Headaches : their nature, causes, and treatment

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Preface To The Second Edition

A SECOND edition having been called for in the course of a few months, the various demands on my time have prevented me from making many additions which I had hoped to carry out. A comparatively unrecognised form of headache is added to the Toxsemic variety, and a few additional observations and illustrative cases are scattered through the other chapters. Beyond this the work remains the same as when first published.

io Manchester Square, January , 1878.

Preface To The First Edition

In the present day there are so many investigators in every field of study, that it would be impossible to keep pace with any branch of it, if worked out satisfactorily and to its full extent, unless we refreshed our ideas from different increasing springs of knowledge, and thought the subject over again and again from every point of view. This applies, perhaps, more to medicine than to any other subject ; for as we inquire into the origin of human maladies, new features continually present themselves, and new mysteries to be solved continually arise.

The views I have here advanced are the results of notes and observations carefully recorded by me, and extending over a period of many years. In most of the cases which have formed the groundwork of the present task, I have had ample opportunities of watching their course and progress. I have, moreover, rather relied on the investigation of facts, as presented by the record of cases, than trusted to

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plausible theories. It is on actual facts I have attempted to lay the basis of the treatment and management which appear to me best adapted to meet the varieties and peculiarities of headache. In all search for truth facts must be recognised, however they appear to contradict an apparently secure and well-established principle. To grasp the general conception and meaning of any subject in which the operations of nature are concerned, and from which a reasonable solution is expected, we must establish the conclusions which lead up to principles on the sure foundation of fact, and not, like the French philosopher, think it so much the worse for the facts if they are not included in our theory. If theory is unsupported by fact, our view and opinions entail disastrous consequences, and any line of argument we may have adopted is rendered utterly futile.

I may here remark that several works have recently issued from the medical press on the subject of headache, teeming with interest both to the patient and the practitioner. Headache has always been carefully studied in its clinical aspect, but the recent advance of physiological knowledge, as derived from experiment, has given a new and powerful stimulus to the study of the diseases of the nervous system. Not only has it furnished a stimulus, but it has tended much to clear up our impressions as to the pathology

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xi of diseased conditions. The recognition of perivascular spaces has enabled us to comprehend how the blood supply of the brain may vary from time to time. These modifications in its physical consistency do not impair its functional activity, but promote the growth and reconstruction of the nervous system, which is undergoing incessant change and regeneration. By means of these spaces the vessels dilate without compressing the brain, and when they again contract the soft structures of the brain are sustained by the effusion of lymph without any serious consequences ensuing.

The researches .of physiologists heretofore had stopped short at the cerebrum, and only comprised the deep-seated ganglia at its base ; but the recent investigations of Fritsch and Hitzig, and still more of our countryman Terrier, have demonstrated that the different portions of each convolution possess special functions. Some are motor-centres, and others are centres of sensation. The vast additions which have been recently made to our previous knowledge by Dr. Ferrier’s experimental researches justify us in drawing certain definite conclusions, not only as confirmatory of the functions of the deeper structures of the brain, but of the convolutions themselves. By applying electricity in the form of local fai'adization to the cortical substance of the brain, he could

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produce at will an intense amount of kypercemia , increasing the quantity of blood and the size of the vessels ; and, in the case of rabbits, he found that the repeated application of the electrodes converted the cerebral substance into a condition resembling fungus hcematodes. By irritating the different portions of the hemispheres in some of the lower animals, he could excite partial or general convulsion, and these were invariably preceded by a hyperaemic state of the cortical tissue. These experiments bear most strikingly on that state of nerve-tension, which Dr. Liveing describes as leading to “ nerve-storms,” when an explosive discharge takes place from the ganglionic centres, reducing the tension and irritability of the parts involved, while lessening the hyperaemia on which they depend. A recognition of these facts is essential to a rightful comprehension of headache. They help in no small degree to explain the intimate relation of the nerve force to the blood supply.

My earnest endeavour throughout the book has been to make it practically useful. I have adopted the division of headaches into several varieties, which may possibly seem to some readers to involve too great a refinement ; but on full consideration, I think they will find it neither unnecessary nor frivolous. The diagnostic features which distinguish hypermmia in some of its forms from congestion and plethora, are

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Xlll somewhat difficult to lay down, but we are most likely right in assuming that there is a physiological difference. As regards the origin of active hypersemia, if we see the subject dimly, we are sure that its active form does not always depend upon the same pathological conditions. The cerebral tissue is over-excited and stimulated by increased cardiac action in the one case of hypersemia ; and in the other, the hypersemia is the consequence of relaxation of the vessels, and vaso-motor paresis. All the states depend upon an enlargement of the capillaries, either with increased activity of the general circulation, or with obstructed or retarded motion of the blood through them. Congestion, in the strict sense of the word, would seem to be the excessive attraction of blood by the tissues, rather than either the active or the passive form of hypersemia. A hypersemic state of the brain, when long kept up, leaves the organ weaker, and disposes it to an asthenic form of congestion. I have described passive hypersemia and passive congestion under separate headings, and although they are in many points identical, I wish to imply by the latter a decrease in the circulating power of longer standing, a more relaxed condition of the vessels, and a greater tendency to serous exudation.

I must here express my indebtedness to Dr. Herbert Major, the Superintendent of the West Riding Asylum,

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for permission to copy a plate of his, which gives the microscopic appearances of the cerebral cells of the convolutions. It is on these cells that cerebral activity depends. I also have to thank Dr. Lauder Brunton, F.R.S., for a copy of a woodcut, which renders very intelligible the association of headache with disturbance in the abdominal viscera.

io Manchester Square,

HEADACHES.

GENERAL INTRODUCTION.

Preliminary Remarks on the Preponderance of Diseases of the Nervous System at the Present Day — Source of the Pain in Headache , and its Common Dependence on the State of the Brain and Nerves — Definition of the Term — Difficulties in adapting Suitable Definitions to embrace all the Varieties of Headache — State of the Brain in some Cases of Apoplexy and Simple Concussion — Importance of Rest iti the Treatment of Headaches at all Periods of Life, and more particularly in the Young, when the Growth of Mind and Body is in Active Progress.

Many affections of the brain rather manifest themselves in impaired functional activity than in actual pain and suffering. Almost any change in the circulating fluid, whether it be degraded from the absorption of noxious ingredients, or impoverished by a diminution of its normal constituents, will give rise to irritation, and that altered sensation which indicates a disturbance in the sensorium.

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The most typical diseases of the present day are those which affect the nervous system, and we need not travel far to ascertain the causes which produce them. The strain to which the nervous system is subjected through the requirements of modern times, renders it far more liable to disease than formerly, and men break down prematurely from overwork and the want of rest. Every branch of study is now pushed forward with a vigour unknown to our ancestors, and the young child is expected to grapple with abstruse questions, which a few yeais ago were only intended for the advanced scholar, and those who made philosophy their peculiar study. The microscope with its revelations, the electric telegraph which brings us in immediate contact with the enterprise and movements of other countries, are both powerful factors in stimulating the brain of man to unusual activity ; the conflicting theories and theological controversies that have sprung out of the discoveries which geological science has called forth, and the generally increased pace at which we live, have all tended to excite and exhaust the brain. The tide, having once set in, rolls with resistless force, and the question may be reasonably asked, where will the waves of destruction stop ? The diseases of the nervous system threaten to be the diseases of the future, as they are of the present day, in spite of any restraint which men can put upon themselves. However desirous they may be to prevent it, they are

GENERAL INTRODUCTION.

helplessly und irresistibly diciwn into the contest, to struggle on and survive, or to fall early in the combat.*

Before civilization had arrived at the high state we now find it, the over-wrought brain was confined to men of letters and laborious students in the solitary contemplation of human knowledge. Nervous exhaustion was not the common disorder we now find it, and physicians were nearly silent on the causes which produced it. In whatever direction a man now turns his attention, he is sure to see competitors who are striving for the same prizes. In trade, in commerce, in literature, and in art it is ever the same — no man has the field to himself. But the professional man may perhaps be singled out as the chief example of overstrained exertion. He must strain every faculty toward the special object he is studying, and dare not leave it till he has worked it out to the minutest detail. If he does quit the field, failing to discover some new stratum, he is followed by another, who digs up the hidden treasure

* This matter has not escaped the attention of observant laymen. “ The politician, the professional man, the merchant, the speculator — all must experience that strain of special faculties in the direction towards special objects, out of which comes nervous exhaustion, with the maladies consequent on over-stimulus and prolonged fatigue. Horace is a sound pathologist, when he tells us that after Prometheus had stolen fire from heaven, a cohort of fevers, unknown before, encamped themselves on earth. In our audacious age we are always stealing new fire, and swelling the cohort of fevers with new recruits.” — Miscellaneous Prose Works, by Edward Bulwer, Lord Lytton, 1868, vol. iii. p. 108.

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which gives a name or builds up a future. His thoughts are ever active and at work, and the brain will not rest, unless other occupations are found, and a new set of organs are called into play. In the physical disorders of man a certain set of muscles require rest, whilst another set are required to perform their lost functions, and disease imitates this in the activity of certain, organs, to allow the worn-out ones to recruit themselves. Rest from thought would obviate much of the fatigue and exhaustion of the brain, if it could be adequately measured and carried out ; but the circumstances of life generally do not enable a man to avail himself of that change of thought and occupation which would be a safeguard against the terrible evils he is fostering.

If there be any truth in this argument, it is not surprising that the complex and delicate structure of the brain, and nerves, should fail under this continued strain and this struggle for existence in the battle of life. Every emotion, every perception, and every action operate through this vast machinery, and invest it with an importance which did not belong to it forty years ago, when the atmosphere of thought was more serene and tranquil. What wonder, then, if the nervous system should suddenly or prematurely give way, if it has to bear a load every day, which at one time only emergency or accident put upon it ! Added to the altered circumstances of modern times, care and anxiety bring their oppressive burden to

GENERAL INTRODUCTION.

bear in greater force, increasing the susceptibility of the nervous framework, and robbing it of much of its power of resistance.

Then, too, the luxuries of a larger portion of mankind have increased, and in a corresponding ratio ; and nervous prostration is the penalty we pay for our indulgence. The sensual pleasures of life, which make such inroads on our strength and powers of endurance, are alarming to contemplate, in the varied forms of suffering which they produce in return for a passing gratification or an idle enjoyment. Sustained and steady work are not the prevalent features of our present life, but laborious strain and tension, followed by brief and broken periods of repose.

A continuity of causes oftentimes produces the same results ; and we see this exemplified in headache, as well as in many other diseases. There is first the influence of excitement, and over-stimulation to the brain, and then the influence of exhaustion. When both act in concert, how rapid is the downfall ! I hold with unshaken fidelity to the conviction of a nerve preponderance in these headaches, which eclipses every other. We cannot set aside its attractive power to implicate the vascular tissues, and to change and modify the signs and symptoms of disease in every texture of which the body is made up ; nor the rival sway it exerts in corrupting the machinery of the whole body, and accomplishing the destruction of the vital parts.

HEADACHES.

In attempting to classify headaches into groups and varieties, some speculations are necessarily indulged in to establish conclusions and to support principles ; but I have endeavoured to place fairly before the reader the chief aspects of the question, and to weigh carefully in the scale of calculation every collateral sign of investigation, that fallacy may be reduced to a minimum, if not wholly got rid of, and that conviction of some sort may be gained.

It has been my desire to consider this matter in a broad light. Devotion to any view or idea gives it an ascendancy in the author’s mind, and, by attaching undue importance to it, he may be led into error. We are all, in fact, more or less disposed to incline to one side or the other, and so to entertain a prejudiced view of things, which has a cramping effect in the pursuit of a study like practical medicine. The mind is to be pitied that extends the range of inquiry no further than the sphere of its own special study, for in this way knowledge is improperly applied. “Men’s thoughts,” says Lord Bacon, “are much according to their inclination, and they speak as they have learned.”

In the disorders we are about to consider we shall deal chiefly with those that are functional, for curable headaches cannot be strictly classified with morbid states of the brain. And yet the difficulty is as real as it is hypothetical. Molecular changes may take place in the cerebral cells, and produce symptoms

GENERAL INTRODUCTION.

allied to organic lesions, having no show of difference except in their transient duration.

The subject of headache is of manifest importance, because it claims so many sufferers and is surrounded by so many difficulties — the pathology is obscure, the diagnosis perplexing, the remedies uncertain. Headache is a disorder of the utmost frequency, and yet there is none which more taxes the experience and scientific knowledge of the physician, or requires closer observation in elucidating its nature and removing its obscurity.

The habitual sufferer from headache allows no other pain to compete with it. Whether he is prostrated by its agony, or has recovered from a recent attack, he is persistent in his statement, that a continuance of the pain would rob him of all pleasure in existence, and make him sigh for escape by death. The aching cerebral mass shut up in its bony cavity only reveals its morbid condition by the statements of the sufferer : in its functional derangement it does not indicate by any reliable signs whether this or that part is at fault, as in disorders of the abdominal or thoracic organs ; the source of the suffering cannot be fixed upon and removed as a decaying tooth, or a calculus in the bladder ; but it goes on, and we are too often left in doubt whether the suffering has originated in the brain itself, or in some other organ of the body from reflex irritation and sympathy. Are the brain and its vessels deficient in the supply

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of blood ? Is the circulation contributing its due supply of arterial nourishment ? Or is it in excess, and are its vessels overloaded ? These perplexing questions constantly present themselves for settlement. The same symptoms arise when very opposite conditions prevail. The delirium of scarlet fever is not the delirium of typhus, although they may present very similar features. There is the sleeplessness of anaemia and of congestion ; and there is the coma of bloodlessness as well as of hyperaemia. How can such dangerous conditions as these be treated with any chance of success, if we have erred in the interpretation of their pathological associations, or ascribed the phenomena to a state of the brain and general system which does not exist ?

Bearing in mind, then, the intricacy of the subject, and the ever-changing circumstances that surround us, we approach the discussion of a disorder which modern habits of life encourage and develop, and threaten to increase tenfold. Our system of railway travelling has no small share in producing that aching of nerves within the brain, which robs existence of enjoyment, and interrupts the serenity of social life ; and which too often drives the pitiable sufferer to the brink of despair, when he finds no relief in the legitimate resources of our art. In clinging to any nostrum within his reach, he increases the evil which is to render his life heavy and wearisome, and to baffle his energies and labours to the end.

GENERAL INTRODUCTION.

In no class of disease do we observe better examples of sympathetic pain than in headache. Pain originating in one part may be transferred to another and weaker part, or to one ready to take on the morbid impression of pain. This communication is regulated to a great extent by the irritability or nervous susceptibility of the patient.

The mere idea of pain is enough to bring on actual pain in some persons ; and the mind can so vivify or exaggerate it, as to give it a reality through sensation. The’ sympathetic pain of the shoulder from hepatic disease, the pain in the knee from hip-joint disease, and the pain of the genito-crural nerve from calculus in the kidney, or the severe pain down the thigh after the removal of ovarian tumours, are all instances of reflected pain. The transference of pain beyond the seat of its production is an interesting fact in physiology, and where the impressions can be traced along a set of nerves the explanation is forthcoming. It is this communication which refers painful sensations to a distant part from which the irritation has sprung, till it finally appears to have its origin in that part, whilst the original seat of mischief is lost sight of altogether.

If, then, the cause of some headaches is traceable to a morbid sensation conveyed along a nerve by sympathetic action, it is explanatory of some painful feelings in the head and face, through the contact of certain articles of food, and intense cold on the terminal

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nerves of the stomach. Any sudden shock of grief may occasion gastric pain, and it certainly awakens fearful headache in some persons. “Putting aside,” says Dr. Symonds, “ for the present, any reference to the patient’s feelings, what do we learn from anatomical considerations as to the probable source of pain within the cranium when the person is the subject of headache ? It does not appear to be in the nervous matter, whether vesicular or tubular, of the cerebral hemispheres, or of the cerebellum. No evidence of feeling has been obtained by vivisectors till they approached the sensory ganglia — the thalami optici and corpora quadrigemina. But these are the centres of sensation to all parts of the body as well as to the head. All analogy must further look for the nerves as the source of pain (though some writers are hardy enough to doubt the necessity of nervous matter as instrumental in sensation). And what are the nerves ? Numerous as are the nerves which come out of the cranium, there are on a superficial view veiy few that go into it. A branch of the sub-occipital accompanies the vertebral artery, but a large majority of the other nerves, destined for intra-cranial purposes, are derived from the sympathetic. These, then, are the nerves which are of the chief interest to our present inquiry. Nerves of this class accompany blood-vessels, and when we observe the large amount of these vessels, the brain and its membranes being more liberally supplied with blood than- any other organ, the

GENERAL INTRODUCTION.

II quantity being computed at as one-fifth of the blood of the whole body, we might, without searching further, feel convinced that there must be a correspondent supply of ganglionic nerves ; but the minute examination of modern anatomists has tracked them in great abundance.”*

By the term headache, we mean to signify pain in the head, accompanied with intolerance of light and sound, and incapability of mental exertion ; a state, from whatever cause arising, in which the brain is temporarily prostrated and disturbed, in proportion to the cause and intensity of the suffering. Thus, many headaches depend primarily on a disturbance in the cerebral structure, on a loss of balance in the relations of the nervous force and vascular supply, or on some intricate phenomena of the mind, which increase the sensibility of the brain, and disturb its functions.!

* “ Gulstonian Lectures on Headache.” — Medical Times and Gazette, 1858.

t “ The headache, a very frequent symptom in all cerebral diseases, is very difficult to explain ; we do not even know if it is of central origin (that is, if it originates in the parts of the brain where irritation causes symptoms of pain after the insensible greater hemispheres have been removed), or whether, as I think is more probable, it depends on irritation of the filaments of the trigeminus going to the dura mater. The great sensitiveness to impressions on the senses depends on the increase of excitability, caused by the cerebral hyperoemia, on the hyperesthesia of those portions of the brain through which peripheral irritations arc perceived. The patients do not exactly feel, see, and hear more sharply than ordinarily, but they are annoyed by irritations far weaker than such as usually annoy them. Light troubles them : a slight sound or an insignificant irritation of the nerves of touch excites disagreeable feelings. Morbid excitation (which must not be identified with increased excitability) of the same central parts causes the dazzling

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Then follows sympathetic disturbance in the digestive organs, which reacting on the brain, increases all the symptoms for a time ; but soon, from the process having advanced further, or from some change ensuing in the current of the circulation, the morbid sensibility of the brain abates, and the headache vanishes.

For some days before the development of a nervous headache, patients will admit, on close examination, that they felt easily fatigued without any real cause ; that they awoke unrefreshed in the morning, with a feeling of weight over the eyes, which passed away after breakfast ; that before the close of the day they were unusually tired, and felt on going to bed some flatulence and indigestion, with dryness of the mouth, and an extraordinary degree of depression and weariness. During the night, or the following morning, the nervous headache is developed, and after that the altered sensibility of the brain and the arrest in the powers of digestion proceed together. Symptoms, therefore, which appear as primarily indicative of disorder in the stomach and intestines, are really often secondary, or sympathetic affections, resulting from the pre-existent disorder within the brain ; and when we come to consider the varieties of headache, we shall see how this disturbance is effected.

before the eyes, seeing sparks, roaring and buzzing in the ears, the sensation of formication, or of undefined pain, which are not induced by peripheral irritation.”- — Niemeyer's Practical Medicine, vol. ii. page 159-

GENERAL INTRODUCTION.

The conditions which produce some forms of headache are wrapped in mystery, and we are carried into the realms of speculation to explain them. The cranium of the adult is air-tight and unyielding. In a healthy state the brain probably undergoes neither dilatation nor compression. Neither the contents of the thorax, nor the abdomen, sustain the same amount of pressure for one second ; the elasticity of their walls through the movements of respiration keeps them' in perpetual activity, and the blood pressure is continually changing ; but the case of the cranium is altogether different. Where a tumour is present, or lymph or blood is effused into the brain, there is an alteration in pressure, and the brain substance is displaced by the encroachment of disease ; but if pressure arises gradually, the brain sometimes adapts itself to the changes which are going on. In some cases of apoplexy the effusion has been so rapid and extensive, that it has pressed upon the brain, so as to cause symptoms of rapid compression and death. It should, however, be borne in mind that the phenomena of apoplexy have ensued, where nothing but a disproportionate amount of blood has been seen in the vessels and sinuses after death, without any rupture ; but then the vascular connection that exists between the vessels of the brain and those that ramify over the face and scalp has a tendency to relieve the sudden determination within the head. The balance of the cerebral circulation is interrupted when the arteries are

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nearly empty, for then the veins are full, and oppression is the consequence. If arterial tension is increased, and the vessels are full, a state of exaltation and excitement then ensues, tending to delirium or mania.

There is no exact evidence of the actual change that takes place in the cerebral mass, when a physical disturbance of the brain and nervous centres is caused by simple concussion. A mere confusion of ideas, or a temporary lull in the mental process, as though the sufferer had just awoke from sleep, and had not yet realized the external world around him, are all the manifestations of the mischief. I apprehend that in these slight cases of shock, when recovery is early and permanent, there is no structural or molecular lesion ; but when headache and congestion of the cerebral vessels creep on after a time, then we may calculate with almost absolute certainty that the force of the circulation through the bruised organ is disturbed, being excessive in some parts, and scanty in others.

If the delicate structure of the brain is susceptible of molecular disturbance from injury, it is a rational inference to suppose that the same may occur from functional disorder and perverted nutrition, when they have been of long standing. A structural lesion at the base of the brain is possible where the vascular supply is the greatest, and the minute filaments of the pneumogastric nerve are abundant, as they spring from the medulla oblongata. Now, in concussion of

GENERAL INTRODUCTION.

the brain the enlightened surgeon, in his treatment, relies more on rest and the exclusion of light and sound, than on any other method of cure. He knows that any plan which does not include these instructions is futile to effect recovery, and to afford the brain a chance of regaining its equilibrium. If it is not allowed a long season of repose, and strain and exertion are put upon it at a time when the utmost quietude is demanded, then softening, inflammation, and gradual degeneration are established.

The brain cannot stand still like a monument, and maintain its integrity. If there is no repair, then there is degeneration ; the morbid condition, instead of subsiding, slowly advances, and the rest, of which sleep is the most perfect form, cannot bring its restorative influence into operation ; the nights are disturbed and restless, and dismal dreams announce that the morbid changes are still in progress. Repair proceeds with activity in persons of adult life, when growth has ceased and the bodily framework is stationary : but in children, when the tissues are building up, and the changes are rapid in all the organic functions, recovery is often tedious, defective, and uncertain. In these young patients a shaking of the cerebral mass has laid the foundation of confirmed headache, and subsequently of organic change in the structure of the brain, sometimes leading to exudative products and morbid growths. Repair is one of the most beneficent manifestations of the