idiopathic neuralgia. From this, however, it differs in the circumstance of its occurring at an earlier period of life. I have observed it only in young women; and I believe it to depend chiefly, if not entirely, upon a disordered and torpid condition of the liver and bowels.

The idea of dividing the affected nerve first occurred to some French surgeons in 1766; but was not generally adopted until the result of Dr. Haighton's experiment, in 1788, became known. In that case the operation proved completely successful; but subsequent experience has greatly diminished the hopes that were entertained of the probable benefits of such a measure. It has even appeared in some late instances to add to the sufferings of the patient. The excision of a portion of the nerve has been practised in a few cases, but without any corresponding advantage.

For the present, therefore, we can do little more than palliate the symptoms by opium. The discoverer of a medicine worthy of general confidence will have a strong claim upon the gratitude of mankind.

ISCHIAS NERVOSUM.

I have too little experience in the other varieties of idiopathic neuralgia, to enter upon their consideration with any prospect of utility to the student; and authors are almost silent on this neglected portion of pathology. One of the most strongly marked among them is that called ischias nervosum, a chronic ailment, marked by severe pain in all the branches of the great sciatic nerve, and not always easily distinguished from the rheumatic sciatica formerly treated of (page 312). In some of these cases, the branches of the pudic nerve have been the seat of excruciating pain, depriving the patient for many successive nights of all sleep, and thereby rapidly exhausting the frame. Nothing is known regarding the causes of such a disorder. It sometimes yields to the mere influence of time, but medicine can do little to shorten its course. Laudanum affords the only relief. It is happily very rare.

NEURALGIA POLLICIS.

A paper by Mr. John Pearson, in the eighth volume of the Medico-Chirurgical Transactions,* gives a detailed account of

* Page 252.

a painful affection of the extremity of the left thumb, of a decidedly neuralgic character. After resisting a variety of plans of treatment, it ultimately yielded under the use of the following liniment, which produced a high degree of irritation in the skin of the arm:

В Olei olivæ, ijss.

terebinthinæ, 3jss.

Acidi sulphurici, 3j. Misce.

A portion of this liniment is to be rubbed upon the affected part, during ten minutes, twice in the day.

To this paper are annexed some useful reflections on the nature and management of those cases of symptomatic or local neuralgia, which are the consequences of injury to a nerve; but on a subject which is strictly within the province of the surgeon, the design of this work relieves me from the necessity of offering any observations. The reader who may wish for some further information on the subject, may consult with advantage Mr. Swan's Dissertation on the morbid local affections of Nerves.*

CHAP. X.

HEADACHE.

Prevalence of Headache in acute and chronic diseases. Of Chronic Headache. Its principal varieties. Headache with Plethora, and increased action of vessels. Of bilious, nervous, and sympathetic Headache. Of the Intermitting Headache, Hemicrania, or Browague. Its symptoms and progress. Treatment of the several forms of Chronic Headache. Of Giddiness. Its pathological

relation to Headache.

ONE of the most frequent occurrences in the progress of acute discases is cephalalgia, or headache. We have recorded it as a symptom of intermitting, remitting, and continued fever. That peculiar variety of it called gravedo, is a characteristic mark of catarrh. Headache is a prominent symptom of scarlet fever and the other exanthemata. It constitutes a leading feature of acute and chronic inflammation of the brain. It is one of the symptoms by which we judge of the probable approach London, 1820.

* Chapters iv. and v.

of apoplexy or palsy. It both precedes and follows the epileptic paroxysm. It accompanies many of the structural changes which the brain and its membranes undergo. In fact, there are few disorders in which headache does not occur, either as an accidental or essential symptom.

On some occasions, unconnected with fever, headache predominates so much over all the other phenomena, as to have emerged from the rank of symptoms into that of diseases. In almost all nosologies, except that of Dr. Cullen, cephalalgia, cephalæa, and hemicrania find a place, and if nosological arrangement was of sufficient importance to deserve the labour, strong reasons might be adduced in support of their claim to this distinction. But whether we view chronic headache as an independent disease, or merely as a leading and prominent symptom, it is of consequence that the student should know under what circumstances of the general system it shows itself, -what is its usual progress, and how it may be most effectually relieved.

There are three principal varieties of chronic headache. The first is connected with plethora or fulness of blood, and is associated with many unequivocal proofs of increased action of the several branches either of the external or internal carotid artery, or both. The second is the nervous or sympathetic headache, which, depending in almost all cases upon a state of indigestion, is usually known by the name of bilious headache, or sick headache. The third is, præ aliis, entitled to be ranked as a separate disease. It is called the intermitting headache, or brow-ague, the cephalea of Sauvages. Each of these forms of headache merits a separate investigation.

1. HEADACHE WITH PLETHORA.

Headache is often met with, accompanied with evidences of general plethora. The pulse is full. There is giddiness on stooping, or a disposition to lethargy. The vessels of the tunica conjunctiva are loaded. There is a constant sense of pulsation in the ear. The temporal arteries, and sometimes even the carotids, may be seen to beat with more than their usual force. The disease occurs in persons who have been living freely, more particularly in those who have been in the daily habit of taking ale or porter. It is met with in those who without such indulgences, use little or no exercise in the open

air, and rise late in the morning. It is a frequent complaint with young unmarried women of full habit of body, and is often associated with irregularities of the menstrual function. It may perhaps have for its exciting cause, a suppression of the menstrual discharge.

In some cases headache is obviously connected with increased action of the vessels about the head, but without evidence of accompanying plethora. It sometimes partakes of a rheumatic character, and has been described by some authors as the rheumatic headache. It occupies the situation of the occipitofrontalis and temporal muscles. The periosteum is sometimes the seat of pain, which frequently extends to the face and teeth. This sort of headache is accompanied with superficial tenderness, throbbing of the temporal arteries, and increased heat of the head. The pulse is frequent and sharp, and the tongue white. Headache of this kind may sometimes be traced to anxiety of mind, long continued study, and a succession of sleepless nights, but its principal exciting cause is cold and wet. It often follows the imprudence of standing in a current of air, after being overheated by exercise.

II. BILIOUS HEADACHE.

Bilious headaches are of two kinds, the accidental and the habitual. The first arise from some obvious error of diet,either overloading the stomach, or taking into the stomach some substance which even in small quantity offends it, such as champagne. Headaches from excess usually last about twentyfour hours.

The habitual bilious headache often arises without any cognizable exciting cause. It is one of the series of symptoms occasioned by imperfect digestion. Persons of weak stomach, therefore, are liable to suffer from it at any time, and the utmost attention to diet is frequently insufficient to ward off an attack. When the stomach is from any cause unequal to its office, the food remaining unchanged irritates the nerves of the stomach, and thus occasions, by sympathy, headache. Under these circumstances the secretion and passage of the bile become slow, irregular, and imperfect. The bowels consequently are torpid, and the general circulation languid.

The weakness of stomach, to which the whole series of phenomena are referrible, is connected in all cases with constitu

tional debility. The temperament is nervous. The system is irritable, and trifling causes will in such habits deprive the stomach of that share of nervous influence which is requisite for the due performance of the duty of digestion.

We are indebted to Dr. Warren for a clear and most comprehensive view of the subject of chronic headache. In his Essay, the dyspeptic form of headache is more especially adverted to, and to it I am chiefly indebted for the following sketch of its character and course.

The attack of dyspeptic headache is preceded by restlessness, indistinctness of ideas, disinclination for mental exertion, coldness and dampness of the hands and feet. To this succeeds pain, or rather dull aching of the head (generally the forehead, but sometimes the crown of the head or occiput) with a sense of weight, pain, distension, or stiffness of the eyeballs. In some cases, the disorder is accompanied with a dimness of vision, succeeded by the sudden appearance of colours and luminous forms. In other cases the headache and indistinctness of vision are attended with giddiness and sense of alarm. The patient is confused and fearful of falling. He feels insecure unless in company, and is at all times unwilling to venture abroad. Coldness and numbness of the feet and fingers accompany this kind of dyspeptic cephalalgia.

The gastric symptoms are seldom so urgent as these sympathetic affections would lead the observer to anticipate. The tongue is usually covered with a white or yellow fur. There is some nausea, but seldom any disposition to vomiting. The appetite, perhaps, is unimpaired. The evacuations, however, generally present an unhealthy aspect; portions of undigested food may sometimes be traced in them. Dr. Warren is of opinion that many cases of headache are rather owing to imperfect action of the duodenum than of the stomach. This opinion is corroborated by observing that the act of vomiting affords but little relief, and that the character of the matter vomited does not present any sufficient explanation of the phenomena.

Headaches of this kind, when habitual, are often protracted through one, two, or even three days. When first occurring their course is usually terminated in a few hours.

▪ Transactions of the Royal College of Physicians of London, vol. iv. p. 233, 1813.