Abstract
The published selections from the diary of the clergyman Francis Kilvert, dating from the 1870s, were systematically searched for accounts of headache, face ache and face pain. Although limited, as all such retrospective studies with restricted documentation must be, nonetheless illustrative quotations from the diaries suggest he may have suffered from cluster headache. This may be one of the earliest accounts by a patient, rather than a physician, of cluster headache.
Introduction
Francis Kilvert (1840–1879) was an obscure Anglican clergyman of the mid-Victorian age who worked in rural parishes in the Welsh border country and in southern England. He would be unknown to posterity were it not for the fact that he kept a diary for the last 10 years of his life (1870–1879), selections from which were published many years later (1938–1940) to public acclaim. The diary has become acknowledged as one of the most notable in the English language, principally as a social documentary of rural life in an era long past. In addition to these features of historical interest, Kilvert's diary may also be of note to neurologists, since it shows that he suffered from headaches and facial pain (1). This article collates all Kilvert's references to headache and facial pains, the nature of which suggests a possible diagnosis of cluster headache.
Methods
The three volumes of selections from Kilvert's diary, made by William Plomer and originally published between 1938 and 1940, which cover the periods 1 January 1870 to 19 August 1871, 23 August 1871 to 13 May 1874 and 14 May 1874 to 13 March 1879, respectively (henceforward referred to as I, II and III), were read over a 2-month period, and all references to headache, face-ache, face pain or neuralgia were systematically recorded. A selection of more recent commentaries on the diarist and his works was also consulted (2–5). There are no detailed contemporaneous records of Kilvert other than his diary.
Results
In the approximately 1300 published pages of the diary, 23 references were found to Kilvert's headaches (n = 7), face-ache or facial pain (n = 11) and neuralgia (n = 5). Only 10 of these references survive the cut for Plomer's 1944 selection from his original selections (1). Kilvert mentions these symptoms in 6 of the 9 years of the diary for which any substantial amount of material remains. Of these ailments, the index appended to the 1961 reprint of the diary includes only face ache (six references). Seven other individuals with these symptoms are also mentioned, each on only one occasion: Mrs Crichton ‘upstairs with neuralgia’ (I.28); ‘old Jones in bed who complained of a headache’ (I.55); Baskerville who ‘rode down with neuralgia’ (I.333); Dora, Kilvert's sister, who ‘had a headache’ (II.27); his father suffering from severe cold and face ache (II.110); Emma Griffiths suffering from face ache (II.163); and Mrs Lewis ‘ill with neuralgia’ (III.390). Kilvert's own headache disorder may have made him more acute in noting these problems in others.
Whether the different terms used by Kilvert represent different entities, or are different ways of describing the same symptoms, is not entirely clear. Headache and face ache seem to occur simultaneously in February 1871 and in December 1871, as exemplified by the following quotes:
Monday 4 December 1871: Knocked all to pieces today with face ache, feeling miserable, stiff, sick and nohow (II.93).
Tuesday 5 December 1871: Shattered with face ache and want of sleep, weak and miserable. Everything seemed unreal and grotesque (II.93).
Wednesday 6 December 1871: A wretched groaning night, sleepless except for some feverish grotesque bad dreams about daybreak. Gnawing face pain and a splitting bursting headache from the heat of the room and the vile gas (II.94).
Sunday 10 December 1871: … home by the upper road crazy with face ache, weak and wretched, and the road never seemed to be so long (II.96).
It seems possible that the ‘bad headache’ with ‘fresh cold and greater tightness of chest’ of March 1878 (III.384) may have been distinct from earlier episodes of face ache and neuralgia. Clearly, Kilvert may have used these words in a sense different from their current medical usage. For example, at one point he reports himself ‘miserable all day with an attack of cholera and diarrhoea’ (II.99), but the diagnosis of cholera as currently understood is untenable.
The character of Kilvert's headache symptoms is severe, for example:
Wednesday 1 March 1871: … all night and all today I have been groaning with a bursting raging splitting sick headache (I.307).
Other headache descriptors include splitting (I.38), crushing (I.301), racking (I.325) and bursting (II.94). Of note, however, nowhere is the word ‘throbbing’ used to describe the headache.
Face ache is similarly severe (see quotes above, II.93, 94, 96), and sleep disturbance is a frequent accompaniment (I.306, II.93, 94, 232, 234). Feelings of restlessness are also mentioned, both in association with face ache (‘awake all night walking about the room … unable to rest anywhere’; II.232) and in relative isolation:
Thursday 14 March 1872: After dinner today I was seized with a strange fit of nervous restlessness … with it came a twinge of neuralgia and toothache (II.149–150).
Neuralgia is often mentioned just as the single word, but it may also render Kilvert ‘prostrate’ (III.89) and cause sleep disturbance (III.391). A sudden cessation of face ache, ascribed by Kilvert to an abscess breaking, occurs on one occasion (II.234).
The date of symptom onset is unknown, but the first mention comes in only the second month of the diary (I.38), and the tone does not suggest that this is a new or unfamiliar occurrence, so onset prior to the age of 29 years may be assumed.
The frequency of symptoms is of particular note, specifically the clustering of attacks: in late February/early March 1871 headache and face ache are mentioned three times in 5 days. This pattern is replicated later: face ache, face pain and headache are mentioned four times in 7 days in December 1871; face ache and ‘mouth … so bad’ four times in 4 days in July 1872; neuralgia is mentioned twice in 2 days in October 1874; and neuralgia is reported to have been ‘very troublesome all the week’ in April 1878. The duration of bouts would therefore seem to be a few days at most, with long intervals between bouts, the longest apparently being October 1874 to March 1878 (although only 1 day of diary for 1877 survives). The duration of individual attacks is not specified, although the impression is that they can last several hours (I.38, 140, 306, 307; II.94, 232, 234; III.391, 447).
Possible symptom triggers are identified by Kilvert. Alcohol is suggested on one occasion ('Drank too much port after dinner … last night and a splitting headache all today in revenge’; I.38). The bout of December 1871 follows immediately after a dinner in honour of his birthday (3 December) at which champagne is consumed, although a later exposure to champagne (II.288) is not followed by any report of ill effects. Heat, from a crowded public gathering (I.301) or from a poorly ventilated gas-heated room (II.94), is blamed, as is cold (‘from sitting on a tombstone in the Churchyard’; II.232).
As regards treatment, there seems little that can be done other than to wait until symptoms pass off. Though mentioned as a possible trigger, alcohol is also tried for symptom relief: ‘after dinner and four glasses of port I felt better’ (II.96), sometimes in conjunction with laudanum (I.140). Sal volatile is mentioned on one occasion (II.232). Improvement of symptoms after sleep also occurs (II.149–150).
Medical intervention does not seem to have been sought, even when Kilvert saw the local practitioner, Dr Clouston, in town on the same day that he was having symptoms (II.94). In the July 1872 bout, Kilvert wrote a note asking Clouston to come, and after a sleepless night changed the wording ‘begging the doctor to come as soon as possible’, but as he gave the note to the postboy the ‘abscess broke’ and the pain resolved, and the note was not sent (II.234). Kilvert was a regular visitor to his dentist, Gaine, a train journey away in Bath (I.328, 376; II.100, 446; III.114–115, 229, 325, 357, 428), and on occasion had teeth ‘stopped’. One such procedure (23 December 1871) occurred shortly after a bout of face ache. The tooth was ‘so sensitive that it could only be stopped temporarily and it was necessary to destroy the nerve’ (II.100). However, there is no explicit linkage made between this and the prior symptoms to suggest that Kilvert thought these were of dental origin.
Discussion
Kilvert's published diary is a fragment of the whole work. Following his death, his widow destroyed parts of it relating to herself and possible other of Kilvert's amatory relationships, and of the 22 notebooks originally delivered to William Plomer perhaps only a third of the material was selected as worthy of publication, this at a time of marked paper shortage. Only two of the original notebooks are known to survive, and the original typescript of all 22 notebooks was also destroyed. It is therefore unlikely that much, if any, new material will come to light. It is possible that the full text of the diary may have included additional references. For example, in an extract from one of the extant notebooks not selected for inclusion in the published diary by Plomer, but subsequently published by Grice (p. 153), another individual with headache is mentioned: ‘Helen had a sad headache from the fierce glare of the sun’ (4).
Previous Kilvert commentators (2–5) have made occasional note of their subject's headaches, but there has been no prior systematic analysis of all references to my knowledge. Le Quesne (2), who may have shared with Kilvert a headache disorder (p. 1), suggests that ‘the pain in his eyes that frequently troubled him’ may have been migraine (p. 45). However, my reading of the diary finds no mention of pain in the eyes, although, to be sure, Kilvert several times mentions problems with his eyesight (I.37; II.52–3, 88; III.45, 75, 358, 431, 443), especially when trying to read services in dim church interiors, and wonders what one young lady will think of his ‘poor disfigured eyes’ (II.37). None of these reports coincides with episodes of headache or face pain. Lockwood (3) states (p. 146) that ‘Some think he [Kilvert] had a squint. If that is so, and it is not unlikely, it would account for his attacks of neuralgia and headaches. They could easily stem from strain in trying to overcome the deficiency in his vision’. Although refractive errors are a recognized cause of headache (6), and headache ascribed to ‘eye strain’ prompting a visit to an optician is a frequent route followed by patients with primary headache disorders (7), it would seem unlikely to account for Kilvert's severe and periodic symptoms. Glaucoma may present with acute and systemic symptoms, but the aforementioned lack of symptom association with low light environments argues against acute angle closure.
Grice (4) refers to neuralgia and headache in the last years of Kilvert's life as components of his ‘failing health’, accepts ‘eating and drinking too much and sitting in an overheated room’ as causes for the headaches, and opines that his neuralgia and face ache were ‘probably both the same’. He also cites a letter of Lois Lang-Sims, which states: ‘[Kilvert] was occasionally overwhelmed by psychic invasions. Evidently he suffered from a severe form of migraine, a common accompaniment of psychic sensitivity’. Toman (5) mentions Kilvert's headaches and face ache only in passing, when illustrating the burdens placed on him by the absence of his Vicar, even when Kilvert was in ill health.
The information vouchsafed to us from the diary suggests Kilvert had a syndrome of severe headache and facial pain, occurring periodically, associated with sleep disturbance and restlessness. Although detail is insufficient to fulfil current diagnostic criteria (6), the symptom pattern, especially the periodicity and the accompanying restlessness, would seem to fit better with a diagnosis of cluster headache than with migraine without aura. Against this formulation, there is no convincing account of autonomic symptoms, and the bouts are apparently of short duration, although such ‘minibouts’ have been described as part of the cluster headache cycle (8). The absence of any mention of unilaterality of symptoms is odd, although this absence has also been noted in the account of another writer, Arthur Ransome (1884–1967), whose letters and autobiography otherwise suggest a diagnosis of cluster headache (9). Although they are a recognized cause of facial pain, there is no strong evidence to suggest dental problems were the cause of Kilvert's symptoms, although there is a long history of dental treatment being undertaken inappropriately in primary headache disorders (10, 11). Atypical facial pain must also enter the differential diagnosis.
Should the formulation of cluster headache be accepted, Kilvert's diary may be one of the earliest accounts of this syndrome. Wilfred Harris (12) published his seminal monograph, introducing the term ‘periodic migrainous neuralgia’, in 1926, and it was acknowledged by later authors as the first record of cluster headache in the English medical literature (13, 14), although it postdated a possible account by Romberg (‘ciliary neuralgia’, 1851/1853). Other possible, and earlier, accounts have been suggested in the works of Nicolaas Tulp dating from 1641 (15), Thomas Willis from the late seventeenth century (16), Gerhard van Swieten in 1745 (17), Giovanni Battista Morgagni in 1761, the Scotsman Robert Whytt in 1764 and Marshall Hall in 1836 (18). These accounts were all by medical practitioners, so Kilvert may still retain the laurel for the first patient self-report. Other authors who may have suffered from cluster headache include Franz Kafka (19) and Arthur Ransome (9).