an injurious manner, how much more would some foreign, though perhaps (with our present analytical capabilities) inappreciable element, finding its way in the circulating fluid, and traversing the system, disturb the balance of cell elements, vital action, or nervous force, and produce various ill consequences. Such being the case, the class of toxæmic headaches is not only a strictly legitimate one, but it is also one comprehensive in its grouping, important practically, often difficult to understand, and not less difficult to successfully treat.

We believe, as previously stated, that all cephalalgias are in fact but symptoms. Such is particularly the case in toxæmic varieties; and yet, as the cephalic pain is often the first and only manifestation of this state, many of them would properly be placed in the generally received catalogue of idiopathic complaints; and too often the measures of relief would be addressed solely to the pain, without attacking the seat of actual disease.

As examples of the known agents which act through the vital fluid and give rise to headache, I may cite alcohol, quinia, tobacco, arsenic, mercury, coffee, strychnia, and the various narcotic drugs which have been demonstrated to act in this way. To this list could be added urea, and several other materies morbi capable of production within the body, and only causing detriment from lack of proper elimination. Nor can I restrict the term toxæmia to the mere presence of abnormal constituents in the blood. I extend it so as to include those cases where the absence of certain natural elements brings suffering on the system, as in actual deficiency of red globules, albumen, fibrine, the several salts, and other chemical components of that fluid in its integrity.

From these statements it will be observed that toxæmia headaches can but be numerous. They also vary much in regard to their duration (when uninterfered with) and intensity, according to the amount of the poison acting, the ease with which the various emunctories eliminate it, the extent to which the brain becomes accustomed to its presence, or the time comes when its introduction into the vessels ceases.

To toxæmia may plausibly be attributed, in whole or in part, the cephalalgia of intoxication, chloroform, and ether, some of the specific and adynamic fevers, respiratory disturbances, cardiac irregularities, syphilis, pyæmia,

true gout and rheumatism, malaria, cholesteræmia, many zymotic affections, gangrene, erysipelas, etc., etc. Doubtless some of the forms of dyspeptic headache, and perhaps also the headache of constipation, which is sometimes so annoying and intractable, may partly be accounted for by regarding them as more or less belonging to this class. Some writers consider all idiopathic cephalalgias as arising from toxæmia. But such a doctrine is too comprehensive for accuracy, though it is a fine one for ignorance, carelessness, and sloth to hide themselves behind. 'Tis hardly rational to conceive that a parent could transmit to his offspring nothing more than a poisoned blood, constantly in motion and subject to daily changes, which should, year after year through life, cause periodical headache, with long intermissions between the paroxysms, and yet that identical pathogenetic fluid be circulating every moment through the whole system of that same son or daughter. When we adopt a theory, which is based on solid facts, enough for its adoption to be rational, let us by all means hold to it rationally, and not bring it into contempt by abusing it, or trying to stretch its little truth into the vast fabric of hypothesis in order to make it cover more unexplored territory.

Lastly, we reach the consideration of my fourth class the neurotic group. It is one which, at the present time, is forced by custom, to father a larger progeny of aches and pains about the head, than either of the other three. My own opinion is, that far too many painful conditions are hastily dismissed in general practice under the convenient diagnosis of neuralgia. I lean strongly toward the belief that the time will come when neuralgias will "grow beautifully less," in our nomenclature and therapeutics. I opine that, though forced now to adopt this last class of headaches into my plan of arrangement, it is only my ignorance that prevents its banishment, and the narrowing down of headaches either into three classes, or the substitution of some new group, based on increased enlightenment, for my present "neurotic."

But, though we may not rest content under things which we can not improve, yet we are forced, often, to accept the situation, just as we find it, and make the best of its evils. So I will define neurotic headaches-as the term is used in this paper-to be all such as can not be shown to belong in one of the other divisions. The word-like

neuralgia-conveying no depth of meaning, admits of my using it for the purpose of affording an orphan asylum for the bastard headaches which can not be fathered by either of the three preceding and respectable family heads. And, as human bastards are numerous, and often attain much importance, so this class of pathological illegitimates is large and consequential. Here we find many cephalalgias which afford no evidence of any vascular, or other disturbance, save the pain. Yet there is no doubt in my mind that a goodly number are caused by hæmal disorder, because some of them yield promptly to remedies which restore the blood and vascular system to its natural state. And we certainly know that often, when simple pain seems to exist at the start, or does really exist alone, hyperæmia, anæmia, etc., follow in due course of time. Apparently these headaches depend on nothing more that a heightened sensibility in the nerve tissue of center or trunks. And perhaps this is the true explanation beyond which we may never be able to go. At any rate, the only view we can take of the matter now, is to resolve these cases into hypersthenic and asthenic conditions of nerve-force. In one, there lacks the usual equanimity of the nerve-system, because its force is below par, or unbalanced, resulting in irritability, which may proceed to the extent of inducing pain. In the other, the force is positively above par, leading to a like irritability and suffering. In neither of these divisions do I include the cases where these nervous states arise from blood stimulus or insufficiency, as both may do, but limit my remarks to cases where the disturbance seems to come from inherent capabilities, or lack of capabilities of the tissue itself.

At times there appears to be a certain withdrawal of cerebral control from the system at large, and a concentration of the major part of its power in the cerebrum, or its immediate neighborhood. Many times this seems centered in the mind, and that is quickened, so that thought has free and rapid play, but no pain occurs. Again, the special sensory centers are the objects on which this electric current expends itself, causing unusual acuity of said centers, or positive perversions of sight and hearing, according to the intensity of the force operating. Finally, either with or without one of the foregoing conditions, pain of every grade arises seemingly attributable to no other cause than pure neural irritability. In other cases, disturbances in

distant parts of the body appear to telegraph to headquarters the fact of their existence, and call for the brain to assert its controlling influence and dispel them. The great nerve-center attempts to rectify the local wrong, puts forth a heightened exertion, and finds its power inadequate for that purpose. This force reacts, and the cerebrum becomes itself disturbed beyond the physiological limits, pain ensues, and headache is inaugurated.

In these several ways are the cephalalgias of this group generally accounted for. This is the popular proximal etiology of the suffering. It may be good philosophy,

and it may not. I accept it for want of a better.

Reasoning this way, many of the headaches of fevers belong in the present class. It comprises a large group of sympathetic, and not a few idiopathic cases. The head pains from trivial injuries, from shock in some instances, from the play of the emotions and passions, from dentition, from excessive pain in distant organs-intestinal spasms and other irritations, hysteria, constipation, indigestion, epilepsy, and the long list of neuroses, are catalogued here as their legitimate place, either wholly or in part.

If my classification be founded, as I believe it to be, on the true pathology of to-day, then it behooves us, when we court success, to fully recognize the divisions. They put us where we acknowledge the necessity of being on the alert to trace these pains back to their proximal causes, and treat them acccordingly. Patience and perseverance are requisite. And we find ourselves bound to discard all lauded specific therapeutical measures based on any other plan, and rationally apply appropriate medication, as the several indications suggest, or experience shows effective. Nor can we become wholly absorbed in the positivism of either one course, as succeeding with a single group of these cases, to the exclusion of the other three. If we accept one we must at least for a time carry all, and, doing this, we may expect better success than the convictions of both the people and profession (as drawn from past experience and shown by the hundreds of sufferers from headache who have lost patience and "thrown physic to the dogs") would lead us to anticipate. So, too, we must not only, when possible, learn to discrim inate the several varieties from another, but we must also bear in mind that 'tis not alone a possibility, but an actuality, that in many cases these types exist together,

so blended as to be difficult, yet deserving, of careful diagnosis.

In a future paper or papers I hope to carry this subject further, and enter fully into the matters of predisposition, heredity, excitation and therapeusis, as based on the tenets set forth in this communication.

Annual Address Delivered Before the American Academy of Medicine.

At Easton, Pa., Sept. 17,1878, by FRANK H. HAMILTON, A. M., M. D., LL. D.,` President of the Academy, Surgeon to Bellevue Hospital, New York.

We hope our readers will give this address of Prof. Hamilton an attentive perusal. We regret that its length precludes our publishing it in full in this number of the NEWS; but on the reception of the following number they can commence again with the present number and read it all the way through. The present portion will bear reading over again. In previous numbers of the NEWS we have spoken of the American Academy of Medicine. -EDITOR NEWS.

GENTLEMEN-Fellows of the Academy: It was not my privilege to have been one of the founders of this society, but I was honored with membership at so early a period of its existence, as to have participated somewhat in the deliberations which were to control its permanent organization, and shape its future policy. I may be permitted, therefore to speak on this occasion-our annual meeting of what I consider to be its purposes, functions, and destiny.

The purposes or objects of this association are thus broadly stated in the second article of our constitution: "First. To bring those who are alumni of classical, scientific and medical schools into closer relations with each other.

"Second. To encourage young men to pursue regular courses of study in classical or scientific institutions, before entering upon the study of medicine.

"Third-To extend the bounds of medical science, to elevate the profession, to relieve human suffering, and to prevent disease."