even of the phantasm which quivers before my eyes in the outset of every attack has continued almost exactly the same. On studying the etiology of my case, I have not met with the success Dr. Dale appears to have met with in his. In no instance have I been able to connect an attack with any deviation from what is my usual mode of life, whether as to diet, amount of work, mental or physical, amount of sleep, or exposure to weather. Nothing whatever in my experience has seemed to point to disturbance of digestion as a cause. I have suffered headache from the latter cause, and I suppose from most of the causes that usually occasion headaches in other people; but my sick-headache stands alone-sui generis-in its peculiar group of symptoms and in the obscurity of its etiology.

In my experiments in treatment I have been more fortunate; indeed my results have been positive, and, happily, decidedly favourable. I have experienced benefit from taking a cup of strong tea at the occurrence of the first symptoms; so, also, from a tumbler of sherry wine; but the remedy par excellence I have found in guarana. The specimen of this drug that I got was put up in a package, containing twelve powders, of, I suppose, about thirty grains each. I took four of those in two hours, and, though perfect relief was not afforded, my suffering was yet diminished to such a degree, that the attack, whose prodromes foreboded unusual severity, proved to be a very small affair indeed. Having tried the guarana only once, it may appear unscientific to speak so enthusiastically of it as the remedy; but so intense had always been my suffering, and so great was the relief following the medicine, that it is impossible for me to regard their connection as otherwise than a propter hoc relation. I have seen one or two other cases reported in which great benefit was derived from guarana. The remarks I have made upon treatment, here, however, are of secondary consideration, my main object being to give the circumstances attending my first attack, as, to my mind, they appear to throw light upon the true character of the affection.



Ar the present time, when attention is being widely directed to the efficacy of phosphorus in nervous diseases, it may be useful to record every incident that throws light on the as yet undecided question of dosage. In the interesting paper by Mr. Ashburton Thompson, in the July Practitioner, it was shown that at any rate a great many patients will bear doses of phosphorus from two to four times as large as those which have been in use during the last few years. I, on the other hand, have to record a case which shows that we may meet with an occasional patient in whom there is a greater sensitiveness than usual to the poisonous influences of the drug.

A gentleman, aged 33, single, applied to me first in May 1872. He had been subject to migraine once a month (or oftener, under circumstances of special fatigue) in boyhood; but the pain was more or less diffused, and not very evidently neuralgic in type, till the age of nineteen. Since the latter date it has been strictly confined to the left side of the head (anterior two-thirds); occasionally it extended into the globe of the eye, and sometimes slightly invaded some descending cervical twigs. It never was felt in either maxilla.

The family history was decidedly bad. A brother was neuralgic; the mother died mentally deranged; a sister is partly insane.

Up to December 1871 the attacks of pain were always attended with vomiting; in that month there was a very bad

attack of typical sick-headache, and then the vomiting altogether ceased to occur. Before the change just mentioned, the attacks were always preceded by vertigo; since that date the vertigo, like the sickness, ceased to appear. There never has been any marked lachrymation; but it is noteworthy that since the attacks have become more like ordinary neuralgia than migraine, the tendency to conjunctival congestion has markedly increased. On questioning the patient as to the nature of the vomiting that formerly occurred, he was quite clear in the statement that no solid food was ever thrown up; the sickness always took place in circumstances of fasting, and the vomited matters were watery and sour. He has not been blessed with a very good appetite; but, on the other hand, there is no history of anything that can be called dyspepsia.

As regards the remedies which had so far been employed, he had taken (among other things) quinine, iron with strychnia, and also arsenic; the latter did him more good for a time than anything else. He had for some years been in the hands of a very intelligent practitioner, and had not suffered from the injudicious kind of treatment to which, unfortunately, migrainous patients are too often subjected.

In advising on this case, it became important to consider the circumstances of the patient's life. He was engaged in a business which often occupied him for many hours in a chiefly sedentary manner, and had likewise evidently undergone much anxiety and worry. I suspended, for the time, the question of his taking an entire leave of absence from business for a prolonged period, but insisted on his taking things more easily. He was recommended to take a steady course of arsenic and cod-liver oil, and to increase his allowance of food.

Early in May of this year the patient's ordinary medical attendant called me to him in consultation. It appeared that he had been better, on the whole, during the past twelve months; still, he had not shaken off the neuralgic tendency, and it became a question whether any further medication should be tried, or whether he should at once be sent on a prolonged sea-voyage. I was anxious to give phosphorus a trial; and on May 5th, accordingly, our patient commenced taking, thrice daily, a pill containing th grain. On July 8th his medical

attendant brought him to my house, with the following interesting history:

From May 5th to May 11th or 12th he took the pills. regularly, but during the two last days suffered from a constant and increasing burning sensation at the epigastrium. What led to the suspension of the phosphorus was the fact, to which the patient himself drew his medical man's attention, that the urine was dark-coloured: on examination it proved to be both albuminous and bloody, but very careful microscopic examination. failed to detect any casts. After a day or two's interval the renal symptoms had almost disappeared, and the stomach was much easier, though the patient felt (and, indeed, still feels slightly) a rather burning pain between the scapula. As to the neuralgia, this is remarkable :-On the whole he had suffered more during the phosphorus-medication than previously, but it was evident that some powerful influence had been exerted on the nervous system, for the rhythm of recurrence of pain was quite changed. There were now two exacerbations daily, but the pain was altogether more of a continuous and less neuralgic type. On the 14th, after two days' rest from the phosphorus, he took one five-grain dose of quinine about an hour before the morning exacerbation was expected, and, singularly enough, never had a recurrence of actual pain afterwards, though there were a few occasional threatenings. He went to St. Leonard's for a little while, and this seemed to help him; and on the 8th July, when brought to me, he was quite free from his neuralgia; but, though fatter than he had been, still undeniably thin. A stranger to the history of the case might suppose that the single dose of quinine had been the cause of the cure; but this seems impossible, for he had been saturated with quinine by his own medical attendant (before I saw him first) without the slightest benefit. At any rate one may say that the quinine would probably not have done him any good, had not a strong impression been previously made by the phosphorus.

I think that it is very evident that poisoning by phosphorus did occur in this case. The burning pain in the stomach, together with temporary hæmaturia, at once relieved by discontinuing the medicine, seem to leave no doubt of this; and thus we must acknowledge it possible that a patient may suffer the

slighter degrees of phosphorus-poisoning from less than threequarters of a grain in minute doses distributed over seven days. At the same time, in view of Mr. Ashburton Thompson's use of the drug in much larger doses, for a large number of patients, without any bad result, we must suppose that the occurrence is quite exceptional, and due to an unusual susceptibility.

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