scapula. Palpitation of the heart and general nervous irritability are also among the continuous symptoms.

The history of the affection often goes back to the earliest recollections of the patient, and in nearly all cases a vast number of supposed remedies have been tried, sometimes with slight temporary relief, but more frequently without any good results. In a considerable number of cases the affection is developed during school-days, a circumstance which has led to the abhorrent supposition that it results mostly from impure thoughts and practices.

Fortunately, this is a gross libel upon a class of humanity on the whole characterized by frankness and intelligence. If we remember that, at the age of from eight to fifteen, nearly all of the children in whom this affection is found are at school, closely pursued by examinations and a multitude of studies, we shall see that the demand upon the ocular muscles is excessive, and that this demand is for the most part made in crowded school-rooms, where the air is vitiated, and nerves and muscles are thereby rendered less capable of enduring the strain. Again, these subjects of migraine are, as a class, unusually ambitious, and such children maintain advanced positions in their classes at an expense of eye-strain even greater than that which attends the exercise of the eyes of the less ambitious pupil. If, added to this, there is an anatomical or physiological reason for unusual strain in doing the ordinary work of the eyes, we have a combination of circumstances conspiring against the strength of these children.

This is not only the more true but the more generous explanation of the occurrence of these attacks, at this period of life, than the one alluded to; and the author, after a careful investigation of both sides of this question, feels justified in earnestly protesting against the unjust insinuation.

Some patients suffer less when absent from home, occupied in travel or repose, or when engaged upon light duties which permit them to be much in the open air. Tonic medicines also sometimes increase the intervals between the attacks and render them less severe. The temporary relief, however, which lengthens the intervals or modifies the attacks can not be regarded as a cure. And a cure can only be assumed when so long a period of time has elapsed since a last attack that, under ordinary circumstances, in the particular case, a very large number of attacks could reasonably have been expected. Again, as in case of most functional nervous diseases, there is a tendency to a change in the form of the complaint, and one subject for several years to migraine may find that he has no longer sick-headaches, but is a sufferer from some form of neuralgia, perhaps equally distressing with the former complaint. Such a case can not be regarded as cured. There has been simply a change in the manifestation of nervous irritation. In all these cases there is an underlying cause, which is to be found and removed. This accomplished, a permanent cure may be anticipated.

Here, as in the case of the more ordinary forms of headache, it will be found that ocular defects play a

conspicuous rôle as causative conditions in migraine. According to the experience of the author, these defects constitute by far the greatest factor in these cases. Unlike the ordinary forms of headache, however, migraine does not so frequently yield to the simple measures of adapting glasses to correct refractive errors. There is often a complicated state of refractive trouble and muscular insufficiency, demanding greater care and judgment in correcting the ocular conditions. With sufficient accuracy in relieving these defects, however, sick-headaches will, in the great majority of cases, cease.

The following are not only typical cases of sick headaches, but are illustrations of the ordinary results of treatment directed to ocular defects in a great number of cases:

Miss N., aged seventeen. November, 1880. Had during the past three years suffered greatly from "blind headaches." She was delicate, anæmic, suffering from nervous irritability almost characteristic of chorea, and quite unable to endure ordinary physical exercise. Paroxysms of headache occurred once or twice a week, and lasted one or two days. The onset of the attack was uniformly marked by a total loss of one half the field of vision and enfeebled vision in the remaining half of both eyes. The hemiopia was heteronymous, the temporal portion of the field of each eye being lost. After half or three fourths of an hour of this visual disturbance, which was associated with pain over the eyes and through the orbits, and with a general

sense of chilliness, the orbital and frontal headache became most intense, nausea followed, and the patient was forced to retire to her bed in extreme torture and prostration. Vomiting usually occurred, but not uniformly. If she could fall asleep, a night's rest might bring relief, but the attacks not unfrequently continued until after the second night.

During the period of visual disturbance of one of these attacks the eyes were examined, with the following results: The field of vision was contracted in all directions, but more especially in the outer portion, as shown in the diagram which represents the field of the

Sup.

90°

90°

70

800

20

180°

rather small, the red

cylinder of the larger

being bordered with

90° 270

Inf.

FIG. 2.

white lines representing the unusually conspicuous sheaths of these vessels. The veins were rather large. The general background lighted up well, but was of paler red than usual.

The young lady's mother, who had died in child

birth, had, during several years preceding the time of her death, suffered from chorea, and her father was a neurotic subject.

No physical cause for these frequent and torturing nervous disturbances was found elsewhere than in the eyes and their appurtenances. She had a moderate degree of astigmatism, and very feeble adducting power.

Cylindrical glasses were employed to correct the astigmatism, and the adducting power was developed by systematic exercise of the muscles, until complete associative action was established. After about three weeks the headaches ceased entirely, her strength improved rapidly, and she was soon in excellent health. In June following a slight return of the trouble caused her to direct renewed attention to the condition of the eyes, when it was found necessary to renew the exercise of the ocular muscles for a few days. Since that time she has continued well.

Migraine not unfrequently alternates with intense neuralgic headaches in which nausea is absent, or the one form of trouble may replace the other permanently.

Mrs. II., aged forty. February, 1879. Is an exceedingly active woman when well, but during nearly all her life has been subject to frequent and tormenting attacks of migraine, which during the past year have alternated with neuralgic headaches. She rarely passes a week without being confined to her bed from one to three days. As soon as the attack of headache or neuralgia is over, she is ready to drive out, and almost compensates