94 T H E B R I T I S H H O M ( E O Y A T H I C J O U R N A L

MIGRAINE

By Tax PRV.SID~NT

I HAVE been interested in migraine for a very long time. Almost as soon as I had qualified, I was consulted by a cousin who was periodically disabled by this fearful headache. Later I learnt that five members of her family of seven were also sufferers.

I would like to stress this well marked hereditary factor--only this week I saw a girl of 17 after her first attack. Her father has been a patient of mine for quite 20 years, and his at tacks are now so at tenuated tha t they rather resemble the smile on the vanishing Cheshire cat in Alice: only a transient aura remains.

I t has been said that migraine is part of an inherited make-up which is as definite a par t of the economy as the colour of the eyes (Alvarez).

The general incidence of migraine in the population has been estimated at 5 per cent . - -but in migraine families it is much higher. American workers studied the family histories of 119 migraine patients and found 343 cases of migraine out of a total of 832 relatives (41 per cent.) (Goodell et alia).

Indeed some neurologists claim that if a family history of migraine is lack- ing, one should suspect an intracerebral lesion, such as a congenital aneurysm of the circle of Willis (Caldwell and Kennedy).

Is there a migraine type? Most authors agree tha t such a type exists, although they differ in de ta i l s - -my old friend, Macdonald Critchley, suggests that the migraine patient is of above average intelligence, of distinctive per- sonal i tywif a woman, she is short, trim, well dressed, bet ter than average in looks, has bright expressive eyes--quick in her movements and responses.

The American migraine subject is described as having a face too big in proportion to the rest of the body; eyes set wide apart, while the chin recedes. The supraorbital ridges are prominent, the teeth are large and separated. The palpebral fissure starts upward; the hands are narrow, the fingers hyperexten- sible. The ensiform cartilage cannot be palpated. In the female leg, the inner belly of the gastrocnemius is overdeveloped (Touraine and Draper).

Another American physician confirms the quickness of thought and move- ments, notes the tendency to worry, to tire easily, to wilt suddenly. They are hypersensitive, poor travellers, poor sleepers. They can ' t stop long-- in a restaurant they choose a table in a quiet dim corner away from the orchestra and the kitchen door - - they dislike crowds, avoid functions; after the strain of planning a party, they are in no fit state to receive the guests (Alvarez).

So much for the typical constitution in descriptive terms what about the pathology?

The real pathology seems fairly clear. A transient tortuosity and tender- ness of the temporal vessels has been observed during an attack, so much so tha t an actual thrombosis in the vessel has been suspected (Critchley). Real tissue changes in the periarticular regions have been described, mostly of an cedematous nature. This cedema, however, seems to have no relation to the general cedema found in some patients who put on weight before an attack. Some patients have gained as much as 19 lb. before a migraine, but diuretics such as diamox, or antidiuretics such as pitressin have no effect on the headache (Ostfield and Wolff). Intravenous noradrenaline by contracting the arterioles will cure the headache (Ostfield and Wolf[), and this is probably the rationale of the t reatment of the at tack by ergotamine (Nevin).

The resemblance between migraine and the headache caused by histamine has encouraged some physicians to use various antihistamines in the t reatment of migraine, but the results were inconclusive--some patients were relieved (Schwartz and Levin) while others were aggravated. Intravenous histamine itself was used by some Americans (Butler and Thomas). This vasomotor dysfunction as a cause of migraine was supposed to explain the fact tha t as the

M I ( ~ R A I ~ 95

migraine patients ' arteries sclerose as he gets older, the calibre of the vessel can no longer alter and give rise to the local cedoma (James), There is an apparent relationship between some eases of migraine and epilepsy. The Russian workers stress the frequent association of the epileptic child with the migrainous parent, and indeed it is an association I have observed on several occasions (Davidenkov). The interesting finding is that the E.E.G. record only shows an abnormality during the prodromal aura (Engel et al., Daw and Whitty).

Another similarity is the tendency for both epilepsy and migraine to be manifested in the premenstrual phase, and to be aggravated by cestrogens and relieved by progesterone (Singh et al.). The relation to eye strain is discredited by modern ophthalmologists who go so far as to say that it is not justified to hope tha t ocular t reatment will stop the headaches (Doggart). This is a far cry from the specialists who insisted tha t eye strain was such an important factor that the migraine patient must keep his glasses by his bed and don his spectacles immediately he woke up (Crookshank).

Another factor that is being played down nowadays, is the question of hepatic dysfunction, and some physicians pooh-pooh the necessity for a fat free diet. As far as gall bladder disease is concerned, it is said that headaches are not a feature of gall bladder disease, and surgery is futile (Mowat and Brisbane), but, nevertheless, after a long experience in treating migraine, I am certain tha t there is often an element of hepatic dysfunction--part icularly in the meta- bolism of fats, and I have found diet a valuable method of prophylaxis.

A great deal of emphasis is placed on the psychologicM factors, and I am inclined to think tha t this has been overdone.

Pleas are made for prophylactic psychotherapy (Friedmann and van Storck), but the psychiatrists and psychoanalysts do not seem to agree on the basic conflicts.

Crookshank was one of the first to underline the contribution of psycho- logical factors and being a follower of Adler's theories, said the migraine at tacks were a defence and flight process and an excuse mechanism for expected failure. He considered most migraine subjects as thinking introverts. The women patients resented their imagined feminine inferiority and were suffering from repressed rage and humiliation over slights real or imagined. The Freudian school, however, tend to see the basic conflict as the desire to escape from maternal influence, and the compulsion not to leave her.

One analyst points out tha t there are no physical symptoms without emotional concomitants, and no mentM disorders without somatic concomitants or causes. At the present state of our medical knowledge it is often possible to uncover only the one or the other element in the process (Fromm-Reichmann).

Migraine patients are often able to provide some peculiar symptoms. The aura is often dist inct ive--and sometimes quite elaborately organized. The dreams, too, are sometimes significant, and dreams of fire are frequent (Harris).

t temianopic dreams in which only half say the house or garden are seen, are uncommon but s tr iking--probably a pathological symptom. In my experience I have had the best results using Ir i s , Nat . mur. , Phos. , Sang. Sepia. Royal has a comment on I r i s - - t h e headache comes on during relaxation after s train--teachers get it Saturdays and Sundays, preachers on Mondays.

REFERENCES

ALVAR~Z L. (1947) Amer. J. Med. Sci., 321, 1. BUTLER and THOMAS (1945) J. Amer. Meal. Ass., 128-173. CA~DW~LL and K ~ E D Y (1953) Archiv. Neurol & Psychiat, 69, 397. CRITC~LEY (1942) Medical Annual, p. 33. C~OOKSH~'~K (1926) Migraine. London. DAVIDENKOV, (1936) Prob. de Neur et de Psych. clin., 35. DAw and WHI~TY (1947) Lancet, ii, 252. DOGG)~T (1952) Medical Annual, p. 167. ENGEL, FEERES "~,T R O ~ O (1945) Amer. J. Sci., 209, 650.

9 6 T H E B R I T I S H H O M ( E O P A T H I C J O U R N A L

F~OMM-R~ICHMANN (1953} Principles of Intensive Psychotherapy. F~IEDM~NN and VAN STORCK (1951) J. Amer Med. Assoc., 145, 1326. GoODELL, LEWONTIN and WOLFF (1954) Archly. Neurol. & Psych, 72, 325. I - I ~ s (1926)Neuritis and Neuralgia. Oxford. JAMES (1945) B.M.J. , i, 663. MOWAT and BRISRANE (1952) Med. J. Australia, 2, 268. lgEWN (1945) Med. Press, September, 182. OSTFIELD and WOLFF (1955) Archiv. Neurol. & Psych., 74, 329, 131-136. ROYAL Homveopathic Theory and Practice of Medicine. SCHWARTZ and LEV~ (1946) New York State J. Med., 46, 1233. S~EGH, SING~ ET SINGH (1947) Lancet, i, 745. TOU~AINE and D~AFER (1934) J. Nerv. and Ment. Dis., 80, 1183.

DISCUSSION

DR. KELLNER said that he was very interested in the President's remarks, many relating to matters which he had experienced or observed in practice in trying to cure migraine. Unfortunately, the operative word was "trying". One

�9 could modify and reduce but very seldom cure. There were certain definite type features about migraine patients, but they

were not necessarily introverts. They were in fact emotional, though that was said on the basis of personal experience only and statistics would not necessarily bear it out. The great difficulty about migraine was that it presented a lying picture. Again and again it gave a text-book picture of N a t r u m mur ia t i cum, but it was not applicable. The same thing applied to the use of Sanguinar ia . Perhaps that bore out the psychological view that the condition might be a defence mechanism or escape mechanism.

Several of his cases accorded with the small, neat-featured person described by the President. They had clear, wide-set eyes and were rather methodical, somewhat apprehensive people and greatly benefited by Arsen icum.

The most unfortunate factor was that the drug picture presented by the patient gave a clear indication and yet, after one had prescribed accordingly, there was very little or no effect. Whether one should go into the family history and modify one's views on that basis it was hard to say. I t was a possibility certainly to be borne in mind after what had just been said.

Dr. Kellner agreed with the comments on the question of hepatic involve- ment and personally believed in that popular view which had been held for centuries as an unproven scientific truth. In some cases the blame was very definitely pinned down by patients. There was the question of biliousness. Some thought that if they ate, for example, half a pound of chocolate on one day they would certainly have a migraine the next.

A patient of Dr. Kellner had done much to help her condition before going to him by eating according to a very frugal and uninteresting diet. In another of his cases it was ascertained by sheer accident that the blood cholesterol was always high if it was taken immediately preceding a migraine attack and low if taken immediately after. Nevertheless, he was not one of those who currently thought that anything from coronary occlusion to carcinoma was due to a high cholesterol.

There appeared to be some connection between the disposal process and migraine. There might be two distinct types, namely, those with a temporary cerebral ischaemia and those with cerebral "plethora". In the latter case there was not necessarily oedema. Such things were controlled mainly by the electro- lytes and not by the actual volume of the flow-through.

DR. BLACKIE thanked the President for his comments about the pathology and hereditary tendencies, which were very much borne out by her own experi- ence in treating migraine. She had been requested to speak on migraine in the acute stage, but could not do so because she did not see cases in that stage. Most of her patients lived some miles away.

I t seemed that migraine cases aged up to 60 could be put into one of two groups. For those in the first group the drug was fairly clearly indicated and the

MIGRAINE 97

patients responded very well; for those in the second group the response was not so good. The period between attacks was lengthened and the severity of the headaches lessened, but over a long period symptoms were only partially relieved.

Dr. Blackie referred to a Polish girl, aged 17, whose father was put into a concentration camp when the girl was aged 2�89 The child and her mother escaped captivity, but for a time they were constantly in hiding, very short of food and subjected to all sorts of difficulties. On arrival in England the mother took a job in a house. The child was rather in the way and at the age of 8 was sent to a convent. During the first year there she suffered at times from numbness of her left side and arm. She went pale on those occasions and did not speak and was thought to be having a fit. At the age of 12 the child went to school and during the first week had one attack; the following week she had two or three attacks, and they were getting more severe. She went cold and clammy during them, lost the use of her leg and got to the stage of falling to the ground. The case was said to be confirmed epilepsy.

When the child then came under Dr. Blackie's care the history was gone into most carefully and it was ascertained that her father had suffered from migraine. The child did not go unconscious and because of that Dr. Blackie decided the condition was not epilepsy but probably migraine. The result of an E.E.G. test, carried out at the National Hospital, was vaguely negative. When the patient was seen by Dr. Sheldon he said she was definitely suffering from migraine not epilepsy. At the time of the attacks the child was silent and rather resentful, with rather greasy hair. She was treated with Natrum muriaticum, and since then had not had another attack. She was said to be clever and getting on well at school, and is calm and happy.

I t might be added that, previously, before the onset of an attack, she awoke in the morning with a severe headache which steadily grew worse.

Another case was that of a man who had been under treatment as an out- patient for three years. He was very intelligent, a hard worker and used to suffer every Sunday from a very severe headache. The attacks were preceded by dizzi- ness and tenderness of the temple region, and accompanied by nausea. Sanguin- aria was given, at first without effect. Other drugs were given and the patient was put on a diet. He said that the first thing that helped him was Rad. bromide 200. Every headache was accompanied by a band of lumbar pain which extended to the hips. The administration of that reduced the frequency of his headaches from once a week to once a month and sickness disappeared. He was given some Sanguinaria 6 to keep by him and, subsequently, Natrum muriaticum, Lycopo- dium and Iris. The patient always reported very intelligently on the effects of what he was given. The backache disappeared.

The patient said that whenever an attack of migraine came on he sat hold- ing a hot sponge on his head. Psorinum was given and the frequency of the head- aches was diminished to once every two months. The patient still took San- guinaria, and ff it was not prescribed for him he bought it himself. He was now able to work all the time.

SIR JOHN WEIR said that he was very grateful for the President's introduc- tion, although it was rather learned for him and he preferred to speak on simpler aspects.

D~. T~PLErO~ who was unable to attend was asked to make a written contribution and he had submitted the following:

"Symptoms which have been useful in choosing remedy for cases of migraine:

"Lac. defloratum: Sick headaches with profuse flow of urine during pain (part of the classical migraine syndrome); pain on rising, with nausea, vomiting, disturbance of sight. Worse for noise, light, motion during MP; better for pressure and bandaging head tightly. One very good case was given Lac deflora- turn on the symptoms worse for milk. Other drugs with the same aggravation are

98 T H E B R I T I S H H O M ( E O P A T H I C J O U R N A L

Bromine and Physostigmine. A useful guide to the latter is 'constriction as from a hat. ' Dazzles or dim vision before headache are often a guide to several drugs, e.g. Gels., Iris, Lac d., Nat. tour., Psor., Sepia, Iris for simple sick headache with this symptom is always worth trying when there are no other marked symptoms. The direction of Gels. from occiput to forehead is also a useful guide; present also in Sil. where the better for wrapping up warm is also a peculiar symptom for most migraines prefer the cold application of vinegar or eau de cologne.

"B. Proteus also has the blurred vision with spots rather than dazzles and the headache wears off as the day goes on.

"The exact hemianopias, i f exact, are useful, e.g., right half lost is a guide to Lithium and on occasion one has given it on little else with a good result. A Lithium symptom of aggravation from chocolate is not too uncommon . . . .

"Calcarea has the loss of vision, either right or left, but one usually expects to find other good Calc. symptoms, but the hemianopia sets one thinking of the drug.

"Where there is the more peculiar symptom of loss of the upper or lower haft (more peculiar since it is difficult to explain neurologically) Aurum has helped, especially ff worse at night.

"Another symptom one has found useful and that is in Tuberculinum, 'deep pain as if in the brain'.

"Local extension, e.g. where the pain extends down the nose---one has found Lachesis useful.

"One would like to repeat what the late Mr. Scoular once said about migraines: 50 per cent. are due to errors in refraction and 50 per cent. are constitutional or, in the same case, 50 per cent. of the intensity or the frequency may clear with properly prescribed glasses and the other 50 per cent. with constitutional treatment.

"Another classical symptom of migraine, increased appetite or increased feeling of well-being, 'could knock the house over the previous day', one finds an indication for Psorinum though Phos. also has it. Not every migraine subject has this so it should not be dismissed as common to the disease."

I t should be remembered that where the 'migrainons' headache is always one sided or if the hemianopia is persistent then the question of a cerebral angioma should be considered.

Sm JOHN WEre went on to say that he was very surprised to hear it said that results could not be obtained from Natrum muriaticum, which had been his chief remedy. I t was Natrum muriaticum which cured him of migraine as a student. Before then, he would perhaps be walking down the street and the vision of the right eye would be lost, everything appearing far away- -a diminish- ing telescopic view. A terrible sensation followed during which one dare not move.

A ease to which he wanted to refer was that of a woman of 43 who had had migraine since a child at school. She was bilious twice a week, seeing black specks before the eyes, the attacks lasting for a day or a day and a half. Vomit- ing was constant and she was pale faced. The pain was worsened by her stooping or turning the head, while walking, and by noise and light. I t was better if she was in a warm room, lying down in the dark with dosed eyes. She was having terrible dreams, and could not bear a fuss.

IVatrum muriaticum was the remedy. She was given some Natrum muria- ticum 30 in November, 1953, and after six weeks was much better. She had had two migraine attacks since, comparatively mild and lasting until midday only. In the following February she seemed a different person altogether, able to go shopping and with no fear of going out.

In the following April she was given "200". That had to be repeated in July. In the following September she had one attack of migraine, and in December. In 1955 she had attacks in April, July and October; in 1956 in March and Sep- tember. None of them was as bad as they had been previously.

MIGRAINE 99

The last note received from the patient said, "Not a single migraine. Very well, very pleased. What a wonderful relief."

For another patient, aged 57, the remedy appeared to be Sepia. In 1954 she was given Sepia 30; in the following March 200, and that was repeated sub- sequently in January, July and September, 1956. This was the case of a woman who had had migraine attacks for as long as she could remember. As an ailing child she had had many operations.

Sir John said tha t one suggestion was that the patient should t ry to get a general improvement in health and avoid undue fatigue and worry. He never despaired of curing migraine.

DR. MCCRAV. believed tha t t reatment of migraine was one of the most rewarding things in Homceopathy. The interesting thing about the condition was tha t it gave very clear-cut symptoms for which to prescribe. Sometimes they were not the symptoms one expected to find in the Repertory in relation to known remedies. In cases of long standing one should not expect to effect a cure within a few weeks or a few months.

Dr. McCrae referred to a retired army officer, aged 60, who consulted him in 1953. The last time he saw the patient was in October, 1956, and he was not cured until then. Nevertheless during the whole of tha t period he made remark- able progress, the migraine attacks occurring at greater intervals and being less severe. I t was very interesting to look at the record to see the kind of medicines indicated from the electro-physical point of view. Many of them were medicines which had an effect on the liver, such as Mercurius and Peeonia. The last medi- clue given was Terebinth, which was not associated so much with liver dis- turbance as with kidney disturbance.

The first spectacular result followed the administration of Ferrum pic, and it might be useful to make a record of the outstanding symptoms of tha t remedy. Some th ing noted by the patient was tha t when an at tack was threatened he developed a pink patch in the anterior glabella. The pain took a "V" course and extended above both eyes. He became extremely tired and felt as though he had exerted himseff very greatly. I t was very good to know tha t since the last remedy was given this patient had had no further attack, although the duration of migraine in his case was 35 years.

Another case was tha t of the manageress of a very busy restaurant who had suffered from headaches for practically the whole of her life. A discomfort always existed in her head. Her father had been driven demented by at tacks of migraine. She was approaching the menopause. During the previous four years she had had to leave her duties in the restaurant at least once a fortnight for at least two or three days with a severe headache. The remedy on the first visit was Cistus canadensis, which caused great aggravation. I t incapacitated her for a week and then she began to improve. From the homceopathic standpoint i t would have been rather difficult to arrive at tha t remedy because it was a remedy of which there was not very much detail available. One outstanding feature was the patient 's desire when an at tack was approaching to eat cheese. The tendency came out very strongly.

Following t reatment on August 8th, 1956, she was, in October, making excellent progress. On November 29th she reported tha t on the 23rd she had felt in absolutely the best condition and had never felt better for as long as she could remember. But, having got to the height of that feeling, she suddenly had a terrible headache, so bad tha t in order to t ry to relieve it she banged her head against a wall. She went from the 10th group of Cistus to the l l t h for Thuja. From tha t t ime she had not been absent from her restaurant and had never had another headache.

I)R. FOUBISTER said tha t he had been very interested in the discussion and had two points to raise. In migraine there were two sets of symptoms, namely, the headache symptoms and the constitutional symptoms of the patient. Some- times, for instance, the Natrum muriaticum type of headache occurred in a

100 T H E B R I T I S H H O M ( E O P A T H I C J O U R N A L

Natrum muriaticum patient, in which event the case was straightforward. With other patients it was difficult to get the Constitutional remedy to fit the details of the headache and in such cases which were the majority seen by Dr. Foubister he gave the constitutional remedy and so far as possible avoided treating the acute attacks. I f the correct remedy was chosen there would not be many acute attacks.

He would not hesitate to use Femergin injections when dealing with an acute attack, but there were likely to be better results ff the patient did not take too many remedies on his own for acute attacks.

The second point concerned the general management of the case. One should go into the patient's history and make sure he was not debilitated mentally or physically. In the early stages it was important for the patient to get sufficient rest.

With regard to diet, aluminium might be a factor in bringing on attacks. Some patients could get a headache by taking a cup of tea the water of which had been boiled in an aluminium kettle. I f symptoms of aluminium appeared in the symptomatology it was as well to keep that in mind. I t was difficult for people to avoid aluminium altogether. Some instant coffees and chocolates were said to be prepared in alumininm.

The question of past history, of course, came into the matter including fright. One patient, who responded to Sepia and Natrum muriaticum, was found to have had a severe fright and, on being given Opium, not only did her headaches disappear but her blood count stayed up.

Where there was a strong family history of cancer, Carcinosin might be considered. I t was complementary to Sepia and IVatrum mur., and helped cases partially influenced by these remedies.

DR. K ~ N ~ D u said that, unfortunately, he was at times called to see patients having acute attacks and he wished that were not so because they were extremely difficult to treat, from the point of view not only of finding a remedy, but also of administering it. Most of the patients were intolerant even to a sip of water, and ff a remedy was given they immediately vomited. Some patients were also allergic to sweet things, and one was left with the tincture as the only possible thing to use.

Often in the acute attack there was intense nausea and at times he gave Ipecac. because undoubtedly it did relieve the nausea, one of the most distressing features. I t shortened the attack, but it did not much affect the headache. The headache was usually intense, and the worse for noise and emotion and better for lying down in the dark.

There was not much doubt about Belladonna relieving the intense throbbing pain. I t did not make much difference to the intense nausea. I t was difficult to prescribe a drug which would relieve both the intense nausea and the intense throbbing pain. Movement very often made the vomiting worse. Vomiting usually occurred immediately after the patient took any fluid. Arsenicum given in tincture form usually afforded some relief, but it was not entirely satisfactory.

I t would be very interesting to hear whether anyone could name a drug which had the effect of Ipecac. on intense nausea and of Belladonna on intense throbbing pain. I f there was such a drug the acute attacks could probably be controlled.

I t was all very well to say one should treat a patient on constitutional lines, but it was not particularly consoling to tell a patient suffering from migraine that once he was better he could be given a remedy which might free him of the condition for months. There was only one thing in the life of a person suffering from acute migraine and that was his intense headache and nausea.

As far as nosodes were concerned, Dr. Kennedy believed there were two groups: first, the Morgan group, for the intense headache associated with con- gestion, and in that group were such drugs as Sepia and Sanguinaria. The

MIGRAINE 101

Morgan group was noted also for congestion of the liver. The second was the Pro- teus group, particularly useful for patients who, having been exposed to pro- longed nervous strain over many years, had broken down. Earlier investigation had shown tha t certain people who had survived the Great War satisfactorily had, nevertheless, undergone a strain which had taken its toll and when they became ill protease was found in the stools.

DR. MCCREADY said he would like to hark back to the pathology and aetiology of migraine. Migraine was doubtless caused by a number of things. One should always bear in mind the possibility of chronic constipation. Now- adays insufficient attention was paid to this. Often patients said that they were not constipated and yet they admit ted taking laxatives regularly. I t was as well to be suspicious of any patient who found this necessary. I f this were so one should immediately enquire what medicines were being taken.

Dr. McCready said he always took patients off any such medicine con- taining strychnine, and he was entirely against the oily preparations made with paraffin. I f something powerful had to be taken senna was very good. At first it might be advisable to consider, in addition to homceopathic treatment, a course of colonic irrigations. Sometimes such t reatment cleared up a chronic stasis quite quickly and helped enormously the constitutional treatment.

An organ which often played an important par t in migraine was the liver. I t was difficult to diagnose when the symptoms were not marked; here labora- tory diagnosis was not really very helpful. Recently an experienced pathologist who had been carrying out a liver-function test for him was asked by Dr. McCready at what point one could detect tha t there was something wrong with the liver. He replied that ff 20 per cent. of the liver were functioning it was very difficult to detect any abnormali ty at all.

There were some simple clinical liver tests which were not yet sufficiently well known. Physicians nowadays did not seem to use their hands enough, but relied too readily on X-rays or complicated laboratory tests. In examining the liver it was important to palpate the epigastrium and right hypochondrium. In many even minor liver conditions this region was perceptibly tender and tense.

There was a second most useful test. A small area frequently sensitive when the liver was involved was to be found 2 inches above the angle of the right scapula. A finger's breadth beneath one came to a reflex area associated with the gall-bladder. Even slight abnormalities of these organs usually pro- duced a distinct sensitivity of the reflex points thus enabling one to make a rapid diagnosis.

DR. FO~:BISTER said that one would not, of course, fail to treat a patient seen in an acute attack. I t was, however, important to realize tha t the aim of constitutional t reatment was essentially to prevent the occurrence of attacks.

SIR JOHN WEIR said that one point for them to remember was tha t they should not do what was done to him. During a very bad at tack of his another doctor asked what his own remedy was and he answered tha t it was Natrum muriaticum. The doctor asked why he did not take it, and so he decided to do so, with very unfortunate results. The chronic remedy should not be repeated during an acute phase.

DR. NV, WPORT (Manchester) said that he had been practising Homceopathy for some 10 months, having been forbidden previously to do so. He tended to use Iris in the t reatment of migraine when more or less uncertain as to the most appropriate remedy, when the condition did not give any clear indications.

The patient with hemianopia was greatly helped by spectacles, and he always advised patients with tha t condition to see an optician. One of his cases was a girl, aged about 21, who worked in an office. In the late afternoon, every day, she had had a lower-half hemianopia, and on looking upwards she blacked out completely. She consulted an optician and her glasses were changed three times within a month.

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A manicurist, who worked in Manchester, had been suffering from a peculiar condit ion--not referred to in Kent ' s or, apparently, elsewhere--namely, a 45 ~ hemianopia. As a result of seeing an optician she had had only two attacks of migraine since last October. The visual acuity of a migraine patient was often quite low..

Whereas Dr. Newport had never used the great pain reliever Colocynth for migraine, he frequently used Thuja, and strongly recommended it for migraine on the left side, from front to back. Often one dose was sufficient.

The question of an E.E.G. result being positive only where aura was present accorded with the general belief tha t migraine was due to a kind of vasoparesis. One wondered whether migraine was not a sensory form of epilepsy which could be considered in relation to a vascular or focal disturbance in the brain. I t would be interesting to hear the views of others on that subject.

Regarding Sir John Weir's references to Natrum muriaticum, they all knew the effect of Apis on cedema. When indicated it might be as suitable as Bry.

Reference had been made to hepatic dysfunction. Dr. Newport referred to a fairly recent article on tha t subject which was very good, but said nothing on t reatment except in connection with the latest idea of giving enormous doses of Vitamin B complex, largely on the premise that the liver was at fault.

He felt tha t t reatment from the constitutional standpoint should be secondary to the approach to the actual headache itseff. He obtained the best results by considering primarily the headache, the direction in which it moved, and such questions.

Did the question which was raised on a remedy for both nausea and throb- bing relate to a throbbing headache? With Theridion patients could not stand grating or jarring. One sometimes came across patients with cervical arthritis who could not move their head because the grating was unbearable and sometimes, after Calc. phos. and other drugs had been tried, Theridion helped considerably.

DR. B~NZA~I~ said that , unfortunately, he could not contribute very much to the discussion on the actual t reatment of migraine because his experience of it was not particularly wide. He would, however, like to refer to what was said regarding the t reatment of constipation. Was not the first step to investigate the patient 's diet? He hardly ever prescribed an aperient of any sort. Constipation was often relieved by the patient changing to a diet which contained plenty of raw fruit and salads, wholemeal bread and, if necessary, some bran for breakfast. The majori ty of constipated patients would find such a diet had a very good action on the bowels.

The PRESIDENT said tha t probably all of them had learnt something from the discussion, which had covered a great deal of ground. Each of them had listened to some interesting ideas supplied from the experience of colleagues. Certainly he had been encouraged to consider some drugs which he would not have thought of in connection with migraine. Perhaps one was apt to get into the habit of restricting oneself to four or five well-tried remedies and it was most informative to hear of the excellent results which wore obtained by the use of somewhat unfamiliar and unorthodox remedies.

He was grateful to everyone who had taken part in the discussion.