Acknowledgments
For permission to consult, and quote from, manuscripts of poems, letters, and other materials we wish to thank Sir John Murray and the following institutions: Armstrong Browning Library, Baylor University, Waco, TX; Balliol College, Oxford; the British Library; Huntington Library, San Marino, CA; Morgan Library, New York; National Library of Scotland (Smith, Elder archive); New York Public Library (Henry W. and Albert A. Berg Collection); Yale University Library, New Haven, CN (Beinecke Library).
We owe a particular debt of gratitude to the Armstrong Browning Library: Jennifer Borderud, the current Director, together with her predecessors, and specialist curators and members of staff, have helped us unfailingly. We are also grateful to the staff of the Department of Rare Books and Manuscripts at the British Library, where the manuscript of The Ring and the Book is housed, and of the library of Balliol College, Oxford, which holds the ‘old yellow book’ from which the poem sprang. We are very grateful to Professor Judith Hawley, of Royal Holloway University of London, and Professor Henry Woudhuysen, Rector of Lincoln College Oxford, for checking variants in copies of the first edition of the poem in the British Library and Oxford (Bodleian Library, Balliol College, and Wadham College) when the editors were unable to do so themselves.
For generous institutional support, including research leave and financial assistance with research trips and materials, we thank De Montfort University and the University of Bristol. Joseph Phelan was A. Bartlett Giamatti Fellow at the Beinecke Library, Yale, in 2014. John Woolford and Joseph Phelan benefited from Visting Fellowships at the Armstrong Browning Library in 2015. The British Academy’s Small Research Grant funded research trips to the British Library and the National Library of Scotland, and enabled the editors to make use of the considerable expertise of Dr David Money, classical scholar and philologist and Research Associate at Wolfson College, Cambridge, who undertook to review the translations of the law-Latin found in the ‘old yellow book’, and Browning’s own translations in the poem. His help was invaluable; any errors or omissions are our responsibility. The same goes for the many insights into Roman Catholic history, scripture and liturgy of the period given to us by the art historian and literary scholar Bruce Redford, and by the music scholar Dennis Crowley, formerly of Groton School, MA.
The published volumes of The Brownings’ Correspondence, edited by Philip Kelley and others over many years, continue to be an indispensable resource; we remain deeply grateful to the editor-in-chief, Philip Kelley, who has given us access to many unpublished letters and documents, and has shared his encyclopaedic knowledge of the Brownings’ biographical and historical context. Michael Meredith’s archival research marked a watershed in the scholarly history of The Ring and the Book, and we are greatly in his debt, even where we have taken issue with some of his conclusions. We likewise acknowledge the work of previous and current editors of The Ring and the Book, making special mention of Richard Altick’s edition of the poem (originally published in the Penguin Poetry Library series, 1971) and the Oxford English Texts edition, edited by Stefan Hawlin and Tim Burnett. The disagreements we occasionally note are more than matched by the many instances in which we have benefited from their work.
Over the course of a decade we have consulted (not to say importuned) many colleagues, friends, and family members for advice on particular aspects of the poem—from the broadest outlines of its historical canvas to the smallest details of punctuation and syntax. We cannot thank them all individually, but we are conscious that without their knowledge and encouragement this edition would be considerably poorer.
Illustrations
Frontispiece. The Franceschini coat of arms, a drawing made for Browning by Seymour Kirkup in Arezzo in July 1868, and pasted on the inside cover of the ‘old yellow book’. Reproduced by kind permission of the Master and Fellows of Balliol College. v
Plate 4. Page [xli] of the ‘old yellow book’: the opening of Pamphlet 3, written by Arcangeli. Reproduced by kind permission of the Master and Fellows of Balliol College.
Plate 5. Page [xcvii] of the ‘old yellow book’ (Pamphlet 7): extract from the alleged love letters exchanged between Pompilia and Caponsacchi. Reproduced by kind permission of the Master and Fellows of Balliol College.
Plate 6. Page [cclix] of the ‘old yellow book’: the ‘Instrument of Final Judgment’, dated 9 September 1698, attesting Pompilia’s innocence. Reproduced by kind permission of the Master and Fellows of Balliol College.
Abbreviations and references
B. Robert Browning EBB. Elizabeth Barrett Browning corr. corrected cp. compare edn. edition
l.c., u.c. lower case, upper case publ. published repr. reprinted rev. revision or revised transl. translated (by)
For books, the place of publication is London unless otherwise indicated.
I. Editions of The Ring and the Book
In our annotation we refer to the poem as Ring MS (in italic) refers to the manuscript of the poem; MS (roman) to any other manuscript (e.g. ‘the MS of this poem is in EBB.’s hand’).
(a) Editions publ. in B.’s lifetime
1868–9
The Ring and the Book, 4 vols. (Smith, Elder, 1868–9); the first British edition.
1st Am. The Ring and the Book, 2 vols. (Boston: Fields, Osgood, 1869); the first American edition.
1872 The Ring and the Book, 4 vols. (Smith, Elder, 1872); the second British edition, though vols. 3 and 4 were not revised until 1882–3; see headnote, p. 3.
1888 The Poetical Works of Robert Browning, 16 vols. (Smith, Elder, 1888–9); Ring occupies vols. viii, ix, and x.
1889 The Poetical Works of Robert Browning, 16 vols. (Smith, Elder, 1889); re-issue of 1888; vols. i–x contain some authorial variants.
Florentine
Ohio
(b) Editions publ. after B.’s death
The Complete Works of Robert Browning, ed. Charlotte Porter and Helen A. Clarke, 12 vols. (New York: Thomas Y. Crowell, 1898); Ring occupies vols. vi–vii.
The Complete Works of Robert Browning, 17 vols. (Athens, OH: Ohio University Press, and Waco, TX: Baylor University, 1969–1985); Ring (ed. Roma A. King, Jr.) occupies vols. vii–ix.
Oxford
Altick
The Poetical Works of Robert Browning (Oxford: Oxford University Press, 1983- [Oxford English Texts]); Ring (ed. Stefan Hawlin and Tim Burnett) occupies vols. vii–ix.
The Ring and the Book, ed. Richard D. Altick (Harmondsworth: Penguin Books, 1971 [Penguin English Poets]).
II. Browning’s works other than The
Ring and the
Book
Titles are in italic for long poems published as a single volume (Paracelsus, Sordello), and in quotation marks for shorter poems (‘De Gustibus’, ‘A Likeness’). References to poems in the headnote and notes are either complete (e.g. ‘Mesmerism’, ‘Confessions’) or use the first word or phrase of the title, omitting the definite article and apostrophes (e.g. ‘Andrea’ for ‘Andrea del Sarto’, Balaustion for Balaustion’s Adventure).
Where a poem has been published in a previous volume of our edition, its location is given by volume and page number following the line reference. For example:
See ‘Bishop Blougram’ 126 (III 167) and Balaustion 138 (IV 343).
The following short titles are used for volumes of shorter works included in vols. I–IV:
B & P Bells and Pomegranates [series title: see Appendix B, II 470]
CE & ED Christmas-Eve and Easter-Day (1850)
DL Dramatic Lyrics (1842)
DP Dramatis Personae (1864)
DR & L Dramatic Romances and Lyrics (1845)
M & W Men and Women, 2 vols. (Chapman and Hall, 1855)
Poems not published in vols. I–IV (which cover Browning’s poems to 1871) are referred to by title and date of publication, followed by line references to the first edition text. Longer poems published after 1871 are referred to by short title (in italic) and date, as in the following list. In the case of shorter poems, the date of publication provides the key to the volume in which the poem was published, as in the following list. One case in particular requires mentioning. B.’s 1887 collection, Parleyings with Certain People of Importance in Their Day, contains a number of poems which are headed ‘With’, the word ‘Parleying’ being understood: ‘With Bernard de Mandeville’, ‘With George Bubb Dodington’, ‘With Christopher Smart’, etc. We omit the preposition in our references to these poems.
Unpublished poems after 1871 are cited from Robert Browning: The Poems, 2 vols., ed. John Pettigrew, supplemented and completed by Thomas J. Collins (Harmondsworth: Penguin Books, 1981 [Penguin English Poets]). We retain the short title Penguin, which was used in previous vols. of our edition, for this edition, which contains B.’s poems other than Ring.
(a) Longer works after 1871 (all publ. by Smith, Elder)
Fifine at the Fair, 1872
Red Cotton Night-Cap Country, 1873
The Inn Album, 1875
Aristophanes’ Apology, Including a Transcript from Euripides, Being the Last Adventure of Balaustion, 1875
The Agamemnon of Æschylus, 1877
La Saisiaz and The Two Poets of Croisic, 1878 [single volume containing two long poems]
(b) Volumes of shorter poems after 1871 (all publ. by Smith, Elder)
1876 Pacchiarotto and How He Worked in Distemper: With Other Poems
1879
Dramatic Idyls [DI]
1880 Dramatic Idyls, Second Series [DI2]
1883 Ferishtah’s Fancies
1884 Jocoseria
1887 Parleyings with Certain People of Importance in Their Day [etc.]
1889 Asolando: Fancies and Facts
III. Letters (incl. those of Elizabeth Barrett Browning)
American Friends Browning to His American Friends: Letters between the Brownings, the Storys and James Russell Lowell 1841–1890, ed. G. R. Hudson (1965)
Correspondence The Brownings’ Correspondence , ed. P. Kelley, R. Hudson, S. Lewis and E. Hagan (Winfield, KS, 1984–)
Dearest Isa
EBB to Arabella
Florentine Friends
Dearest Isa: Robert Browning’s Letters to Isabella Blagden, ed. E. C. McAleer (Austin, TX and Edinburgh 1951)
The Letters of Elizabeth Barrett Browning to Her Sister Arabella, 2 vols., ed. S. Lewis (Winfield, KS 2002)
Florentine Friends: The Letters of Elizabeth Barrett Browning and Robert Browning to Isa Blagden 1850–1861, ed. P. Kelley and S. Donaldson (Winfield, KS and Waco, TX, 2009)
LH Letters of Robert Browning collected by Thomas J. Wise, ed. T. L. Hood (1933)
Learned Lady Learned Lady: Letters from Robert Browning to Mrs Thomas Fitzgerald 1876–1889, ed. E. C. McAleer (Cambridge, MA 1966)
Letters of EBB
New Letters
RB & JW
Trumpeter
The Letters of Elizabeth Barrett Browning, ed. F. G. Kenyon, 2 vols. (1897)
New Letters of Robert Browning, ed. W. C. DeVane and K. L. Knickerbocker (1951)
Robert Browning and Julia Wedgwood: A Broken Friendship as Revealed in Their Letters , ed. R. Curle (1937); text corr. from Sue Brown, ‘Robert Browning and Julia Wedgwood: the Unpublished Correspondence’, Journal of Browning Studies iii (2012) 29–52
Browning’s Trumpeter: The Correspondence of Robert Browning and Frederick J. Furnivall 1872–1889, ed. W. S. Peterson (Washington, DC 1979)
ABL
IV. General
Armstrong Browning Library (Baylor University, Waco, Texas)
Allingham William Allingham’s Diary, ed. G. Grigson (1967)
Berg Henry W. and Albert A. Berg Collection, New York Public Library
Bibliography L. N. Broughton, C. S. Northrup, and R. B. Pearsall, Robert Browning: A Bibliography 1830–1950 (Ithaca, NY, 1953) [Cornell Studies in English xxxix]
BL
Casanatense
Collections
Cook
Corrigan
Fantozzi
Farulli
Gest
Griffin and Minchin
British Library
Pamphlet on the Franceschini trial, in volume titled Varii successi curiosi e degni di esser considerate [Various curious events worthy of being considered], Misc. Ms. 2037, Royal Casanatense Library, Rome
P. Kelley and B. A. Coley, The Browning Collections: A Reconstruction with Other Memorabilia (Winfield, KS, 1984); online edn. www.browningguide.org/collections
A. K. Cook, A Commentary upon Browning’s The Ring and the Book (Oxford, 1920)
Curious Annals: New Documents Relating to Browning’s Roman Murder Story, transl. and ed. Beatrice Corrigan (Toronto, 1956)
Federigo Fantozzi, Nuova Guida ovvero Descrizione Storico-Artistico-Critica della Città e Contorni di Firenze (Firenze, 1843)
Abate Pietro Farulli, Annali overo Notizie Istoriche della Città di Arezzo in Toscana [Annals or Historical Reports on the city of Arezzo in Tuscany] (Foligno, 1717)
John Marshall Gest, The Old Yellow Book, Source of Browning’s The Ring and the Book: a New Translation with Explanatory Notes and Critical Chapters upon the Poem and its Source (Philadelphia, 1927)
W. H. Griffin and H. C. Minchin, The Life of Robert Browning, 3rd ed. (1938)
Huntington The Huntington Library, Pasadena, CA
J. Samuel Johnson, A Dictionary of the English Language, 1st edn. (1755)
Lemprière
J. Lemprière, A Classical Dictionary, 12th edn. (1823)
LION Literature Online (ProQuest database)
Morgan Morgan Library, New York (formerly the Pierpont Morgan Library)
ODP
OED
Oxford Dictionary of Proverbs (online edn.)
Oxford English Dictionary (online edn.)
Orr Handbook Mrs [Alexandra Sutherland] Orr, A Handbook to the Works of Robert Browning, 7th ed. (1896)
Orr Life
Mrs [Alexandra Sutherland] Orr, Life and Letters of Robert Browning (1891; repr. with revs., 1908)
OYB Charles W. Hodell, The Old Yellow Book, Source of Browning’s The Ring and the Book, in Complete PhotoReproduction, with Translation, Essay, and Notes, 2nd edn. (Carnegie Institute of Washington, 1916)
PMLA Publications of the Modern Language Association of America
PL John Milton, Paradise Lost
Secondary Source Morte dell’ Uxoricida Guido Franceschini Decapitato [The Death of the Wife-Murderer Guido Franceschini, by Beheading] in Miscellanies of the Philobiblon Society xii (1868–9); repr. in this edn., Appendix B.
Story William Wetmore Story, Roba di Roma, 3rd edn. (1864)
Thomas Charles Flint Thomas, Art and Architecture in the Poetry of Robert Browning (Troy, NY, 1991)
Treves Sir Frederick Treves, The Country of “The Ring and the Book” (1913)
The Bible is cited from the King James or Authorized Version (1611), in modern spelling. Names of books in the New Testament are given in the standard abbreviated forms, e.g. Matthew = The Gospel according to Saint Matthew, 1 Corinthians = The First Epistle of Paul the Apostle to the Corinthians, 1 Peter = The First Epistle General of Peter, etc.
Greek and Roman works are cited, with a few exceptions, from the current Loeb Classical Library editions, publ. by Harvard University Press; online texts have been used where available. The exceptions concern instances where B.’s phrasing has clearly been influenced by an older translation (e.g. Pope’s Homer).
Shakespeare’s plays and poems are cited from the Riverside Edition, 2nd ed., ed. G. Blakemore Evans et al. (New York 1997).
Paradise Lost is cited from the Longman Annotated English Poets edition, 2nd edn., ed. Alastair Fowler (Harlow, 1998).
EBB.’s poems are cited from The Works of Elizabeth Barrett Browning, ed. Sandra Donaldon et al., 5 vols. (Pickering & Chatto, 2010)
POMPILIA
Iamjust seventeen years and five months old,
And, if I lived one day more, three full weeks; ’Tis writ so in the church’s register, Lorenzo in Lucina, all my names
5 At length, so many names for one poor child, —Francesca Camilla Vittoria Angela
Pompilia Comparini,—laughable!
Also ’tis writ that I was married there
Four years ago: and they will add, I hope,
10 When they insert my death, a word or two,—
Omitting all about the mode of death,—
This, in its place, this which one cares to know, That I had been a mother of a son
Exactly two weeks. It will be through grace
Title For B.’s preview see i 1076–1104 (p. 216), and for the historical figure see headnote, p. 108. The setting in ‘the good house that helps the poor to die’ (i 1085), identified by Other Half-Rome as ‘the long white lazar-house . . . Saint Anna’s’ is B.’s invention; Pompilia was cared for, and died, in the family home in Via Vittoria where the murders took place (see iii 35–7n., p. 329, and headnote, p. 128). The date is 6 Jan., the day of Caponsacchi’s speech (see note to bk. vi title, p. 623); Pompilia’s arithmetic in ll. 1–2, counting from the day of her birth, is accurate. At l. 40 she speaks of herself as being ‘to die to-night’ and at l. 84 says that she has ‘a whole day to live out’; the duration of her speech represents this interval of time, assuming that she speaks the last words with her dying breath.
vii 1–7. Based on the certified copy of Pompilia’s ‘baptismal record’ in the register of S. Lorenzo in Lucina, the parish church of the Comparini family (see headnote, p. 108, and ii 6–14n., p. 235).
vii 8–9. Also ’tis writ that I was married there / Four years ago: on the date of Pompilia’s marriage, see headnote, p. 109.
vii 9–14. and they will add . . . Exactly two weeks: the record of Pompilia’s death in the church register, to which B. did not have access, is reproduced in Treves (p. 300); it is dated 7 Jan. 1698, and mentions neither her ‘mode of death’ nor the fact that she had a son.
vii 13–14. That I had been a mother of a son / Exactly two weeks: B.’s chronology dates the birth of Pompilia’s son to 18 Dec. 1697; this date is given by Bottini
15
O’ the Curate, not through any claim I have; Because the boy was born at, so baptized Close to, the Villa, in the proper church:
A pretty church, I say no word against, Yet stranger-like,—while this Lorenzo seems
20 My own particular place, I always say.
I used to wonder, when I stood scarce high As the bed here, what the marble lion meant, With half his body rushing from the wall, Eating the figure of a prostrate man—
25 (To the right, it is, of entry by the door)
An ominous sign to one baptized like me, Married, and to be buried there, I hope.
And they should add, to have my life complete, He is a boy and Gaetan by name—
30 Gaetano, for a reason,—if the friar Don Celestine will ask this grace for me
(OYB 151). ‘Exactly’ is therefore not right, since two weeks from 18 December would mean that Pompilia was speaking on 2 Jan.; this mistake may, however, be deliberate on B.’s part, since that was the day of the murders.
vii 15. O’ the Curate] Of the Curate (MS). In bks. i–vi MS almost always has ‘of the’ and ‘in the’, revised to ‘o’ the’ and ‘i’ the’ in 1868–9; from this point on (with the partial exception of bk. x) ‘o’ the’ and ‘i’ the’ are already present in MS.
vii 16–20. For the ‘Villa’ (l. 17), see i 604–5n.; the nearby church is unidentified (for obvious reasons, since the location itself is fictitious). No record of the child’s baptism has been found in the register of S. Lorenzo or that of six adjoining parishes (Treves, pp. 125, 300).
vii 18.] added in MS, beginning ‘Pretty and what’.
vii 21–7. There is a ‘marble lion’ (l. 22) on either side of the portico of S. Lorenzo in Lucina; both lions appear to be ‘rushing from the wall’ (l. 23), and the one on the right (as you look out from the church) has something between its paws, though it is difficult to be sure what this is meant to be. It is possible that these lines draw on the information B. obtained from Frederic Leighton; see ii 6–14n. (p. 235).
vii 26. and to be buried] and even buried (MS 1st reading).
vii 28. they: i.e. the people entering Pompilia’s death into the church records.
vii 29–30. Gaetan . . . Gaetano: see ll. 100–7n. Both forms of the name are pronounced as three syllables (i.e. ‘Gae’ counts as two syllables in ‘Gaetan’ but only one in ‘Gaetano’).
vii 31. Don Celestine: see iii 18n. (p. 328).
35
Of Curate Ottoboni: he it was Baptized me: he remembers my whole life As I do his grey hair.
All these few things I know are true,—will you remember them? Because time flies. The surgeon cared for me, To count my wounds,—twenty-two dagger-wounds, Five deadly, but I do not suffer much—
40 Or too much pain,—and am to die to-night.
Oh how good God is that my babe was born, —Better than born, baptized and hid away Before this happened, safe from being hurt! That had been sin God could not well forgive:
45 He was too young to smile and save himself. When they took, two days after he was born, My babe away from me to be baptized And hidden awhile, for fear his foe should find,— The country-woman, used to nursing babes,
50 Said “Why take on so? where is the great loss? These next three weeks he will but sleep and feed,
vii 32–4. Curate Ottoboni . . . his grey hair: the copy of Pompilia’s baptismal record was made by Pietro Ottoboni, but the baptism itself was carried out by Bartolomeo Mini; see ll. 1–7n.
vii 38. twenty-two dagger wounds: a detail taken from Secondary Source (Appendix B, p. 1358, §11).
vii 42–5. Cp. v 1478–9n. (p. 597).
vii 49. The pro-Guido Pamphlet 10 states that the child was ‘intrusted secretly to a nurse’ (i.e. a wet-nurse, It. balia) (OYB 122); such women were often recruited by city-dwellers from the surrounding countryside, where the air was thought to be healthier. Cp. B. to Arabella Barrett, 13 Mar. 1849, following the birth of Pen: ‘We have got a famous wet nurse, from the country’ (Correspondence xv 241). The nurse in question is identified by the editors as Tecla Celavini; ‘Tecla’ is used as a specimen name for a gossiping servant by Guido (v 63–4) and as the name of one of Pompilia’s friends (l. 480). In her letter of 8–16 Apr., EBB. added that ‘she has had two children, & been out as nurse before, & so she doesn’t hold the baby as if she were drawing a sword’ (ibid. 251). For another quotation from this letter relating to Bottinius’s evocation of a ‘young and comely peasant-nurse’, see ix 49–53n. (p. 927).
Only begin to smile at the month’s end; He would not know you, if you kept him here, Sooner than that; so, spend three merry weeks
55 Snug in the Villa, getting strong and stout, And then I bring him back to be your own, And both of you may steal to—we know where!” The month—there wants of it two weeks this day! Still, I half fancied when I heard the knock
60 At the Villa in the dusk, it might prove she— Come to say “Since he smiles before the time, Why should I cheat you out of one good hour? Back I have brought him; speak to him and judge!” Now I shall never see him; what is worse,
65 When he grows up and gets to be my age, He will seem hardly more than a great boy; And if he asks “What was my mother like?”
People may answer “Like girls of seventeen”— And how can he but think of this and that,
70 Lucias, Marias, Sofias, who titter or blush When he regards them as such boys may do? Therefore I wish some one will please to say I looked already old though I was young; Do I not . . say, if you are by to speak . .
75 Look nearer twenty? No more like, at least, Girls who look arch or redden when boys laugh, Than the poor Virgin that I used to know At our street-corner in a lonely niche,— The babe, that sat upon her knees, broke off,—
vii 57. The implication is that the Comparini are planning to move to a third location, neither the house in Via Vittoria nor the ‘Pauline’ villa; Pietro alludes to this ‘other villa’ as lying ‘outside the city-gate’ (see ll. 235, 238). It is wholly B.’s invention.
vii 58. Pompilia claims that Gaetano was baptised on 20 Dec. 1697 (see l. 46); as she is speaking on 6 Jan. 1698, it still ‘wants’ two weeks to the 20th, exactly one month after the event.
vii 67. “What was my mother like?”] “What was Pompilia like?” (MS 1st reading).
vii 74. say, if you are by to speak: Pompilia is dying and cannot clearly perceive the people around her bed.
vii 79. broke off: ‘broken off’; the whole line is in apposition to ‘the poor Virgin’ in l. 77.
80 Thin white glazed clay, you pitied her the more: She, not the gay ones, always got my rose.
How happy those are who know how to write! Such could write what their son should read in time, Had they a whole day to live out like me.
85 Also my name is not a common name, “Pompilia,” and may help to keep apart A little the thing I am from what girls are. But then how far away, how hard to find Will anything about me have become,
90 Even if the boy bethink himself and ask! No father that he ever knew at all, Nor ever had—no, never had, I say! That is the truth,—nor any mother left, Out of the little two weeks that she lived,
95 Fit for such memory as might assist: As good too as no family, no name, Not even poor old Pietro’s name, nor hers, Poor kind unwise Violante, since it seems They must not be my parents any more.
100 That is why something put it in my head To call the boy “Gaetano”—no old name For sorrow’s sake; I looked up to the sky And took a new saint to begin anew. One who has only been made saint—how long?
vii 85–7. See headnote, p. 109.
vii 91–2. Towards the end of her monologue, Pompilia repeats her insistence that Guido is not Gaetano’s father, though she does not mean by this that Caponsacchi is: see ll. 1762–4.
vii 92. I say!] I say— (MS).
vii 98. Poor kind unwise] Kind unwise (MS 1st reading); the same addition was made at l. 286.
vii 100–7. Gaetano dei Conti di Thiene (1480–1547), also known as St. Cajetan, a religious reformer within the Catholic Church; he co-founded the Order of the Theatines, which combined the spiritual discipline of monastic life with good works; he was canonised by Pope Clement X in 1671. Pompilia, ‘wander[ing] in her mind’ during the flight to Rome with Caponsacchi, utters the name, which he does not realise is a premonition of her pregnancy (vi 1388–9, p. 691). B. wrote to
105 Twenty-five years: so, carefuller, perhaps, To guard a namesake than those old saints grow, Tired out by this time,—see my own five saints!
On second thoughts, I hope he will regard The history of me as what someone dreamed,
110 And get to disbelieve it at the last: Since to myself it dwindles fast to that, Sheer dreaming and impossibility,— Just in four days too! All the seventeen years, Not once did a suspicion visit me
115 How very different a lot is mine From any other woman’s in the world. The reason must be, ’twas by step and step It got to grow so terrible and strange: These strange woes stole on tiptoe, as it were,
120 Into my neighbourhood and privacy, Sat down where I sat, laid them where I lay; And I was found familiarised with fear, When friends broke in, held up a torch and cried “Why, you Pompilia in the cavern thus,
125 How comes that arm of yours about a wolf? And the soft length,—lies in and out your feet And laps you round the knee,—a snake it is!”
his friend W. C. Cartwright on 17 May 1867: ‘Ask any instructed person, why a mother in want of a name for her child would be led to call him “Gaetano”—what virtues are there in that saint’s patronage?’ (ABL MS). Cartwright’s answer is not extant; it would not have helped B. much to learn that Gaetano is the patron saint of bankers, gamblers, and the unemployed.
vii 107. five saints!] four saints! (MS). As Charles LaPorte observes, ‘There exists no “St. Pompilia” in the Catholic canon, as Browning surely knew when he revised the poem’s manuscript’; he suggests that the list ‘may retrospectively be considered to include herself’ (Victorian Poets and the Changing Bible [Charlottesville and London, 2011] 171).
vii 110. at the last] all at last (MS).
vii 121. Sat down where I sat: a possible reminiscence of Ezekiel iii 15: ‘Then I came to them of the captivity at Tel-abib, that dwelt by the river of Chebar, and I sat where they sat, and remained there astonished among them seven days’.
And so on.
Well, and they are right enough,
130 By the torch they hold up now: for first, observe, I never had a father,—no, nor yet A mother: my own boy can say at least “I had a mother whom I kept two weeks!”
Not I, who little used to doubt . . I doubt
135 Good Pietro, kind Violante, gave me birth?
They loved me always as I love my babe (—Nearly so, that is—quite so could not be—) Did for me all I meant to do for him, Till one surprising day, three years ago,
140 They both declared, at Rome, before some judge In some court where the people flocked to hear, That really I had never been their child, Was a mere castaway, the careless crime Of an unknown man, the crime and care too much
145 Of a woman known too well,—little to these, Therefore, of whom I was the flesh and blood: What then to Pietro and Violante, both No more my relatives than you or you?
Nothing to them! You know what they declared.
150 So with my husband,—just such a surprise, Such a mistake, in that relationship!
Everyone says that husbands love their wives, Guard them and guide them, give them happiness; ’Tis duty, law, pleasure, religion: well,
155 You see how much of this comes true in mine! People indeed would fain have somehow proved He was no husband: but he did not hear,
vii 146–8.] added in MS.
vii 149. to them! You know] to them,—you know (MS). You know what they declared: according to Arcangeli, Pietro and Violante ‘did not blush to declare that Francesca [Pompilia] had been conceived illegitimately, and had been born of a harlot’ (OYB 99).
vii 156–7. somehow proved / He was no husband: see ii 1287–93n. (p. 310).
Or would not wait, and so has killed us all. Then there is . . only let me name one more!
160 There is the friend,—men will not ask about, But tell untruths of, and give nicknames to, And think my lover, most surprise of all! Do only hear, it is the priest they mean, Giuseppe Caponsacchi: a priest—love,
165 And love me! Well, yet people think he did. I am married, he has taken priestly vows, They know that, and yet go on, say, the same, “Yes, how he loves you!” “That was love”—they say, When anything is answered that they ask:
170 Or else “No wonder you love him”—they say. Then they shake heads, pity much, scarcely blame— As if we neither of us lacked excuse, And anyhow are punished to the full, And downright love atones for everything!
175 Nay, I heard read-out in the public court Before the judge, in presence of my friends, Letters ’twas said the priest had sent to me, And other letters sent him by myself, We being lovers!
180 Listen what this is like! When I was a mere child, my mother . . that’s Violante, you must let me call her so Nor waste time, trying to unlearn the word, . . . She brought a neighbour’s child of my own age
185 To play with me of rainy afternoons; And, since there hung a tapestry on the wall, We two agreed to find each other out Among the figures. “Tisbe, that is you, With half-moon on your hair-knot, spear in hand,
vii 181, 183. The inconsistency between the two-point ellipsis in l. 181, and the three-point ellipsis in l. 183, is present in MS.
vii 188. Tisbe: Italian form of Thisbe, best known from the Greek legend of Pyramus and Thisbe; B. had used it before in Soul's Tragedy i 366 (II 196). vii 188–96. The tapestry remembered by Pompilia depicts the goddess Diana and the nymph Daphne, figures from classical mythology associated with virginity;
190 Flying, but no wings, only the great scarf Blown to a bluish rainbow at your back: Call off your hound and leave the stag alone!”
“—And there are you, Pompilia, such green leaves Flourishing out of your five finger-ends,
195 And all the rest of you so brown and rough: Why is it you are turned a sort of tree?”
You know the figures never were ourselves Though we nicknamed them so. Thus, all my life,— As well what was, as what, like this, was not,—
200 Looks old, fantastic and impossible: I touch a fairy thing that fades and fades.
—Even to my babe! I thought, when he was born, Something began for once that would not end, Nor change into a laugh at me, but stay
205 For evermore, eternally quite mine.
Well, so he is,—but yet they bore him off, The third day, lest my husband should lay traps And catch him, and by means of him catch me. Since they have saved him so, it was well done:
210 Yet thence comes such confusion of what was With what will be,—that late seems long ago, And, what years should bring round, already come, Till even he withdraws into a dream
As the rest do: I fancy him grown great, 215 Strong, stern, a tall young man who tutors me,
Tisbe becomes Diana the huntress, whose dogs hunt down Actaeon whom she has transformed into a stag, after he sees her bathing naked (Ovid, Metamorphoses iii 138–252); Pompilia is seen as Daphne, daughter of the river-god Peneus, who was transformed by him into a laurel in order to escape the lustful attentions of Apollo (ibid. i 453–567). As moon-goddess Diana is often depicted with a crescent or half-moon above her head, and as huntress holds a spear or bow, accompanied by hounds; the motif of the drapery blown behind her is also common, most famously in Titian's Diana and Actaeon (National Gallery). Thomas (p. 314) suggests Gerard Hoet's Apollo and Daphne (1700) as a source for the image of Daphne; it is in the Dulwich Gallery, which B. knew well. He would also have known Bernini's sculpture (1622-5), now in the Galleria Borghese in Rome. vii 201.] added in MS. fades and fades] fades at once (MS 1st reading).
vii 214. grown great] grown tall (MS 1st reading).
Another random document with no related content on Scribd:
even two or three months. I have seen a number of patients who have attacks of migraine on Sunday with regularity, and escape during the interval. Some of these cases ascribed the attacks to sleeping later on this day than on others, but it is more likely that the attacks were the result of the culminating effect of a week's hard work. Between the attacks the patient is usually quite well as far as headache is concerned, but he may have slight neuralgia in branches of the trigeminal. The attacks are more or less alike. They are often preceded by prodromal symptoms for a day or two. The patient may feel languid or tired for a day before the attack. Sometimes there is unusual hunger the night before a paroxysm, or there may be violent gastralgia before each attack. The patient often wakes in the morning after sound sleep with a pain in the head. Should the attack come on in the day, it may be preceded by chilliness, yawning, or sneezing and a sense of general malaise. Ocular symptoms are frequent as a forerunner of an attack. First muscæ volitantes are seen, then balls of fire or bright zigzags appear before the eyes, making it impossible for the patient to read. These symptoms last for a few minutes or a half hour, and then cease, to be immediately followed by pain. Hemianopsia is a precursory symptom of rather frequent occurrence. Ross mentions a case in which the hemianopsia usually lasted about a half hour, and was followed by severe hemicrania. The ocular symptoms are often very alarming to patients.
The pain, as a general rule, is at first in the ophthalmic division of the fifth nerve and its branches. It may begin in the branches of the occipital nerve or in the parietal region. It comes on gradually, is dull and boring at first, but becomes more intense and spreads to one lateral half of the head, more especially the front part. As it increases in intensity the pain seems to involve the entire head. Either side of the head may be affected. Eulenburg thinks that the left side is attacked twice as often as the right. An individual may have the pain on opposite sides of the head alternately in different attacks. The pain is described by patients as dull and boring or intense, and the head feeling as if it would burst. Patients often make pressure on the head to obtain relief. At times the pain seems to be of a violent,
throbbing kind, keeping time, as it were, with the pulsation of the arteries. Lying down usually relieves the pain, but if it is violent the recumbent position seems to favor the afflux of blood to the head, and thereby increases the pain. The eye of the affected side becomes bloodshot, and the tears stream from it. The eyelid droops, and the sight is dim and clouded or may fail entirely. The least light is unbearable. During the attack the subject is chilly and intensely depressed, and the feet are very cold. The pulse is at first slow, small, and compressible.
Painful points (Valleix's points) are not present, but there is usually tenderness over the supraorbital notch during an attack of migraine, and after the paroxysm there is a general soreness of the scalp and forehead. Sometimes there remains a tenderness of the parts surrounding the affected nerve. This is not in the nerve itself, but in the adjacent tissues. Anstie9 says that in his own case, after repeated attacks of migraine, the bone had become sensibly thickened in the neighborhood of the supraorbital notch. There is sometimes hyperæsthesia of the skin in the affected regions of the forehead and scalp during an attack. As well as hyperæsthesia, there may be an abnormal acuteness of the sense of touch. Deep pressure over the superior and middle ganglia of the sympathetic causes pain, according to Eulenburg. This observer also states that the spinal processes of the lower cervical and upper dorsal vertebræ are painful on pressure.
9 Op. cit., p. 182.
During the attack of migraine there is complete loss of appetite, and any food that may be taken remains undigested in the stomach for hours. As the pain intensifies there comes on a sense of nausea, there is a profuse flow of saliva, and large quantities of limpid urine are passed. Finally, when the pain seems to have reached its maximum, vomiting occurs. Immediately afterward the pain is greatly increased, but this is the result of the increased amount of blood in the cranial cavity from straining. Soon after, the patient is easier, and falls into a sleep, from which he awakes free from headache. The
crisis is not always accompanied by vomiting. In some instances there is no nausea, but at the acme of the pain there are two or three profuse diarrhœic stools, after which the pain is relieved. I have lately seen such a case in a young man of twenty-three years of age. Sometimes there is only a profuse sweat or large flow of urine.
During the attack there are disorders of the circulation. The pulse may be intermittent or irregular, and the extremities are usually cold. Disorders of cutaneous sensibility are also often present. A condition of numbness confined to one lateral half of the body is sometimes experienced during the early part of the paroxysm. This numbness is noticed even in one half of the tongue.
The German writers have divided migraine into two types, and the arrangement may be followed in some instances. The first is called hemicrania spastica or sympathico-tonica. In this form there is supposed to be vascular spasm and a diminished supply of blood in the brain. The symptoms are as follows: When the attack has reached its height the face is pale and sunken; the eye is hollow and the pupil dilated; the arteries are tense and feel like a cord. The external ear and the tip of the nose are cold. Eulenburg10 states that by actual measurement he has found the temperature in the external auditory meatus fall 0.4° to 0.6° C. The pain is increased by stooping, straining, or anything which adds to the blood-supply in the head. At the end of the attack the face becomes flushed and there is a sense of heat. The conjunctiva becomes reddened, the eye is suffused, and the pupil, which had been dilated, contracts. The sense of warmth becomes general, the pulse is quickened, and the heart palpitates. The crisis is reached with vomiting and a copious flow of urine or perhaps a diarrhœic stool. There is sometimes an abundant flow of saliva. One observer has reported that he has estimated a flow of two pounds of saliva during an attack.
10 Op. cit.
The other variety is termed hemicrania angio-paralytica or neuroparalytica. Here we find the opposite condition of things from that met with in hemicrania spastica. There is marked increase in the
amount of blood in the brain. When the attack is at its height the face on the affected side is flushed deeply, hot, and turgid. The conjunctiva is injected, the lachrymal secretion increased, and the pupil contracted. Sometimes there is slight ptosis. The ear on the affected side is hot and red. The temperature of the meatus may rise 0.2° to 0.4° C. The temporal artery is swollen, and throbs with increased force. The carotid beats visibly. There is free perspiration, which is sometimes unilateral. Compression of the carotid on the painful side relieves the pain, while pressing on the opposite carotid makes it worse. The heart beats slowly, the pulse being sometimes as low as 48 to 56. At the end of the attack the face becomes paler and the other symptoms subside.
There are many cases in which the vascular conditions present no peculiarities during the attack, and which cannot be classed with either of the varieties just described.
In all forms, if the patient can be quiet, he usually falls asleep after the crisis has been reached, and awakes free from pain, but feeling haggard and prostrated.
The paroxysm lasts for several hours, generally the greater part of the day. It may last for several days, with variations of severity. The attacks are at longer or shorter intervals of time, and in women they often appear at the menstrual period. The attack may be brought on by over-mental or bodily exertion, imprudence in eating or drinking, and exposure to cold draughts of air. It will often begin as a supraorbital neuralgia from exposure to cold, and go on through all the phenomena of a regular migraine.
Seizures are often brought on by fatigue, and there are some persons who invariably have a violent attack of migraine after a journey. Nursing women are liable to more frequent paroxysms, and I have recently seen a lady who within a few days after delivery after both of her confinements suffered from typical attacks of migraine, although during gestation she had escaped them.
DIAGNOSIS.—Migraine can readily be distinguished from the other forms of headache by the comparative regularity of the attacks and its numerous other characteristics. It differs from neuralgia in the pain being less acute and shooting. The pain of migraine is more dull and throbbing, and extends more generally over the head. The ocular phenomena are more or less constant in migraine and do not occur in neuralgia.
PROGNOSIS.—Migraine is never fatal, and usually becomes less severe and less frequent as middle life is reached. Some patients continue to suffer from it during their entire life, and often when the typical migraine has ceased it is replaced with paroxysms of neuralgia. Therapeutic and hygienic means are of decided influence in the course of the disorder, and many patients experience great relief or temporary immunity from attacks as a result of treatment. Cases of long standing and those of an hereditary type are most unfavorable as to relief from treatment or by spontaneous cure.
PATHOLOGY AND MORBID ANATOMY.—Migraine not being a fatal disease, we know nothing of the changes which exist in the brain; we can only surmise what are the conditions which exist in the brain during and before an attack.
It is evident that there is a strong relationship between migraine and neuralgia of the trigeminal nerve, and if we study the symptoms of the two conditions, and consider the causes which produce attacks of each, we cannot but arrive at the conclusion that migraine is a variety of a neuralgia of the ophthalmic division of the fifth. The late Anstie has most clearly and forcibly given his reasons for believing this to be the case, and we cannot but uphold his view.
Migraine is constantly met with in early life as the type of a neuralgia which in later years loses the special features of a sick headache and becomes a pure neuralgia. The same forms of trophic lesions may occur in migraine and in trigeminal neuralgia. Anstie instances his own case, in which in early life he had distinct attacks of migraine, with corneal ulceration, orbital periostitis, and obstruction
of the nasal duct, while later in life his attacks were only neuralgic, without any stomach complications.
Migraine, as already remarked, attacks early life especially at the time of sexual development, and the same is true of epilepsy. There is also the same hereditary predisposition to the former as to the latter. Patients who have migraine belong often to families other members of which suffer from epilepsy, chorea, and an uncontrollable tendency to alcoholic excesses. Indeed, occasionally migraine and epilepsy are interchangeable in the same individual. Many cases of epilepsy have suffered at some time of their lives from severe headaches.
Hughlings-Jackson describes the attacks of migraine as arising from a discharging lesion of the cortex of the brain in the sensory area, or in that part of it which corresponds to the region of pain in the head. Genuine epilepsy he holds to be due to a discharging lesion from the motor area of the cortex. During an attack of migraine the discharging lesion does not remain confined in the sensory portion of the cortex, but extends into the medulla oblongata and the ciliospinal region of the cord, causing irritation or paralysis of some of these centres, and causing the vaso-motor and oculo-pupillary symptoms which are conspicuous during an attack.
In the form of migraine known as hemicrania sympathico-tonica there is tonic spasm of the vessels of one side of the head. This explains the pallid face, the lowered temperature, and the sunken eyes. After the cause of the contraction is removed, then the vessels relax and the amount of blood-supply greatly increases. Hence the redness of the conjunctiva, lachrymation, and redness of the ear at the close of an attack. The vomiting is explained by Eulenburg as being due to variations in the intracranial blood-pressure. This causes fitful contractions of the vascular muscles, alternating with partial relaxation. These conditions must arise in the sympathetic nerve of the corresponding side.
The dilation of the pupil during an attack depends upon irritation of the cervical sympathetic ganglia. Other symptoms, such as the
largely increased flow of saliva and the flow of tears or drying of the Schneiderian mucous membrane, indicate a morbid condition of the cervical sympathetic. The sensitiveness to pressure in the region of the upper cervical ganglia and over the spinous processes of the lower cervical and upper dorsal vertebræ, corresponding to the ciliospinal region of the cord, confirms the idea of a morbid state of the cervical sympathetic.
In hemicrania angio-paralytica there is supposed to be a relaxed condition of the vessels of one side of the head. Here, instead of an irritation of the sympathetic, there is a paralytic condition, and we have the same results as are seen in animals when the cervical sympathetic is divided. There seem to be good grounds for holding this view when we consider the flushed face, contracted pupil, retraction of the eyeball, and occasional ptosis which accompany this form of headache. Possibly there may be a brief stage of spasm of the vessels preceding the relaxation which occurs in hemicrania angio-paralytica.
The slowing of the pulse during an attack of migraine is due probably to cerebral hyperæmia from relaxation of the vessels, or to the secondary anæmia and irritation of the medulla oblongata. This irritation of the medulla is also able to explain the other symptoms of vaso-motor disturbance which occur during an attack of migraine; for instance, the small and contracted radial artery, the extreme coldness of the hands and feet, and the suppression of perspiration over the whole body except perhaps on the affected side of the head. Following the stage of irritation of the medulla with contraction of the vessels comes one of exhaustion with relaxation of the vessels. This latter state may account for the profuse flow of saliva and the copious secretion of sweat and urine, as well as the increased secretion of bile and the condition of broncho-tracheal catarrh during the attack.
We now come to the question of the origin and seat of the pain in migraine. This question has involved a great deal of thought, and has been answered in various ways by different writers. E. du Bois-
Raymond thought that the pain was due to tonic spasm of the muscular coats of the vessels, and that thereby the nerves in the sheaths of the vessels were pinched, as it were, and so caused pain. Moellendorff was of the opinion that the pain was due to dilatation of the vessels, and not to contraction; and this theory might explain the pain in the angio-paralytic form. There are many cases in which neither of these views is sufficient, for we have no reason to believe that a condition of either anæmia or hyperæmia is present.
Romberg believed that the pain was situated in the brain itself, and Eulenburg holds that the pain must be caused by alterations in the blood-supply, without regard to their origin, in the vessels of one side of the head. He thinks that the vessels may contract and dilate with suddenness, just as is often seen in some neuralgias, and thus intensely excite the nerves of sensation which accompany the vessels. The increase of pain upon stooping, straining, or coughing, and the influence upon it by compression of the carotids, seem to give force to this view. But are we not here confusing cause with effect? Are not these variations in the calibre of the vessels due to the irritation of the sensory and vaso-motor nerves, which are in a state of pain? No doubt increase in the blood-supply augments the pain, just as it does in an inflamed part when more blood goes to the part. Let a finger with felon hang down, or let a gouty foot rest upon the floor, what an intensity of pain follows!
Anstie very ably advocated the theory of migraine being a variety of trigeminal neuralgia in the ophthalmic division; and we incline strongly to his view. An attack of migraine often begins with pain distinctly located in the supraorbital nerve as the result of exposure to cold. Frequently it begins in the infraorbital nerve or in the branches of the inferior maxillary division of the fifth. The pain then spreads over one side of the head, both outside and inside, and goes through the recognized symptoms of migraine. In my own case I have often had an attack begin with sharp pain in the supraorbital notch in a spot which could be covered by the tip of the finger. The nerve has seemed swollen, and has been highly sensitive to pressure. Then have come pain extending over the entire side of the
head, without its limits being distinctly definable, and the accompanying phenomena of lachrymation, excessive salivation, and copious flow of urine, winding up with vomiting or ineffectual nausea and retching.
Anstie brings forward as arguments to support his view the facts that the attacks of migraine often interchange with neuralgic seizures, and that a person who has been migraineuse in early life may in later years lose his hemicranial attacks, and have violent neuralgia in the ophthalmic division of the fifth nerve.
The true seat of the lesion, if we may so call it, upon which the exaggeration of pain-sense depends, is probably in the nerve-centre; that is, in that part of the trigeminal nucleus back to which the fibres go which are distributed to the painful areas. The pain is no doubt chiefly intracranial, and in those portions of the cerebral mass and meninges to which branches of the trigeminal are distributed. All of the divisions of the trigeminus send branches to the dura mater. Many nerves are found in the pia mater as plexuses around the vessels, some of which penetrate into the centre of the brain. Most of these nerves come from branches of the trigeminus.
TREATMENT.—The treatment of migraine must be directed to the palliation of the attacks and to their prevention. So little is known of the direct cause of the disease that it is difficult to lay out any distinct course to be followed. Many cases, however, which seem to depend upon a run-down state of the patient are vastly improved by a course of tonics and building up. I have often seen anæmic and feeble women whose attacks were frequent become exempt for a long period by simply taking iron, quinine, and strychnia, and taking an increased amount of nourishment. The rest-treatment of Weir Mitchell is particularly applicable to these cases. In persons whose digestion is bad, and who suffer from constipation, much can be done by relieving these conditions. Some cases which are due to uterine disturbances are benefited by treatment directed to the womb. There are many cases, however, in which no cause is apparent. The patient is well nourished, his eyes are good, he
undergoes no strain mentally, morally, or physically, and yet the attacks of migraine come with tolerable regularity. In these persons change of climate sometimes works marvellously beneficial results. I saw last year a young lady who suffered from terrific headaches which sometimes lasted for days. No plan of treatment or regimen seemed to exert the slightest influence upon the attacks, and yet on going to the far West for the summer she remained without an attack during the whole time she was there. In some individuals all forms of treatment may be tried in vain. Anti-periodics have been tested, but with doubtful benefit. Cannabis indica is probably the most potent remedy which is at our command. Its effects are most decided, and many cases of severe hemicrania have been cured by this means alone. It must be given for a long time, and in some instances it is necessary to give gradually-increasing doses up to the physiological effects. The drug must be of good quality, otherwise we need expect no good from it. Indian hemp is well known to be variable in strength, and the best form in which to use it is a fluid extract made by some reliable chemist. Arsenic, phosphorus, and strychnia do not seem to do as much good as in other neuralgias, except so far as they build up the general health.
Ergot has been used with success as a curative means, and it probably acts by contracting the vessels of the medulla oblongata. A combination of ergotin and extract of cannabis indica may be given together; and if persisted in for a long time will often be of benefit in lessening the frequency of the attacks. The prolonged use of one of the bromides is sometimes found curative.
Anstie has found the careful use of galvanism to the head and sympathetic of positive advantage in keeping off attacks, and Eulenburg has had the same experience.
In the treatment of the attack the patient should be freed from all sources of external irritation. He should lie down in a darkened room, and all noises should be excluded. If the attack is of the hyperæmic variety, the patient's head should not be low, as this must favor increase of blood to the head. In this form the patient is often more
comfortable sitting up or walking about. Occasionally an impending attack can be warded off by the administration of caffeine, guarana, or cannabis indica. Purgatives are of but little value in this form of headache. The local application of menthol or of the oleate of aconitia to the brow of the affected side will sometimes prevent an attack. If a person can lie down quietly when he feels an attack coming on, one or two doses of fifteen grains each of the bromide of lithium will enable him to sleep, and wake free from pain. I have found the lithium bromide far more valuable in migraine than any other of the bromides. An effervescing preparation known as bromocaffeine is often efficacious in aborting a paroxysm or in palliating it when it has got under way.
Quinine, in my experience, seems to be of little use in preventing or cutting short a paroxysm of migraine, although Ross11 has found that a dose of ten or fifteen grains may arrest it. Ergot has been found useful, and, as it acts by contracting the arterioles, should be given only in the angio-paralytic form. The fluid extract of ergot may be administered, but ergotin in pill form is more acceptable to the stomach.
11 Diseases of the Nervous System, vol. ii. p. 558.
Inhalations of nitrate of amyl have been used with advantage. Berger, who was the first to employ this remedy, found that a single inhalation of a few drops relieved the pain at once, and it did not return that day. It is indicated only in the sympathico-tonica type. If it is used, two or three drops of the nitrate in a glass pearl may be crushed in the handkerchief and inhaled. Nitro-glycerin may also be given in this variety of migraine.
Once the attack has begun fully, we can only attempt to mitigate the pain. Firm pressure on the head generally gives relief, and encircling the head firmly with a rubber bandage is often of great comfort. Compression of the carotids gives temporary but decided ease to the pain. Strong counter-irritation in the shape of a mustard plaster to the nape of the neck or a stimulating application, like Granville's lotion, to the vertex, will afford relief. I have found in some cases that
placing a hot-water bag, as hot as could be borne, against the back of the head alleviates the pain. In other instances cold affords more relief, and an ice-bag resting upon the forehead is the most efficacious way of applying cold. Hot bottles to the feet are an accessory not to be overlooked.
In the way of medicine we may give the bromide of lithium every hour. The bromide of nickel has been recommended by DaCosta as having peculiar advantages. Cannabis indica may be given in doses of a quarter of a grain of the extract every two hours until relief is obtained. Anstie believes strongly in chloral, and says that a single dose of twenty or thirty grains will often induce a sleep from which the patient wakes free from pain. The same writer advises the administration of muriate of ammonium, but it is too nauseous a dose to be given when the stomach is as much disturbed as it usually is in an attack of migraine.
Croton chloral is preferred by some to the chloral hydrate. Ross, for example, gives it in doses of five grains every four hours until relief is obtained.
Galvanism through the head is often of relief, especially at the beginning of an attack; but this means is not often available, for it is not easy to have the suitable apparatus for the constant current at a patient's home when it is needed. Should galvanism be used, one pole should be placed on each mastoid process, and a weak current passed through the head for two or three minutes. The sympathetic may be galvanized by placing one pole over the upper cervical ganglion, just behind and below the angle of the jaw, while the other pole is held in the hand or placed upon the sole of the foot. In hemicrania spastica the positive pole is put over the ganglion, and in the angio-paralytic type the negative pole is placed in this location.
Should all of the above means fail, we may resort to morphia hypodermically. Jewell12 favors the administration of morphia and atropia, either by the mouth or hypodermically, from the beginning of an attack until the pain is eased; but I believe that morphia, except as a last resort, is very undesirable in migraine. Although a small
dose hypodermically will usually promptly bring relief, there are the unpleasant after-effects of opium felt, and the patient feels more prostrated and with more disordered digestion than had no morphia been used. Besides, the morphia habit is liable to be formed, especially in women, when the drug has once begun to be taken.
12 Journal of Nervous and Mental Diseases, 1881.
It is for this reason that I prefer to use the bromides, and if a patient is seen at the beginning of a paroxysm, given a fifteen-grain dose of bromide of lithium, his feet put in hot mustard-water, and he then goes to bed, he will almost always cut his attack short, and on waking from sleep will feel refreshed and able to take food.
I am strongly convinced of the importance of arresting or shortening the paroxysms of migraine, especially in the young, at the beginning of the disease. By this means the habit of long attacks is prevented, and their prostrating after-effects are avoided. Should we succeed in checking the first few attacks, we may by tonics and regimen improve and fortify the constitution so as to eradicate or modify the neuralgic tendency.
BY S. WEIR MITCHELL, M.D.
VERTIGO.
DEFINITION.—The clinical meaning of vertigo has gone, as is common, far beyond what the term implies. We may define vertigo to be a sense of defective equilibrium, with or without actual disturbance of position, and accompanied by varying amounts of subjective feelings of motion of external objects, of the body itself, or of the contents of the cranium.
SYMPTOMATOLOGY.—Vertigo consists of attacks which are single or repeat themselves during a continuous condition lasting for hours or days, and which I have elsewhere described as the status vertiginosus.1
1 Med. and Surg. Rep., June, 1877.
The mildest form of vertigo is that in which the patient has a sensation of the contents of the head as being in motion. If more severe, there is disturbed equilibrium, an effort is needed to stand erect, or there is, as in most vertigo, a fear of falling. The brain seems to be moving round or upward. This type is found in insanity, in hysteria, and in the vertigo of mental effort observed in extreme cerebral exhaustion.
In a second clinical species of vertigo the patient appears to himself to be in motion, while outside objects maintain for him their places. This may or may not be accompanied with sensory disturbance or an approach to mental confusion. It is really a delirium of movement. The patient feels as if he were rolling or falling or reeling or dropping through space. Meanwhile, however grave the hallucination, he walks and stands without the least sign of defect in balancing power. These cases are very rare, but are sometimes seen as temporary results of hysteria.
Perhaps it is doubtful whether we should really class this symptomgroup as vertigo.
The more common or typical expression of vertigo is marked in its fulness by a false sense of the movement of external objects and of the relations in space of the individual to such objects. The pavement rolls or seems to be coming up in front of him; the houses stand at angles; walls, pictures, chairs, and tables reel around him, are still a moment, and again move; or the bed seems to be aslant or to rock to and fro. In extreme instances objects are seen as if inverted, and whenever the vertigo is marked the victim reels or falls, or seeks by rest supine or by closing his eyes to lessen the terrors of the attack. In severe examples no such help avails, and for hours or days the patient may lie clutching at the bed for support or in deadly fear of a new onset of vertigo, which in some cases is brought on by the least movement of the head, by taking food, by efforts to think, or by mechanical vibrations.
In most cases there is some mental confusion, or even brief loss of consciousness at the close of the attack, and nearly always more or less nausea or vomiting occurs—symptoms which have frequently misled observers as to the cause of the vertigo, but which have in most cases only the significance gastric disturbance has in migraine. As in that disorder, but more rarely, the emesis may be associated with or replaced by looseness of the bowels, and is very apt to be followed by a flow of pale clear urine.
Fits of vertigo are often as distinct clinically as epileptic attacks. The patient has for a few moments, in an acute form, all of the phenomena of vertigo, and may then recover promptly, or it may chance that he has a vertiginous status and a series of fits, or remains for long periods in a state of chronic disorder of head, with now and then an acute onset.
Physicians do not often witness these fits: I have been so fortunate as to see several. I take this description of one from my notes: A young clergyman, after excessive overwork among the poor, came to consult me for vertigo. As I talked to him an attack came on. I asked him to keep as composed as possible and to tell me what he felt. He said: “It has just begun. The objects in the room are moving from
right to left; I can seem to hold them still for a moment, then they go on and move faster. If I shut my eyes it is relief, but only for a time. I feel myself as if I were now going round with them. The chair rocks, and my brain seems moving too.” At the same time he became very pale, and slipped from his seat. His pulse was quick and feeble and rapid, and as he lay on the floor unconscious a profuse sweat broke out on his face. In a moment he was again himself, but did not recover so as to walk for a half hour. He then complained of headache, but was able to walk home. This is a fair example of a fit of vertigo, due, as it proved, to at least two of the causes of vertigo, which I shall presently discuss.
A few persons insist that something like a distinct aura precedes the attacks. In other cases the brain symptoms develop gradually, from a faint sense of dizziness up to a tumultuous feeling of confusion with sensory illusions. In a few rare cases there is, as in that above mentioned, an abrupt onset. Something seems to snap in the head, and the vertigo follows; or, most rare of all, we have a sensory discharge felt as light or sound, and followed by the ordinary symptoms.2
2 See the author in lectures on Nerv. Diseases, Disorders of Sleep, p. 63, 2d ed.
DIAGNOSIS.—Vertigo is of course, as a rule, only a complex symptom of one or more numerous conditions. Acute isolated fits of vertigo are sometimes puzzling, because epilepsy may be preceded by brief vertigo and exist without notable spasms. Time may bring to us a frankly expressive epilepsy to explain former and less distinct fits. But usually it is the attacks of vertigo which are the causes of doubt. A man has sudden giddiness, and falls unconscious for a moment. These attacks persist. How shall we know them as vertigo? how be secure that they be not some form of the lesser epilepsy? As a rule, if they be vertigo there will be nausea or emesis, while the intervals between attacks will offer the usual signs of confusion of head, fear of losing balance, and all the numerous evidences of disturbed and easily excitable states of the sensorium—conditions rare in the interepileptic periods. The effect of bromides may aid the diagnosis,
for, although often of use in vertigo, they have not such power to inhibit the fits as they possess in epilepsy. Persons long liable to any form of vertigo can readily cause attacks, or at least vertiginous feelings, by closing the eyes while standing, by the least rotation, or by putting a prism on one eye, so that among these tests we may frequently find the material for a diagnosis, which will of course, in many instances, be made easy enough by the presence of causes obviously competent to occasion the one or the other disease.
PROGNOSIS.—In true vertigo, if we exclude the organic causes, and especially intracranial neoplasms, there is very little to be feared. Deaths have been seen in Menière's disease, but are most rare. Even in grave examples of labyrinthine vertigo there is a probability that the worst which can occur will be deafness, and that vertigo will gradually cease as the delicate neural tissues become so degenerated as to cease to respond to irritations.
The DURATION of other forms of vertigo it is less easy to predict. Ocular vertigoes get well soon after the eye trouble is corrected, and the like is true of most vertigoes due to peripheral causes. So also the giddiness which is sometimes seen as a very early symptom in locomotor ataxia is transient, and will be apt, like the ocular and bladder troubles which mark the onset, to come and go, and at last to disappear entirely. It is to be remarked that vertigo at the beginning of posterior sclerosis is common, and is not due to ocular motor conditions.
Sometimes in vertigo, as in epilepsy, the removal of a long-existing cause may not bring about at once a cessation of the abnormal symptoms its activity awakened, so that it is well, as to the prognosis of duration, to be somewhat guarded in our statements. Nor is this need lessened by the fact that vertigo may be an almost lifelong infliction, without doing any very serious damage to the working powers of the person so disordered.
ETIOLOGY.—It is generally taken for granted that vertigo has always for its nearest cause some disorder of cerebral circulation; but while either active congestion or anæmia of brain may be present with
vertigo, and while extreme states of the one or the other are certainly competent to produce its milder forms, it does not seem at all sure that they are essential to its being. Indeed, there is much reason to believe that vertigo is due in all cases to a disturbance of central nerve-ganglia, and that the attendant basal condition is but one incident in the attack.
In vertigo there are the essential phenomena, as disturbed balance, with a false sense of movement within or without, or of one's self. Then there are the lesser and unessential phenomena, which vary in kind and degree, and these are the moral and mental symptoms— terror, confusion of mind, and sensory illusions; and, last, the nausea and sickness met with here as in migraine, and the flow of clear, thin urine.
All of these symptoms should be accounted for in speaking of the intracranial organs, disorder of which causes vertigo. Ferrier has especially made it clear that equilibration involves afferent impressions, co-ordinative centres, and efferent excitations preservative of balance.
Guiding impressions, which direct the muscles through centres below the cerebrum, so as to aid in preserving our balance, reach these centres from the skin and the muscles, so that great loss of tactility or of the compound impressions called muscular sensations results in disturbance of equilibrium, but not in true vertigo, which is clinically this and something more.
A second set of impressions, of use in preserving equilibrial status, come through the eye, or rather habitually through the eyes, because the consensual impressions arising out of double vision and the co-ordinate movements of the two fields of sight have, as is well known, much to do in this matter. It is hardly needful to dwell on this point. Certain parts of the ear have, however, the largest share in maintaining our balance, and it seems likely that the semicircular canals—the part most concerned—although lying within the petrous part of the temporal and receiving nerves from the stem which constitutes the nerve of hearing, may have slight relations or none to
the sense of audition.3 When the horizontal canals are cut, the head moves from side to side and the animal turns on his long axis. When the posterior or lower vertical canals suffer, the head sways back and forward, and the tendency is to fall or turn over backward. When the upper erect canals are cut, the head moves back and forward, and the tendency is to turn or fall forward.
3 I have seen a single case of vertigo, with slight deafness on both sides, in which the sense of the position of sounds was absolutely lost.
In pigeons, injury on one side may get well, but when the canals are cut on both sides there is permanent loss of balance. In some way, then, these little organs appear to be needful to the preservation of equilibrium; and of late some interesting attempts have been made to explain the mechanism of this function. It probably depends on the varying pressure relations of the endo-lymph to the nerve-ends which lie in the membranous canals.
Wm. James of Harvard has shown that total loss of hearing is usually accompanied by lessened susceptibility to vertiginous impressions, so that the stone-deaf are not apt to be seasick or giddy from rotation, owing to their having lost the organ which responds to such impressions. It would seem also that the entirely deaf have peculiar difficulty in certain circumstances, as when diving under water, in recognizing their relations to space.
There is a general tendency to regard the cerebellum as the centre in which all the many impressions concerned in the preservation of equilibrium are generally received and made use of for that purpose. There may be several such centres, and the matter is not as yet clear. Whatever be the regulative ganglion, it seems clear that it must be in close relation to the pneumogastric centres, to account by direct connection or nerve-overflow for the gastric symptoms. But, besides this, vertigo has clinical relation to moral and mental states not easy to explain, and in extreme cases gets the brain into such a state of excitability that mental exertion, emotion, strong light, or loud sounds share with the least disorder of stomach capacity to cause an attack.
Vertigo may be due to many forms of blood-poisoning, as at the onset of fevers, inflammations, the exanthemata—notably in epidemic influenzas. It may arise in malarial poisoning, sometimes as the single symptom, as well as in diabetes, albuminuria, lithæmic conditions, and in all the disorders which induce anæmic states. Common enough as sign of brain tumor, and especially of growths in or near the cerebellum, as a result of degenerated vessels, it is also not very rare in the beginning of some spinal maladies, especially in posterior sclerosis, and is not always to be then looked upon as of ocular origin.
Alcohol, hemp, opium, belladonna, gelsemium, anæsthetics, and tobacco are all, with many others, drugs capable of causing vertigo.
In hot countries heat is a common, and sometimes an unsuspected, cause of very permanent vertigo.
Lastly, excess in venery, or, in rare cases, every sexual act, profound moral and emotional perturbations, and in some states of the system mental exertion, may occasion it, while in hysteria we may have almost any variety of vertigo well represented. Outside of the brain grave organic diseases of the heart are apt to produce vertigo, especially where the walls of the heart are fatty or feeble from any cause. Suppression of habitual discharges, as of hemorrhoids or menstrual flow, is certainly competent, but I have more doubt as to the accepted capacity of rapidly cured cutaneous disease.
The following are some of the more immediate causes of vertigo: They are disorders of the stomach or of the portal circulation; laryngeal irritation; irritation of the urethra, as passing a bougie, especially when the patient is standing up; affections of nerve-trunks; nerve wounds; sudden freezing of a nerve (Waller and the author); catarrhal congestion of the nasal sinuses; inflammation and congestion of inner ear, many irritations of the outer and middle ear; prolonged use of optically defective eyes; insufficiency of external muscles of the eye.
It will be needful to treat of some of these causes of vertigo in turn.
