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<h2>ON THE TREATMENT OF CONGESTIVE HEADACHE.</h2>
<h3>By J. LEONARD CORNING, M.D., New York.</h3>
<p>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[1] 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."</p>
<p>[Footnote 1: On Chronic and Periodical Headache, by E.H.
Sieveking, M.D., <i>Medical Times and Gazette</i> London, August
12, 1854.]</p>
<p>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.[1] "What Hippocrates said of spasm," says Dr. Sieveking,
"that it results either from fullness or emptiness, or, to use more
modern terms, from hyperæmia or anæmia, 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 hyperæmia and
anæmia, 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
hyperæmia and anæmia 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 hyperæmia, (2) cerebral
anæmia, 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.</p>
<p>[Footnote 1: <i>Vide</i> Carotid Compression and Brain Rest, by
J.L. Corning, M.D. New York: Anson D.F. Randolph & Co.]</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<p>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 hyperæmic 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.--<i>Med. Record</i>.</p>
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