Reprinted from the 
University Medicae Magazine, 
May, 1889. 
HEADACHE ASSOCIATED 
WITH UNUSUAL 
VISUAL PHENOMENA. 
By G. E. de Schweinitz, M.D., 
Ophthalmic Surgeon to the Philadelphia and Children1 s Hospitals; Ophthalmologist 
to the Infirmary for Nervous Diseases. Reprinted from the 
University Medical Magazine, 
May, 1889. 
HEADACHE ASSOCIATED WITH UNUSUAL VISUAL 
PHENOMENA.' 
By G. B. de Schweinitz, M.D., 
Ophthalmic Surgeon to the Philadelphia and Children's Hospitals ; Ophthalmologist 
to the Infirmary for Nervous Diseases. 
In June, 1887, Dr. Weir Mitchell presented a communication to the Fellows 
of the College in which he described four examples of a peculiar variety of 
migraine, associated with apparitions of an unusual character. In these cases 
the ordinary zigzag lines and rotating wheels, which have been so commonly 
reported in connection with hemicrania, were replaced by definite shapes so real 
that in some instances the belief was induced on the part of the patient that a 
ghost had been seen. In two of the persons described by Dr. Mitchell the 
vision came as the only prodrome of a severe headache. I will briefly recapitu- 
late the chief points, as far as the apparitions are concerned, in Dr. Mitchell's 
cases. 
In the first instance a woman, aged thirty, had attacks of migraine of great 
severity ; when nineteen years old, before the headaches, a bright gold-tinted 
cloud appeared ; nine years later the vision which preceded the headache was 
1 Read before the College of Physicians of Philadelphia, April 3, 1889.  deSCHWEINITZ, HEADACHE AND VISUAL PHENOMENA. 
2 
that of a large black dog which usually appeared as the patient was going up- 
stairs, and was so real that once she put forth her hand to touch it. In the 
second case, a woman aged thirty-eight, the apparition which preceded the head- 
ache consisted in the appearance of a sister who had long been dead, dressed 
for the street. In the fourth case, a man aged thirty, saw a variety of visions ; 
complex and geometrical figures of brilliant pink or red, multiple red circles in 
rapid rotation, and once a red eye which apparently came from the distance ; on 
one occasion a crescent of silver on the wall and suspended from it numerous 
heads in profile, some were strange to him and some were the revivals of faces 
which had long been forgotten. In one attack a red spider appeared which 
merged into a series of red rectangles revolving in swift motion. 
Since this communication I have examined many cases of severe headache 
with the purpose of elucidating the presence or not of apparitions as prodromal 
or associated symptoms. More than this, I have searched very industriously 
through the literature in order to ascertain whether similar cases are upon 
record, a search in which I was aided by Drs. Fletcher and Lorini, of the Army 
Medical Museum. It is the result of this investigation which I desire to pre- 
sent to the Fellows of the College this evening. 
Two of the cases sought relief in the service of Dr. Mitchell at the Infir- 
mary for Nervous Diseases, and so far as I know are the only instances which 
have appeared in that Clinic, which is so singularly rich in all the phases of 
nervous disease. Two others I use with the permission of Dr. Morris J. Lewis, 
and are from his private practice. He has kindly permitted me to examine 
them. One of these cases is from the private practice of Dr. F. X. Dercum, 
who permits me to use the case, as he also accorded me the opportunity of ex- 
amining the patient. Finally, the last case is one from my own practice, a 
patient that I have had under observation for more than a year, and who also 
has on several occasions been seen with me by Dr. Lewis. 
Case I.-Sarah W., aged forty-four, married, has seven living children, three dead, 
and has had five miscarriages. The youngest child is now five years old. The patient had 
scarlet fever and smallpox when eight years of age, but since then no other severe illness. 
When a girl she was struck on the left side of the head with a stone. The family history is 
good, so far as this is obtainable. Eighteen years ago, after severe exposure to the sun, she 
had an attack of pain in the head associated with vomiting, purging, etc., which lasted for a 
week. Since this time up to the present day at intervals she has suffered with severe head- 
pains. For the past year these pains have been worse, coming on once a week as follows : 
the pain begins at the supratrochlear point of the left side, crosses the brow and goes to 
the occiput, or begins on the left side of the postcervical region and runs forward, the char- 
acter of the pain being that of a succession of severe electric shocks of the most violent 
type, lasting sometimes twenty-four to thirty-six hours. 
After the headache has reached a certain grade of severity, visions appear. Figures 
of all sizes and shapes, startling and horrible in their reality, or, to use the language of the 
woman herself, "I see all manner of ugly kind of varmint, I call them, such shapes as I 
believe no one ever really did see." 
Under treatment, which consisted of cannabis indica, antipyrine, and the use of a 
boracic acid injection for a leucorrhoea from which she suffered, some modification of the 
head-pains resulted ; at all events, for several months the visions disappeared. deSCHWEINITZ, headache and visual PHENOMENA. 
3 
Iii January of this year a severe paroxysm of head-pain again occurred, this time asso- 
ciated with a large green snake as the only visual apparition. 
An examination of the eyes of this patient has revealed healthy, oval, optic discs, 
hypermetropic refraction, and slight insufficiency of the internal recti muscles. Correcting 
glasses were given ; ascending doses of nux vomica were ordered, together with a generous 
diet and bromide of lithium during the paroxysms. Later, owing to her anaemic condition 
(although a blood count revealed 1,600,000; haemoglobin 80 per cent.), iron was ordered. 
The last record in February of this year states that the headaches are better. Two weeks 
have elapsed without a severe paroxysm, and since the appearance of the green snake, no 
new visions have been seen. 
Case II.-Miss Susan B., aged forty-eight, applied for treatment in the Infirmary for 
Nervous Diseases, and gave the following history : Has long been troubled with dyspepsia 
and malaria. Eight years ago had an attack of intermittent fever which now is most mani- 
fest in the spring and fall. For the last two months has had a dull aching rheumatic pain 
in the bones of the right arm, in the right knee-joint, and in the right wrist. Severe head- 
aches, which formerly appeared once in two months, now came on every other day, the 
occiput being the situation of the most intense pain. This headache is ushered in by the 
following visual phenomena :- 
The appearance of a rainbow or a rainbow7 light in the eyes which is relieved by shut- 
ting the eyes. 
Zigzag lines, seen also in the dark, for the headache not infrequently comes on during 
the night. 
Definite shapes of animals, cats and dogs, and quite usually the faces of people, both 
homely and comely, always unfamiliar and always with headache. 
A very usual order has been first a chill, second, fever, third, the visions and the head- 
ache, and fourth, though rarely, vomiting. 
Physical examination revealed a normal heart and some increased splenic dulness. 
Full doses of quinine and hydrobromic acid produced slight amelioration, but did not stop 
the headache or the chills. She was then ordered the oil of eucalyptus, five minims six 
times a day. From the time that this remedy was exhibited, the headaches, and with them, 
the visions, absolutely disappeared, although once after its administration a slight chill 
occurred. Acute rheumatism of the wrist and knee developed, the pain of which was 
modified by the use of salicylate of soda, but there was no return of the headache. 
An examination of the ocular conditions revealed slight, simple hypermetropic astig- 
matism, with two degrees of insufficiency of the external recti at five meters. The pupils, 
facing a bright light, were unequal, the right being the larger ; their reactions were normal. 
The anterior chambers were shallow. The tension was normal. Each optic disc was a ver- 
tical oval, somewhat gray in the deeper layers, physiologically cupped, and the edges 
veiled by hazy retina. There was no change in the fields of vision. 
Case III.-W. L., unmarried, a patient of Dr. Morris J. Lewis, in reasonable general 
health, gives the following history of her headaches, and of the visual disturbances which 
preceded them : Up to sixteen years of age she was free from any form of headache. Then 
headaches without visual hallucinations began, usually coming on every day. At this time, 
for a number of months, her eyes were inflamed, probably with granular conjunctivitis. 
Exactly at what time the visions appeared as prodromes of the headaches, the patient 
is unable to accurately state. The pain now begins above the right eyebrow, or in the back 
of the head. Often preceding the attack, gold rings appear, while linked silver rings are 
constantly present. Once, and this quite recently, the vision which preceded the headache 
was a band of Indians seated in a wagon. Not infrequently the appearances take on, to 
quote the language of the patient, " faces of men and women hideous enough to make me 
vomit."  deSCHWEINITZ, headache and visual phenomena. 
4 
In this particular case the eyes revealed the results of the former granular lids. In the 
left eye, where the fundus was visible, there was an oval optic disc, gray in its deeper layers, 
with a broadened scleral ring below, and a low degree of simple hypermetropic astigma- 
tism. In the right eye the cornea was too hazy to admit of perfect ophthalmoscopic exam- 
ination. A slight convergent squint was manifest, and also ptosis, or rather a droop in the 
lids, the result of a former trachoma. These headaches were never in any apparent associa- 
tion with eye-strain. 
CASE IV.-Andrew L., aged fifty-three, a patient of Dr. Morris J. Lewis, a night 
watchman by occupation. He consulted Dr. Lewis for relief from vertigo, violent head- 
aches, unusual visual phenomena, and nausea. These headaches were both ushered in and 
associated with peculiar and striking visions, which, for the most part, took on the form of 
baskets of fruit, like oranges, and gaudily colored flowers. 
His eye-sight was very defective, owing to a high grade of hypermetropia, the correc- 
tion of which did not yield him more than one-fifth of normal vision. The optic discs on 
each side were oval ; a web-like haziness surrounded their margins, especially above and 
below, and both arterial and venous lymph sheaths were full. The field of vision for 
form was not changed ; that for colors was not taken. 
Case V.-Mrs. H. B., aged thirty-seven, a patient of Dr. F. X. Dercum. Since early 
childhood this lady has suffered from a violent type of " sick headaches." About the time 
that she was married, or shortly afterwards, a very constant prodrome of the attacks of 
head-pain was a singularly real apparition, first usually in the form of her servant or some 
other known member of the household, which appeared just at her left shoulder. In a few 
moments after the appearance of the spectral form, violent headache began, generally in 
the temple and upon one side, followed by nausea and sometimes by vomiting. At present, 
the vision which most frequently appears is that of the forms of her own children, of whom 
she has had six, so real that on many occasions she has put forth her hand to touch then'. 
Two years ago Mrs. B. had pneumonia, and she is now the subject of uterine disorder. 
The eyes are entirely healthy ; the external eye muscles normal, and both direct and 
indirect vision natural. Treatment in this case has, I think, not very much modified the 
headaches or the vivid apparitions which are their prodromes. 
Case VI.-Miss Emily Z., a patient of my own, sent to me by Dr. Lewis for the treat- 
ment of aggravated headaches, in February of 1888. Before 1887 she never suffered from 
severe headaches, but frequently saw rising and falling silver balls and bright stripes, 
especially if looking intently at any near work. After 1887, during the summer, headache 
began, situated in the right parietal eminence and gradually creeping backward to the 
occiput, associated with a drawing backwards of the head, and golden balls flying every- 
where through the air. 
This patient had reasonably healthy optic discs, slight insufficiency of the internal 
recti, and well-marked, compound hypermetropic astigmatism. This was corrected under 
. . . O. D. + .5°s~|- i-5oc axisqo0 15 
a mydriatic, the glass proving to be xv. This she wore con- 
O. S. + .50s l- i.c axisqo0 
stantly ; took iodide and bromide of potassium, and locally employed a weak solution of the 
sulphate of eserine in her eyes. Under this treatment for many months th headaches were 
distinctly alleviated. 
In December of 1888 she returned, stating that for three months the headaches had reap- 
peared. The rising and falling silver balls and the flying golden balls in the air were still 
present. Now, also, marked visions of animals, always either mice or dogs, were associated 
with the headache, which, however, was not more intense than on former occasions. Appa- 
rently the objects, so she stated, were seen only with the right eye. Once, in the morning, 
the vision took on the form of the water pitcher in the room through the handle of which a 
constant stream of running mice playfully chased each other. Once, while sitting in a 
church, the vision was that of a small black dog that curled himself at her feet. On these, deSCHWEINITZ, headache and visual phenomena. 
5 
as on former occasions, the headache was present, but not more pronounced than when 
unassociated with visual apparitions. 
The patient is somewhat anaemic ; suffers from chronic constipation ; has an obstinate 
leucorrhoea, and is nervous in her motion and speech, but not hysterical. Her family his- 
tory appears to be good as far as general health is concerned ; the eye history is the follow- 
ing : the father's sight is normal; the mother has progressive myopia, and is now nearly 
blind ; two sisters are myopic. 
A field of vision taken during one of the headaches revealed little or no change in the 
extent of the form field, but marked concentric contraction of the color fields. 
Dr. Mitchell at the close of his communication remarks: " Comment in regard 
to these cases is difficult. The phenomena are not uncommon in disease, but 
their association as part of the complex symptom, hemicrania, is undescribed." 
This statement is very completely borne out by an exhaustive search of the 
literature, which resulted in a failure to find the records of exactly similar cases. 
It is evident, however, that occasionally cases are on record of a somewhat 
analogous nature generally to be found amongst the many accounts of spectral 
illusions with which the writings and reports of long ago are richly endowed. 
In Brewster's 11 Tetters on Natural Magic," a case is quoted, as mentioned by 
Dr. Abercrombie, of a gentleman, who was a patient of his, of an irritable habit, 
and liable to a variety of uneasy sensations in his head, who saw one day a 
female figure enter wrapped in a mantle with the face concealed by a large black 
bonnet. He knew that the figure was an illusion of vision, amused himself for 
some time watching it, observing as he did so that he could see through the 
figure and perceive the objects behind it. 
From the " Philosophy of Sleep," by Robert McNish, chapter 15, "Spec- 
tral Illusions," pp. 243 to 277, I quote the following :- 
" Mr. Simpson, in the second volume of the Phrenological Journal, has published a case 
of spectral illusions, which, for singularity and interest, equals anything of the same kind 
which has heretofore been recorded. The subject of it was a young lady under twenty years 
of age, of good family, well educated, free from any superstitious fears, in perfect bodily 
health, and of sound mind. She was early subject to occasional attacks of such illusions, 
and the first she remembered was that of a carpet which descended in the air to her, then 
vanished away. After an interval of some years, she began to see human figures in her 
room as she lay wide awake in bed. These figures were whitish, or rather gray, and trans- 
parent like cobweb, and generally above the size of life. At this time she had acute head- 
aches, very singularly confined to one small spot of the head. On being asked to indicate 
the spot, she touched, with her forefinger and thumb, each side of the root of the nose, the 
commencement of the eye-brows and the spot immediately over the top of the nose. . 
On being asked if the pain was confined to these spots, she answered that some- 
time afterwards it extended to the right and left, along the eye-brows and a little above 
them, and completely round the eyes, which felt as if they would burst from their sockets." 
The account then goes on to describe in further detail the spectral illusions 
to which this patient was subjected, the variations which took place in them, 
and the fact that for a period of two years Miss S. was free from her frontal 
headaches, and untroubled by visions or any other illusive perceptions. After 
a time, however, all her old distressing symptoms returned in great aggra- 
vation, associated with even more severe pain along the frontal bone and around 
the eye-balls. The apparitions consisted frequently of single figures of absent 6 
deSCHWEINITZ, HEADACHE AND VISUAL PHENOMENA. 
and deceased friends which she met upon the street, but which proved phan- 
toms when she approached to speak to them. 
From the same book I quote an abstract of another case :- 
" In the fifth volume of the Phrenological Journal, p. 319, a case is mentioned where the 
patient was tortured with horrid faces glaring at her, and approaching close to her in every 
possible aggravation of horror. She was making a tedious recovery in childbed when these 
symptoms troubled her. Besides the forms, which were of natural color, though often 
bloody, she was perplexed by their variation in size, from colossal to minute. She saw also 
entire human figures, but they were always as minute as pins, or even pin heads, and 
described the pain which accompanied her illusions, viz : acute pain in the upper part or 
root of the nose and all along the eye-brows." 
In the same volume other cases, as for instance, that of Dr. Bostock, where 
spectral illusions were a prominent feature, are described, but they are even less 
relevant than the instances which I have just quoted, belonging rather to that 
class of cases where apparitions form part of the phenomena making up a case of 
general illness, and are not prodromal or associated symptoms of hemicrania or 
other type of neuralgic headache. 
It should be remembered that the instances which Dr. Mitchell has recorded, 
and to which I have added these six cases, are peculiar in that the visions were 
"part of the complex symptom, liemicrania." They must then not be con- 
founded with similar phenomena in association with disease, nor with the visions 
that have been seen by a number of sane persons: "the Number-forms;'' 
the association in some people of color with sound ; the phantasy of certain 
individuals to connect visualized pictures with words ; and that form of vision 
which is a phantasmagoria, or the appearance of a crowd of phantoms hurrying 
past like men in a street, it may be in broad daylight or more frequently in the 
dark-visions which have been seen and described by men eminent in the scien- 
tific and literary world.1 
It is not a little singular that cases such as Dr. Mitchell and I have described 
have been so seldom recorded. Two explanations of this are evident, either that 
the instances are very rare, or that the patients thus afflicted suppress that par- 
ticular portion of their symptoms in which spectral illusions play a part when 
detailing the histories of their cases to their physicians-suppress them for 
fear of bringing upon their heads the unbelief with which anything that pertains 
to what may seem for the time to be supernatural is so frequently met. Moreover, 
as one of these patients once said to me, "I never told anybody about this 
because I was ashamed''-ashamed, I presume, lest the person, physician or 
otherwise, to whom the statement would have been made might have seen fit to 
scoff at the unfortunate sufferer. As Dr. Mitchell has pointed out, it seems 
difficult to find an explanation for these rare cases of headaches preceded by 
hallucinations, just as it is impossible to find an adequate explanation of other 
spectral illusions in regard to which the accuracy of observation cannot well be 
1 Those interested in this subject will find a chapter of great interest, in which the varieties of visions 
seen by sane people just referred to may be studied in detail, in "Inquiries into Human Faculty and its 
Development," by Francis Galton, F.R.S., 1883. de SCHWEINITZ, HEADACHE AND VISUAL PHENOMENA. 
7 
called in question. In this connection let me quote from Brewster who says :- 
" Although it is not probable that we shall ever be able to understand the actual man- 
ner in which a person of sound mind beholds spectral apparitions in the broad light of 
day, y.t we may arrive at such a degree of knowledge on the subject as to satisfy rational 
curiosity, and to strip the phenomena of every attribute of the marvellous. Even the vision 
of natural objects presents to us insurmountable difficulties if we seek to understand the 
precise part which the mind performs in perceiving them ; but the philosopher considers 
that he has given a satisfactory explanation of vision when he demonstrates that distinct 
pictures of external objects are painted on the retina, and that this membrane communicates 
with the brain by means of nerves of the same substance as itself, and of which it is merely 
an expansion. Here we reach the gulf which human intelligence cannot pass ; and if the 
presumptuous mind of man shall dare to extend its speculations further, it will do it only to 
evince its incapacity and mortify its pride." 
It is manifest from a study of the cases recorded by Dr. Mitchell and by 
myself, and also from those of somewhat analogous nature which have been 
gathered from the literature, that this form of headache, with unusual visual 
phenomena, may be arranged into three groups : First, those varieties-and 
these are the most unusual-in which the apparition conies as the only prodrome 
of a violent headache of a neuralgic type. Second, those varieties in which 
the apparitions appear after the headache has been present for some time. 
Cases of this kind I believe more exact inquiry would prove to be more 
frequently present than the records seem to show. These are types analogous 
to the not very uncommon association of spectral illusions, and various unusual 
visual phenomena in other forms of disease. Third, those varieties-and these 
may be considered as a subdivision of the class just quoted-in which the 
apparition appears at the end of the headache, and is, in short, the last scene 
in a more or less violent nerve storm. 
Finally, it is interesting to remember that visions have occasionally been 
seen by patients just before the development of a lateral hemianopsia in that 
portion of the field of vision which afterwards became totally and permanently 
dark. Thus Seguin has recorded a case in which chickens and other animals 
were seen by the patient who subsequently developed a complete homony- 
mous hemianopsia, and I have myself seen and recorded a case in which the 
statement of the patient was that he had seen visions, chairs, tables, and other 
articles of furniture not really present, in the fields which were afterwards 
obliterated. At the time I examined him, the hemianopsia was already com- 
plete. Such phenomena must be explained by temporary congestions in the 
highest visual centres, the function of which is later to be entirely destroyed by 
a permanent lesion.