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marked diagnostic symptoms. In these types of organic disease of the brain, headache, often localized, is generally present, but often intermittent or paroxysmal in its character. If cephalalgia. should not be present the patient will complain of sensations of vertigo, tinnitus aurium, defective memory, and occasionally of confusion of intellect; but I have observed in several cases of tumour and abscess of the brain, an absence of acute local pain, or even uneasiness in the head. In all cases of suspected organic disease of this kind, it is important to inquire minutely into the antecedents of the patient. In many of these affections it will be found that blows have been inflicted upon the cranium many years previously to the appearance of cerebral symptoms. Abscess of the brain is often associated with chronic purulent discharge from the internal ear. Under these circumstances persistent headache, vertigo, distressing noises in the ear and head, and pain upon pressure over the mastoid process, are important diagnostic signs.

I have, in a. former part of this work, addressed myself to a consideration of two important general symptoms usually indicative of organic disease of the brain, viz., headache and sickness of the stomach. Cerebral cephalalgia may be confounded with hemicrania, nervous, neuralgic, gastric, and rheumatic headache. In cerebral headache the pain may be either acute, lancinating, throbbing, or obtuse. The intensity of the suffering of inflammatory headache is occasionally so great that the patient is obliged to remain for a considerable time in one position, the slightest motion aggravating the pain to perfect torture. The patient, says Dr. Abercrombie, cannot generally bear a warm room, the noise of company, or even the exertion of cheerful conversation, without feeling greatly distressed and the headache being increased. There is also connected with this type of

DIAGNOSIS or CEREBRAL HEADACHE. 655

cephalalgia, intolerance of light, and, in fact, in many cases great sensorial acuteness. In this type of headache, says Romberg, the pain “is generally characterized by the following peculiarities: it is permanently confined to a larger or smaller portion of the cranium. There is a sensation of pressure, tension, or pulsation, or the pain has a shooting, tearing, or rolling character. It varies in intensity, and is excited and exalted by bodily or mental fatigue, movement of the head, elevated temperature, highly spiced food, and long and sound sleep. The pain is relieved by raising the head or by assuming the erect position, or resting the head firmly against something; it possesses a remittent character. There are intervals, but during the intermissions the,hea1th is impaired. Spasmodic action or paralysis, generally confined to one side of the face or trunk, supervenes, or the organ of sense becomes afflicted with anaesthesia, and delirium follows. The pain abates and ceases altogether as the paralysis and sopor advance.

“It is a matter of much difficulty to define these features with accuracy sufficient for the purposes of diagnosis, as the organ is withdrawn from examination by a rigid osseous case; still one means of approach has been overlooked, which we ought certainly to avail ourselves of. It is a fact that during every vigorous and long-continued act of expiration the brain is elevated, the cerebellum being passed against the tentorium, the cerebrum against the cranial bones. We may easily convince ourselves of the latter by placing the hand upon the fontanelli of a child while it is crying. The old surgeons, acting upon a knowledge of this circumstance, recommended their patients who sufl'ered from penetrating wounds of the cranium, to cough violently, or to sneeze, in order to promote the discharge of blood or pus.

“We may, therefore, employ continued expiration, or holding the breathing during expiration, in cerebral diseases, especially if it affects the surface, as a sort of substitute for the external pressure which we so fre~ quently have recourse to in the exploration of the abdomen or thorax.

“The patients alluded to generally complain of the headache being brought on by straining in defecation. For the purposes of diagnosis, we may cause the patient to imitate this effort by holding the breath for some time during expiration, while the abdominal muscles are contracted. This at once brings on the pain, or if it were present, increases it to the utmost. The same occurs in screaming, coughing, and vomiting. Similar experiments may be instituted during inspiration, during which the brain falls and approaches the basis of the skull.‘ YVe may thus obtain some information on the diseases affecting the base of the cerebrum and cerebellum.

“‘Ve are more in the habit of using the influence of position and movement of the head as the means of diagnosis. Swinging the head from side to side, stooping down, rising rapidly from the horizontal to an erect position, are apt to produce and augment the pain.

" The modifications and relations of cephalalgia to definite diseases of the brain, are important in a diagnostic point of view. Before investigating them, it is neces

' Ravina found that during inspiration he was able to introduce a quill between the skull and the brain of a pointer. On placing a cork cylinder divided into degrees upon the brain, it sank during ordinary inspiration one line, during strong inspiration three lines. If a cylindrical glam tulve filled with water was placed upon the brain, the fluid disappeared during inspiration and returned discoloured with blood on expiration—See Lund: “ Physiologischc Resultate der Viviscctionen neuerer Zeit," p. 149 : and the still more recent experiments of Dr. Ecker, in “ Physiologische Untersuchungen

iiber die Bewegungen des Gehirns und Riickenmarks," 1843, pp. 27—102 and pp. 112—122.

DIAGNOSIS OF CEREBRAL HEADACHE.

sary to point out that, in order to determine the existence of the pain in these diseases, it is even more necessary than in afl'ections of other organs, to have an accurate history and a continued series of observations of the patient. This is necessary, not only on account of the longer intermissions, but also on account of the recurrence of pain when other symptoms, and especially paralysis, supervene, and on account of the loss of memory which ensues in many cases.”E

The absence of well-marked symptoms of gastric disorder, such as furred tongue, loss of appetite, acidity of the stomach, flatulence, pain or uneasiness after eating, vitiated secretions, sluggish action of the liver as well as intestinal canal, will assist the physician in his diagnostic examination of a case of headache suspected to proceed from organic disease of the brain.

In cases of neuralgic and rheumatic cephalalgia, the pain will not be confined to the head, but will be felt in other parts of the body, particularly in certain conditions of the atmosphere and alternations of temperature.

In types of nervous headache, the pain is generally frontal, and often relieved by cheerful society, and when food and stimulants are administered. Attacks of this kind are seldom of long duration, whereas in cerebral headache, arising from softening, tumour, and abscess of the brain, the cephalalgia is, in acute cases, rarely absent. The pain, undoubtedly, in many instances intermits, but it is generally followed by, or associated with vertigo and distressing noises in the head, often compared to the roaring of the sea.

The headache symptomatic of the presence of tumours of the brain, Romberg affirms, is considerably diminished, if not in some cases altogether removed, by the accumulation of serum in the cavities and between the membranes

" Romberg, p. 159.
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of the brain, but the pain is aggravated when inflammation and softening occur in the immediate vicinity of the tumour. The headache that accompanies cancerous affections of the brain is generally acute and lancinating in its character. In abscess of the brain it is generally paroxysmal.

I have previously referred to the intimate sympathy existing between the brain and the stomach, and to the frequent presence of nausea, gastric irritability, and actual vomiting, in many cases of obscure organic disease of the brain. Romberg has, with his usual perspicuity and accuracy, described the characteristic diagnostic syunptoms, by means of which we are enabled to distinguish cerebral from idiopathic sickness of the stomach. They are as follows :—

l. “The influence of the position of the head; the vomiting is arrested in the horizontal, and recurs, and is frequently repeated in the erect position. It is also easily induced by movements of the head, by swinging, shaking, or stooping, or suddenly rising. 2. The prevailing absence of premonitory nausea. 3. The peculiar character of the act of vomiting; the contents of the stomach are ejected without fatigue or retching, as the milk is ejected by babies at the breast. 4. The complication with other phenomena, the more frequent of which are pain in the head, constipation, and the irregularity of the cardiac and radial pulse, which is increased during, and subsequent to the act of vomiting. The duration of the vomiting is limited in the inflammatory affections of the brain, meningitis, encephalitis, and acute hydrocephalus to the first stages of the disease; and the prevailing rule is, that as the paralytic and comatose symptoms increase the vomiting remits and ceases.”

TREATMENT AND Pnorm'LAXIs.-In all acute affections of the brain and disorders of the mind the cure and life

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