valuable in those cases where there is weak circulation. Sumbul and solanum have their advocates, but so has had every other remedy ever known to man. Flechsig has proposed the use of opium, to be followed by bromids, in cases of long standing. He gives opium in doses gradually increasing from one to fifteen grains or more a day, if well borne, and after a few weeks abruptly stops the opium, substituting bromid, twenty to forty grains, three times daily. Bechterew combines bromid, adonis vernalis, and codein with favorable results. Any one of these plans may be tried when bromid alone fails or loses its force.

CHAPTER VIII.

MIGRAINE.

The

MIGRAINE is an explosive, paroxysmal psychoneurosis. attack, usually commencing with sensory and mental symptoms, is almost always attended by headache, which is frequently one-sided, and there is generally nausea and vomiting. It is sometimes called hemicrania, sick headache, or megrim. Owing to the vomiting, it is often erroneously attributed to biliousness.

Etiology. Heredity is often strongly marked. It is more commonly direct than in almost any other neurosis. Migraine may sometimes be traced through several generations, numbering dozens of cases in a single family tree. Any neuropathic family is almost sure to present cases of migraine. It seems capable of transmission by transformation, alternating with hysteria, epilepsy, and insanity. It may be associated with the graver neuroses, or with psychoses, in a given patient. Gout and arthritism have similar close relations with it. Thirty per cent. of cases begin between five and ten years of age, and the balance appear mainly at puberty, adolescence, and during early adult years. In rare instances it may begin after thirty. The female sex is somewhat more commonly affected than the male.

The inciting cause is often obscure. Some cases date from periods of lowered physical health arising from any cause. The cases beginning in early childhood very frequently follow the first systematic use of the eyes for near vision, as in school-work. Eye-strain, arising from accommodative or muscular asthenopia, is certainly competent to incite migrainous attacks in those predisposed. Gouty or lithemic conditions, constipation, indigestion, fatigue, lactation, emotional disturbance, or any febrile movement may set up the attack.

Symptoms. The symptoms of migraine are those of the attacks. These vary considerably in different patients, but are tolerably uniform for the given case. There are usually: (1) Premonitory symptoms; (2) sensory disturbances; (3) headache; (4) nausea; (5) vomiting; (6)

sleep; and (7) complete recovery, occurring generally in the order given. In addition, there are usually vasomotor symptoms and occasionally mental and motor phenomena.

The premonitory symptoms are most common in the cases in which the early sensory symptoms are least marked. For a few hours or a day the patient feels heavy, dull, apathetic, and is usually indifferent and irritable. There may be slight headache or somnolence. After a nap he may wake up with a fully developed one-sided headache, or this may present on awakening in the morning. The sensory symptoms occur in over half of the cases. They usually begin quite suddenly. Bright spots before the eyes, colored rings, luminous zigzags, hemianopsia, dimness of vision, clouds, etc., are some of the subjective visual disturbances. They affect both eyes, and are sometimes lessened if the eyes are closed. They are usually most pronounced or entirely confined to the homologous half fields. Some patients only feel a vague ocular discomfort, or decided photophobia may be present. Taste and hearing are exceptionally affected in a similar manner. In some cases there are sensory symptoms in the limbs, face, throat, or tongue, but especially in the hand or foot. A tingling or numbness invades the parts and gradually advances toward the center. These sensory disturbances usually last ten to twenty minutes and then subside, the headache immediately displacing them.

Motor symptoms, though exceptional, are very valuable indications of the cerebral nature of this neurosis. The extremity which presents tingling may show paresis, and the following headache is usually on the opposite side. Motor aphasia may be added to right-arm tingling and left hemicrania, and the left halves of the retina may be disturbed by visual sensations, which are referred outwardly to the right fields. Temporary word-deafness has also been recorded. In another group of rare cases there is transient unilateral paresis of the oculomotor, marked by ptosis, outward squint, double vision, pupillary dilatation, and loss of accommodation, constituting the so-called ophthalmoplegic migraine.

Slight mental changes occur in some patients, such as depression, mental confusion, restlessness, loss of memory, stupor, double consciousness, or a recurrence of some vivid memory.

The headache is the most uniform, dominant, and distressing symptom. It varies in different cases in degree, duration, and location, but is commonly intense and ordinarily circumscribed, at least at first. Often commencing as a localized, intense pain in a small spot in the temporal, frontal, ocular, or occipital region, it gradually spreads to the rest of the same side of the head, or may become diffused all over the head. Less commonly it commences on both sides as a frontal or occipital pain. Rarely, it passes down the back of the neck and into the arm. The character of the headache is tolerably uniform in the same case, but some patients have several varieties, which reappear from time to time, and are recognized as old acquaintances. The headache lasts from one or two hours to ten, twenty, or forty, and may subside abruptly after nausea or nausea and vomiting, or gradually grow less and

disappear. During the height of the headache the patients usually shun light and noise, and remain as quietly recumbent as possible. Movement, such as rising or stooping, intensifies the pain. Tenderness of the scalp or nerve-trunks is unusual.

In most cases nausea appears after the headache develops or has reached its height, and there is complete anorexia. Digestion appears to be stopped, as unchanged food is sometimes vomited many hours after its ingestion.

The nausea leads to vomiting in a fair proportion of the cases, and emesis is attended by much retching and difficulty. It is often repeated and protracted, so that biliary matter may finally appear in the ejecta. Usually, once commenced, it is provoked by swallowing any fluid, or even by the saliva, which is commonly apparently increased in amount. Often the patient is cold, pinched, clammy, and suggests the collapse of seasickness or choleraic disturbance. Frequently, as the vomiting subsides, a feeling of great relief is experienced, the headache ceases, and the patient falls into a quiet sleep of a few minutes or several hours, from which he arises and asks for, or tolerates, a little food.

The vasomotor symptoms are interesting, and have attracted great attention. Early in the attack, before the headache has appeared, there is frequently pallor or mottling of the face. In some instances a vivid red streak in the middle of the brow or a one-sided flush invariably appears. The pallor is succeeded by flushing, in some, and there may be general profuse perspiration. Commonly, the extremities are cold during the severe pain, the pulse sharp and retarded. Usually the contracted pupils show the participation of the cervical sympathetic. This rarely is unilateral, and may produce retraction of the eyeball. The inhibited digestion may be due to a similar angiospastic condition of the gastric arterioles. As the attack declines, the surface reddens, the pulse resumes its proper rate, the pupils relax, the pallor disappears, and in rare cases some puffiness in the scalp has been noted. Increased diuresis may follow. In the intervals the patient may feel perfectly well.

Course. Migraine has a tendency to persist for many years, when once established. Commonly, in women, after the menopause, it subsides, and it disappears in men after fifty-five or sixty. The attacks occur with more or less regularity, and sometimes with remarkable periodicity. Menstruation may provoke it monthly in women. It sometimes occurs every Sunday, especially in men who change their daily routine at that time. Irregular intervals of weeks or months may intervene, when any of the inciting causes may precipitate it; but it is usually noticeable that an inciting cause or condition, acting soon after an attack, fails to induce an immediate recurrence. It is evident that the attack has cleared the atmosphere and exhausted the susceptibility. In certain rare instances the migrainous attacks have been replaced by epileptic seizures presenting the same premonitory features. A case has been seen presenting migraine, epilepsy, and transitory mania, apparently as alternating equivalents. Krafft-Ebing 1 1 "Alienist and Neurologist," Jan, 1900.

After

reports a number of cases in which transitory mental disorder occurred as part of, or in alternation with, migraine. The premonitory hemiopia in a case reported by Noyes became permanent. In advanced years the migraine may apparently be replaced by labyrinthine vertigo. many attacks, some intellectual impairment has been noted. Granting the neuropathic substratum in migraine, the association or succession of other neuroses and psychoses is surprising only by its rarity.

Pathology. In the absence of knowledge regarding the morbid anatomy of migraine, we are thrown back upon theories and analogies. Attracted by the vasomotor symptoms, many attributed the migrainous attacks to disturbance of the sympathetic. This is a clear confusion of effect and cause, of symptom and disease. Taking into consideration the cortical features manifest in sensory disturbance, hemiopia, tingling, aphasia, motor loss, crossed hemicrania, mental features, cardiac and digestive inhibition, and the vasomotor disturbance itself, there can be little doubt that migraine is a cerebral disorder. Its resemblance to epilepsy, if not its actual relationship, points to the same conclusion. The exact nature of the cortical instability is for the future to reveal.

Diagnosis. The diagnosis of migraine depends mainly upon its paroxysmal and recurrent character and its definite clinical features. The sensory premonitions and vasomotor phenomena are very significant when present. In cases presenting migrainous attacks of the milder sorts, it is difficult to be sure that the headache is not due to some ordinary cause, until its repeated recurrence under somewhat similar circumstances declares its nature. "Sick headache" is almost invariably migraine. The vesperal headaches of syphilis, and the quotidian or tertian headaches of malaria, occur with greater periodical regularity and with much shorter intervals than the attacks of migraine. Both lack the nausea, vasomotor symptoms, and complete recovery. From petit mal the diagnosis may often offer considerable difficulty. The premonitory sensations may be taken for an aura, but their prolonged duration is unlike the momentary warning of epilepsy. Unconsciousness does not occur in migraine; it is the most constant feature of epilepsy. Headache, as a symptom of other disease developing in a migrainous patient, may be overlooked and the concurrent malady neglected. The headaches of Bright's disease, of cerebral tumor, of syphilis, or malaria may be wrongly attributed to the neurosis.

Prognosis.-Migraine is usually a stubborn and persistent malady. It has a tendency to last until involutional changes in the organism commence, when it frequently spontaneously subsides by a gradual increase of the intervals between the attacks, rather than by a lessening of their severity. If the disease is of short duration, and some removable cause can be discovered, the prognosis is fairly good. In older cases the attacks can usually be rendered less frequent and often aborted if the patient is watchful and persists in treatment.

Treatment.-Unless the condition or agent provocative of the attacks can be discovered and removed, there is little likelihood of fully

64

1 Wilfred Harris, "Transient Hemiopias," Brain," 1897

successful management. To this end all sources of peripheral irritation and auto-intoxication must be carefully investigated. Eve-strain, improper diet, excesses, or bad habits of any sort must be corrected. In some migrainous patients any relative excess of nitrogenous food is sure to induce an attack. As a rule, for these patients an abundance of outdoor air, free cutaneous and intestinal excretion, and an unstimulating diet are indicated. A tablet of of a grain of nitroglycerin, allowed to dissolve in the mouth, and taken at the earliest premonition, will sometimes abort an attack. Caffein has a similar effect with some patients. Others, by taking a large dose of bromid and lying down, occasionally escape. Others, again, by inducing emesis, or by washing out the stomach, interrupt the paroxysm. When the attack is once on,

00

heat or cold to the head, warmth to the extremities, and a mild sinapism over the stamach are helpful. A dark, quiet room is usually demanded. Morphin will control the pain, but should, if possible, be avoided, to prevent setting up the opium-habit.

If the attacks are of considerable frequency,-say one or two a week,a continuous course of bromid, as in epilepsy, may give good results. In the forms marked by paretic symptoms of onset-by ophthalmoplegia, for instance the bromid treatment is of the greatest value, and such cases should be managed much as cases of epilepsy with incomplete attacks.

CHAPTER IX.

NEUROSES FOLLOWING TRAUMATISM.

THE subject of neuroses following injuries is one of vast importance to the general practitioner, and has a medicolegal side of much interest. The question has been greatly befogged for many reasons. The first important work directing attention to this class of cases was the publication of Erichsen in 1871 on "Spinal Concussion," reprinted in 1875. In it he reports fifty-three cases resulting from injuries, received mainly upon railways. These cases present all manner of lesions, alone having in common the negative feature-absence of external evidence of injury. In this list are embraced cases of fracture of the dorsal vertebræ, hemorrhage into the cord, division of the cord, meningitis, simple nervousness, hysteria, neurasthenia, and pretty much everything else. Unfortunately, "concussion of the spine," as set forth by Erichsen, was seized upon by lawyers as the basis for prosecuting suits for damage against corporations, and it became fixed as a disease-entity in the legal and medical mind. In 1883 Page, a railway surgeon, brought out a book written from an ex parte standpoint to counteract the contentions of Erichsen, and the battle raged fiercely from both sides for a number of years. Subsequently, in Germany, Oppenheim, in 1889, made a closer