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 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. "What Hippocrates said of spasm," says Dr. Sieveking, "that it results either from fullness or emptiness, or, to use more modern terms, from hyperaemia or anaemia, 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 hyperaemia and anaemia, 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 hyperaemia and anaemia 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 hyperaemia, (2) cerebral anaemia, 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 hyperaemic 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.