Pain and its indications; an analytical outline of diagnosis and treatment

Front matter

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AN ANALYTICAL OUTLINE OF DIAGNOSIS AND TREATMENT

Contents

INTRODUCTION n

I. HEADACHE 14

Organic, 14 — Arteriosclerotic, 19 — Active Hyperemic, 20 — Passive Hyperemic, 24 — Anemic, 25 — Hysterical or Imitative, 27 — Neurasthenic, 28 — Migrainous or Nervous, 30 — Toxemic, 33 — Febrile, 40 — Neuritic, 43 — Syphilitic, 44 — Osteoalgetic, 45 — Ocular, 45 — Nasopharyngeal, 48 — Miscellaneous Reflex, 50 — Traumatic, 53 — Adolescent, 53 — Cephalic Neuralgia, 54.

Foreword

To the patient, pain is the most important of symptoms. It is indeed that which most often leads him to seek medical advice. The great variety of causes of regional pains and the consequent difficulty of differentiation and of rational causal treatment, are appreciated by physicians and surgeons. In this reference outline are to be found all sorts of pains, systematically arranged for comparison in a few types and regions, and fully indexed. I trust that my labors in this connection will prove of practical service to my fellow practitioners. With the paragraphs on treatment due credit is given to the authors whose therapeutic ideas I have gleaned. For diagnostic points I am specially indebted to the following authorities : American Text-Book of Surgery, Anders, Bishop, Bosworth, Byford, Church and Peterson, Da Costa, De Schweinitz, Ewald, Garrigues, Gould and Pyle's Cyclopedia, Hare, Head, Hirst, Kyle, Musser, Osier, Pershing, Ranney, Roberts, Sajous, Skene, Tyson, Vierordt, White and Martin.

Denver, February i, 1904.

Introduction

Local inflammatory pain. — Generally severe, constant, throbbing, sticking, cutting, gnawing, radiating along peripheral nerves and increased by firm deep pressure and by movement of part; with heat, redness, swelling and rigidity and diffuse soreness of muscles over affected part, or disturbance of function. Constant aching in muscular pain; dull pain in connective tissues (aching) and mucous membranes (soreness or burning) ; sharp and stabbing in serous tissues (increased by deep breathing in pleural and peritoneal) ; tingling and shooting along nerve in neuritis (with herpes and tenderness all along course) and neuralgia (tender points and often local flushing; sometimes due to pressure by growths or scars) ; burning and itching in local skin lesions ; constant, deep, boring in diseases of bones and periosteum — often worse at night; modified by weather in neuralgic, neuritic lithemic or rheumatic pain; paroxysmal, colicky in obstruction of channels.

General pain, soreness and fatigue in toxemia; general aching, sometimes with chill, at onset of acute infections. Pain increased by movement in diseases of bones, joints, muscles and nerves; pain diminished or absent in shock or gangrene.

12 INTRODUCTION

Local non-inflammatory pain. — Generally remittent or intermittent and relieved or not increased by firm, deep pressure; very limited pain, usually functional; rhythmical recurrence in contractile pain (labor pains, distended tubes or bladder.)

Referred or reflex pains. — Due to lesions at other points having the same or related nerve supplies; not affected by pressure, but with cutaneous tenderness in same area — constant if dependent on chronic disease elsewhere; pain cuts across ribs in segments of the spinal areas as follows: Heart=l — 3 dorsal; hmgs=l — 5 dorsal, and cervical plexus; stomach=6 — 9 dorsal (pyloric, 9) ; liver and gall-bladder=7 — 10 dorsal and cervical plexus; intestines above rectum=9 — 12 dorsal; rectum=2 — 4 sacral; kidneys and ureters=10 — 12 dorsal and 1 lumbar; bladder=ll — 12 dorsal and 1 lumbar (overdistention) and 2 — 4 sacral (neck of bladder; incontinence) ; prostate=10 — 11 dorsal, 5 lumbar, 1 — 3 sacral; epididymis=ll — 12 dorsal and 1 lumbar; testis=10 dorsal; ovary=10 dorsal; uterus=l lumbar (contraction) and 2 — 4 sacral (os uteri) ; Fallopian tubes=ll — 12 dorsal. Algo-genesia (persistent or reviving pain on directing attention to it) is common in traumatic neurosis.

Neuralgic pain. — Shifting, intermittent, re-

INTRODUCTION 13

ferred to nerve trunks or to deeper distribution; firm pressure usually relieves; movement may aggravate or not; no characteristic disturbance of function. Intercostal neuralgia is distinguished from organic disease by freezing tender spinous processes with ethyl chlorid spray, when, if neuralgic, the pain, tenderness and muscular contraction all disappear.

Hysterical pain. — Usually burning, subject to suggestion, not influenced by rest; zones of pain (often geometric) independent of course of nerves.

Traumatic pain. — Specific in character; very intense at first, soon diminishing.

Pressure pain. — Constant, uneasy, at seat of causative organic lesion; often radiates along course of affected nerve trunk.

Nerve supply of head and neck. — Forehead and vertex^supraorbital ; temple and lower jaw— auriculotemporal; over malar bone=malar; middle of cheek^buccal ; upper lip=rinfraorbital ; chin=mental; upper occiput=great occipital; lower occiput and upper neck=small occipital; front of neck^superficial cervical; mastoid and post-maxillary region=great auricular; side of neck and post-auricular region=small occipital; lower part of neck= descending cervical.

Chapter I. Headache

[Two or more forms often combined.]

Organic. — Severe (may prevent sleep) and generally persistent, but variable, not ceasing with stupor or delirium; often circumscribed, with fulness and throbbing; increased by mental or physical effort, coughing, jarring or stooping, or by percussing over area of lesion if cortical ; often apparently causeless vomiting, slow breathing and pulse, vertigo, drowsiness, irritability, spasms, paralysis, optic neuritis.

General treatment. — Try potassium iodid in large doses for some time; morphin with coca wine and dr.i tinct. hyoscyamus or gr.x chloral. — Corning.

Meningitis. — Usually constant and boring (often paroxysmal in tubercular) diffuse frontal, occipital, vertical or parietal; in excess of fever; explosive vomiting, photophobia, stiffness of neck ; rapid onset in acute ; passes into stupor and coma ; patient shrieks out during sleep; no gestures as a rule.

Treatment. — Ice bag or ice-cold compresses to head; leeches to mastoid apophyses; wet cups to neck; morphin. — Debove and Douvin.

Brain Tumors. — Slow course, paroxysmal and varying — boring, gnawing, splitting, benumbing, local or diffuse; often worse at night; cerebellar and cortical forms most severe — glioma least; may be local tenderness; often choked disc.

Treatment. — Phenacetin and antipyrin in combination sometimes give great relief. — Mills.

Potassium iodid in full doses sometimes gives marked relief; ice cap; Paquelin cautery for occipital; morphin last resort. — Osier.

Cerebral Abscess. — Usually localized, very severe and persistent in acute, worse in early night; patient bores head into pillow; fever and chills, vertigo, mental dullness; history of injury to head or focus of infection, particularly middle ear disease.

Treatment. — Trephine and evacuate.

Cranial Trauma. — Concussion, pressure or laceration, or depressed fracture, causing meningitis; pain circumscribed at site of injury or on opposite side of head; history, scalp tenderness and other signs.

Treatment. — Eest, stimulants, warmth to extremities; surgical intervention if indicated.

Cerebral Syphilis. — Constant, rushing, frontal or temporal, with somnolence; worse at night; quasiperiodical.

Treatment. — Potassium or sodium iodid gr. xx t. i. d. increasing a grain each day until improvement or iodism ; fresh air, appropriate diet, bathing, exercise and rest. — Anders.

Thrombosis of Cerebral Sinuses. — Earache and marked edema back of ear if lateral sinus affected

(chronic otorrhea) ; edema of eyelids and face on affected side in cavernous; epistaxis in superior longitudinal.

Treatment. — Open and cleanse mastoid and lateral sinus; stop bleeding by plugging with strips of iodoform gauze; ligate internal jugular vein, wash out and make aseptic. General treatment of pyemia for other forms. — Am. Text-Book of Surgery.

Cerebral Thrombosis and Softening. — Dull, continuous, frontal; vertigo, tingling in fingers, aphasia, loss of memory, gradual paralysis and loss of consciousness.

Treatment. — Stimulants and small doses of digitalis if heart's action weak and irregular ; keep bowels open without active purgation; potassium iodid freely, with mercury if case is recent, in syphilitic form. — Osier.

Hydrocephalus. — Severe headache in acute, moderate or absent in chronic; vertigo, vomiting, convulsions, paralysis; enlarged, rounded skull.

Treatment. — Systematic support to exterior of skull as long as possible ; from time to time apply mercurial ointment or oleate of mercury (5 per cent) ; internally iodid of iron and cod-liver oil. — Goodhart.

Intracranial Aneurism. — Constant or paroxysmal; occipital if basal artery; may be distinct rushing feelings; rarely objective murmur; vertigo, epistaxis and tinnitus aurium in miliary.

IB PAIN AND ITS INDICATIONS

Treatment. — Ergot for miliary form — Bartholow.

Potassium iodid, nitroglycerin and morphin for ordinary form.

Disseminated Sclerosis. — Dull headache from early emotional stage; intention tremor, nystagmus, slow scanning speech.

Treatment. — Coal tar analgesics; warm baths. Hereditary Cerebellar Ataxia. — Reeling gait as if inebriated; intentional choreiform movements; speech hesitating, abrupt, defective.

Diffuse Encephalitis and Chronic Insanity. — Headache often localized.

Treatment. — Cold wet pack, using enough blankets to get good reaction and wetting head also.

Acute Delirium. — (Bell's Mania.) : Rapid, violent outbreaks and wild hallucinations with fever.

Treatment. — Calomel in early stage; cold baths and ice bag to head; hyoscin; stimulate freely later; forced feeding with milk, eggs and broths. — Anders.

Epilepsy. — Vertical or occipital ; severe, sudden, before and after fits (may take place of fit) ; nocturnal tongue-biting, vertigo, lassitude, mental confusion.

Treatment. — Pre-convulsive : Diffusible stimulants, especially nitrites and large doses of bro-

HEADACHE i9

mids. Postconvulsive: Strong, hot, black coffee.— Jos. Collins.

Hydrophobia. — Throat spasms on attempting to swallow.

Chloroform inhalations for spasm; morphin hypodermically ; cocain to throat. — Osier.

Arteriosclerotic. — Severe, dull, throbbing, waking patient in early morning ; part or whole of head; increased by exertion or excitement; tinnitus, vertigo, slight syncopal attacks; slight mental deterioration; sensation of head being drawn backward; general lowered vitality; hard pulse; elderly subjects.

Brain Syphilis. — Persistent, usually diffuse; history and scars.

Treatment. — R. Potassii iodidi gr. x; liq. hydrarg. bichlor. m. xxx-lx; tinct. gent. comp. dr. i; aq. cinuam. q. s. : An ounce in water t. i. d. after food. — Day.

Degenerative Nephritis. — Frontal or occipital; gastrointestinal crises and other uremic symptoms; albuminuria and casts.

Treatment. — Dilute nitric acid m. xx in water ; also pilocarpin injections. — Ealfe.

Citrate of caffein 1 or 2 gr. in pill; or nitroglycerin 1 or 2 m. 1 per cent sol. in a little water. — Saundby.

Milk and vegetable diet; no alcohol; water freely; woolen underclothing; Turkish bath once a week; easy, quiet, regular life; avoid exposure to damp cold. — Edwin F. Wilson.

See uremia under toxic.

Chronic Alcoholism. — Persistent with tremors.

Treatment. — Withdraw poison ; bromids, trional, chloralamid, sulphoual in the dose of not less than 15 gr. to produce sleep; lryoscin hydrobromate, 1/96 gr. to quiet excitement; some means of restraint usually indispensable; abundance of nutritious food; tea and coffee freely; strychnin 1/30 gr. 3 or 4 times a day or quinin. — Tyson.

Chronic Lead Poisoning. — Colic with constipation; tremors; wrist-drop.

Treatment. — Iodids in full doses in plenty of water; magnesium sulphate as a hydragogue.

Senility. — May be premature; depends on state of arteries.

Treatment. — R. Spt. Chloroformi m. v; liq. ergotse ext. m. xx-xxx; aq. purae ad oz. i: Take t. i. d. — Day.

Active Hyperemic. — Pulsating, throbbing, tensive frontal or diffuse; induced by exertion or excitement; increased by lowering head; vertigo, wakefulness; tinnitus, spots before eyes, feeling of fulness and tightness, irritability and depression; subjective throbbing of temporal and carotid arteries; flushed face, injected eyes, heated vertex.

HEADACHE <Sl

General Treatment. — Cold applications (Leiter coil or ice cap) to vertex and sinciput; suboccipital cuppings; electrocompression of common carotids; hot foot-baths or sitz-bath, Eussian or Turkish bath; artificial epistaxis. — Corning.

Bromids with ergot.

Congestive Headache with Insomnia: K. Chloral hydratis gr. viiss; morphinae hydrobrom. gr. -£; aq. camph. q. s. ; dessertspoonful every 2 hours till relieved. — Shoemaker.

Excitement or Prolonged Mental or Physical Efforts. — Treatment: R. Strych. sulph. gr. 1/16; cinchonidin. sulph. gr. ii; syr. limonis et acidi phosphorici dil. aa q. s. : A teaspoonful after eating. — Hamilton.

"Catching Cold." — Treatment : Stimulating foot-baths and hot sitz-baths.

Tinct. aconiti m.i in a tablespoonful of water every half hour. — Day.

Salicjdates and ordinary diet if fever; otherwise, sodium bicarbonate freely and partial feeding.—Haig.

Indigestion Reflex. — Increased intraocular tension and tenderness on upper surface eyeball.

Treatment. — Sodium bicarbonate with bitters before meals. — Brunton.

Atonic: E. Ferri sulph., quin. sulph. aa gr. i:j ■; sodii arsenit. gr. 1/24; pulv. rhei et zingiber.

aa gr. i; One pill t. i. d. after meals. — Jos. Collins.

Suppressed Menstruation or Hemorrhoidal Discharge.— Treatment: Belladonna or cimicifuga with gelseminm, and hot sitz-bath for menstrual headache; aloes for suppressed hemorrhoidal discharge.

Plethora. — Overindulgence; florid aspect; vertigo, tinnitus, spots before eyes.

Treatment. — Change mode of life; aconite, chloral, bromids; active saline cathartics; ergot. — M. L. Goodkind. Oil of eucalyptus, 5 drops every 4 hours.

R. Sodii et potass, tart. dr. ii; potass, bicarb, gr. xx ; syr. aurant. dr. iss. ; aquae ad oz. iss. : Effervescing draught with 15 gr. citric acid dissolved in a tablespoonful of water early in morning.—Day.

Climacteric. — With hot and cold flushes and other nervous symptoms.

Treatment. — Tincture of aconite, a drop every half hour or hour for high arterial tension; wine of colchicum in 5-drop doses for deficient elimination; veratrum viride, m. v-x every hour if needed for severe throbbing pain; potassium bromid dr. ss. for excitement. — A. H. P. Leuf.

Cannabis indica given with uniform good results.— Potter.

Sunstroke or Heatstroke. — Persistent; greatly increased by moving head.

Treatment. — Cold affusions to head; cold bath or ice-pack if much fever.

Cardiac Hypertrophy. — Enlarged and overacting heart.

Treatment. — Aconite or veratrum viride internally and cold water compresses to cardiac region.

Exophthalmic Goitre. — Swelling of thyroid; exophthalmus ; tachycardia.

Treatment. — Absolute rest; aconitin 1/200 gr. every 3 or 4 hours if pulse tension high ; digitalis in full doses if low blood pressure. — Jos. Collins.

Acute Alcoholism. — History; odor of breath; irritable stomach and tremors.

Treatment. — One-half dr. each of rhubarb and magnesia ; also arom. spt. ammonia m. viiss., tincture of camphor m. vi, tinct. hyoseyamus m. x, spt. lavender comp. q. s. — dr. i every hour. — A. A. Smith.

Acute Mania. — Wild delirium and hallucinations with fever.

Treatment. — Stomach washing and hypernutrition with milk, eggs, broths, or predigested food; mild laxative in morning; paraldehyd in evening; blanket baths; hospital treatment required. —Frank C. Hoyt.

Drugs. — Alcohol, tobacco, ammonia, nitrites, nitroglycerin, quinin, salicylates.

Passive Hyeeremic. — Dull, heavy, frontal or diffuse, increased by lowering head; somnolence or stupor; mild delirium at night; cough, cyanosis and other signs of venous obstruction.

General Tonic and Stimulant : E. Tinct. cinch, comp. m. xl; spt. amnion, arom. m. xx: A teaspoonful in a wineglassful of water thrice daily. —Day.

Belladonna most generally useful remedy in nervous and congestive headache. — Win. Gay.

Mitral Regurgitation. — Cardiac murmur and dilatation and dropsy.

Treatment. — Digitalin 1/GO gr. bis die in congestive hemicrania. — Bartholow.

Constriction of neck by tight clothing. — Disappears on removal of cause.

Vasomotor Insufficiency. — Due to excessive sexualism, chronic alcoholism or arteriosclerosis.

Treatment. — Sluggish Circulation : Caffein the remedy par excellence when vascular tension subnormal— cannabis indica when excessive. — Jos. Collins.

Bright's Disease with Vasomotor Eelaxation: Calomel 5 gr. and compound jalap powder given at once, followed every 6 hours by £ dr. potassium acetate in a tablespoonful infusion of digitalis. — Thornton.

Certain Postures.

Pregnancy. — Treatment: Cream of tartar and other salines to deplete plethora.

Repeated Epileptic Attacks.

Tumor of Neck.

Anemic. — Burning or sore and band-like feeling about forehead and eyes ; or clawing sensation at vertex, intensified by temporary effort (throbbing), relieved by lowering head and sometimes by pressure; area of occipital pressure; weakness, giddiness, day-drowsiness, palpitation, photophobia, phonophobia; sometimes subjective systolic murmurs; pale face, drooping eyelids, cold vertex; usually in women.

General Treatment. — Alcohol in moderate quantities; meat, milk, eggs; stimulate appetite with bitters; rest.

More Pronounced Early in Day: Cup of hot tea or ammonia in some form often gives relief. To cure give a pill t. i. d. of £ gr. ext. cannabis indica and 2 gr. citrate of iron and ammonium. — Hamilton.

Anemias. — Headache on exertion; syncope on slight pressure over carotids.

Treatment. — E. Quin. sulph., ext. aloes aq. aa. gr. i ; pulv. capsici et ipecac, aa. gr. ss. ; glycerin. q.s. : One pill at midday. — Jos. Collins.

With Vital Depression : R. Ext. nucis vomicae gr. ss. ; pil. rhei comp. gr. iii ; pulv. capsici gr. £ : One pill at midday. Also iron. — Jos. Collins.

Nervous anemic headaches usually relieved by valerian or ammonium valerianate. — Butler.

Chlorosis. — Similar to anemias; piercing pain in one spot; peculiar greenish complexion; deficiency of hemoglobin.

Treatment. — Blaud's pill t. i. d. persistently until blood-count is normal.

Leukemia. — Hyperleukocytosis and enlarged spleen.

Treatment. — Good food, fresh air, inhalations of oxygen ; iron, quinin and large doses of arsenic. —Tyson.

Hemorrhages. — Treatment: Menstrual: E. Tinct. cannabis indicae m. xii; ess. menthae pip. m. iv ; ammonii bromidi gr. xv ; syr. acaciae q. s. : A teaspoonful t. i. d. in water. — Hamilton.

Cardiac Weakness. — With palpitation and dyspnea on exertion.

Treatment. — R. Strych. sulph. gr. 1/40 ; quinin. et ferri citrat. gr. ii; pulv. digitalis gr. ss. ; pulv. hyoscyami gr. i : One pill after each meal. — Hamilton.

Dilated or fatty heart. — A dessertspoonful of infusion digitalis t. i. d. — Day.

Cardiac Tonic. — R. Tinct. digitalis m. v-xx;

mist, camphorae ad oz. i: Take thrice daily. — Day. 4

Aortic Stenosis and Regurgitation, or Uncompensated Mitral Regurgitation. — Cardiac murmurs and enlargement and dropsy.

Treatment. — Digitalis, strophanthus, caffein and other cardiac tonics.

Brain Exhaustion from Prolonged Mental Effort. — Treatment: Belladonna of service for headache in young persons, with pain in eyeballs and forehead and a sensation as if orbits were too small for eyeballs. — Hare.

Advent of Puberty in Girls. — Treatment: Potassium bromid for attacks; iron, potassium permanganate and ammonium bromid. — Goodhart.

Hysterical or Imitative. — Often boring and limited to small area at vertex (clavus), or irregular and increasing to climax; greatly affected by emotion or suggestion and persisting after all physical causes are removed; replaced by pain in other parts of body ; hysterical stigmata ; imitative headache in emotional, precocious children of neurotic parents.

Treatment. — E. Zinci valer., ferri sulph., ext. rhei, asafetidae aa. gr. i: One pill t. i. d. — Jos. Collins.

Moral treatment; suggestion; tonics, nutrients, good food, gymnastics, bathing and outdoor exercise.— Mills.

Vertical Headache in Women. — Nitric acid internally, 5 drops of the strong acid, well diluted, t. i. d.— Bulkley.

Emotional Cases. — Ignatia useful in monthly or bimonthly clavus with sensation of weight at back of head. — Wm. Gay.

Neurasthenic. — Disagreeable local sensations (tightness or looseness of scalp, lightness or heaviness, helmet sensation) rather than actual pain; usually continuous and intractable (docs not interfere with sleep), aggravated by excitement or mental and physical exertion, and by pressure, but unaffected by suggestion ; commonly geometric and mainly occipital (sometimes frontal or vertical) with neck weariness; begins in morning, wearing off toward evening; often associated with asthenopia, vertigo, sensations of burning or cold, or tender muscles and creaking vertebral articulations; subjects of nerve exhaustion. Sunday or postponed headache common in school children and bookkeepers. Traumatic may follow injuries to head which do not produce surgical conditions. "Habitual" headache a congenital or degenerative form of neurasthenia. Worry a strong predisposing factor.

Treatment. — Hair being thoroughly wet, a light wire-gauze helmet, lined with some soft conducting material, is fitted as accurately as possible to head and attached to plus pole, with anode at pit of stomach — current of 5 to 50 m. a. — beware of sudden interruptions. — Rockwell.

Apply water at 80°-50° to chest, abdomen and back from hollow hand of attendant, combined with friction during application and after if need be. Eest or more physical exercise. — Jos. Collins.

R. Ext. cannabis indicae gr. 1/6; zinci phosphidi gr. 1/10; acidi arsenosi gr. 1/30: One pill twice daily for some time. — Lucking.

Potassium bromid 20 to 40 grains t. i. d. with strychnin; rest, proper diet, systematically graduated exercise, mental discipline, outdoor life, baths, adequate sleep. — Patrick.

Autotoxemic. — Avoid tea, coffee, alcoholics and coarse vegetables; take water very freely; calomel and podophyllin to stimulate liver ; intestinal antiseptics after meals; hot bath for 3 minutes on rising, followed by cool sponging for | minute; relax before and after meals. — Starr.

Low Vascular Tension: R. Caffeinae cit. gr. v; sodii brom., sodii bicarb., acidi tart. aa. gr. x. Or, R. Caffeinae salic. gr. i; ammon. salic, phenol salic. aa. gr. v: One capsule every 3 or 4 hours. — Collins.

Or, R. Caffeinae purae gr. ss.-iss. ; phenacetini gr. v : Repeat in an hour if necessary. — Jos. Collins.

Or, R. Ammon. carb. gr. vi; tinct. sumbul m.

xii; spt. lavand. m. xv; elixir amnion, valer. q. s. : A dessertspoonful every 3 hours. — Jos. Collins.

With Sleeplessness: Full -warm baths (96°- 102°) just before retiring; add 1 or 2 oz. of pineneedle extract. — Jos. Collins.

General Debility: Syrup of iron and calcium lactophosphate dr. 1 or 2 in a wineglassful of water twice a day after food. — Day.

Idiopathic: Cold water treatment; general faradization or franklinization; home gymnastics; travel, change of climate. — Hirt.

Habitual : R. Ammonii chloridi (bromid if much ovarian pain) gr. iii; ext. hydrastis fl. (non-alcoholic), ext. viburni op. fl. aa. m. x; elix. simp. q. s. : A teaspoonful t. i. d. — Jos. Collins.

Daily or Continuous: Croton-Chloral 5 gr. every 3 hours. — Ringer.

Nervous: Zinc oxid 2 to 5 gr. in pills t. i. d. after meals. — Hammond.

Migrainous ("Nervous"). — Severe, steady, pulsating, throbbing, periodic (increasingly frequent) and usually unilateral (anterior frontal, temporal or parietal), with nausea and hyperacid vomiting, vertigo, drowsiness, photophobia, spots before eyes, hemianopsia, paresthesiae ("pins and needles," numbness), chilliness or aphasia; dilated or contracted pupil and hot flushing or cold pallor of affected side; pain often markedly increased by slight pressure and by exertion — relieved by stimulants ; rarely oculomotor paralysis. Inception nearly always under 20 years.

Neurotic constitution (usually women, often hereditary), frequently excited by anemia, digestive disturbances, mental strain, dysmenorrhea and other uterine and ovarian affections, ametropic eye-strain or decayed teeth ; also a symptom of tabes, general paresis, brain tumor and early stage of secondary syphilis and after alcoholic debauches; sedentary life and school- work predispose.

Treatment. — Arsenic often cures dull, throbbing pain in one brow. — Ringer.

Stomach washing at outset may cut short attack.

Twenty drops dilute nitromuriatic acid well diluted before meals, and 2 to 5 gr. sodium salicylate after meals. — Haig.

Caffein citrate 1 or 2 gr. every half hour, sometimes aborts attack if given early. — Mills.

Prophylaxis. — Continued prolonged administration during intervals of ext. cannabis indica in physiologic doses — beginning with 1/10 gr. t. i. d. — H. C. Wood.

Prodromal Stage. — Phenacetin, antipyrin or caffein often relieve; tinct. opii deod. m. xx and potassium bromid gr. xlv almost invariably relieve without narcotism or vomiting. — H. C. Wood.

During Attack. — Absolute rest; 10 gr. each of salol and phenacetin and 2 gr. caffein salicylate with hot milk or hot water and whisky, to be repeated once only in 3 hours if necessary. If face is flushed give a capsule containing 2 gr. each of camphor, menthol salicylate and caffein salicylate; if pallor, amyl nitrite inhalations relieve. — Jos. Collins.

Bromids in 10 to 30 gr. doses followed by hypodermic of morphin -J to 1/6 gr. in congestive form; ice or hot water bag. — Corning.

E. Spt. eth. comp., elixir lupulini, tinct. amnion, valer. aa. dr. i-ii: Take in water every 15 or 20 minutes. — Shoemaker.

Lie down unless hyperemic (sit or walk) ; caffein, guarana or cannabis indica at onset to abort — or menthol or oleate of aconitin applied to brow of affected side; lithium bromid 15 gr. every hour; rubber bandage around head; ice bag on forehead, or hot water bag to occiput and hot mustard foot bath. — Wharton Sinkler.

Sodium salicylate in 15-20 gr. doses. May be given in tea. — Kinger.

Sick headache with Light-Colored Diarrhea. — Mercuric chlorid, 1/100 gr. t. i. d. — Kinger.

Sick Headache. — First give an emetic, then 15 gr. chloral every hour till sleep is produced. — Harvey L. Byrd.

Migraine with Vasomotor Relaxation and Cold Extremities. — R. Atropinae sulph. gr. 1/120;

ext. cannabis ind. gr. 1/3 ; ext. nucis vomicae gr. ss. : One pill every 4 hours till dryness of mouth or dilatation of pupils. — Thornton.

Eye-Strain. — Full doses of strychnin or nux vomica of service. — Hare.

Migraine. — Eest in bed in darkened room; stomach lavage with hot water or drinking large amounts of hot water ; after this a saline cathartic or a teaspoonful or two of Carlsbad salts, aided if need be by a hot soap and water enema; antipyrin, acetanilid, caffein, salicylates or ergot may be tried ; mild galvanic current to head and static sparks sometimes of benefit; remove all possible sources of reflex irritation, and exclude from diet red meats and all easily fermented articles; cannabis indica long continued to tolerance most successful drug — may be combined with arsenic or in case of a gouty diathesis with ammonium salicylate; sodium phosphate or Eochelle salt before breakfast also of service; avoid excessive mental and physical strain and lead regular outdoor life. —Potts.

Toxemic. — Dull and heavy (pressure or throbbing) or sharp, frontal or occipital, more or less habitual and variable in location ; usually afebrile (often sudden, high fever and vomiting in children) ; distinctive symptoms in other organs preceding nervous manifestations.

General treatment. — G-ive at night 15 to 30 gr.

sodium salicylate with 10 to 30 gr. potassium bromid and a half dram of aromatic spirit of ammonia ; when salicylate given regularly it may be advisable to combine with it a little iron. — Brunton.

Gastrointestinal Autointoxication. — Persistent, confused, apathetic, lower frontal or occipital; pulsating, with full, slow pulse, if due to digitalislike toxin; flushed face and hot, dry skin from belladonna-like toxin; pallor, faintness and feeble pulse from aconite-like toxin; headache nearly always worse in morning, relieved by vomiting, purging and hot foot-baths; coated tongue, foul breath ; often pain in back, nausea, eructations and constipation; sometimes diminished vision, mental confusion, staggering; headache may be brought on by certain foods; headache throbbing, pulsating in acute indigestion, much worse on sudden movements.

Treatment. — Palliative: Eemove source of poison by emesis or lavage; cathartic or colon flushing; diluent drinks; relieve pain by small doses of bromids combined with caffein, or by cautious use of phenacetin, or in very severe cases by a small dose of morphin hyopdermically. — Frank Billings.

Curative. — Application of laws of hygiene modified to suit individual case; selected diet for each individual; free use of pure water as a diluent drink; recreation in form of physical exercise or physical rest; correct irregular habits of sleep and time of taking food and exercise; withdraw tobacco, tea, coffee and alcoholic drinks; lavage of stomach when necessary; overcome constipation by hygienic measures, if possible without drugs; restorative tonics and abundant, simple diet for malnutrition and anemia. — Frank Billings.

With Flatulence and Pyrosis. — E. Sodii bicarb., bismuthi subgal., pulv. acaciae aa. gr. ii; liq. amnion, anisi m. iv ; aquam q. s. : A dessertspoonful before meals, repeated in 3 hours if necessary. — Jos. Collins.

Gastric Dilation. — Stomach washing; hot water before each meal.

Chronic Dyspepsia. — E. Ferri sulph., quinin. sulph. aa. gr. i ^; pulv. rhei et zing. aa. gr. i: One pill t. i. d. after meals. — Collins.

Constipation. — Diffuse, frontal.

Treatment. — Calomel 1/6 gr. and sodium bicarbonate 2 gr. every -J hour, followed by seidlitz powder. — Thornton.

Chronic Fecal Eetention in Sigmoid Flexure. — Complete evacuation of sigmoid by continuous irrigation, followed by faradism, one electrode applied externally and one internally. — Herschell.

Sluggish Liver. — Dyspepsia and plethora.

Treatment. — E. Magnesii sulph. dr. ss. ; sodii bicarb, dr. iv ; liq. tarax. dr. i ; tinct. zirigib. m. x ; aquae ad oz. i: Mix with 20 gr. tartaric acid (previously dissolved) and take early mornings. —Day.

Biliousness. — R. Podophylli gr. ss. ; pil. hydrarg. gr. i; ext. hyoscyami gr. ii: One pill every night. — Day.

Bilious Sick Headache. — E. Podophylli res. gr. \ ; tinct. zingib. m. xv ; alcohol q. s. : A teaspoonful in a "wineglass of water every night at bedtime, or every second, third or fourth night as required. — Dobell.

R. Euonymin gr. ii with ext. hyoscyamus at bedtime, followed in morning by an aperient water. — Rutherford.

Lithemia. — Frontal, often unilateral, worse mornings; vertigo, flashes of light or dark spots before eyes and ringing of ears.

Treatment. — Vegetable diet with milk; avoid meats, especially young flesh, herrings, eggs, meat soups, tea, coffee and cocoa; moderate exercise; mercuric iodid followed by or alternated with salicylates.— Haig.

R. Lithii citrat. gr. v; potassii bicarb, gr. xx; tinct. aurantii m. xxx ; aquam. q. s. : A tablespoonful in a half glass of water t. i. d. — Day.

Effervescent sodium phosphate. — A teaspoonful in water an hour before breakfast.

R. Vini sem. colch. m. viiss. ; potassii acetat. gr.

xii; tinct. cimicif. m. viii; aquam menth. pip. q. s. : Teaspoonful every 4- hours. — Hamilton.

Bilious Headache. — Fel bovis 1 or 2 gr. with 1 m. oil of wintergreen in pill each evening at bedtime.— C. K. Fleming.