Volume 5 — DISEASES OF THE NERVOUS SYSTEM. (continued 13)

²⁹ Transactions of the London Epidemiological Society, vol. i. p. 116.

³⁰ De la Maladies du Sommeil, 1869.

³¹ The Medical Record, July 1, 1882, p. 23.

Lethargy.

A pathological variety of sleep, in which the repose of the body is even more complete than in coma. The victim of coma often presents a countenance suffused with blood; the pulse beats vigorously, and respiration may become stertorous. But in lethargy the abolition of bodily movements is almost total. In the milder forms of this disorder the patient may be partially roused, so as to attempt an answer when addressed, appearing like a person in very profound sleep; but in the majority of cases he remains insensible, unconscious, and utterly irresponsive to ordinary forms of irritation. Respiration and circulation are reduced to a minimum, even becoming for a time imperceptible. Uncomplicated with hysteria, the disorder is rapidly fatal, but according to Rosenthal³² hysterical lethargy is never mortal.

³² Real Encyc. der ges. Heilkunde, vol. viii. p. 276.

Many examples of this disorder have been furnished by the records of apparent death.³³ I am well acquainted with a lady who in early childhood was laid out for burial at the supposed termination of some infantile disease. Her mother alone insisted that the child was still alive. After some time spent in weeping and expostulation, she applied a blister to the thorax of the babe, who at length began to exhibit signs of consequent irritation, followed by a complete recovery. Still more instructive is the case related by Rosenthal³⁴ of a young woman twenty-four years of age who in consequence of violent emotional excitement became unconscious and presented no sign of life, though tested with a mirror before the mouth and by dropping melted sealing-wax upon the skin. On raising her eyelids the pupils gave no response to light; the limbs remained perfectly placid and the radial arteries were motionless. Careful auscultation, however, detected a very feeble and intermittent sound in the cardiac region. The thorax exhibited no movement, but the lateral surfaces of the abdomen presented a slow and almost imperceptible oscillation. Gentle faradization of the muscles and nerves of the face and hand aroused definite muscular contractions. By these observations Rosenthal became satisfied that, although the patient had remained for thirty-two hours in this condition, she was only apparently dead. In fact, after continuing forty-four hours in a state of suspended animation she awoke spontaneously, made a rapid recovery, and enjoyed as tolerable health as an excitable nervous temperament would permit.

³³ See article “Mort apparente,” Dic. Encyc. Sci. méd., 2d Series, vol. ix. p. 598.

³⁴ Loc. cit., p. 272.

Apparent Death.

Certain authors make a distinction between lethargy and apparent death. But, leaving out of view the cases of so-called lucid lethargy, a variety of the trance state, the difference is rather one of degree than of kind. The movements of respiration and of circulation, though greatly diminished, are readily observed in ordinary forms of lethargy, while in apparent death the pulse can no longer be discovered, and only the faintest sound can be distinguished in the region of the heart. It therefore becomes imperative to have within reach a crucial test of the persistence of general vitality. Such a test, according to Rosenthal, exists in the faradic current. Within two or three hours after genuine death the muscles cease to be excitable by the induced current, but in a case of apparent death this form of electro-muscular contractility never disappears. Every other test that has been proposed has failed under certain circumstances. This alone gives uniformly positive indications.

Lucid Lethargy.

In certain cases of apparent death the patient presents the external phenomena of suspended animation, but the power of conscious perception does not cease. The senses of sight and hearing remain, and are perhaps intensified by inhibition of the power of projecting cerebral volitions into space. The sufferer hears and sees; perception, memory, reasoning, judgment, emotion, volition, all persist. The possibility of centrifugal projection from the sphere of consciousness into the realm of space seems to be the only thing that is wanting.

The victims of this form of apparent death are usually women, or men who are characterized by a feminine nervous organization. Great mental excitement, fatigue, semi-starvation, and exhausting diseases are the principal proximate causes of the event. The following case, which was observed by my friend P. S. Hayes of Chicago, illustrates all these facts: A female physician, about thirty years of age and consumptively inclined, after a long and wearisome hospital service was attacked with typhoid fever. After a period of great prostration the hour of death seemed to have arrived. In the presence of her physician and surrounded by her relatives she ceased to breathe and the pulse stopped. Bottles of hot water were applied to the limbs, and other methods of restoration were employed, but a number of hours elapsed before these efforts yielded any result. At last she began to breathe once more; life was resumed and a gradual recovery followed. During all this time of apparent death consciousness had been preserved. She seemed to be looking down from above her bed, by the side of which she could see the physician holding her wrist, and she felt grief at witnessing the sorrow of her friends. Ordinary sensation was suspended, for she did not feel the scalding heat of the bottles that were applied to her limbs. Borne upon the wings of a liberated imagination, she thought she beheld the celestial city, but might not enter within its gates. In this exaltation the reasoning faculties also shared, so that certain philosophical problems which had long baffled her intellect were now perfectly comprehensible, and the memory of their interpretation persisted after recovery.

Many similar narratives have been duly authenticated, but the limits of the present article will not permit a discussion which properly belongs to an investigation of the phenomena of trance. The important fact for present consideration is the persistence of conscious life despite the appearance of death. In this preservation of consciousness, notwithstanding temporary suspension of certain forms of sensibility, together with loss of the power of voluntary motion, may be discovered a relationship between the events of lucid lethargy and various somnambulic modifications of sleep which have been previously passed in review.

ACUTE AFFECTIONS PRODUCED BY EXPOSURE TO HEAT.

BY H. C. WOOD, M.D., LL.D.

There are two distinct diseases—or, more correctly, conditions—of the human body which are produced by exposure to heat, and which have a certain similarity in their symptoms, but are very different in their immediate pathology and require directly opposite methods of treatment. Although their individuality was pointed out as long ago as 1851 by the late D. F. Condie of this city,¹ yet they have been frequently confounded by writers upon the subject, and the terms heat-exhaustion and sunstroke have not rarely been used as strictly synonymous. In the present article it is proposed to consider them as separate affections under the respective names of heat-exhaustion and thermic fever.

¹ Amer. Journ. Med. Sci., Jan., 1852.

Heat-Exhaustion.

Any one who has been long exposed to a high temperature under circumstances requiring physical exertion must have noticed the feeling of general weakness and relaxation which results. Thus far reaches our every-day experience, but cases in which acute symptoms are severe enough to cause alarm occur, although somewhat infrequently. The attack may come on slowly, but may be as abrupt as that of true sunstroke, and the severest cases may happen in those who have been in robust health as well as in the weak and feeble. The mind is usually clear, the pulse rapid and feeble, the surface cool, the voice very weak, muscular strength greatly lessened, and the feeling of exhaustion extreme. If this condition be intensified, syncope may be developed with its usual symptoms. In all this there is nothing peculiar and little that is necessary to notice here; but there is a form of heat-exhaustion in which the heart does not seem to suffer principally, but in which there is collapse with palsy of the vaso-motor system, great fall of the bodily temperature, and marked general nervous symptoms. At the International Exhibition of 1876 a very powerful man, whilst working in an intensely hot, confined space, fell down without giving warning, and was brought into the hospital. He was in a state of restless, delirious unconsciousness, incessantly muttering to himself, and when shaken and shouted at responding only by a momentary grunt. The pulse was rapid, fluttering and feeble. The surface was covered with a very heavy sweat and exceedingly cold. The muscular relaxation was extreme. The facies was that of collapse, and the temperature, as taken in the mouth, 95.25° F.

The PATHOLOGY of heat-exhaustion is best discussed in conjunction with that of thermic fever, and will therefore be for the present postponed.

The TREATMENT of heat-exhaustion is a very obvious one. The indications are to stimulate the circulation and warm the body by external heat with an energy proportionate to the severity of the attack. In mild cases the exhibition of a whiskey punch or similar beverage may suffice, but in severer attacks alcohol acts too slowly and is not capable of filling all the indications. It may re-excite the flagging heart, but it is probably not a vaso-motor stimulant, and if given too freely may even increase the vaso-motor depression. Digitalis is an excellent stimulant of the heart, and probably also of the vessels. It acts, however, comparatively slowly even when hypodermically injected, but in severe cases it should always be employed. The tincture is the most eligible preparation, and when injected under the skin in doses of fifteen drops causes no local irritation. Ammonia would be a very valuable remedy did not its use offer so many difficulties of administration: injected into the cellular tissue, it causes great pain and usually sloughing, and its intravenous use is by no means always easy. As a vaso-motor stimulant atropia is an excellent remedy, and, as it has also a very powerful influence in arresting the secretion from the skin and in raising the animal temperature, it should produce very good results in the peculiar form of collapse under consideration.

When the bodily temperature is below normal the most important measure of treatment is the use of the hot bath: the water should be from 100° to 120° F.—i.e. as hot as can be borne—and the whole body should be immersed in it until the mouth temperature becomes normal.

Thermic Fever.

SYNONYMS.—Coup de soleil, Sunstroke, Heat apoplexy, Heat asphyxia, Heat fever, Sun fever, Thermohæmia, Erethismus tropicus, Insolation.

The immediate cause of thermic fever is always exposure to excessive heat in some form. As the body can cool itself much more readily in a dry than in a moist atmosphere, it is able to resist the influence of a dry, overheated air much better than when there is also moisture. It is for this reason that sunstroke is so much more infrequent upon the high table-lands of Abyssinia or in the dry belt of our Texan prairies than in the lowlands of India or upon our own seacoast. For the same reason it is especially prone to attack indoor workers in confined, moist factories, and especially in laundries and sugar-refineries. At one time it was thought that exposure to the direct rays of the sun was the chief cause of the disease, but there is now abundant clinical testimony to the fact that such exposure is in no sense necessary. Without occupying space in giving detailed references, it suffices, as an illustration of the fact that the most complete darkness is no protection, to allude to the epidemic upon the French man-of-war Duquesne, as recorded by M. Boudin, in which a hundred cases of sunstroke occurred in a short time, most of them at night when the men were lying in their bunks. Bonniman² says: “By far the greater number of cases that yearly occur in India are of men who have not been exposed to the sun. It is not unusual for men to go to bed in apparent health, and to be seized during the night; and patients in hospitals who have been confined to bed for days previously are frequently the subjects of attack.”

² Edinburgh Med. Journ., vol. xiv. p. 1029, 1864.

Although the immediate cause of the attack is excessive heat, there are certain conditions which act as predisposing causes by lessening the power of the system to resist the heat, or, in accordance with the theory of sunstroke which I believe established, by so weakening the inhibitory heat-centre that it is readily exhausted. The chief of these predisposing causes are race, excessive bodily fatigue, and intemperance. It is true that males are much more frequently affected than females; thus, in an epidemic occurring in St. Louis, Missouri, in 1878, there were 115 deaths in males and 39 in females. This is due, however, not to one sex being predisposed to the attacks, but to the habitually greater exposure of males than of females to heat. The much greater frequency of sunstroke in the laboring than in the upper classes has similar explanation.

Those races which are least accustomed to a tropical climate are most apt to be attacked; thus, both in this country and in India, Europeans suffer far more than do the natives. No race is, however, absolutely exempt. Even the negro and the Hindoo inhabitant of tropical India are occasionally prostrated.

The general experience in the United States shows that habitual excess of alcohol very strongly predisposes to attack, but some of those who have had widest experience in India are inclined to deny this. It has been especially noted in India that persistent bodily fatigue greatly weakens the resisting power of the European. As an instance of this may be cited the case of the Forty-third regiment of the line during the Sepoy rebellion, as recorded by its surgeon, Barclay. It had made a most extraordinary march of over eleven hundred miles, chiefly through the lowlands of India, and at the hottest season of the year. This march was continuous, with the exception of a few brief halts. No cases of sunstroke occurred until nine hundred and sixty-nine miles had been traversed and the men had become thoroughly exhausted and even markedly emaciated. Shortly after this the regiment rested some eight days, and then started again, arriving soon in a narrow ravine in the Bisramgunge Ghat, with precipitous walls nearly a mile in height. During the day the thermometer in the tents ranged from 115° to 127°, and on one occasion was noted 105° at midnight. The number of cases of insolation now became very great, and, although most of them recovered, 2 officers and 11 men were lost in the four days during which the regiment remained encamped. The air became cooler as the command emerged from the hills, yet 7 more fatal cases occurred in three days.

SYMPTOMS.—Under the name of ardent continued fever, or febris continuis communis, has been described in India an affection which may be considered as representing a mild form of thermic fever. In C. Morehead's clinical work On the Diseases of India the following account of the symptoms is given: “The attack is generally sudden, often without much chilliness. The face becomes flushed; there are giddiness and much headache, intolerance of light and sound. The heat of skin is great; the pulse frequent, full, and firm. There is pain of limbs and of loins. The respiration is anxious. There is a sense of oppression at the epigastrium, with nausea and frequent vomiting of bilious matters. The bowels are sometimes confined; at others vitiated discharges take place. The tongue is white, often with florid edges. The urine is scanty and high-colored. If the excitement continues unabated, the headache increases, and is often accompanied with delirium. If symptoms such as these persist for from forty-eight to sixty hours, then the febrile phenomena may subside, the skin may become cold, and there will be risk of death from exhaustion and sudden collapse. In most cases the cerebral disturbance is greater in degree, and in these death may take place at an earlier period in the way of coma.”

Until very recently the existence within the United States of this class of cases has not been recognized. But in a very able article in the Therapeutic Gazette of March 16, 1885, John Guiteras shows that the so-called typhoid fever of Key West is the disease described by Morehead.

In the Philadelphia Medical Times, vol. v. p. 664, C. Comegys calls attention to the cases of entero-colitis which are so abundant in the young children of our cities during the hot months. The immediate enormous rise of the mortality-rate among children which always accompanies a marked rise of temperature during July or August indicates very strongly that excessive heat is the chief factor in the production of the disorder. The symptoms may be summed up as high fever, dry tongue and mouth, rapid pulse and respiration, intense thirst, vomiting, purging of greenish, watery, fecal or serous matters with undigested particles of food, and more or less pronounced evidences of cerebral disturbance, such as insomnia, headache, contracted pupils, delirium, and finally coma. In some cases the bodily temperature rises before death to a point comparable with that it reaches in sunstroke of the adult. As pointed out first by Comegys, these cases are almost uniformly relieved by cold water used either, as Comegys himself employs it, in the form of cold affusions practised until the temperature of the child becomes normal, or, as, according to my own experience, is preferable, simple cold baths administered every two to three hours, with just sufficient vigor to produce the desired effect.

Thermic fever in the adult and in this latitude is usually first seen by the physician after the stage of insensibility has been reached. In many cases this condition comes on with great suddenness, but in other instances there are distinct prodromata, such as inaptitude and disinclination to exertion, vertigo, headache, confusion of ideas, great oppression or distress at the præcordia or epigastrium, and disturbances of the special senses. Swift has noticed a peculiar chromatopsia, the sufferer seeing everything of a uniform color, in most cases blue or purple, but in others red, green, or even white, and W. H. Kesteven³ has reported a case in which a man, after exposure to an excessively hot sun, was seized with severe headache, saw everything red or green, and had for some days a distinctly impaired color-sense.

³ Trans. Clin. Soc. of London, 1882, xv. 101.

At one period I saw a large number of advanced cases of sunstroke in the hospital, and the symptoms were quite constant. Total insensibility was always present, with, in rare instances, delirium of the talkative form, and still more rarely the capability of being roused by shaking or shouting. The breathing was always affected, sometimes rapid, sometimes deep and labored, often stertorous, and not rarely accompanied by the rattle of mucus in the trachea. The face was usually suffused, sometimes, with the whole surface, deeply cyanosed. The conjunctiva was often injected, the pupils various, sometimes dilated, sometimes nearly normal, sometimes contracted. The skin was always intensely hot, and generally, but not always, dry; when not dry it was bathed in a profuse perspiration. The intense burning heat of the skin, both as felt by the hand and measured by the thermometer, was one of the most marked features of the cases. The degree of heat reached during life was, in my cases, mostly 108°–109° F., but it sometimes reaches 112° F. The pulse was always exceedingly rapid, and early in the disease often not wanting in force and volume; later it became irregular, intermittent, and thready. The motor nervous system was profoundly affected: subsultus tendinum was a very common symptom; great restlessness was also very often present, and sometimes partial spasms or even violent general convulsions. The latter were at times epileptiform, occurring spontaneously, or they were tetanoid and excited by the slightest irritation. Sometimes the motor system suffered paralysis, the patient moving neither hand nor foot.

This extreme motor relaxation, which in my observation is rare, seems to have been very common in the epidemic described by Barclay,⁴ as he states that in a large proportion of the cases, from the commencement of the attack until its termination in death, the patient never moved a limb or even an eyelid. Petechiæ and ecchymoses, the evidences of broken-down blood, were present in some of my cases, and there was in one or two instances a fetid hemorrhagic exudation from the nostrils during life. A symptom which has almost escaped the attention of authors was a peculiar odor, which was most marked in patients who had involuntary passages, but was very distinct from any fecal odor. The stools emitted it very strongly, but so did the skin and breath. It was so distinctive as to render possible the recognition of a case by the sense of smell alone. The discharges from the bowels were liquid and very often involuntary. None of my cases passed urine whilst under observation.

⁴ Madras Quarterly Journal, 1860, 364.

It is plain that the symptoms of coup de soleil, as usually seen, may be summed up as those of intense fever, accompanied by profound nervous disturbance (as manifested by insensibility with or without delirium, and by motor symptoms, such as convulsions or paralysis), by arrest of glandular action, and by changes in the blood. In this ordinary form of sunstroke death takes place by asphyxia or by a slow consentaneous failure of both respiration and cardiac action. It very rarely occurs in less than half an hour after the first decided symptoms, and usually is postponed for a much longer period.

There is a form of coup de soleil in which death results almost at once, and probably always by cardiac arrest, and to which the name of the cardiac variety may well be given. It is very rarely, if ever, met with in civil life, and among soldiers is especially seen during battle or at other times when great exertion is being made. These cases will be more fully discussed in a later portion of this article.

POST-MORTEM CHANGES.—Owing to the excessive heat of the body, putrefactive changes occur very rapidly after death from sunstroke, and various described lesions, especially of the heart, have been undoubtedly the result of post-mortem changes. Later observers have confirmed my original observation, that if the body be opened directly after death the left ventricle will be found firmly contracted, though the right heart and the pulmonary arteries, with their branches, are gorged with dark fluid blood. In my cases the lungs did not present at all the appearance of congestion of their minute capillaries, but when they were cut the blood poured from them abundantly, seemingly from their larger vessels. Not only do the lungs suffer from venous congestion, but the whole body also. The blood appears to leave, as it were, the arterial system and collect in the venous trunks. The arterial coats are often stained red, apparently by the broken-down red corpuscles of the blood.

There can be no doubt that the blood suffers in sunstroke very similarly to what it does in low fevers. Its coagulability is impaired, but not always destroyed; and it is possible that in the very rapid cases it may not be decidedly affected. After death it appears as a dark, often thin, sometimes grumous fluid, whose reaction is very feebly alkaline, or, as I have seen it, even decidedly acid. Levick⁵ appears to assert that the blood-discs, as seen by him under the microscope, were shrivelled and crenated, and showed very slight tendency to adhere in rouleaux. In several of my cases the blood was carefully examined by the microscope, but nothing abnormal was found. The extravasations of blood which have been found by K. Köster in various parts of the nervous system are probably of the nature of petechiæ, the results of the altered blood-crasis, and not due to any especial affection of the nerve-centres.

⁵ Pennsylvania Hospital Reports, 1868, 373.

THEORY OF THE DISEASE.—The theories which have been brought forward as explanatory of the phenomena of sunstroke are so various that it would be impossible in the limits of this paper to discuss them. It does seem, however, proper to give a very brief historical sketch of the development of our present knowledge of the subject. In 1854, H. S. Swift⁶ said that the disease is “now generally admitted to be merely exhaustion produced by fatigue,” although he recognized the existence of an “apoplexy produced by insolation.” The cases which Swift so well describes as those of heat-exhaustion were true instances of thermic fever. The physicians of the Pennsylvania Hospital, especially Gerhard, early called attention to the resemblance of sunstroke to a fever, but it was not until January, 1859, that their views found expression in print in the paper published by James J. Levick in the American Journal of Medicine. This observer tabulated the post-mortem appearances of typhus fever and of sunstroke in contrast, calling attention also to the similarity of symptoms during life. In 1863, H. C. Wood⁷ claimed distinctly that sunstroke is a fever due to the development of a poison in the blood, and gave to the disease the name of thermic fever. To R. Cresson Stiles is due the credit of having first proven⁸ the possibility of producing in animals a sunstroke with symptoms and pathological changes similar to those which occur in man. He also came to the conclusion that the symptoms are the results of the direct action of heat, especially upon the muscular system. He says: “The dilatation of the capillaries is explicable by the direct effect of the heated blood upon the muscular fibres of the arteries and the arterioles. The cerebral symptoms and the full and forcible pulse may also be due to this dilatation.” George B. Wood, in the sixth edition of his Practice of Medicine (Philadelphia, 1866), wrote an elaborate article upon the disease, giving it the name of heat fever, and affirming that it “is, I believe, strictly an idiopathic fever.” He further asserts: “In heat fever all the organs, the brain, heart, lungs, stomach, kidneys, etc., are excessively stimulated by the great heat, and all exhibit disorder and at length depression of their functions.” The article of George B. Wood was not based upon experimental researches, but upon a very philosophic rendering of the clinical phenomena, and was a carrying out of the ideas which had permeated the medical teaching of the Pennsylvania Hospital.

⁶ New York Med. Journ., vol. xiii. p. 53.

⁷ Amer. Journ. Med. Sci., October.

⁸ Boston Med. and Surg. Journ., June, 1864, p. 349.

About 1869, Eulenberg and Vohl⁹ advanced the theory that death from sunstroke is the result of the sudden liberation of gases in the blood; and Weikard affirmed that the death is due to the increase of the coagulability of the blood and consequent formation of clots in the vessels, being in this supported by Richardson of London.¹⁰ Contrasting with these in its being really an important contribution is the article of Vallin:¹¹ its chief merit is the conception of the idea of the local heating of isolated parts of the body, and the devising of a plan for carrying the idea into effect. The experiments of Vallin did not themselves prove very much, and led him to the erroneous conclusion, first, that the death in sunstroke is the result either of a coagulation of the left ventricle or else of a disturbance of the innervation of the heart by an action of the heat upon the nerve-centres in the base of the brain; second, that these two forms of death correspond to sthenic and asthenic varieties of insolation—varieties which, I believe, have no proper existence.

⁹ Virchow's Archiv, t. lxii.

¹⁰ St. Bartholomew's Reports, vol. vii.

¹¹ Archives générales de Médecine, Fèvrier, 1870.

The first experiments of Claude Bernard upon the action of external heat were given in a lecture upon muscular respiration on May 3, 1864, published in his Leçons sur les Propriétés des Tissus vivants (Paris, 1866). They were merely incidental to another research, and simply showed that when a warm-blooded animal was exposed to heat it died, the death being, according to the observations of Bernard, the result of cadaveric rigidity suddenly attacking the heart. The more elaborate researches of Claude Bernard upon the effect of exposure of animals to external heat, so far as I have knowledge, were not published in detail until after the nature of sunstroke was determined, although the lectures were delivered in the years 1871 and 1872; they may be found reported in full in his Leçons sur la Chaleur animale, sur les Effets de la Chaleur, et sur la Fièvre (Paris, 1876).

It is proper also to state here that some of the physicians of India had previous to this time more or less imperfectly recognized the relation of sunstroke to fever, but, I believe, none of them distinctly postulated the theory.

The above historical sketch shows that by many authors the relation of sunstroke to fever had been more or less dimly perceived, and that George B. Wood had very clearly stated the true nature of the affection, in that it was simply the result of the direct action of heat. Such statement, however, not resting upon proof, had not been accepted: it was also wanting in detail, and where such details were attempted the surmises were not always correct. Under these circumstances my researches, made in 1870 and 1871, and first published in 1872, led to the complete understanding of the affection.

The space allotted to me in the present volume will not allow of any detailed account of my experiments, but I shall quote from my summing up of the results obtained by them. It was shown that sunstroke may be produced in animals as readily as in man either by natural or artificial heat; that the symptoms are similar to those seen in man; that death takes place ordinarily by asphyxia; that after death the characteristic lesions are alteration of the blood and rigidity of the heart, with immediate or quickly-appearing post-mortem rigidity of the general muscular system; that this rigidity of the heart comes on in most cases after, not before, death, and is a result, not cause, of death; that post-mortem rigidity is dependent upon coagulation of myosin, and that the rigidity of the heart is of similar origin, coagulation of the muscle-plasma occurring almost instantaneously at 115° F., a degree almost attained in sunstroke; that when a muscle has been in great activity immediately before death, myosin coagulates at a much lower temperature, and that the cases of sudden cardiac death occurring in battle among the East Indian English troops were no doubt due to the coagulation of the heart's myosin; that heating the brain of a mammal produces sudden insensibility, with or without convulsions, at a temperature of 108° F., and death when a temperature of 113° is reached; that this effect of the local application of heat is not due to induced congestion, but is the result of the direct action of the heat upon the cerebrum, and that consequently the nerve-centres are as perniciously affected by high temperature as the muscles are; that the nerve-trunks bear a temperature of 125° F. without their conducting power being immediately affected; that whilst the general symptoms induced by heating the brain of a rabbit are very different from those of sunstroke, the nervous symptoms are exactly similar; that the life of the blood is not destroyed by any temperature reached in sunstroke, the amœboid movements of the white blood-cells and the absorption power of the red disks not being injured; that the amount of oxygen of the blood is greatly lessened, as the result of gradual asphyxia combined with abnormal consumption of oxygen; that there is no reason for believing that capillary thrombi are common in sunstroke; that there is no specific poison developed in the blood; that the deterioration of the vital fluid is due to the rapid tissue-changes induced by the fever and the more or less complete arrest of excretion; that such deterioration is secondary to the nervous symptoms, not primary; that if the heat be withdrawn before it has produced permanent injury to the nervous system, blood, or other tissues, the convulsions and unconsciousness are immediately relieved and the animal recovers.

As a postulate from these facts and deductions, I think it follows that the nature of sunstroke is that of a fever; or, in other words, that coup de soleil is a fever, not dependent upon blood-poisoning, but upon heat.

It is of course possible that the external heat causes the fever, simply by preventing the body from throwing off the caloric which it is constantly forming. The extreme suddenness of the onset, however, indicates that in at least many cases there is a sudden outburst, as it were, in the production of heat in the body. This indication becomes more important when it is remembered that in cerebral rheumatism, so called, there is often an equally sudden attack of symptoms plainly the result of a sudden production of animal heat.

In an elaborate research¹² I showed the truth of Setschenow's theory, that there is in the pons a centre whose function it is to inhibit the production of animal heat, and that in the medulla a centre (probably the vaso-motor centre) which regulates the dissipation of the bodily heat; and that fever is due to disturbance of these centres, so that more heat is produced than normal, and proportionately less heat thrown off. Let it be supposed that a man is placed in such an atmosphere that he is unable to get rid of the heat which his body is forming. The temperature of his body will slowly rise, and he may suffer from a gradual thermic fever. If early or late in this condition the inhibitory heat-centre becomes exhausted by the effort which it has been making to control the formation of heat, or becomes paralyzed by the direct action of the excessive temperature already reached, then suddenly all tissues will begin to form heat with the utmost rapidity, the bodily temperature will rise with a bound, and the man drop over with some one of the forms of coup de soleil.

¹² Fever, Smithsonian Institute, 188-.

Under this view of the case the widespread popular belief, that protecting the back of the head and upper neck from the direct rays of the sun is useful against sunstroke, gains in significance, because it is possible that local heating of the parts spoken of may occur and aid in the production of inhibitory paralysis.

If this theory of thermic fever be correct, heat-exhaustion with lowered temperature probably represents a sudden vaso-motor palsy—i.e. a condition in which the exhausting effects of the heat paralyzes not the inhibitory heat-centre, but the vaso-motor centres in the medulla, since my experiments have shown that vaso-motor palsy increases enormously the loss of animal heat and diminishes its production.

In most cases of sunstroke death comes on gradually by arrest of respiration, such arrest being without doubt due to direct paralysis of the respiratory centres by the excess of heat. Allusion has already been made to the cases of sudden death by cardiac arrest, which have especially been seen in India, almost always during a march or during a battle. “As an example of it may be cited the account given by a witness to Parkes, and incorporated in his work on hygiene,¹³ of an occurrence during the first Chinese war. The Ninety-eighth regiment was marching on a very hot day, and the surgeon who was with the rear-guard stated to Parkes that the men fell suddenly on their faces as though struck with lightning, and on his running up and turning them over many of them were already dead. Maclean, who was present at this occurrence, confirms the account given by Parkes, but states that it was at the attack on Chiang-Kiang-Foo. The men were thickly clothed, with tight accoutrements and tight, rigid stocks, and were charging up a very steep hill. A great number of them were stricken down, and fifteen died instantly, falling on their faces and giving merely a few convulsive gasps.”

¹³ Pract. Hygiene, 2d ed., p. 360.

It has been shown that excessive exercise so alters the condition of the myosin of muscle as to cause it to coagulate much more readily than normal. During battle the amount of muscular effort that is made is enormous, and hence it is that men are so often found stiffened in the attitude in which they were struck by the bullet, instantaneous death being followed by equally instantaneous post-mortem rigidity. The description that has been given by Parkes and Maclean of the circumstances in which the sudden deaths just described occurred shows that the heart-muscles must have been strained to their utmost limit. The men were making violent exercise going up hill, so that the heart must have been in exceedingly active exertion, increased by the impediment to the circulation afforded by the tight accoutrements, and under these circumstances the victims probably died instantly because the heart-muscle suddenly set itself from life into the stiffness of death.

The DIAGNOSIS of thermic fever is usually made with great readiness. In distinguishing between it and heat-exhaustion the temperature of the body is the guide. In apoplexy with high temperature it is possible that a little embarrassment might be experienced, but in apoplexy the high temperature follows the nervous symptoms after a distinct interval, but in thermic fever it precedes the unconsciousness. An apoplexy may develop during a sunstroke, but such occurrence is rare. T. S——, now under my care, has had frequently repeated attacks of local convulsions affecting two fingers of the right hand, and one general epileptic attack whilst under observation. He dates his illness to a sunstroke on July 7, 1885, and O. D. Robinson of Georgetown, Delaware, writes me that the attack was undoubtedly true thermic fever, and that the movements of the fingers came on whilst the patient was recovering consciousness. It is probable, therefore, that there was a rupture of a small vessel in the brain-cortex during the sunstroke. The appearance of local convulsions or of localized paralysis during a sunstroke would be good ground for believing that either a clot or a thrombus had formed.

PROPHYLAXIS AND TREATMENT.—The prophylaxis of sunstroke is so evident in its nature that it may be dismissed in a few words. When exposure to heat is imperative the bodily health should be maintained by avoidance of alcoholic, sexual, or other excesses, and, as far as possible, of great bodily or mental fatigue; the diet should be almost purely farinaceous, and the glandular apparatus of the bowels, kidneys, and skin kept in an active state by the use of fruit, water in abundance, and mild salines if necessary. Many persons have a very strong prejudice against the drinking of cold water during exposure to heat; and it is conceivable that large draughts of intensely cold ice-water may do harm by suddenly chilling the stomach; but when the water is taken in small quantities at short intervals, by its action in reducing the general temperature, but especially by its rendering free perspiration more easy, it must exert a most favorable influence. The addition of claret or some other local stimulant to the water is often of great service when there is a tendency to gastric or intestinal depression.

In the mild cases of continued thermic fever the basis of the treatment should be the use of the cold bath. The plan adopted by Guiteras at Key West was to wrap the patient in a dry sheet, lift him into a tub of water, having the temperature between 80° and 85°, and then rapidly cool this water by means of ice. The time of the immersion lasted from fifty to fifty-five minutes, it being regulated by the thermometer in the mouth of the patient. The patient was then lifted out upon a blanket, the skin partially dried, and the body covered. Guiteras found great advantage by giving a moderate dose of whiskey and thirty minims of the tincture of digitalis twenty minutes before the bath. He states that it is very important to avoid currents of air blowing upon the patient and to have the bath given in a small warm room. The result of the bath was invariably a lowering of the temperature, a reduction of the rate of pulse and respiration, and a refreshing sleep. After the second bath the course of the temperature seemed permanently influenced for the better. It was never necessary to give more than two baths in the twenty-four hours, but in some cases they had to be used for many days.

In the severe acute form of thermic fever it is essential that the bodily temperature be reduced at once, and no time should be lost waiting for a physician. As soon as the patient falls he should be carried into the shade with the least possible delay, his clothing removed, and cold affusions over the chest and body be practised. This must not be done timidly or grudgingly, but most freely. In many cases the best resort will be the neighboring pump. In the large cities of the United States during the hot weather hospital ambulances should be furnished with a medical attendant and with ice and antipyrin, so that when a sunstroke patient is reached he may be immediately stripped underneath the cover of the ambulance and remedial measures applied during his passage to the hospital. I believe many lives are now sacrificed by the loss of critical moments in the interval between the finding of the patient and his reaching the hospital ward.

If circumstances favor, instead of the cold affusions, rubbing with ice may be practised. The patient should be stripped and the whole body freely rubbed with large masses of ice. When practicable, a still better plan is to place the patient in the cold bath (50° F.) The employment of enemata of ice-water, as originally suggested by Parkes, may sometimes be opportune.

In using these various measures it must always be borne in mind that the indication is the reduction of temperature: if the means employed do not accomplish this, they do no good.

Relaxation of the pupil is said to be “the first symptom that shows the good of the cold affusion;”¹⁴ but as, in my experience, the pupil frequently has not been contracted, reliance cannot be placed upon this, and the thermometer in the mouth or the rectum affords the only proper guide as to the effect of the treatment.

¹⁴ Aitken, Practice of Medicine, vol. ii. p. 394.

It must be borne in mind, however, that the cold douche, cold bathing, etc. are powerful remedies, and are capable, if used too long, of doing harm. In my experiments upon animals I have seen the temperature, when reduced by the cold bath after sunstroke, continue to fall, after the animal had been taken out of the water, until it was many degrees below normal.

In the cases which have come under my own observation after the use of the cold bath but little treatment has been required. If, however, the period of insensibility has lasted too long, there may be no return to consciousness, even though the bodily temperature be reduced to the norm. Under such circumstances the case is almost hopeless, and I know of no treatment other than that of meeting the symptoms as they arise, excepting that a large blister should, in my opinion, be applied to the whole of the shaved surface of the scalp.

After the temperature has been reduced, and even after consciousness has returned, there is sometimes a great tendency to a fresh rise of temperature, and consequent relapse. This tendency may be met by wrappings in wet sheets, and, if necessary, by a recourse to the more powerful measures for reduction of temperature which have been already cited. It can be to some extent controlled by the use of quinine, ten grains of which may be given hypodermically. During the heated term of the summer of 1885 antipyrin has been used both in New York¹⁵ and in Philadelphia¹⁶ with asserted most excellent results; and the testimony is so strong that I think it should always be employed as an aid to, not as a substitute for, the direct extraction of the bodily heat. It should be given hypodermically, as soon as the patient is found, in doses of from fifteen to thirty grains.

¹⁵ B. F. Westbrook, New York Med. Journal, July 25, 1883.

¹⁶ Orville Horwitz, Trans. College of Physicians of Philada., Oct., 1885.

In cases complicated with repeated severe convulsions, hypodermic injections of one-quarter of a grain of morphia have been very frequently given in the Pennsylvania Hospital, with excellent results. In such patients the use of anæsthetics to facilitate the giving of cold baths would be very proper, but so long as the temperature is high nothing should be allowed to substitute the external cold.

Severe headache and other evidences of cerebral inflammation, manifesting themselves directly after the recovery of consciousness, should be met by local or even general bleeding, blistering, the use of arterial sedatives, mercurials, etc.; or, in other words, by the treatment of cerebral inflammation from other causes adapted to the exigencies of the individual case.

Formerly, venesection was largely practised in sunstroke, with occasional excellent effects, but with, on the whole, very bad results. As free bleeding lowers temperature markedly, it can be readily understood that in some cases it might bring about a return of consciousness and yet be a very improper remedy. If in any instance sthenic apoplectic symptoms persist after the lowering of the bodily temperature by the bath, venesection should be carefully considered. There are cases of sunstroke in which the high temperature irritates the brain or its membranes into an acute congestion or inflammation. These complications are especially prone to occur when the high temperature has been allowed to continue for a long time. A case of this character, in which the autopsy revealed proof of the presence of an acute meningitis, may be found on p. 121 of my book on Thermic Fever. When, then, the patient has a tendency to excessive headache and continuous fever, bleeding may become an essential remedy, not for the cure of thermic fever, but of the cerebral inflammation which has been produced by that fever. The case of S. Weir Mitchell is in point. In his early manhood he had a sunstroke, and when consciousness began to return “the first sensation was that of an intense, agonizing headache, and the next was the perception of his father—J. K. Mitchell—and Mütter discussing the possibility of his recovery. As soon as he could speak, he said, ‘Bleed me.’ His father, coming to the bed, shook his head, but the son repeated, ‘Bleed me.’ He persisted in simply repeating this until they thought him delirious; but at last he mustered strength to say, ‘I am not delirious, but have a frightful headache: if you don't bleed me I will die.’ By this time his pulse had become full and bounding, and finally he sat up and was bled. Ten or fifteen ounces were taken without avail; but as more blood flowed the headache vanished, to be succeeded by a feeling of most delightful languor and rest from pain. Between twenty-five and thirty ounces were taken, and afterward recovery was a very simple matter.”

That Mitchell by the bleeding was saved from meningitis appears almost certain, but it is most probable that if he had been primarily immersed in a cold bath no bleeding would have been required.

SEQUELÆ.—Almost all persons who have had a coup de soleil suffer from after-effects. In the mildest form these are inability to bear exposure to heat without cerebral distress or pain, with more or less marked failure of general vigor, dyspeptic symptoms, and other indications of disturbed innervation. In other cases the symptoms are more decided. Pain in the head is usually prominent: it may be almost constant for months, but is always subject to exacerbations. It sometimes seems to fill the whole cranium, but not rarely is fixed to one spot; and I have seen it associated with pain in the upper cervical spine and decided stiffness of the muscles of the neck. With it may be vertigo, decided failure of memory and of the power of fixing the attention, with excessive irritability. When the symptoms approach this point in severity, there is usually marked lowering of the general health, loss of strength, possibly some emaciation, and the peculiar invalid look produced by chronic disease.

Epileptic convulsions occasionally follow a sunstroke, but, at least in my experience, are always associated with more constant evidences of cerebral disease.

A pathognomonic symptom in the sequelæ of sunstroke is the effect of heat. The glare and heat of summer are the most trying, but usually artificial heat is not well borne. It is very common for headache and severe general distress to be produced by going into a warm room even in the winter months. Where cerebral symptoms are affirmed to be the result of a sunstroke, if there be no excessive susceptibility to heat the alleged sunstroke has almost certainly been an attack of some other nature; and on several occasions I have been enabled to determine that a supposed epileptic attack or a fall followed by unconsciousness from violence was really a sunstroke by noting the extreme susceptibility to heat. The symptom I believe to be a diagnostic one.

The lesion in these cases is usually chronic meningitis, though it is possible that in some instances the gray matter rather than the membrane of the brain may be affected, and in severe cases the gray matter is of course more or less compromised. In one case occurring in the care of S. Weir Mitchell, and in one in my own practice in which death occurred from extraneous causes, severe chronic meningitis was found at the autopsy.

The TREATMENT of these cases is that of chronic meningitis, with the added precautions against exposure to heat. In any severe case change of habitation to a cool climate during the hot period of the year is essential: twenty-four hours' exposure may undo all the good achieved by months of careful treatment.

It is hardly proper here to enter into a detailed discussion of the remedial measures to be employed in this as in the other forms of non-specific chronic meningitis. Local bleedings, the use of counter-irritation, especially by the actual cautery, the internal administration of mercurials and of iodide of potassium in small continued doses, with abstinence from brain-work and the regulation of the habits of life, constitute an array of measures which will no doubt be fully discussed by the author of the article upon Chronic Meningitis.

Provided the patient can be entirely controlled, the PROGNOSIS in these cases is not so bad as at first it appears to be. As an instance of a remarkable recovery I condense from my notebook the case of T. W. H——, aged 49, who came under my care with a history that two years previously he had been seized during a hot day in the summer with a very violent headache, which continued for five weeks, confining him to bed, and was associated, as he said, with fever, but no other symptoms. This attack had been diagnosed by several physicians variously, but as I found that he was excessively affected by any exposure to the sun, was always worse in summer, and that in winter his symptoms were extremely exaggerated even by such heat in a room as is agreeable to many persons, I concluded that the original attack had really been one of thermic fever. He had lost about forty pounds in weight; his memory had become so bad for recent events that he could not call to mind things which had transpired one or two hours previously. Sight had failed much, and there was double vision. He suffered from almost incessant dull headache and excessive general wretchedness; the optic discs were slightly swollen, and one of the margins obscured. There was no albuminuria, and the dyspeptic symptoms were so bad that the man had been treated for months for dyspepsia. Nine months of treatment sufficed to restore this patient almost to his original health. The treatment consisted essentially in the alternate administration of minute doses of calomel and of iodide of potassium—in the meeting of various minor symptoms as they arose, but chiefly in the persistent, merciless use of counter-irritation at the nape of the neck. The actual cautery was applied every one or two weeks, and antimonial ointment freely used on the burnt surface.

HEADACHE.

BY WHARTON SINKLER, M.D.

SYNONYMS.—Cephalalgia, Cephalœa.

It is not possible to give in a few pages a complete treatise on headache, and it is therefore intended merely to describe the most common types of this malady.

Many forms of headache are symptomatic of some organic cerebral disease, like tumor of the brain or syphilitic diseases of the skull. Headache also constantly accompanies fevers of all kinds. A great number of cases are met with in which no cause for the headache can be discovered, and in which the pain is the only symptom. In these there must be some disordered state of the sensory nerves within the cranium, but just what the nature of the abnormal condition is it is impossible to decide.

The character of the pain in headaches is various. In some cases there is a violent general pain over the entire head. In others the pain is localized in one particular spot, feeling as if a nail were being driven into the skull. This is called clavus, and is often met with in hysterical patients.

Patients sometimes describe the head as feeling as if it were splitting open, or, again, as if it were being compressed. The pain may involve one side of the head alone, hemicrania, or it may be only in the back of the head. The top of the head is a frequent seat of pain, especially in women who have uterine disorders. In short, the pain may be in any or every portion of the head, or it may move about from place to place.

In almost all varieties of headache the pain is aggravated by noises or strong light. Any movements of the patient increase it, and coughing, sneezing, or straining—as, for instance, at stool—adds to the suffering. Tapping on the head usually does not increase the pain, and in some instances alleviates it.

Accompanying the headache is a variety of other symptoms: some of them are nervous, while others are not. There are often disturbances of vision, such as bright spots or zigzags before the eyes; and there may be ringing in the ears; palpitation or slowing of the heart. Nausea occurs in most varieties of headache, and a feeling of general prostration or nervous excitability is often experienced both during and after an attack.

The duration of an attack of headache varies from a few minutes to days or even months: one occasionally sees a patient who says she has not known what it is to have been without pain in the head for years.

The character of the pain may be either a dull aching or it may be excessively intense, so as to cause temporary aberration of mind. As to the structures within the cranium in which the pain is located, it is a mooted question. Some writers believe the dura mater may be the seat of pain in headaches, while other observers have declared this membrane to be insensitive. Probably the intracranial branches of the fifth pair of nerves are the principal site of pain.

We will now consider particularly the different varieties of headache most commonly met with.

ANÆMIC HEADACHE.—The pain is of a dull kind, often diffused over the head, but frequently in the vertex or temples. It occurs in weak, thin-blooded persons, and is relieved by the recumbent position. If the patient is sitting or walking, the pain becomes worse, and there is a sense of faintness or dizziness. Women are the most common sufferers from this form of cephalalgia, and uterine diseases or disorders of menstruation are connected with it. It is associated with palpitations of the heart, difficulty of breathing, a tendency to faint, and general weakness. Anything which exhausts the nervous system, like over-study or anxiety, loss of rest and sleep, is likely to bring on an attack.

CONGESTIVE (HYPERÆMIC) HEADACHE.—In this variety of headache, which is common, the pain seems to affect the whole head and is of a dull, throbbing character. The recumbent position aggravates it, as does coughing or straining. During the paroxysm the face is flushed, the eyes suffused, and the arteries throb violently. Sleep relieves the pain of a hyperæmic headache for a time, but as soon as the patient begins to move about, or even to exercise the mind, the pain returns. Erb¹ speaks of a violent pain in the brow and temple, with a sense of pressure and fulness in the head, and heat and redness in the face and ears. This form may come in regular paroxysms. He has seen one case of this kind in which there was violent pain accompanied by fainting, and intense redness of the brow and vertex was observed.

¹ Cyclopædia of the Practice of Medicine (Ziemssen), vol. xiv. p. 140.

THE HEADACHE OF HYSTERIA is usually seen in females, although it may occur in males. It is sometimes general throughout the head, but is often located in one spot (clavus), and is very intense. The seat of clavus hystericus is at the top of the head to one side of the sagittal suture. The pain is described as boring, gnawing, and burning. The headache is more severe at the menstrual period, and is increased by worry or trivial excitement. Nervous and hysterical subjects complain of headache which never ceases.

TOXIC HEADACHES are the result of the introduction into the system of various kinds of poisons. The headache following alcoholic excesses is a well-known instance of this kind. The pain, which is deep-seated and often intense, is supposed to be in the sensory nerves of the dura mater. Other forms of chronic poisoning give rise to headache. Lead, when retained in the system, produces headache, and so do many of the narcotic drugs. In some persons the administration of iron always causes pain in the head. The headache following a dose of opium is familiar to all. The excessive use of tobacco is often followed by dull headache next day. The intense pain in the head caused by uræmic poisoning is a well-marked symptom of this condition. Seguin has lately well described the headache of uræmia.²

² Archives of Medicine, vol. iv. p. 102.

RHEUMATIC HEADACHE is often violent, and the pain seems to be located in the head-muscles. It occurs in rheumatic subjects. It is brought on by exposure to cold, and is increased by damp changes in the weather. In acute rheumatism there are sometimes met with attacks of intense headache. Headache also is associated with the gouty cachexia, and is accompanied usually by depression of spirits and sometimes vertigo.

PYREXIAL HEADACHES.—In all of the acute fevers headache is a prominent initial symptom, and usually continues throughout the course of the disease. The pain is generally dull and deep-seated, and is probably congestive in character. The headache of typhoid fever is constant, and often precedes the fever by many days. Following an attack of typhoid fever, it is not infrequent to find headache persisting for months or even for years.

SYPHILITIC HEADACHE is one of the most violent forms of headache. The pain is diffused or limited to one part of the head, and is associated with tenderness of the scalp. It becomes most severe at night, but never entirely intermits. The nocturnal exacerbations, although very common, do not always occur. The pain is so violent and so constant that the patient is unable to do any work or to occupy himself in any way. There is great mental depression, and the patient becomes gloomy and morose. The pain may be dull and heavy or acute and lancinating; sometimes it is like a succession of heavy blows on the skull. During a severe paroxysm of pain the scalp becomes so sensitive that the lightest touch cannot be borne. The sufferer is unable to sleep, and presents a worn, haggard appearance. Often he has hallucinations at night. Syphilitic headache is often a forerunner of some form of organic cerebral disease. One of the characteristic features of syphilitic headache is its constancy. It never ceases entirely, although at times there are paroxysms in which the pain is so intense as to cause great agony. During the little sleep the patient is able to get he is moaning or tossing about his bed. Minute doses of mercury, repeated at short intervals, have been found to afford great relief in headaches of this kind.

ORGANIC HEADACHE may be described as the headache which accompanies organic disease of the brain or its membranes. Violent pain, seated in one spot and constant in character, is one of the most unvarying symptoms of tumors within the cranium. Brain tumors may exist without headache, but rarely. The pain may be situated in any part of the head: sometimes it is occipital and sometimes frontal, and occasionally it extends over the entire head. It does not always correspond to the seat of the disease. The pain is constant and lasting, and, like syphilitic headache, is liable to exacerbations of excessive violence. These often occur at night. Localized tenderness of the scalp is often present, and percussing the skull over the seat of the disease will increase the pain.

Disease of the membranes of the brain, such as meningitis or new growths in the dura mater, will give rise to persistent headache. So will caries or any syphilitic affections of the skull. Catarrhal inflammation of the frontal sinuses causes dull frontal pain. In inflammatory diseases of the ear there is often headache. In these latter conditions the cephalalgia is probably reflex.

NEURASTHENIC HEADACHE is more or less allied to the hysterical headache. It is met with in persons who are run down in their nervous system by mental worry or overwork—in other words, in persons who are suffering from neurasthenia. Such patients describe the pain as being constant and deep-seated—seldom acute, but dull and throbbing. It is accompanied by a sense of weight and pressure on the vertex, and sometimes by a feeling of constriction. Mental effort increases the pain, and the patient usually prefers solitude and quiet on account of the relief he obtains. The headache of neurasthenia often persists after other symptoms of the affection have disappeared.

SYMPATHETIC HEADACHE is generally connected with disorders of the digestive and sexual organs. The headache of ovarian disease is well known to gynæcologists, and most of us have experienced the pain in the head associated with gastric disturbances. The headache from eye-strain may be considered in this connection, and deserves careful consideration. Many persons have suffered from headaches for years from this cause without its being suspected. Weir Mitchell brought prominently to notice the frequency with which headaches may be caused by defects of vision.³ The fact had been long known to oculists that disorders of the refractive apparatus of the eye would give rise to cerebral discomfort and pain, but it had not before occurred to physicians to look to defects of the eye to explain headaches whose cause was obscure. The points made by Mitchell were—1, that many headaches are caused indirectly by defects of refraction or accommodation; 2, that in these instances the brain symptom is often the only prominent symptom of the eye trouble, so that there may be no ocular pain, but the strain of the eye-muscles is expressed solely in frontal or occipital headache; 3, that long-continued eye troubles may be the unsuspected cause of insomnia, vertigo, and nausea; 4, that in many cases the eye trouble becomes suddenly injurious, owing to break-down in the general health or to increased sensitiveness of the brain from mental or moral causes.

³ Med. and Surg. Reporter, Aug. 1, 1874, and Amer. Journ. of the Med. Sci., April, 1876.

Occasionally the form of headache produced by eye-strain is a migraine, but most commonly there is a steady frontal or occipital pain, which comes on after undue use of the eyes, which are defective as to refraction or accommodation. Accompanying the pain are sometimes nausea and occasionally vertigo. It is not only over-use of astigmatic eyes in reading or other near work which causes the cerebral disorders, but the use of the eyes in the ordinary walks of life may produce pain in a sensitive brain should there be any imperfection in refraction or accommodation.

HEADACHE FROM SUNSTROKE.—A person who has had an attack of sunstroke often suffers from headache for years. The attacks are most likely to occur from exposure to the sun and in summer months, but they are brought on in some individuals even in winter should they be in the sun. Sometimes heat-exhaustion or exposure to the influence of the sun in hot weather, even should there be no actual sunstroke, is followed for a long time by violent headaches. Persons who have suffered in this way have to be extremely careful about exposing themselves to the sun or they will have severe and prostrating pains in the head. The cephalalgia in these cases is probably from congestion of the cerebral meninges or some disturbance of the submeningeal gray matter of the brain. The pain is usually frontal or on the top of the head. Sometimes it is confined to one side of the head. Mitchell⁴ has seen two cases in which this form of headache was relieved by ligature of the temporal arteries.

⁴ Med. and Surg. Reporter, July 25, 1874.

HEADACHE OF CHILDHOOD.—Children often suffer from headaches unconnected with meningitis or other organic brain trouble. Over-use of the brain in study is a frequent source of headache, in children especially, if associated with worry or anxiety. If a child complains of headache after study, it is always important to examine the eyes for defects of vision; but while this is often found to be the cause of the headache, in many cases there will be discovered no errors of refraction sufficient to account for the pain; and here the only relief will be to take the child from school and give him plenty of exercise and fresh air.

Another cause of headaches in children is hypertrophied tonsils, which prevent the free return of blood from the brain. Children also suffer from headaches from over-eating or improper food, or from over-exercise in the sun. Migraine, as will be seen later, is a disease which often begins in early childhood, and a child may suffer from frequent attacks of headache of this nature for a long time before they are understood.

Children who are precocious in any way are apt to be sufferers from neuralgias and headaches; but sexual precocity especially predisposes to headaches of the type of migraine. Anstie⁵ goes so far as to say that the existence of a severe neuralgic affection in a young child, if it be not due to tubercle or to other organic brain disease, is, primâ facie, ground for suspecting precocious sexual irritation.

⁵ Neuralgia and Diseases that Resemble it, p. 31.

Hillier⁶ observes that anæmic children from seven to ten years of age frequently suffer from neuralgic headache, and that girls between eight and twelve have violent headaches accompanied by nausea and vomiting (migraine).

⁶ Diseases of Children, p. 194.

HEADACHE FROM DYSPEPSIA.—Persons who have indigestion have more or less headache, either in paroxysms or as a constant pain. The pain is either frontal or occipital, and may affect the whole head; but it is not confined to one side of the head, as in migraine. The pain is usually dull, and is accompanied by nausea from the beginning of the attack. The tongue is coated, and has red edges, and there are general evidences of gastric disturbance, together with a history of some indiscretion in diet. Sleeping does not always relieve the headache.

DIAGNOSIS.—The diagnosis of the different forms of headache may be made by considering the symptoms. All of the means at our command should be used to carefully distinguish the variety of headache we have to deal with. The head should be palpated for tender or swollen and soft spots, such as are found often in syphilitic headaches. Sometimes percussion of the head will give us some indications as to the kind of headache which exists. The eyes should be examined ophthalmoscopically for changes in the fundus oculi, and the vision should be tested for errors of refraction should there be any reason to connect the pain with the use of the eyes. Inquiry into the habits, occupation, and family history of the patient will aid in arriving at a correct diagnosis.

TREATMENT.—Having reached a correct diagnosis, the treatment will naturally be directed to the special form of headache with which we have to deal. The indications vary more or less with the different varieties, but in all the same object is in view; that is, the relief of pain in the paroxysms, and the breaking up of the diseased condition which leads to the attacks. The means to be used for the former will be considered in the treatment of Migraine, and are more or less applicable to the treatment of all forms of headache.

In children, if no ocular cause is present, it will often be necessary to take them from school and study, and make them take plenty of exercise in the fresh air.

In all varieties of cephalalgia change of climate and travel exert a most beneficial influence. The seashore does not always benefit sufferers from headache, and sometimes the sea air seems to increase the pain.

Migraine.

SYNONYMS.—Hemicrania, Sick headache.

This form of headache is of great importance, from the frequency with which it is met in practice. It occurs in paroxysms at longer or shorter intervals, but the attacks come at periods of tolerable regularity, and, generally speaking, the intervals are entirely free from pain. From the name hemicrania it may be inferred that the pain is confined to one side of the head. This is often the case, but is not invariably the rule.

Migraine has been known for many years, and the term hemicrania is used by the old writers. Until recently, however, there has been some confusion regarding it. Hemicrania often meant trigeminal neuralgia, and nervous sick headache was generally believed to have its origin in the stomach or to be the result of biliousness. Of late years the disease has come to be better understood, and the valuable works of Liveing, Anstie, and others have given a full literature of the subject.

Various conditions predispose to migraine, and of these the foremost are period of life and hereditary influence. Sex also bears a part in the etiology. The majority of patients who are victims of migraine are females. Eulenburg⁷ states that the proportion is about 5 to 1 in favor of females. My own experience would lead me to believe that in this country the preponderance of migraine in females is not so great. Men are not so likely to consult a physician about headaches, unless they become very frequent and severe; especially is this true of the laboring classes, from whom Eulenburg's statistics were mainly taken. It is true that women are especially prone to neuroses of various kinds through menstrual disorders and at the time of the climacteric, but these do not always take the form of migraine.

⁷ Ziemssen's Cyclopædia, vol. xiv. p. 5.

Age has a decided influence on the production of migraine. Sometimes the attacks begin in very young children. Eulenburg mentions cases at four or five years. It is during the period of bodily development that the first outbreaks of migraine occur, but more particularly do they set in in both sexes at puberty, a time when sexual development is active and making a strong impression on the whole nervous system. Should migraine become established at this time, it will probably continue to harass the individual until he is forty-five or fifty years of age. After the development of puberty migraine is not likely to originate; indeed, Tissot⁸ declares that a person who is not attacked by migraine before his twenty-fifth year will escape from it for the rest of his life. It certainly is the case that in later life this affection is much more rare than earlier, as many of the old cases get well and new ones scarcely ever develop. It is a common thing to hear a patient who has reached the age of fifty extolling some new system or remedy as a cure for his headaches, from which he has suffered all his life, when in reality the attacks have ceased or become infrequent on account of the natural course of the disease.

⁸ Quoted by Eulenburg, op. cit.

Hereditation markedly affects the production of migraine. Eulenburg states that it follows the female line, and is inherited from the mother only; but this is surely a mistake, as we often see males whose fathers suffered from migraine. Persons whose ancestors were of a neurotic type, who suffered from neuralgias, paralysis, hysteria, insanity, etc., are particularly liable to migraine. Epilepsy is also likely to be in the family of an individual who has migraine. There has been observed by many writers the association of migraine and epilepsy in the same person. Epileptics who are predisposed to the disease by inheritance are likely to have attacks of it preceding the outbreak of epilepsy. In families of constitutional nervous tendencies it is common to see certain members who have hemicrania, while others have epilepsy or are insane.

Other predisposing causes in migraine are not so marked as those already mentioned. Station in life exerts but little influence in the causation of the disease. It is met with as often in the laboring classes as in the wealthy. Those who use the brain to any extent in study or business are likely to suffer more often from migraine than those who lead an outdoor life with much physical exercise. Habitual loss of sleep and anxiety also predispose to it.

As to the conditions connected with the immediate production of an attack of migraine, we are in ignorance. It has been thought to depend upon disorders in the circulation of the blood, but then the question arises, Whence these disturbances of circulation? Probably those circulatory disorders which are marked in every case are effect rather than cause of the attack. Indigestion and biliousness must be admitted to favor outbreaks of migraine.

SYMPTOMS.—Migraine occurs at intervals of one or two weeks or longer; often the attacks are not more frequent than every month or even two or three months. I have seen a number of patients who have attacks of migraine on Sunday with regularity, and escape during the interval. Some of these cases ascribed the attacks to sleeping later on this day than on others, but it is more likely that the attacks were the result of the culminating effect of a week's hard work. Between the attacks the patient is usually quite well as far as headache is concerned, but he may have slight neuralgia in branches of the trigeminal. The attacks are more or less alike. They are often preceded by prodromal symptoms for a day or two. The patient may feel languid or tired for a day before the attack. Sometimes there is unusual hunger the night before a paroxysm, or there may be violent gastralgia before each attack. The patient often wakes in the morning after sound sleep with a pain in the head. Should the attack come on in the day, it may be preceded by chilliness, yawning, or sneezing and a sense of general malaise. Ocular symptoms are frequent as a forerunner of an attack. First muscæ volitantes are seen, then balls of fire or bright zigzags appear before the eyes, making it impossible for the patient to read. These symptoms last for a few minutes or a half hour, and then cease, to be immediately followed by pain. Hemianopsia is a precursory symptom of rather frequent occurrence. Ross mentions a case in which the hemianopsia usually lasted about a half hour, and was followed by severe hemicrania. The ocular symptoms are often very alarming to patients.

The pain, as a general rule, is at first in the ophthalmic division of the fifth nerve and its branches. It may begin in the branches of the occipital nerve or in the parietal region. It comes on gradually, is dull and boring at first, but becomes more intense and spreads to one lateral half of the head, more especially the front part. As it increases in intensity the pain seems to involve the entire head. Either side of the head may be affected. Eulenburg thinks that the left side is attacked twice as often as the right. An individual may have the pain on opposite sides of the head alternately in different attacks. The pain is described by patients as dull and boring or intense, and the head feeling as if it would burst. Patients often make pressure on the head to obtain relief. At times the pain seems to be of a violent, throbbing kind, keeping time, as it were, with the pulsation of the arteries. Lying down usually relieves the pain, but if it is violent the recumbent position seems to favor the afflux of blood to the head, and thereby increases the pain. The eye of the affected side becomes bloodshot, and the tears stream from it. The eyelid droops, and the sight is dim and clouded or may fail entirely. The least light is unbearable. During the attack the subject is chilly and intensely depressed, and the feet are very cold. The pulse is at first slow, small, and compressible.

Painful points (Valleix's points) are not present, but there is usually tenderness over the supraorbital notch during an attack of migraine, and after the paroxysm there is a general soreness of the scalp and forehead. Sometimes there remains a tenderness of the parts surrounding the affected nerve. This is not in the nerve itself, but in the adjacent tissues. Anstie⁹ says that in his own case, after repeated attacks of migraine, the bone had become sensibly thickened in the neighborhood of the supraorbital notch. There is sometimes hyperæsthesia of the skin in the affected regions of the forehead and scalp during an attack. As well as hyperæsthesia, there may be an abnormal acuteness of the sense of touch. Deep pressure over the superior and middle ganglia of the sympathetic causes pain, according to Eulenburg. This observer also states that the spinal processes of the lower cervical and upper dorsal vertebræ are painful on pressure.

⁹ Op. cit., p. 182.

During the attack of migraine there is complete loss of appetite, and any food that may be taken remains undigested in the stomach for hours. As the pain intensifies there comes on a sense of nausea, there is a profuse flow of saliva, and large quantities of limpid urine are passed. Finally, when the pain seems to have reached its maximum, vomiting occurs. Immediately afterward the pain is greatly increased, but this is the result of the increased amount of blood in the cranial cavity from straining. Soon after, the patient is easier, and falls into a sleep, from which he awakes free from headache. The crisis is not always accompanied by vomiting. In some instances there is no nausea, but at the acme of the pain there are two or three profuse diarrhœic stools, after which the pain is relieved. I have lately seen such a case in a young man of twenty-three years of age. Sometimes there is only a profuse sweat or large flow of urine.

During the attack there are disorders of the circulation. The pulse may be intermittent or irregular, and the extremities are usually cold. Disorders of cutaneous sensibility are also often present. A condition of numbness confined to one lateral half of the body is sometimes experienced during the early part of the paroxysm. This numbness is noticed even in one half of the tongue.

The German writers have divided migraine into two types, and the arrangement may be followed in some instances. The first is called hemicrania spastica or sympathico-tonica. In this form there is supposed to be vascular spasm and a diminished supply of blood in the brain. The symptoms are as follows: When the attack has reached its height the face is pale and sunken; the eye is hollow and the pupil dilated; the arteries are tense and feel like a cord. The external ear and the tip of the nose are cold. Eulenburg¹⁰ states that by actual measurement he has found the temperature in the external auditory meatus fall 0.4° to 0.6° C. The pain is increased by stooping, straining, or anything which adds to the blood-supply in the head. At the end of the attack the face becomes flushed and there is a sense of heat. The conjunctiva becomes reddened, the eye is suffused, and the pupil, which had been dilated, contracts. The sense of warmth becomes general, the pulse is quickened, and the heart palpitates. The crisis is reached with vomiting and a copious flow of urine or perhaps a diarrhœic stool. There is sometimes an abundant flow of saliva. One observer has reported that he has estimated a flow of two pounds of saliva during an attack.

¹⁰ Op. cit.

The other variety is termed hemicrania angio-paralytica or neuro-paralytica. Here we find the opposite condition of things from that met with in hemicrania spastica. There is marked increase in the amount of blood in the brain. When the attack is at its height the face on the affected side is flushed deeply, hot, and turgid. The conjunctiva is injected, the lachrymal secretion increased, and the pupil contracted. Sometimes there is slight ptosis. The ear on the affected side is hot and red. The temperature of the meatus may rise 0.2° to 0.4° C. The temporal artery is swollen, and throbs with increased force. The carotid beats visibly. There is free perspiration, which is sometimes unilateral. Compression of the carotid on the painful side relieves the pain, while pressing on the opposite carotid makes it worse. The heart beats slowly, the pulse being sometimes as low as 48 to 56. At the end of the attack the face becomes paler and the other symptoms subside.

There are many cases in which the vascular conditions present no peculiarities during the attack, and which cannot be classed with either of the varieties just described.

In all forms, if the patient can be quiet, he usually falls asleep after the crisis has been reached, and awakes free from pain, but feeling haggard and prostrated.

The paroxysm lasts for several hours, generally the greater part of the day. It may last for several days, with variations of severity. The attacks are at longer or shorter intervals of time, and in women they often appear at the menstrual period. The attack may be brought on by over-mental or bodily exertion, imprudence in eating or drinking, and exposure to cold draughts of air. It will often begin as a supraorbital neuralgia from exposure to cold, and go on through all the phenomena of a regular migraine.

Seizures are often brought on by fatigue, and there are some persons who invariably have a violent attack of migraine after a journey. Nursing women are liable to more frequent paroxysms, and I have recently seen a lady who within a few days after delivery after both of her confinements suffered from typical attacks of migraine, although during gestation she had escaped them.

DIAGNOSIS.—Migraine can readily be distinguished from the other forms of headache by the comparative regularity of the attacks and its numerous other characteristics. It differs from neuralgia in the pain being less acute and shooting. The pain of migraine is more dull and throbbing, and extends more generally over the head. The ocular phenomena are more or less constant in migraine and do not occur in neuralgia.

PROGNOSIS.—Migraine is never fatal, and usually becomes less severe and less frequent as middle life is reached. Some patients continue to suffer from it during their entire life, and often when the typical migraine has ceased it is replaced with paroxysms of neuralgia. Therapeutic and hygienic means are of decided influence in the course of the disorder, and many patients experience great relief or temporary immunity from attacks as a result of treatment. Cases of long standing and those of an hereditary type are most unfavorable as to relief from treatment or by spontaneous cure.

PATHOLOGY AND MORBID ANATOMY.—Migraine not being a fatal disease, we know nothing of the changes which exist in the brain; we can only surmise what are the conditions which exist in the brain during and before an attack.

It is evident that there is a strong relationship between migraine and neuralgia of the trigeminal nerve, and if we study the symptoms of the two conditions, and consider the causes which produce attacks of each, we cannot but arrive at the conclusion that migraine is a variety of a neuralgia of the ophthalmic division of the fifth. The late Anstie has most clearly and forcibly given his reasons for believing this to be the case, and we cannot but uphold his view.

Migraine is constantly met with in early life as the type of a neuralgia which in later years loses the special features of a sick headache and becomes a pure neuralgia. The same forms of trophic lesions may occur in migraine and in trigeminal neuralgia. Anstie instances his own case, in which in early life he had distinct attacks of migraine, with corneal ulceration, orbital periostitis, and obstruction of the nasal duct, while later in life his attacks were only neuralgic, without any stomach complications.

Migraine, as already remarked, attacks early life especially at the time of sexual development, and the same is true of epilepsy. There is also the same hereditary predisposition to the former as to the latter. Patients who have migraine belong often to families other members of which suffer from epilepsy, chorea, and an uncontrollable tendency to alcoholic excesses. Indeed, occasionally migraine and epilepsy are interchangeable in the same individual. Many cases of epilepsy have suffered at some time of their lives from severe headaches.

Hughlings-Jackson describes the attacks of migraine as arising from a discharging lesion of the cortex of the brain in the sensory area, or in that part of it which corresponds to the region of pain in the head. Genuine epilepsy he holds to be due to a discharging lesion from the motor area of the cortex. During an attack of migraine the discharging lesion does not remain confined in the sensory portion of the cortex, but extends into the medulla oblongata and the cilio-spinal region of the cord, causing irritation or paralysis of some of these centres, and causing the vaso-motor and oculo-pupillary symptoms which are conspicuous during an attack.

In the form of migraine known as hemicrania sympathico-tonica there is tonic spasm of the vessels of one side of the head. This explains the pallid face, the lowered temperature, and the sunken eyes. After the cause of the contraction is removed, then the vessels relax and the amount of blood-supply greatly increases. Hence the redness of the conjunctiva, lachrymation, and redness of the ear at the close of an attack. The vomiting is explained by Eulenburg as being due to variations in the intracranial blood-pressure. This causes fitful contractions of the vascular muscles, alternating with partial relaxation. These conditions must arise in the sympathetic nerve of the corresponding side.

The dilation of the pupil during an attack depends upon irritation of the cervical sympathetic ganglia. Other symptoms, such as the largely increased flow of saliva and the flow of tears or drying of the Schneiderian mucous membrane, indicate a morbid condition of the cervical sympathetic. The sensitiveness to pressure in the region of the upper cervical ganglia and over the spinous processes of the lower cervical and upper dorsal vertebræ, corresponding to the cilio-spinal region of the cord, confirms the idea of a morbid state of the cervical sympathetic.

In hemicrania angio-paralytica there is supposed to be a relaxed condition of the vessels of one side of the head. Here, instead of an irritation of the sympathetic, there is a paralytic condition, and we have the same results as are seen in animals when the cervical sympathetic is divided. There seem to be good grounds for holding this view when we consider the flushed face, contracted pupil, retraction of the eyeball, and occasional ptosis which accompany this form of headache. Possibly there may be a brief stage of spasm of the vessels preceding the relaxation which occurs in hemicrania angio-paralytica.

The slowing of the pulse during an attack of migraine is due probably to cerebral hyperæmia from relaxation of the vessels, or to the secondary anæmia and irritation of the medulla oblongata. This irritation of the medulla is also able to explain the other symptoms of vaso-motor disturbance which occur during an attack of migraine; for instance, the small and contracted radial artery, the extreme coldness of the hands and feet, and the suppression of perspiration over the whole body except perhaps on the affected side of the head. Following the stage of irritation of the medulla with contraction of the vessels comes one of exhaustion with relaxation of the vessels. This latter state may account for the profuse flow of saliva and the copious secretion of sweat and urine, as well as the increased secretion of bile and the condition of broncho-tracheal catarrh during the attack.

We now come to the question of the origin and seat of the pain in migraine. This question has involved a great deal of thought, and has been answered in various ways by different writers. E. du Bois-Raymond thought that the pain was due to tonic spasm of the muscular coats of the vessels, and that thereby the nerves in the sheaths of the vessels were pinched, as it were, and so caused pain. Moellendorff was of the opinion that the pain was due to dilatation of the vessels, and not to contraction; and this theory might explain the pain in the angio-paralytic form. There are many cases in which neither of these views is sufficient, for we have no reason to believe that a condition of either anæmia or hyperæmia is present.

Romberg believed that the pain was situated in the brain itself, and Eulenburg holds that the pain must be caused by alterations in the blood-supply, without regard to their origin, in the vessels of one side of the head. He thinks that the vessels may contract and dilate with suddenness, just as is often seen in some neuralgias, and thus intensely excite the nerves of sensation which accompany the vessels. The increase of pain upon stooping, straining, or coughing, and the influence upon it by compression of the carotids, seem to give force to this view. But are we not here confusing cause with effect? Are not these variations in the calibre of the vessels due to the irritation of the sensory and vaso-motor nerves, which are in a state of pain? No doubt increase in the blood-supply augments the pain, just as it does in an inflamed part when more blood goes to the part. Let a finger with felon hang down, or let a gouty foot rest upon the floor, what an intensity of pain follows!

Anstie very ably advocated the theory of migraine being a variety of trigeminal neuralgia in the ophthalmic division; and we incline strongly to his view. An attack of migraine often begins with pain distinctly located in the supraorbital nerve as the result of exposure to cold. Frequently it begins in the infraorbital nerve or in the branches of the inferior maxillary division of the fifth. The pain then spreads over one side of the head, both outside and inside, and goes through the recognized symptoms of migraine. In my own case I have often had an attack begin with sharp pain in the supraorbital notch in a spot which could be covered by the tip of the finger. The nerve has seemed swollen, and has been highly sensitive to pressure. Then have come pain extending over the entire side of the head, without its limits being distinctly definable, and the accompanying phenomena of lachrymation, excessive salivation, and copious flow of urine, winding up with vomiting or ineffectual nausea and retching.

Anstie brings forward as arguments to support his view the facts that the attacks of migraine often interchange with neuralgic seizures, and that a person who has been migraineuse in early life may in later years lose his hemicranial attacks, and have violent neuralgia in the ophthalmic division of the fifth nerve.

The true seat of the lesion, if we may so call it, upon which the exaggeration of pain-sense depends, is probably in the nerve-centre; that is, in that part of the trigeminal nucleus back to which the fibres go which are distributed to the painful areas. The pain is no doubt chiefly intracranial, and in those portions of the cerebral mass and meninges to which branches of the trigeminal are distributed. All of the divisions of the trigeminus send branches to the dura mater. Many nerves are found in the pia mater as plexuses around the vessels, some of which penetrate into the centre of the brain. Most of these nerves come from branches of the trigeminus.

TREATMENT.—The treatment of migraine must be directed to the palliation of the attacks and to their prevention. So little is known of the direct cause of the disease that it is difficult to lay out any distinct course to be followed. Many cases, however, which seem to depend upon a run-down state of the patient are vastly improved by a course of tonics and building up. I have often seen anæmic and feeble women whose attacks were frequent become exempt for a long period by simply taking iron, quinine, and strychnia, and taking an increased amount of nourishment. The rest-treatment of Weir Mitchell is particularly applicable to these cases. In persons whose digestion is bad, and who suffer from constipation, much can be done by relieving these conditions. Some cases which are due to uterine disturbances are benefited by treatment directed to the womb. There are many cases, however, in which no cause is apparent. The patient is well nourished, his eyes are good, he undergoes no strain mentally, morally, or physically, and yet the attacks of migraine come with tolerable regularity. In these persons change of climate sometimes works marvellously beneficial results. I saw last year a young lady who suffered from terrific headaches which sometimes lasted for days. No plan of treatment or regimen seemed to exert the slightest influence upon the attacks, and yet on going to the far West for the summer she remained without an attack during the whole time she was there. In some individuals all forms of treatment may be tried in vain. Anti-periodics have been tested, but with doubtful benefit. Cannabis indica is probably the most potent remedy which is at our command. Its effects are most decided, and many cases of severe hemicrania have been cured by this means alone. It must be given for a long time, and in some instances it is necessary to give gradually-increasing doses up to the physiological effects. The drug must be of good quality, otherwise we need expect no good from it. Indian hemp is well known to be variable in strength, and the best form in which to use it is a fluid extract made by some reliable chemist. Arsenic, phosphorus, and strychnia do not seem to do as much good as in other neuralgias, except so far as they build up the general health.