By J. LEONARD CORNING, M.D., New York.
If we examine the literature of our theme, we are astounded by the
apparently hopeless confusion in which the whole is involved. Everywhere
attempts at ill-founded generalization are encountered. We are compelled
to admit, after perusing long debates in regard to the relative merits
of various therapeutic measures, that those who were foremost to
disparage the treatment pursued by others were totally ignorant of the
fact that those same symptomatic manifestations which they were
considering might be owing to entirely different causes from similar
conditions described by others. Hence a commensurate modification in
therapy might not only be admissible, but eminently desirable. It is
more especially of recent years that a laudable attempt to differentiate
the various etiological factors involved in different forms of headache
has been made. In 1832 Dr. James Mease, of Philadelphia published a
monograph on "The Cause, Cure, and Prevention of the Sick Headache,"
which is substantially a treatise on the dietetics of this particular
form of headache. The work, however, is conspicuously lacking in those
philosophical qualities which are so necessary to a true understanding
of the questions involved. Dr. E.H. Sieveking published in 1854[1] a
most interesting paper on "Chronic and Periodical Headache." The views
therein expressed are remarkable for their succinct and thoroughly
scientific elucidation of the two great physiological principles
involved in the consideration of by far the greater majority of
instances of cephalalgia. I refer namely to the importance ascribed by
this eminent physician to the fluctuations of the blood-stream within
the cranial vault. In speaking of this subject Dr. Sieveking says:
"Nothing is of more importance in reference to the pathology and
therapeutics of the head than clear and well-defined notions on the
physiological subject of the circulation within the cranium; for, among
the various sources of medical skepticism, no one is more puzzling or
more destructive of logical practice than a contradiction between the
doctrine of physiology and the daily practice of medicine."
[Footnote 1: On Chronic and Periodical Headache, by E.H. Sieveking,
M.D., _Medical Times and Gazette_ London, August 12, 1854.]
What Dr. Sieveking said in 1854 holds equally good to-day; and, indeed,
the position then taken has received substantial indorsement through the
positive results of more recent experimental physiology. Conspicuous in
this connection are the inductive researches of Durham, Fleming, and
Hammond, touching the modifications in the cerebral circulation during
sleep and wakefulness. By these experiments it has been conclusively
proved that the amount of blood in the brain is decreased during sleep
and increased during wakefulness. More, recently I have had occasion to
confirm the experiments of Fleming in this direction, and have published
the results of those researches in various papers and articles.[1] "What
Hippocrates said of spasm," says Dr. Sieveking, "that it results either
from fullness or emptiness, or, to use more modern terms, from hyperæmia
or anæmia, applies equally to headache; but, to embrace all the causes
of this affection we must add a third element, which, though most
commonly complicating one of the above circumstances, is not necessarily
included in them, namely a change in the constitution of the blood."
While I agree with Dr. Sieveking as regards the importance to be
ascribed to the first two factors--cerebral hyperæmia and anæmia, in the
production of the group of symptoms known as "headache,"--I fail to
perceive why especial prominence should be given to the third condition
mentioned by Dr. Sieveking. Indeed, I am quite unable to imagine how the
periodical, and more especially the intermittent form, of headache is to
be explained by what Dr. Sieveking describes rather ambiguously as a
"change in the constitution of the blood." It is quite evident,
admitting that such a change is capable of producing an amount of
cerebral irritation sufficient to develop well-marked cephalalgia, that
the latter must of necessity be within certain limits continuous. This
is not the case, as the causative factor is constant and not
fluctuating. I am, therefore, not prepared to accept this third
causative factor without question. Nevertheless I am perfectly willing
to admit that other factors besides cerebral hyperæmia and anæmia may
produce the functional variety of headache. There would seem to be ample
ground for ascribing great causative importance to excessive irritation
of the brain plasma itself. Hence those forms of headache which while,
being unaccompanied by any especial circulatory derangements, succeed,
oftentimes, with relentless regularity upon any considerable degree of
mental work. It is not my purpose to discuss the treatment of the
multifarious forms of cephalalgia on this occasion, did time permit. As
regards the so-called "neuralgic" variety I content myself by referring
to the admirable work on "Neuralgia and Kindred Diseases of the Nervous
System," by Dr. John Chapman of London, in which will be found many
interesting facts bearing on the question. Accepting the propositions,
then, that the more adjacent causes of headache are (1) cerebral
hyperæmia, (2) cerebral anæmia, and (3) irritation of the cerebral
plasma itself, let us now consider how these morbid factors are most
scientifically and speedily met at the bedside; and how, more
particularly, those distressing conditions of engorgement, which are so
baneful an item in the causation of a certain form of cephalalgia, are
best overcome.
[Footnote 1: _Vide_ Carotid Compression and Brain Rest, by J.L. Corning,
M.D. New York: Anson D.F. Randolph & Co.]
Two years ago I began a series of experiments on epileptics and maniacs,
which involved the application of protracted pressure to the common
carotid artery on both sides. In the course of these experiments the
thought suggested itself that suppression of the carotids might prove a
salutary means of reducing that form of cerebral congestion which is so
prolific a source of headache and vertigo. Accordingly I made a
protracted series of experiments with carotid compression upon those
suffering from congestive headache, and I can only say that I have been
so far pleased with the uniformly good results obtained, that I have
felt it a duty to call the attention of the profession to a procedure
which, for obvious reasons, possesses all the advantages of local
depletion by leeching or cupping, without the manifest disadvantages of
either of these methods. The instruments which I have devised as
substitutes for the primitive procedure of digital compression of the
carotids have already been described in former communications. It is
only necessary to say that the implements in question are of two kinds;
one, the "carotid fork," is an adjustable instrument, which being held
in the hand of the operator permits him to exert any degree of pressure
upon both carotids for any desired length of time. The other instrument,
which I have designated as the "carotid truss," for lack of a better
name, is a circular spring provided with adjustable pads at each
extremity. The spring is placed about the neck of the patient, and by
suitable appliances the pads at the extremities can be placed directly
above the trunks of the two common carotid arteries. By turning the
screws to which the pads are attached the desired amount of pressure can
be applied to the arteries, and the apparatus can be worn for any length
of time by the patient.
With these instruments I have frequently succeeded in arresting the most
obstinate form of congestive headache in an incredibly short time (on
one occasion in about five minutes). Where, however, the headache is of
manifestly nervous origin and uncomplicated by any especial circulatory
derangements, I have never been able to achieve notable results with
this method. Indeed, pressure upon the carotids is an excellent method
of differentiating the congestive form of headache from the nervous
varieties of head pains.
Of galvanism this much may be said, that it is one of the most valuable
methods which we possess for treating the form of headache under
consideration, for not only does it cause contraction of the smaller
arteries, but it also exerts a soothing influence upon the plasma of the
brain itself.
A powerful therapeutic agent, and one which has been more or less
extensively employed in the treatment of various forms of head and
spinal symptoms, is cold.
A very excellent method of applying both cold and galvanism to the head,
at the same time, is afforded by a species of refrigerating electrode,
designed by myself for this purpose. The apparatus in question consists
of a concave sponge electrode, the concavity of which corresponds to the
convexity of the external aspect of the cranium. Above the electrode is
a chamber of metal or India-rubber, designed to contain ice. The whole
is secured to the head of the patient by a single chin-strap, and
connection established with an ordinary galvanic battery by means of an
appropriate clamp and insulated cord. The indifferent pole is applied
over the sternum or other convenient point. Care should be taken not to
employ too strong currents, as otherwise vertigo and other unpleasant
symptoms may be produced. An application of from five to ten minutes is
usually sufficient to arrest the head-pain. As an additional security it
is well to recommend the patient to take a hot foot-bath, and to remain
as quiet as possible for twelve hours succeeding the treatment. In
hyperæmic headache cupping and blood-letting have been recommended; but
as a rule both procedures are not only unnecessary but positively
inadmissible, as exclusion of the superfluous amount of blood by
compression upon the carotids, followed by a corresponding dilatation of
the peripheral circulation by means of the foot-bath, will almost always
be sufficient to cause a permanent cessation of the symptoms. Among the
internal remedies which may be employed with good effect in certain
cases are aconite, bromide of potassium, and Indian hemp. The inhalation
of from five to ten drops of chloroform is an excellent expedient in
some instances. Chlorodyne, which is nothing more than a mixture of
sedatives, often works well, and indeed frequently excels other
remedies. The regulation of the heart's action is also of very great
importance in these cases, and the physician should have no hesitancy in
resorting to such remedies as digitalis and belladonna for the purpose
of reducing the tension in the domain of the cerebral circulation. As a
matter of course the digestive functions should be carefully looked to;
the bowels should be kept open; and in all cases where there are
indications of a congestive origin, alcohol in all forms should be
absolutely forbidden.--_Med. Record_.
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