In the relation of the brain to the intellectual faculties that are so closely associated with it, we must remember that direct connection between the two has not been demonstrated and that the relations of the brain and the mind are almost as mysterious as they ever were. There are some who still think that the frontal convolutions are especially concerned in carrying out mental operations. All that we know about them in pathology, however, is that they are the silent convolutions. When a lesion occurs in other portions of the brain we see the effect of it practically always without delay, in some way, either in the sensory or motor functions of the body. Large lesions in the frontal region, however, often give no sign. Large tumors have been found [{550}] pushing frontal convolutions from their ordinary positions without any noticeable effect upon the individual.
Hard Study and Headache.—It is worth while to impart this knowledge to patients who suffer from headaches, because it at once improves their outlook on life. I have known hard students—men who had spent twenty or thirty years in work at a special subject—live in constant dread that sometime their minds would give way because they frequently suffered from headaches, or at least from some uncomfortable sensations in their heads, which they feared as a portent of ultimate mental breakdown. The assurance that such a thing is utterly unlikely and quite apart from the physician's ordinary experience, not only relieved their anxiety and made their headaches more bearable, but in a dozen of cases in my note-books the headache has gradually disappeared as certain habits of life were corrected and modified, as their habits of eating were varied, as bodily functions were controlled and as diversions of mind were introduced into lives that had before been too unvaried for healthy functions.
I do not think that I have ever seen a case, and I have been closely in touch with hard students for over twenty years, where I felt that the cause of a headache was mental overwork. I have known men who at the age of seventy or over have taken but four or five hours of sleep and who have worked at their favorite subjects for the better part of half a century. They never complained of headaches. Of course, there are others whose physical and mental power is less and who cannot be expected to stand a strain that for large-minded men is only the normal exercise of function. It has not been the mental work that they were doing, however, that was the source of whatever central nervous disturbance was to be found in lesser minds, but worry and anxiety and dread over what they were doing, anxiety as to what they were going to do that constituted the real pathological agents at work.
Local Conditions.—A striking case that impresses patients much more than the physician's declaration and is more likely to be remembered and is therefore of psychotherapeutic value, is that of Von Bülow, the German musician. He suffered for many years from excruciating headaches. They were so severe as almost to drive him crazy. His only relief was morphine and he and his friends lived in the midst of no little dread that sometime or other either the pain or the process which caused it would bring about a deterioration of mentality. After his death an autopsy was made. It was found to be a small nerve fiber pinched by a scar in the dura as a consequence of an injury received when Von Bülow was very young. Many other stories of this kind have been told.
It must not be forgotten that in many cases the pain is not within the skull itself or at least its cause is not and other sources should be carefully looked for. The connection of the eyes with headache has been so well worked out, owing to the initiative of S. Weir Mitchell, that nothing more need be said of it. One feature perhaps deserves to be mentioned. While strain of accommodation is a frequent source of headache and is at once looked for by ophthalmologists, there seems no doubt that some headaches, much fewer than accommodation cephalalgias, are due to muscle difficulties, that is, a lack of balance among the external muscles of the eye, whose full pathological significance has perhaps not yet been worked out. Headaches are [{551}] frequently due to sinus troubles, especially to disturbances in the frontal sinus and to intranasal difficulties. These must be eliminated before the patient can be helped. Sometimes these nasal and sinus difficulties are signs of a deeper constitutional disturbance, due to lack of fresh air and exercise and are relieved promptly by the establishment of hygienic habits.
Congestion Headaches.—Some headaches require changes of habit and persuasion of the necessity for arranging the day's work so as to give proper intervals for relaxation. Much experience with persons whose absorption in their work causes them to miss a meal or delay taking it for seven or eight hours from the last time of eating has shown me that this disturbance of the routine of vegetative life is particularly likely to be followed by headache. This headache is not a mere dull ache and is much more than a sense of discomfort; it is often an excruciatingly painful condition that usually does not come on until toward the end of the day and then may seriously disturb sleep. An interesting thing about this class of headaches is that nearly always they are increased by lying down. Often only a faint preliminary symptom of it is apparent when the patients go to bed, though they may be wakened after two or three hours of disturbed slumber by a headache that prevents further sleep, and pass the remainder of the night in painful wakefulness.
Usually it becomes impossible to continue lying down. The head must be raised and much relief is afforded by sitting up. The headache does not disappear at once but it will gradually pass away and sleep may be resumed after a half an hour of sitting up, though the sleeper will have to be in a sitting posture. Older people get up and sit in an arm-chair. I have found that placing a chair with a rather long back beneath the mattress, the mattress slanting along the chair back at an angle of about forty-five degrees and then an arrangement of three or four pillows above that, will enable these patients to get to sleep better than anything else. The ordinary remedies for headache afford some relief, but even very large doses of the coal-tar products will not relieve the pain entirely unless some arrangement is made for keeping the head quite high and immovable.
The headache is evidently due to congestion. The reason for it is perhaps the failure of the blood to be recalled from the brain to do its usual physiological work at the digestive tract, with a consequent distention of arterioles in the brain so that a little later they do not react to prevent congestion. Usually with the headache there is some digestive disturbance, a feeling of unrest, flatulency with perhaps acid eructations. Accordingly the headache is often attributed to digestive disturbance. But both would rather seem to be effects of the same cause—the failure to supply the digestive apparatus with the proper amount of material to work on at the time when it expects it, while the mental absorption naturally attracts blood to the head. We know from delicate experiments made in physiological laboratories that at times of mental work there is an appreciably larger amount of blood in the head. A proof of the connection between the lack of a meal and the headache seems to be the fact that with most people even a glass of milk and a cracker, taken at the time when the meal is normally eaten, is sufficient to prevent the otherwise inevitable headache.
Whenever some such simple explanation as this for a headache is found and the patient made to realize its truth on his own observation, the [{552}] significance of the headache at once dwindles and it becomes much easier to bear it. Before the very real pains of it were emphasized by the dread of the consequences that would result from it. If it was really a brain ache patients would find it hard to understand how under its influence even serious changes might not take place in the brain. This is only a rational suggestion, but it is mental healing of the best kind.
Many of the aches which are spoken of as headaches are really forms of tenderness associated with the integuments of the skull. Certain of the muscles particularly are likely to suffer from achy feelings which are spoken of as headaches. This is true of certain feelings of discomfort in the frontal region and also of those that occur on the occipital region. External applications of many kinds relieve headaches in these regions, particularly in the frontal region. It is easy to understand that such applications do not affect the contents of the skull.