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 {399} 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.
{400} 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.
{401}
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
{402} 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.
Erb[1] 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.
[Footnote 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 {403} 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]
[Footnote 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 {404} 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.
[Footnote 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 {405}
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. Mitchell[4] has seen two cases in which this form of headache
was relieved by ligature of the temporal arteries.
[Footnote 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. Anstie[5] 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.
[Footnote 5: _Neuralgia and Diseases that Resemble it_, p. 31.]
Hillier[6] 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).
[Footnote 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 {406} 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.