Reviews.

On Megrim, Sick-headache, and some allied Disorders: a Contribution to the Pathology of Nerve-storms. By EDWARD LIVEING, M.D. Cantab., Hon. Fellow of King's College, London; formerly Assistant Physician to King's College Hospital; Examiner in Medicine, University of Cambridge, 1870-71. London Churchill, 1873.

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THERE are two kinds of books to the reviewing of which the critic, after perusal, sits down with an easy and a happy mind. There is the really first-rate book, and there is the book which is so perniciously stupid that it gives one a thrill of joy to execute justice on the offender who has fouled the stream of literature with his muddy discharge. Either of these, we say, it is a pleasing entertainment to criticise. Alas that so much of our labour should be spent upon that large and uninteresting middle class of works which have no distinct savour at all, whether of life or death, of badness or goodness! It is those that really try the temper and endurance of the reviewer who happens to possess a conscience.

Dr. Liveing's book, we are happy to say, belongs unmistakably to the first-named kind; it is entirely an excellent work in every regard. Nothing has been spared; neither painstaking research into the opinions of predecessors and contemporaries, nor diligent and acute clinical observation, nor (above all) the lucid arrangement of facts in a manner which should best display their mutual bearings, and the general interpretation that ought to be put upon the whole. When we add that the language and style are elegant and scholarly throughout, and that a most interesting subject is treated in a manner to heighten rather than decrease its natural attractions, we trust that our readers will perceive that we are introducing them to an intellectual treat such as the literature of practical medicine provides but rarely.

Like so many other physicians who have written valuable monographs, Dr. Edward Liveing has been for years a sufferer from sick-headache, and he has also had ample opportunities of studying it in the persons of relatives and friends. This has led him to pursue the subject con amore; and though we may

regret that the diffidence of which he speaks in his preface, and other unavoidable causes, have delayed the appearance of the work for several years, the general result obtained is one which, perhaps, would have been impossible if there had been more haste in production. The book is divided into seven chapters, with an appendix and an elaborate table of cases. In the very first chapter, Dr. Liveing touches the key-note of his subject by showing that megrim is of various kinds, but that in each aspect it shows a truly nervous character, both by its own immediate origin, and even yet more remarkably by its connection, through hereditary descent, with other neuroses. Our readers are aware that the latter subject is one which has particularly engaged our attention; and it was, therefore, with the deepest interest that we followed the author's investigations of this matter. Not only has he illustrated the fact of neurotic inheritance (direct and transformed) abundantly from his own recorded cases, but he has done great service in bringing together isolated observations of earlier writers, now little read, which show that a large body of evidence on this question really existed, unrecognised by the general profession, long before the researches of Morel and Moreau had given a definite shape to the doctrine of the inherited neurosis.

Nothing, in fact, can be more instructive than the research into the first origin, the rudimentary traces, of a great doctrine like that of the inheritance and transformation of the neuroses; more especially when the author of such a research has at once the patience and the impartiality of mind to enable him to estimate with correctness the various influences that have tended to modify and obscure the pathological and practical conclusions which must otherwise have been arrived at by the authors of the original observations. Dr. Liveing has resuscitated for us a number of most suggestive observations of various authors (beginning with old Willis in the 17th century) who had had the hereditary and also the neurotic characters of megrim and its allies forced upon their attention, and who have very plainly acknowledged the importance of these facts, but have in almost every case been diverted from the fruitful path of inquiry thus opened up by the tyrannous influence of prevalent pathological theories.

He passes in review the various pathological doctrines which have been broached from the time of Willis (1674) up to the present day enumerating (1) the doctrine of biliousness, (2) that of sympathy and of eccentric neurosis, (3) gastric megrim, (4) uterine megrim, (5) ophthalmic megrim, (6) modern reflex and inhibitory theories, (7) determination of blood to the head, (8) congestion of the brain, (9) Dubois-Reymond's theory of vascular spasm, (10) Möllendorff's and Latham's theories of

vaso-motor paralysis; and shows, as we think very clearly, how all of these doctrines have been the result of exclusive attention to a particular set of phenomena, owing to preconceived notions which precluded a broad and impartial view of the clinical, and especially of the family, history of the disease. The theory which he has himself adopted is, that the whole group of disorders classed under the name of megrim and sickheadache have for their essence the production of "nerve-storms" —that is, explosive displacements of nerve-force, in a territory of the central nervous system, which is hereditarily weak and susceptible; that this territory, taken in its full extent, includes the optic thalami and the medulla oblongata; but that, while the former of these may be supposed to be engaged in those forms of the disease which are attended with peculiar visual phenomena, with emotional disorder, with numbness and tingling of the extremities, disturbance of the speech-faculty,1only the medulla oblongata may be affected in those cases in which there is merely sick-headache without any of these other phenomena.

As regards the probable seat of the disease, we are in entire accordance with Dr. Liveing, and it may be remembered that we ourselves have independently expressed the opinion that the medulla oblongata must be the part essentially affected in ordinary sick-headache, on the double ground of the anatomical connections between the roots of the trigeminus and vagus which are situated therein, and of the remarkable family connections of migraine, and its frequent interchangeability with other disorders, especially asthma, angina pectoris, and gastralgia, which could hardly have their common meeting-ground in any other part except the medulla oblongata. And we are inclined to agree with Dr. Liveing as to the inclusion of the optic thalami in the (rarer) cases where visual, emotional, anæsthetic, or aphasic symptoms are present. We are also in full accord with him in rejecting totally the idea (recently advanced, in different forms, by Dubois-Reymond, Möllendorff, and Latham) that vaso-motor changes stand in the relation of cause to migraine. We can verify his statement as to their marked inconstancy of the vasomotor phenomena, which are very often quite absent, and which, when present, show no uniformity in time or manner of appearAnd as regards the seat of the vaso-motor disturbances in those instances in which they undoubtedly do occur, we think with Dr. Latham that it is more reasonable to believe that the higher vaso-motor centre, suggested by Möllendorff as probably existing in the cerebral peduncle or the optic thalamus, is engaged, than that the vaso-motor fibres of the great sympathetic are concerned in the matter.

ance.

1 Through the connection of the optic thalamus with the corpus striatum.

As regards the theory that migraine and its allies are examples of "nerve-storms," we would remark as follows. We have no objection to the use of a phrase which certainly very happily describes the external characteristics of the clinical phenomena. We grant that there is much in the observable series of events to suggest an accumulation of nerve-force previous to the paroxysm, and its discharge during the time of the attack, with the consequent resumption of a stable equilibrium during the intervals, or until the new "storm" begins to brew. But we cannot help wishing that the author had ventured a little further, and suggested at any rate his own idea as to the general nature of the corresponding nutritive changes-for such there must surely bein the physical seat of the malady. Our own expression of a rhythmically recurrent "molecular atrophy" has been freely objected to: and yet it is difficult to see what general kind of cause can be predicated as likely to start these various forms of disturbance of tension-equilibrium in the medulla and mesocephale except a distinct weakening of nutritive action, i.e. if we agree with Dr. Liveing that the whole group of allied neuroses of these parts takes its origin always or almost invariably under circumstances when the nervous centres are especially feeble and delicate. We may gather, however, from Dr. Liveing's generally very excellent chapter on treatment, that he seems to hold the doctrine that there is so real and tangible an accumulation of force in the affected centres, that we ought expressly to endeavour to divert it into other channels: it is in this way that he explains, not merely the relief which has occasionally been produced by the intercurrence of a new and violent emotion-a therapeusis which is not available in ordinary practice-but also the wellknown beneficial influence of sustained muscular exertion (short of prostrating fatigue).

For our own part, we have always felt inclined to look upon the effects of well-directed muscular exertion in mitigating the paroxysmal condition in asthma, migraine, epilepsy, and the like, as simply produced by the improvement in general constitution which they tend directly to promote.

As regards the general character of the treatment-prophylactic and curative-which Dr. Liveing propounds, we have only to express a thorough approval; with the one reserve that we wish that it had fallen within his opportunities thoroughly to try certain remedies which he appears to have scarcely sufficiently appreciated. We think he should certainly have tested the value of galvanisation, a very important matter as to which (in the case of megrim) there is much dispute among good authorities. Arsenic, again, he scarcely mentions, save in connection with the malarial form of megrim: but certainly, this is to give a far too restricted idea of its value. And

with regard to bromides of potassium and ammonium, there is yet much that we should have liked to hear him discuss; in particular the degree of its relation to the dependence of megrim on conscious or unconscious sexual excitement, and also the exceedingly important matter of dosage. We should particularly like to know whether Dr. Liveing employed it in the full doses (30 to 40 grains thrice daily) in which it is now mostly used in epilepsy; our own experience has shown that the true value of the drug for migraine can only be appreciated by one who has employed it systematically in this manner.

We close this hasty and most insufficient notice of a remarkable book, by again expressing our hearty admiration of it. No monograph of anything like the same value has been written in the English language, so far as we are aware, of late years; and we can only hope that every medical man will read it, and profit, not merely by the mass of practical information that it contains, but still more by the example which it affords of painstaking and conscientious scientific labour.

Treatise on the Continued Fevers of Great Britain. By CHARLES MURCHISON, M.D., LL.D., F.R.S., &c. &c. Second Edition. London: Longmans, 1873.

THE appearance of a second edition of Mr. Murchison's great work calls for, at any rate, a brief notice. Even this might seem superfluous, considering that everyone will at once be anxious to read the book for himself; but we cannot deny ourselves the gratification of introducing it to our readers with a few words of remark.

The present edition of Dr. Murchison's book is the result of greatly increased experience in fever-including the treatment of nearly 15,000 additional patients at the London Fever Hospital. We believe there are few physicians who have ever preserved cases so systematically, and subjected them to such careful analysis, as Dr. Murchison has done, and he has rather become more than less diligent in recent years. Of forty-four detailed illustrative cases contained in his first edition, five have been expunged, and fifty-four fresh cases added; besides which the new volume deals much more fully and exactly than its predecessor with the question of temperature in the different forms of fever. It need not be said that Dr. Murchison has also taken advantage of every observation which has been made by others during the last eleven years; and he has displayed much skill in assimilating the results obtained by fresh observers. The general result is that we obtain a volume, large, indeed, yet not much larger than the first edition, and one which never for a moment suggests the idea of padding, but rather that of severe concentration.