Raid Frequently Render the Use of Antipyretic Measures Plete

20. Therapeutic fasting allows an uncomplicated symptoms, that it seems hardly fair to discuss both typhoid infection to pursue a normally mild course types together. The suggestion of Plavec,1 that the without any mixed infection, by reducing the bacterial ordinary form is the precursor of the ophthalmoplegic content of the intestines. This was applied only to the form, seems to have little basis, and his proposed path- severe cases. ology (periodic swelling of the hypophysis) as concerns 21. Fasting will enhance the effect of hydrotherapy, the ordinary migraine, is purely speculative. raid frequently render the use of antipyretic measures A case reported some years ago by Dr. Cheney and unnecessary. myself has a practical bearing on this question. A man 22. Gelatin is a valuable food in that it lessens the of middle age had suffered many years from what was nitrogenous waste and prevents hemorrhage. supposed to be the common type of migraine, though it 23. The low mortality in this series of cases was was accompanied by the unusual symptom of persistent greatly due to the elimination of relapses and compli- homonomous hemianopsia. The headaches became more cations among the mild or abortive cases by restricted severe, various paralyses appeared, mental deterioration feeding and lessening the dangers in sthenic patients by ensued, and death followed. The autopsy revealed fasting. pituitary tumor. 24. In this report forty-five consecutive cases occurred While this case bears favorably on Plavec's location without a death. Of the 144 whites, five, or 3.4 per for ophthalmoplegic migraine, it is far from aiding us in cent., died, and the low mortality, 4.7 per cent., of all the pathogeny of ordinary migraine. Nor does it suggest cases was ascribed to the dietetic management, though that ordinary migraine was the precursor of the more many of the cases had very inefficient nursing. serious trouble. The migrainous headaches in this case should rather be regarded as symptomatic of the local lesion, no more allied to or resulting from ordinary MIGRAINE, AN OCCUPATION NEUROSIS. migraine than epileptoid seizures from cerebral tumor are allied to, or result from, idiopathic epilepsy, though GEOEGE LINCOLN WALTON, M.D. they may be mistaken for it at the outset. Consulting Neurologist, Massachusetts General Hospital. BOSTON. Whatever theory is advanced for the pathogeny of ordinary the use of the eyes can be left is not that this will a com- migraine, hardly It claimed paper present out.2 The arguments connecting the use of the eyes of it is however, plete explanation migraine; hoped, and migraine are easily preponderant. In the first place that it will start a line of on suggestive thought bearing too many cases of migraine have been relieved, in a which can be at the best part pathogeny only hypothetical. or entirely, b}r correction of refractive error, particularly The form of migraine to which I shall confine myself of to be coincidence. In the have astigmatism, explained by is the every-day type, the variety which I found second attacks have been aborted in form in 17 cent. of place, frequently by occurring complete per healthy the mere of as I have many times and in form in more. straightening glasses, young adults, incomplete many verified in my own case. In the third It reaches its in life and place, migraine greatest intensity early gen- has lessened and disappeared in innumerable cases after erally disappears after middle life. It is often pre- accommodative has and numb- paralysis appeared. Finally, study ceded by scotomata, by temporary aphasia of the blind shows that the the blindness the loss of of mental and greater ness, memory, signs incapacity less the migraine. own examination of a series and even as Gowers the My long confusion, possibly, suggests, by convinced me that migrainous headaches are half that is a of only peculiar feeling the present reproduction as the blind as individuals of thus described frequent among among the past, the feeling by Coleridge: corresponding age and under like conditions.3 Oft o'er my brain does that strong fancy roll It may be objected that migrainous headaches are not the flash doth Which makes the present (while last) quite unknown among the blind. But it must be remem- Seem a mere semblance of some unknown past, bered that it is a common practice for the blind, as for Mixed with such feelings as perplex the soul to their accommodation to the distance Self questioned in her sleep. others, adjust of their work as judged, even in the absence of sight, Any of these symptoms may appear without the pain by the position of the hands. in the head. Loss of consciousness never occurs, a fact Assuming, then, that disturbance of the accommoda- from which sharply distinguishes migraine epilepsy, tive centers plays a part in migraine, it need not be ex- though there have been attempts to make them analo- pected that the blind shall be quite exempt. gous. The frontal and temporal regions are most often Another peculiarity of eyestrain which has an impor- involved, the occipital next often, the vertex practically tant bearing on my proposition is the almost continuous never alone. frown of the astigmatic. This frown involves princi- At the time of greatest intensity the pain is sometimes pally the corrugator supercilii and the anterior- part accompanied by nausea and vomiting, especially in early of the occipitofrontalis, which muscles occupy the re- life, whence the term "sick headache." The time varies gions in which the pain most frequently appears. in duration from several hours to a day or more. It If one voluntarily contract the brows for fifteen does not often materially interfere with sleep, though minutes he will a sensation which It experience disagreeable it frequently appears on awakening in the morning. suggests migraine in mild form. This leads to the ques- does not necessarily accompany extreme use of the eyes, is to after such use, as on the 1. Deutsche Ztschr. f. Nervenheilk., 1907, xxxii. though it apt appear 2. This statement does not apply to the views of those who find morning following a theater party. in migraine the precursor of vascular disease and cerebral soften- The so-called form of migraine is so ing. My conce[ill]tionof migraine is widely at variance with theories ophthalmoplegic which include such outcome. When we weigh the isolated cases with this and so in its rare in comparison form, distinct supporting this proposition against the hordes of cases running an innocuous course, it seems reasonable to assume that these few Read in the Joint Meeting of the Section on Nervous and cases represent either coincidence of migraine and organic disease Mental Diseases, and the Section on [ill]pithalmologyof the Ameri- or symptomatic headaches which resemble migraine. can Medical Association, at the Fifty-ninth Annual Session, at 3. Eye Strain, Its Importance and Its Limitations, Boston Med. Chicago, June, 1908[ill] and Surg. Jour., June 22, 1905. Downloaded From: http://jama.jamanetwork.com/ by a University of Michigan User on 06/15/2015 tion whether we must assume the pain of migraine to be tenderness of the forearm. There was no objective anesthesia or loss of of neurosis entirely intracranial, a doubt emphasized by the recent power. The diagnosis occupation was observations of the non-sensitiveness made. Cushing4 showing Treatment.—No from rest, of to more improvement appeared simple the dura, the part which perhaps than any but when a was and the arm in a other the of has been credited. It splint applied placed sling, pain migraine may thus producing absolute rest, improvement soon appeared, and us to a somewhat assist recall analogous pain which complete recovery followed. She can now use the hand per- sometimes appears in the back of the neck and "base of fectly, but has learned to keep its use within reasonable the brain" after long-continued eyework in which the limits. one I not head is held firmly in position. have been The following case presents a connecting link between have . infrequently consulted for this pain by persons who such cases and migraine: undertaken an uncommon line of work, requiring this Patient.—A successful from another state had of laryngologist posture, the commonest illustration being that the worked for twenty-five years without vacation. He complained person who has recently undertaken the position of of paroxysms of pain in the left side of the neck and behind secretary. This pain so often appears after the com- the ear, sometimes accompanied by tenderness. The pain pletion of the day's work, rather than during the work, would come on when his head was placed in the position of that its source is apt to be overlooked. The pain is apt operating, become rapidly unbearable if the posture was main- tained, and after its discontinuance. It would some- first to appear during the night or in the early morning, persist and is sometimes The relief times come on at an interval after operating. Attempts to decidedly paroxysmal. only read sometimes the He had with is found in or the produced pain. astigmatism discontinuance, lessening constancy, correction by a competent oculist. The condition had nat- of the mere of re- work (unless, happily, the correction urally given rise to much solicitude, and obvious relief of mind fraction serves the turn). This form of headache is followed the diagnosis of "occupation neurosis." The day fol- Surely muscular rather than intracranial; its analogy lowing the consultation he spent in and about Boston, and for to migraine is shown by the fact that it is sometimes thirty-six hours was entirely free from pain, an experience by twinkling scotoma.

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