Biographies de neurologues
Nouvelle Iconographie de La Salpêtrière
 L'histoire des neurosciences à La Pitié et à La Salpêtrière J Poirier
The history of neurosciences at La Pitié and La Salpêtrière J Poirier 

mise à jour du
8 novembre 2007
Edward liveing
On Megrim, sick-headache
and some allied disorders
A contribution to the pathology of nerve-storms
Edward Liveing
texte intégral


living megrim
p 383-387
I shall only notice one more instance. The momentary shock and rigidity of the frame which occurs as an effect of surprise or alarm when we "jump," as we say, at an unexpected appearance, is not without its pathological representatives. The painful and violent shock which some persons experience when first dropping off to sleep is an occurrence of a similar kind, and if too familiar to be considered morbid, it certainly occupies the confines between health and disease, like hiccup, sneezing, and so many minor explosive nervous actions; and with some persons at certain times it occurs so frequently and occasions so much distress as to amount to a positive malady; it exhibits, moreover, in the time of its occurrence a further conformity to the neurosal character. Sir H. Holland has pointed out that a very similar affection may occur by day a as distinct malady of the epileptic class -" In another instance which happened to me lately, where the remarkable symptom at the time was that singular shock or jar which patients themselves often compare to an electric shock, and which in this case occurred with frequency and violence in the lower limbs, the attacks when most severe in degree, came on almost exactly at equal intervals of somewhat more than two minutes . . . . The patient in this case described the sensation as 'a sudden shot into the limbs, seeming as suddenly to disperse itself into innumerable sparks which penetrated into every corner of them.' Most persons," continues Sir Henry, "will probably recognise in this description a frequent occurrence of ordinary health, where a sudden shock or jar is felt to spread in an instant through the whole body, happening generally without obvious cause, yet most frequently during the approaches of sleep."
There remains one other class of facts connected with the history of neurosal disorders to which we have not hitherto referred, but which may be briefly noticed here, as forming an additional link between those disorders and the actions of the healthy nervous system which most nearly resemble them. I refer to the influence of Involuntary Imitation and Habit in determining or reproducing the seizures.
Recurring once more to those normal convulsive actions which belong to the respiratory system. We all know how involuntarily and often unconsciously the act of yawning, if once started, will go the round of a whole circle of people who are not very actively engaged, and the interest and significance of the fact are only lost sight of in its familiarity. It is much the sanie with the act of coughing; it sometimes requires a considerable effort to resist the impulse to cough in sympathy with another, and its epidemic propagation through a whole assembly of people may often be noticed in our churches. The same influence may be observed in connexion with the sensations and movements of sickness; many people are made sick by merely seeing others so, and in susceptible persons this is not confined to the sense of nausea, but may extend to the convulsive actions of retching and vomiting. Cullen says of himself, "I have often coughed when another person has coughed; and I cannot help vomiting when I see another person straining and vomiting." Even the natural appetite for food admits of being considerably heightened by company, and the sight of others eating.
It should be observed however, and the fact bears directly on our present inquiry and the analogy of neurosal phenomena, that this influence of imitation becomes much more apparent when the persons concerned are in any way predisposed to the actions in question; to yawning, for example, by weariness, to coughing by the prevalence of catarrh, and to sickness by being at sea.
Again, in the case of the emotions and their outward expression we trace the operation of the same principle. Every due knows how a laughing face makes us laugh and a suffering one makes us sad; how quickly women and children are moved to tears by the sight of others crying. Let a person unexpectedly find himself in merry company, and he is instantly caught by the prevailing humour and laughing with the rest before he has any distinct idea of the cause of merrimeni. A curious instance of this involuntary imitation of laughter is quoted by Percival from Wesley's Journal. "Part of Sunday my brother and I then used to spend in walking in the meadows and singing psalms. But one day, just as we were beginning to sing, he burst out into loud laughter. I asked him if he was distracted, and began to be very angry, and presently after to laugh as loud as he. Nor could we possibly refrain, though we were ready to tear ourselves in pieces, but we were forced to go home without singing another line."
The power which great actors and orators possess of working on the feelings of their audience lies in their ability successfully to assume the outward expressions and gestures of the deeper passions. We have instances too of the propagation of violent emotions among large bodies of people, and of the accumulated intensity they may attain by sympathetic imitation, in the outbreaks of fury, of panic, and of admiration, to which mobs and armies are liable.
If now we turn our attention to pathological cases, we shall have no difficulty in tracing the same influence of imitation in the case of various neurosal seizures which we have just observed under circumstances of health. Thus it is a well established fact, that persons have been rendered epileptic by seeing others so affected. In a case of epilepsy recorded by Mr. Solly, to which reference has already been made, a little girl became epileptic at the age of seven, after seeing her nurse in an epileptic fit. So Van Swieten observes:-" I have known a great many rendered epileptic and who have remained so for the rest of their lives, from another person falling down in a fit before them; and there are a great many such cases to be met with among medical writers."* The same influence is still more strikingly seen in hysteria. "It has frequently happened in the ROyal Infirmary here (Edinburgh)," writes Robert Whytt, "that women have been seized with hysteric fits from seeing others attacked with them ;"t and this experience has been repeatedly confirmed. Dr. Bright relates in his reports of cases at Guy's Hospital that having occasion to pass a probang for an hysterical patient, the operation was followed by a convulsive paroxysm, which was immediately repeated among several patients in the same ward. Dr. Laycock bas given an interesting account of the spread of hysterical retching and vomiting with other symptoms among four female patients in the wards of the York Hospital, so as to give rise at first to a suspicion of poisoning; and it would be easy to refer to many more instances.

p 357-359
1f now we pursue the comparison which has here been suggested a little further into detail, with particular reference to some of the problems our subject presents, we shall find much to confirm the foregoing analogies, and we shall be able to trace among the same physiological actions the representatives of many circumstances in the history of megrim and other neuroses which are among the most singular and anomalous we have to explain. The class of facts which more particularly deserve our attention are the following
A. The assumption from time to time of a distinctly morbid and neurosal type by the natural actions of which we have spoken, in consequence either of a great exaggeration of character or frequency or spontaneity of recurrence.
B. A certain capacity of substitution or mutual replacement among such physiological actions under circumstances of health, reminding one of that same kind of equivalency among various neurosal seizures which we have been at some pains to trace in the preceding chapter.
C. The transition not unfrequently observed between these normal modes of activity and certain well-known forms of neurosal seizure, so that the former become influential exciting causes of the latter; as when a mental emotion determines an epileptic fit, or the latter aborts in one of laughter.
D. The still more remarkable, and at first sight paradoxical power these normal actions possess, not only of exciting but occasionally also of dispersing others of a pathological kind, and the consequent possibility of sometimes anticipating the occurrence of an expected neurosal paroxysm by the artificial induction of a vicarious physiological action of an explosive character.
E. The occasional determination of these definite trains of normal action by other influences or impressions besides those to which they are especially affiliated in connexion with their final purpose in the economy, and which call to mind the varied character and operation of the different exciting causes of neurosal seizures.
These several points I shall now endeavour to illustrate by reference to as many instances as occur to me; and I think it will thus appear that we are dealing with a class of phenomena, both healthy and morbid, which are united in obedience to certain common laws, and mutually illustrate one another; their consideration moreover will suggest I think some useful reflections on the theories of neurosal phenomena already discussed, and will help to correct or enlarge our views in this branch of pathology.
I shall again have recourse for a first illustration to those minor explosive nervous actions which are limited to the Respiratory Apparatus, such as sneezing, yawning, and hiccup. It is an observation which we owe to no less an authority than Hippocrates that-" Sneezing coming on in a person afflicted with hiccup removes the hiccup-"
The engagement of a neighbouring nervous circle in repeated acts of deglutition will have the same effect; so will the development of any sudden emotion; and so will the induction of that painful state of nervous tension-the sense of "want of breath." We are all familiar with the nursery expedients for the cure of hiccup-the charm of the "three drops," the frightening it away by a sudden surprise or other emotion, repeating the well-known rhymes in one breath, which requires at the same time a strong effort of articulation.
Trifling as these illustrations may seem, they bring before us in epitome the operation of the principles I have just enunciated; nor should we forget, as I have already pointed out, that although hiccup and sneezing are ordinarily trivial occurrences, referrible to some transient local irritation, they are sometimes presented to us under a very distressing form, as distinct idiopathic neuroses. Some years since I had under my care, at King's College Hospital, a case of this kind: the patient was a man past middle-age, and hiccup had occurred in paroxysms of twelve hours' duration, about twice a week for four years. Dr. Prichard relates the history of a little girl of twelve, who for nearly three years was subject to fits of violent hiccup, attacking her during sleep by night as well as by day, the paroxysms lasting from ten minutes to an hour, and recurring three or four times in the course of a day and night. Sneezing and gaping occasionally set in towards the close, and the paroxysms usually ended in headache. There were no worms, but the child was cured by turpentine. Dr. Prichard justly observes of such cases "that we may look upon them as imperfect attempts to produce epilepsy, or as differing from general epilepsy in some, perhaps, trivial modification."

p 405-409
Malarial Megrim
Hemicrania Intermittens," or "Brow Ague," was once very common in this country, but is now seldom met with, at least in town. I have already referred to the endemic prevalence of a malady of this kind in the Migrafia of some parts of Spain and other malarial countries. Most of the writers on megrim have recognised Marsh poison as one of the causes of the disorder. Robert Whytt, besides the idiopathic, gastric, catamenial, and arthritic varieties of periodical headache, describes a fifth as maintaining exactly regular periods and evidently of an aguish character, and he mentions having found opium of great value in the treatment of a violent quotidian hemicrania.* Tissot himself appears to have suffered from the epidemic prevalence of a migraine of this kind. "When thus epidemic," he says, "it is symptomatic of intermittent fever, as I have experienced in my own case, and as has been observed by M. Schobeit in a case where the affection returned very regularly at the same hour every other night, and terminated by sweating."
Dr. Macculloch, who has left us by far the best treatise on malarial disorders which we have in our language, and has especially directed his attention to the aguish origin of many neuroses, describes periodical headache as one of the commonest of the masked or irregular forms of intermittent fever; and with regard to the situation and character of such headaches, he considers "Hemicrania as undoubtedly the most important variety." In other instances the pain may be of a still more circumscribed character and take the form of "clavus hystericus," which is but a variety of megrim; and many of the cases commonly known as "nervous headache," and the so-called "determinations of blood to the head," he believes to have a similar origin. As an acute affection, or "brow ague" strictly speaking, such periodical headache may, he says, present "any of the types of Intermittent; and if I have not myself seen it under every form, I have at least known it as a double quotidian, as a single one, and as a tertian."t It is, however, the more chronic forms which have the greatest interest for us, assuming as they do more nearly the character of idiopathic megrim in respect to periodicity and the length of intervals. "Where the intermittent has been of long duration, it is more common for the periodical headache which is united with it to recur in a very irregular manner, as is true generally of the disorder in all its modes, when of such standing; and it is in these cases especially, that its real nature is so commonly mistaken, as it then wants those obvious characters which alone would arrest the attention of a superficial observer."
With regard to the dependence of such hemicrania on malaria, "It will be found," Dr. Macculloch says, "that this disorder is most common in situations of the unhealthy nature formerly described, and that it is often directly brought on by causes which produce ordinary Intermittent. But what affords a much stronger proof of its identity, is the fact that it occurs frequently, perhaps most frequently, in those who labour under chronic Intermittents or Remittents, or have formerly suffered from these disorders. Thus it may occupy the whole period of one relapse, as the substitute of what would otherwise have been a common one; as it is even found to do, in frequent interchanges, and through a long life, in those who possess that inveterate habit of intermittent which may almost fairly be esteemed incurable. Still more remarkably, it is sometimes found to interchange by paroxysms with the common intermittent; or the ordinary fever of one day is replaced on another by the headache. Thus I have seen the headache and the ague fit occupy alternate days, a modification which may be considered a double tertian, and proceeding thus through a long period."
Respecting the nature of its relation to ague, Dr. Macculloch holds that the difference between the regular and irregular forms of malarial disorder is merely a difference of localization of the same essential morbid action in different territories of the nervous system: "The action of malaria is on the nervous system, on the whole and on the parts; or affecting the whole in a slender manner, it may exert its chief influence on some peculiar nerve or portion of a nerve. And till we know more of their nature and of this action, we cannot pronounce a negative, or say, that no cause but malaria shall produce even a simple intermittent." And again-" Everything tends to show that if the diseases produced by malaria are not purely, and all, mere affections of the nervous system, the principal action of this poison is on that system, and the greater proportion of the disorders which are caused by it, disorders of the nerves."
Under this view of its affinities with ague, some other nervous phenomena which often attend the headache, or form a part of the same paroxysm, become at once intelligible-" Such as previous yawning, increased and sudden secretion of urine, spasmodic and hysterical affections, derangements of the mental faculties, and, as I conjecture, vomiting." With regard to this associated vomiting, he adds-" In this particular disorder (headache) that act generally occupies the same place in the paroxysm which it does in the common intermittent (terminal); and though I do not doubt that there is a headache, terminating in vomiting, of a different nature, and commonly called 'bilious headache,' I have had no difficulty in tracing many reputed cases of this nature to the disorder which I am now describing."* In an earlier part of the treatise he had written of this sickness, thus :-" I have already remarked that the ordinary paroxysm of an Intermittent sometimes terminates in vomiting, while nausea also occurs in them as in Chronic Remittents; often very durable and forming a very distressing addition to the other symptoms. In the cases to which I would here specially call attention, and which are the chronic ones, the vomiting becomes the most conspicuous symptom, or even the only one which the patient may notice.
. . . I must also remark that it is very commonly preceded by a state of drowsiness of which it is the termination. It is, in reality, in all cases where it occurs, the real termination of the paroxysm, as in well-marked Intermittents.
I need only add, that as far as I have seen, the vomiting is very transitory; occurring whether the stomach is full or empty, and when past, leaving it without any derangement, or rather being the immediate forerunner of the interval of temporary health. And when its period is arrived, the slightest cause, even a glass of water, will bring it on instantly; while it also comes on at times with so little previous notice, that the patient has not even time to leave his seat or change his position. Thus have I seen it continue for three months; being either removed only bt the cessation of that particular relapse, or else becomig exchanged for some other local symptom."