J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from

VOL. 102 JULY, 1956 No. 3 Vol. 102, No. 2,was issued on 25th June, 1956

Authors are alone responsible for the statements made and the opinions expressed in their papers.

Journal of the Royal Army Medical ,Corps

THE, CAUSES AND CHARACTERISTICS OF CHRONIC guest. Protected by copyright. BENIGN HEADACHE IN SOLDIERS

OBSERVATIONS ON HEADACHE NOT .ATTRIBUTABLE TO SERIOUS , PHYSICAL OR MENTAL DISEASE BY D. E. MARMION, M.A., M.D.(Camb.), M.R.C.P. Major, Royal Army Medical Corps (Retired)

HEADACHE is a symptom ubiquitous in both civil and military medical practice, and is a common and troublesome problem Jor the regimental medical officer and the medical specialist. No apology is therefore needed for an attempt to examine the subject from the standpoint of the military physician.

A proper comprehension of the causes and characteristics of headache is http://militaryhealth.bmj.com/ impossible without some knowledge of the relevant anatomy and physiology, and as much of this is barely touched, upon in current teaching in this country it will be necessary to summarize it.

THE ANATOMY AND PHYSIOLOGY OF HEADACHE ~eadache is ~sentially pain in the head, and pain may be "felt" in a part of the body for one or more of several reasons, which are summarized in Table 1. h is outside the scope of this article to' consider in greater detail the physiology

of pain, though some understanding of it'is essential for the intel1igent 'practice on September 28, 2021 by of medicine; A good brief account of aspects of it relevant to the present topic will be found in Fletcher's Medical Disorders o/the Locomotor System (Fletcher, 1951).; , " :Not all- the structures_ of the head. and' neck are pairi~sensitive. Outside the 167 J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from

168 Chronic Benign Headache in Soldiers cranial cavity, the skin, subcutaneous tissues, arteries, most nerves, -muscles, tendons, aponeuroses, the eye and orbital contents, the mucous membranes of the oro-nasal cavities, the teeth and the jaws are in varying degrees pain-sensitive; the superficial veins, the cranial bones and diploe are insensitive or nearly so. Within the cranial cavity the dural- floors of the anterior and posterior fossre, the dural venous sinuses and their larger tributaries, th~ arteries at the base bf the brain, their larger branches, the meningeal arteries and the dura in their tmmediatevicinity, and some cranial ~erves (V, VII, IX, X, XII) are pain­ sensitive. The rest of the dura, the pia-archnoid, the smaller intracranial vessels, the ependyma and choroid plexuses, the parenchyma of the brain a~d the other cranial nerves are insensitive. - - . Supratentorial structures are innervated by the trigeminal nerve, and pain arising in them is referred to various sites in the anterior half of the head. Infra-. tentorial structures are innervated by the -last four, cranial nerves and the first three cervical, and pain from them is referred to the posterior half of the head j the subocciput and the upper part of the neck. The exact sites of reference from many intracranial and extracranial situations_ have been worked out experi­

mentally with great ingenuity by Wolff (1948) and his colleagues, and other guest. Protected by copyright. workers, but for a variety of reasons much of this information is of limited value t-O the clinician. The forms of stimulation that give rise to pain in extracranial structures are in general familiar enough to require no special mention, except to draw attention_ to the importance and peculiarities of the arteries and muscles, which will receive detailed attention later. Within the cranium distortion is the main pain-produc­ ing stimulus. Traction upon large vessels and sensitive dura, or over-distension or excessive pulsation of large arteries are examples. Inflammation, as in meningitis, and chemical irritation by blood or air -introduced into the sub:':'_ arachnoid space, may also cause pain ; raised or lowered intracranial pressure of itself does not, except in so far as it causes or permits distortion, as in the headache following lumbar puncture (Pickering, 1949). This explains the well-known fact that it is possible to· have greatly increased intracranial pressure without http://militaryhealth.bmj.com/ headache. We must noW proceed to consider more carefully the principal mechanisms­ involved in the productiori of benign headache. Vascular headache Overdilatation or excessive pulsation of intracranial o~ extracranial arteries is by far the commonest cause of headache (Pickering, loco cit.). The "ordinary" headache of universal experience, whether from emotional causes, acute infec­ tion, a blow on the head or alcoholic excess, is for the most part and in most cases the result of excessive pulsation of cranial arteries, especially those within the on September 28, 2021 by cranial cavity; though the exact mechanism is obscure, it is clear that somehow_ there is disproportion between the intra-arterial blood-pressure and the pressure of the extra-arterial supporting structures (within the cranium this may be regarded as equivalent to the cerebrospinal fluid pressure), so that the relatively J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from D.E. Marmion 169

unsupported arterial wall dilates and pulsates, causing pain by stretching the periarterial nerve plexus. This state of affairs can be reproduced experimentally, by giving an injection of histamine .. Hence this type of headache is sometimes called the histamine-type in contradistinction to the predominantly extracranial migraine-type referred to· below. The resulting throbbing headache is im­ mediately relieved by intrathecal injection of fluid to raise the cerebrospinal fluid pressure. In migraine and arterial hypertension, the extracranial arteries are especially affected, and it is common to see the superficial temporal' arteries ·standing out and pulsating violently. Firm pressure on this artery in front of the auricle will relieve the pain (though not in the later stages when the vessel wall is also redematous). But even in classical migraine the intracranial arteries are involved to some extent, and the distinction between intracranial (histam!ne-type) and extracranial (migraine-type) headache is by no means firm. Headache from distortion of intracranial structures Space-occupying lesions, scars, adhesions and foreign bodies cause displace.,. ment and distortion of intracranial structures and hence may give rise to pain. guest. Protected by copyright. Table 1. Pain mechanisms and pathways l\i1echanism Physiology Common Example Headache EXample· Direct Pain felt at site of noxious Pain of cut finger Temporal headache in stimulus. felt at site of cut. temporal arteritis.

Referred Pain referred from site of noxious Shoulder-tip pain in Supra-orbital headache stimulus to another site of diaphragmatic in internal carotid an­ similar segmental innervation. pleurisy (both C4). eurysm (both trige­ minal). Spread Noxious stimulus causes excita­ Crush injury of one Toothache. in· upper tion of sensory neurons, with finger causes pain in jaw spreads to face "overflow" of excitation to other adjacent fingers, or and head if severe neurons in same and neighbour­ even hand and arm . (trigeminal). ing segments, so that pain ap­ (cervical and thoracic pears to spread .to areas inner­ segments). vated by those neurons. http://militaryhealth.bmj.com/ Muscular Noxious stimulus causes reflex Pain, tenderness and Occipital headache .in spasm of muscles innervated by spasm of loin mus­ upper cervical arth­ involved segment: persistent cles in kidney disease ritis (C2-3). spasm of muscles causes pain (thoraco-Iumbar seg­ and tenderness. ments). Neurogenic Disorders of neural pathways and Neuritis, herpetic Occipital, supra-orbi­ centres subserving pain sensation neuralgia, thalamic tal,. etc.; neuralgia. i.e. nerve, posterior root and syndrome, etc. ganglion, posterior horn, spino­ thalamic tract, thalamus (and homologous cranial nerve struc­

tures and connexions). on September 28, 2021 by

Psychogenic Pain exists only in sensorium "Cardiac" pain in Some types of hyste­ (i.e., is "suprasegmental") and neuro-circulatory rical headache. has no physical basis at the asthenia (effort syn­ periphery. drome). J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from 170 Chronic Benign Headache in Soldiers

Clinical examples are legion. Minimal displacement of structures consequent upon withdrawal of cerebrospinal fluid is probably also a factor in the pathogenesis of post-lumbar puncture headache. On more commonplace ground, the ag­ gravation of almost,any headache by jolting or violent shaking of the head is due to the inertia of the cranial contents causing them to drag\lpon their anchorages, whose pain-threshold is already lowered by pre-existing headache. '. Neurogenic and neuralgic headache It is a common observation that a patien~ with a neuralgia of the head usually complains of "pain in the head" rather than "headache." In fact neuralgic pain is different from the famiiiar, if indescribable, pain of headache, even though. the two may oh. occasion coexist: as when neuralgia causes' secondary muscle spasm and consequent muscular he~dache. .' Neuralgia may occur in several cranial nerves (particularly V, VII, and IX) and the cervical nerves, and possibly in association with some of the ganglia· such as the geniculate and sphenopalatine~ But in most cases neuralgia or neuritis of these nerves causes faceache, neckache, earache, and so on rather than headache . .For the sake -of completeness we may here mention other forms of neurogenic

pain such as those due to lesions involving the spino-thalamic tracts and. the guest. Protected by copyright. thalamus, though as causes of headache they are of litde importance.

Head~he of mUscular origin' Lewis (1942) showed that any muscle, maintained in spasm eventualiy 'becomes painful and tender, and those about the head and neck are no exceptions~ The spasm may be due to causes within the muscle itself (e.g., fibrositis), its lower motor neuron (irritation of the nerve, tetanus), 'or the higher centres (emotional tension, or maintenance of an awkward posture); or it may be secondary or reflex, due to a noxious stimuh~s in the area whose segmental innervation is the same as that of the muscle. Familiar examples of secondary or reflex muscle spasm are the fixation of a painful joint, or the rigidity of the abdominal wall over an area of peritonitis. Similar spasm with pain and tender­ riess occur inthe course of any headache, especially if long-continued, a common http://militaryhealth.bmj.com/ example being the spread of a migrainous headache to the occiput and down the hack of the neck, even into the shoulder. Part of the headache of sinusitis, eyestrain, dental disease', and that following' trauma to the head is muscular in origin, and it is clinically important to realize this because the muscular component of a headache can ~ften be relieved quite simply even when t~e underlying cause proves resistant to treatment.

CLINICAL PATTERNS OF HEADACHE

With some knowledge of the mechanisms by which headache is produced, we can on September 28, 2021 by now proceed to examine some common patterns of headache as manifested by patients who have this symptom unrelated to serious disease. Vascular headaches are the commonest, an.d .we will first consider the classical vascular headache syndrome known, as migraine. J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from D. E. Marmion 171 Migraine The syndrome of hemicranial headache, preceded by visual disturbance and accompanied by g~tric upset and prostration, with a tendency to run in families; was called by. Galen hemicrania, which has become corrupted to migraine. Semantic abuse has even exceeded etymological corruption, and the word is ail too often used today for any severe headache whether or not it fits the well-. defined syndrome which inspired it. In classical migraine there isa unilateral headache which may becom~ bilateral as the attack wears on, and it is seldom on the same side on every occasion (should it be so it raises the suspicion of an organic basis such as an aneurysm or angioma). It is preceded by an allra which is commonly visual, for example a field defect, fortification spectra or flashes of light, and it is accompan-- ied by photophobia, prostration, nausea and vomiting, and intense m~sery. There may be a family history of migraine or at least of severe headaches, and the patient may have suffered from "bilious attacks" or acidotic vomiting in childhood. Anxiety, stress or emotional unrest or overwork increase the frequency of attacks, as may a hot climate, and they may be precipitated by specific emotionlll stimuli, by menstruation, and by many agencies which in non-migrainous subjects' would occasion non-specific vascular headaches, such as eyestrain, a guest. Protected by copyright. head injury, or alcoholic excess; rarely there appears to be an allergic basis. The onset is usually in adolescence but may be in childhood or later in life. Mter reaching a climax in young adult life, the condition tends to regress slowly with advancing years, especially in men. In women the menopause may bring cessation, temporary aggravation, or a change in the character of symptoms. Pregnancy often brings an increase in severity at first, followed by relief. The attack varies greatly in severity: at its worst it may be totally incapacitat­ ing, the patient being able only to crawl to a quiet place and sleep it off. Alvarez (1943) says graphically, "One look at the dejected, apathetic and utterly miserable woman, and I know that only migraine or perhaps sea-sickness could produce such a picture and not kill the victim." The attack may last from two or three

hours to as many days or more, but most often does not outlast the day of its http://militaryhealth.bmj.com/ commencement, passing off with sleep or leaving merely a '~hang-over" thefol­ lowing day. Sometimes a bout of vomiting brings relief of the headache. It is not uncommon for a patient to have occasional long or severe headaches inter­ spersed with more frequent milder ones. Within the syndrome there is much scope for variety. The aura may be other than· visual; for instance, somatic (parresthesire), autonomic (vasomotor changes, epigastric sensations), motor (paresis), aphasic, psychomotor, etc. It may be preceded by a variable period of. prodromata such as depression or elation. Sometimes the aura is absent, or occurs at the same time as the headache. The headache may be bilateral from the start, or replaced by neckache, faceache, or on September 28, 2021 by abdominal pain. Nausea or vomiting may be slight or absent, or may, on the other hand, occupy the centre of the stage at the expense o(other features (so that the lay term "sick headache" becomes especially apt.) Flushing, blanching, vertigo and syncope are common accompaniments, and as there is water- J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from 172 Chronic Benign Headache in Soldiers retention during the attack there is often a noticeable diuresis at the end of it; The aura of migraine is presumed to be caused by local vasoconstriction of branches of the internal carotid artery. It may persist into or even outlast the headache, and rarely may remain permanep.tly, probably owing to thrombosis of a constricted artery. Cases of migraine with gross neurological abnormalities such' as ophthalmoplegia at any stagein their development should be suspected of having an organic basis. ' Most authors state that migraine is commoner in females than in males, and in the intelligent and sensitive than in the dull and stolid; but Kinnear Wilson (1940) quotes extensive statistics which suggest that it afflicts about equally all sorts and conditions of both sexes. Much stress has been placed in recent years, -especially in the United States, on the association of migraine with an obsessional, perfectionist, self-critical and uncompromising temperament, and there is little doubt that the "migraine personality" is a reality; nevertheless migraine is also very common'in those whose temperaments are very different. Over four out of five cases of migraine respond symptomatically to treatment with ergot derivatives. Ergotamine tartrate, 1-5 mg., is given sublingually at th~ earliest possible moment during the attack, preferably during the' aura; the action may be potentiated by caH:eine citrate orally, 100 mg. for each 1 mg .. ' guest. Protected by copyright. of ergotamine. Resistant cases may' be helped by sodium amy tal, t gr., codeine phosphate, i-I gr., or compound codeine tablets in addition; or ergotamine tartrate, 0.5-1 mg., may be given subcutaneously. Dehydroergotamine may also be'given by injection to those who are intolerant of ergotamine. Cases failing to respond to ergot derivatives will sometimes gain relief from other drugs acting on the vasomotor system, such as carbachol, neostigmine, nitrites, priscol, nicotinic acid, inhalation of carbon dioxide, etc. Details of the use of ergot derivatives and many other drugs will be found in the works of Friedman (1951) and Wolff (1948). Attempts to reduce the frequency of attacks other than by adjustments in the' ways of living and thinking of the patient are usually unsuccessful, though sedation may tide over an emotional crisis or period of tension, and there are a http://militaryhealth.bmj.com/ few reports of the routine prophylactic use of dehydroergotamine, such as that of Dalsgaard-Nielsen (1950). Syndromes of the external carotid artery and its branches A number of uncommon syndromes of ,unilateral facial or cranial. pain, usually with local vasomotor or secretomotor disturbances, have been described, such as Horton's cephalalgia (Horton, 1940) (paroxysmal orbital headache of brief duration but frequently repeated, with marked ipsilateral vasomotor changes, lacrimation, nasal congestion, etc.) and Sluder's lower-half headache (referred to later). There cis little doubt that Wolff (1948) is correct in stating. on September 28, 2021 by that all these syndromes are closely interrelated and are due to disturbances of vasomotor control within the distribution of the branches of the external carotid artery. They are apt to be confused with migraine or with trigeminal neuralgia; but there is neith~r aura nor gastric disturbance, nor is there a true trigger area J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from

D. E. ,Marmion 173 as in tic douloureux. Sufferers quite often give a history of allergy or of long­ standing sinus trouble, and physical allergy (where the "allergen" is a physical stimulus such as a change in temperature acting upon, for instance, a sensitive nasal mucosa) seems to be a fairly common precipitating factor. Treatment is apt to be difficult, because the attacks are often of rapid onset and fairly brief Juration, although the pain may be very severe. Ergotamine is sometimes effect­ ive, and 'antihistaminics may reduce the frequency of attacks in some cases. Non-specific vascular headaches. These form the majority of the "ordinary" headaches of everyday life; and' detailed description is unnecessary. The greater number are of the. so-called histamine-type, but others resemble migraine more or less, and the borderline between the two is vague and arbitrary. Nevertheless, there are sounder reasons than mere pedantry for restricting the term migraine to the classical syftdrome, for it is the experience of many physicians that the more closely a patient's symp­ toms resemble migraine, the more likely are they to respond to ergotamine therapy. Non-specific vascular headaches may be" provoked in any person by suffic­ iently strong stimuli, for example an acute infection, a blow on the head, or an guest. Protected by copyright. injection of histamine. Most normal persons suffer an occasional such headache from a variety of causes, including anxiety, fatigue, hunger, constipation or a hot and stuffy atmosphere; whilst a few are constitutionally prone to headache and suffer the symptom in response to minor or even quite undiscernible stimuli. A detailed history will usually disclose the factors concerned, and hence suggest lines of prevention and treatment. ' , Specific drug therapy is usually disappointing, though the remedies used for migraine are sometimes successful. The best hope lies in prevention by manage": ment and psychotherapy, along with symptomatic treatment of such headaches as still occur by common analgesics, the best combination probably being aspirin, phenacetin, caffeine and butobarbitone.

VasomotoT instability http://militaryhealth.bmj.com/ All vascular headaches of the kinds already discussed are examples of localized vasomotor instability, and it is not therefore surprising that headache forms a prominent feature in the syndrome of general vasomotor instability. This very common condition is curiously neglected. In the army (Carter, 1950) it is seen chiefly in young men of slender ·build with hypotonic musculature and poor posture, apt to flush and sweat easily, intolerant of extremes of temperature, and subject to syncope and headaches. The headaches are of any vascular pattern, including migraine, and are especially provoked by excitement, mental stress, exertion, heat fatigue, changes in posture and prolonged standing. Postural faintness on rising from bed is common, and may be accompanied by headache; on September 28, 2021 by fainting while washing in the morning is a characteristic story. When faintness, is associated with exertion it usually occurs just after rather than during strenuous effort; for instance, during a brief rest in the course of physical training, or after a sprint. J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from

174 Chronic Benign Headache in Soldiers

In a given case either headache or fainting may predominate; in different patients, or on different occasions in the. same patient, headache may precede, accompany or follow faintness. Syncope is almost always preceded for a few seconds or longer by sweating, buzzing in the ears, vertigo, dimness of vision, spots before the eyes, nausea, or other characteristic subjective sensations; ftequently these prodromata may occur without syncope, especially if the subject takes heed ofthe warning and lies or sits down. Rarely prodromata appear to be absent, making the differential diagnosis from ak~netic epilepsy difficult. There may be evidence of general autonomic instability such as hyperidrosis, bro~cho­ spasm or frequent micturition, and the incidence of allergy also appears to be high in these subjects. . The syndrome is exceedingly common in young soldiers. It may be associated with an anxiety state; a history of a significant he;ld injury, chronic otitis media, convalescence from an illness, or first going to a hot climate (where it may appear in exaggerated form due to increaSed cutaneous vasodilatation and superadded salt deficiency). Though it is occasionaily seen in young men of robust physique and .active habits, it often seems to be an expression of what Alvarez (1943) has aptly termed "constitutional inadequacy." However, the syndrome is less guest. Protected by copyright. common in older men, and presumably-most young sufferers "grow out of it"; indeed, army experience suggests that it is a common and almost specific disorder of late adolescence. . .'., The best treatment is a full conditioning course at an approp,iate centre or, failing this, firm reassurance and a course' of exercises designed to improve muscle tone, posture, and venous return. Drugs such as ephedrine, amphetamine and caffeine have a very limited usefulness, but ergotami'iie on waking in the morning often prevents early-morning headache. 'A change of employment may be necessary, because·these young men cannot tolerate hot cookhOlJses or long hQurs on parade, and some must be forbidden to drive, handle firearms, and go to hot climates; but most will make a satisfactory recovery in a few weeks _or months if handled properly...... http://militaryhealth.bmj.com/

Muscular headaches t' Secondary muscular headache due to spasm in the vicinity ofa painful lesion is exceedingly common and often present as a component of any kind of severe head pain, such as that of sinusitis, earache, toothache, occipital lymphadenitis, and headache proper. In such conditions the muscular ache may occasionally precede, overshadow or outlast the local pain of the causative lesion, leading,to difficulties in diagnosis. Primary muscular headache is rather less commonthan .. secondary, ,the form' most frequently encountered in. young men being fibrositic. Fibrositis on September 28, 2021 by is especially apt to occur in the trapezii, the, nuchal muscles, the scalp muscles, and toa less extent the temporal and sternomastoid muscles. It gives rise to aching pain of appropriate distribution associated with neck stiffness and perhaps torticollis.' It is worse in cold, damp weather, and when the patient is tired, in poor health or suffering from a chill or some other infection. It is worse on rising J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from

D. E. Marmion 175 in the morning and improved with the day's activity, but interferes with getting to sleep at night because of a curiously vague but distressing ache of low intensity that commences after a short time in anyone position. As would be expected, there is often evidence of fibrositis elsewhere than in the head and neck. On examination, tender nodules are felt in the affected muscles, and pressure on some of these will usually evoke a spreading headache or neckache. Infiltni­ tion of such trigger-points with procaine solution gives complete though not always 'permanent relief. Treatment by heat (especially short-wave diathermy), massage and active exercises gives excellent results, but fibrositis is difficult to eradicate· and the patient should be warned that recurrence is likely but will respond to a further course of treatment. Muscular headache of postural origin is usually occipital and is seen in typists, . draughtsmen, microscopists, leamer-driversand aircraft-spotters, among others. There is very often coexistent fibrositis, and emotional tension and eyestrain may be contributory factors ; in fact, it is preferable to designate most of these headaches as "occupational" rather than strictly "postural." Muscular headache is usually characterized by persistence and relatively

low intensity, but trauma to the neck muscles (such as a nuchal tear due to guest. Protected by copyright. hyperflexion) may cause headache of acute onset and extreme severity. As it is accompanied by nuchal spasm it may mimic subarachnoid hremorrhage (Mar­ mion, 1954). Other varieties of muscular headache, such as those due to emotional tension and to the effects of head injury, will be considered later.

PROXIMATE AND ULTIMATE CAUSES OF HEADACHE: PSYCHOLOGICAL FACTORS We have so far considered chiefly· the physiological processes which produce headache-the proximate causes of the symptom. But to the physician this is only a part of the story, for prevention depends upon discovering the ultimate cause. In the majority of patients presenting with benign headache this will lie wholly or partly in their mental and emotional life, and it is with this that we http://militaryhealth.bmj.com/ must now concern ourselves. Psychogenic headache Headache in young men is. most often a manifestation of stress, a symptom indicating that the man in question is finding difficulty in adapting himself to his environment. Furthermore, it is usually a truly psychosomatic symptom, inasmuch as its origin is psychic whilst the,means by which it is produced are physiological or somatic. True psychosomatic disorders are perversions of the body's physiology, or on September 28, 2021 by the results of such perversions, and therein differ from the conversion symptoms of hysteria, whose proximate cause is entirely mental. The former have been described as physiogenic to differentiate them from the latter which are in the strict sense psychogenic. The vital point is that a psychosomatic (physiogenic) headache is a real pain perceived at the periphery by the usual sensory apparatm~ J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from

176 Chronic Benign Headache in Soldiers and conveyed to the sensorium via the normal neurological paths. It is not in any sense imaginary or even-to make a somewhat subtle distinction-imagined (in the sense of existing only in the sensorium, as in the case of a conversion headache). It may be vascular or muscular or mixed, and the appropriate physical characteristics and signs will always be present, however deeply buried under a ".psychogenic overlay." . . The commonest psychosomatic headache is that associated with anxiety or emotional tension, and is therefore called a tension headache; it is sometimes said to be purely muscular in origin, but in fact a typically .vascular headache can occur under identical circumstances. Less common is the relaxation head­ ache, occurring after a stressful episode rather than before or during it, for in­ stance after the day's work or at the week-end. Even in those not unduly prone to headache it is riot rare following such powerful provocation as an important interview, an examination, or a battle. Pressor headaches of emotional origin are uncommon, but there is a specifically military headache syndrome of combined emotional and exertional origin which is not without interest. It consists of a headache accompanying the shouting of orders on the parade-ground, and in the

author's experience is a by no means rare occupational disease confined to drill­ guest. Protected by copyright. instructors. It is important to appreciate that migraine, orthostatic headache, and other more or less specific patterns of headache may be partly or entirely emotionally conditioned. Thus a headache that is, descriptively speaking, classically migrain­ ous II).ay in its time-relationships be a typical relaxation-headache. Muscular tension headaches have been mentioned. The generally raised muscle tone of emotional tension is familiar, and has been well demonstrated electromyographically by Sainsbury and Gibson (1954), who have also recorded increased electrical activity of the scalp muscles coinciding with the onset. of typical tension headache. Paroxysmal vascular headaches of emotional origin frequently provoke a secondary muscular component which may provide an almost permanent background of dull aching upon which the paroxysms are superimposed more or less frequently. http://militaryhealth.bmj.com/ The coriversion headache of hysteria referred to above, is present in the sensorium only and has no physical foundation at the periphery. It tends to be atypical, inconsistent, even bizarre. There are no accompanying physical signs such as arterial pulsation or muscular spasm. It responds poorly to analgesics, and is usually accompanied by other hysterical symptoms or at least evidence of an hysterical personality. But it must be emphasized that a truly psychosomatic (physiogenic) headache is as common in hysteria as is the conversion type, and not infrequently the two are inextricably interwoven.

Headache is a common symptom in depression, obsessional states, and the on September 28, 2021 by psychoses ; an occasional early schizophrenic may complain solely of headache which is apt to be' attributed to an anxiety state until further symptoms or more thorough examination reveal the fundamental derangement of mental processes. Though the general physician must be on the watch for such cases, detailed consideration of them falls outside the scope of this article. J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from

D. E. Marmion 177

The background of psychosomatic headache in the army The young man's introduction to army life is a period of considerable mental and physical stress, especially to those who have never before lived away from home, and psychosomatic disorders are correspondingly common. The symptom­ atology is varied and includes headache, fainting, neuro-circulatory asthenia, asthma, dyspepsia, bowel disorders, skin diseases, backache and frank neurosis. Precisely what dictates that this man will have headache and that man neuro­ dermatitis is far from clear, but sometimes it is possible to see in psychosomatic symptoms a consequence, or merely an echo, of past events. A boy who has had three or four attacks of migraine a year since puberty now has that number in a month or even in a week; another not previously subject to headache now follows his mother's example and becomes, as she probably expresses it, "a martyr to them." An occasional trivial headache the legacy of a past head injury too often becomes an incapacitating disability when barrack-room and barrack-square replace more familiar and comfortable environment, or the aggravation may be delayed until the prospect of overseas service looms ahead. A fortuitous trivial head injury or the febrile headache of an acute infection may precipitate chronic headache; but often enough it comes out of the blue, guest. Protected by copyright. for headache is a socially acceptable disability carrying no stigma and fairly sure of evoking sympathy. Indeed, headache is a commonplace excuse for avoiding unwanted social commitments, and many a suggestible person cart "will" himself (or more usually herself) into a headache pro re nata, so that the distinc­ tion between malingering and hysteria becomes blurred or non-existent (a disconcertingly frequent occurrence in military medicine). And in this connec­ tion it must not be forgotten, as the late Sir Hugh Cairns (1942) has observed, that "It is one thing to have a headache: it is quite another to complain of it." In the nature of things the stresses that cause headache in older men differ from those that afflict the young soldier; family and financial troubles, too much work or responsibility, real or imagined ill-health, the prospect of retiring-with

inadequate financial means, and simply being a square peg in a round hole. http://militaryhealth.bmj.com/ Anyone familiar with service life today need not be reminded of the difficulties and frustrations, the separations and financial stringencies, that affect the majority in grea~er or less degree. Most men and women survive ,he slings and arrows without serious harm; some produce frank neuroses, euphemistically called 'bervous breakdowns"; many more manifest their stress in psychosomatic disorders such as duodenal ulceration, hypertension, asthma, skin disorders, backache and headache. This last group especially contains many persons of great value to the army and to society, men of high intelligence, initiative and integrity, whose symptoms are in no small measure the result of their uncom­ promising sense of duty and the frustration this gives rise to in an imperfect on September 28, 2021 by world; much can be done to help them by a wise doctor. Post-traumatic headache The interplay of physical and mental factors is nowhere better seen than in the after-effects of a head injury. After all except the most trivial head injuries J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from

178 Chronic Benign Headache in Soldiers

and operations, headache for-a few hours or days is to be·expected, but if it persists it constitutes a manifestation of the post-traumatic syndrome, which also includes vertigo, fainting, impaired concentration, memory and intellect and more or less of the symptoms of chronic anxiety. Although some authorities (McConnell, 1953) consider that the syndrome is often, perhaps always, caused by an intracranial hrematoma or loculated fluid, the more generally accepted view is that usually there is no such structural abnormality . Wolff (1948) and his colleagues have demonstrated three sorts of post­ traumatic headache, two muscular and one vascular. There is a persistent generalized muscular ache or feeling of constriction, accentuated by firm palpation of the larger pericranial muscle masses; a similar ache, restricted to the vicinity of the injury (or scar, if present), with marked local tenderness, and apt to merge from time to time into a generalized muscular headache; and a periodic paroxysmal vascular headache, more or less migrainous in character, precipitated by emotion, exertion, postural changes~ noise, and the like. Muscular headaches are accompanied by generalized and localized musclar tension respectively. This can be demonstrated electromyographically, and is guest. Protected by copyright. considered to be partly organic and partly psychological in origin. The causation of this is obscure. What is clear is that the psychological component of the syndrome is closely akin to an anxiety state, and requires treatment along the same lines. Since the muscular headaches are often fairly easily relieved by methods already described, they may provide an opportunity for the physician to gain the confidence of the patient, which is a necessary first step in treatment of the syndrome as a whole. The vascular headache, though much more severe than the muscular ones, is usually short-lived, and may in fact be superimposed on the persistent dull muscular pain. Symptomatically it sometimes responds to treatment as for migraine. In the absence of demonstrable organic cerebral damage the post-traumatic http://militaryhealth.bmj.com/ syndrome in the keen,. fit and stable soldier may usually be nipped in the bud by sensible management reinforced by reassurance and symptomatic treatment. But in the unenthusiastic conscript or the social misfit who has drifted into the army faute de mieux the problem is altogether more formidable. SuchplI-tients may with difficulty be prevented from developing the syndrome, but once it is established (and this happens all too readily) its cure is unlikely so long as tIle patient is retained in the service. To the uneducated, even to many educated people, the head is not merely the seat of the brain and the mind but is symbolic of the Self, and hence endowed with mystical qualities. It is commonly believed to be fantastically vulnerable and the brain itself fragile as thistledown, so that on September 28, 2021 by the knowledge of an indisputable physical insult to it acts as a powerful bar to the acceptance of reassurance. But despite these and other difficulties, patience and perseverence in management along the lines indicated by Russell (1942) are sometimes rewarded. Much of what has been said about the cli~ical features and management of J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from

D. E. Marmion 179 post-traumatic headache applies also to the less common headaches following meningitis, encephalitis and cerebral vascular accidents. CHRONIC HEADACHE DUE TO MINOR ORGANIC DISEASE We are not concerned here with headache due to major organic disease such as hypertension or intracranial tumour, but it would be unrealistic to ignore the minor ailments of the eyes, nose, sinuses, teeth and neck, which are frequently responsible for headache. The eyes Glaucoma, IrItiS, optic neUrItiS, choroiditis, orbital tumours, and other serious diseases of the eyes cause headache among other symptoms, but they usually produce obvious signs as well and therefore do not enter greatly into the differential diagnosis of headache as such. Most of the minor disorders which cause headache and little or nothing else form an ill-defined group collectively referred to as eyestrain. The symptoms of eyestrain include ocular tiredness and aching, blurring of vision, frowning, lachrymation and conjunctional suffusion, and headache in various regions including frontal, temporal and occipital. These tend to be guest. Protected by copyright. associated with reading or other intensive use of the eyes, especially if unfamiliar or unaccustomed. According to Riddell (1954), the commonest cause in young people is uncorrected long-sightedness. In general, eyestrain is usually related to fatigue of the ocular musculature from excessive, unbalanced or unaccustomed action, in turn brought about by abnormalities of structure or function such as anisophoria, errors of refraction, or rarely aniseikonia (inequality of the retinal images in the two eyes). A further important cause is simply prolonged use of the eyes with no significant abnormality. As Duke-Elder (1949) says in a masterly account of the subject, "The manifestations of eyestrain depend partly on the uses to which the eyes are put, partly on the efficiency of the visual apparatus and partly on the capacity to the individual to withstand sustained effort." Not only does intensive use of normal eyes produce strain eventually, http://militaryhealth.bmj.com/ but activities that involve it tend to be headache-producing through emotional tension, intense concentration, and unphysiological posture. Therefore, even if the eyes are incriminated as the main cause of headache, treatment will be incomplete and unsatisfactory without attention to the other factors involved. To quote Duke Elder again, "Optical efficiency is necessary, but treatment should never degenerate into a routine correction of the optical defect with spectacles." Headache from exposure to intense sunlight is fairly common in the tropics and snowfields, especially on high glaciers. Though it is often said to have its origin in pupillary spasm, it may also be related to the intense frowning and screwing-up of the eyes which is also present. on September 28, 2021 by The nose and sinuses A very small proportion of the headaches attributed by doctors and patients alike to sinusitis is in fact due to sinus disease. Proetz (1943) estimated that less than 5 per cent. of headaches are so caused. J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from

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In acute sinusitis there is usually headache, but the picture is dominated by the upper respiratory infection. In chronic sinusitis, too, there are nearly always indications of the seat of the trouble in the form of easily detectable clinical or radiological signs. This is no place to enter into the minutice of the diagnosis of sinus disease, but it is worth mentioning that the maxillary antrum is by far the most commonly infected sinus, and that the frontal sinus is seldom, the other sinuses almost never, infected in the presence of healthy maxillary antra. This is of help in diagnosis, because the maxillary antrum when diseased gives rise to pain below as well as above the orbit, and is anyway relatively easy to examine clinically and radiologically. The headache or other pain of chronic sinusitis is of a dull aching quality, seldom very severe, and rapidly relieved by drainage of the offending sinus. The pain of maxillary sinusitis is chiefly zygomatic, orbital, and to a less extent frontal, and is associated with maxillary, upper dental and sometimes frontal tenderness. Frontal sinusitis causes pain in the distribution of the supra-orbital nerve. Sinus pain generally is notable for its punctual return at the same time each day. Precise knowledge of the areas of reference of pain from the various sinuses is of limited value in diagnosis because there is so often spread of pain guest. Protected by copyright. as well as concomitant toxic vascular headache or muscle-spasm pain. "Vacuum headache" (Sluder, 1918) is a disputed entity. It is said to be caused by obstruction of the nasofrontal duct by redema or viscid secretion, followed by partial absorption of the air within the frontal sinus. It probably accounts for an occasional example of typical sinus pain without evidence of active sinusitis. Sluder (1908) also described "lower-half headache,~' often equated with sphenopalatine neuralgia. This consists of ocular, orbital zygo­ matic and low temporal pain of a peculiarly unpleasant character, with lachryma­ tion, photophobia, rhinorrhrea and tenderness of the eyeball, and appears sometimes to be related to sinusitis or rhinitis. Irritation of the nasal mucosa, apart from the sinuses, causes pain, usually a faceache but sometimes a frontal or orbital headache. It may be due to a cold, http://militaryhealth.bmj.com/ allergic rhinitis, a polyp, a displaced septum, or merely hot or cold air on a sensitive mucosa. The ears Pain in the ears is felt as "earache," but true headache may occur by spread or from muscle-spasm, as well as from fever and toxremia. Inflammation of a lymph gland lying against the sternomastoid muscle can cause spasm of the muscle and pain in the mastoid region which may give rise to the suspicion of mastoiditis.

The teeth and jaws on September 28, 2021 by Dental disorders occasionally cause puzzling headaches, which sometimes Qvershado\V the local pain and ca~se diagnostic confusion. The site is usually the temporal regioll ,_ and there is associated spasm of th~_ temporal is muscle. Costen (1936) has described a syndrome, of which headache is a prominellt J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from

D. E. Marmion 181 feature, due to malocclusion in the edentulous or those with ill-fitting dentures. Temporo-mandibular arthritis and parotitis sometimes present as temporal headache. The neck and cervical spine Occipital headache from disorders of the cervical spine is fairly often seen, common causes being osteoarthritis, spondylosis, and the effects of trauma. Fibrositis is the commonest soft-tissue condition to cause headache, but occipital lymphadenitis from any cause also produces muscle spasm and consequent pain. Even painful conditions of the shoulder can cause headache by the same mechanism.

THE DIAGNOSIS OF HEADACHE The more important benign headache syndromes and their causes, so far as we understand them, have now been briefly considered, and it remains to make a few remarks on diagnosis. When a patient complains of headache he sets a threefold diagnostic problem which involves the answering of three questions: (1) Is this headache a symptom of serious physical or mental disease, or of minor local disease in the eyes, guest. Protected by copyright. sinuses, etc.? If not, (2) what is the proximate cause, or mechanism by which pain is produced (vascular, muscular, etc.)? Finally, (3) what is the ultimate cause (constitutional predisposition, emotional tension, etc.)? The most important serious organic diseases which cause chronic headache in the age-group with which the military physician is most concerned are -intracranial space-occupying lesions and hypertension. Less important are chronic infections such as brucel1osis, malaria, and tuberculosis; barbiturate and other intoxications ; anremia, urremia and (in the tropics) salt deficiency. Head­ ache is almost always accompanied by other prominent symptoms in epilepsy, hypoglycremia, phreochromocytoma, neurosyphilis, and a wide variety of other diseases. The diagnosis or exclusion of such possibilities need not be dealt with

here as they are adequately described in standard text-books. http://militaryhealth.bmj.com/ The proximate cause or causes of a benign headache may be clear from the history and physical examination, provided that the head and neck are examined as thoroughly and methodically as the surgeon examines the abdomen of a patient with obscure abdominal pain. It is often helpful to examine the patient when he has a headache. In the diagnosis of the ultimate cause (often a combination of causes, physical and psychological) the physical factors seldom present any great difficulty. It is the psychological investigation that takes time, patience and skill, and as the majority of-the headaches of soldiers (and other people) are psychosomatic, it is by farthe most important part' of the interview. 1t is essential to learn what sort on September 28, 2021 by of a person the patient is, how intelligent, conscientious,candid, nervous, aggressive, and mature ; what are his problems, fears, hopes;' difficulties,. and ,how. he reacts to them; something of his family, his job,hobbies, recre~tions and' interests'; his estim~te of himself, and his attitude to his ,symptoimCWith J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from

182 Chronic Benign Headache in Soldiers

a little practice much can be learned about a person in a few minutes' interview (though it is essential that it should be unhurried), and with this knowledge the patient's symptoms can be seen in their proper perspective as part of his life~ and the relation between cause and effect is usually obvious. It is 'of practical value to recognize three degrees in the psychological com­ ponent of the retiology of a headache, according to whether it is (1) insignificant or slight, and likely to clear up with the relief of physical symptoms; (2) mild to moderately severe, making a significant or even predominant contribution, but fairly superficial and likely to be amenable to simple reassurance and psycho­ therapy of the sort that any physician can give; or (3) paramount, the physical symptoms being merely expressions of a severe psychological disorder which. will require expert psychiatric investigation and treatment. The psychosomatic headaches of youpg soldiers are remarkably stereotyped. Thus the experienced military physician will recognize at once the immature recruit whose headaches accompany an anxiety about his "mum" which is merely a reflection of his own dependence upon her; the· youth with flabby muscles, pot-belly and hollow back who does not play games and whose life is

punctuated by "blackouts," "dizzy spells" and headaches; the village "tough" guest. Protected by copyright. who volunteered for parachuting out of bravado and now regrets it, developing a persistent headache following a trivial bump on the head during training; the officer or senior N.C.O. whose incompatability with his immediate superior is the cause of his persistent tension headaches; the classical migrainous subject whose perfectionism brooks no compromise and who consequently lives in a state of permanent headache-ridden frustration; and the hopelessly inadequate man who has met every stress of life, from childhood through adolescence to what passes for manhood, with a psychosomatic protest of one sort or another.

THE MANAGEMENT OF HEADACHE IN THE ARMY The civilian who is a little "off colour" stays at home in bed or in an armchair

for a day or two, but the soldier has no such limbo and must be either fit or sick. http://militaryhealth.bmj.com/ Consequently military medicine is much concerned with early disease, prolonged convalescence and trivial disorders. Minor disabilities like headache cause a disproportionate amount of trouble to all concerned, especially where there is insufficient understanding, confidence and mutual respect between the regi­ mental authorities and medical services. Good liaison between the two will .prevent unnecessary hospitalization and promote common-sense toleration of the weaknesses of the flesh. For instance, the recruit with frequent stress head­ aches must not be sent to hospital when all he needs is a: few hours' bedded down, firm reassurance, and some aspirin; admission to hospital will militate strongly against rapid recovery. On the other hand, the ,obsessional and consci­ on September 28, 2021 by entious chief clerk whose migraine necessitates an occasional day off duty will be made worse if threatened with the loss of his job or his rank on this account . .soldiers with headache should only exceptionally be admitted to hospital, ,as Vtis strongly reinforces the belief that the disability is serious; it is unnecessary J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from D. E. Marmion 183 to emphasize how difficult it often is to return a headache patient to duty after his stay in hospital. If he must be admitted for investigation he should be told beforehand how long this will take, and that he will be discharged at the end of this time (assuming that no serious disease is found) whether or not the headache is still present, treatment being commenced only on discharge from hospital. This scheme, firmly but tactfully applied, saves much mental trauma to both patient and doctor. Most sufferers from chronic benign headache are victims of minor psycho­ logical disorder, and it is sometimes held that only psychological methods of investigation and treatment are effective, though the manifest absurdity of this contention will be clear to anyone who has himself experienced the efficacy of aspirin in relieving a tension or relaxation headache. Furthermore, the stresses that produce headache in soldiers and others are often transient, and symptomatic treatment helps the patient over a crisis until circumstances change or he learns to adapt himself to them. Symptomatic relief also increases well-being, self­ confidence, and confidence in the doctor, and enables the common vicious circle of headache-anxiety-headache, to be broken. Drugs therefore have a definite, logical and important part to play in the ' management of headache. The ergot derivatives have been briefly dealt with, guest. Protected by copyright. and common analgesics mentioned; there is no place for the use of habit-forming anodynes in the treatment of benign headache, and sedatives such as the barbitu­ rates should be prescribed with more discretion than. is sometimes shown (barbiturate headache as a COmplication of treatment is no rarity). Mephenesin, 0.5-1 g., three or four times daily is useful for obtaining muscular relaxation in fibrositis, traumatic lesions, and especially in. psychological tension states. A vast number of other drugs are or have been used in the treatment of different forms of headache, but those mentioned above or previously in this article are by far the most important. Details of treatment will be found in the books by Friedman (1951) and Wolff (1948), amongst others. Headache should seldom necessitate invaliding from the service, unless it

is merely an expression of severe emotional instability or personality defect. http://militaryhealth.bmj.com/ The psychopathic personality may sometimes be rid of his headache by a therapeutic tour de force, but the victory is an empty one because some other psychosomatic or hysterical symptom almost always takes its place. . Soldiers with severe vascular headaches are often made worse by heat and may have to be placed in a non-tropical category. It must not be forgotten, furthermore, that a man subject to severe paroxysmal headaches under stress may be genuinely incapacitated by them, and he should not be allowed to occupy a key position in a combatant unit where he may be a menace to others as well as to himself.

In the management of such minor but important disorders as headache in on September 28, 2021 by the army much depends upon the skill, patience, local knowledge, resource and authority of the regimental medical officer. Lack of these qualities cannot be made good by any amount of technical virtuosity on the part of a hospital specialist. The management of minor maladies is, in fact, an aspect of man J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from 184 Chronic Benign Headache in Soldiers management, a military art,of which the regimental medical officer should be one ,'of the most skilful exponents.

CONCLUSION Condensation of a large subject into a small compass must lead to omissions, generalizations, and dogmatic asseverations in the place of reasoned statements -all potential sources of error and misunderstanding. Therefore the reader ,whose interest has been stimulated is recommended to read the excellent work by Moench (1951), or for more succinct information, Kunkle & Wolff (1951). Despite the neglect it suffe'rs, the topic is not without interest. As an exercise in pure clinical medicine the study of headache has few equals, requiring neither elaborate equipment nor complex techniques, but demanding a high standard of clinical observation whIch, to quote Wilfred Trotter (1930), "should be the source and reservoir of that flow of ideas which alone can maintain the fertility of the whole field of medical science."

REFERENCES guest. Protected by copyright. ALVAREZ, W. C. (1943). Nervousness, Indigestion and Pain, pp. 230, 379. Heinemann, London. CAIRNS, H. (1942). Proc. R. Soc. Med., 35, 300. CARTER, A. B. (1950). J. R. Army med. Cps., 95, 125. COSTEN, J. B. (1936). J. Amer. med. Ass., 107,252. DALSGAARD-NIELSEN, T. '(1950). Acta psychiat. Kbh., Suppl., 59, 65. DUKE-ELDER, S. (1949). Text-Book of Ophthalmology, vo!. 4, p. 4466. Kimpton, London. ' FLETCHER, A. P. (1951). Medical Disorders of the Locomotor System, 2nd Edition, ed. by E. Fletcher, p.32. Livingstone, Edinburgh. 'FRIEDMAN, A. P. (1951). Modern Headache Therapy, Mosby, St. Louis. HORTON, B. T. (1940). Call. Papers, Mayo Clinic., 23, 1048. KUNKLE, G. C., WOLFF, H. G. (1951). In Modern Trends in Neurology, ed. by A.

Feiling, p. 90. Butterworth, London. http://militaryhealth.bmj.com/ LEWIS, T. (1942), Pain, p. 158. Macmillan, London. MCCONNELL, A. A. (1953). Brain, 16, 473. MARMION, D. E. (1954). J. R. Army med. Cps., 100,99. MOENCH, L. G. (1951). Headache, 2nd Edition. Year Book Publishers, Chicago. PICKERING, G. W. (1949). Brit. med. J., 1,907. PROETZ, A. W. (1943). Ann. Otol. Rhinol. Laryngol., 54, 73. RIDDELL, W. R. (1954). Communication to Section of Ophthalmology, British Medical Association Annual Meeting, July, 1954 ; reported in Brit. med~ J., 2, 229. RussELL, W. R. (1942). Brit. med. J., 2, 521. SAINSBURY, P., & GIBSON, G. (1954). Neurol. Neurosurg. Psychiat. 17;216. J. J. on September 28, 2021 by SWDER, G. (1908). N. Y. St. J. Med., 87, 989. SWDER, G. (1918). Headaches ~nd Eye Disorders of Nasal Origin. Kimpton, London. TROTTER, W. (1930). Brit. med. J., 2, 129. WILSON, S. A. K. (1940). Neurology, 1st Edition, Vo!. 2, p. 1570. Arnold, London. WOLFF, H. G. (1948). Headache and Other Head Pain, Oxford, New York. J R Army Med Corps: first published as 10.1136/jramc-102-03-01 on 1 July 1956. Downloaded from guest. Protected by copyright.

Fig. I. Longitudinal .'~cction of the appendix !; howing a carcinoid tumour obstructing the lumen. H. &E.x5. http://militaryhealth.bmj.com/ on September 28, 2021 by

Fig. 2. CarCinoid tumour of ilppendix, showing compact groups of Fig. 3. Groups of carcinoid cells, some arranged compactly, others tending typical "carcinoid" cdIs and undeclying inflammatory infiltnllion of suh­ to fonn acinar structures. T ht: tumour masseslare surrounded by collections mucosa andlmuscularis. of polymorphonuclt:ar leucocytes. 1-1 .'& E.x90. 11. & E. X 165.