The Modern treatment of headaches

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Cooper Medical College

Date ^^xy. Af'^'./

No. !if^d/ . CLASS .^S-CJ...

— THE —

4_^ B. WM. tt MwAn

MODERN TREATMENT

, J J J -/
... , J ■J J

- '-" -

— OF —

■ ■> - -

■J ■J

^ w ^

J J -^ "

HEADACHES.

— BY —

ALLATJ McLANE HAMILTON, M. D.

if

18^8.
GEORGE S. DAVIS.

DETROIT, MICH.

:b

' • • ■ • • •

• • • t •

• • • •• •

>• • • • •

Copyrighted by
GEORGE S. DAVIS.

x888.

iSS8

PREFACE.

A little book of this character hardly needs a preface. I
might, however, offer a word of apology for my failure to men-
tion many remedies, which in the hands of my reader have
doubtless been of great value in the treatment of this most
common of ailments.

I have written these few pages, drawing from my own
experience, without any great reference to other articles or
books, and the remedies suggested are those in which I believe.
I hope imperfect as they are, they may contain here and there
a serviceable hint.

Allan McLane Hamilton.

20 East 29th St., New York.

INTRODUCTION.

HEADACHES

The complex nature of head pain must, to a great
extent, affect such a thing as exactitude in diagnosis,
and the multitude of immediate and remote etiological
factors, and the circumstances of a modifying character
in such cases, require a survey of the whole domain of
disease. General symptomologj' must be regarded,
and in but few cases can we consider headache as a
distinct disorder. Head pain is external or internal,
and due to a variety of influences that affect the sens-
ory parts either of the scalp, or the contents of the
cranium. Circulatory variations with resultant modi-
fications of pressure — either hyperremic or ansemic —
the presence of toxic agents, fungus growths, trans-
mitted irritation from remote centres, malnutrition
or some grave disease of the fifth nerve; ali enter in-
the production of this most common form of distress.
No one disputes the fact that extensive disease
within the skull may exist without headache. When
we consider the arrangement of the skull and its soft
parts, we immediately ascribe to the dura an important
role as a developerof headaches. This membrane con-
tains a large number of blood vessels and sinuses, and
whenever hyperaemia, or a serious lesion is found where
there are resisting bony parts, headache is almost a
certainty. Many headaches, I am sure, are alone due

to extra-cranial disturbances, notably scalp congestion" '
and inflammation, and it is very probable there are
headaches of an annoying character, which, as Briquet
and Mills have pointed out, are simply myalgic. I am
clearly of the opinion that many alleged " eye " and
"uterine" headaches are ordinarj' myalgic affections
of the temporal and occi pi to-frontal is muscles.

Location. — The localization of pain is of value
in determining the nature of headache, but not' so
much as some authors would have us believe. Some
years ago all vertical headaches were considered
" uterine," now much sub-occipital pain is supposed to
be due to pelvic disorders. There is no absolute cer-
tainty in connecting a headache with this or that
bodilv disorder, so far as its seat is concerned, but a
study of the accompanying symptoms is of great
moment, for there is after all, a more or less relative
connection. It is of importance to study the time of
appearance, duration, modifying influences, age of the
patient, and his appearance and behavior.

The individual is very likely to be mistaken
in regard to the seat of his pain, and is disposed to as-
cribe what may undoubtedly be a superficial pain to
deeper parts. Wilks says.- " 1 suppose that one's
feelings ought not to influence the judgment, other-
wise it would be thought that the pain is situated in
the very depths of the brain itself. I once had an op-
portunity of testing the power which the individual
hfts in discovering the seat of pain. Having scalded

my head with steam rising from a pipe to vaporize a
sick-room, I endeavored to analyse the character of
the pain which followed, but was unable to discern
how it differed in kind from the pain of ordinary head-
ache." This 15 quite true, and the hyperfesthesia of
many terminal filaments is quite apt to confuse the
powers of space perception. An intense local pain, on
the other hand, may appear to be general, as in
migraine.

As I have said, the most important pathological

tes which are conducive to headache are those

i which bear relation to the condition of fulness or

emptiness of the cerebral vessels. As one-fifth of all

the blood in the body goes to the head, we may ex-

I pect to find important disturbances in function when

f the amount is either greatly increased or modified.

' As results of cardiac excitement or disease, increased

' vascular tension, determinations or hypertemic states of

' other organs; or. exhausting fluxes; we find varieties of

headache which are known as cmigesthe or anamk,

I though their distinction is by no means an arbitrary

one. Certain toxic feeadache.s belong to the first

order, and neurasthenic ones to the latter. Anseraic

' headaches are often " uterine," and if we mingle the

' clinical and pathological terms we find ourselves

Mn a helpless tangle. I prefer a different classification,

I which is the following:

1. Congestive headaches.

2. Anaemic headaches.

— 4 —

3- Organic headaches (as a rule due to struc-
tural cerebral changes).

4. Toxic headaches {e. g. lithaemic, uraemic, ma-
larial, et al,)

5. Neuralgic headaches.

6. Neurasthenic headaches.

CHAPTER I.

CONGESTIVE HEADACHES.

Under this head come two forms: (n) that in
which there is a general cerebral congestion and paiiy
[i) that which begins at least in one-sided pain, with
lateral hyperfemia. Its forms are numerous and its
causes very extensive. No age is free from it and it is
perhaps the most common of all headaches. Generally
speaking it is accompanied by a subjective sense of
fullness, by more or lesss psychic hyperKsthesia at
one time, and dulness at another; by confusion of
ideas; throbbing and distension of the temporal ves-
sels, suffusion of the skin, injection of the conjunctiva
and sometimes of the sclerotics. Brilliancy of the eyes,
or a lack-lustre expression, and a tendency to sleep,
diffused pain, which causes the patient to declare
that his head is encircled in an iron band, or that "it
feels as if it would burst," are the sensorial disorders.
It may occur quite suddenly in the course of an attack

digestion, or gradually develope in the person who

suffered from obstinate constipation for a few
days. In point of duration it may last for several
days, or be almost continuous during the existence of
I as exciting cause.

In its familiar form it may result from want of
[ sleep, a late supper, or a debauch, in which event
' it is often matutinal, and is associated usually with

nausea and what the Germans call "katzenjammer,"a
sense of intolerable " seediness." The eructations or
emissions from the stomach are quite apt to be in-
tensely acid, and there is besides the diffused pain, a
peculiar weight above the brows.

The treatment for such a headache is, first a good
brisk saline purgative, such as Hunyadi water,
Friedreichsalle, or a solution of Crab Orchard salts;
a cold bath and douche, and the use of the diffusible
stimulants. I have 'given many of my patients the
following:

Cocx hydrochloras, gr, x.
Amiuon. bromidi., | iss.
Aqus ca.mphoraE, ad § iv.
M. S[g. — One teaspoonful in iced water to be repeated
hourly until relief is obtained.

In some cases an aromatic bitter tonic and car-
minative will relieve the patient if his headache be due
to alcoholic

S Tt. Nucis vomicK,
Tr. Capsici, aa Z iisB.
Tr, Genlianx Co.. |ii.
M. Sig. — One leaapaonful in water at a dose.
These headaches, especially if there be gastric
derangement, are helped by effervescing drinks. Here
is a domestic prescription which is a valuable one.
The juice of one-half a lemon in a pint of cold apol-
linaris water.

There is a form of congestive headache due to
ejiposure to the sun, which is accompanied by dizzi-
ness, constipation and some confusion of the mental
operations, and a great sense of prostration. The
headache is not so intense as some others, but it is
low, continuous and "muttering." With it is either
an irregular fluttering, or a slow small hard pulse.
There is a passive hyperaemia of the brain, notwith-
standing the fact that there is pallor. Under such
circumstances the improvement of the heart's action
will do more for the sufferer than local remedies.
Digitalis in increasing doses, its administration being
guided by the behavior of the patient, ice bags to the
back of the neck and diffusible stimulants, such as
ammonia or alcohol are the indications. Cold douches
to the head, and the application of heat to distant
parts may also be required.

A congestive headache due to insolation of an
active type, is often benefitted by aconite in small and
repeated doses, or veratrum viride either in combina-
tion with the bromides or alone.

There is an imperfectly developed congestive
leadache that may occur in aniemic patients, as
the result of head work.* Wood thus speaks of this
form of trouble; "headache is another of those fortun-
ate symptoms which are of a character to make them-
selves so felt as to force the attention of the brain

n-work and over-nork, p. i

worker. The head is often the seat of unpleasant
sensations which are not headache, but which, as the
signs of mental over-driving, are of even more serious
meaning than is headache. Such are a sense of
weight on the top of the head, a feeling of constric-
tion of the forehead, or a more general cephalic dis-
tress. Such phenomena occurring after long con-
tinued strain, are very significant and should always
be heeded," This form of suffering, is as a rule,
associated with insomnia, lassitude, inability at con-
centration, great depression and irritabilility, and
often by actual pain. The headache is always most
aggravating after hard work, a long day in court, the
preparation of a sermon, or speech, a difficult case or
a sleepless night, I have met with a variety of head-
ache in men between forty and fifty, in which profuse
discharge of limpid urine, and some irregularity of
heart action betoken a profound impression made
up)on the sympathetic nervous system. As in other
headaches of the congestive type, dizziness, pulsating
carotids, tinnitus muscfe volitantes and contracted
pupils are often recognized.

Sub-occipital headache of a sympathetic type is
also not uncommon among brain workers, and is un-
doubtedly due to some hyperemia of posterior cere-
bral parts due to the inefficient action of the vaso-
motor nerves governing the vertebral arteries,

Woakes* describes a form of congestive occipital

* London Praelitioner, 187B p, 362,

tieadaches, attended by feebleness of the arms, runnJngf
at the eyes and nose, blueness and coldness of hands,-
and at the end of an hour culminating in an attack of
vomiting. Two hours after the onset of the sub-occi-
pital pain there were superadded general pains of the
back and neck and great prostration. The symp-
toms Woakes compares to those of mild poisoning by
tobacco, but there was no vertigo. The patient had
been subject to migraine for several years and was
weak, sallow and emaciated. Camphor, or ice held in
the mouth would cut the attack short. This author
is inclined to believe this form of sub-occipital head-
ache a sympathetic disorder, and due to reflex irritation
of the gastric branches of the pneumo-gastric and to
dilatation of the vertebral artery. This patient's neck
was painted with a strong sokition of camphor and
the headache was speedily relieved.

The cutaneous nerves at the back of the head which
are brought into relation with the ganglia through the
medium of the plexus of the vertebral artery doubt-
less, when stimulated by the external application, pro-
duced contraction of the blood-vessels.

In headache due to overwork it will, of course,
be suggested to every intelligent physician to reg-
ulate his patient's mode of life; to advise rest and
recreation, and prescribe remedies directed to reg-
ulate the cerebral circulation, and improve the nutrition
of the nervous tissue. Irregularity of intellectual work
is perhaps inore conducive to headache of this kind

— 10 —

aod cerebral exhaustion than anything else. The
bypersemia of the brain which is brought about by
abnormal use of that organ is eventually succeeded by
capillary dilatation, and a passive condition takes the
place of an active one. Working under pressure, or
at hours when one's fellows are abed is to be depre-
cated. So, too irregularity of mental habits, improper
care of the stomach, and the fictitious aid of to-
bacco and stimulants are at the bottom of much
trouble. One of the worst headaches I ever knew was in
the person of an editor who ate a hearty supper, com-
menced his labors shortly thereafter, and at ten o'clock
drank a pint of strong black coffee he nightly made
in a bigen in his office.

Such patients need the phosphates, and are more
benefited by these preparations than any other. The
judicious addition of remedies which improve vascular
tone, such as nux-vomica and its derivatives is coun-
selled.

I append a number of formula:

S Strychnine sulph., gr. i,

Cincbon. sulph, 3 i,
Acid phosphoric! dil.

M. Sig. — 3 i in wa.[er afier eating.

This combination occasionally produces gastric
trouble and I then use the following in preference:

" 8 Tr. nucis vomic*

GlyceriDie. ii % se.

Acid pbospborici dil.

Syr. zioKib, iii 3 ji.

M, Sig. — 3 i in water after eatiog.

In many cases there is a great deal of cardiac
weakness when the habitua! use of small doses of ni-
tro-glycerine (gr. -^) morning and night do good.
For such patients I have also employed a pil) which is
the following;

B Zinci pliosphidi, gr. iv,

Ext. pliysostigma venenos, gr, xii,
Ext. gentianse, gr. xlviii.
M. Sig.— Ft masssc et divid in pillula- No, xlviii.

Sig.-

ader e;

meal.

This combination is indicated especially when
there is a suspicion of mental trouble or impending
central disease as is the following:

$ Tr. digitalis, 3 ss.

Syr. hypophosphiii Co.. J viii.

M. Sig. — One to two (easpoonsful tlirice daily.

The improvement of surface circulation in con-
gestive headaches due to brain exhaustion is a prime
necessity. Morning bathing in water colder than the
body to which sea salt has been added, is to be ad-
Tised, and I have been in the habit of using an artifi-
cial salt made by Mr. R. Fingerhut, cor. zSth st. and

— 12

4th ave., New York, which contains a large amount of
potash and oxide of iron in combination. One pack-
age of this salt is to be placed in a bath-tub of warm
water in which the patient is to remain ten minutes
before retiring.

For the immediate relief of the headaches I rely
upon cold applications and sub-occipital cupping; ab-
solute rest and quiet. Occasionally, a large dose of
the bromide of potash does good, and in those ex-
citable cases when the hyperaemia takes place in an
ordinarily anaemic brain it is especially good. Foth-
ergill in his admirable paper in the West Riding re-
ports has fully explained the philosophy of this form
of hyperaemia, which he believes to be due to cell ir-
ritability.

The use of chloroform is very popular with Eng-
lish practitioners, and Day recommends it in the con-
gestive headaches of aged people.

The following is one of his formulae, which I
have used for several years.

9 Spts. chloroform, lUv,

Liq. ergotae ext., tt^xx — 3 ss,
Aquae purse, ad | i.

M. Sig. — To be taken three times a day.

The congestive headaches of school children are
not only due to over-work but to gastric and intestinal
causes. The appearance of the child is characteristic,
and abundant evidences of cutaneous suffusion are

— 13 —

present. The headaches are throbbing, accompanied
by irasciblity, and are worse after eating, or towards
the latter part of the day. Bad dreams, night terrors
and a clouding of brain action are accompaniments,
and such children are apt to be dull at school, or uneven
in their capacity. Sometimes we find them to be of
the neurotic temperament so graphically described by
Maudsley. They are usually bright in some things
and very stupid in others. In some cases the head-
aches which are always aggravated by digestive dis-
turbances and confinement in school, are the precur-
sors of more aggravated cerebral mischief, and even of
tubercular meningitis. They are best treated by
anaemiants such as the bromides. A combination of
the bromides is excellent, and the largest dose may
be given at bedtime:

Q Sodii bromidl,
Potass, bromidi,
Ammon. bromidi,
Calcii bomidi, US 5 ss.
Syr. Rubri, J ij.

Sig. — One to three teaspoonsful in water, thrice daily or
when needed.

Removal from school, gymnastic exercises, salt
bathing and open air exercise are of the utmost im-
portance, and it will be found that if some prepara-
tion of phosphorous is given at the same time, much
good will result. I think in many cases iron is con-
traindicated, and it not only increases the headache,

— 14 —

but disturbs the already impaired digestion. When it
is given it should be in some assimilable form. The
syrup of the iodide is the best of these, and in com-
bination with cod-liver oil we very promptly see its
good effects.

^ Syr. Ferri iodidi, 5 ss.
Ol. Morrhuae, §iiiss.

M. Sig. — 3 ij to 5 ss, t. i. d.

In some cases of headaches in children the use of
the syrup of the bromide of nickel is recommended.
It is best prepared by the combination of carbonate of
nickel with dilute hydrobromic acid, and five grains
should be contained in each teaspoonful of syrup.
This is especially beneficial when there is much rest-
lessness and emotional activity. Many headaches of
early life are due to injudicious diet, and especially to
the consumption of large quantities of meat. The
influence of a preponderating nitrogenous diet has
been shown to increase the number and frequency of
epileptic paroxysms, and I have repeatedly witnessed
its bad influence in the development, not only of dis-
turbed sleep, but hysteria, and congestive headache.

The headaches which are so often connected with
cardiac hypertrophy and renal disease, are common,
especially in middle aged persons. I have already
spoken of a passive variety, but there is an active
form as well which is associated from time to time
with conditions in which the arterial tension is sud-

denly increased from even slight causes. In winter,
especially when the cutaneous circulation is poor, we
find that these subjects are most often troubled, and
attacks of head pain are common in persons who eat
and drink to excess, and take little or no exercise.
The possessors of such congestive headaches present
facial evidence of cutaneous engorgement, amounting
often to a purple suffusion, acne and dilated capil-
laries. The pulse is hard and full and the urine is
scant and loaded with phosphates or urates. Slight
exertion is followed by great fatigue, and the head-
aches are dull, throbbing and often preceded by
drowsiness. The head pain is often attended by cos-

ktiveness, and relieved by purgation. The general
state of the patient must be attended to. Blue ptll
and colocynth are both excellent, and have a tradi-
tional reputation which has not been diminished by
time, and has been handed down by our port-drinking
ancestors. A capsule like the following may be given
occasionally at night.
B Hydrarg. niassa;,
Ext. colocyothii..
Exl. (el. bovis.. aa 3 i-
M. Divide in capsulx No. x.v.
Sig. One or iwo at night.

Podophyllin
Hydrarg. nii

Divide in pilluli No. lii.
. One at niglil when required.

An excellent pill for the relief of the intestinal
condition, especially when the headaches are attended
with drowsiness and depression of spirit is the follow-

Hydtatg. chlor. mile., gr. vi.

Ext. Hyoscyaoiice,

Pulv. ferri. exissicads.

Pulv. aloes, ai gr. xxiv.
Ft. massK et divide in pillulx No. xxiv. M.
Sig. One every other night.

Lemaire-Picquot, and Bartholowboth speak highly
of arsenic in congestive headache. The. former was
the first to suggest its use in those cases where the
signs of atheromatous change were visible, and when
there was drowsiness and other symptoms dependent
upon loaded vessels.

The use of small, repeated doses of calomel, say
one-half grain nightly, relieves hepatic congestion,
and if it is followed up by Sprudel salts in the morn-
ing its efficacy will be much increased.

Some patients of this class do well on the saline
waters, Hunyadi Janos, or Mattoni.

For the relief of the headaches themselves a
variety of remedies have been suggested. Ergot
and the bromides rank high as cerebral anie-
miants. These two remedies should not be given
together under any circumstances. The aqueous ex-
tract is preferable to any other form of ergot, and does

not derange the digestion. An active and convenient
preparation is the ergotin of Bonjean, but it is more
expensive than the American aqueous extract and no
more efficacious.

The combination of aconite with other remedies
of this class is advisable, provided there be no decided
cardiac disease, and I have used the following with
success:

Q Sodii bTomidi,,

Ammpn. bromidi., aa 3 ss.
Chloral, hydralis, ; ii.
Tr. aconili rad., 3 Us.
Aqua menth. pip., ad | iv,
M,

Slg. A leaspoonfu! iwiee daily, or ofleoer if required.
Some congestive headaches in elderly people are
probably in great part meningeal, and ergot under
such circumstances is to be at once tried. Its action
is prompt, and I have never seen anything worse than
gastric derangement in consequence of its extended

In congestive meningeal headaches, and these
W'aie often exhibited by great muscular restlessness men-
tal confusion, injection of the eyeballs, belladonna is
a valuable remedy. The following prescription is
worthy of an extended tria! :
Q Tr. Belladunnie. 3 ii.
PoLass. iodidi, 3 vi.
Aquaanisi, Jiv.
M.
Sig. One leaspoonful in a wineglassful of Vichy water

The doaes should be increased lis tolerance is
established.

Dr. VVra. C. Glasgow, * of St. Louis, has called
attention to a very ingenious system of treatment
which is of service in congestive headaches of a fami-
liar kind, viz: the abstraction of blood by pricking the
cavernous bodies and relief of the constriction. Dr.
Glasgow speaks of his experience as follows: "The dis-
turbing cause (vascular distension) is seen in the
frontal headache brow-ache, or so called catarrhal
headache radiating from the root of the nose; it may
be limited to the forehead; it may be felt as a dull,
throbbing pain in the temples; it may give rise to in-
tense dull ocular pain, or, extending over the head, it
may be felt in the occipital region occuring frequently
from cold or exposure. We also find it often con-
joined with certain vaso-motor disturbances of the
mucous membrane. It is frequent at the menstrual
epoch, coincident with the turgescence of the cavern-
ous bodies and is the cause of many of the so-called
nervous headaches, or uterine headaches with which a
similar condition of the cavernous body will he found.
If we examine the nasal chamber during the attack of
congestive headache, we shall find the cavernous
bodies in a state of tension; they may not be greatly
swollen or enlarged, but to the eye the condition of
the raucous membrane is that of tension and fulness.

•N. Y. New Jour.. Sept. 3, il

The degree of tension corresponds in measure witli
the sevKity of the headache.

" A few years ago 1 treated those cases with hot
aikahne sprays, gently applied, and the use of hot
fomentations combined with the use of the usual con-
stitutional remedies. This mode of treatment has not
been altogether satisfactory and during the past four
years I have substituted for it the local abstraction of
blood, for which I can allege unqualified success.

A simple bleeding may relieve the headache, or it
may have to be repeated in a day, a week, or a month,
I have seen but four cases which were not perma-
nently relieved by a bleeding repeated from two to six
times. • * * To produce the bleeding
no cut is required, the cavernous body is simply
pinched and the blood flows freely until the tension
has been reduced; then it ceases. The amount of
blood drawn rarely exceeds one ounce. In many
cases it is less than this, and in many cases a single
drachm of blood removed will give the required relief.
In cases of extreme congestion the flow will equal
several ounces before it ceases. The quantity of
blood being dependent upon the distention of theves-
sels and this corresponds with the severity of the
symptoms."

One of the most common forms of headache is
that knoi^n as migraine, and two varieties are recog-
nized with reference to the pathological states which

give it origin. The form that now interests us is the
angio'parelic. It is a clearly nervous headache, and
one of a sympathetic nature. The subjects of such
headache are usually those who inherit some neurotic
tendency, and I have known of several generations of
the same family who have been victims. Not infre-
quently is it associated with epilepsy, and if we go
back into the family history we may find a history of
phthisis, insanity or various disorders of the pulmon-
ary or nervous systems. A large portion of the cases
are women, and it seems to bear some relation to the
menstrual periods, being worse with dysmenorrhrea,
and often ceases, even in bad cases, with the arrival of
the menopause. It is a unilateral headache affecting
more often the left side of the head than the right,
and is more or less sudden in its development, so far
as the attack is concerned. The patient may feel a
sense of malaise or languor and a chilliness and
drowsiness, and shortly afterwards a smart twinge of
supra-orbital pain. Others follow, and the face, which
was perhaps pallid, becomes red and congested. The
pain may invade one side of the head alone for a
time, but eventually involves the whole head
so that both sides are affected. The pain is
intense when established; throbbing, burning and
insupportable. The eyes are bright and suf-
fused, the bodily temperature is sometimes elevated,
and the patient is restless and excited. Darkness re-
lieves to some extent the photophobia, and the most

^Tand quiet spot is sought. Every noise in-
tensifies the patient's sufferings, and the jar of a pass-
ing wagon, or a noisily closed door disturbs him.
After a variable period of suffering, the continuity of
the pain is broken or it again becomes paroxysmal, or
muttering, like the thunder at the end of a storm. At
this time nausea may occur, and the patient more or
less successfully empties his stomach. It is a mistake
to suppose that this symptom indicates that the di-
destive organs are necessarily at fault. Though such
headaches have been called "sick headaches" they
are not as a matter of course due to the condition of
the stomach, and it is probable that this symptom
originates from an irritation of the pneumogastric.
The headaches often bear oo relation to the state of
digestion— they come after or before a meal or when
digestion is most perfect. There is a tendency in
migraine to chronicity, and attacks may occur daily.
The pathological state is an unequal paresis of the
muscular fibres of the vessel coats and the repeated
attacks lead to a varicose condition, and possibly to
miliary aneurisms.

In the treatment of this form of congestive head-
ache two indications present themselves: i. The
improvement of the genera! system, z. The rehef
of the attack itself. The migrainous patient is often an
ansmic individual, and the ansmia is of that kind
which is the most troublesome. There is often a dis-
position to make fat, and a tax upon the

J

22

tern, which directs the function of the s)rmpathetic
nervous system into other directions. There is a vast
amount of useless tissue that demands blood that is
needed elsewhere and the balance of vascular tension
is constantly interrupted — one moment the brain
is anaemic, the next congested. The cerebral vaso-
motor nerves lose their tonus and a condition of un-
equal angio-paresis occurs. Such patients need iron
and digitalis, tri-nitrine or strophanthus.

In the relief of the headaches themselves we may
resort to diffusible stimulants, and I have for many
years resorted to the treatment, which consists in the
administration of large and repeated doses of the
muriate of ammonia — 20-grain powders should be pre-
pared and these should be given in a large quantity of
water every hour until the headache is broken up.
Some patients are relieved by repeated large draughts
of green tea, or black coffee. Effervescing draughts
of bromo-caffeine act in much the same way.

Bearing in mind the irritability of the brain in
such cases and the existence of the headaches as a re-
lation to epilepsy — it may be well to resort to the bro-
mides. The use of this class of drugs should be con-
tinuous and without relation to the actual occurrence
of attacks. Large doses may be given thrice daily,
and do more good than their irregular administration;
or, if the attacks are periodical, with reference to the
time of the seizures. Chloral hydrate may be com-
bined with the bromides but care must be taken not to
form the habits of cMoralism,

— 23 —

I( Sodii bromidi, § iss.

Chloral, hydratis, 3 vi.

Aquae anisi, J iv.
M. Sig. — One teaspoonful in water morning ard night.

The vascular tonus should be improved, and ar-
senic either in combination with strychnine or quinia
is apt to help the patient and destroy the migrainous
habit. This is Routh's * formula which is also excel-
lent in malarial headaches.

I^ Quinia disulph., § ss.
Acidi Arseniosi, gr. i.
Acidi nitrici dil., 3 i.
Aquae purae, ad 3 i.

M. Sig. — Gtts XXX in a wineglassful of water after eating.

Elderly women at the time of the menopause are
often affected with a peculiar congestive headache
which seems to be connected in some way with the
"flashes," which are so often the subject of complaint.
The pain is often vertical and throbbing, and in some
individuals is attended by very great depression of
spirits.

Such headaches are relieved by agents which
quiet pelvic irritability. Warm douches repeated twice
or thrice daily are of benefit, and I have been in the
habit of administering large doses of dilute hydro-
bromic acid or Fothergill's solution, which is made by^
the addition of tartaric acid to a solution of bromide

* Day on Headaches.

— a4 —

of potash. This should be well diluted, and from half
an ounce to an ounce is sometimes required to bring
relief. The use of the mustard foot bath, brisk ex-
ercise and massage are often necessary as adjuvants.
These headaches are often helped by the compound
spirits of ether.

Sexualexcitementof a protracted kind without gra-
tification, or what Fox calls "mental onanism," is apt
to result in a variety of headache of a sympathetic
nature and with all the evidences of congestion. The
head pain is short lived, closely follows the cause,
and is easily relieved by rest and quiet, and a large
dose of any one of the bromides. I have often met
with this variety in patients suffering from incipient
insanity of the masturbatic type. Such young people
are apt to present rather lively emotional excitement,
and to be boastful and conceited at times. The pain
is frontal, and accompanied by a sense of supraorbital
pressure.

Spinal douches consisting either of a jet of cold
water or sponging tend to arouse the dormant viscera
and equalize the distribution of blood. Warm foot
baths are of course excellent auxiliaries to other
remedies in the acute attack. Turkish and Russian
baths though admirable remedial agents are danger-
ous and should be used with the greatest caution. I
have known of several deaths as a result of their in-
judicious use, and if there is the least suspicion of
atheromatous degeneration or cardiac disease they
should be forbidden.

— 25 —

""As to miaeral baths and water, there is much to
be said which is, however, found in special works
upon baleonology. The Canadian and American
springs best suited for the treatment of cerebral con-
gestion, notably the passive variety, are those at
St. Leon near Quebec; Caledonia near Ottawa; St.
Catherines; Richfield; Sharon and Saratoga in New
Vork State; Buffalo Lithia Springs, Virginia; the
Berkeley Springs, and the Red Sulphur Springs, Va.;
Spring Lake Well, Ottawa Co., Mich.; the Wisconsin
; 'Springs (Waukesha, etc.). The foreign springs which
' are especially serviceable are: Vals and Vichy,
(Grande Grille) France; Salzbrun, Freiburg, Horn-
bourg, Carlsbad, A\x la Chapelle, Baden Baden;
Friedrichshal!. Kissengen, Marienbad. Seidlitz and
Adelheidsquelle, Germany, and Leamington and Chel-
, tenham in England. There are many others, but this
list I think is sufficient.

In congestive headache, especially passive, do I ad-

f vise the use of saline purgative waters and baths. It

I is better to give some of the stronger German or

(.'Hungarian waters than to allow the patient to _fius/i

himself with the milder aperients — Congress water

I and the like, and those which should be used in great

..moderation. The waters of Carlsbad or its evapor-

|.'ated salt, which is now for sale, while not so good as

Hunyadi or Rubinat, are excellent alteratives. Puilna

I irater heated or cold is especially beneficial in those

I headaches where there is much venous turgesence of

the face.

— a6 —

The constant use of baths and douches of well
regulated temperature is all important. A cold bath
of brief duration for the purpose of stimulating the
surface capillaries is a prime necessity. Better than
the immersion of the whole body is the use of the
douche or needle bath. In the absence of elaborate
apparatus we may employ the ordinary "rose spray"
and a rubber tube fitted to the cold water cock. Fig.
I is an elaborate needle bath made by John Sim-
mons, no Centre St., New York, which is perhaps
better suited to hospitals than private houses. At a
small expense, however, a practicable needle bath may
be constructed and its therapeutical advantages will
fully warrant a moderate outlay.

The diet of the patient who suffers from these
headaches should be simple, and as a rule, consist of
a reduced quantity of the hydro-carbons. It is amis-
take to err in going to the extreme of entirely abolish-
ing, as is too often the custom, certain articles which
are not positively. injurious. It should be our aim to re-
duce the labor of the digestive organs, and. therefore,
it is better to give small quantities of well digested
food frequently, than large quantities at long inter-
vals. Lean meat, poultry, game, fish, eggs, the green
vegetables, and stale bread, agree with persons sub-
ject to congestive headache, as a rule, better th^n
articles of diet containing much starch or fat. Veal
and pork and the watery or aromatic vegetables are
to be dispensed with, as are all substance which are

slow of digestion. Tea and coffee are not as harmful
articles as they are generally supposed to be, though
of course in some instances they must be rigorously
excluded.

Alcohol in some cases of congestive headache is
absolutely necessary, though of course in others it is
directly contraindicated. The passive hyperEemic
headaches are certainly benefitted, and if the stimu-
lant selected is a proper one, I can see every reason
why it should be allowed. Brandy, Rum, Burgundy,
Champagne, Port and Sherry wine, malt beverages
and the liqueurs, are harmful under all circumstances,
but light wines and whiskey or gin in regulated quan-
tities, in angio-paretic conditions do much to improve
the vascular tonus. In the headaches of middle or
old age, they are nearly always of great service.

There are many palliatives which may be resort-
ed to for the external relief of congestive headaches.
Cold applied to the nucha, or to the top of the head
by means of ice-bags; cold douches and ether spray to
the temples are useful.

Benham in an excellent article (West Riding Re-
ports, vol. iv, p. 152,) refers to the mechanism of cold
as follows: " It may be that the decreased tempera-
ture and consequent lessened nerve sensibility pro-
duced by the cold upon the exnemities of the sensory
nerves, are shared in somewhat by the centres under
the cranium, from which they spring; and thus it may
be that that portion of the sensorium to which the irrl-

""ration on the nerve peripheries in the stomach or else-
where — causing headache — is conveyed, shares in the
dinainished sensibilityof those centres, and is therefore
less capable of receiving impressions as vividly as be-
fore; the sensation of pain felt by the patient being;
consequently much lessened. When we consider the
proximity of the central tracts of the fifth, and the
pneumogastric branch of the eighth pairs of nerves, it
seems probable that cold applied to those peripheries
of the fifth distributed over the forehead should pro-
duce such an effect in parts in close proximity to the
origin of the pneumogastric as to be capable of some-
what modifying the impression in the course of its
transmission to the sensorium from the peripheries of
that nerve irritated by a disordered stomach." It
should be born in mind that in some cases of con-
gestive headache the headaches are increased instead
of benefitted by a too extensive application or a too
intense degree of cold.

I have been in the habit lately of using pressure by
means of compressed sponges. These may be had of
most apothecaries and are about one-half inch thick
when dried. One sponge is to b'e applied over either
temple, and both are held in place by a bandage
passed several times around the head and (irmly
fastened. When this is secured, water may be applied,
and when the sponges e.vpand, steady and even pres-
sure is made upon the temporal vessels. Many con-
gestive headaches are simply due to hyperemia of the

— 32 —

the victims of cerebral congestion, or headaches due
to such a pathological condition; and mountainous
districts are to be avoided as places of prolonged
residence.

CHAPTER n.

AN/EMIC HEADACHES-

Cerebral anaemia is far more common anuing
women than men, and in a very large number of
instances is a feature of the depressed condition of the
nervous system dependent upon loss of b!ood, ani
Uterine disorder. In others, it is due to loss of bloo4
from hemorrhoidal fluxes, general malnutrition, an<l
debilitating causes of many kinds. It is confined to n» '
age, but is usually most pronounced in women during
the catamenial years.

The ansemic headache is rarely continuous, though
in some individuals, it exists in a dull unpronounced
form with occasional exacerbations of decided pain.
It is accompained by a sense of very great vertical
pressure and throbbing. At limes it is associated with
neuralgia of the fifth nerve. The patient is pallid, has
enlarged pupils, a small weak pulse, pale lips and
buccal mucous membrane. The tongue is apt to be
indented, furred and pale. Digestion i.s weak, and
palpitation common. An aortic murmur is oftea
heard, the sphygmographic tracing is almost straight;
and the number of red corpuscles is greatiy reduced.

Cold clammy hands and feet, phosphaticor limpid
urine, great muscular fatigue, and insomnia are char-
acteristic. In many individual.a there is decided ten-

— 34 —
derness of the spinous processes and the vertebra
promineiis is especially tender.

In some women these headaches occur with great
mental depression just after the menstrual period, and
this is especially the case where there is menorrhagia.
They often recur daily, and in patients under treat-
ment, where iron is given, and the uterine condition
not improved, it will be found that just before the
menstrual period, and when some recuperation has
taken place, that there is a marked diminution in the
character and severity of the attacks, with subsequent
* relapse however.

The anxmic headache is more pronounced in the
early part of the day. In fact the patient commonly
awakens with some nausea and head distress. This
may often be abated by a cup of hot strong tea, or
ammonia in some form.

Fothergill, in writing of antemic headache, says
in one of his early contributions: "The pain is dull,
persistent and unvarying, and the sensation is not un-
commonly as if the skull was opening, or the upper
halfof the calvarium was being lifted off. Chronic head-
ache in conditions of cerebral ansmia is usually, or at
least often, vertical; while frontal headache is rather
associated with passing conditions of exhaustion from
sustained intellectual labor. The why of this will be
seen presently.

Vertical headache is most distinctly associated
with anajmic conditions of asthenic gouty states, and

— 35 —

is often of much diagnostic value, often, also, point-
ing very clearly the direction which our therapeutic
measures must take if we wish them to be successful.
At other times headache, often vertical, sometimes
frontal, is found along with those ansemic states when
the patient complains chiefly of "low spirits," simple
states of mental depression and unhappiness, from a
defective blood supply to the encephalon."

The bromides and chloral are useless and
aggravating remedies in such forms of headache and
should never be given. In some cases of anfemic
headache when the seizure is unilateral, in fact when
we have an angino-spastic migraine, the use of
bromide is indicated, but only then. I much prefer
cannabis indica which may be given in pill form in
increasing doses, commencing with one-eighth of a
grain of the extract, and increasing until mild toxic
effects are reached. When such- headaches occur
about the menstrual period a mixture of the bromide
and cannabis indica is an excellent one.

5 Amiooo. bromidi, J i.

Tr. cannabis ind.. 3 vi,

Mucilag. BCacis, 1 iv.

Ess, mcnth. pip., 3 ii.

M. Sig. — One teaspoonfu] thrice daily in water.

The bromide of ammonium seems to exercise a
special influence on the uterine functions, and in cases
of disturbed sympathetic regulation a

_ 36 -

which are common accompaniments, the relief af-
forded by the above combination is very considerable.
Sometimes it is admirable to combine the canna-
bis indica with a hyperemiant. I have foimd the fol-
lowing useful:

S Esl. cannabis indica, gr. vi.
Ferri ammon. cilras, gr. Klviii.
Fl massK el divid in pillula! No. xxiv,
M. Sig.— One thrice daily.

It is of the greatest importance that the disturb-
ance that leads to the uterine hemorrhage should be
found and remedied. In cases of simple relaxation,
when there is no organic difficulty, the use of gallic
acid, or hot syringing has done good in many cases.
In some of my patients a lacerated cervix, intra-uter-
ine polypi, or fibrous tumors have been at the root of
their ansemic headaches.

I have lately seen a number of cases of amemic
headache where the cause was found to be the loss of
blood from some unsuspected source. Two or three
of these had hemorrhages from the rectum as the re-
sult of hemorrhoids; one had attacks of expistaxis;
and I discovered the, cause of an almost constant
headache in a person who had lived in the tropics, to
be hiematuria which was the result of malarial dis-
turbances and iilaria. A lady sent to me by Dr. P.
Bryson Delavan, of this city, had vertical anjemic
headaches of great severity, and bodily exhaustion
which' was at times alarming, and in this case

— 37 —

there existed hEemophiiia. Bleeding from the gums,
nose, dysenteric fluxes and menorrhagia, or rather
metrorrhagia were the causes of the drain. It is always
well in these cases to inquire as to the existence of
such possible troubles and remove them by appropri-
ate means. In the case of hemorrhoids of course
there is nothing effective but surgical procedures. In
the other cases our reliance must be upon astringent
remedies and hEemiants. Gallic acid alone, or with
the acetate of lead, astringent injections of various
kinds, and iron or arsenic are to be made use of.
Those who have described or seen much of such dis-
eases as progressive pernicious anaemia, or other con-
ditions in which the red corpuscles disappear, find that
arsenic is often superior to iron — a conclusion with
which I am inclined to agree. Such idiopathic dis-
orders as those of which I speak are undoubtedly
neurotic, and the value of arsenic is a matter of easy,
practical determination. When iron does good in such
cases I have found the alkaline or neutral preparations
better borne and assimilated than the others. The
older French writers placed great reliance upon the
carbonate, the peroxide and the mild salts generally,
and the Germans have given us the malate, which is
an easily digested and excellent preparation. The
albuminate,* or peptonate, may be selected when there

•In Ihe N, Y. Medical Record, Aug. 28, 1S84, I first
the value of the albuminate of iron in
hyslerical vomen. and those with idiosyncrasies

is much of the gastric feebleness which is pronounced
m so many bloodless women. I have combined the
albuminate of iron with the carbonate of soda in small
quaniiUes We must not lose sight of the fact that the
use of soda in large amounts, or of Vichy water, is
qmte apt to hamper our efforts at cure by blood im-
poverishment, and other alkaline mineral waters should
be forbidden as well.

With manganese as a substitute for iron, I have
had little or no experience, and such as I have had
is not encouraging.

During the past few months I have found that
the appropriation and conversion of iron in the sys-
tem is helped by the conjoint administration of some
substance rich in oxygen. Oxygen gas itself has been

who often declare ibeir unwfllmgness or inability to contiauc
Ihe iron even in mosL minute doses.

In 1S71 Diehi announced the discovery of the albumiaa.te
of iron, which after all is not a tnie salt.

Miahle has held that "the albuminate of the peroxide of
iron ia formed in the blood, and that Ibis is the basis of the
red globules," and il has been shown that the presence of an
alkali favors the catalytic change. Some iron salts are abso-
lutely inert as remedies, and pass unaltered from the body.
Among these are iheferroand ferricyanides of potassium, and
other double salts which are not precipitated by the alkalies.
The combination of iron and albumen ivilb an alkali seems to
be at once a measnre likely to be of value from a therapeutic
point of view, and so 1 have found it. The preparation I use
Is in lozenge form, each containing about twelve grains of the
albuminate o( iron.

— 39 —

used for this purpose for several years by many French
therapeutists and by Dr. A. H. Smith and others in
this country, and 1 have used nitrous oxide gas. If
the permanganate of potassium be given alternately
with any soluble preparation of iron it will immeasur-
ably increase the good effects of the latter, and if the
former be made up with coca butter it will produce no
gastric irritability or intolerance. Five grains of the
albuminate or ten grains of the sub-carbonate may be
taken after eating, and one-half to one grain of the
permanganate in a tablet before eating.

FothergiU advises the combination of arsenic,
sulphate of iron, nepaul pepper, and the pills of aloes
and myrrh.

In the headaches due to imperfect cerebral cir-
I culation and heart weakness, I place much reliance
I upon strychnia and drugs of its class. The following
s an excellent tonic:

H Stryeh. aulph., gr, ss.

Ferri Ft quin. citias, 3lvss. ,

Digitalis pulv,. gr, xsiv,
Ext. hyoscyamis. gr. xlviii.
M. Ft, masss et divid. in pill, no. xlviii. Sig.— One
sftcr each meal, to be increased.

Digitaline which has been' recommended bymany,

I am convinced, a dangerous and unreliable

f remedy, and occasionally produces collapse, or ob-

I stinate vomiting. I prefer the older preparations

provided they be fresh. In cases of chronic cerebral

- 40 -

lowered arterial tension I have used
, which is safe and not cumulative, la
s I have obtained aid from the foi-

st rophant hut
some recent c
lowing:

K Hrucia;. gr. i.

Tr. ferri chlor., 3 vi.
InfuB. digitalis, liv.
M. Sig.— One tcaspoonful in water after each nieHl.

When the ana;mic head aches are attended by varied
sj'niptoms of general nervousness, and fall under the
head of " neurasthenic," we find much benefit from
ihe phosphates and hypo phosphites. Day recommends
ihe combination of the hypophosphite of soda with a
bitter tonic. In combination with one of the cinchona
series, provided the dose of the latter be not too large
h is excellent. Quinia though physiologically indi-
cated, often aggravates an antemic headache when ad-
ministered in unsuitable quantities. The ansemic brain
is irritable, and as I have before said is liable to
hyperemias of rapid development.

A congestion is likely to occur from a dose of
quinine that in the ordinary individual would scarcely
be appreciated, and the ansemic headache may be re-
placed by another of a diiTerent type. I therefore
make use of very small'doses of the sulphate of qui-
nine or cinchona, or sometimes prescribe Huxhams'
tincture. Some of us wonder why many of the pro-
prietary combinations of iron, quinine and strychnia
either do no good, or else aggravate the patient's

— 41 —

sufferings, but it is not surprising that an arbitrary pro-
portion of component parts will not suit every case.
The physician should use his own judgment more
often than he does in dosage. " Ready mixed " medi-
cines are apt to be convenient to the busy man, but
unreliable.

In cases of ansemic headache with depression, the
administration of opium in combination with iron and
phosphorus, is likely to do good, but on no ac-
count should the patient be told what remedy is given
f him.

B Phospbori, gr. i.

Opii putv., gr. KX,

Ext. belladonna, gr. v.

Ferri redacli, 9iv.

Fi massie el divid in pillulx No. xl.

M. Sig.— One morning and night.

For the

I. acid and quinine.

ief of the same complication we may
1 combination with dilute phosphoric

Tr. ferri chlor.

Acidi phasphorici dll , * i,
Syr. surunlii flor.. j iv.
M. Sig. — One teaspoon/u] ihrice daily in water.
When there is constipation, a state very common
in cerebral ansemia, and attendant mental depression;
it is important to clear the lower howel, and aloes
or its derivative aloin is indicated.

The following will do for occasional use:
Q Slrych. sulpb., gi. i,

Ext. belladonnEE, gr. viii.

But. fel. bovis Jiii.
Divid in capjuls. No. Ix.
M. S[g. — One or tivo every oihernighL or when needed

f

^H Saline purgatives are not suited to anemic pa-

^H tients, nor are alteratives such as iodine or its com-

^H pounds, with the exception of the iodide of iron.

^H In cases where there is much insomnia and de-

^H pression, opium may be given with some mixed cathar-

^H tic, and Day's formula is a good o.ie:

^H Q Ext. opii

^L Pu[v. rhei, afi gr. i.

^^I^^H Pil colocynlh co., gr. iss,

^^^^^1 M, Sig.— Ala dose at

l^^^^^f I have found paraldehyde to be well borne and

free from disagreeable after-effects. It is best given
in capsules and each soluble capsule should contain
ten minims. IIH 30 — ^nj; 60, repeated if necessary, will
usually secure sleep. It does not seem to have any
analgesic effect.*

The elixir of absinthe is an excellent menstruum
in the tonic prescription. I have used it as well as the

• In large doses it is sometimes excreted in great part by
Ihe ajtillary sweat glands and, as the odor is far from sweet,
the result is often embarrassing lo the patieni.

L

elixir chartreuse, and am sure it has helped many
anasmic women, with headache due to depleted brains,
and both are of service when there is an antipathy
which is often purely notional, against wine.
? Fcrri. iodidi., gr. xxxii.

Tr. stranionii, I iii.

Elixir absinthii., | ii.

Syrups simplicis, ad. ^ Jv.

□ teaspooDsful in water after meals.

9 Fcrri. et potass, tartras., J vi.

Aquas bull., q. s. to dissolve.

Tr. belladonna:, 3 iiss.

Elixir chartreuse viridi., ad ^ xii.
Sig. — One to two leaspoonsfui every four hours in water.

5 Ferri. et cinchonidiffi cilras.. 3iss.
Fl. Ext. gossypii. radicii. corticis., Ji.
Elixir chartreuse viridi.. Jiv.

Sig. — One lo two teaspoonsful in water every four hours.
The above is of benefit when the anemic head-
l^hes are due to some uterine drain and relaxed
HiDscular fibre.

Diseases or defects in the apparatus of respiration

Old which interfere with the proper oxygenation of the

ffilood are quite apt to induce anaemia and chlorosis,

*hich may lie at the foundation of headaches of a

Ptonstant and distressing nature. Any obstruction of

■the upper air passages is prone to interfere with the

free admission of air to the lungs; and this difficulty
may consist in the enlargement of the tonsils, or de-
pend upon various diseases of the nasal fossa. Hy-
pertrophied turbinated bones and polypi have been
found by Curtis and others to account for persist-
ent headaches among their patients, and the use of the
nasal trephine has worked wonders in cases that have
resisted drugs. I have myself cured many headaches
by the removal or reduction of enlarged tonsils in'
children, and in two cases epileptic paroxysms have '
ceased to recur after this operation. If the patient is
disinclined to permit surgical measures, it will be
found that the careful application of chromic acid will
cause a cicatricial reduction of the glands.

In some asthmatic individuals or sufferers from
chronic capillary bronchitis or emphysema, such head-
aches are by no means an uncommon result of defect-
ive oxygenation. Belladonna or its alkaloid may be
made use of with confidence, for they act well in most
cases.

Aged people of spare build and gouty habit are
apt to suffer from anaemic headaches, the explanation
of which is probably gouty spasm of the vessels, and a
h mi ted anemia. The headaches are often accom-
panied by insomnia, and by weakened digestion. In
such cases much can be done with the diffusible
stimulants, and Hoffman's anodyne agrees well when
given alone, or with ammonia. The moderate use of
alcohol by such patients is in every way advantageous,

— 45 —
and 1 prefer for them either a good rye or Scotch
whiskey taken at meals, or a very dry champagne.
Horseback or tricycle exercise is to be counselled, es-
pecially when the person is performing intellectual
labor. Many such persons live upon farinaceous, and
so-called health foods of a cereal nature, which under
the circumstances are about as injurious as can be
imagined. Oatmeal is no exception and its use should
be forbidden. Fats are also bad.

The genera! treatment of these persons should be
supporting. Phosphorous is contraindicated but not
arsenic. The use of soda in combination with the
bitter tonics is apt to do good in improving the weak
digestion that usually accompanies the condition and
the old formula so familiar to most practitioners of the
bicarbonate of soda and tincture of gentian, and the
syrup of rhubarb with perhaps a few grains of the car-
bonate of ammonia will often prove to be of great

There is an alarming form of headaches which
k anxmic children sometimes present, and the appre-
hension consists in the fact that it is symptomatic of a
grave disorder which is ultimatively fatal. I allude to
Ihe formation of the hydrencephaloid condition of
Marshall Hall; or the deposition of adventitious sub-
stance in the brain. Distention of the perivascular
spaces characterizes one of these, and the pressure of
a tuberculous mass may produce anremia, both of
which result in severe and constant headache. If

_ 46 -
vomiting be present with such head pain, and the
child becomes listleness and stupid, a very grave out-
loolc may be taken. Decided and prompt alterative
measures are imperative. Cod-liver oil, phosphorous,
feeding, and possibly the iodide of potassium with bel-
ladonna are indicated, and if the child be at school it
should promptly be removed and sent into the country.

Sinkler • has called attention to the occurrence of
migraine which he believes is more common among
children than is generally suppposed. His conclusion
that it may begin at the eighth or ninth year, must be
accepted by those who see much of children's head-
aches. He goes further by stating that the form of
the disease being thus early, is apt to disappear at full
development fi. e. adult life). 1 cannot agree with
him in this so far as girls are concerned.

Sinkler insists upon the use of fatty food — cod-
liver oil, cream or butter — the exhibition of bromide
in small quantities, the correction of possibly existing
ocular defects, and " in all cases of migraine we should
look carefully into the condition of the teeth, and
have unsound ones filled or removed."

Two new remedies have been suggested for the
cure of headaches — antipjrine and acetanilid, or anti-
febrine.

In January, 1887, Ungar related his experience
with antipyrine in the treatment of hemic ran ia, and in

• Medical News. Ocl. ag, 1887.

— 47 —
March Ur. C. B. Lyman, who had been induced to
try the remedy after the publication of Ungar's suc-
cess, administered it in several cases of neuralgia of
the cervical, facial, and supra-orbital or mixed varie-
ties, with more or less benefit. The first of these
observers CKperimented with it as a successor to the
salicylates, which had proved to be of great value in
his hands in several varieties of headache, and he wit-
nessed no evil results from doses of even 23 grains.
Lyman used an initial dose of 15 grains, repeated
two or three times if necessary, and relieved the par-
oxysms, but did not prevent their recurrence. In
March last* I began a trial of this drug, and after-
I ward its successor, antifebrine, in a variety of head-
laches, in insomnia, and in epilepsy. Some of these
f cases had been treated with more or less success with
the salicylate of sodium, and the usual remedies, and
the cases of epilepsy were under modified bromide or
other treatment. The cases of headache selected were
I those of migraine of the an geio -spastic and angeio-
Iparetic varieties, as well as ordinary facial or sub-
l.occipital neuralgias; and the cases of epilepsy which
I were chosen were those of the symptomatic form com-

■ plicated with objective and subjective indications of
I cerebral disease, as well as the simpler forms which

■ seemed to be dependent upon continued states of
f cerebral ischcemia, cerebral instability, etc.

In angeio-spaslic migraine with evidences of
N. Y. Med. Jour.. May aS, iSS?.

- 48-

cutaneous ar^mia, dilated pupils, and coldness, the
headache commencing In the morning, I found thai
both antipyrine and antifebrine would quickly abort
the paroxysms after the first dose.

Miss. T. had taken salicylate of sodium in doses
of gr. XXX repeated once or twice, with variable relief,
Cannabis indica and the chloride of ammonium failed
to do good. Her headaches were connected with sex-
ual irritation and excitement; She was very anfemic
and hysterical. One powder of fifteen grains of anti-
pyrine relieved the pain in less than an hour. The
repetition of a daily dose in the morning completely
suspended the headaches for a period of two weeks
during which the patient was under observation. She
was put upon a course of iron, which she took mean-
while.

Mrs. R. suffered from vague headaches, a sense
of vertical pressure, and general anaemia which was
largely due to frequent uterine hemorrhages. After
the catamenia, and during the first half of the month
she had attacks of angeio-spastic migraine. Five
grains of antifebrine produced tinnitus, but relieved
the headache. This patient subsequently obtained
slight relief from cannabis indica.

I have used these drugs in a large number of cases
and have given as much as 45 grain.s of the antipyrine
in two. hours, a comparatively short space of time.
Antifebrine is the safest, and though one case is
reported where large quantities produced a variety

— 49 —

of disagreeable symptoms, I can only say from my
own experience that I have never seen an)rthing but
temporary unpleasant consequences. Antipyrin may
be administered hypodermically in doses of eight or
ten grains in an equal quantity of water. S^e/ who
has used it, believes it to be superior to morphine, and
it has none of the disadvantages of the latter. Of tne
local analgesic properties when used in this way I will
say more when we copae to the discussion of neuralgia.
Dujardin-Beaumetz recommends ethroxy-caifeine,
a new drug, but it should be used with the greatest
caution for it is dangerous and unreliable.

9 Ethroxycafifeine, gr. xii,
Sodii salicylat, gr. xv,
Aquae de^ill., 3 iiss,

Sig.r-From five to ten teaspoonsful as indicated.

Of othe'r comparatiuely untried new preparations
of this series, I will not speak.

Iodoform is an excellent remedy in some cases of
intractable anaemic headache in strumous subjects and
may be given in repeated doses alone, or with iron.

The citrate of caffeine is of value in anaemic
headaches, but should be given in much ' larger
doses thlan are generally prescribed — it rarely has
much effect in less than five grain doses. Various
effervescing salts such as the " bromo-caffeine " or
the effervescing citrate of caffeine taken when the

' Les Nouveaux Rem^des, Dec. 8 i886.
5 «

— so —

headache first appears will often arrest it. I have
obtained good results from a distillate of coffee
made by Mr, Angelo, of this city, at my suggestion,
and use it in half dram and dram doses, well diluted.

I have lately used salol — another coal tar pro-
duct — in several cases with good effect. The dose is
five grains, to be repeated. Antipyrine is quite sol-
uble in water, but antifebrine sparingly so.

Germain S^e recommends that these drugs be
given in ice water which counteracts their depress-
ing effects on the digestive organs.

Betol or naphthalo!, which was introduced by
Neushe of Bern, is useful not only in anfemic head-
aches but those of a neuralgic character.

Moxon recommends morphine in headaches with
extreme prostration and sickness, when the extremi-
ties are cold and the pulse is feeble and the patient
has been days without getting relief. In such cases
one-sixth grain of morphine with the addition of -^
grain of atropine are injected hypodermically at reg-
ular intervals.

Some years ago, at the suggestion of Dr. John E.
Blake, I administered nitrous oxide to anjemic patients
as an hypnotic, and incidentally found that its value
was very great when anaemic headaches existed. The
ordinary apparatus used by dentists was that tried,
and I turned the valve so that air was admitted in
varying proportions. I have within the past ten years
used the nitrous oxide treatment in hundreds of

— S' —

cases — many being those in which headache was a
feature. My conclusions as I have elsewhere said
are that rot only is the assimilation of iron very much
Increased when gas is administered but the in-
tegrity of the cerebral capillaries is brought to a
much higher standard. The clinical results are the
improvement in sleep, a gain in weight and color; and
the subsidence of headache. The gas should not be
given to the point of insensibility — or great vertigo —
but as soon as any tingling of the lips or tongue
is produced, its use should be discontinued for a few
minutes. Four gallons of mixed gas and air should
be given daily.

Certain drugs which rapidly congest the cerebral
blood vessels are of service, . Among these as im-
mediate remedial agents I may mention nitrite of
amyl (which by the way is not an entirely safe remedy),
I and trinitrine or nitro-glycerin. The first named may
I be used at the commencement of an attack, or inhaled
in small quantities several times daily. The latter
. may be given in tablet form or in liquid combination
^ irith iron.

The patient should be made to seek a recumbent
l-po5ture so that the head shall be to some degree
I lower than the rest of the body, and he should lie in this
I way several hours daily.

The diet of all patients with headache of anemic
I origin should be of the most nutritious kind and
P largely nitrogenous. As the digestion is weak the

food should be selected with great care, and given
frequently. Milk peptonized or skimmed, the beef
peptonoids. Koumyss (that with the true Russian
ferment the Cranmoor being the best), or Matzoon
which are easily digested milk preparations; butter-milk
which is serviceable in the gouty cases; eggs, beef juice
or raw meat should form the staple diet, while articles
which simpJy satisfy hunger or stimulate the appetite
should be given only when the patient has recovered
his power of assimilation. The good effects of con-
densed food are most conspicuous when enforced rest
is obtained. The so-called "rest treatment," is often
a misnomer. It may be so purely an arbitrary and
ill-suited therapeutical measure as to do more harm
than good. Not only is the patient's bad physical
condition aggravated, but many a woman is made
hypochondriacal or worse. The term has covered a
multitude of blunders. Like everything extreme, it is
powerful for good or evil, and should never be re-
sorted to, except with a due consideration of the pa-
tient's exact state, and what is to be accomplished.
It does not do to put any or every woman to bed, as
has been the fashon of past years, for no two cases
can be managed in exactly the same way, and one
woman will grow nervous and more miserable under
the compulsory "rest " that may cure another. The
real end in view should be the prescription of rest
that will prevent the expenditure of nervous force in
muscular movements, from exceeding the production

— 53 —
I energy and food assimilation. Nothing more or
less. This means watchfulness and care, a good
nurse, sometimes removal from home when the patient
is unreasonable, hysterical or fanciful; regularity in
eating, passive movements and massage when needed,
slcin stimulation by spongings of dilute alcohol; or
faradization when the woman tires easily. One of the
greatest benefits of massage is the exercise it affords,
without the use of volition, and when the effort of
volition is tiresome, the tone of the muscle is im-
proved by the exercise effected by another!

Genera! faradization by means of broad sponge-
covered electrodes, and mild currents passed generally
over the body are beneficial. In persons with weak
digestion, galvanization of the sympathetic is advan-
tageous.

In many cases anemic headaches are connected
with gastric derangements which need treatment.
Bismuth, the bitter tonics— calumbo being the easiest
of digestion — quassia and the peptonoids should be
used as occasion requires. The capacity of some
women to make blood is so poor that nothing can be
done for their headaches until their digestive power
and assimilation are strengthened, and it does little
good to give iron or specific drugs while no gain is
being made in other directions.

In very extreme cases — the method of rectal injec-
tions of fresh blood — dried blood, or beef juice made
.in suppositories with gelatin may be necessary. These

— 54 —

headaches often exist in women who have hysterica(
vomiting, when besides moral treatnjent some such
means as those just suggested are in order.

The mineral springs, which best suit the subjects
of chronic anaemic headaches, are of course those of
a chalybeate nature. The Rockbridge a.lum and
Sweet Springs of Virginia, Columbian Spring of Sara-
toga and Sharon are all within reach in this country;
and those at Bournemouth, Tunbridge and Hast-
ings Wells of England, Spa of Belgium, St. Moritz,
Switzerland, Schwalbach, Pyrmont, Alexis-Brunnen
are the best known in. Europe.

Most of the foreign and domestic iron waters as
well as the arsenuiretted waters are bottled and may
be had without trouble.

CHAPTER III.

ORGANIC HEADACHES-

Nothnagei,* one of the most practical of all Ger-
man writers, is not disposed to attach much import-
ance to the significance of headache as a diagnostic
aign in organic brain disease; he even goes so far as
to say that in chronic cerebral aniemia he doubts if
headache is actually due to the chlorosis (sic) or the
antemia itself, for the intense and pernicious anaemia
which is produced by carcinoma is rarely expressed by
headache. It cannot be denied, however, that the
constant existence of localized pain, or of pain asso-
ciated with other symptoms, is suggestive of mischief
within the cranium, which is more or less grave, and
is to be taken out of the category of functional dis-
orders. The location of a constant pain often points
to cerebral abscess, and this is especially true when
this lesion is a result of aural disease.

The most familiar form of headache of the kind
of which I speak, is that associated with syphilis in
some of its stages. When we find a nocturnal head-
ache of very great intensity, it is usually of specific
origin.

" There is no description of headache," writes
Dowse, " and one might say, no kind of pain, which

•Wiener Med. Presse, No. 13, 1879,

■ equals in intensity that which results from a localized
hyperplasia of the dura mater."*

It is sometimes almost unbearable, and varies in
character. In cases where the bones of the skull are
involved it is diffused, and affects the entire scalp, is
deep and increased by contact, and in this respect some-
what resembles rheumatismal headache. The head-
aches of syphilis are also of a localized character, and
may in this respect resemble clavns. In old cases the
pain seems to disappear when the cerebral mass is in-
vaded, and the dura is not subjected to so much pres-
sure as in the beginning. It is not usually connected
with tibial pain. When it is a feature of syphilitic
epilepsy it, as a rule, precedes the paroxysm. In the
early stages of the disease it may be of a light char-
acter and both nocturnal and diurnai. Some authors
spe^k of a headache of a low grade with paroxysms of
great severity, and exacerbations which occur every few
weeks as the result of depressing causes. Dowse de-
scribes this form very graphically; " The pain is of a
different kind to that of the other forms of headache;
it is of a dull heavy aching character. It has no
central point from which it radiates. It is usually dif-
fused more or less over the whole of the forehead,
and gives to the patient a bang-dog look; often the
complaint is that the eyelids cannot be raised, they
feel so heavy; the whole of the vessels of one eyeball
'Syphilis o! [he Brain and Spinal Cord, Part i, p. M^

— 57 —
may be congested and not the other, or both may be
similarly affected." Temporary ptosis, squinting di-
plopia, vomiting, tinnitus, somnolence, slow speech,
monoplegise, and a variety of greater or less troubles
suggest syphilis. I have always been suspicious of
headaches with attendant stuporous symptoms or
vertigo.

Our therapeutical indications are simple, and one
can hardly go wrong, for the list of efficient drugs is
so small. My reliance is upon the Iodide of potassium,
but in large doses.'' I have cases under treatment at
present who are taking one hundred and twenty grains
thrice daily, or more than half an ounce in the twenty-
four hours, and this quantity alone keeps the disease
in check and the headaches absent. In most cases ii
is safe to begin with ten grains, three times daily, in
-water. A saturated solution is better dispensed than
■ any other, and more convenient, and the daily dose
can be at first increased one drop, then two, then five,
until the point of tolerance is reached. It does no
good to give large doses when coryza is produced
and saturation indicated, but the patient should be
kept on the border line. The iodide is best given in
alkaline solution, and I prefer Vichy water as a
vehicle. If this plan is followed the patient will not be

* Taylor says: "A fraclion of a grain of c
limate, or three to Rve grains of the potassium iodide, admin-
Isteied three times a day, will do no more good than would the
water In which Cbey are diasolved." P. 663.

n pillulte No. x

1 the early

annoyed by the unpleasant metallic taste or gastric
derangement. In persons who cannot tolerate iodide
this way, I have followed the advice of my friend, Dr.
Keyes, and administered it in milk. In some cases
mixed treatment may be employed after a course of
the iodide.

A pill of great service in anaemic cases of cerebral
syphilis is the following:

B Pill bydrarg. raassse,
Ferri sulph. c
Exi. hyoscyatnlK. s

M. Ft. masBx it divide ir

Sig. One Ibrice daily.

This combination is especially good i
headache of the disorder.

In these cases, and those more advanced, we may
hasten improvement by inunctions, either of the old-
fashioned blue ointment, or of the 20-per-cent. oleate
of mercury; mercurial baths are sometimes excellent.
Both ergot and opium give the patient much relief,
and particularly the latter. I have lately use anti-
pyrine and antifebrine with good effect. Much coai-
fort is derived in these and other headaches from the
use of cold applications to the head, and a convenient
and cleanly apparatus is the head-coil, made of India
rubber pipe. One end is attached to a vessel filled
with ice water, the other hangs over the side of the
bed and discharges into a suitable vessel. An effectual
method of cooling the head was devised by Hughes,

— 59 —
of St, Louis, who applies sulphuric ether to the scalp.
For immediate use there is nothing better than the ice
bag filled with ice and salt, and changed from time to
time.

The headache of meningitis either pachy, or
lepto, is, as a rule, diffused and very intense. Thai
of the first named is ordinarily chronic, may be of
traumatic origin and is dull and connected with suffu-
sion of the face, redness of the conjunctivas, and is
accompanied by some of the symptoms of cerebral
congestion. The characteristic puise which was de-
scribed by Nothnagel is sometimes irregular, and
when there is irritation of the pneumo-gastric nerve
in basilar cases there is periodical acceleration. Con-
fusion of ideas, meiita) weakness and feebleness of
memory are often present, and when there is a men-
ingo- encephalitis we are quite apt to have cortical
sclerosis, delusions of grandeur and dementia. The
headache in chronic cases is always present, but just
as in the form of syphilis just mentioned, there may
be painful exacerbations of an acute character, which
are neither confined to day or night, but are precipi-
tated by exposure to the sun or by excitement.

Belladonna, ergot and opium are the three
remedies which promise most in the way of relief, and
these should be used energetically. The first may be
give to the toxic point, and the second in doses as
large as can be borne by the stomach. Less than one-
half dram of the fluid extract thrice daily does little

— 6o —

trio good. The belladonna in combination with the
potassium iodide is an excellent form of continuous
treatment. Small doses of the bichloride of mercury
act nicely sometimes even when there is no suspicious
of specific disease. In cases of rheumatismal origin
the salicylate of soda in good full doses repeated fre-
quently in alternation with the acetum opii wil! often
lull the pain. Aconite andgelsemium are recommend-
ed. The latter is spoken of very highly by Bartholow,
especially when there is a febrile state, where he rec-
ommends TiEv. doses of the fluid extract repeated every
two hours, so as to maintain a uniform physiological
effect. The extreme method advised by the Germaris,
which consists in shaving the hair and painting the
scalp with croton oil, is not believed to do much good,
nor is extensive cauterization or blistering.

Cerebral tumor is a fruitful cause of organic
headache, and in an excellent article in Pepper's
System, the statistics collected by the writer show that
of loo cases of cerebral tumor 66 patients complained
of headache, which was described as " torturing,"
or agonizing in twenty instances.

The headache of cerebral tumor is very intense,
and has been looked upon by many clinicians as one
of the chief indications and before the days of absolute
(?) localization as of pathognomonic importance. The
pain always bears more or less relation with the situation
of the growth. With tumors of the convexity it is situ-
ated anteriorly or posteriorly or laterally, when we may

find motorial or sensorial symptoms upon the other
side of the body. In one case alluded to by Rosen-
thal "the headache was accompanied by painful sen-
sations and formications in the right arm; these symp-
toms disappeared after a lime and were replaced by
an anEsthesia of the limb. At the autopsy, a tuber-
culous tumor of the size of a walnut was found upon
the convexity of the left cerebral hemisphere; the
pathological changes extended to the deeper portions
of the brain, lesions of which are accompanied by an-
aesthesia of the limbs." Of five cases of gliomatous
tumor three complained of no pain whatever. These
authors find that cerebellar tumors were not necessarily
associated with occipital pain.

A headache of intense character with mono-
plegias or more extended losses of power, convulsions
or vomiting, is always suggestive of an adventitious
deposit; and if the symptoms are irregular, the patient
having great pain which subsides after a compara-
tively long siege and return again with a new acces-
sion of motorial or sensorial symptoms, the diagnosis
is strengthened. This temporary disturbance may be
and often is suggestive of an accomodation of the
brain to the pressure.

Organic cerebral headaches are as a rule pre-
ceded by symptoms of greater or less significance and
are not of sudden onset. Such headaches as a rule
are intractable and puzzling. Headaches due to tu-
mors are often mistaken for those of a functional

— 6« —

nature, the existence of the growth being unsuspected,
I can recall two cases where a profound central anae-
mia with headaches of a commonplace type existed
for a long time, and only afterdeath were large central
growths found. Happily the ophthalmoscope will
usually reveal the existence of neuritis and choked
disk. The symptom of a suspected central change
may turn out after all to be the manifestations of a
general condition and Wood relates a case of head-
ache of this nature in his excellent work.

The patient was a man who suffered for years
from agonizing headaches of daily occurrence. In
time the headaches became associated with petit mal-
and Wood made the diagnosis of organic disease of
the brain. At last the small joint and some of the
larger ones were attacked simultaneously with a furious
sudden and general gout, with deposits, eta, etc.,
when the headaches were relieved to some extent.
Thepatientwasentirely crippled but had his headaches
only occasionally. Wood was led to believe that this
was originally a gouty thickenjng of the dura mater
with deposit.

Percussion of the skull is a useful diagnostic
means in determining the location of a tumor at the
convexity, but care should be taken not to confuse
scalp fenderness with that of a more subtle nature.

The therapeutical indications are varied. In the
case of tumor we are to diminish the pressure caused
by the presence of the growth, and lessen its irritant

-63-

effects. One of the peremptory hygienic measures
which is applicable in this form of organic trouble as
well as others, is the abstinence from anything that
may increase the cerebral blood supply. Mental labor,
alcoholic indulgence, heated rooms, and over-eating,
are all apt to aggravate the pain. The hair should be
kept cropped short and the head gear should be light
and well ventilated. Tight collars should be dis-
carded. The use of cups to the back of the neck, oc-
casional bleeding, such as has been recommended by
Dr. Glasgow, and leeching the nostrils, or scarification
will afford the patient relief. Of course cold applica-
tions are in order.

So far as medicines are concerned one may em-
pirically use the potassium or ammonium iodide, both
in large doses. Hypodermic injections of morphine
atropij or antipyrine are to be resorted to when the
pain is intense, and the mixed bromides are useful.
The combination of the iodide and bromides is a good
one in nearly all forms of grave cerebral disease:

1( Potass, iodide, 3 v.

Sodii bromidi, 5 iss.

Potass carbonas. Z iij •

Tr. columbo. J viij.
M. Sig. One teaspoonful Lhnce daily.

Galvanism and faradism should be given a trial
and the former especially will often relieve an organic
headache, though of course only temporarily.

^

I

— 64 — *

Now that cerebral localization has been of such
great aid to the surgeon, and " brain surgery ", has be-
come a measure which is not necessarily a very dan-
gerous one so far as operations that do not result in
opening the dura mater are concerned, it seems as if re-
lief might be afforded more often than it is; especially
when evidence of cortical pressure are concerned; aAd
when there is evident tension of the most tolerant of
the meninges.

CHAPTER IV.

TOX/EMIC HEADACHES.

Under this head may be included the form of
head pains which are due to the retention in the blood
of various substances which may be the production of
disease, or the result of administration, unconscious or
otherwise. Among the first I may mention lithffimic
headaches, uremic headaches, the headaches of fever,
of drugs, of tea and coffee and tobacco, and of metal-
lic poisoning. Though pathologically some of these
might better be described under the head of congestive
or antemic headache, I think their clinical character-
istics prominent enough to entitle them to separate
description.

An experience of many years has taught me that
lithsemic poisoning is at the bottom of many functional
nervous diseases, as well as some organic ones. Its
effects are shown in a multitude of perversions of
sensibility, and even motility, and the importance of
toxemia due to retained nitrogenous substances is
too often unrecognized or disregarded.

Many individuals of the gouty habit, without
actual classical gout, but with a thousand and one
erratic symptoms, are the subjects of headaches which
readily disappear when a proper alteration of habits
and food is made and when they are placed upon
remedies of a suitable nature. The subjects of such

— 66 —

headaches are often men, and more usually those pas!"
middle life, though the headache of lithwmia is con-
fined to no particular age. The victims are usually of
sedentary habits, whose powers of excretion are im-
paired, and who meanwhile live upon articles of food
which are improperly assimilated. Editors, literary
men generally, lawyers, doctors, clergymen, clerks and
others who are compelled to spend long hours indoors,
and who rarely use their voluntary muscles are quite
subject to attacks of head pain, and such states mark
the accumulation of uric acid. The urine is loaded
with the familiar brick-dust sediment; it is scant, and
often is passed frequently, and they have an annoying
tickling or burning sensation in the urethra. The
bowels are constipated, digestion is slow and poor and
there is flatulence. Sleep is broken and bad, and dis-
turbed by dreams and eructations of wind. The patient
is depressed, morbid, easily fatigued; has muscular
soreness, and formication, perhaps, of his finger tips,
feet, tongue, lips or buccal mucus membrane. Mental
work or physical exercise is irksome and disagreeable,
and he has diffused headache and heaviness over the
orbits. There may be frontal pain, and it may be
worse on arising, or may take a migrainous type and
be very sharp and distressing. In some cases there
may be some alteration or complication of remote
joint pain of the ordinary gouty type. If the urine
be examined, it will be found to contain the oxalate
of lime and the hthates. When the specific gravity of

- 67 -

the urine is lowered and when the bowels become
regular, the passages losing their clayey color and
consistency which belongs to them; there is some
amelioration of the headache. These headaches are
often attended by giddiness and tinnitus and by gas-
tric derangement.

Haig,* who has devoted much attention to the
relation of headaclie to the excretion of uric acid
conducted a series of observations: "Meat and
cheese were taken with the object of bringing on a
headache, for purposes of experiment. The relation
of this headache to the excretion of uric acid at first
appeared equivocal, but definite results were obtained
on separating the urine excreted during the headache
from that before and after. There appears to be re-
tention of uric acid before the headache, excessive
excretion during the headache, and diminished excre-
tion after the headache. The excess during, balances
the diminution before and after; there is no absolute
excess of uric acid; hence the previous equivocal re-
sults. During a headache there is little or no altera-
tion of the excretion of urea. The theory which best
explains everything in this connection is that of di-
minished alkalescence of the blood. A dose of acid,
either introduced from without or formed internally,
may cause temporary retention of uric acid, and so
lead to headache. Beer will do this. Retention pos-

• London Lancet. May aS, 1887: also Practitiot

sTbly does not explain everything, as the excess during
headache appears to exceed the previous retention."

Both Haig and Hutchinson recognize a condition
which they call "quiet gout," where there are no
violent symptoms of the real disease. These patients,
besides presenting the symptoms I have above
detailed, present as well the indications of hereditary
influence, and what Hutchinson speaks of as the
"irritable hypersesthetic and tired eye." The treat-
ment of such headaches must consist in the reforma-
tion of habits, both of eating and drinking, and the
indulgence in exercise of a proper sort.

Meat is to be partially, if not altogether, dis-
pensed with; and cheese and other highly nitrogen-
ous substances discarded. No wine or beer should be
allowed, and the green vegetables, fish, oysters and
poultry are to form the staple diet.

The exercise provided for the patient should be
that taken in the open air, but when this is impossible,
I would suggest the use of Ruebsam's or other rubber
gymnastic apparatus, the "rowing machine," dumb
bells, or Indian clubs. An hour in the gymnasium
has cured the headache of many a hard-worked clerk,
and tennis, football, baseball, or other good out-door
sports where there is general muscular exercise, arc
of importance.

The salicylate of soda, iodide or acetate of
potash, the preparations of mercury or colchicum are
useful, and suited to different cases and conditions.

Haig uses the former in small doses, two or three
grains being given every quarter of an hour for three
or four doses. I believe that larger doses are of
greater service, and I rarely give less than ten or
fifteen grains, and direct the patient to take the salt
continuously for several days. It should be well
diluted and always taken when the stomach is not en-
tirely empty. In some cases it may be combined with
success with iron when there is ansemia, but there are
few methods of doing this for the two agents do not
readily combine. Peabody* has devised the following
formula which is compatible:

B Acldi Salicylic!, gr. xx.

Fcrri pyrophosphatis, gr. v.
Sodii phosphalis, gr. j.
Aqu», Sss,

M.

He gives this dose which is a rather large one
every two hours. It may with propriety be diminished
in the cases of which I speak.

Dr. J. Solis Cohen, f of Philadelphia, has fur-
nished another combination which is perhaps more
agreeable:

^ Sodii salicylatis. I iv.
Glycerin!, 01!].
Ol, gaullheria:, Tlxx.

•Medical News, Dec. ii, 1886.

tMedical and Surgical Reporter, May aS. 1887.

— 70 — .

Tr. ferri chloridi, fl 3 iv.

Acidi citrici, gr. x.

Liq. ammonii citratis (B. P.). q. s. ^ iv.

M. Sig. 3 ij in water three or four times daily.

When salicylic acid or its compounds produce
dizziness or gastric distress, the dose should be dimin-
ished.

Salol in doses of from five to ten grains acts
sometimes much better than the salicylates.

In some cases the headaches will only succumb
to colchicum which may be administered in combina-
tion with alkalies:

Q Vini sem colchici, J ss.
Potass, acetas,
Potass, iodidi,
Tr. cimicifugae rac, aa 3 v.
Aquae me nth. pip., 5 iv.

M. Sig. One teaspoonful every four hours.

Some of the older combinations of colchicum and
opium are energetic and will often promptly break up
an attack, for example:

Q Ext. colchici acetici, gr. xxiv.

Ext. opii, aq,, gr. vi.

Ext. colocynth co., gr. xviij.
M Ft. massae et divid in pill. No xxiv.

Sig: One or two every four hours when pain is acute.

The use of small doses of calomel during the con-
tinuance of the lithaemic state is likely to result not

"onTy'Tii an improvemenl in the function of the liver,
but correspondingly in the cerebral circulation.

In headaches due to pure cholffimia, when there
is much drowsiness, and sometimes a light degree of
mental aberration, the use of the above pill, or of large
doses of phosphate of soda will relive the apathetic
condition of the organ. In this 'form of cephalalgia
which is, as a rule, diffused, the mineral acids and
strychnia are also indicated, and acid baths and gen-
eral cutaneous frictions are likely to be followed by
greater ehmination of bile. All such patients should
seek a high altitude and dry climate, and should in-
dulge freely in exercise of all kinds.

Urtemic, or rather renal headaches are familiar
forms of troubles. They are not distinctive so far as
location is concerned, though many of them are basal
and posterior, with ocular pain and frontal and vertical
pressure. The conjoint symptoms of disease of the
kidneys, urinary and otherwise, makes the diagnosis
clear, and the head pain is apt to keep pace with or
be modified by the condition and amount of the urine.
Attacks of headaches are likely to follow a sudden
dhninution in the amount of urine voided, though this
is by no means the invariable rule. Vomiting, a ten-
dency to somnolence, and some alalia are indications
of a rather desperate state of affairs, and in such cases
the headache is likely to be followed by coma. The
constancy of the dull pain, and the presence of con-
■spicuous nervous symptoms, are sometimes likely to

— -JI —

suggest the existence of cerebro-spinal meningitis, and
the prolonged manifestation of light grades of speech
and psychical disturbances, with profound sub-occi-
pital pain tends to lead even the most careful diag-
nostician into the commission of an error. A case of
this kind came under my care sometime ago, which
had been pronounced meningitis by one of the ablest
clinicians of the city, and I accepted his opinion almost
without question. The patient's somnolence deepened
almost into coma and there were suspicious fore-
bodings of convulsions. Her urine became scant, and
when examinee! abundant evidences of waxy kidney
were found.

A prompt recourse to hot air baths, diaphoretics
and remedies directed to favor elimination resulted in
an immediate lightening up of symptoms and an
eventual disappearance of the headaches. They
then returneo some time afterwards when the patient
became careless in her habits, and after two or three
months of suffering she died.

Wood speaks of the headaches which may occur
in the pre-albuminuric stage of gouty kidney when the
vessels are rigid and the arterial tension raised. This
headache, however, cannot be said to be fully due to
retained effete material. It is hardly necessary to re-
mind my readers that meat should be excluded from
the bill of fare, and stimulants of all kinds rigidly
tabooed. A light nutritious, farinaceous and vege-
table diet, with milk, or a milk diet alone, is that most

Agents which in-
should be

— 73 -
likely to agree with the patie
crease the action of the organs of e
vigorously employed. In many cases the uremic
poisoning is associated with ansemia of a profound
type when we may resort to iron— and the old-fash-
ioned muriated tincture is the best. This may either
be given with digitalis, or strophanthus; or these
agents may be tried alone. In some cases the
use of tri-nitrine is attended with the happiest results,
and convallarin which is a perfectly safe remedy may
be prescribed when digitalis is likely to produce gas-
tric irritability.

tThe compound jalap powder at night, or any of
the purgative mineral waters do good when an exten-
sive process of renal degeneration has taken place.
In some cases acetate of potash either in combin-
ation with digitalis or nux vomica will mildly stimulate
the kidneys and mcrease cardiac tonicity. Nux vom-
ica is I am convinced a better remedy in many cases
than digitalis and when our desire is to coax the kid-
neys we may use with propriety.
oil.
ol<
:

B Tr. nux vomkce, H iii,
Potass acelatis. | i,
Infus. digitalis, J viiL
M. — One Id tno leaspoonsful, every three hours or

A good reliable pill for many years in use at the
old New York Hospital is the following, and is es-
pecially valuable when the disease has led to anasarca.

Pulv. digitalis
Kydrarg mass:

M. Sig:— Oi
Fl[i

every night or oftener.
divid in piiluls No. xlviii.

These have a mild diaphoretic as well as diuretic
action.

Malarial headaches which are so common in
many parts of this country are really of a congestive
type. They are not always distinctive and the term is
loo often made use of when a definition must be
given, and the medical man is not exactly sure of
what he has to treat. The headache can only be re-
cognined with certainty when it has a periodical
character, and disappears with the use of quinine, and
other anti-periodics. Though the pain may be asso-
ciated with fever and sweating, the chill being absent,
it is a rare condition of affairs, and we now often find
headaches of this kind which are the direct results of
an impoverished condition of the blood; a_ sequel
rather than a part of the malarial attacks. The pain
is often suboccipital, and when it is periodical, it
is frontal, very intense, commening in or over
one eyeball. It is commonly confused with supra
orbital neuralgia, but is probably a hyperemia of one
hemisphere, a species of angio-paretic migraine.
It is attended by great misery and suffering and a
paroxysm rarely sub.sides under several hours. Some-
times it alternates with the chill. Quinine in very

— 75 —

large doses, the other salts of cinchona, Warburg's
tincture or the expissated extract, and arsenic are all
useful. In many cases the hepatic and gastric de-
rangement which attends the headaches must be at-
tended to, and calomel or blue mass in combination
with capsicum or ipecac in small doses is advised. If
arsenic be given it should be pressed so that the ap-
pearance of slight puffing beneath the eyes, and a
warning epigastric tenderness are produced. The
paroxysms of headache should be treated just as the
ordinary ague. With a very large dose or series of
doses of quinine a few hours before their expected
appearance. In one case lately seen, fifteen grains
of antipyrine quickly broke up the headache, and I
was not obliged to give a second dose.

As most of these patients are anremic and debili-
tated, iron is naturally indicated. The tincture of the
chloride is the best of these in combination with qui-
nine. The arsenite of iron, or the water of the
Rocegno spring of the Tyrol which is now imported,
are worthy of a trial.

Diabetic headaches are usually the precursors of
more marked nervous symptoms, and especially coma.
They are diffused and connected with dizziness, and
more familiar indications of the disease. They are
by no means as common as the neuralgia of the
lower branch of the fifth nerve which is sometimes
found, or of the sciatic. A diet which excludes starch
and sugar, and the use of a carbonic acid water which

- 76 -

contains the carbonate of lithia and arsenic are the
chief indications. The bromide of arsenic has been
recommended.

Tobacco, tea and coffee, or narcotic drugs may
produce headache of anasmic or hypersemic character.
In most cases the diminution of the amount used, or
its abolition is enough to effect a cure. The head-
aches due to the injudicious use of the former are apt
to be connected with more or less gastric disturbance,
heart irregularity, fleeting pains about the cardiac
region or back, coldness of hands, indisposition and
muscular feebleness, and a feeling of distension
with "tightness of the scalp." The pain is dull and
attended with some "burning" of the eyelids, and
there may occasionally be a sense of vertical pressure
and light -vertigo. Attacks of slight tinnitus are occa-
sionally described. I know of no remedy which is so
nearly an antidote to the bad effects of tobacco, and
so quickly removes the headache as nux vomica, or its
alkaloids.

The headaches which result from immoderate
coffee drinking have been called by Wood caffeimc.
My own impression and experience is that the head-
aches of both tea and coffee are after all due to gas-
tric derangement with consequent malnutrition and
anaemia, and not strictly toxasmic. Any one familiar
with dispensary practice recognizes at once the exist-
ence of a digestive disturbance, which is probably a
low grade of gastritis, and which prevails among

— 77 —

servants who drink large quantities of tea. This is
usually helped by abstinence, and diet; and the head-
aches cured by quinine and iron. It cannot be dis-
puted that some neurotic persons cannot touch coffee
or tea; and that insomnia, headache and a host of light
nervous troubles result from persistent indulgence.

The consideration of headaches of various febrile
states, and of a temporary nature more properly be-
longs to works upon general medicine.

CHAPTER V.

NEURALGIC HEADACHES.

A neuralgia of the fifth nerve is apt to be mani-
fested by paroxysmal as well as dull pain, and by
limited or general expression. No age is exempt, and
men and women suffer alike. Its causes are various,
and its duration and severity variable. If we consult
any anatomical chart we may appreciate, how obscure
is its origin in certain cases, especially those where the
neural disturbance is due to some central change. In
such instances, if the lesion be sufficiently profound,
we may find not only pain, but disturbance of trophic
function, and of the sense of taste in the anterior half
of the tongue; as well as various anomalies in the
functions of the parotid, lachrymal, and submaxillary
glands.

As the results of peripheral trouble; cicatricial
and otherwise; anfemia or congestion of the nerve
trunk; the pressure of bony or other tomors; reflex
irritation from bad teeth; and a number of other
pathological changes; we are furnished with a painful
affection of the nerve which has been called trigeminal
or faciei neuralgia, and ophthalmic or supraorbital,
infraorbital, dental and occipital neuralgia with refer-
ence to the branches of the nerves that are involved.
The pain is essentially paroxysmal, very agonizing
when once established, and sudden in its onset. The

— 79 —
paroxyms in a well-established attack are so closely
connected as to give the impression of continuous!
pain. The attacks of neuralgia in a chronic case,
though occasional in the beginning, tend to become
more and more constant, and are readily lighted up
by any exciting cause, such as a cold draught* the act
of eating very hot or cold substances, fatigue or pres-
sure. The pain commonly begins in the supra-orbital
branch of the trigeminus, and when developed, in-
volves the entire side of the head, and when acute
and general, we find lightning pains which affect .this
region, the back of the head as well, and the teeth of
both jaws.

At certain points where the nerve branches be-
come superficial, we find great tenderness. These are
known as supra-orbital, pafpgbral, nasal, ocular and
trochelar; tnfra-orbital, malar, superior labial; temporal,
inferior dental, lingual, inferior labial, parietal, oecipittti,
and vary as one of the three or all the divisions of the
nerve are affected. During the course of a neuralgia,
or afterwards, we find these painful spots.

The neuralgic pain which involves the ophthalmic
branch is a common and easily distinguished form.
The pain runs over the side of the head, the nose and
eye of the affected side, and is relieved somewhat by
pressure over the supra-orbital foramen. The face
may be flushed or pale, and the eye is bached in tears,
and there is hyperemia of the conjunctiva. In some
cases there is a copious flow from the lachrymal

ducts of the affected side, or the contact of air with the
filiaments which supply the interior of the nose may
result in sneezing, or, more rarely, a puffing up of the
mucous membrane with obstruction. There is a pain-
ful point above the eye — over the supra-orbital notch.
Sometimes, as in the case of Anstie, the eyebrows or
hair become the seat of a change of color, and dryness.
brittleness or exfoliation are the consequences of re-
peated and persistent attacks. Ross speaks of neuro-
paralytic ophthalmia. In old cases of neuralgia we
not only find trophic disorders such as I mention, but
sometimes ulceration of the cornea, and persistent
changes in color, consisting of pigment deposition in
the skin.

The anatomical distribution of the nerve will en-
able us to trace the variety and character of the pain
which symptomatizes neuralgia of the lower branches.
Besides the painful points enumerated, we will find
violent faceache and toothache which is more or less
general. Sometimes the upper and lower rows of
teeth on one side will be affected, or in one jaw alone.
The mucous membrane of the mouth is exceedingly
tender, perhaps tumefied, and in some cases a crop of
herpes is present as the sign of an unusual attack.
The tongue may be swollen. This, however, is rare,
but it is common to find a tenderness of the gums,
and sometimes a great increase in the amount of
saliva secreted.

The intra-cranial causes of neuralgia are very

M

obscure. Vulpian reports a case of violent nature due
to the perforation of the gasserian ganglion. (See
plate.) Tumors, meningeal thickening, or the forma-
tion of syphilitic or other adventitious deposits, may

Fro. •4.

Vulpian's Case.
A. — Bony Epicula penetrating Gasserlaa gani^lion.

give rise to the affection, but it is a curious fact that a
Eyphilitic deposit may completely surround a nerve
without any impairment of function.

Disease of the antrum or alveolar processes which
is entirely unsuspected may give rise to severe neu-

-83 -

ralgic disturbances. A gentleman from the West con-
sulted me who was the victim of intolerable dental
neuralgia with painful shooting pains in the roof of the
mouth, gums and pharynx. The slightest pressure upon
any of the teeth of the upper jaw on the left side would
inaugtttate a paroxysm of neuralgic pain, which would
finally involve the whole nerve. Soft food could be
taken only in small quantities, and it was necessary to
avoid extreme temperatures, for a mouthful of ice-
water would cause intense neuralgic twinges. Two
molars had been drawn without relief, and all methods
of treatment were made use of unsuccessfully. Upon
his return home a dentist extracted one of his bi-
cuspids, which contained a verylong root, and this was
removed with great difficulty. A profuse discharge
of pus followed and after a few days the pain dis-
appeared and never returned.

The simpler cases of neuralgia due to cold
{especially the ophthalmic form) malaria or gastric
trouble, are relieved by anodynes, and the local use
of galvanism. I have already spoken of the malarial
headache which is often neuralgic, and have specified
the antiperiodic remedies. It remains now for me to
refer to the virtues of certain drugs which seem to
have a decidedly specific action upon the trigeminus.
The most important of these is aconite or its alkaloid
aconitine. The tincture of the root may be used,
in large doses, so that decided toxic efforts are
produced; carefully feeling the way. Small doses are

- 84-

almost useless. Perhaps the most convenient form of
the drug is its alkaloid. Duquesnel's aconitia is the
best, and the dose should vary from jj^jth to -ji^th of
of a grain, to be repeated. A sufficient quantity to help
the disease will produce some prickling of the tongue
and lips, shivering, and a feeling of subjective cold-
ness; and may even produce numbness of the ex-
tremities. The pulse should be watched and the dose
regulated with reference to the heart's force. It is
unwise to give aconitia in pill form, or in a manner
that may interfere with its solubility, and the danger
of a cumulative dose is great. I have used it for years
either in tablets {the Fuller method) or in solution.

The plan of using aconitine adopted by Dr.
beguin and by him suggested to the N. V. Thera-
peutical Society is the following;

9 Aconltinz (Duquesnel's), gr. i-io lo t-6.
Glycerioli,

Spts. vial rec, aS J j.
Aqass mcnlh pip., ad | ij.
M. Dose, ; j t. i. d. before eating, to be carefully in-
creaeed.

Another remedy of value is the croton-chloral
hydrate which also has a direct action on the fifth
nerve. In doses of from fifteen to thirty grains,
it is given in water and will occasionally modify the
pain.

The salicylate of soda, antipyrine or acetanilide
have been spoken of before in connection with other

-8s-

forms of headache. They are all useful in neuralgia.
Wilks recommends chloride of ammonium in fifteen
grain doses, three or four times daily, but I believe
this does good only in a limited number of cases,
and these are not examples of true neuralgia, but
migraine.

Tonga, a Fiji remedy of great local reputation,
has been extensively employed in England and
America. It is of unquestioned value in some cases
of supra orbital neuralgia, and may be administered
in the form of a fluid extract, and in doses of from
one to two teaspoonsful, to be repeated.

Cimicifuga, in combination with aconite and bella-
donna, has been recommended by Metcalfe in sciatica.
I have also used the combination in facial neuralgia
with success. Equal parts of the tincture'of cimicifuga
racemosa or actea racemosa, tincture aconite root, and
tincture belladonna are to be combined, and doses of
six drops are to be repeated every hour until relief or
physiological effects are produced.

Ammoniated copper has been praised by the
French writers. 1 have never found it reliable and
hesitate to recommend it.

The treatment of the general condition which
leads to the development of neuralgia is important.
Arsenic, iron, cinchona and its alkaloids; alteratives
such as mercury and the iodides, the phosphate of sil-
ver, and many others makes a formidable list. I have,
in speaking of an rem ic headaches, given some formulae,.

— 86 —
i here have nothing more to add except it be to
reiterate the advice that the exhibition of all drugs of
a restorative nature should be in large doses. The
silver salts are indicated in inveterate cases, and I
prefer the tri basic- phosphate of silver to any other
— even the nitrate. It should be given with argil-
laceous earth, for the confection of roses, and other
vegetable excipients are very apt to decompose the
silver salts which are exceedingly unstable.

Some chronic cases are materially benefitted by
Donovan's solution an old and valuable combination,
and others by the use of one of the iodides of mercury,
preferably the red. The salicylate of iron may be sug-
gested in cases of gouty origin.

In sub-occipital neuralgia, which is commonly of
malarial origin I place great reliance upon large
doses of quinine carried to the point of cinchonism.

In cases of facial neuralgia with zona ophthal-
mica or herpes, there is no better remedy than that I
have just mentioned, in addition to galvanism. In fact
the indications are those which lead us to select the
same treatment in herpes zoster.

Phosphorous in its pure form is one of the best
regenerators of diseased nerves in existence, and in
neuralgia of the fifth nerve is an excellent agent.
The solution in absolute alcohol which I believe was
first recommended by Thompson, of England, is an
admirable preparation and produces little or no gastric
disturbance.

Phosphori, gi. i.

Alcohol absolut., q. s. ut disf^olv,

Glyceriri.ad J iv.

SpiB. menth. viridis, 3 se.
M.
Sig. One leaspoonfal after eating, lo be increasecJ.

The phosphorated oil in capsules, or pills of pure
phosphorus made up with bread crumbs, are good
preparations, as is the combination of pure phosphor-
us and sulphur.

The actual cautery may be used with benefit in
cases where there are well-defined painful points, A
small platinum tip is to be employed, and the hyperass-
thetic area whether it be in the scalp or elsewhere may
be lightly touched. In cases of neuralgia of the
great occipital this therapeutical measure is one of
importance.

The bisulphide of carbon has been used as an
external irritant. Gasparini has treated fifteen cases
successfully, and his method is to apply to the painful
point cotton-wool saturated with bisulphide. A few
drops of the essence of peppermint will disguise the
offensive odor.

External applications of ointments or liniments
which contain anodyne substances sometimes do good,
especially when there is much diffused hypersesthesia.
Among these are menthol, morphine, veratria, aconite,
and belladonna; hypodermic injections of aconite,
belladonna or daturia or osmirc acid are at times
beneficial.

An ointment containing morphine and veratiia

is sometimes excellent, and the following formula is
recommended :

S Veratrioa;, gc. x.

Spts. vini ledt., lUxxx.
Morphina sulph., gr. xx,
Vaaelioi, J as.
M. Sig. For external use.

Bartholow recommends the oleate, and an oint-
ment made up with benzoated lard.
" Oleaiui

IJ Veratrine, 2 parts.

Oleic acid, 98 pans.
M.

" Unguentum veratrinae : "
B Veratrine, 4 parts.

Alcohol. 6 pans.

Benzolnaled lard, gb parts.

4

M.

Very great care should be exercised in using
these preparations as well as aconite embrocations,
and the hands should always be washed after their ap-
plication.

An ointment prepared by the combination of
equal parts of chloral and camphor, with vaseline is a
useful external application:

B Chloral hydrat.,
Campborre, Sa3ij.
Vaseline, i SE.

M.
and we may add morphine to the prescription.

^

Various observers have used cocaine in neuralgia
of the fifth nerve, both hypodermic ally and by apph-
cation to the fauces and nasal fosste. Papoff cured
one bad case by local hypodermics of a lo per cent,
solution, using about half a syringe full. In one case
of which I know when it was used by a demist, and
injected in the neighborhood of the inferior dental
nerve, it produced facial paralysis, but I am unable to
find others which contra-indicate its use. In some
neuralgias due to catarrhal rhinitis, it promptly re-
lieved the pain when it was used in the atomizer.

An excellent remedy in vogue in the country is a
tincture made from the fruit of the belladonna. The
berries should be crushed when green, and covered by
strong alcohol. This makes a valuable external ap-
plication.

Sclapiro* lays great stress upon the value of
osmic acid. He cured five of eight cases and relieved
the others. His formula is the following:

B Osmic acid. KT- 1-6.

Distilled naier, Z iss.

Pure glycerin. 3 j.
U.

This preparation keeps two weeks, but without
the glycerin readily decomposes, ■nflv should be given
hypodermically, and several injections are often neces-
sary. Neuber has injected as much as 3 centigrammes

• Der Foitschritl. Dec, 5, 1885, No. 23.

— go-
of osmic acid within a period of three months without
any bad results.

The use of cold obtained by means of the spray-
producer is strongly advised. Some years ago I em-
ployed sulphuric ether for this purpose. The appli-
cation should be made just in front of the ear over
the painful points. The nasal injection of carbonic
oxide, as recommended byDupr^ and Brown-Sequard
some years ago, is, I believe, a useless or at least un-
reliable mode of treatment.

Debove, Vinay, Peyronnet de Lafonviile and
Jacoby have all used with greater or less success the
spray of methyl-chloride in the treatment of neuralgia
of the fifth nerve. The primary results are freezing
and anassthesia, followed by redness and hyper-
esthesia which subsides after a whiie, with a disap-
pearance of the pain. An accident to be avoided is
vesication.

I have devised a method of applying cold to a
small territory which will often break up an attack of
neuralgia. This consists of the adoption of a large
felt-covered test tube, which is filled with finely-crack-
ed ice and salt, or muriate of ammonia. An intense
cold is produced, and the convex end, which is un-
covered, may be applied to the sub-orbital foramen, or
over any or all of the painful points in turn. The
advantages over ether is the absence of danger where
there are lights or fires, and of the odor of the
latter, which often nauseates the patient.

Fig. 5.
Apparatus for Using Methyl-Chloride.*
" In use, the direction of the spray having been
determined by means of the thumb-screw c, a slight
turn is made at B by means of the key e; this allows
the vapor to pass into the tube connected with d; by
turning d the amount and duration of the spray is
regulated,"

The treatment of neuralgic pains by vibrations as

suggested by Mortimer Granville, Boudet and myself

may be resorted to. The electrical apparatus devised

, by me, and afterwards modified by Boudet, may be

I employed. It is simply a flat piece of hard wood, on

* The above apparatus may be procured from Messrs.'
^ He KesBon & Robbins, of Nen York City.

which is mounted a vibrating tuning fork, actuated by
a strong magnet. The current is supplied by a
bichromate or other battery. The board is fitted
with a projecting rod terminating in a knob which is

Fig. 6.

to be pressed against the painful point. When the
current is connected the vibrations of the tuning fork
are transmitted to the rod and in turn to the nerve.
Though not uniformly beneficial, the use of the vibra-
tor is often curative.*

*AIeo see reference to author's instrument and more ex-
tensive details in " Nervous Diseases, Their Deseriptlon and
Treatment." H. C. Lea's Sons & Co. Philadelphia. 1881.
Second Edition.

— 93 —

Faradization or massage of the scalp are to be re-
sorted to in severe cases with a decided prospect of

Fig. 7.
Points for electrization and cauterization of painful points.

benefit. The former, if not too strong, will soothe the
patient, but if violent currents are applied there will
be a decided aggravation of the pain of the neuralgia

itself. A mild current passed through the hand of ttw
operator — the patient holding one of the poles will
often produce a feeling of drowsiness, and is followed
by a subsidence of the paroxysm. The " wire brush "
may be passed over the painful tracts.

In neuralgias of rheumatic origin when there are
painful points, and tenderness which lasts several days,
the use of an ordinary wire hair-brush with connec-
tions with the faradic battery; or light massage of the
scalp (care being taken not to pull the hair), will be
found to diminish the hypersesthesia. In sub-occi-
pital neuralgia faradization is highly efficacious.

The galvanic treatment of neuralgia of the fifth
nerve is of immense importance, and it is generally
recommended by the authorities upon nervous diseases.
Small electrodes with sponge or chamois -cove red heads
are the best, or we may use a carbon-tipped electrode
which may be covered with absorbent cotton. If cur-
rents of high tension or quantity are selected, it will be
better to use an electrode with greater surface, other-
wise we may cause intense pain when the smaller elec-
trode is placed, as well perhaps as vesication. The
cathodal electrode should be applied firmly on the
tender points, and the anodat electrode just anterior
to or below the ear. Currents that produce vertigo
are to be avoided, and do no good. Daily applica-
tions of five or ten minutes duration are usually suffi-
cient. In some cases the patient may be relieved by
galvanization of the interior of the mouth.

— 95 —

For the relief of sub-occipital pain I have used
nuchal applications of GaiiTe's revulsive disk with en-
couraging success.

Rosenthal has suggested the moist pack for one-
half hour to an hour at a lime in rheumatic cases, fol-
lowed by galvanism. Static electricity, except in these
cases, is of little or no use.

*Rasori, of Rome, has used the tuning fork inthe
treatment of neuralgia, applying it while vibrating
over the course of the painful nerves.

The instrument was applied from ao to 40 min-
'Jtes. It also relieved nervous vomiting.

Tic douloureux {or prosopalgia) is best relieved
by gelsemium — in fact I regard it as the best remedy
at our disposal, but it must be given in large doses,
and at least a mild toxic effect should be produced.
From two to six or even eight minims should be the
initial dose, and this may be increased. In the case
of a medical friend who had taken an overdose by
mistake, an epileptiform tic of several years standing
was suddenly and completely cured by an overdose
taken by mistake, which produced semi-collapse and
many alarming symptoms. Croton chloral in
twenty-grain doses sometimes does good, and Bram-
well curedf a case by the use of drop doses of the one
per cent, solution of nitro-glycerin thrice daily.'

* The Jouroa) of Nervous and Menial Diseases, OcL I
3-
f Briliah Medical Journal 1884, p. 609.

- 96 -

* Dr. R. G. Simpson has reported a case where
ice cap relieved tic douloureux when even morphine
had failed.

Surgical measures are often necessary and may
consist of traction, exsection, or those calculated to re-
live periostitis or disease of the antrum. Of the first
of these I cannot speak in commendation, for the
suits are by no means permanent, and sometimes
suit in dangerous complications. A year or two ago
it was a fashionable and sometimes successful opera
tion. Lemaistref has written fully upon his success,
and details a number of experimental observations
made by him with a view to determining the expen-
diture of force. A tension force equal to 8,83 lbs.
was needed to stretch the nerve, and that there was
never laceration of the gasserian ganglion, he explains
by the protection afforded to this organ by the dura
which covers it. Lemaistre prefers nerve stretching
to the operation of Carnochan, which consists in
breaking through the walls of the antrum.

Various other forms of nerve stretching have
been suggested for prosopalgia, Ledentu has stretch-
ed the lingual nerve for a tic of five years standing,
the nerve being elevated 12 mm. on a hook; and
Polaillon has stretched the inferior dental, first trephin-
ing the inferior maxilla.

Nerve section is after all the only effectual method

^Cincinnati Lancet and Clinic, Oct. 20, 1883.
+ Revue de Chirurgie, iSSt, No. 12,

rcuring obdurate neuralgia, but as many surgeons
know, this operation affords only temporary relief un-
less it is extensive or thorough, and the following case
of Richardson is an example in point. The first neu-
rectomy was insufficient, the second effectual.

" Neuralgia of inferior dental nervefor five years.
Division of nerve inside mouth; relief for two years.
Return of pain in aggravated form, lasting one year.
One inch of nerve destroyed by opening inferior
dental canal from outside. Immediate recovery and

" S. P. B., seventy-two years old, entered Sept.
3, i8S6. Eight years ago, developed severe neuralgia
in the right side of the face, over the lower jaw.
Three years ago, inferior dental nerve was divided
just above the point where it enters the dental foramen.
This operation gave relief for two years, when the
same trouble returned.

"August 4th. One inch of the inferior dental
nerve was cut out. An incision parallel to, and
through the fibres of the masseter muscle, three inches
in length, was made down to the jaw-bone. With a
gouge and mallet a narrow opening, one inch long,
was made through the ramus of the jaw over the
dental canal. The nerve and artery thus exposed
were cut at each extremity of the opening, and the
whole curetted out. There was little hicmorrhage.
The external wound was closed with siik, and iodo-
form dressings applied.

- 98 -

" Two days later, stitches and drainage-tube were
removed. For some days after the operation there
was complaint of slight pain in the parts supplied by
the mental branch of this nerve. This rapidly disap-
peared. He was discharged on the loth.

"August 25th. Came and reported that 'it was
a real pleasure to live; that he had had more real
pleasure in life since leaving hospital than in any ten
years before.'"

Epileptiform tic or prosopalgia has been cured by
Perkovsky by division of the auriculo-temporal nerve.
An incision ten centimeters long and five millimeters
deep, should be made between the condyloid portion
of the lower jaw and the anti-tragus.

Cadge* reports four cases of tic by neurectomy.

Richardsonf in an admifable report upon neural
operation, reports the following case of neurectomy
for tic:

"Epileptiform neuralgia" of side of nose and
face. Neurectomy of infra-orbital nerve; complete
cure.

Tim O'Brien, sixty, married, laborer; entered
hospital August 8, 1885, with history of trouble in
face for sixteen years. Some years ago had an opera-
tion done in an English hospital, without reUef. Has
pain in right side of face and nose, in parts supplied
by the infra-orbital nerve. This is spasmodic, and

» British Medical Journal, July 15, i83a.

f Boston Medical and Surgical Journa.!, Oct, 21, 1SS6.

_ 99 —
extends from the inner canthus of eye down to the
ala of the nose. During this paroxysm he leans
his head upon his hands, with evidence of great
pain, and the muscles of tlie nose contract spasmodic-
ally upon the right side, drawing up the ala and
wrinkling the skin.

August 12. Under ether, the infra-orbital nerve
was found, a needle having been first inserted into the
infra-orbital canal. The nerve was pulled out of the
canal as far as possible, and cut. The peripheral end
was then drawn up, and its branches dissected down
an inch or more, and then divided.

The next day patient reported himself very com-
fortable, with pain much relieved. What pain still
existed was referred to the ala of the nose.

August 1 8th. Five days after operation the pain
had entirely left the face.

August 2ist. No return of pain; face healed.
Discharged.

In neuralgia of the inferior maxillary nerve, an
I infra-buccal .operation is the easiest and best, and it
f may be divided just before it enters the dental canal.
Heustis" has cured a case of infra-orbital neural-
. gia by cutting down and exposing the infra-orbital fora-
n and drilling back as far as the spheno-maxil-
r lary fissure with a fine dentist's drill, thus removing
* the nerve.

Severe measures are often imperative, and re-

* Medical News, Dec. 8, 1883,

moval of Meckel's ganglion is an operation which often
suggests itself.

Dr. Vanderveer* has cured two cases of infra-
orbital neuralgia by removal of this ganghon. In one
case the neuralgia renaained absent for eight years.
In another case there was no cure, and it was found
that there was disease of one eye. However, when
this was removed the patient recovered.

Dr. Vanderveer's first ca.se and the operation
therefor is the followingr

"Miss B., aged 40, first consulted me July, 1875,
giving the following history. For three or four years
previous she had suffered from neuralgic pains in
right side of the face, differing as to length of time
and degree of severity. Her general health up to
this time had been good. Passed the menopause
about two years before. Since that time she had had
little relief from pain unless under the influence of
medicine. All her teeth had been removed (one or
two at a time) from right side upper jaw, and some
from the lower jaw on that side, with but little, if any,
relief resulting. Had taken medicines almost con-
stantly. For the previous six months she had had no
remission of pain, though taking large doses of mor-
phine, chloral and bromides. The pain would start
in the upper jaw, extend over the face, pass down,
around and through the lower, to chin and along
right side of tongue, also penetrating the temporal

• S. Y. Medical Record, June 0, iSBs.

region, leaving a heat or inflammation in the mouth,
very severe.

"At times she would be unable to take a drink
without having the pain aggravated for hours.

"I gave her large doses precip. carb. iron; also
Brown-Sequard's neuralgic pills, but with no apparent
benefit. Gave hypodermic injections chloroform with
a few moments' respite from pain, but the inflamma-
tion following was very severe. Aiso gave morphine
in the same manner, but so little good followed that
she readily consented to an operation.

" On September 5, 1875, ether being given, I pro-
ceeded to remove the infra-orbital nerve and Meckel's
ganglion in the following manner: Making an in-
cision from the right angle of the eye, down to the
bone, along the nerve at a distance of little more than
an inch; then another incision, similar in length, at
right angles, under the infra-orbital ridge, raising the
flap and periosteum, I exposed enough of the anterior
wall of the antrum to admit the application of a good-
sized trephine, removing a button of bone, so that the
upper edge, opening, exposed the infra-orbital nerve
and itscanai. Lifting the nerve from its bed bymeans
of a bone chisel, grooved director and probe, I follow-
ed it until the posterior wall of antrum was reached,
where, by means of a smaller trephine, another button
' of bone was removed, and the spheno-palatine fossa
reached. The ganglion was now lifted from its bed
and, with curved scissors, the nerve and it were sever-

ed and removed. This was followed by a sharp
htemorrhage, and at first somewhat alarming, but
controlled by portions of sponge, firmly applied, to
which a silk ligature had been tied. The wound In
the face was then closed by interrupted sutures, a
drainage tube, with ligature from sponge, being placed
in most dependent point. The patient rallied nicely
from the anesthetics, and was immediately relieved
1 all pain. There was considerable trouble in re-

moving the sponge, and the parts suppurated quite a
good deal, but ultimately healed kindly. From that
lime on she has been in perfect health, increasing in
fiesh, attending fully to her work, and a more grate-
ful patient I have never seen, * * * •
By taking out a good-sized button from the posterior
wall of the antrum, and watching carefully, the in-
ternal maxillary artery can be seen pulsating, and
thus avoided, while a most excellent view of the
ganglion can be obtained. As with all operations
upon the nerves, I am convinced the operation needs
to be done thoroughly; if not, failure is likely to re-
sult, as it will, in cases where the pathological lesion
is still more central and the cause not peripheral. In
lifting the infra-orbital nerve from its bony canal, I
found, in my last operation, the instrument here shown

— I03 —

figured of great service, as by its use the operator i
not so likely to tear or separate the nerve — something
very important to avoid, for, by keeping the nerve in
its continuity, he has a sure and safe guide to and
along the ganglion."

In a patient with stubborn neuralgia of the infra-
maxillary branch of the nerves, Hach found a large
granulation at the back of the pharynx, and when this
was cauterized the patient's pain left almost as by
magic. It cannot be questioned that disease of the
nasal fossa, or middle ear troubles are at -the bottom
of many neuralgias.

Gross* has described a form of neuralgia, met
with chiefly in elderly persons who have lost their
teeth. It is confined chiefly to the upper jaw, and
depends upon a low grade of periositis with deposits
of bony material and pressure of the smaller nerve
filiaments.

Some neuralgias may be cured by empirical
means, and that reported by Durham is one in
point. Durham vainly tried to relieve an inveterate
supra-orbital neuralgia by stretching the superior
branch; only temporary comfort was obtained, but
when the trephine was applied over a cicatrix upon
one side of the head, which had been left by the kick
of a horse, it was found that an immediate cure was
effected.

I. Journal of Med. Scier

1S70. p. 4S.

— I04 —

The simple excision of old cicatrices is often im-
I>erative, even when no bone disease is suspected, but
when there is periositis and necrosis, it is absolutely
necessary to resort to appropriate surgical measures.

CHAPTER VI.

NEURASTHENIC HEADACHES.

Under this head conies a long list of irregular
headaches of obscure causation, but dependent more
or less upon conditions of neural weakness. The
headaches of neurasthenia include some already
spoken of as anEemic. They have oftentimes an
hysterical element, or depend upon reflex mischief.
Oculists have for a long time recognized the head*
ache from eye-strain; gynecologists, those from
ovarian and uterine disorders.

Hysterica! headaches are likely to be of the most
varied description, and but one form is at all charac-
teristic, that known as clavus hystericus. This consists
of an intense and localized head-pain, which has been
compared to that which might follow the driving
t nail into the head. It is nearly always vertical.
■ 'Hysterical women are very apt to complain of very
ftgrcat diffused hyper jestbesia of the scalp, so that the
leimple act of brushing the hair causes great distress.
Bah hysterical headaches are worse at the catamenial
■periods, and are aggravated by fatigue, excitement,
llate hours, etc. There is often attendant ovarian iiri-
■tation or backache, and much mental irritability. The
Bjiain of clavus is rather intractable, and actual re-
»urces to the hypodermic injection of morphine and

— io6 —

atropine in «^>metime« ab»f>lutely necessar}-. These
patients arc more apt than any others to form the
opium habit, or that of alcoholism, and great care
Khould be taken le^t, by yielding to their demands, we
foHter H^>mething wor»e than the headache or hysteria.

Kxternal applications of the wire brush with
mild faradic currents will often mitigate the suffer
ing, and nhould this fail, we may resort to the ether
wpray. MaHsage to the head is recommended by
Webber, but it is by no means agreeable to all
patientH. The citrate of caffeine or bromide of caffeine
are c)ften serviceable. Valerinate of ammonia and
cjy|)ri|)e(lin arc also useful. The latter may be used
in the form of the fluid extract, and dram doses fre-
<|uently repeated will be found to increase the patient's
comfort.

The following formula is recommended:

U Ammon carbonas, I iij.
Tr. moschi, J vj.
Sptt. Iftvandulie, J i.
Elixir ammon valerianfis, ad 3 viij.

M.

Two teaapoonsful at a dose, in water.

A rectal injection of half an ounce of the tincture
rtssafu^tiila in a pint of thin starch water will not only
help thc>ie headaches, but is useful in other hysterical
troubles, notably thi>se of a convulsive nature. Most
patients of this kind need iron and it may be given in

combination with small quantities of the hydrochlorate
of cocaine.

3 Cocaini bydrochlor., gr. St.

Ferri et strychnia citras, gr, xxiv.
Ext. geniiaiiie, gr. xlviii.

Sig.

Fl. massse et divid in pillulx, No. xxlv.
One ailer each meal.

The iodide of iron is often more serviceable than
any other preparation especially in combination with
Calumbo.

Great good results froni the application of the ac-
tual cautery, or blisters over the ovaries, and in many
cases the left ovary will be found hype rtesthe tic.

The headaches of exhaustion have been alluded
to before under the head of cerebral hyperemia. It
remains for me to call attention to a variety which
bears no relation to the condition of emptiness or ful-
ness of the blood-vessels of the brain — a headache,
in fact, with exhaustion of the nerve cells. Such a
cephalalgia always follows unusual fatigue, be it mental
or physical; is occasionly frontal, but more often verti-
cal, and is neither paroxysmal or sharp. It disappears
sometimes quite promptly after a glass of whiskey
and water, or champagne; or a good night's rest. The
faculties are often pre-naturaJIy active, and the indi-
vidua! is mentally hyper;esthetic. He may have insom-
nia, but his sleeplessness is of the quiet kind, and he
simply lies wide awake and there is no tossing, heat

J

of head, or anxiety. The surface of the body may
be cold and the face pale.

Diffusible stimulants bring relief as does the "phos-
phoric acid lemonade," which may be made by the
addition of a few drops of lemon juice and a lump of
sugar to a half teaspoonful of dilute phosphoric acid
and a tumblerful of water. A new preparation, the
benzoate of sodium and caffeine, may be given in five
to fifteen grain doses hourly. Guarana or the fluid
extract of pautlina sorbilis in tablespoonful doses.
Cocaine in doses of one-half of a grain. Strong
coffee or green lea are excellent abortants of an at-
tack of headache of the kind. Wurm has given qui-
nine or morphine in combination with guarana with
excellent effect. In the cases where it is useful, dry
heat to the head is more agreeable than cold or ice
compresses. A glass of Very dry champagne, or a
teaspoonful or two of absinthe which have been poured
over finely cracked ice, are also recommended.

The most efficacious preparations for continuous
treatment are those of the restorative class, A pill of
the arseniate of strychnine, strophanthus and quinine is
recommended.

B Strychnine arsenlas. gr. ss,
Sem. Etrophanthii pulv.. gr. vi,
Qulnie sulpb., gr. xlviii.

I masss et divid in pillulx No. xlviii.
I. Sig. — One lo two afler each meal.

— I09 —

A stimulating preparation of iron may be sug-
gested, and I know of none better than the ethereal
acetate. This may be given alone or in combination
with strychnine.

B SirychniK acetas, gr. ss — gr. i,
Tr. ferri acet ether, J vi.
Aquae lauro cerasi, | iv.
M. — One leaspoonful after eating in water.

Iron and ignatia, perhaps in combination with
arsenic may be prescribed with advantage.

K IgnatiiE,

Acidl arscQiosi. Six gr. J,

Ferri rcdacli,

Ext. gentianiE. aS gr. xl.

Fl massiE el divid. in pillals No. xl.

M. — One after each meal.

Besides iron, we may make use of one of the
preparations of phosphorus before enumerated.

Burgess* recommends the use of aconite for the
treatment of the headache of exhaustion, and it may be
uaed mainly in small repeated doses of one or two
minims until relief is obtained.

General hygienic measures, such as bathing and
massage, head shampooing, and rest as far as possible;
change of scene and air are necessary and important
adjuvants.

Certain vague headaches have been called

p. 95-105.

'Edinburgh Medical and -Surgical Journal, 1840,

"sympathetic." The application of this term must
lead to confusion, for little or no attention is paid to
the actual pathological state. The same fault may be
found with the term "nervous." All practical men
recognize the existence of irregular headaches from
gastric, hepatic, or visceral disorders generally, and
each case must be studied from a different standpoint,
and the individual indications properly met and over-
come.

Various remote disturbances which tax nervous
energy to its utmost, or a constant, remote, and often
unsuspected irritation are productive of these head-
aches. In women they are ctosely related to the
menstrual periods, or with the condition of the diges-
tive organs. Following upon the ingestion of rich or
improper food they symptomatise a gastric irritation.
Some people call them " bilious," though the function
of the liver may in every way be normal.

I have already alluded to a form of headache in
which ovarian irritation plays a part, and in such cases
it is, not unusual to find leucorrhcea, backache,
coldness and clamminess of the hands, insomnia,
palpitation and muscular feebleness.

The so-called "bilious" or stomachic headache
usually affects individuals who present epigastric un-
easiness, eructations of acid fluids, sudden hunger
which is easily appeased. "sinking" sensations,
cardiac distress, fJatulence; and a decided atony of
the bowels which is manifested by alternating consti-

patioti and looseness. The stools are not well formeii.
Iced or very hot drinks taken into the stomach often
produce immediate head pain which is frontal, and
an acute attack of indigestion. is the origin of a reflex
headache which may be vertical, and not attended by
any signs of disturbed cerebral circulation.

A cause of " sympathetic " headaches originates in
the irritation from bad teeth which need not neces-
sarily produce neuralgia, and the reflex irritation at-
tendant upon the appearance of the wisdom teeth
often gives rise to headaches of a diffused and almost
constant character, which only ceases with complete
dentition. Aural disease is perhaps a more common
cause of headache than we imagine. It may, or not
be attended by tinnitus, but often is by vertigo, which
may be general or lateral. Not only may disease of
the organs of hearing produce a neuralgia or a head-
ache which affects the side of the head and is dull
and accompanied by tenderness, but there is a re-
ftected irritation which may be the starling point of a
genuine sympathetic headache.

Besides the proper surgical or mechanical measures,
such as operation, syringing, etc., we may administer
strychnine in large doses, or belladonna, 1 have bad
unusual success with the latter drug" pressed to the
point of tolerance. The removal of a plug of wax
will sometimes cure headaches that have de6ed many
remedies, and warm syringing will decidedly amelior-
ate the patient's suffering.

Dr. Harrison Allen, of Philadelphia, has called
the attention of the profession to a purely nervons
headache due to catarrhal disease of the nose. The
pain he considers reftex, and it is confined to the side
of the head and face and sometimes the vertex.
Wood says that the patient can often define it by
"drawing the index finger across the face from the
middle of the nose to the temple, and thence in some
cases to the parietal eminence." Sometimes the pain
re.sembles migraine and is associated with nausea.

It has been the fashion of late to ascribe to dis-
orders of accommodation and refraction, not only
many forms of headache, but other nervous dis-
orders as well, such as epilepsy and chorea. Certain
disingenuous or ignorant persons have even claimed
to cure posterior spinal sclerosis, and degeneration
of the pyramidal columns of the spinal cord by ocular
myotomy; and all manner of extreme operative inter-
ference, which smacks strongly of charlatanism, has
been indulged in.

The existence of headaches due to eye-strain
has been recognized for years by those who have
made the eyes a study, and the provision of proper
glasses and treatment calculated to improve the tone
of the ocular muscles has often been promptly fol-
lowed by substantial relief. The location and char-
acter of pain vary greatly, but as a rule the former
is either suboccipital or frontal. Some ophthalmol-
ogists ascribe the sub-occipital pain to accommoda-

lion weakness, and the frontal headache to refractive
disturbance, but others are equally sure there is no
constancy in the connection. The headache of eye-
strain is of course produced by reading, and aggra-
vated by persistent use of the eyes, and by bright
lights. It is dull and continuous, and may be accom-
panied by lachrymation and photophobia.

Hypermetropic persons are those who most often
suffer from headaches of this character, and witii the
hypermetropia there is often considerable astigmatism.
Myopic persons, through injudicious use of their
eyes, also suffer from dull, persistent vertigo and a
great deal of distress. The victims of ocular head-
aches, as a rule, have red swoilen eyes, and when the
inner surface of the lids is exposed, there will be
found a low grade of inflammation with granulation.
Through insufficiency of the recti, a variety of mus-
cular asthenopia occurs with headaches. This is de-
veloped by close application to fine work, and obstin-
ately resists ordinary treatment. After the patient's
power of ocular adduction or abduction is determined
by means of prisms, a pair of concave glasses may be
selected, or prisms may be provided to overcome the
weakness of the recti. In hypermetropic headaches,
convex glasses are indicated, and at first those of tow
power may be provided, which are to be afterwards
increased.

Some observers have noted a variety of migraine,
which is due to eye-strain and diiTers but little from

— 114 —

the common forms, except, perhaps, that it is more
localized.

There is a form of headache from mechanicaj
vibration which is neurasthenic, and I have met with
it among railroad men or machinists. It is diffused,
present a great deal of the time, and attended by
mental hyperaesthesia. When it is possible the pa^
tient should be made to discontinue his work and seek
rest, but if this cannot be done, the treatment should
consist in cerebral sedatives, the bromides ranking
first.

Ability to Locate Pain a

Acetanilid 46

Aconite in Neuralgia 83

Actual Cautery 87, 107

Alcohol S8

Alcoholic Headache 6

Alkaline Baths n

Ammonia, Valerianate of 106

Aosmic Headaches 5a

Rest Trcaiment in 53

Ani^o-Paretic Migraine 20

Angio-Spastic Migraine 35

Antlfibrine 4b

ADiipyrine in Neuralgia S4

Aoilpyrine 46

Antruni, Disease of 8a

Arseniate of Strychnine 108

Assafcetlda id6

Aural Disease as Cause of Headache iii

Bad Teeth 46, iii

Baths, Alkaline 11

Baths, Needle a6

Q Cold 38

jf Sodium and CaReine 108

Bromide of Ammonium n

BUIoni Heftdache no

Cttffeii

. io6

Citrate lo6

CaSeinic headache 7*

Cannabis Indica 35

Case, Vulplan's 8a

Cerebral Anasmia of Aged People, 44

Chloride of Ammonium 85

Chloroform H

Classification of Headaches 3

Clavus Hystericus 105

Cocaine , 108

Cod-Liver Oil 14

Congestive Headaches s

Causes of 7, 8

Symptoms of. s

Cold, Benham on 38

in Neuralgia go

Coming's Method 30

Connection of Visua] Defects , iij

Cracked ice go

Croton Chloral 84

Cypripedin 106

Diet in AnsEmic Headaches 44

Lith^emic Headache 67

Diabetic headache 7S

Division of Inferior Dental Nerve gS

Donovan's Solution B6

Duquesnel's Solution S4

EpUeptifor
Ergotin. . .

Eicision of Cicalri:

I Tic, Division of Auriculo-Temporal Net

— 117 —

EscredoD of Uric Add in Gout; Headache 67

ExhauslioD 107

Eye Strain as Cause of Headache 112

Farad iialion. General . 53

Facial Neuralgia -78

Formula for Osmic Acid Injection 89

FothergiU in Regard Co Anemic Headache 34

FothergiU'a Solution as

Fork. Ihe Tuning gS

Gaiffc's Disk 95

Galvanism 30, 94

Gouty Headache 67

Gas, Nitrous Oxide 39

Oxygen 39

Goul, 0" '=' ^8

Haig on Diet 67

Htemophilia as Cause of Anaemic Headache 3O

Headache, Alcoholic 6

Aural Disease as a Cause of iii

Bad Teeth as a.Causeof iii

BiUons 110

Bitter Tonici In - 6

Bromides in la

Brain- iTOrk as a Cause ol 7

Caflein in 7^

Canahis Indica in 3$

Cerebral Surgery for Relief of 64

CholBmic 71

Cerebral Tumor a Cause of 60

ClaulGcation of 3

Dlkbelic 7S

Digitalis in 7

Headache, Anaemic Absinthe in

Aibumioate of Iron in

Chartreuse in

Gtraie of Caffeine in

Cocaine in

Fothergill on

General Faradization in

Hypophosphites in

Injection of Dried Blood in

Iron in

Marshall Hall on

Metrorrhagia in

Nasal Stenosis as a Cause of

Nitrous Oxide Gas in

Opium in

Symptoms of

Strychnia in

CoDgestive

Alcohol in

Cardiac Hypertrophy

Climate for

Cod-liverOil in

Diei in

Galvanism in

Ergot in

Meal Diet Harmful in

Meningeal

Mercurials for 15,

PhosphateB in

Pulse in

Symptoms of

Head«che,CoDgcstlTe,Turbi9h Baths la 14

Conjeslivc J

Alcoholic S

Alkaline Baths In 11

Aperient Water it) 6

Bromides in 6

Camphor in q

Cupping in 12

Cutaneous Revulsion In 9

Exposure to Sun, from 7

In Anzmic Patients 7

Purgatives in ij

Veratrum Viride in 7

Head Evil lo;

Head Symptoms no

Herpes in Neuralgia Bi

Hjdrencephalold Condition 45

Hungarian Waters ag

Hunyadi Janos Water 95

Hysterical Headache los

Infra-orbital Neuralgia. 78

lotra-cranlal Neuralgia Bi

Introduction I

Insolalion, in Cases of 7

Iodoform 4f

Iron, Albuminate of 3I

Koumyss. .

»•

Liniments jo

Lith«mic Headaches 6;

Lemaire Picquot on Arsenic 16

Left Ovary, Hyperieslbcnia of 107

121

PAGE.

Lemonade, Phosphoric Acid io8

Localization of Head Pain 2

Malarial Headaches 74

Malate of Iron 37

Massage of Scalp 93

Matzoon 52

Meckel's Ganglion, Removal of 100

Methyl Chloride 90

Meningeal Congestive Headache 17

Meningitis, Headache of 59

Migraine 19

Ammonia Muriate in 22

Angio-paretic 20

Angio-spastic 35

Association with Epilepsy 20

Bromo-caffein in 22

Bromides in 22

Coffee in 22

Chloral in 22

of Children 46

Routh's Formula 23

Symptoms of 20

Treatment of 22

Mortimer Granville's Apparatus 91

Nasal Bleeding ^18

Nasal Headache 112

Nasal Stenosis 44

Needle Bath 26

Neuralgia, Aconite in 83

Actual Cautery in 87

Ammoniated Copper in 85

Antipyrin and Antifebrin in 84

Belladonna in 87

122

PAGE.

Neuralgia, Bi-sulphide of Carbon in 87

Chloride of Ammonia in 85

Chloride of Methyl in 90

Cimicifuga in 85

Cocaine in 87

Croton Chloral in 84

Divisions of 78

Division of Infra-dental Nerve in 98

Donovan's Solution in 86

Electricity, Static in 95

Ether Spray in go

Frontal .* 78

Gaiffe's Disk in 95

Galvanism in 94

General Treatment of 85

Herpes in 81

Intra-cranial 81

Local Treatment of 87

Methyl Chloride in 90

Moist Pack in 05

Neuro- Paralytic Ophthalmia in 8r

Nerve Stretching in 96

Nitrous Oxide Gas 39

Ointment for 87

Osmic Acid in 89

Phosphorus in 86

Refrigeration in 90

Supra Orbitral 79, 81

Sub-occipital 86

Tonga in 85

Trophic Disease in 81

Tr. Actea Rac in 85

Use of Cold in 90

Veratria in 87

Vibratory Treatment of 91

123 —

PAGE.

Neurasthenic Headaches 105

Nervous Headaches no

Ointments , 87

Organic Headaches, Belladonna in 59

Diagnosis of 55

Ergot in 59

Ether Evaporation in 59

HeadCoil in 58

Operation on Eyes for Cure of Headache. . ■ 112

Osmic Acid Injection 89

Ovarian Headache 105

Phosphorus 86

Pathology of Headache i

Percenter 92

Percussion of Skull 62

Periostitis of Alveolar Process as Cause 103

Phosphorus, Thompson's Solution of 87

Phosphoric Acid Lemonade 108

Pharyngeal Granulation as Cause of Neuralgia 103

Physostigma 11

Prosopalgia 98

Purgation 25

Quiet Gout 68

Rectal Injections of Assafoetida 106

Dried Blood 54

Salicylate of Soda 69

Salol 70

Scalp, Faridization of 93

School Children, Headache of 12

Sick Headache 21

Sexual Headache 24

124 —

PAGE.

Solution, Fothergill's 23

Routh's 23

Springs, Mineral 24, 25

Strophanthus 108

Strychnine, Arseniate of 108

Supra-Orbital Neuralgia. 81

Surgery Cerebral 64

Sympathetic Headache no

Syphilitic Headache 56

Large Doses of Iodide in 57

Tic Douloureaux 9o

Gelsemium in 95

Nitro-glycerin in 95

Neurectomy in 9S

Nerve Stretching in 96

Tonga 85

Toxaemic Headache 65

Tobacco as Cause of 76

Trigeminal Neuralgia 78

Trophic Disorders in Neuralgia 81

Tumor as Cause of Headache 60

Uraemic Headache 71

Symptoms of 71

Diet in 72

Tri-Nilrine in 73

Use of Cold 28

Ophthalmoscope in Diagnosis of Headache 62

Valerianate of Ammonia 106

Vulpian's Case 82

Wax in the Ear as Cause 1 1 1

Wire Brush 94

Woakes on Headache 8

LANE MEDICAL LIBRARY

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