The Bradshaw Lecture
Authors: E. L. Fox
Journal: BMJ (1882)

study of hemicrania show definite abnormality of the sympathetic?The peculiarity of pain referred to only one side of associated with very opposite vascular conditions.i. or spastic hemicrania, the prevailing phenomenon the muscular coat of the arteries on the affected side of head, the region supplied from the cervical portion of the sympathetic nerve.That this is the condition of the vessels is shown by the temporal artery, the pale and sunken face,* the small eye, diminished temperature.The pupil is dilated during the height the attack from increase in the tonic excitation of the dilator fibres, which arise from the cilio-spinal centre, and follow the course sympathetic.The extreme action of these fibres overcomes abnormally the contracting power on the iris of the oculo-motor nerve.subsequent contraction depends on a secondary diminution in in- nervation, akin to fatigue, corresponding to the condition of the vaso- fibres.Thus too, towards the end of the attack, the ear be- warm, and the conjunctiva, from relaxation of its vessels fol'lowing the tonic spasm, becomes injected.Increase of saliva, with a tenacity of this secretion, is met Nvith in this form.Eulenberg Guttmann consider that the pain is caused by tonic spasm of the unstriped muscles of the vessels (as in cramp and colic); that is, from pressure nerves of sensation distributed within the muscular tissue.not quite certain which branches of the fifth nerve are affected by pain.Some localise the pain in the frontal branches, but it is probable that the branches implicated are those which supply mater, coming from all three divisions of the fifth nerve.other form, hemicrania neuro-or angio-paralytica, is charac- terised by relaxation of vessels, arterial hyperomia, and increase of temperature on the affected side.The state of this side of the head is not unlike that of an animal, in which the cervical sympabeen cut.But the explanation of the pain in this variety is straightforward.It is said to be due to irritation or compression nerve-elements by the temporary increase of the blood-pressure, greater quantity of blood in the small arteries and veins.But pain not usually felt from congestion, at least pain of the acute in- tensity hemicrania.And although in the later stages of the spastic form, the vascular spasm gives place to dilatation, the paretic congestiveness does not perhaps equal the marked hyperoemia of hemi- angio-paralytica, yet it is remarkable that in these latter stages spastic form the pain diminishes pari 5assu with the spasm, whilst, fact, the vessels are getting more or less into the same con- that is said to cause the pain in the paralytic form.The symptoms, however,of each form of this affection, especially the oculo-pupillary phenomena, point to the cervical sympathetic, or to the corresponding cilio-spinal region of the cord as the part specially impli- the success of caffeine, quinine, guarana, an(l ergot in the paralytic variety, and of nitrite of amyl, carbonic acid inhalation, hot drinks, etc., in the spastic, points to the same conclusion.frequent occurrence of nausea, vomiting, muscce, tinnitus, and taste, all points directly or indirectly associated with the sympathetic; and not only is tenderness met with on pressure over the last and fourth dorsal vertebra, but deep pressure over the cervical ganglia excites pain.Dr. Latham's dictum is good for the spastic form, that the disease is characterised by a morbid activity of the sympathetic nerve, in consequence of a defective control or inhibition by exhausted or enfeebled cerebro-spinal system.In hemicrania alternans, where the patient is affected sometimes by one form, some- times by the otlher, the law of paretic fatigue following inordinate action -~~~~~~~~~~~~~~~~~~~~~~~~~9