Under the designation of headache, I propose to consider a group of painful sensations located in the head, and usually accompanied by more or less sensory hypersesthesia, mental irritability and intellectual pros- tration. As the clinical significance of these head -pains differs more or less widely, it is not surprising that they should be attributable to the most varied causes. Thus experience has shown that some of these pain- ful sensations about the head may be due to extra- cranial causes, such as osteosis of the cranium and dura mater, syphilitic periostitis of the cranium, disease of the internal ear, neuralgic and rheumatic affections of the scalp, and tumors of various kinds. On the other hand, it is equally certain that an extensive category of headaches is directly attributable to intra- cranial causes. Under the latter conditions the mental disturbances are decidedly more marked than when the cause of the pain is located externally to the cranial vault, and we are therefore justified in speaking of these headaches as cerebral or brain-pains. Before proceeding to discuss the symptomatology of headaches, it will be well to consider the mechanism 16 HEADACHE AND NEURALGIA. of their production, as classification and treatment are alike dependent upon some conception, however im- perfect, of the pathological features involved. Uf the purely extra -cranial pains little more need be said than that they are evidently one and all attribut- able to disturbances in the molecular conditions of jbhe sensory nerves involved. Whether the immediate source of such disturbances be an organic lesion (ex- ostosis, syphilitic periostitis), or whether it consists in some occult external (rheumatic, neuralgic) element, matters httle in so far as the final result is concerned. The elucidation of the mechanism of the intra- cranial or brain-pains is, however, a ma-tter of far greater difficulty. In considering this point. Dr. Sy- monds ' pertinently observes : ' ' Putting aside 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 craniuui when the patient is the subject of headache ? It does not appear to be in the nervous matter, whether vesicular or tub- ular, of the cerebral hemispheres, or of the cerebellum. No evidence of feeling has been obtained by vivisectors till they approach the sensory ganglia, the thalami optici and corpora quadrigemina. But these are the centres of sensations to all parts of the body as well as to the head. All analogy must further look to the nerves as the source of pain (though some writers are hardy enough to doubt the necessity of nervous mat- ter as instrumental in sensation). And what are the nerves ? Numerous as are the nerves which come out of the cranium, there are on a superficial view very few that go into it, A branch of the suboccipital ac- companies the vertebral artery, but a large majority ' " Tlie Gulstonian Lectures on Headache," Medical Times and Gazette," 1858. INTRODUCTORY AND RETROSPECTIVE. 17 of the other nerves, destined for intra- cranial purposes, are derived from the sympathetic. " These, then, are the nerves which are of chief inter- est to our present inquiry. Nerves of this class accom- pany blood-vessels, 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 corresponding supply of ganglionic nerves; but the minute examination of modern anatomists has tracked them in great abundance. ' ' Discussing the same point, Memeyer' observes that: "Headache, a very frequent symptom in all cerebral diseases, is very difficult to explaiu; 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 hemispheres have been removed), or whether, as I think is more probable, it depends on initation of the filaments of the trigeminus going to the dura mater. The great sensitiveness to impressions on the senses depends on the increase of excitability, caused by tlie cerebral hyperaemia, or the hyperaesthesia of those portions of the brain through which peripheral irrita- tions are perceived. The patients do not exactly feel, see, and hear more sharply than ordinarily, but they are annoyed by irritations far weaker than such as usually annoy them. Light troubles them; a slight sound or an insignificant irritation of the nerves of touch excites disagreeable feelings. Morbid excitation (which must not be identified with increased excitabil- ^ " Memeyer's Practical Medicine," Vol. II., p. 159, quoted by Dav. 18 HEADACHE AND NEURALGIA. ity) of the same central parts causes the clazzhng he- fore the eye. seeing sparks, roaring and buzzing in the ears, the sensation of formication, or of undefined pain, which are not induced by peripheral irritation." And again, Erb,' referring to the subject, feels com- pelled to admit that: '^Physiology affords little aid in determining the sensory nerves in which the irrita- tion is seated. Experiments upon the sensibility of different structures in the interior of the skull have given contradictory results: for whilst Leyden, Hitzig and Ferrier have found the dura mater to be highly sensitive, Pagenstecher ascribes a very low degree of sensibility to it, and Bartholow " who experimented on the human subject, found it to be but shghtly sensi- tive to mechanical stimuli. The greater number of experiments seem to show that the pia mater is also not very sensitive, and the same may be said in regard to the greater part of the substance of the hemispheres. When Bartholow pushed his needles deep into the substance of the cerebral tissue, pain was only ex- perienced in the neck after they had been pushed in to about the depth of the great ganglia at the base of the brain." ''We are unable, again, from physiological consid- erations to explain why headache should be experi- enced when the intra-cranial disease is situated in so many different parts of the brain or of its membranes; we must either admit that the tissues, which under ordinary circumstances are insensible or are only en- dowed with a low degree of sensibility, become sensi- tive under pathological conditions, and give rise to ' " Beard's Archives of Electrology and Neurology," New York, 1874, p. G8. ' "Diseases of the Peripheral Cerebro-Spinal Nerves," article "Cephalalgia," " Ziemssen's Cyclopaedia," p. 138 et seq., 187G. INTRODUCTORY AND RETROSPECTIVE. 19 pain; or we may imagine that in diseased states the influence of pressure and irritation spreads to consid- erahle distances, involving tissues that are sensitive. The dura mater may undoubtedly be included amongst such sensitive structures, since it receives sensory branches from the trigeminus and vagus; perhaps the nerves of the choroid plexus, which Benedict ' has re- cently described, are of a sensory nature, and may be answerable for the ' internal ' headache sometimes com- plained of. To what special locality, however, we should refer these ' nervous ' headaches, is still unde- cided, and we can only offer guesses at the truth." The most recent theory regarding the mode of pro- duction of pain along the course of nerves, as in neu- ralgia, is that promulgated by Prus.'' According to this writer there are filaments in the sheaths of nerve- trunks, the irritation of which gives rise to the painful points found in neuralgic affections. These filaments, the presence of which was made known by careful microscopical examination, have received the some- what ponderous appellation of nervi nervorum peri- phericoriim. What part these structures are destined to play in the pathology of the future, experience alone can show. As to the opioions entertahied by myself with regard to the precise location and mechanism of these painful intra-cranial sensations, I can only agree with Xie- meyer and Erb that the ground we tread upon is un- certain; and that, as far as deriving definite conclu- sions from anatomy and physiology is concerned, we are left somewhat in the dark. This much I will ven- ture to affirm, however, that inasmuch as psychical ^ Virchow^s Arch, band 59 ' Archives Slaves de Biologic, IV., 2 Sept, 1887. See also Brain, Vol. X., p. 557. 20 HEADACHE AND NEURALGIA. disturbances assuming the form of grief, worry and apprehension are of themselves quite capable of evok- ing severe intra- cranial pain, the latter is certainly in some manner due to cerebral agency. That such a connection must of necessity exist, is shown bv the fact that when the disturbing psychical element is re- moved the pain frequently ceases instantaneously. To be sure such facts do not adequately explain the oc- currence of the form of headache due to a variety of purely physical causes, but they are nevertheless eminently suggestive, since they are clearly instances of headaches evoked by forces operating solely by and through the brain. On a superficial view, it would appear, then, that we meet with overwhelming obstacles on the very threshold of our investigation into the origin of these pains within the skull. The problem is, however, from a clinical standpoint at least, not so discouraging as it would appear at first sight; for, owing to the fact that we are acquainted with a considerable number of the factors concerned in the evolution of these pains, we are able to apply such knowledge to the practical ends of treatment. Again, although for the same rea- son, it is impossible to arrange the numerous varieties of headache upon the basis of their respective and ultimate pathological terms, we are at least able to classify the prominent forms of intra-cranial pain in accordance with their more obvious pathogenesis. Fol- lowing this method, we may classify the various forms of headache as follows: (1.) Anaemic Headache. (2.) Hypersemic or Congestive Headache. ^ Nos. 3 and 5 are commonly known as " Sick Headache.' INTRODUCTORY AND RETROSPECTIVE. 21 (3.) Nervous or Cerebral Headache. (a) Cerebro-Hyperaemic Headache. (b) Cerebro- Anaemic Headache. (4.) Toxic Headache. (5.) Sympathetic Headache. BiHous Headache, &c. (6.) Headache dependent upon organic disease of the brain or its appendices. EXTRA -CRANIAL HEADACHE. (1.) Neuralgia, General Considerations om (a) Rheumatic Headache. (2.) Osteal and Periosteal Headacheo CHAPTER II, ANEMIC HEADACHE. The proximate cause of this form of head-pain is deficiency of blood Avithin the cranial cavity. It is an almost invariable attendant on general anaemia and chlorosis, and consequently young women of feeble constitution are particularly liable to its attacks. The affection is not, however, restricted to any particular form of w^eaknesS; but, on the contrary, it is a common attendant on all forms of debility. Uterine hemor- rhage, epistaxis, haemorrhoids, mal-nutrition, chronic diarrhoea and over exertion both mental and physical may produce it. Masturbation in both sexes may give rise to it; and excessive indulgence in strong tobacco may cause it. One of the most prolific predisposing causes of the affection is morbid sexualisnij as I have frequently observed both in married and single indivi- duals. Symptoms. — Sometimes those affected by this variety of headache complain of a sensation of tightness about the forehead, as though the head were encircled by a band. Sometimes again the pain is more restricted in character and manifests itself in clawing sensations, which are particularly well marked at the vertex. Whatever the location of the pain may be, it is almost invariably less pronounced when the subject is in the recumbent position than when the body is maintained in an erect attitude. Less pain is there- fore felt during the latter part of the night and early ANEMIC HEADACHE. 28 morning than during the day. In the more exquisite cases the simple act of rising is sufficient to cause vertigo and even syncope; indeed symptoms of giddi- ness and weakness in the lower extremities are almost constant accompaniments of this form of headache. Sleep is also more or less affected, though during the day the subject is frequently beset by a morbid drow- siness which he endeavors to exorcise by the copious use of stimulants. The energy of the heart's action is reduced; and in very severe cases the venous murmur may be present in the neck as well as oedema of the ankles and of the legs. The latter condition is for- tunately rare. Palpitations, extreme fatigue upon the slightest exertion and attacks of sudden fainting are frequently met with. The surface of the body and particularly the face are cold to the touch, and the countenance has a peculiarly blanched and waxy ap- pearance. A morbid susceptibihty to sensory impres- sions, particularly of light and sound, is present in most cases. The sensitiveness to light is often so great that the subject insists upon remaining in a darkened room during the day, while an artificial light of any kind is absolutely unendurable. The susceptibility to acoustic impressions of all kinds may also be abnor- mally increased, so that such trivial occurrences as the squeaking of a door, the rumbling of a cart, or ordin- ary conversation are absolutely unendm^able. The peculiar flaccid state of the heart, which is so characteristic of this condition, has been graphically alluded to by Dupuytren as " relachement du coeur. " A symptom of considerable diagnostic importance is the feeble pulsation of the carotids — a phenomenon which is never absent in pronounced cases. Very slight pressure upon these arteries is sufficient, where the ana3mia is severe, to provoke an immediate attack 24 HEADACHE AND NEURALGIA. of syncope. I first called attention to this symptom some time ago, and I have since had occasion to verify the assertions then made over and over again. The surface thermometer when properly applied over the vertex shows a considerable diminution in temperature as compared with the rest of the body. Again, persistent drooping of the eyelids is an almost constant symptom in this form of headache, and one of considerable diagnostic value^ from the fact that the phenomenon may be produced experimentally by the aiDpropriate apphcation of compression to the caro- tids, as I have frequently demonstrated.^ Treatment. — The temporary relief of this form of headache is a matter of no great difficulty, especially if the cerebral anaemia is due rather to vaso motor than to general causes. The inhalation of a few drops of the nitrate of amyl is often followed by immediate relief, but the latter is usually of only temporary duration, unless special means be adopted to perpetuate the good effects of the remedy. This object may be accomplished in a variety of ways: the inhalations of the nitrate may be repeated several times a day; the patient may be placed upon a sofa or bed, the foot of which is elevated by means of blocks of wood; alcohol may be given in frequent doses; the salts of iron and quinine may be adminis- tered, or opium may be given in small doses, a mode of treatment which has yielded good results in the hands of various practitioners in certain cases. Of all the remedies above enumerated pre-eminent importance must be assigned to alcohol; when taken in moderate quantities it increases the energy of the heart's action and at the same time causes dilatation * "Brain Rest," by J. Leonard Coi-ning, Gr. P. Putnam's Sons. Also the various papers and articles alluded to in this work, I _. ANEMIC HEADACHE. 25 of the minute blood-vessels of the brain. It should never, however, be given in very lai^ge quantities, since when thus administered it causes depression of the nervous centres, besides exercising the most prejudicial effects upon the digestive and assimilative systems. McTjane Hamilton has found that the inhalation of nitrous oxide is of great benefit in anaemic headache. The ordinary apparatus used by dentists was employed in administering the gas. The importance of maintaining a horizontal position, especially during the early stages of the affection, can hardly be overestimated; and the benefits thence to be derived may be greatly enhanced by elevating the lower extremities by means of cushions, or preferably by raising the foot of the bed or lounge by means of blocks placed beneath the feet. After all has been said, however, with regard to re- medies, it must be admitted that the ultimate reliance of the physician consists in enhancing the powers of the apparatus of digestion and absorption. Cod-hver oil, rare beef -steaks and mutton-chops should occupy a prominent place in the dietary; while milk and eggs may be given ad libitum, where the digestive powers are not seriously impaired. As a matter of course, if the anaemia be due to the presence of some obviously morbid element^ the latter should be gotten rid of as soon as possible. If the di- gestive apparatus is impaired it should be put in good condition as soon as possible; if there is hemorrhage from the uterus or any other portion of the body it should be arrested, and in short from whatever source the debih fating influences emanate, they should be neutralized or removed as expeditiously as circum- stances will admit. CHAPTER III. HYPER^MIC OR CONGESTIVE HEADACHE. Syinptoincdologij. — In this form of head-pain the subject complains of a severe tensive pain, and at the same time experiences a sensation of fuUness, as though the cranium were too small for its contents. As a rule the painful sensations are not circumscribed in character, but are distributed throughout the entire extent of the cranium. The pain is constant, and is augmented by assuming the recumbent posture; conse- quently sleei3 is more or less profoundly affected. All forms of mental or physical exertion are followed by exacerbations of pain accompanied by more or less vertigo. The subject is extremely irritable and aroused to inordinate passion by the most trivial circumstances; he is pessimistic, depressed and lachrymose, and in- ch ned to find fault with all about him. Sensory dis- turbances are also more or less common, and may con- sist in functional exaltation or depression. Sometimes the action of the heart is inordinately in- creased in strength and considerably accelerated, so that the patient complains of throbbing in the tem- poral and carotid arteries, which in some cases is so violent as to be easily discovered with the naked eye. There is also a well-marked increase in temperature, particularly above the vertex, and the face is suffused to such a degree as to present a livid, coppery appear- ance. Causation. — The immediate cause of the above group of symptoms is an increase in the arterial blood- CONGESTIVE HEADACHE. 27 tension, accompanied by more or less relaxation on the part of the cerebral cai)illaries. A somewhat similar series of phenomena may, however, be evoked by dis- tension of the intra-cranial veins consequent upon some form of obstruction to the flow of blood in the same (passive congestion). When the impediment is serious, coma may be induced. Yaso-motor insuffici- ency, especially that affecting the intra-cranial circula- tion, is a prolific cause of the congestive form of head- ache ; it may result from the most varied causes, and is especially prone to occur as the consequence of excessive sexualism and the protracted abuse of alco- holic stimulants. To enumerate all the pathological conditions which may give rise to this form of head- ache would, however, involve the recapitulation of a considerable segment of special and general pathology, and would, of course, be supererogatory in a work of this kind. Treatment. — Without doubt the most expeditious mode of affording relief in uncomplicated cases of con- gestive headache —those which are attributable to abnormal heart or vaso-motor conditions, or both — consists in the skillful application of compression to the common carotid arteries ' by means of appropriate instruments. Electro-compression ' also yields excel- ^ " Prolonged Instrumental Compression of the Primitive Car- otid Artery as a Therapeutic Agent," by J. Leonard Corning, M.D., "New York Medical Record" for Feb. 18th, 1882. Also article in "Philadelphia Medical News," for June 17th, 1882 ; this arti- cle may also be found in the "American Journal of Neurology and Psychiatry," 1882. See also, " Carotid Compression," Anson D. F. Randolph & Co., New York, 1882, Ibid. "Brain Rest:" A Disquisition on the Curative Properties of Prolonged Sleep, by J. Leonard Corning; M.D., G. P. Putnam's Sons, New York, Second Edition, 188G. - For the original paper on the combined application of com- 28 HEADACHE AND NEURALGIA. lent results, especiall}^ in those cases ^vhere the adipose covering of the neck is of such thickness as to render the application of strong pressure without implication of the jugular difficult or practically impossible. Of the two procedures electro-compression will on the whole be found most effective and universally ap- plicable. As some of my readers may not be familiar with the rules which I have elsewhere given for carry- ing out this mode of treatment, I will give the salient points involved. MODE OF EXECUTING ELECTRO-COMPRESSION. For applications of short duration, and these are the most uniformly useful in the treatment of congestive varieties of headache. 1 have found the following device convement : It consists in the first place of two curved metallic branches, resembling in shape an ordinary horse shoe. To each of the extremities of these branches is attached a small sponge electrode. These electrodes are insulated by means of hard rubber plates. To each of the electrodes is attached a con- ducting cord. These cords unite in one common stem, which being secured to the binding post of a galvanic battery renders the polarity of the two sponge elec- trodes the same. (Fig. 1.) It is possible by means of a screw provided with a detachable key to place the electrodes at an angle. The object of this device is to enable the operator to exercise pressure upon the carotids in an oblique direc- tion, so as to press them away from the jugular veins pression and electricity, see " Electrization of the Sympathetic and Pneumogastric Nerves, Avith Simultaneous Bilateral Compres- sion of the Carotids," by J. Leonard Corning, M.D., "The NeAv York Medical Journal " for February 23d, 1884 ELECTRO-COMPRESSION. 20 Fig. 1.— Author's Electro-Compressor.— a a', insulated sponge electrodes in con- nection with the bifurcated conductiu,^ Avire 6; c, milled wheel, tli£ rotation which causes the screw d to act upon the armatures e e', thus enabling the operator to ex- pand or approximate the latter at will. 30 HEADACHE AND NEURALGIA. in the direction of the spinal column. By this means it is possible to reduce venous pressure to a minimum. Again, the branches themselves may be extended or approximated at will, an advantage obtained by the use of the Archimedean screw. An exceedingly fine adjustment is thus rendered possible. The method of employing the instrument just de- FiG. 2.— Showing Mode of Applying Electro-compression. A, differential calo- rimeter, connected with the thermo-electric piles d d, by means of the conducting: wires e e'. B, galvanic battery connected with the electro compressor C by means of the bifurcated conducting wire /. The electrode at the extremity of the other conducting wire /' is placed on the neck. cribed is exceedingly simple. The patient, if in bed, is placed in a horizontal and semi-dorsal position, with the head supported by a cushion beneath the neck, in such a manner as to allow the head to fall slightly backward, while the cervical vertebrae are protruded anteriorly (Fig. 2). The operator then takes his place ELECTRO-COMPRESSION. 3) by the bedside, his left side being turned toward the patient. Then, having with the index-finger and thumb ascertained by careful exploration the exact position of the carotids, he proceeds, after accurately adjusting the armatures, to apply the instrument in such wise that the electrodes will press the arteries away from the pneumogastric nerve and jugular vein in the direction of the spinal column. In applying the instrument it should be held in the right hand, the handle forming a perpendicular to the arteries. By pressing the left hand firmly against the posterior portion of the neck, the operator is enabled to execute any counter-pressure which may be required, and at the same time to contribute to the support of the head in the desired position. Compres- sion should, however, never be carried so far as to cause entire closure of the lumina of both arteries ; such a procedure may cause convulsions, as the anas- tomotic facilities at the circle of Wilhs are usually unequal to these unwonted circulatory exigencies. This contingency is, however, not liable to arise, as the degree of pulsation in the temporal arteries affords reliable information as to the extent of the circulatorv obstruction. When the instrument has been properly adjusted, an assistant applies the disengaged electrode (usually the positive) over the posterior aspect of the cervical vertebrae. All being in readiness, the strength of the battery is gradually increased. It is impossible to determine in advance how many cells may be required, as this will depend greatly upon the strength of the battery, the thickness of the cervical adipose tissue, and the degree of compression employed. The greater the amount of compression the 32 HEADACHE AND NEURALGIA. less the strength of the current should be, and vice versa. Care should be exercised to avoid dizziness or syn- cope, and the strength of the current and degree of pres3U]^e should at all times be regulated with the ut- most nicety. Sudden variations in either of these factors are to be carefuU}^ avoided. By this mode of treatment we accomplish a threefold end: (1) Dimi- nution of the amomit and pressure of the cortical blood- stream; (2) Contraction of the cerebral capil- laries; and (3) Eeduction of the intensity of the heart's action (when currents of considerable strength are employed). I have frequently caused entire cessation of the con- gestive form of head-pain in the course of from five to eight minutes by the use of this method of treatment. Only secondary in importance to the above method of treatment is the application of cold to the head. This may be done by means of the ice-bags in general use, or better still by the employment of the apparatus recommended by Mr. Joseph Leiter, Dr. Knowsley Thornton and others. This appliance consists in a series of india-rubber spirals, which are wound around the head in the form of a cap. By passing a stream of cold water through these spirals it is possible to main- tain the water in them at an exceedingly low tempera- ture. This method of treatment has been extensively employed, I believe, by Mr. Spencer Wells of London, especially after the operation of ovariotomy. This ice- water cap may be employed with increased benefit in conjunction with hot water both to the feet and calves; the effects thus attahiable being striking. Hot baths to the entire body ranging in temperature from 103° to 110° may be prescribed with advantage, where other means of treatment are not accessible. BATHS. 33 Baths of this cliaracter a,ffect the central nervous system to a niucli greater extent, and in a shorter space of time than warm baths. The skin becomes rapidly congested ; respiration is increased and inspiration becomes deeper. As a rule these baths are followed Fig. 3.- Mode op Applying Ice-water Cap. (After Letter.) by profuse perspiration, and their derivative action upon the engorged cerebral centres is not to be over- estimated. The hot-air or Turkish bath has a wide application in the treatment of the congestive form of headache; 34: HEADACHE AND NEURALGIA. and I have no hesitancy in recommending its employ- ment in this connection, though fully aware that a prejudice exists against the use of hot haths in brain affections. The sojourn of the patient in the hot-room should not, however, be of too long duration ; twenty or thirty minutes are quite enougli. When possible, the subsequent application of the douche should be in the form of the hot water stream, as recommended by certain French physicians, in order to redden the skin, especially about the back and lower limbs. As soon as this operation is completed the patient should be put to bed and wrapped in warm blankets. A most excellent expedient, in severe cases, is the application of a leech at each side of the septum narium, about half an inch above the nares. This may easily be accomplished by the aid of a curved leech glass. The hemorrhage which follows is sometimes profuse, but may be arrested by the application of a tampon of styptic cotton on each side of the septum. In order to increase the bleeding, it is only necessary to hold the head over a bowl of hot water. Should the liemorrhage from the mucous membrane prove obstinate, the application of a soHd point of nitrate of silver over the bite may be resorted to. It is hardly necessary to add tliat, in the application of leeches to the septum, care should be taken to prevent the passage of the animals into the nasal cavity. This may be accomplished by previously plugging the nostrils with cotton wool. In order to avoid the employment of leeches, I have had con- structed an apparatus, by means of which artificial epistaxis may be produced in a satisfactory manner, and without the slightest possibility of accident. It consists, in the first place, of the jar (e), which is connected with the air pump ih), by means of which ARTIFICIAL EPISTAXIS. 35 it is possible to cause a vacuum in the vessel (e). The gauge (/) registers the degree of approach to a vacuum. An india-rubber tube connects the jar with the small bottle (c), which is provided with a scale. A bifur- cated tube (h) connects the bottle with the two small cupping bowls (a d) ; the latter are sufficiently minute to admit of their introduction into each nostril respec- tively. As they are provided with india-rubber gar- nitures, it is possible to adapt them accurately to the sides of the septum. ~^^^^^=^3!^p.^* Fig. 4.— Author's Apparatus for Artificial Epistaxis. The mode of employment is simple enough. The cupping bowls having been introduced, a small scalpel is inserted in turn beneath the edge of each, by means of which the mucous membrane of the septum is slightly scarified. The cupping bowls are then connected with the vacuum jar and with the bottle by opening the appropriate stop -cocks. These valves (^, ^, i, i) require no explanation, as their function is self-evident from the situation which they occupy. Short segments of glass tubing, inserted in 36 HEADACHE AND NEURALGIA. the india-rubber pipes below the cupping bowls, enable the operator to observe whether the blood is flowing properly, or whether further scarification is necessary. As the blood flows into the graduated bottle already described, it is possible to determine with accuracy the amount removed. Blisters to the nape of the neck and sinapisms to the calves of the legs have been highly praised by some as adjuncts to other modes of treatment; while the scari- fication of the nape of the neck has also found advo- cates. The apphcation of the constant galvanic current to the head is a useful expedient in some cases, but too much reliance should not be placed upon it. On the other hand, dry- cupping when extensively practised is sometimes attended with happy results, es- pecially in the milder forms of congestion. A very good method for carrying out this form of treatment is to smear the posterior portion of the neck and the back throughout its entire extent with spermacetti ointment: the exhaust glass (which should be large) is then re- peatedly applied and voided by means of the air pump. This procedure is repeated until the entire back be- comes livid. It is evident that such a degree of super- ficial congestion must exercise no little derivative action upon the deeply seated tissues; and indeed the results obtained in cerebral and other forms of conges- tion are sometimes all that could be desired. Where the engorgement is very considerable, however, it is usually necessary to resort to some one of the more powerful remedies already referred to. Venesection, to which resort was had by the older physicians in congestion and other forms of headaclie, can only meet with unqualified condemnation by the modern neuro pathologist as at once a supererogatory and even dan- ELECTRO -COMPRESSION. 37 gerous procedure. Local depletion by epistaxis— the most direct mode of affecting the cerebral circulation by blood-letting, — or compression of the carotids by means of appropriately constructed instruments, are certainly far more direct in their effects than general depletion, and at the same time quite devoid of danger or dis- agreeable consequences of any kind. CHAPTER IV. NERVOUS OR CEREBRAL HEADACHE. Under this designation I propose to consider that variety of headache which, in its typical form, is char- acterized by the absence of all circulatory derange- ments and neuralgic symptoms. The most logical supposition relative to the pathology of this form of headache is that which ascribes the painful phenomena to certain subtle morbid changes originating in the substance of the nervous centres themselves. To be sure, we have no further proof of the truth of this hy- pothesis than that afforded by the fact, that this variety of headache may be readily evoked by pro- found emotional disturbances — factors which appeal directly to the psychical centres — in the absence of all purely physical causes, such as neuralgia or derange- ments of the intra-cranial circulation. Neither this nor any other theory relative to the nature of the affec- tion can, however, be accepted as in any sense final. Unlike the anaemic and hypersemic varieties of head- ache, the form of the affection which we are consider- ing is not readily amenable to experimental inves- tigation, and hence, as already intimated, we are reduced to the necessity of forming our conclusions from data which, to say the least, are insufficient. Pending more exact knowledge, however, the theory which ascribes the phenomena of the affection to some subtle disturbance in the cerebral substance may be accepted; and it may also be added that this hypo- NERVOUS HEADACHE. 39 tliesis will be found to lead to a thoroughly enlight- ened and effective practice. Symptoms. — In many persons the onset of the head- ache is marked by the occurrence of digestive derange- ments in the form of eructations, flatulency, or consti- pation. There is always more or less malaise and mental irritability in the beginning, and the latter symptoms usually become greatly exaggerated in the course of a few hours. The pain begins in some persons with a certain amount of visual disturbance; the sight becomes clouded, and at the same time an acute pain is felt in tjie corresponding temple. With these symptoms the |)atient usually experiences more or less nausea, con- fusion of ideas and vertigo ; while, at the same time, his thoughts become concentrated on his real or antici- pated misfortunes, with the result of greatly augment- ing the intensity of the head-pains. Sometimes the pain is felt in the vertex, forehead or occiput ; but in a considerable percentage of cases, it becomes located in one temple, in one -half of the head, or in one eye ; so that the supposition may be formed that the nerves of the head are implicated, as in neuralgia. There is also more or less sensitiveness to sensory impressions of all kinds ; the patient shuns the light and stops her ears with pledgets of cotton, or with her fingers, in order to keep out the din of the house and street. Sometimes the subject complains of feeling as though her eye were being forced out of the socket, or as though the side of her nose were being burned with a hot iron. I have already mentioned the cerebro-hyperaemic and cerebro-anaemic varieties of headache, in the table of classification at the head of this article. It would be 4:0 HEADACHE AND NEURALGIA. an easy matter to discourse at length upon those mod- ifications of the nervous headache, but to do so would be somewhat supererogatory, since, in their fundamen- tal characteristics, they are closely allied to the latter affection. The only point of difference consists in the presence of certain vaso-motor disorders of the cerebral blood-vessels, which find their chief clinical expression in either pallor or flushing of the countenance and in diminution or increase in the strength of the carotid pulse. These circulatory phenomena are, however, strictly speaking, purely secondary to the primary morbid changes in the cerebral substance. It is well to bear this fact in mind, since, if the efforts of the physician be directed solely toward the modifi- cation of these vascular changes, he will inevitably meet with disappointing results. On the other hand, if appropriate efforts be made to remove the primary condition of irritability, resident in the cerebral sub- stance itself, good and even brilliant results may often be obtained in a comparatively short period of time. Causation. — The most potent predisposing element is undoubtedly found in the neurotic and impression- able constitutions of the patients, or their ancestry. Debilitating diseases, spermatorrhoea, leucorrhoea, mental disorders, and profound digestive disturbances may also predispose to the occurrence of the nervous or cerebral form of headache. Among the exciting causes, worry, disappointment, pecuniary losses, and in short the whole category of depressing emotions occupy the most prominent posi- tion. Only secondary to these in importance is ex- haustion of the nervous centres, particularly those of the brain. Treatment. — The point of paramount importance is to calm the irritable nervous centres. This is best ac- NERVOUS HEADACHE. 41 complished by the administration of remedies which- exert a soothing influence upon the cerebral paren- chyma, and at the same time tend to promote sleep. To this end, I usually administer the bromides in ten, twenty or even thirty-grain doses, where the stomach is sufficiently tolerant, and follow these remedies with a hypodermic injection of from one-eighth to one-sixth of a grain of morphia. At the same time, the patient being secluded in a dark room, ice is applied to the head— a procedure often followed by excellent results, especially if there be some tendency to cerebral con- gestion. On the other hand, if the face is bloodless and the conjunctivae are pale, the hot- water bag is indicated, and should be resorted to at once. The question as to whether the elastic band ' should be applied above the superciliary arches, will depend greatly upon whether there are any concomitant neuralgic symp- toms or not. Where these are present, the pressure caused by the band is usually not well borne, and consequently this otherwise useful adjunct to treat- ment is contra -indicated. If sleep is not readily produced by the remedies above indicated within a reasonable length of time, hyoscyamus may be prescribed. I usually give it in the form of tincture in drachm doses, either alone or combined with the bromides. Chloral has been recom- mended in nervous headache by some writers, but is not to be compared with the 'hypodermic injection of morphia. If the subject, as not infrequently happens, is averse ' The object of the elastic head-band is to compress the vessels of the scalp, thereby materially reducing the diffusive influence of the extra-cranial blood stream, and rendering the effects of cold or hot applications upon the braiu much more hitense, 42 HEADACHE AND NEURALGIA. to its subcutaneous exhibition, it may be gi\^en in the form of suppositories, but the effects thus obtainable are not always as striking as those witnessed when the remedy is injected beneath the skin. If there is pain over the temple or in the eye. and if the subject complain of "soreness in the teeth" and neuralgic pains in the face, it is well to make the in- jection in the neighborhood of the painful district, though this is considered unnecessary by some authors. It is sometmies stated that, while morphia is very efficacious at the beginning of the attack, it is of less value after the headache has continued for some time. My own experience does not corroborate this state- ment ; and I have not the slightest hesitancy in stating that, previous to the introduction into practice of antipyren, this remedy was the one upon v/hich I based a goodly portion of my hopes whether the pa- tient was seen after the pains have become estab- lished, or at their very inception. The aim of the physician, when brought face to face with a severe case of nervous headache, should be to afford relief, and that as speedily as possible : indeed it is almost impossible to overestimate the suffering incident to one of these attacks : and the confidence and gratitude inspired by prompt and succesful treat- ment are a source of lasting satisfaction to physician and patient alike On the other hand, want of success brings mortification, if not permanent loss of profes- sional prestige. If possible, it is well to see the patient towards evening, when the soporific tendency conse- quent upon habit is greatest. As soon as a diagnosis has been made, antipyren may be exhibited in doses of fifteen grains every twenty minutes during the first two hours. The bromides may then be given — preferably in a dose NERVOUS HEADACHE^. i^ of from twenty to thirty grains in conjunction with one drachm of the tincture of hyoscyanms. Should there still he persistent pain the eighth of a grain of morphia may he injected heneath the skin. Sympathizing friends should then be sent away, and the patient allowed to remain quiet in a perfectly dark room, while the medical attendant occupies a neighboring apartment, leaving the door ajar. If in due course of time the patient fall asleep, the attendant may depart, resting assured that on the following morning there will be improvement, if not absolute cure. Should sleep, however, remain absent after these first endeavors, there should be no hesitancy on the part of the physician in resorting to a further hypodermic injection of morphia, even though there be nausea and a tendenc}^ to vomit. Usually, though not always, the nausea may be controlled by giving half a grain of cocaine in a teaspoonf ul of watei- just previous 1 3 making the injection. I make it an mvariable rule never to leave the patient until sleep has been produced, as the therapeutic effects of eight or nine hours of unconsciousness are simply marv^ellous in these cases. Sleep, indeed, is the grand objective point of all treatment, in so far as the realization of permanent cure is concerned. Its skiUful induction in the cases which we are considering will often procure the physician lasting gratitude, with the advantages which naturally foUow. CHAPTER V. TOXIC HEADACHE. This form of headache is caused by some chemical change in the constitution of the blood, due either to poisonous substances introduced into the system from without, or evolved in the economy itself through the agency of some organic or functional derangement. The best instance of the first named condition is the headache due to alcoholic poisoning ; while the head- pains of Bright 's Disease and of fevers, are examples of the effects produced by septic influences arising from morbid processes within the organism itself. Symjjtoms. —The nature of the pains arising from toxsemic causes is variable in character. Sometimes the subject complains of a heavy, dull sensation in the head, which may or may not be accompanied by ver- tigo. Again, the pain is sharp, and is described as splitting or boring. This is the form of headache described by Fournier; ' it is frequently met with among other phenomena of secondary syphilis. According to the extent of the intoxication, the fac- ulties of the mind are more or less affected. There may be delirium as in violent febrile disturbances, or the only symptoms noticed are heaviness and slight mental confusion, as in the headache resulting from inhalation of carbonic acid gas. The latter form of headache is frequently met with among the school children of Germany, who, owing to * Fournier, " Legons sur la Syphilis, ■' Paris, 1873. Toxic ilfiADACHEJ. 45 the defective ventilation of educational institutions, are compelled to breathe the same air over and over again. The prejudicial effects of such bad hygienic arrangements are not alone confined to the central nervous system, but are visible in other departments of the economy as well. Facial pallor, baggy muscles and permanent interference with the processes of growth and physical evolution are some of the penal- ties which are the inevitable result of flagrant dis- regard of the most ordinary sanitary laws. Among workers in brass and chemical manufac- tories a dull, heavy, persistent form of headache is fre- quently encountered, which is evidently the result of the noxious fumes such persons are compelled to inhale during a considerable portion of each day. Chronic lead poisoning frequently gives rise to head- ache of an aggravated and persistent type, and the same may be said of the toxic effects of a large num- ber of other substances, such as the noxious gases already alluded to, narcotics, and alcoholic stimulants. Uraemic intoxication is another and common source of headache. The secretory power of the kidneys be- comes impaired by reason of the destructive inflamma- tory changes incident to chronic diseases ; the excre- mentitious matters of the blood accumulate, and their presence is manifested by disturbances of the central nervous system — headache, drowsiness and coma. Every physician is acquainted with cases of this kind, and nothing more need be said regarding them, except that the headache in question is often an early warn- ing of renal trouble. Treatment, — When the headache is the result of the introduction of some noxious substance into the sys- tem, every effort should be made to eliminate it from the economy. The bowels should be opened ; diuretics 46 HEADACHE AND NEURALGIA. should be given, and the secretions of the skin stimu- lated by appropriate diaphoretics. Buckthorn (rhamnus), o, purgative which I have fouiid most useful in asylum practice, is particularly applicable in this variety of headache ; it may be given in the form of the fluid extract, in doses of from one to two drachms. The fluid extract of aloes may also be given, but I prefer the buckthorn. Whatever the purgative employed it should be fluid in form, in order to obtain as speedy action as possible. Pilocarpin is useful, but I prefer the Turkish or Eussian bath. If the headache be the result of some form of con- stitutional disease, such as syphilis, it is evident tha,t the efforts of the physician should be directed to the primary affection. The same may be said of the head- aches of fevers and kidney affections. It is clear, from these cursory remarks, that the proper treatment of this form of headache requires no little insight and tact on the part of the medical attendant. To attempt to deal with such cases by the aid of any stereotyped procedure would avail little; and to lay down any such arbitrary laws on the subject, would be but a lament- able confession of pedantry. CHAPTER VI. SYMPATHETIC HEADACHE, BILIOUS HEADACHE. This is a very common though obscure form of head- ache, being dependent upon eccentric sources of irrita- tion. Any disease of the peripheral organs may cause it. Ovarian or uterine affections, hemorrhoids or decayed teeth may give rise to it ; but its most prohfic cause is undoubtedly found in the manifold digestive disturbances, to which those of feeble constitution are hable. It would be a mistake, however, to imagine that the sole explanation of its origin is to be sought in peripheral disturbances alone, though these un- doubtedly constitute the exciting factor. A certain impressionability of the sensorium, such, for example, as that exhibited by neurotic young women, is essen- tial, in order that the irritation proceeding from a dis- tance shall culminate in the production of the painful sensations. All kinds of hypotheses have been advanced in ex- planation of these curious head -pains ; the most uni- versally accepted is that which assumes that the peri- pheral irritation becomes manifest in the brain through the agency of the pneumogastrics and sympathetic system of nerves. Quite an array of clhiical facts might be advanced in support of this theory ; but to maintain its integrity by the aid of experimental physi- ology is, in the present state of knowledge, not so easy a matter. Still, some theory is better than none at all, and pending further researches, the opinions cur- 4$ HEADACHE AND NEURALGIA. rently advocated may be accepted. Nor need this course cause apprehension, since the theory itself is a good guide, as far as actual practice is concerned, and can only lead to enlightened treatment. Of the latter point I shall take occasion to speak presently. As to the Symptoms themselves, very little particu^ larization is necessary. Sometimes the pain is local in character and may manifest itself in a sensation of fullness or constriction about the forehead, or it may DO of a rasping, clawing nature, confining itself to one lateral half of the head or to the region of the vertex. As a rule, the painful sensations are aggravated by stimulants ; but this is owing, in part at least, to the digestive disturbances which so frequently constitute the exciting cause of the affection. That form of headache characterized by the presence of a yellow skin, by the accumulation of bile in the duodenum, and by more or less imperfect digestion, has received the designation of ''bilious headache." There is every reason, however, to regard this variety of head- pain as of purely sympathetic origin, since the head- ache comes on after the digestive disturbances have become established, and disappears as soon as they have been removed. It is a matter of common ex- perience, moreover, that the '^sick" headache which supervenes upon minor gastric disorders is frequently relieved immediately by vomiting. True bilious headache is more common among men than among women, on account of the excesses of the table committed by the former. The pain may begin after any meal, but is more common after a hearty evening dinner than after lunch or breakfast. Sometimes, however, the headache be- gins in the morning as the result of a previous noctur- nal debauch, and renders the subject entirely unfit for SYMPATltEtIC AND BlLiOtrS HEADACHE. 49 the duties of the day. The head may be hot or cold, but whatever the vascular conditions they are sec- ondary to the cerebral irritability which is the factor of prime importance. If vomiting takes place spon- taneously or by the aid of emetics, the relief experi- enced is often magical. When, however, the gastric and cerebral disturbances have persisted for a con- siderable length of time, the consequent irritability and exhaustion of the nervous centres is so great that the only chance of relief is more or less prolonged un- consciousness. Under these circumstances, sleep is certainly the remedy par excellence ; and to procure it, resort should be had to hypodermic medication alone, as the introduction of remedies into the in. flamed stomach is usually followed by vomiting, or at least great discomfort. Treatment. — The control of a single attack is, as we have seen, a matter of no great difficulty. To finally vanquish and definitely suppress the exciting cause of these paroxysms is, however, a task of greater magnitude. It involves in many cases nothing less than the removal of dyspeptic and other gastric dini- culties of long standing, and the tranquilization of a morbidly irritable nervous system. The first portion of the problem requires for its solution the manifold resources of general medicine. As to the suppression of morbid irritability of the nervous centres, all that has been said on the subject in the paragraph oji cerebral or '^ nervous " headache applies here with equal force. I will only add that the preparations of coca often prove exceedingly useful in treating this form of head- ache. This is partly due to the anaesthetic effect of the drug upon the irritable gastric mucous membrane ; and in part to the tranquillizing influence exercised by the coca upon the hiizher cerebral centres. i 50 HEADACHE AND NEURALGIA. As all practitioners are aware, one of the most disa- greeable features connected with the treatment of this form of headache consists in the intolerance of the stoQiach to remedies. Until the introduction of the coca preparations into practice, I w^as frequently at no little loss as to the pursuit of a consistent plan of med- ication in such cases, owing to this same intolerant condition of the stomach. I soon ascertained, however, that by adding a certain quantity of the fluid extract of coca to the remedy that I was anxious to prescribe, the latter was borne wdth much less inconvenience. The good effects thus attained were greatly enhanced by the addition of half a grain of cocaine or more. This was particularly exemplified in those cases where I had occasion to prescribe considerable quantities of the bromides A pill compound of : Ees. Podophylli gr. i, Extr. Col. comp. pulv. gr. 1, Extr. Hyoscyami gr. i, Hydrarg. Chlor. mit. gr. 1, is an excellent cath- artic where brisk action on the liver is desired. The addition of a small quantity of the extr. of belladonna is advisable where the tendency to griping is pro- nounced. The following formula, recommended by Day, some- times renders good service where there is a tendency to flatulence and acidity : Sodae Bicarb. Bismuth Subcarb. Pulv. Acaciae, aa. 3j. Spt. Amm. Arom., 3ij. Sqr. Zingib., 3 iij. Aquae purae, ad. 1 viii. Two tablespoonfuls three times a day half an hour before eating. Here also the efficacy of tlie prescrip- tion is greatly enhanced when its administration h SYMPATHETIC AND BILIOUS HEADACHE. 51 preceded by giving cocaine hydro-chlorate, half a grain in a teaspoonful of water. I have tested this point many times, often in exceedingly intractable cases. Bismuth in doses of from fifteen to twenty grains before meals may be given where there is evidence of intestinal irritability. Sometimes two or tliree drops of the tincture of nux vomica given every half hour for three or four hours renders good service. An excellent expedient is that of Dr. A. A. Smith,' who gives half a drachm of saccharated pepsin in a wineglassful of sherry three times a day at meal times. A drop or two of the tincture of aconite, given in a small quantity of water and repeated at intervals, some- times proves efficacious where the pulse is small and rapid. Where the extremities are cold tlie application of hot-sand bags, which have previously been covered with flamael, proves beneficial by equalizing the cir- culation and promoting the general comfort of the pa- tient. Quinine may also be given when there is a suspicion of malaria, or when there is pronounced facial pallor and weak carotid pulse; but should there be the slightest suspicion of cerebral congestion it should be withheld. ' A lecture delivered at the Bellevue Hospital Medical College. "The Medical Record," September 15th, 1876. CHAPTER VII. ORGANIC HEADACHE. OR THAT WHICH IS DEPENDENT UPON PROFOUND CHANGES IN THE CONSTITUTION OP THE BRAIN OR ITS MEMBRANES. The consideration of this variety of head-pctin does not strictly speaking belong in a work of this charac- ter. For the sake of differential diagnosis, however, a word or two respecting its more important charac- teristics will be found of service. Headaches due to organic disease of the brain are usually more or less continuous in character and are referred to a circumscribed portion of the cranium. There may or may not be accomjDanying disturbances of sensation and motion assuming the form of local spasms, paresis or impairaient of vision. Sometimes cases are encountered in which progres- sive loss of muscular power, vertigo, visual impair- ment and derangement of the faculty of recollection are the prominent symptoms. If headache, accom panied by epileptic phenomena, disturbances of speech and facial paralysis, takes place at the period of ado- lesence, there is strong presumptive evidence that we have to do with organic disease, more especially if a history of previous syphilis is forthcoming. The probability that a correct diagnosis has been made is considerably enhanced if there is vomiting and inability to retain food on the stomach, in the absence of obvious gastric disturbance. ORGANIC HEADACHE. 53 Organic disease is by no means as frequent a cause of headache as miglit be imagined from the percent- age of gross cerebral lesions. Nor is the diagnosis of this form of headache always an easy matter Some- times the headache resulting from organic changes may be circumscribed in character and located by the patient with great precision ; whereas a subsequent post-mortem examination may prove such localization to be entirely subjective, the lesion being found in an entirely different portion of the brain. Again, there may be more or less profound organic changes without headache ; or there may be intense local pains, more or less persistent in character, and which are wholly due to some circulatory instability. In the face of such facts, it is evident, that only by the exercise of the utmost caution is the liability of error to be reduced to a mininam. Causes. — The lesions which are most liable to give rise to this form of headache are : arterial disease, sy- philitic and other varieties of tumor, tuberculosis, cerebral softening, hydatids and ossified formations within the cranial vault and meningitis. Treatment. —The treatment of headache due to or- ganic lesions of the intra-cranial structures is in the highest degree unsatisfactory, as far as the prospect of ultimate recovery is concerned. This at least is true as regards non-syphilitic lesions. Where there is reason to believe that the disturbances are due to the presence of syphilis, the iodide of potassium should be given in large doses two or three times a day, and the treatment persisted in until improvement becomes evident. Sometimes there is no apparent benefit in the beginning ; but this should not deter the practi- tioner from persevering in the only course which offers the slightest hope of ultimate amelioration. 54 HEADACHE AND NEURALGIA. And it must be confessed that great patience will be required, both on the part of the patient and physician, in order to withstand the lack of success which fre- quently attends the beginning of this heroic medica- tion. Sooner or later, however, if the lesion be really due to syphilis, improvement may occur, and the spectacle of the patient's improvement under such unpromising circumstances is an ample reward for all previous anxiety. The iodide of potassium has been recommended as efficacious in the treatment of non -syphilitic tumors, as well as in those traceable to specific influences. I cannot say that the bulk of clinical evidence accessible up to date goes far to confirm this opinion ; but in spite of this fact, it is evident that the iodide should always be given a fair trial in all doubtful cases. As to the treatment of the pains themselves, mor- phine is unquestionably the remedy upon which the greatest reliance is to be placed. There is one draw- back to its administration, however, the serious de- pression which it sometimes produces in neurotic, irritable subjects. This collateral disadvantage is best overcome by the administration of one of the coca preparations,— either the extract or Mariani's coca wine. I usually give the latter in wineglass doses as soon as there is the slightest tendency to depression. The amount of morphine required is of course exceed- ingly variable ; usually, however, one-sixth of a grain will be found to render good service, especially if fol- lowed by a drachm of the tincture of hyoscyamus, or ten grains of chloral. The latter remedy when given alone or in conjunction with the bromides usually fails to render substantial aid ; and I would therefore insist that opium in some form be invariably given previous to the exhibition of the cliloral preparations. Anti- ORGANIC HEADACHE. 55 pyren has not helped me much in this class of cases, when given alone. In conjunction with small doses of morphine, however, I have seen good results follow its exhibition. CHAPTER VIII. CASES. Having in the preceding chapters discussed the prin- cipal phases of headache, it may perhaps prove of benefit to cite a few illustrative cases:— T. B., a merchant, native of St. Kitts, West Indies, was referred to me by the late Dr. Cornelius E. Ag- new, on account of severe headaches, accompanied by certain mental disturbances, such as temporary loss of memory and lassitude. Patient had already consulted several eminent Eng- lish authorities, among whoQi I believe was Sir Andrew Clarke. When I first saw this gentleman in November, 1886, he exhibited the following symptoms : Periodic exacerbations of cerebral hypersemia, ac- companied by tensive pains and sensations of fullness in the head. Sometimes there is vertigo; at others the patient, though ordinarily of an even disposition, is irritable and aroused to worry and fretfulness by trivial or imaginary causes. The heart's action is also more or less increased dur- ing the attack. During the head-pains the face is suf- fused, whereas at other times his complexion is of a yellowish grey appearance. Patient has suffered from constipation for many years, and of late his venereal functions have exhibited a well-marked decline. I prescribed purgatives and the bromides, with CASES. 57 directions lo take a hot bath as soon as the first symptoms of an impending attack shoukl make their appearance. While sitting in the bath, the warm water extending up to his arm-pits, I instructed him to press upon his carotid arteries with an implement which I loaned him for the purpose. These simple meas- ures never failed to give him instant relief. On one occasion he had a slight attack of syncope while in the bath, and the attendant, who was always present, removed him at once. There wei'e no farther evil effects from the treatment that I ever heard of , nor do I believe that this slight syncope need have oc- curred had the patient obeyed my injunction not to remain in the bath more than ten minntes, which for a man of his age was quite enough. By prohibiting alcohol and cutting down the patients' diet somewhat, the headaches were eventually entirely cured ; but I never succeeded in entirely abolishing a peculiar '^buzzing sensation in the head" (tinnitus?), of which the patient complained more or less while under my care. A. N. D., a young woman of twenty, consulted me on account of severe headaches, from which she suffers more or less constantly, and more especially during the menstrual period. She is an excellent illustration of that common class of head- pains which is the direct result of the devitalized and anaemic condition of the patient. For the last four years she has suffered from dysmenorrhoea ; her appetite is poor, and she has been a victim of constipation more or less during her whole life. Her heart's action is weak, as reflected in a feeble pulse, which at times is irregular. Her com- plexion has a tawney, sallow appearance, the conjunc- tiva is pale and the pupils somewhat dilated. The indications afforded by the carotids were also 58 HEADACHE AND NEURALGIA. characteristic. When the head was thrown shghtly backwards so as to protrude the cervical vertebrae in an anterior direction, these arteries are seen to pulsate slightly ; but on applying the finger they are found to be decidedly more compressible than in healthy or hyperaemic individuals. When both arteries are com- pressed by the aid of an appropriate instrument, sen • sations of faintness are at once induced. On suddenly rising from the recumbent posture this feeling of faintness may also be induced, and at the same time the characteristic "clawing" pains of anasmia are at once evoked. There is some sensitiveness to light, but no special hyperaesthesia of the sense of hearing. The diagnosis in such a case as this is at once appar- ent : in a word, we have to do with a typical case of anaemic headache ; and the indications for treatment are the counteracting of all those features implied by the word anaemia. In the first place relief of the cerebral anaemia by alcohol, w^ith consequent immediate stoppage of the headache. For the purpose of further facilitating the blood- flow to the cerebrum, the patient is to be kept upon her back. Finally, in order to secure permanent results, the patient's appetite is to be stimulated by bitters, and she is to be put upon a course of systematic over-feeding. Exercise is to be studiously avoided in a case of this kind, at least until there is total disappearance of the head -pains. ToAvards the end of treatment, massage and general faradization may be resorted to, usually with great benefit. Nothing of the kind should, however, be attempted at first on account of the danger of diverting the blood- stream from the already impoverished nerve centres. CASES. 69 Under the treatment indicated, the improvement in this case took place with reasonable promptness. At the end of a month there were no pains of conse- qneiice ; the patient had already gained several pounds, and I was able to allow her to go about a little. From this time forwards, her improvement was a rapid one, so that at the end of three months, with the exception of the dysmenorrhoea, she was entirely cured and she could take her place in society without discomfort. C. E T., middle-aged married lady, has suffered ever since girlhood from " sick-headache." The pain is exceedingly intense, and is generally lo- cated in the forehead. The attacks usually begin in the afternoon, but this is not always the case. Soon after she feels the premonitory symptom of the attack — a '^ dull feeling in the head "—she is afflicted by in- tense nausea, which is speedily followed by vomiting. These symptoms are invariably followed by vertigo, great mental depression and prostration, so that she is obliged to take to her bed, where she remains till the middle of the following day. When she is able to obtain relief, there is practically an end of the mat- ter on the following day ; but where unconsciousness fails to come to the rescue, there is much pain on the following day, and the headache may even persist for three days or more. Her complexion is sallow, her appetite fair ; but her digestion is habitually impaired, and she has always suffered from constipation. In her case a pill of podophylline and extr. col. comp. with i gr. of hyoscyamus and 1 gr. hydrarg. chlor..mit. never failed to give relief . In addition to this I am in the habit of giving her large doses of bro- mo-caffein combined with grain doses of the hydro- chlorate of cocaine, the latter being administered in 60 HEADACHE AND NEURALGIA. half a tablespoonful of water, ten minutes before giv- ing the bro mo-caff ein. She declared that she obtained more prompt relief from these measures than from anything she had ever tried. Her tendency to diges- tive trouble, howevei', still remained a factor of such obstinacy that, with all I could do for her, I was never able to effect a final abolition of the attacks, which occurred upon the slightest indiscretion of the table, and even as the result of comparatively slight worry, where there was no history of any indiscretion what- ever. This is a typical case of that form of megrim of which every practitioner of large experience en- counters many cases every year. In giving these brief histories of the more common forms of intra cranial pain, I trust that I have not trespassed too much upon the patience of the reader. It is now in order to consider the second and larger field of our subject, the ex bra- cranial pains and those CO- related phases of neuralgia involving the peripheral nerves at large. It has also seemed appropriate to supplement the discussion by a chapter on that inter- esting and important affection known as spinal irrita- tion* PART II. NEUKALGIA, PAINS WHICH OWE THEIR ORIGIN TO EXTRA-CRANIAL CAUSES. CHAPTER IX. GENERAL CONSIDERATIONS. Under the designation of neuralgia, I propose to consider an affection of the nerves, the chief charac- teristic of which is severe and sudden pain occurring in one or more nerve trunks and radiating towards the periphery. Characteristics. — As Dr. Anstie' has rightly ob- served, the first attack is always preceded by a condi- tion of debility resulting from general or special causes. The disease is especially liable to occur in those whose dehcate constitutions render them susceptible to sud- den changes in the weather or cold draughts of air. This applies with particular force to persons of neurotic temperament, in whom the power of ac- commodation to violent and rapid changes of tempera- ture is but imperfectly developed. The onset of the disease is usually heralded by vague muscular twitch ings or sensations of pricking, quickly succeeded by evanescent darting pains. The pains are recurrent in character, and succeed each other with ever-increasing frequency and intensity, until, in the more severe attacks, the patient suffers the most excruciating agony. Sometimes the pains are described as resembling the sensations produced by the prick of red-hot needles ; at others the subject complains that he feels as though he were being lacerated with a saw, or as ' "Neuralgia and the Diseases that resemble it." London, 1871. 64 HEADACHE AND NEURALGIA. if electric sparks were projected along the course of his nerves. These pains are sometimes stationary and are ascribed by the subject to particular districts, which are found to correspond to the course of a nerve trunk. At other times they are ambulatory and dart from place to place — usually from the centre towards the periphery, but sometimes in an opposite direction. On the application of pressure above the affected nerve, the latter is often found to be extremely hyperaesthetic throughout its entire course, whereas, on the other hand, in a considerable number of cases exploration with the point of the finger reveals the existence of isolated painful spots — " the painful points " of Vallei. These painful spots are usually located at the points where the nerve -stems emerge from bony canals, or transfix fibrous tissue. They are present in the major- ity of cases of neuralgia, and careful digital explora- tion will rarely fail to result in their accurate localiza- tion. When exploration with the finger fails to reveal the presence of these piinda dolorosa, they may fre- quently be discovered by resort to the induced current, apphed by means of the wire brush. The latter should be gently applied along the course of the suspected nerve, the strength of the current being gradually in- creased or decreased, to suit the susceptibiUty of the individual. A small sponge electrode may be substi- tuted for the wire brush ; but I prefer the latter, pro- vided that the current can be acccurately regulated. Where the state of the nervous system is one of ex- treme irritability, the pains are sometimes distributed by irradiation to districts remote from the seat of the primary lesion. It has been asserted by Trousseau that pressure applied to the vertebrae situated at the origin of the painful nerves, causes pain in all neural- gic affections. These sensitive areas along the course GENERAL CONSIDERATIONS. 65 of the cord have been designated by this author as " points apophysaire, or spinous points.'' ' It is evident, however, that tliere is nothing pathog- nomic in the phenomena, since they may be present in several affections of the spinal cord; but, neverthe- less, they call for special local treatment, of which more will be said in the Appendix on spinal irritation. Disturbances of sensation are frequently encoun- tered in neuralgia. These may consist in subjective feelings of numbness or formication, or the derange- ments of sensibility may be more marked, assuming the form of anaesthesia or hyperaesthesia." As a rule, these phenomena are more or less strictly confined to the district throughout which the painful nerve is dis- tributed. Neuralgic affections are sometimes accom- panied by certain reflex phenomena, which, as Rosen- thal remarks, may be explained by the numerous communications of the posterior root-fibres ^^ith the gray substance of the cord. Thus, in neuralgia of the limbs, the latter are subject to spasms which may be local or diffuse in character ; while in facial neuralgia sensory irritation gives rise to muscular contractions with more or less distortion of the countenance. Yaso-motor disturbances are frequently met with in neuralgia. These may consist in circulatory disturb- ances, properly speaking, or in cutaneous eruptions. ^Trousseau's "Clinical Medicine," Vol. I., London, 1868. ^ " Beitrag zur Lehre von der Hy perse sthesia und Anjesthesia/ von L. Tlirck, Zeitschrift d. Ger. der Aerzte zu Wien, 1850. CHAPTER X. CLASSIFICATION OF NEURALGIA. (1). TRIGEMINAL NEURALGIA. In most of the books it is the custom to designate the various nerve-pains according to the nerve-stem or branch chiefly imphcated. Thus we speak of trigemi nal neuralgia, supra-orbital neuralgia, etc. Following this well-established precedent, we may distinguish the following varieties of neuralgia: (1). Trigeminal Neuralgia with its sub-varieties. (a). Supra-orbital (Ophthalmic) Neuralgia. (6). Supra-maxillary (Infra -orbital) Neuralgia. (c). Infra-maxillary Neuralgia. (2). Cervico- Occipital Neuralgia. (3). Cervico- Brachial Neuralgia. (4). Crural Neuralgia. (5). Lumbar Neuralgia. (6). Lumbo- Abdominal Neuralgia. (7). Dorso-Intercostal Neuralgia. (8). Sciatic Neuralgia. (9). Plantar Neuralgia. (10). Coccygodynia. (11). Mastodynia. (12). Muscular Neuralgia. In the foregoing classification, I have purposely omitted the visceral pains, as their origin seems stiU too obscure to admit of final classification. I may add that the forms of nerve-pain above enumerated are of peculiar interest to the physician, inasmuch as they CLASSIFICATION OF NEURALGIA. 67 are amenable to rational treatment of a local character, owing to the accessibility of the nerve-stems involved. Though the previous general survey of neuralgia affords a fair conception of the main points of interest, as far as the symptomatology is concerned, it will be well to bestow a glance upon the affection as mani- fested in different localities of the body. Following this plan, I shall adhere strictly to the classification of nerve-pains just given, as it is at once simple and sufficiently comprehensive. trigeminal neuralgia (neuralgia of the fifth nerve). This form of neuralgia is characterized by lightning- like pains, which may extend throughout the entire area supplied by the fifth nerve, or may confine itself to one or more branches of the latter. When the entire nerve is affected, excruciating pain is felt throughout the lateral half of the face and head. Sometimes these pains assume the form of gnawing sensations more or less constant in character, and extending through- out a wide area. At other times the pains resemble those induced by the electric brush, are ambulatory and intermittent, and are referred to by the patient as " flying about " or " shooting through the head." The painful points are observed at the localities where the nerve emerges from a bony canal or pene- trates a fascia. As in other forms of neuralgia the painful sensations do not always confine themselves to the district supplied by the affected nerve, but on the contrary they are projected to regions more or less remote from the primary seat of the affection. The usual vaso- motor disturbances of neuralgia are observed in this variety of the affection ; they consist in pallor and coldness of the skin in the beginning of phine are tried, witli tlio hope of afToidiiiti; a renewal of vigor. But the relief obtained is at most transi- tory in character, and the reaction, which inevitably follows, leaves the subject in a far worse condition than before. Where tlie temperament of the patient is abnormally emotional, the insomnia is of a far graver character than where the cast of mind is es- sentially intellectual. Adv^ersity, worry and suspense are not well endured by such persons; and even trivial disappointments give rise to all manner of dismal forebodings. The cares of the day, instead of being abandoned at bed -time, take entire possession of the mind, and effectually exclude sleep. It is, moreover, an unfortunate circumstance that the occupations usually preferred by this class of individuals are such as appeal powerfully to the emotions; and thus the mind is kept in a perpetual state of erethism. On the other hand, those in whom the ratiocina- tive faculties assume great prominence, though sub- ject at times to attacks of insomnia, are far less liable to become victims of chronic wakefulness than those in whom the emotional faculties are predominant. Moreover, the insomnia peculiar to the former class of persons is not usually accompanied by the extreme mental irritation which is so constant and painful a symptom of the emotional type of sleeplessness. A vivid imagination is also extremely prone to ag- gravate an attack of insomnia. The fancy, instead of becoming gradually subdued, until the supervention of unconsciousness, increases in activity; while myiiads of fantastic thoughts crowd upon the mind in endless procession, and baffle every attempt at repose. Those possessed of great imaginative powers and strong emotions are particularly dependent upon sleep. De- prived of the latter, they become listless, irritable and ^Ott HEADACHE AND NEURALGIA. emaciated; and in an incredibly short time the ardor of even the most sanguine dispositions is entirely quenched. During the early part of the night such persons lie awake for several hours, tormented by a constant succession of thoughts and emotions of the most varied character, and not till towards morning do they usually succeed in falling asleep. This sleep, though short in duration, is far from physiological in character, being accompanied in most instances by a succession of morbid dreams, which are th3 direct out- grow^th of the previous condition of mental extrava- gance. On awaking, complaint is made of sensations of heaviness, of head pains, which may be variously loca- ted, or of a feeling of constriction about the forehead. Sometimes a sensation of distention is noticed in the region of the vertex, which may or may not be accom- panied by pain. There is a large class of persons in cities, employed in hotels, theatres, and other public places of resort, who from the nature of their employment are com- pelled to remain awake during the whole or a greater portion of the night. It is the habit of these individ- uals to seek to compensate for the loss of sleep entailed by their various nocturnal employments, by resort to day sleep. Such repose, is, however, both as regards duration and quality, far inferior to the normal sleep enjoyed at night; and the persons who are compelled to resort to it are rarely if ever able to compete in energy or endurance with those whose employments permit them to retire soon after sunset. They be- come either sallow and emaciated in appearance, or pale and flabby, especially when addicted to the use of alcoholic stimulants. As to the sleep itself, not only is it deficient, as we have seen, in ultimate restorative IDIOPATHIC INSOMNIA. 205 effect, but also with regard to quality. Morbid dreams, unconscious cerebration, and nightmare are the usual accompaniments of day sleep. In the ma- jority of cases, persons whose only alternative was the form of sleep just described, have been obliged, after the lapse of but a few years or even months, to desist from the nocturnal employment and adopt some other form of occupation. CHAPTEE XXX. SECONDARY INSOMNIA. SLEEPLESSNESS ARISIXG FEOM IRRITATIOiT OP THE CEN- TRIPETAL XERYES. In order to insure the most ^Derfect form of natural slee^D, there should be, as far as possible, an absence of sensory imjDressions. When there exist neither imta- ting disorders within the body nor upon its sm-face, and when no impressions are transmitted through the special senses, it is evident that the requirements of the above proposition are fulfilled. During normal sleep, it is true, the receptive centres are blunted because of the exhausting effects of the previous stage of activ- ity. As a consequence, moderate sensory impressions, which drudng the waking condition w^ould have led to active perceiDtion, leave no imjDrint upon the exhausted protoplasm. ^^Hien, however, impressions of consid- erable intensity are transmitted to the exhausted re- ceptive centres, the latter become irritated and aroused from the lethargy consequent upon exhaustion, and finally the entire cerebral mechanism is aroused — the individual is awakened. Tliis is the essental morbid physiology of w^hat I have considered under the head of secondary or symp- tomatic insomnia. Dr. Eobert J. Graves ' has given an excellent de- ' Clinical Lectures, hy I)r. Eobert J. Graves, second American Edition: Ed. Barrington & Geo. 1). Howell, Philadelphia, 184?. SECONDARY INSOMNIA. 207 scription of tlie insomnia i)ro(luce(l by tlie api)lication of blisters. Such cases are practically e;x:periniental cor- roboration of the views advanced by myself with regard to the nature of symptomatic insomnia. Moreover, they serve to illustrate the anti-soporific effects pro- duced by irritation of the peripheral organs of centri- petal nerves. In speaking upon this subject, Dr. Graves observes: — '' The bad effects on the nervous sys- tem occasionally produced by the application of blis- ters, are somewhat analogous to those which result from wounds and other external injuries, and to be accounted for on the same principle. . . . Wounds and injuries sometimes make an impression on the nervous system by no means proportioned to the im portance of the injured organ to life, or to the extent of the mischief. . . . An injury produced by a body which strikes the sentient extremities of the nerves with great force will sometimes produce very remark- able effects on the system. . . . Thus a musket ball striking a limb may, without wounding any great artery or nerve, or destroying any part of importance to life, produce a train of nervous symptoms of an ex- traordinary character. The person, without feehng much pain, and scarcely knowing that he has been wounded, without being terrified, or having his imag- ination excited by an apprehended danger, turns pale, gets a tendency to faint, and sometimes actually dies from the impression made on the nervous system. ... In the same way an exteriial hijury (or even a comparatively slight impression') reacting on the nerves (and centres of perception) may bring on high mental excitement, delirium, and a total privation of sleep. The delirium and sleeplessness arising from blisters is by no means an uncommon disease." ' The pareiitlietical remarks are mine, J. L. C. 208 HEADACHE AND NEURALGIA. The majority of cases of secondary insomnia are traceable to some irritative process affecting the ter- minal organs of the centripetal nerves, or to some acute or chronic form of organic disease, by w^hich a vast number of sensory nerves are kept in a more or less continuous state of irritation. If the pathological physiology advanced by myself be accepted, it v^ill readily be understood why acute and chronic affections should produce obstinate sleepless- ness, even where no considerable degree of pain is present. Furthermore, the views expressed by Dr. Graves concur with mine in every particular. Among the diseases which most frequently produce insomnia are : Cutaneous affections, acute and chronic pulmonary diseases, neural hypersesthesia (neuralgia), stomachic disorders, syphilis and fevers. It is suffi- ciently obvious also that pain, whatever may be its origin, is one of the most prolific sources, if not the most prolific cause of insomnia. Again certain forms of kidney and hepatic troubles may produce more or less protracted wakefulness. Without pursuing the subject in all its ramifications, which would be a useless loss of time as far as any practical benefit is concerned, it will be well to bestow a glance upon the various forms of morbid dreams, which are so constant an accompaniment in almost all cases of wakefulness. CHAPTER XXXI. CONSIDERATIONS ON DREAMS. The composition of dreams is determined in great measure by the individuality of the subject, and by the sum total of the impressions of which he has been the recipient. As to the contents of a particular dream, it is a matter of common experience that the acciden- tal emotions and ideas, present in the mind previous to retiring, exert a determining influence upon its consti- tution. All the multifarious factors of the mental life of the individual— all that he has felt, willed, or expe- rienced—may be revived in his dreams. The impressions which may give rise to dreams by acting upon the individual during sleep are of various kinds. In the first place the impressions which act upon the central ganglia through the five senses very often give rise to dreams.* Secondly, the subjective excitation of the senses, as well as muscular sensa- tions and general impressions of the most varied char- acter, may result in the production of dreams. Even where a certain sense is closed to outward impressions, the individual is by no means necessarily deprived of the sensations and ideas arising from the same when in a normal condition. Thus Esquirol ' mentions the case of a man who when forty-one years of age was afflicted by double cataract, and who nevertheless be- ^ Vide the opinions entertained by Schopenhauer relative to this point, Parerg. und. Parahpom. Leipzig, 1877. 2 Cited by Radestoek. U 210 HEADACHE AND NEURALGIA. came enraged with persons whom he supposed he saw. Blester relates that there Hved in Anspach, not many years since, an old midwife entirely blind, who com- plained tliat she was troubled not by ghosts, but by the frequent appearance of animals and men. The apparitions were quite as vivid as though she were in full possession of the power of vision. ' Malposition of the body, indigestion and other causes which tend to impede the circulation are said by some to give rise to cardiac palpitations, difficulty of respiration, and, when the phenomena are very pro- nounced, to nightmare. While willing to admit that such may often be the case, I feel compelled to affirm that I have known of many cases of nightmare in which no such factors as malposition of the body in bed or indigestion could be ascertained. Indeed the only possible assignable cause of the disorder was a condition of cerebral irritation or exhaustion. It is my firm belief that precisely as palpitations and diffi- culty of respiration are produced by excessive emotions during waking, so the same derangements may be caused during sleeping as a result of the excessive emotional disturbances often present during dreams. "Where the subject of dreams is of a neurotic tempera- ment or a sufferer from cerebral exhaustion or irritabil- ity, the influence of purely psychological disturbances (whether occurring during w^aking or as accidents of sleep) upon the respiratory, cardiac and general bodily functions, is far greater than in those of more robust constitution. Among ancient and mediaeval peo- ples the frightful phenomena of nightmare were as cribed to some supernatural agency, and demonology and witclicraft have at all times received substantial support from the same frightful source. The inhabi- ' Berliner Moriatssclirift, October, 1800. CONSIDERATIONS ON DREAMS. ', 211 tants of New Zealand regard the apparitions of dreams as hurtful deities, and similar opinions are entertained by some of the tribes of Central America and by some of the inhabitants of the coast of Africa. So excellent an authority as Augustin believes that the visits of the incubi have been attested by so many competent witnesses, that a further denial of the fact is impossible. The following narrative, recorded by Raoul Glaber, embodies such a grapliic illustration of nightmare, that I give it in full, in lieu of further description: ** One niglit towards early morning, I saw, sitting at the foot of my bed a little monster of hardly human shape. It appeared to me to be of medium size, thin necked, emaciated form, vv^ith black eyes and a narrow wrinkled forehead. The nose was broad, the mouth large, the lips thick, and the chin short and sharp. A goat's beard, straight pointed ears, dirty dry hair, dog's teeth, pointed occiput, projecting breast, hump back, withered loins, and dirty clothes completed the picture. It seized the side of my bed, shook it with fearful strength, and said: Thou shalt not remain here long. Upon that I awoke terribly frightened, spra.ng out of my bed, ran to the cloister, and cast myself before the altar, where I remained for a long time petrified with fright." ' Guibert de Noigent relates: '^ One night I was awakened by difficulty of breathing; I believe it was winter. I lay in my bed and considered myself safe in the glow of a brightly burning lamp. Sud- denly the deep stillness seemed to be broken by a myriad of voices proceeding from above. At the same time my head seemed to be wrapped, as it were, in a dream; I lost the use of my senses and thought I saw a certain dead person appear before me, and a ' Op. cit., p. 127. 212 HEADACHE AND NEURALGIA. loud voice declared that he had been murdered in his bath. Frightened by this apparition, I sprang from my resting place with a loud cry, the lamp was extin- guished, and in the midst of the horrible darkaess I saw the demon in his true form standing by the bed," In our own day the substance of dreams is some- what less demoniacal in character; and witches, devils and hags have given place to the denizens of the jun- gle and the forest. Tigers, boa constrictors, scorpions, centipedes, all the fear-inspiring shapes which adorn the pages of a hideous zoology, are the companions of tlie modern dreamer. But the repertory of dismal shapes is by no means confined to natural history. Theology, history, romantic Hterature, love and hate, all afford material for dreams. Sometimes those afflicted with nightmare experience a sensation as though the chest were bound down with chains, or as though a huge stone were rolled upon the breast. All such sensations are the outgrowth of the disturbances of respiration to which reference has already been made. Since nightmare usually occurs shortly after midnight, Prout is led to the conclusion, that the cause of this form of dreaming is to be ascribed to the condition of the blood, which at that time according to his observa- tions is saturated with carbonic acid to a maximum degree. Macnish found that he was attacked by nightmare when he sat in an arm-chair or when his head reclined upon the table, or even when lying upon his side. ' Such a position as the one first described is well calculated to cause interference with the freedom of the inspiratory act; and thus an undue accumula- tion of carbonic acid in the blood is the inevitable ' Der Schlaf in Allen seinen Gestalten, (translated from the English) Leipzig, 1835, CONSIDERATIONS ON DREAMS. 213 result. J. Bonier' has shown experimentally, that interference with the ingress and egress of air to and from the air passages may result in the production of the phenomena of nightmare. In order to prove this he fastened the bedclothes over the mouth and nose of a person in deep slumber, so that respiration was par- tially interrupted. Upon this it was observed that the face of the sleeper became suffused and his respiration retarded; while the respiratory muscles were thrown into violent action and the veins of the neck became gi'eatly swollen. After awaking the person experi- mented upon related that he had suffered from the symptoms of nightmare, the apparition appearing in the form of an ugly monster. Severe catarrhal affec- tions, when coupled with a somewhat heavy evening meal, may give rise to difficulty of respiration and morbid dreams, if we are to accept the testimony of Binz.' But dreams are by no means always characterized by the pressure of the terrible or hateful. On the con- trary they present not only the shadows, but also the brightest side of real and imaginary existence. Only in dreams do the majority of mankind ever succeed in realizing their most fondly cherished wishes, their highest ideals. Many a talent, many a genius con- demned by the relentless circumstance of environment from adequate expression, has found in dreams a temporary emancipation from the thraldom of reality. Eiches, power, perfect health, achievementj are all pos- sible in dreams, and only thus are the majority of man- kind ever to know them. If dreams were invariably the outgrowth of impressions and ideas originating in ^Das Alpdriicken, seine Begriindung und Verhtitung-Wiirz- burg, 1855. 2 Cited by Rhadestock, Op. cit., p. 130. 214 HEADACHE AND NEURALGIA. the occupations of the previous day, then, indeed our nocturnal reveries would be far from agreeable. The circumstances, however, are fortunately very different. It is a matter of experience, in fact, that dreams are often built up of remote ideas, the very remembrance of which has long since faded from memory. The resuscitation of these dim ideas from the lower strata of consciousness, as a consequence of central stimula- tion, is certainly one of the marvels of psychology. Moreover, owing to a further automatic excitation, the reproduced ideas are interwoven with other revived impressions, so that the dream receives the most varie- gated coloring. CHAPTER XXXII. THE DIFFERENCE BETWEEN DREAMS AND AVAKING THOUGHT. From what has ah^eady been said with regard to the constitution of dreams, it will be seen that a scientific classification of the phenomena is beset with unusual difficulty. So manifold, and, at the same time, so devoid of all sequence and coherence are the manifes- tations of dreams, that the comparison of the latter with insanity seems in a certain sense justifiable. Pfaff, Krauss, Artemidoros, Purkinje, Spitta and Nicol have sought to classify the phenomena of dreams; but, with the exception of the subdivisions of Spitta, these systems possess little practical value. The most rational method of approaching the sub- ject is that which is based upon a consideration of the elements of dreams, and the laws governing the asso- ciation of ideas. A glance at the composition of dreams reveals the fact that ths distinguishing feature of individual con- ceptions is their great exaggeration and vividness, which is doubtless attributable to the inordinate excit- ability of the higher centres. Comparatively insignifi- cant impressions transmitted through the centripetal nerves are sufficient to arouse a series of the most ex- aggerated conceptions. The crackling of a dry floor becomes the tramp of the assassin, the moonbeams falling upon the eyelids are magni ffed to the dignity of a conflagration; while the rusthng of leaves or the 216 HEADACHE AND NEURALGIA. gentle sighing of the wind becomes the roaring of a tornado. An insignificant irritation, such as the bite of a mosquito, gives rise to a positive sensation of pain, and a shght tickUng sensation in the throat causes a feehng of suffocation. It is a noteworthy circumstance, and one difficult of explanation, that the exaggerated conceptions and emotions of dreams are far less liable to result in seri- ous detriment to the organism than the corresponding perturbations of the waking condition. Thus sudden and violent grief during waking has frequently re- sulted in immediate death; and even imexpected emo- tions of intense pleasure have been known to result fatally. A soldier returning from the battle -field is suddenl}^ apprised of the death of his mother; and although inured to the hardships and terrors of the campaign, is unable to withstrmd the effects of the sudden mental contest, and falls dead, as though smit- ten by one of his own bullets. A poor laborer, accus- tomed to severe toil, is informed that a relative, of whose very existence he was perhaps unaware, has died and bequeathed to him a competency, which will render him independent for the remainder of his days. Instead of manifesting joy he becomes insane or dies. The examples are legion. Earely, however, are simi- lar effects witnessed even after the most severe attacks of nightmare. Although we are unable, by a mere fiat of the wiU, to cause a cessation of our concej^tions, we are yet able to control, within certain limits, the direction of our thoughts. What is possible in the waking condition, however, becomes impossible for the erratic cerebra- tion of sleep. The conceptions arisiug during dreams admit of no guidance; the only governing influence being the law of the mutual relation of ideas. As a DREAMS AND WAKING THOUGHT. 217 matter of fact, however, the impressions received be- fore retiring, as well as the focalization of the thoughts in a certain direction for a protracted period of time generally have a marked influence upon the con] posi- tion of the dreams ol the individual. Thus the financier whose mind has long been occu- pied with apprehensive speculations, will naturally dream of accounts, dollars and cents, and compound interest; whereas the captain of a ship is more liable to be troubled by nocturnal visions of sea-serpents and shipwreck. It will thus be seen that, although we can exercise no volitional effect upon the composition of our dreams, in the sense that we give direction to our waking thoughts; we may, nevertheless, by throwing the energies of the mind in a given direction, before retiring exert a predetermining influence upon the character of our nocturnal reveries. I have been thus explicit, as the subject is an impor- tant one from a therapeutic standpoint. The rapid evolution of conceptions during dreams is favorable to the development of new psychological combinations. This fact explains the frequent, but, at first sight, inexplicable circumstance of a high order of rhythmical intellection occurring during dreams. Poems, musical compositions, and philosophic epi- grams have been compared, and even complicated in- ventions conceived during dreams. As a rule, how- ever, these nocturnal achievements cannot stand the test of daylight; and even the most superficial logic serves to reveal their extravagance and worthless- ness. The capacit}^ for forming correct inferences and judgments is, in fact, greatly reduced during dreams, owing to the volatile nature of the concep- tions. The feeHng of personality, the ''I," is the result of 218 HEADACHE AND NEURALGIA. a summation of all the psychical activities, feelings, volitional activity, etc. In the construction of the *' I " two factors are principally concerned. First, the permanent conceptions formed by ourselves, and which are the outgrowth of our motor and "general" sensations, and of the memories (and their associa- tions) resulting from the repetition of external impres- sions. Secondly, the attention or active apperception. Now, since in dreams the last named factor of the ''I" assumes a passive form, the reunion of various groups of conceptions under one uniform head is inter- fered with, by reason of the chaotic perception and remembrance of fragmentary portions of the former (the conceptions).' As a consequence of the dimin- ished attention, then, the feehng of individuality, the sensation of the "I." which is so characteristic a fea- ture of the waking condition, is in dreams reduced to the last degree. The foregoing are the more important points of dif- ference between the psychology of dreams and that of the waking condition. If, in treating the subject somewhat in extenso^ I have rendered myself liable to the charge of undue prolixity, I can only plead in extenuation the great im- portance of the subject to a true understanding of both the pathology and therapeutics of sleep. It is precisely pain, in its various manifestations, which serves quite as much as psychical difficulties to cause derangements of sleep. To deal successfully, therefore, with these painful conditions, one must have a thorough understanding of sleep and its de- rangements. * Rhadestock, Op. cit., p. 157. CHAPTER XXXIIL MOEBID SOMNOLENCE. In the previous portion of this discussion we have described at some length the various conditions which tend to reduce the amount of sleep normally required by the organism. It now remains to consider briefly that condition in which the duration of the sleeping period is abnormally increased. Any one who has paid special attention to the mat- ter, will be able to recall the cases of individuals who, by reason of long sleeping or on account of a general drowsy habit, have become known to their acquain- tances as lazy, thriftless members of society. And yet, such persons are frequently far more deserving of compassion than of censure; for a closer insight re- veals the fact that their inactivity is neither the result of defective ambition nor feeble volition, but is rather the outgrowth of morbid physiological conditions wholly beyond their control. Here is an illustration in point : A lady, for whose intelligence and Christian character I entertain the highest respect, consulted me some time since with re- gard to her husband, a man who, up to within a com- paratively recent period, had been exceptionally active in business. Of late, however, he had become '' ab- sent " in mamier, and had besides developed habits of extraordinary lethargy. In former times he was in the habit of retiring about eleven o'clock ; now he sought his bed at nine, where he remained until S20 HEADACHE AND NEURALGIA. eleven or twelve o'clock the next morning. Instead of exhibiting his former vivacity, he remained dur- ing this brief period of wakefuhiess, if wakefuhiess it could be called, in a condition of apathy, hke one over- come with fatigue and about to fall asleep at any moment. Such conditions as this are doubtless familiar to most physicians who have devoted special attention to the physiological questions pertaining to sleep. The following classical cases, reported by Eobert Macnish, are extreme illustrations of morbid somno- lence : "The case of EHzabeth Perkins is remarkable. In the year 1788, she feU into a profound slumber, from which nothing could arouse her, and remained in this state for between eleven and twelve days, when she awoke of her own accord, to the great joy of her relatives, and wonder of the neighborhood. On re- covering she went about her usual business; but this was only for a short period, for in a week after she relapsed again into a sleep which lasted some days. She continued, with occasional intervals of wakeful- ness, in a dozing state for several months. ' ' ''The case of Elizabeth Armitage of Woodhouse, near Leeds, may also be mentioned. The age of this person was sixty-nine years. She had been for several months in a declinej during which she had taken very little sustenance, when she fell into a state of lethargic stupor, on the morning of the 1st of July, 1827, in which condition she remained, without uttering one word, receiving any food, or showing any signs of life, except breathing, which was at times almost imper- ceptible. In this state she continued for eight days, when she expired without a groan." One of the most extraordinary instances of excessive MORBID SOMNOLENCE. . 221 sleep, is that of the lady of Nismes, published in 1777, ill the " Memoirs of the Eoyal Academy of Sciences of Berlin." ''.Her attacks of sleep took place periodi- cally at sunrise and about noon. The first continued till within a short time of the accession of the second, and the second till between seven and eight in the evening, when she awoke, and continued so till the next sunrise. The most extraordinary fact connected with this case is, that the first attack commenced always at daybreak, whatever might be the season of the year, and the other always immediately after twelve o'clock. During the brief interval of wakeful- ness, which ensued shortly after noon, she took a little broth, which she had only time to do, when the second attack returned upon her, and kept her asleep till the evening. Her sleep was remarkably profound, and had all the characters of complete insensibility, with tlie exception of a feeble respiration, and a weak but regular movement of the pulse. The most singular fact connected Avith her remains to be mentioned. When the disorder had lasted six months, and then ceased, she had an interval of perfect health for the same length of time. When it lasted one year, the subsequent interval was of equal duration. The af- fection at last wore gradually away; and she lived entirely free of it for many years after. She died in the eighty-first year of her age, of dropsy, a complaint which had no connection with her preceding disorder." Of the pathology of these strange cases we know nothing; nor can we form an estimate of their causa- tion. The most that we can say is that in certain cases of extreme exhaustion or intoxication (due to renal difficulty, etc.), certain somewhat analogous con- ditions may be provoked. The comparison is at most, however, but a crude one. CHAPTER XXXIV. SOME GENERAL OBSERVATIONS ON THE TREAT- MENT OF INSOMNIA. We have already had occasion tx) refer to the im- portant relations existing between derangements of the function of sleep and mental disorders. But not only has it been shown that sleeplessness is one of the concomitants of insanity; for, we have also seen that it is an important factor of most painful maladies, and particularly of that variety of pain which is traceable either to morbid conditions within the skull or such as are located outside of it. Facts of this kind point clearly enough to the im- portance of possessing some knowledge regarding this matter of sleep; indeed it is quite inconceivable that one should be able to do much for the painful affec- tions which we have been considering without such knowledge. I shall, therefore, offer no apology for recording a few of the more important principles underlying the treatment of insomnia. In the first place, then, when we are confronted with some one of the painful conditions described in previous portions of this work, we should at once make a careful investigation into the habits, bodily condition, and possible hereditary influences of our patient. If we find that he is a night -worker of long stand- ing, we should attempt to gradually abate the vicious habit; should we find that the patient has formerly THE TREATMENT OF INSOMNIA. 223 been of a robust habit, and has suddenly or even gradually lost flesh, inquiry should immediately be made as to the existence of some form of excess or wasting disorder, so that we may put a stop to the one and address our skill to the amelioration of the other. Should, on the other hand, a history of syphilis or scrofula be forthcoming, we shall at once know what we have to do, if we aspire to achieve fundamental results. There is nothing in these painful conditions more significant than a sudden variation in the weight or circulatory conditions of the patient. For example, we are called to see a young married woman suffering from some form of head-pain. Her complexion is pale and sallow; she complains of sleeping poorly; she has had a miscarriage, or it may be that she has suf- fered from leucorrhoea or catarrh of the cervix. In such a case as this there are two conditions which strike us at once— loss of weight and small, compressi- ble pulse. Where this duo exists, more particularly if the subject be of neurotic temperament, we are certain to have an exacerbation of some form of head pain with its baneful accompaniment, sleeplessness. Take the exactly opposite condition of a man who has gained flesh rapidly. In a considerable proportion of such cases the history of alcoholic excesses, with its accompanying stasis of the cerebral blood stream, is forthcoming. At the same time we learn that the patient is a sufferer from cerebral hyperaemia, with its consequent symptoms of irritability, depression, vertigo, headache and insomnia. Here are two dia- metrically opposed conditions. In the case of the woman we have general anaemia, with consequent impoverishment of the entire nervous system; in the 224 HEADACHE AND NEURALGIA. man we have engorgement, passive expansion of the cerebral capillaries with consequent tui'gescence of the cerebral circulation. To treat these two cases in a similar manner, to pin our faith exclusively to mere sedation by chemicals, would be simply to ignore the appositeness of the physiological circumstances with which we have to deal. And yet, these are precisely the things which are most systematically ignored; indeed one may say, that ninety-nine cases of headache with insomnia are attacked through the medium of the apothecary's shop, without any regard whatever to special hygienic indications. Under the special headings of anaemic and hyperae- mic headache, I have already discussed the means to be resorted to for the relief of the circulatory derange- ments, which play such an important part in the two affections. All that I then said regarding the appli- cability of baths, both warm and cold, as well as what was stated regarding the Russian and Turkish baths, applies with equal force to the treatment of the anae- mic and hyperaemic varieties of insomnia. To repeat, in detail, what was then said, would be but a repetition of what has already been thoroughly discussed; I would therefore merely observe that the two principles to be borne in mind in the treatment of these cases of insomnia with circulatory disturbances, are first of all to correct the latter by appropriate means, and secondly, while so doing, to address our efforts to calming the irritated cerebral protoplasm. The second part of the problem is best accomplished by the use of chemical substances, which, having an affinity for the cerebral substance, tend by uniting with it to interfere to some extent with that metamorphosis which is essential to function. Such chemical substances are THE TREATMENT OF INSOMNIA. ^25 the so-called narcotics and sedatives, of which more or less has already been said in earlier portions of this work. But, while it would, therefore, be a work of supererogation to enter again into details regarding these substances, I desire to give a general hint or two respecting their employment, in connection with in- somnia. To begin then with the bromides, that group of substances so important in the treatment of nervous affections of a functional character, I would observe that these remedies should be employed with a view to exerting a gradual sedative action upon the central nervous system, so that a predisposition to slumber may be induced. They should therefore be given during the day, and preferably during the latter portion of it, their administration being in fact continued until shortly before the patient betakes himself to bed. A moderate dose of chloral, or the tincture of hyoscya- mus, or both combined, as in the preparation known as bromidia, may then be given, so as to materially augment, at the critical moment, the drowsy predis- position. We have here the key to the secret of obtaining results in the treatment of insomnia, whether the condition be found in conjunction with mental de- rangement, or whether it be an accompanying com- plication of a painful affection, or, in short, whatever the predisposing factors may be. But this is not enough. Were we to rest content with the chemical treatment of sleeplessness, we should be in grievous error; and yet this is precisely what is constantly being advocated in print and in the lecture-room. We must look deeper; we must go to the bottom of the morbid problem, with which we are confronted, so that, having recognized it, we may 15 226 HEADACHE AND NEURALGIA. combat it with all the resources at our disposal. If we have to do with pain- provoking conditions we must remove them; if we are confronted with inordinate worry we must combat it by the aid of substitution; if, finally, we have to do with some morbid condition of the organs, resident I care not where, it must be met with all the resources at our command. In this connection, what has been said regarding secondary insomnia may be recalled with advantage. Above all things let us eschew inordinate drugging, especially before putting our patient to bed. I have protested against this custom and shah continue to protest against it, as long as I am witness of such flagrant abuses of sedative substances both in and out of asylums. And again, let us not show undue readiness to lay hold of the resources of the drug-shop; rather let us not forget that, in the ordinary ahments of plain every- day life, much is contained which may jjrove useful to us. I will merely recall in this connection the hop preparations— those ales, stouts, malt hop toniques and beers of German make, which in themselves constitute an armamentarium somniferum. Again, let us but direct our attention to the diges- tive organs; what possibilities are here ! So commonly are digestive disorders either the immediate cause, or, at least, the perj^etuating factor of these derange- ments of sleep, that, without a thorough understand- ing of the stomach in health and disease, we should be quite unable to cope with the secondary conse- quences, involving the nervous centres. Of electricity, baths, and cognate adjuncts in treat- ment, a sufficiently extended mention has already been made in the earlier portions of the work. I shall, there- fore, close this discussion of the various questions per- THE TREATMENT OF INSOMNIA. 227 tainiiig to normal and morbid sleep by observing, once again, that the subject is of the first importance to a correct understanding and management of the painful affections which we have been considering, and more particularly of those pains, located in and about the head, which constitute such prolific sources of human unhappiness. CHAPTEE XXXV. THE LOCALIZATION OF THE ACTION OF REMEDIES UPON THE BRAIN. — ADMINISTRATION OF CHEMICALS AYHICH ACT IN SMALL DOSES, BY THE NOSE ; THOSE AVHICH MUST BE GIVEN IN LARGER AMOUNTS TO PRODUCE THEIR EFFECTS, BY THE MOUTH. — COM- PRESSION OF THE INTERNAL JUGULARS. In the previous portions of this work, we have de- voted considerable space to the consideration of the various theoretical and technical questions pertaining to the local use of remedies in neuralgia. And let me say, that the prominence accorded this portion of the subject is not merely a question of individual pre- dilection, but rather of indisputable expediency, justi- fied as it is by what we know of neuritis as well as by the practical results obtainable in the clinic. Indeed, so apparent are the advantages derivable from the lo- calization of remedies in the treatment of painful affec- tions due to inflammatory or other changes of the peripheral nerves, that I have long desired to extend the principle to the central nervous system, and more especially to the brain. For it will occur to any medi- cal man of average perspicuity that the solution of this problem must render material assistance in the management of various functional difficulties of in- tracranial origin, not the least of which are certain idiopathic varieties of headache and insomnia. It THE ACTION OF REMEDIES UPON THE BRAIN. 220 may as well be admitted, however, at the very thresh- old of these reflections, that the concentration of the effects of chemical solutions upon the internal organs is beset with difficulties, insurmountable ones too, in many instances. Thus one reads in the journals from time to time accounts of injections of medicinal fluids into the parenchyma of the lung, or other im- portant viscus, but the thought at once occurs that these fluids can at best produce but evanescent effects upon neighboring morbid products; for they — the fluids — are soon carried away to distant parts of the organism by the circulation ; and being thus dissipated, their local remedial effects are proportionately attenu- ated. There is, however, one organ which is exceptionally well placed with respect to the possibility of concen- trating the action of remedies upon it ; I refer to the brain, and more especially to the cortical layers of the cerebrum. To appreciate how true this is, it is necessary to place in juxtaposition the following facts : 1. That the main blood -supply of the cortex is con- tingent, or largely contingent, upon the unobstructed flow through the carotid and jugular vessels. Hence, when the blood flow in one or both of these sets of vessels is arrested, or even partially arrested, as by compression, cortical function is directly interfered with, as is shown by the confusion of ideas, stupor, and even unconsciousness engendered. 2. It has long been known — and the fact has fre- quently been commented upon in medical literature — that chemicals applied, especially in a fluid state, to the lining membrane of the nasal cavity are speedily 230 HEADACHE AND NEURALGIA. absorbed, producing in this way characteristic physio- logical effects. Thus calomel has been blown into the nose, producing in a short time severe salivation.' Narcotic substances, and more especially morphine and cocaine, have also been spread upon the mucous membrane of the nasal cavity, giving rise in a short time to characteristic phenomena. I am told that the effects thus induced upon the central nervous system, and more especially the brain, by the use of the last- named drug are familiar to rhinologists. The most reasonable and generally accepted explan- ation of the prompt action of narcotic substances when used in this way is that which assumes that the ab- sorption of the remedy — or at least the greater part of it — takes place by the way of the vessels which penetrate the lamina cribrosa. If we admit the plausibility of this hypothesis, we shall then perceive that remedies administered b}^ way of the mucous membrane of the nose must reach the brain, and especially the cortex cerebri, in a more concentrated state than when administered at a distance, either hypodermically, per rectum, or by the stomach. Even though the amount of medicinal substance absorbed be not great, its increased concentration at the seat of influence (the brain) must of necessity result in physi- ological effects out of proportion to the quantity of chemical administered. Here we have an explanation, and I think a true one, of the remarkable cerebral symptoms often pro- ' De rAdministration des Medicaments par rintermediaire de la Muqueuse des Fosses nasales ; par Rainbert, Journal de Medecine de Chirurgie et de Pharmacologie, Bruxelles, 1867, vol. xlv. , p. 17, seventh line from top of page. THE ACTION OP REMEDIES UPON THE BRAIN. 231 duced by exceedingly small quantities of medicinal substances when applied in solution to the eye and conjunctiva. 3. It is a fact that, if narcotic fluids be introduced into the nasal cavity in the manner previously set forth, and if shortly thereafter the flow of blood in the jugular veins be considerably retarded by the ap- plication of pressure at a suitable point in the neck, the effects of the remedies thus administered may be appreciably enhanced and prolonged. This accords with all that I have been able to ascertain respecting the behavior of remedies when brought in contact with the peripheral nerves, by hypodermic injection, and maintained there by occlusion of the capillaries, or by constriction of the artery, veins, or both, above the point of injection (next the heart). These pre- liminary observations will, I trust, make the principles involved abundantly clear to any physician of average intelligence. Let me pass, then, at once, to the de- scription of the simple procedure which I have found most serviceable in giving practical effect to the prin- ciples above enunciated. ' The first step of importance is the introduction of the remedy by way of the nose. To do this most effectually the mucous membrane should first be cleansed with warm water, the latter serving at the same time to expand the capillaries. The medicament (morphine, cocaine, atropine, etc.) may then be introduced in solution through the nos- trils by the aid of an ordinary medicine dropper or atomizer. This simple manipulation is best accom- plished while the patient reclines upon his back. After the lapse of ten or fifteen minutes the second 1 Vide the "Medical Record " of December 31st, 1893. 232 HEADACHE AND NEURALGIA. step may be proceeded with. This consists in materi- ally restricting the lumen of the internal jugular veins by the application of pressure. After numerous trials, I have found that the jugu- lars are best compressed by the application of small dry cups over the course of the vessels, one at each Fig. 16. side of the neck on a level with — or a little below the level of — the thyroid cartilage. The cups, which are joined together in front by an adjustable steel band, are about two inches long and half an inch wide ; they are made of metal — silver or steel — and are held in place by an elastic strap, which passes around the neck and is secured in place behind by the aid of a simple buckle (Fig. 16). The open side of the cup is, moreover, somewhat concave in au THE ACTION OF REMEDIES UPON THE BRAIN. 233 antero-posterior direction, which admits of elevating the veins and surrounding tissues more effectually. In this way it is possible to draw the vessels into the cups, partially at least, thus causing the edges of the latter to act energetically upon the lumen of the veins. The little dry cups being maintained in position over the vessels by the aid of this simple band, the air con- tained in them is rapidly exhausted by means of an air-pump and vacuum-chamber, which exert their in- fluence upon the interior of the cups through the intermediation of small, non -collapsable india-rubber tubes (Fig. lY). It is self-evident that the cohesion of the compress- ing apparatus thus obtained, as well as the elevation of the tissues within them, render valuable assistance by preventing the slightest displacement of the subja- cent vessels. In a word, the veins, instead of being compressed in a backward direction, are, as previously pointed out, drawn toward and compressed by the edges of the cups. When all is properly adjusted, the elastic bands previously described may be tight- ened at will, thus adding mechanical to atmospheric pressure. This last step is usually, however, unneces- sary, the atmospheric pressure being adequate. When slight vertigo has been induced in this way, the evidence is conclusive that the stasis of the intra- cranial venous circulation is sufficient for therapeutic purposes. There is no special limit to the length of time dur- ing which compression may be continued ; but from what I have been able to determine, I should fancy that from twenty minutes to half or three-quarters gf an hour are sufficient. 234 HEADACHE AND NEURALGIA. Illustrative Cases. — The following cases are cited with a view to illustrate the facility and rapidity with which a variety of disagreeable sensations in. the head, including minor degrees of pain and depression, are relieved by resort to this simple procedure. Mr. A. C was referred to me over three years THE ACTION OF REMEDIES UPON THE BRAIN. 2)35 ago by Dr. C. H. Avery, on account of "severe and persistent headache." When I first saw him the headache was diffuse in character, continuous, but not specially severe. He informed me, however, as I find by reference to my case -book, that at times he is afflicted by sudden and very severe exacerbations of pain ; and that, at such times, the pain is almost en- tirely confined to the occipital region. There is very little difference between the pain felt at night and that experienced during the day. There are no ataxic symptoms; the disks of both eyes are normal, but the pupils are quite uneven, the right one reacting little or not at all to strong light. I sent him to Dr. David Webster for an opinion, who wrote me that there was undoubted "paresis of the right sphincter iridis, without paresis of the ciliary muscle." A high degree of hypermetropia was also present, for which Dr. Webster prescribed the neces- sary glasses, to be worn constantly. Incidentally he also expressed the belief, in spite of the absence of a specific history, that the mydriasis, and probably also the headache, were due to nervous syphilis. My own suspicions having taken a like direction, I placed him at once upon large doses of the iodide of potash, which were gradually increased to the point of tolerance. After several weeks there was appreciable diminu- tion of the pain, so much so that after three months his visits were discontinued. A year or two later I saw him again, and he stated that he was often free from pain for prolonged periods — from several days to three or four weeks. The paresis of the right sphincter iridis was also 236 HEADACHE AND NEURALGIA. apparently improved, though the contraction 'of the pupil was quite sluggish. So far as my case-book reveals, I did not see him again till October 19th, 1892, when he called at my office, complaining of an unusually severe paroxysm, the predominantly painful area being located in the frontal region. This seemed a good opportunity of testing the above method of locating the action of remedies upon the intracranial structures. Accordingly I placed the patient upon his back, in- jected into both nostrils, as high up as possible, several drops of a medicated solution, aggregating morphine i grain and atropine y^. Ten minutes later, there being as yet little diminution of the pain, I compressed both jugular veins in the manner previously set forth. The relief thus afforded excited the wonder of the patient, who declared, after the lapse of five minutes from the time of applying the compression to the jugulars, that he "felt no pain." Later he informed me that the relief thus obtained was unusually prolonged, there being little or no pain experienced during the entire following week. I shall have something to say regarding the subsequent history of this interesting case, at some future time. My object in citing it on the present occasion is merely to show how promptly a relatively severe frontal headache was relieved by medication by the nose, combined with simultaneous compression of the in- ternal jugulars. Mrs. E. N. T was referred to me by Dr. Charles A. Limeburner for severe, continuous local headache, possibly the result of circumscribed chronic menin- gitis (?). THE ACTION OF REMEDIES UPON THE BRAIN. 237 Five months ago, while walking in the garden, patient stepped upon the prongs of a rake, which had been allowed to remain in an upright position, so that the handle leant against a wall. The result of this action was to cause the implement to fly forward, inflicting a blow of such severity upon the left side of her head that she fell to the ground in a state of partial or total unconsciousness. On regaining consciousness, she felt nothing more than the soreness which might naturally have been anticipated from the violence of the contusion. In a few days, however, quite severe pain set in, the pain- ful sensations being deep-seated and corresponding quite accurately with the area of traumatism, i.e., the left parietal region. As the pain was not relieved by extracranial meas- ures, and as the various coal-tar derivatives did not seem to help her much, or, at all events, but slowly, I decided to endeavor to act more directly upon the intracranial structures by invoking the method of medicinal localization previously described. Accordingly, while the patient lay on her back, I sprayed into her nostrils morphine, gr. -J; atropine, gr. 2-J-o. Ten minutes thereafter, patient experiencing little relief, I applied the pneumatic compressor over the jugular veins, with the result that, within five or six minutes from the moment of its adjustment, there was complete cessation of pain. Here, again, we have conclusive proof of the increased physiological potency of medicinal solutions, when they (the solu- tions) are made to linger in the tissues of the brain or other portion of the central nervous system by the aid of artificially induced stasis or partial stasis in the 238 HEADACHE AND NEURALGIA. capillaries. Such stasis may be induced in three ways — and I have tried them all — first, by compressing the carotids; secondly, by compressing the jugulars; and lastly, by compressing both, the arteries and veins. Compression of the jugulars with the least possible interference with the circulation in the carotids, will alone be discussed on this occasion. Compression of the jugulars by the aid of the pneu- matic compressor, as here described, is not difficult, especially when the patient reclines in a dorsal posi- tion, the head being thrown slightly backward so as to place the vessels slightly on the stretch. This pro- cedure may be invoked without hesitation in the treatment of individuals under forty years of age. In elderly persons, on the contrary, where an athe- romatous condition of the cerebral blood-vessels is among the possibilities, it will be well either to aban- don this mode of treatment, or to compress both arteries (carotids) and veins (jugulars) at once, thus avoiding an increase in intra -arterial pressure and consequent danger of rupture and hemorrhage. Mr. V. N , also kindly referred to me by Dr. Charles A. Limeburner, has suffered for several months from what • Dr. Limeburner believes, and rightly, I think, to be neurasthenic headache. The chief complaint of this gentleman is that he is beset by a sensation of heaviness in the head, more or less continuous, and frequently coupled with dull pain at the vertex and profound depression. In addition to these symptoms, he also evinces dread of respon- sibility and society, loss of memory, especially for recent events, inability to concentrate his attention for any length of time without discomfort; and, in THE ACTION OF REMEDIES UPON THE BRAIN. 239 short, he affords a typical illustration of the classical form of cerebral neurasthenia. With a view to at once gain his confidence by re- lieving his head symptoms — the vertical pain, the heaviness, and the depression — I jDroceeded to invoke once more the aid of medicinal localization. Instilling into the nasal cavity a few drops of water containing atropine, y^-g-, and cocaine, gr. J, I applied the pneumatic compressor, as already so frequently described. After the lapse of five or six minutes there was a decided feeling of relief, and in ten or twelve minutes the disagreeable head symptoms had entirely disappeared. The relief in this case was complete during the following five or six days, when the procedure was again repeated, with the same re- sults. As a matter of course, various measures di- rected to the removal of the exciting cause were employed in this as in all similar cases, but as they have no bearing on the point at issue, and involve, moreover, matters which are part of the common knowledge of the profession, I have made, and shall in future make, no detailed reference to them. As a matter of theoretic interest, I may observe that, after instillation of the atropine and application of compres- sion to the jugulars, there was marked dilatation of the pupils. Mr. J. E. K has been kindly referred to me by Dr. Fayette Smith, on account of an obstinate form of myalgia. He also suffers from attacks of mental hebetude, depression, and headache. During one of these seizures, which failed to yield to either salol and phenacetine, or antipyrine and ammonia, I instilled into his nostrils morphine, gr. |-, atropine, gr. y^^-, S40 HEADACHE AND NEURALGIA. and hyoscine hydrobrom., gr. -^^-q, and shortly there- after applied the pneumatic compressor to the jugulars. As a result all the disagreeable symi)toms disap- peared within ten or fifteen minutes, much to the delight and astonishment of the patient, who had hitherto failed to obtain relief from several remedies administered in the conventional manner. Mr. L. E has been referred to me by Dr. David Webster, on account of paralysis of the third nerve, with concomitant headache, both phenomena being doubtless specific in origin. Dr. Webster has already obtained some amelioration by the administration of the iodide of potash combined with inunctions of the oleate of mercury. As, however, there is still con- siderable diplopia, Dr. Webster feels that local appli- cations of electricity should be tried. Accordingly, I have made such applications (of faradism) as near the vicinity of the affected muscles (left internal and in- ferior rectus) as possible, employing for the purpose a delicate conical sponge electrode. The benefit accruing from this phase of treatment has been rapid, the double vision having quite disap- peared after the third application. I may add, in this connection, that the eye was thoroughly cocain- ized before applying the electrode, the lids being held apart by an ordinary eye -speculum. And this brings us to the point of special interest in connection with the present argument. As has already been said, this patient was a sufferer from headache of a persistent, dull character, culminating, at times, in exacerbations of considerable severity. At my request he called at the office during one of these attacks, and I proceeded at once to attempt to THE ACTION OF REMEDIES UPON THE BRAIN. 241 abolish the painful symptoms. Spraying the nasal cavity with an aqueous solution of morphine, gr. -J-; cocaine, gr. i; and hyoscyaminse sulphas, gr. y-Jir^ I had the patient remain in a recumbent position for ten or fifteen minutes. At the end of this time, he stated that he felt "somewhat better;" but, as the relief was not complete, I at once applied the pneu- matic compressor to the jugulars, when the patient almost immediately declared that all pain had van- ished. Mrs. C. L. V was referred to me by the late Dr. James E. Leaming, on account of persistent in- somnia, accompanied by attacks of dull, clawing pain at the vertex. As the patient was much debilitated, and as changes in position — and notably lying down and suddenly sitting up — had a perceptible effect upon the character of the pain, I concluded that circulatory anomalies, probably anaemia, had something to do with its genesis. Accordingly, I applied the com- pressor to the jugulars, with the result that consider- able relief was at once afforded. This improvement was, however, evanescent ; for, on removal of . the compressor, it shortly returned. I then proceeded as in the previous case, instilling at first the analgesics and sedatives into the nasal cavity, and then applying the compression to the jugulars. Precisely the same results were obtained as in the previous case — relief from pain, lasting several hours. This case is interesting, as it affords incontestable proof of the superiority of jugular compression com- bined with intranasal medication over jugular com- pression alone. 16 242 HEADACHE AND NEURALGIA. Mr. G. F was referred to me several years ago by the late Dr. Cornelius R. Agnew, on account of spinal neurasthenia, accompanied by impairment of sexual vigor and insomnia. For several years patient had been harassed by imperative craving for alcoholic stimulants, the morbid desire occurring periodically, twice or thrice yearly. The excesses which resulted from these impulses always left the patient tremulous and greatly prostrated, and eventually he became a victim of obstinate and constantly recurring headaches, in addition to the symptoms which had more espe- cially attracted Dr. Agnew 's attention. The eye con- ditions bore no special relation to the case, consisting as they did in a minor degree of hypermetropia and conjunctivitis. Appropriate glasses had corrected the first, and a simple eye-wash the second element, so that when he arrived at my ofQce the nervous phe- nomena were the predominant, and indeed the only, feature. These I was able to abate by a course of treatment of reasonable length ; but I was not able to overcome the patient's imperative impulses to periodic spreeing. Thus it happened that, for the last few years, this gentleman has been in the habit of seeking me out, after one of these debauches, with a view to having the results — the head pains, the tremor, the depres- sion — eliminated. Recently he called upon me for the usual purpose, suffering, as he declared, more than on former occasions. Especially annoying was the sensation of fulness and pain in the head, which made him feel, as he expressed it, "as though he would like to jump off the dock." This seemed a good opportu- nity to endeavor to relieve the pain by concentrating THE ACTION OF REMEDIES UPON THE BRAIN. 243 the effect of the remedies employed by the aid of jugular compression. As the patient was a sufferer from an old catarrhal difficulty, which had evidently deprived the nasal mu- cous membrane of much of its absorbent power, I decided to administer the remedies by the mouth. I quite realized that in doing this, I was resorting to a method inferior to that previously described, when judged by rigid physiological standards; for these demand the placing of the medicament as near the nervous structure to be affected as possible. However, I could not help feeling that the retardation of the medicated blood in this way would eventuate in some enhancement of physiological effect, and the sequel proved that the inference was a correct one. As a preliminary precaution, the patient was given forty drops of the aromatic spirits of ammonia, and shortly afterward fifteen grains of antipyrine were administered. Though the ammonia, being quickly absorbed, induced a considerable increase in the fre- quency and vehemence of the heart's action, there was no abatement in the head symptoms — the pain, hebetude, and depression — even after the lapse of half an hour. And yet there was some diaphoresis, show- ing that a considerable quantity of the antipyrine had been absorbed. It was at this juncture that I applied the pneumatic compressor to the jugulars in the usual w^ay. The phenomena thereby evoked appeared within five minutes and were truly remarkable, if credence is to be given to the patient's own statements. He declared that thB heavy feelings in the head had dis- appeared; that he no longer felt pain; that the de- 244 HEADACHE AND NEURALGIA. pression had entirely relinquished its hold upon him ; and that, in a word, he was "cured," as he laconically expressed it. Obviously, the plan of treatment just described has distinct advantages; for, when the nasal mucous membrane is sufficiently healthy to absorb the medi- cament, the stomach, if delicate, may be spared the reception of chemical products which might add to the local derangement. Powerful alkaloids are those best adapted to this form of administration, as they may be given in small doses, and are, therefore, readily taken up by the nasal mucous membrane, whose power of absorption is limited. Again, there is little or no danger of setting up a pernicious habit, as is the case in hypodermic exhibition. Then, too, the prompt relief of intractable symptoms in a rela- tively short time, and without inordinate drugging, is a notable advantage. Finally, I would add that where the nasal mucous membrane is not sufficiently healthy to absorb the medicated fluid in sufficient quantity it may be injected into or beneath the intra- nasal mucous membrane by the aid of a long hypo- dermic needle attached to the syringe conventionally employed. This I have done on one occasion, only. APPENDIX. EYE STRAIN AS A CAUSE OF HEADACHE BY DAVID WEBSTER, M.D., Professor of Ophthalmology in the New York Polyclinic ; Surgeon to the Manhattan Eye and Ear Hospital ; Consulting Eye Surgeon to the Skin and Cancer Hospital ; to the Hospital for the Ruptured and Crippled, to the Hackensack Hospital, to the House of Mercy, New York, etc., etc. NEW YORK: E. B. TREAT, 5 COOPER UNION London: H. K. Lewis, 136 Gower St. 1894 INTRODUCTORY. That headaches are frequently caused by eye-strain resulting from various abnormal conditions of the vis- ual organs has long been well known to the ophthal- mologist, and is beginning to be recognized as a fact by the medical profession generally, as well as by the laity. A considerable proportion of the practice of every ophthalmologist is made up of patients referred to him by their family physician, or coming to him of their own accord, who are conscious that their head- aches are directly traceable to the use of their eyes, and who hope to get relief by wearing properly selected glasses, or by such other means as the skilled ophthal- mologist may suggest. Headaches dependent upon inflammatory condi- tions of the eyes, or of their appendages, do not come within the scope of this paper. We shall confine our remarks to those headaches which are dependent upon 1. Errors of refraction, 2. Impaired accommodation, and 3. Insufficiency of the extrinsic ocular muscles. CHAPTER I. HEADACHES DEPENDENT UPON ERRORS OF REFRACTION. It must not be supposed that all persons who have errors of refraction are sabject to headaches, or other reflex troubles, caused by the same. On the contrary, this is true of a very small proportion of such persons. The fact is that very few persons are free from refrac- tive errors. Probably there are not more than half a dozen emmetropic eyes out of every hundred. But the great majority of ametropes suffer no especial inconvenience from their refractive errors. The fact remains, however, that a certain proportion of such cases are the victims of headaches, and that nothing but the wearing of glasses correcting their ametropia will afford them relief. Therefore, in all cases where the patient refers his headache to the use of his eyes, either for near or for distant vision, he should be care- fully examined by a competent ophthalmologist, and if ametropia be found it should be duly corrected. Indeed, in every case of headache, where aU other causes have been excluded, it is weU to have the con- dition of the eyes investigated. For it is not uncom- mon to find a considerable degree of refractive error, entailing a large amount of ciliary strain, where the patient does not refer any of his symptoms to his eyes, but is inclined to boast of the perfection of those organs. The strain is there, nevertheless, but it makes itself felt elsewhere. The following case illustrates the relief of headache by the constant use of glasses correcting a moderate 250 HEADACHE AND NEURALGIA. amount of hypermetropia, or oversight edness, in a young person. Case L— Feb. 9, 1887.— John E., get. 20, student, complains of pain in the eyes after reading, and on exposure to bright light. The reflection from snow is especially trying. He has, for the last three or four weeks suffered from headaches after even moderate use of his eyes. Visional S ; Hm -^V, both eyes. Orthophoiia (physiological equilibrium of ocular muscles). Abduction 1:° ; adduction 10°. Ophthalmoscopic examination shows that the media and fundus are normal, Feb. IT. — Under atropia, \ = |J with + ^, both eyes. Abduction 5° ; adduction 13°. Feb. 26. — Ordered spectacles + 3V for constant use. Jan. 26, 1889. — Mr. E. returns, saying that he wore the glasses only about three months, when finding on trial that the pain in his eyes and head did not return on leaving them off, he discarded them entirely. He is now married, and is devoting himself to the study of paleontology, involving a great deal of close use of the eyes. About a month ago the headaches returned. The pain is confined mostly to the frontal region, and the attacks occur about twice a week. Each attack lasts five or six hours. When the attack comes on he goes to bed as soon as possible, and after five or six hours' suffering he goes to sleep and "sleeps it off," awaking, after some hours of sleep, free from head- ache. These attacks are sometimes accompanied with nausea, never with vomiting. The severer attacks come on after prolonged use of his eyes. The print often appears blurred after he has read for a short time. Y = f I ; Hm 0.5 D., both eyes. ON EYE STRAIN. S5l Hyperphoria 0° ; esophoria 2° ; in accommodation, none. Abduction 6° ; adduction 14°; sursumduction, R. 1° ; L. r. No lesion of media or fundus. Ordered glasses + 0.75 D. for all the time. April 16. — Mr. E. says he has been wearing the glasses constantly as ordered, and that he has not had more than three attacks of headache in the last three months. Two of these attacks were, he feels sure, not due to eye-strain, but occurred after imprudence in diet. The other attack was one of the old headaches, and he had to go to bed and *' sleep it off " as he used to do. The eyes are so constituted, and are in such rela- tion to the nervous centres, that they tuill see as clearly as possible, independently of any conscious volition on the part of the individual. It is necessary to distinct vision that the rays of light proceeding from the object seen should be brought to a focus upon the retina. In ordinary distant vision, the emmetropic, or normally shaped eye accomplishes this without any effort, be- cause its antero- posterior diameter bears such a relation to its refractive media that parallel rays are brought to a focus upon its retina without any effort of adjust- ment, that is, with its ciliary muscle in a state of relax- ation. But in the hypermetropic eye, which is shorter in its antero-posterior diameter than the emmetropic, when the ciliary muscle is at rest the focus for parallel rays is behind the retina. If it were possible for a hypermetrope to go about without keeping up a con- stant accommodative effort he would see all objects under circles of dispersion, and his distant vision would be as indistinct as that of a myope, or near-sighted person. This state of things actually exists in all cases where the power of accommodation has been lost in •25 -2 Headache and keuiialgia. hypermetropic eyes, either from old age, or from dis- ease, or from the use of mydriatics ; and indeed it is always present in very high degrees of hypermetropia, the hypermetropia heing so great that the individual cannot overcome it by any effort of accommodation. The ciliary muscle, failing to increase the focalizing power of the crystalline lens sufficiently to secure even moderately clear vision, gives it up, so to speak, and the eye contents itself with such poor vision as it can secure without any effort. It is hardly necessary to say that in these cases of hypermetropia, where the ciliary muscle remains relaxed, and the alternative of blurred vision is accepted, there is no headache, so far as the factor that we are now speaking of is concerned. But in all moderate, and even considerable, degrees of hypermetropia, in young persons, clear vision is con- stantly kept up by constantly contracting the ciliary muscle. In near work, such as reading, writing, draw- ing, sewing and painting, the ciliary muscle of the hypermetrope has to do exactly as much work as that of the emmetrope, in addition to the work that it has to perform constantly when gazing upon distant ob- jects. In short, the ciliary muscle of the emmetrope is at rest except when he is engaged in 7iear work, while that of the hypermetrope is at work always, except when his eyes are closed, and does additional work while looking at near objects. In consequence of this constant and unremitting use the ciliary mus- cles of the hypermetrope become increased in size and in strength, and thus, in the great majority of cases are enabled to bear the additional strain. But if the general muscular system chances to be weakened by an attack of illness, or if the already overworked cili- ary muscle is given additional labor, as in the case of a college student preparing for examination, or in the ON EYE STRAIN. 253 case of a person studying any science enthusiastically day and night, the result is likely to be headache, which can be relieved only by resting the ciliary muscles. Thus in the case of the hypermetrope reported above, his first breakdown was caused by over-use of his eyes at college. He needed the relaxation afforded ]yy glasses only to bridge him over that period. As soon as he was in circumstances to give his ciliary muscles a partial rest the glasses were laid aside with impunity. When he plunged into work again, involv- ing extra use of his eyes, the headaches returned in a worse form than before, and he was compelled to resume the use of spectacles. Case II.— July 1, 1880.— Mrs. Dr. J. J. R., set. 33, has all her life been subject to attacks of migraine, but the attacks have been more frequent and more severe for the last eight or nine years. Although she does not complain of her eyes her husband brings her for examination in the hope that the headache may be found to be due to eye-strain, and that she may get that relief, through treatment of her eyes, or through spectacles, which all other means have failed to afford. R. V = li ; |{f + with + ^V cylindric, axis 90°. L. V = 1^ ; IS- - with + ^V cylindric, axis 90°. Orthophoria ; exophoria in accommodation 4°. Abduction 4°; adduction 14°. Ophthalmoscope ; no lesion. July 2. — Both eyes under atropia: R. V = If + with -f A- s, C + A c, ax. 90°. L- V = U + with + h s, C + eV c, ax. 90°. July 12. — The patient accepts only the cylindrics, rhe glasses which improved her vision before atropia was dropped into her eyes. Glasses, + i-^ c, ax. 90°, for right eye, and + -J^ c, ax. 90°, for left eye, were prescribed for constant use. 254 HEADACHE AND NEURALGIA. January 3, 1887. — Dr. E. says the patient has been very much better, but not entirely free from her attacks of headache. April 26.— The patient states that her attacks of headache are reduced at least seventy- five per cent., but that for the last two months they have been com- ing on more frequently again. The glasses which were found to correct the total error of refraction were now accepted by the patient, and she was advised to wear them instead of the partial correction which she had been using. I received a letter from her husband, dated Feb. 1, 1889, nearly two years after the last glasses were prescribed, in which he stated that she had experienced great relief, but that she had recently had a partial relapse. I referred him to another oph- thalmologist in a distant city to which he had re- moved, and have not since heard from the patient. The eye-strain which caused the headache in this case was due to compound hypermetropic astigma- tism. The unequal contraction of the ciliary muscle which is necessary to produce a compensatory assym- metry of the crystalline lens, and thus to neutralize the astigmatism of the cornea and procure as clear vision as possible, is, I believe, a prolific source of head- ache. As in the case just related, correction of the astigmatism alone is often sufficient to afford tempo- rary relief. It generally becomes necessary later to correct the hyper metropia also. Case III.— January 28, 1889.— Sidney G., set. 33, bachelor, no occupation, was referred to me by Dr. J. Leonard Corning with a letter, saying : '' Mr. G. is a sufferer from general anaemia coupled with various nervous symptoms, notably exhaustion, vertigo and painful sensations in the head. These phenomena are pnrticularly pronounced in the morning. The head symptoms are often evoked by reading." ON EYE STRAIN. 255 Mr. G. had been under severe emotional strain for several years on account of the incurable illness of his mother, had kept late hours and had studied hard. His attack of nervousness and headache had lasted for over six weeks. R. V = fl ; Hm 0.50 D. L. V = U ; IT with + 0.50 D. cyL, ax. 90°. Orthophoria ; exophoria in accommodation, 1°. Abduction 6°; adduction 29°; sursumduction R. 1°, L. 1°. January 30. — Under homatropine: R. V = 14} -; ^ with + 0.50 D. cyl., axis 70°. L. V = U - ; -H with + 0.75 D. cyl., axis 110^ Ophthalmoscopic appearances normal. February 1.— The above cylindrical glasses, which gave him the best vision while his accommodation was suspended by homatropine, being now placed before the patient's eyes, in trial frames, were found to be comfortable while they sharpened his vision a little. They were, therefore, prescribed for constant use. February 16. — Mr. Gr. has been wearing the glasses constantly since ordered, and expresses himself as much relieved by them. Dr. Corning, who kept the patient under treatment for some time, assures me that the glasses aided him greatly in the restoration of Mr. G.'s health, and in the permanent relief of his headache. Thus we find that the correction of ocular errors, while not of itself always sufficient to relieve head symptoms, is often an invaluable adjunct to medical treatment. Case IV.— Nov. 15, 1887.— O. E. K., set. 33, banker, was referred to me by Dr. E. C. Seguin, who wrote : ''He presents the occipito-cervical symptoms charac- teristic of eye-strain." ^56 HEADACHE AND NEURALGIA. I found that Mr. K. had been fitted with cylindrical glasses by a distinguished ophthalmologist some years previously, but that they failed to relieve his eye-strain and headache. The glasses were + 1.25 D. c, axis 90°, both eyes. E. V = 1-^ + ; fl with + 0.50 D. c, axis 90°. L. V = H + ; II with + 0.50 D. c, axis 90°. He could still see f f with both eyes at once if + 0.50 s. were added to the above glasses. Although there was insufficiency of the externi of 1° to 2°, and his power of abduction was only 4°, about half what it ought to be, he rejected prisms as making him very uncomfortable. After much patient testing I found +0.75 D. c, ax. 90° both, to be the glasses which afforded him the most reUef. I therefore or- dered them for constant use. April 19, 1889. — Mr. K. says he has worn the glasses constantly since they were ordered, except when exer- cising in the open air, and that since he has been wear- ing them he has experienced entire relief of his occipito- cervical pain, except when he indulges in over-work, which easily brings it on. Recently he has felt a ^^sort of nervousness " in and about his eyes. Upon testing his eyes again, it was found that they now accepted -f 1 D. c, ax. 90°, both. He was there- fore directed to have his glasses changed accordingly. The glasses which this patient had been trying to do his near work with before I saw him gave him very little relief, because they over- corrected his hyperme- tropic astigmatism. I corrected his manifest astigma- tism and the glasses were worn with relief from the first. It was necessary to change them for stronger ones because some of the hitherto latent hyperme- tropic astigmatism had been made manifest by the spontaneous relaxation of the ciliary muscles. CHAPTER II. HEADACHES DEPENDENT UPON IMPAIRED ACCOMMODATION. The most common form of impairec' accommoda- tion is that due to presbyopia, or old sight. The crys- talHne lens, like all the other tissues of the body, becomes harder as we grow older, and therefore less easily changed in shape by the action of the ciliary muscle. So that the presbyope is compelled to put forth additional effort in order to focalize upon the retina rays of light coming from near objects. The ciliary strain thus induced often causes headache, among other symptoms of asthenopia. The most familiar indication of presbyopia is a tendency to hold the book farther away from the eyes, and a blurring of fine print at any distance. When this occurs the cause is generally understood, and the patient cures himself by selecting glasses at an optician's. But when pain in the eyes and head, or slight blepharitis or conjunctivitis with sensitiveness to light, itching of the eye, etc., are the first symptoms that show them- selves, the patient is apt to apply for relief to the neurologist or ophthalmologist ; or, perhaps, first to his family physician, who refers him to the latter. We should not omit, then, to prescribe glasses for such patients, even although the power of accommodation still appears to be ample. Weak convex glasses usu- ally give the required relief, provided the patient can be persuaded to wear them notwithstanding his ability 25S headaciit: AT^D KEITEALGIA. to read without them. Weak accommodation oc- casioned by paresis of the ciHary muscle should be supplemented by well-selected spectacles. Some have reported good results from the local use of a weak solution of eserine or pilocarpine in cases of weakness of the cihary muscle. CHAPTER III. HEADACHES DEPENDENT UPON INSUFFICIENCY OF THE EXTRINSIC OCULAR MUSCLES. A FRUITFUL source of headache is the want of pro- per balance, or of physiological equilibrium, of the mus- cles that move the eyes. Binocular single vision for distant objects should be maintained without effort. When one set of ocular muscles is relatively stronger than the opposing set an extra out-put of nervous energy is required to keep both eyes fixed upon the same object. There is a tendency of one eye to turn away from the object in the direction of the stronger muscle. An extra innervation has to be communicated to the weaker, opposing muscle. The eye -strain thus produced, with the multitude of consequent asthenopic and nervous symptoms, can only be relieved by restor- ing the ocular balance, and this is generally only to be accomplished by the use of prismatic spectacles, or by graduated tenotomy of the too-strong muscle. Case V.— Oct. 19, 1888.— Mrs. Dr. C. E. F., set. 28, has suffered, for many years, with severe pain in the back of the head and neck, tenderness over the mas- toids, and aching of the eyes. These pains have been aggravated by use of the eyes for reading and other near work, but she has suffered more or less from them most of the time. She has made it a rule never to give up as long as she could possibly help it, but some- times she has had to go to bed. She was kept under morphine for two or three days at one time, but as 2G0 HEADACHE AND NEURALGIA. soon as the effects of the drug passed off the pains re- turned as bad as before. Mrs. F. has been wearing spectacles — tVs., which have improved her distant vision without reheving her headache. V = -gVo ; f|- with - 3.50 D., each eye. Hyperphoria 0°; esophoria 2° to 3°, the same in ac- commodation. Abduction 5°; adduction 28°, sursum- duction E. 1°, L. 1°. Ophthalmoscopic examination shows slight *^ ero- sion " at temporal edges of disks. Ordered— 3. D. Opi'ism 1|^°, base out, each eye, for all the time. April 17, 1889. — Mrs. F. says that since she has been wearing the glasses ordered last October she has had very little headache. After the first month's use of the glasses she has had scarcely any. In this case it was not sufficient to correct the error of refraction. It was also necessary to take the strain off her too weak externi, and this was done by com- bining prisms with her concave glasses. Case VI. -Jan. 21, 1887.— Miss Ada P., set. 36, has all her life been subject to neuralgic headaches. They always occurred when she got tired, or when anything caused the blood to rush to her head. In 1876, while attending the Centennial Exhibition at Philadelphia,, she noticed that after using her eyes continuously for two or three hours she was sure to have pain in the back of her head. Last winter a New York optician fitted her with glasses for distant vision which she wore with benefit. Last Christmas she sewed most of the day and in the evening read, and was attacked with a feeling of involuntary contraction in the eyes. Then pain came on and extended from her eyes to the root of her tongue, to her left ear, and to the back of her head and down her shoulders and back. She has been ON EYE STRAIN. / 201 unable to use her eyes since without producing similar sensations. K- V = i H — ; emmetropic. L. V -= IS- - ; I!} with - ,V cyl., axis 180°. She is wearing, Rt.— -4V c, ax. 180°. Lft.- aVc, ax. 180°. No insufficiency for the distance. Esophoria in accommodation 13°. Abduction 6°; adduction 10°. January 22. — R. V = fl with - xk c, ax. 180°. L. V = fl with - tV c, ax. 180°, The above glasses were ordered for the distance. January 24. — Ordered for reading: Rt. + ji^ c, ax. 90°. Lft. + 4V c, ax. 90°, G prism 4°, base to nose. With these glasses the patient was directed to read twice daily, beginning with five minutes and increas- ing the task two minutes daily. February 7. — Miss P. is reading half an hour morn- ing and afternoon without disagreeable sensations. February 25.— Her tasks have reached an hour twice a day. As she had experienced no further trouble she was advised to stop her regular tasks and use her eyes as occasion might demand. I met her some time afterward, at the Manhattan Eye and Ear Hospital, where she brought a poor patient to see me, and she said that her glasses seemed to have banished the headaches permanently. Case VH.— February 23, 1886.— Lizzie V. S., aet. 19, complains of pain in her eyeballs and of *' heavy head- aches." She has been out of work for three months on account of ill-health caused, as she thinks, by strain- ing her eyes. V = -g¥o ; If ^^'ith - yV,^ each eye. 2G2 HEADACHE AND NEURALGIA. Orthophoria; exophoria in accommodation, 14°. Ophthalmoscopic examination shows commencing staphyloma posticum in both eyes. Under atropia, E. V = |^ with - yV; L. V = f^ with — yV- Exophoria 4°. The right eye appears to turn out at times. Ordered — yi s., O prism 2°, base in, both eyes. May 28. — The patient states that she has worn the glasses constantly, for near and for far. She has had no headaches since wearing the glasses. She has had only one attack of pain in her eyeballs and that was not severe and lasted only a short time. I might multiply cases in which headaches had been totally, partially, or temporarily relieved by the use of prisms alone, or combined with spherical or cyhndrical glasses. But that is unnecessary. I have cited a sufficient number to show that in all cases of headache not relieved by other means prisms should be tried. Unfortunately the vast majority of patients who theoretically need prisma,tic spectacles and should be relieved by them are unable to wear them. The effects produced upon vision and upon the nervous system by them are so unpleasant that the glasses are quickly rejected. They change the shape of objects ; they make the floor or side-w^alk appear to approach the eyes or to recede from them, thus giving the wearer the sensation of walking up or down an inclined plane, while really walking on level ground; they make one end of the page that is being read narrower than the other end, or give it a slanting or oblique direction when it is being held squarely before the eyes ; or they produce faintness, dizziness or nausea. In such cases I have generally found it utterly useless to persuade the patient to continue to wear them. He is rarely able to overcome tliese disagreeable sensations by any / ON EYE STRAIN. 2G3 effort of the will. He rarely can compel himself to ignore fchem. When the ophthalmic sm^geon insists upon his continued attempts to do so he quietly solves the problem for himself by laying aside the glasses and doing the best he can without them, or by consulting another eye surgeon, who prescribes glasses without prisms. Not infrequently the patient accepts the pris- matic glasses when placed before his eyes in trial- frames, but rejects them after they have been made for him. CHAPTEE IV. GRADUATED TENOTOMY OF THE OCULAR MUSCLES. Where there is good reason to believe that the headache is due to insufficiency of the ocular muscles (heterophoria), and prismatic spectacles are rejected, there only remains the resort to graduated tenotomy of the stronger, opposing muscle, so as to restore, as perfectly as possible^ the condition of physiological equilibrium (orthophoria). I propose to close this chapter by relating a few cases treated after this method. Case YIII. — Miss Alice A., age 27, consulted me on June 13, 1887. After using her eyes she has headache. She cannot look steadily at anything. Her father died insane. His mother, sister and cousin also were insane. She has a cousin in an insane asylum. She broke down after a hard winter's work, and has since had headache almost without intermission. She has a feeling in the back of the head and neck as if her head were being drawn back. She also has a 'h'ump- ing headache " all over the top of her head. The jar of walking hurts her. Sometimes she feels *^ sort of lost," as if she did not know anything. For many years she has observ^ed that her left pupil is a little smaller than the right. E. V = i H — ; Hm ^V ; L. Y = llj — ; Hm jV- Spectacles + 4^0 were prescribed, and she was put upon increasing reading tasks. August 20. — She now reads four hours a day with her glasses, Exophoria 12°; abduction 15° She has ON EYE STRAIN. 205 single binocular vision in reading. Tenotomy of left extermts, leaving orthophoria. June 21. — The head- ache she had yesterday before the operation was for- gotten after it, and has not come on since. August 27. — She has done her usual work as gov- erness since last here. She has experienced none of the *^ drawing feeling "in the back of the head and neck, but she has a tired feeling. Orthophoria ; ab- duction 10°; adduction 12°. Case IX. — Wm. H., age 44, married, merchant, came May 23, 1887. Mr. H. was troubled with headache all his life, and supposed it was due to indigestion until three years ago, when it was suggested that it might be due to eye-strain. He then went to Dr. Stevens, who gave him glasses and exercised his ocular muscles with prisms. The glasses relieved his headaches ; but recently he has had a relapse. If he reads at all with- out his glasses, or even three minutes with them, ^^ his head is wrong," and he becomes intensely sick all over, but does not vomit. His general health is good, his bowels regular ; he sleeps well. He never had any disease except malaria. E. V = f^ ; Hm -^ ; L. V = |g - ; 11 + with + j\ c, ax. 90°. Esophoria 3° to 6°; in accommodation 15°; no hyperphoria ; ab- duction 2°; adduction 23°; sursumduction, E. 0°, L. 0°. His glasses are prisms, base out. May 24. — Tenotomy of left internus, leaving orthophoria. September 20.— Mr. M. thinks he was helped very much by the operation, but is not entirely relieved. September 21.— Esophoria 6°; abduction 2°; adduc- tion 22°; tenotomy of right internus. October 10. — No headaches since the last operation; wears no glasses, and uses his eyes with comfort ; orthophoria. Case X.— Dr. W. S. K., age 32, consulted Dr. C. 266 HEADACHE AND NEURALGIA. R. Agnew on April 25, 1877. He stated that he had no trouble with his eyes until September, 1876, when neuralgic pains about the root of his nose set in while reading. There was a f eehng of severe tension over his brow while reading. He used belladonna ointment over his brows until his accommodation grew weak, and he had to give up reading altogether. He then became excessively nervous all over. He consulted Soelberg Wells, who dilated his pupils and found his fundus normal, but that he had Ht 3V each eye. He has worn + -3V constantly since. Dr. K. says his eyes first ^* broke down'^ while working all day with the ophthalmoscope and micro- scope, and then reading late at night. At Christmas he observed that he would become worse when the gas was lighted. He went to church on one occasion, and the bright light caused great infra-orbital neural- gia and neuralgia of the third division of the fifth nerve. This has been confirmed a dozen times. Read- ing or walking in bright sunhght invariably brings on pain in the inferior maxillaiy region, the pain being more especially referred to the front teeth below. His teeth were never tender in mastication, and he has only one carious tooth, the first molar on. the right side, and that is well filled. He is troubled with spasms about his internal canthi when he lies down. His digestion seems to be good. Never venereal disease. His father was rheumatic and perhaps gouty. He says he is as nervous as a hysterical woman. He jerks and starts when he goes off to sleep. He suffers from sci- atica of the left hip, but he attributes that to a fall from a horse when a boy. y = l^ each with + ^. No insufficiency. Oph- thalmoscopic examination gives him excruciating pain, lasting twenty -four hours or less. ON EYE STRAIN. 267 The patient was referred to Dr. E. C. Seguin for an opinion. Dr. Seguin wrote : *' April 25, 187T, Dr. K.'s case has seemed very in- teresting to me. I am disposed to look upon his hyper- aesthesia (face and limbs) as due primarily to insuffi- cient nutrition. He has worked hai'd and used a diet, which I look upon as perfectly fitted to develop anaemia and neuralgia. I would suggest beefsteak and roast meats twice a day, ale or claret for dinner, and not much starchy food. Thompson's solution of phos- phorus may also do good, and relief may be had by the positive pole of the galvanic battery. I don't find the usual symptoms of asthenopia." April 26. — Hm ^ each. Cooper, and Wells, and Purvis, of London, all examined his eyes under atro- pine and found that his Ht was + gV- April 19, 1887. — The patient returns to me with a letter from Dr. A. W. Calhoun, of Atlanta. He stated that he got no relief from his glasses, and finally discarded them alto- gether. Since ten years ago he has suffered agony every hour that he has been awake, and he has been kept awake many nights with pain through the tem- ples, through the roots of the nose, and through the teeth and malar bones. The main pain is through the malar bones and nose. No pain in top of head or in occipital region. E. V = |f — ; f f with + A ; L. V = M ~ ; fo with + ^V- No hyperphoria ; esophoria 2°; abduction 2°; adduction 12°. May 7.— Esophoria 4°; in accommodation 0°; hyperphoria, R. 1°; abduction 4°; adduction 13°; sursumduction, R. 0°, L. 0°. The patient was now referred to a physician skilled in dis- eases of the nose, who found that he had a deviated septum and operated upon it. He also operated upon his hypertrophied turbinated bone, but without much apparent benefit. May 12. — Tenotomy of right inter- 268 HEADACHE AND NEURALGIA. nuSj leaving orthophoria, with abduction 8°; as found on testing half an hour after the operation. May 13. — Went to bed last night with a freedom from pain which he has not experienced for years. Esophoria 4° ; abduction 8°. May 21. — Orthophoria: abduction Y°; adduction 19°; much improved. April 2, 1888. — The patient writes, *' I have done a hard winter's work in the college and with my practice, and my eyes have held up very well." Case XI. — Nellie C, age 20, came to me at the Manhattan Eye and Ear Hospital on February 17, 1888. For several years she has suffered from severe head- aches, which occurred almost every other day. The pain was principally across the forehead, and very sel- dom extended to the back of her head. The headaches last two or three hours, and are usually brought on by reading, but sometimes occur without any exciting cause. She has a great deal of facial neuralgia also. Within the past seven months she becomes sleepy after using her eyes in reading or sev/ing any length of time. She is very often taken with fainting spells, fainting away and becoming quite unconscious. Eight days ago she had two or three such fainting spells. The first fainting spell w^as about four years ago, when she was attacked with it while grinding coffee. She has usually had these spells not more than once or twice a month. She was ill during the whole of last summer. She was cashier in a store at the time and got very weak. R.V = f^; ifw.+J^. L.V = H;Em. Hyper- phoria, E. 3°; esophoria 2°; abduction 3°; adduction 16°; sursumduction, E. 4°, L. 5°. February 25. — Divided the right superior rectus, leaving the hyper- phoria exactly corrected. The patient fainted twice during the operation. February 26. — She had some ON EYE STRAIN. ' 209 headache after reading this morning. February 27. — Orthophoria ; abduction 6°; adduction 16°; sursum- duction, E. 3°, L. 3°. March 2.— Orthophoria. Sep- tember 14, 1888. — The patient states that she has had no headaches or fainting spells since the operation, a period of nearly a year. K. V = II - ; U with + "^Vc, ax. 90°. L. V = f ^ ; Hm^V- Orthophoria; abduction 5°; adduction 16°; sursumduction, R. 3°, L. 3°. May 11, 1889. — I saw this patient at the Manhattan Eye and Ear Hospital about a week ago. She came to report that she had had no headaches or fainting spells since I last saw her, and that she considered herself permanently cured. Case XII.— Rev. F. D. G., age 30, missionary to China, was referred to me by Dr. E. C. Seguin, with the following letter, dated December 27, 1887 : *^ Rev. Mr. G. has congestive symptoms about the head and a degree of nervous probtration — now relieved. Since eight years he has noticed occipital pain and distress on the prolonged use of his eyes, symptoms suggestive to me of muscular insufficiency in accommodation. He has good vision, and to me, his eyes are about emmetropic." Upon testing Mr. G., I found : R. V == t| ; E. L. V = f ^ ; Hm 0.25 D.; hyperphoria, L. 1°; esophoria 1°; exophoria in accommodation '4°; abduction 4°; adduction 14°; sursumduction, R. 3°; L. 2^. Decem- ber 28.— Under homatropine : R. V = ff with + 0.50 D.; K V = Hwith + lD.; hyperphoria, L. |; ab- duction 7°. Ophthalmoscopic examination shows physiological excavation of both discs and pulsation of the retinal veins in both eyes. There was no lesion of either eye except a small white spot just above the right macula. 270 HEADACHE AKD NEUEALGIA. December 30. — Hyperphoria, Left 1°; tenotomy of the left superior rectus, sHghtly OYer-correcting the hyper- phoria. January 3, 1888. — Abduction Y°. January 6. — Esophoria 2°; hyperphoria, L. ^; abduction 5°; adduction 18°; sursumduction, E. 4°; L. 3°. He was instructed to exercise his interni daily with prisms. January 9. — Abduction 1°; adduction 50°; esophoria 6°; in accommodation 6°. January 13. — Abduction 5°; esophoria 2° to 5°. January 20. — Abduction '7°; hyper- phoria, L. 1°; ordered glasses Et. + 0.25 D., Lft. + 0.25 D. O l°j t)ase down, to wear all the time. Janu- ary 27. — Abduction 6°; hyperphoria, L. 1°. He said he had experienced relief from the use of the glasses, although reading with them for three hours brought on occipital headache, and after continuing the use of them four hours longer the headache was as bad as ever. Tenotomy of Right Inferior Rectus, leaving a sHght over-correction. February 10, 1888. — He reported that his headache had been better and that he read six or seven hours the day before without headache. The tests show orthophoria ; ordered glasses + 0.25 D., both eyes, without any prism. March 15. — The patient says his head symptoms have almost disappeared. For a month or more the eyes have been '^ sore to the touch," and more or less red, especially on rising in the morning. The redness disappears after a while He has had these inflammatory symptoms since wear- ing the glasses. He was now advised to stop wearing the glasses, and the camphor and borax wash was pre- scribed for him. Examination showed orthophoria. June 15. — I met the patient outside my office and he informed me that he had no special trouble with his head, although he had been hard at work for some months, and that he anticipated a speedy return to his ON EYE STRAIN. r " 271 missionary duties. October 2. — Orthophoria ; eso- phoria in accommodation 6°; abduction 5°; adduction 30°; sursumduction, K. 2°; L. 2°. Mr. G. was unavoid- ably detained in this country. He considers himself greatly benefited by the tenotomies, and is doing full work with his -i- 0.25 D. May 11, 1889. — Mr. G. states that he has not been troubled by any head symptoms since I saw him and works as comfortably as ever. Orthophoria ; adduc- tion 7°. He is about to return to his work in China. INDEX. Brain, localization of the Dreams, 209 cerebration of, difficulty of controlling the, 215 classification of, difficulty at- tending the, 215 comparison of, to insanity, 215 composition of, 209 conceptions of, rapid evolu- tion of, 217 difference between, and wak- ing thought, 215 emotions of, less hurt fuithan those of the waking state, 218 indigestion as a cause of, 210 impressions which give rise to, 209 malposition as a cause of, 210 reduction of the feeling of personality during dreams, 218 "supernatural agency" in, 210 Electro-compression of the caro- tids, mode of executing, 28 Headache, anaemic, 22 alcohol in, 24 diet in, 25 elevation of lower extremi- ties, 24 horizontal position in, 25 action of remedies upon, 228 Headache, anajmic, nitrite of amyl in, 24 nitrous oxide in, 25 opium in, 24 symptoms of, 22 treatment of, 24 cases illustrative of different phases of, 56 Headache, congestive, 26 blisters in, 36 carotid compression in, 27 causation of, 26 cold to the head in, 34 dry-cupping in, 36 electro-compression of the carotids in, 28 epistaxis, artificial in, 35 galvanic current in, 36 hot baths in, 32 hot water to feet in, 32 ice- water cap in, 32 symptoms of, 26 treatment of, 27 Headache, nervous, 38 antipyrene in, 42 bromides in, 41 causation of, 40 chloral in, 41 compression of scalp and hot- water bag in, 41 definition of, 38 hyoscyamus in, 41 morphine in, 41 seclusion in, 43 274 INDEX. Headache, nervous, sleep in, 43 symptoms of, 39 treatment of, 40 Headache, organic, 53 causation of, 58 chloral in, 55 diagnosis of, 53 iodide of potassium in, 54 morpliine in, 54 symptoms of, 53 treatment of, 53 Headache, sympathetic (bilious headache), 47 causation of, 47 intolerance of the stomach to remedies in, 50 Headache, symptoms of, 48 treatment, 49 Headache, toxic, 44 causation of, 44 defective ventilation as a cause of, 45 lead poisoning as a cause of, 45 pilocarpin in, 46 purgatives in, 46 treatment of, 45 Turkish bath in, 46 uraemic intoxication as a cause of, 45 Head-pains, 15 classification of, 30 dura mater in, 19 Erb on, 18 mechanism of, 15 Niemeyer on, 17 Prus on, 19 Symondson, 16 Insomnia, 199 classification of, 199 idiopathic, 301 secondary, 306 treatmenl.of, 333 Insomnia, weight, variation of in, 333 Neuralgia, general considera- tions on, 63 aniesthesia in, 65 characteristics of, 63 classification of, 66 debility in, 63 hyperassthesia in, 65 points apophysaire, 65 puncta dolorosa of, 64 spasms, muscular in, 65 vaso-motor disturbances in, 65 Neuralgia, forms of, 66 cervico-brachial, 71 cervico-occipital, 71 coccygodynea, 76 crural, 73 dorso-intercostal, 74 lumbar, 73 lumbo-abdominal, 73 mastodynia, 77 muscular, 77 osteal, 140 periosteal, 140 plantar, 75 sciatic, 74 Neuralgia, trigeminal, 67 (a) supra-orbital, or oph- thalmic neuralgia, 69 (b) supra-maxillary neural- gia, 70 (c) infra-maxillary neural- gia, 70 Neuralgia, summary causation, 79 diagnosis, 83 pathology, 84 prognosis, 86 Neuralgia, treatment of, 88 aconitia in, 139 arsenic in, 133 INDEX. 275 Neuralgia, atropine, 128 batiis in, 135 bromide of potassium, 131 cantharides in, 133 cases illustrative of the effi- cacy of local measures, 100 chloral in, 130 chloroform in, 129 cocaine, introduction of into the skin about the face, 94 electricity in, 119 freezing, local in, 135 heat in, 140 iodine in, 133 iron in, 133 local medication of nerves, 93 morphine in, 126 narcotics in, 125 ointments in, manner of em- ploying the, 128 phosphorus in, 132 pressure and electricity in, 121 quinine in, 132 remedies adapted to local medication, 93 remedies, endermic use of in neuralgia. 111 remedies, introduction of in- to the integument by the aid of galvanism, 95 remedies, prolongation of the local action of, 97 strychnine in, 133 surgical expedients in, 138 turpentine in, 133 valerian in, 133 veratrine in, 129 Neuralgia, zinc in, 133 Sleep, 187 carotid circulation in, 187 cerebro-spinal fluid, increase of within the skull in cere- bral anaimia, experiments of Nounym and Schreiber, 194 definition of, 187 derangements of in painful affections, 187 essential factors of, 198 excretion of phosphates and sulphates diminished dur- ing, 197 physiology of, 188 Schiff's experiments on, 192 urine composition modified by, 196 Somnolence, morbid, 219 cases illustrative of, 220 Spinal irritation, 145 cases illustrating the efficacy of local medication of the cord, 161 diagnosis of, 149 local medication of the cord, 154 local medication of the cord, author's method of execute ing the, 158 pathologj^ of, 148 symptoms of, 145 treatment, 151 Spinal irritation due to shock, 169 cases, 171 symptoms of, 170 APPENDIX. Eye Strain, a Cause of Headache 345 THE INTERNATIONAL MEDICAL ANNUAL A Complete Work of Reference for Medical Practitioners. By a Corps of Thirty-Seven Specialists and De- partment Editors, widely known in Europe and America. THE MEDICAL ANNUAL brings to the Practitioner, in a form for rapid reference, every advance in medical knowledge, worthy of record or preservation, It differs from a Retrospcctor Digest; in tlielarjie number, and scope of its original and special papers, its Practical Hints and Suggestions. Each review and contribution being credited to its respective author, thus giving merit, character and increasing value to ihe production. 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THIRD.— APPENDIX, comprising Special Contributions such as Sanitary Science; Progress of Pharmacy; New Inventions and Ap- pliances ; Books of the Year, etc., etc. ITS YEARLY ISSUES since 1882 form a complete and permanent Library of Medical Reference of great value to the dispensing chemist as well as the Medical Practitioner. In one large octavo volume. Illustrated. Nearly 700 pages. $2.75* Back Volumes can be had only of 1889, 90 91,92,93, post-paid, $2.75 each, E. B. TREAT, Publisher, 5 Cooper Union, N. Y. NERVOUS EXHAUSTION [Neurasthenia] , Its Hygiene, Causes, Symptoms and Treatment, By GEORGE M. BEARD, A.M., M.D., Formerly Lecturer on Nervous Diseases in the University of the City of New York ; Fellow of the New York Academy of Medicine, etc. Second Edition Revised and Enlarged by A. D. ROCKWELL, A.M., M.D., Professor of Electro-Therapeutics in the New York Post-Graduate Medical School and Hospital, Fellow of the New York Academy of Medicine, etc. Neurasthenia. — In spite of its frequency and importance, although long recognized in a vague way among tne people and the profession under such terms as "general debility," "nervous prostration," "nervous debility," '•nervous asthenia," " spinal weakness," it is beginning to find recognition in the literature of nervous diseases. It is the most frequent, most interest- ing, and most neglected nervous disease of modern times. Among specialists and general practitioners alike, there has been, on the whole subject, a fearful and wondrous confusion of ideas. The present work is the result ot the experience and study of my entire professional life in the subject to which it relates. — (From Author's Preface.) Neurasthenia is now almost a household word, and equally with the term malaria, affords to the profession a convenient refuge when perplexed at the recital of a multitude of symptoms seemingly without logical connection or adequate cause. The diagnosis of neurasthenia, moreover, is often as satisfactory to the patient as it is easy to the physician, and by no means helps to reduce the number who have been duly certified to as neurasthenic, and who ever after, with an air too conscious to be concealed, allude to themselves as the victims of nervous exhaustion. The doctrine to be taught and strongly enforced is that many of these patients are not neurasthenic, and under any hardly con- ceivable circumstance could they become neurasthenic. They do not belong to the tyep out of which neurasthenia is born, either mentally or physically. Many of them are unintellectual, phlegmatic, and intolerably indolent, and are pleased at a diagnosis which touches the nerves rather than the stomach, bowels and liver. Instead of rest, quiet and soothing draughts, they need mental and physical activity, less rather than more food, depletion rather *.han repletion. — From Editor s Preface. In one large octavo vol., nearly 300 pages. Price, $2.75. (Jniform in style with Medical Classics, Price of the 1 2 Vols.^ % E. B. TREAT, Publisher, 5 Cooper Union, New York,