Abstract

William Richard Gowers (1845-1915) was a pioneer of British neurology [1]. He is credited with the first (or best) descriptions of numerous neurological disorders, including dystrophia myotonica, myasthenia gravis, ataxic paraplegia, vasovagal attacks, musicogenic epilepsy, sleep paralysis, palatal myoclonus, and many others. His “chief monument” (according to Gordon Holmes) was the Manual of Diseases of the Nervous System (1886, 1888; 2nd edition 1892, 1893; 3rd edition 1899 (volume I only)). In this essay, I discuss Gowers’ writings on migraine, specifically focusing on the subjective visual phenomena of migraine (aura), and his views on the link between migraine and epilepsy.

Headache and migraine in Gowers’ Manual

Headache and migraine appear in Volume II of William Gower’s Manual of Diseases of the Nervous System, in the section on Functional Disorders. There is a short discussion of headache as a symptom, distinguishing headache as a symptom of organic disease from that caused by functional disturbances, including migraine. In the former category Gowers recognises toxaemic, congestive, gastric, neuralgic, and anaemic causes, and headaches brought on by brain-work and ‘neurasthenia’.

‘Migraine’, writes Gowers, ‘is an affection characterised by paroxysmal nervous disturbance, of which headache is the most constant element. The pain is seldom absent and may exist alone, but it is commonly accompanied by nausea and vomiting, and it is often preceded by some sensory disturbance, especially by some disorder of the sense of sight.” Migraine, he contends, is ‘often associated with high intellectual ability’, citing sufferers such as John Fothergill, Albrecht von Haller, Emil Du Bois Reymond, and William Herschel. Gowers specifically directs readers to Edward Liveing’s 1873 monograph On Megrim (‘the best systematic account of the disease’) and Hubert Airy’s 1870 paper on transient hemiopsia in the Philosophical Transactions of the Royal Society [2,3].

Gowers discusses the aetiology and symptoms of migraine (with subsections on varieties, course, complications and associations), its pathology, diagnosis, prognosis, and treatment. The influence of Liveing’s monograph is clear; Gowers supplements this with personal cases. Few other authorities are mentioned, except in the section on pathology where he mentions the vascular theories of Du Bois Reymond, Mollendörf, Eulenberg and Latham, only to dismiss them on the basis that they do not explain the phenomena. He approves of Liveing’s view of a neural origin, but calls the ‘nerve-storm’ a “somewhat inapt metaphor” and points out that Liveing’s view (which was also Hughlings Jackson’s view) that the seat of the attack was the optic thalamus was based on theories ‘that we now know to be erroneous’, concluding that ‘the sensory symptoms are probably due to a peculiar kind of functional disturbance in some of the nerve-cells of the cerebral cortex… the cause of the headache is obscure’. This section was truncated in the 2nd edition, Gowers stating that when “all has been said that can be, mystery still envelops the mechanism of migraine.”

Gowers’ Manual was the predominant English language textbook of neurology for fifty years, throughout the era in which, as Stephen Caspar has shown, a nascent scientific and medical community of practitioners interested in diseases of the nervous system were defining themselves as ‘neurologists’ [4]. The Manual was also hugely influential in the wider medical community, providing a template for the neurological sections of important general medical textbooks, notably William Osler’s Principles and Practice of Medicine (1892), and Clifford Allbutt’s System of Medicine by many writers (1899).

Prodromata and subjective visual symptoms

Gowers recognised the association of migraine with subjective sensory symptoms (‘sensory’ in its wider sense including visual symptoms). In the Manual Gowers’ discussion of the visual accompaniments of migraine was largely drawn from Airy’s paper, albeit supplemented with personal cases. He includes a paragraph on the sensory symptoms felt in the ‘limbs, face, throat, and adjacent parts… very seldom in the leg’, in which there ‘is the same combination of sensory irritation and sensory loss.’ He notes that the sensory symptoms of migraine sometimes occur without headache: ‘These cases are of great importance, because their nature is often misunderstood.’

On 14th June 1895 Gowers delivered the Bowman Lecture at the Ophthalmological Society; his subject was  ‘Subjective Visual Sensations’ [5]. This lecture comprised sections on migraine and epilepsy (in the original epilepsy came first, but in the revised version they were reversed). Discussing migraine, he presented Airy’s illustrations and supplemented them with further illustrations made by one of his patients, Mr E H Beck, a ‘mechanical draughtsman’ mentioned in the Manual. Beck had been under Gowers’ care at the National Hospital from 1879 until his death five years later; he gave Gowers a book of drawings ‘accompanied with some rather quaint descriptions, in which it is easy to discern a definite degree of aphasia’. Beck had wanted the book to be shown to the Queen; Gowers presented it to the Society.

Migraine and epilepsy

As mentioned above, migraine and epilepsy were both considered members of a family of functional nervous disorders, which included conditions that we now regard as neurological (neuralgia) and those which we do not (angina, asthma, whooping cough) [6]. Liveing’s work draws analogies between all these conditions, and also normal actions such as sneezing, yawning, hiccupping. In 1877 Hughlings Jackson specifically refers to the visual and sensory accompaniments of migraine as ‘epilepsies in the sense that there are ‘discharging lesions’ of some part of the cerebral cortex’ [7].

| Sign up to the ACNR email newsletter here |

In the first edition of the Manual Gowers discusses 12 cases in which migraine and epilepsy co-existed: ‘the connection of these diseases is of special interest because the sensory disturbance of the two has so many common features… it is intelligible that the two should occur in the same subject, and that intermediate forms of nerve disturbance should be met with’. By the 2nd edition he was more circumspect: ‘In epilepsy, as we have seen, we must assume a disturbance of function, in some cases so similar in character that we cannot doubt the identity of its seat with migraine. But the process in the two differs in its course, associations, and other features, and these imply an essential difference in its minuter characters.’  In the Bowman Lecture, Gowers contrasts the characteristic visual sensations seen in epilepsy (‘extremely brief… followed by loss of consciousness or convulsion’) from those of migraine (‘deliberate, slow in evolution, occupying more minutes than… seconds… followed… by a headache lasting hours’).

Gowers returned to this topic in The Border-land of Epilepsy, a series of lectures delivered at the National Hospital in 1906, reprinted in the British Medical Journal, and subsequently revised for publication as a monograph the following year [8]. In the version published in the BMJ, he is explicit about the dangers of confusing migraine and epilepsy, though this is toned down somewhat in the published version: ‘It is, indeed, somewhat curious that the most frequent relation of migraine to epilepsy that we have encountered in our survey of facts is as a source of error. The danger of this is greater than I had anticipated when I began to consider the cases that brought the two maladies together, and to lessen this has become of greater importance.’ He concluded that the ‘actual evidence’ of a link between migraine and epilepsy is ‘very slight’: ‘in each malady a state of nervous tension seems slowly to develop, which is at last relieved by a violent functional disturbance… this disturbance differs so much in character that we should, perhaps, not be surprised to find that there is so little evidence of a direct relation between them’.

Conclusions

Gowers was a hugely influential figure in late 19th century British neurology, but it was by no means inevitable that he would influence thought and practice in migraine. It is clear, however, that he did exert an important influence in several areas: the idea that migraine was a separate neurological entity, distinct from other forms of neuralgia or neurosis; the concept of migraine as a disorder comprising of a headache with accompaniments, specifically the sensory disturbances covered in his published writings; the promotion of the work of Edward Liveing and Hubert Airy (we understand their importance in the history of migraine through Gowers); and the uncoupling of the link between migraine and epilepsy, though a lifetime of careful observation and record of patients’ accounts of subjective sensations.

References

  1. Scott A, Eadie MJ & Lees AJ. William Richard Gowers 1845-1915: Exploring the Victorian Brain. Oxford: Oxford University Press, 2012. https://doi.org/10.1093/med/9780199692316.001.0001
  2. Liveing E. On megrim, sick-headache, and some allied disorders. A contribution to the pathology of nerve-storms. London: J & A Churchill, 1873.
  3. Airy H. On a Distinct Form of Transient Hemiopsia. Phil Trans R Soc Lond. 1870;160:247-64. https://doi.org/10.1098/rspl.1869.0051
  4. Caspar S. The neurologists. A history of a medical specialty in modern Britain. Manchester: Manchester University Press, 2016. https://doi.org/10.7765/9781526112590
  5. Gowers WR. The Bowman Lecture on Subjective Visual Sensations. Lancet. 1895;145:1564-66. https://doi.org/10.1016/S0140-6736(01)90825-6
  6. Lardeau E. The difference between epileptic auras and migrainous auras in the 19th century. Cephalalgia 2007;27:1378-85. https://doi.org/10.1111/j.1468-2982.2007.01447.x
  7. Hughlings Jackson J. An address on ophthalmology in relation to general medicine. Br Med J. 1877;i:703-05.
    https://doi.org/10.1136/bmj.1.858.703
  8. Gowers WR. The Border-land of Epilepsy. Br Med J. 1906;ii:1617-22. https://doi.org/10.1136/bmj.2.2397.1617