III. HEMICRANIA, OR INTERMITTENT HEADACHE.

The third variety of headache is characterized as well by the severity of the pain, as by its tendency to recur every day, or every other day, at the same hour, and often with a degree of regularity equalled only in the phenomena of an ague. By the vulgar, this disease is sometimes called the brow-ague, and some pathologists have attributed its origin to malaria. There are no adequate grounds, however, for this opinion. The disease has for its predisposing cause constitutional weakness. I have traced it to the exhaustion occasioned by frequent pregnancies and nursings, to the want of due bodily exercise, and to long continued mental anxiety. It differs from the preceding species in not being so distinctly connected with disturbed function of the digestive organs.

Intermittent headache usually has its seat on the left side of the head. It generally makes its attack in the forenoon, and the paroxysm of pain lasts three or four hours. The violence of the pain is sometimes excessive. There can be no doubt that the vascular system is either primarily or secondarily involved in it. In one very severe and obstinate case of it, I witnessed extensive ecchymosis of the forehead and eyelid, from the bursting of a small blood-vessel. Intermittent headache is often unconnected with any cognizable disorder of the stomach and bowels. In many cases it runs a certain course, uninfluenced by medical treatment, reaches its crisis, and then gradually declines. In this way I have seen it protracted through a period of several months, the patient ultimately recovering, and no disposition to relapse being left, as in the true bilious headache.

Treatment of headache.-The several species of headache now separately described for the convenience of elementary instruction, will often be found in practice, to run into each other. I shall, therefore, in the following remarks on treatment, consider headache as a generic disease, and satisfy myself with pointing out the principles on which its cure or relief should be attempted.

The indications of cure are three :-First, to aid the digestive process, and to free the stomach and duodenum from irritating matters. Secondly, to relieve the tension or congestion of the blood-vessels of the head. Thirdly, to strengthen

nerves.

the general system, and by so doing to give energy to the To fulfil these objects the principal remedies resorted to are, emetics, purgatives, mild aperients, absorbents, cordials; -general and local blood-letting, cold spirituous lotions to the head, blisters;-tonics, nervines, and, lastly, change of air.

An emetic is fit only for an acute attack of headache, attributable to an overloaded stomach, and accompanied by nausea. In all other cases it contributes to weaken the stomach, and thus favours a recurrence of the disease. Active purgatives are very useful in strong and plethoric habits. Four grains of calomel with six of colocynth extract is a convenient formula. But such active purgatives are ill suited for the habitual bilious headache. It will often be found that the symptoms yield long before any evacuation has been procured, showing that the irritable condition of the intestinal mucous membrane, upon which the headache depended, was confined to the stomach, duodenum, and jejunum. Rhubarb and magnesia, combined according to the following formula, constitute a very appropriate aperient for such cases :

An attack of dyspeptic headache is frequently relieved by some medicine that promotes languid digestion, such as a teaspoonful of powdered ginger, or a glass of brandy.

When headache occurs in full and plethoric habits, blood must be taken from the arm. When the evidences of locally increased action are unequivocal, relief is sometimes afforded by leeches. Eau de Cologne to the temples is a familiar and useful application for the same purpose. In severe cases it is often necessary to shave the head, and to apply cold lotions diligently. A blister behind the ear is often advantageous.

In that aggravated form of headache called the brow-ague, a more complicated system of management, steadily pursued, is requisite to re-establish the health. Due consideration must be given to the weakness of the general habit, and the aid of tonics and nervines must be called in. The bowels should be relieved by warm aperients, such as the compound decoction of aloes, or the compound rhubarb pill. The tone of the stomach must be supported by aromatic bitters, such as the infusion of

cascarilla and calumba, to which ten grains of the powder of valerian, or a drachm of the tincture, may be added. The efficacy of quinine is often strikingly displayed in the relief of intermittent headache, and contributes to the belief that the affection is really of an aguish nature. It may be given in full doses frequently repeated. In the advanced stages of the disease, nothing will contribute so essentially to recovery, as change of air.

It is hardly necessary to add, that in all cases of headache, but especially in those connected with faulty digestion, the utmost attention should be paid to regimen. Regular exercise and early hours are to be encouraged. Hot and crowded rooms are to be avoided. The feet are to be protected from cold, and warm clothing should be rigidly enforced. But, above all things, the diet is carefully to be regulated, both with respect to quality and quantity.

It remains to be observed, that headache depends, in some cases, simply upon costiveness, the functions of the upper bowels being duly performed. The diagnosis and treatment of this variety of headache are sufficiently obvious.

VERTIGO.

Closely allied to headache is that peculiar nervous feeling denominated dizziness, giddiness, or vertigo. It very often accompanies headache, and its pathology is, in all important points, as regards practice, the same. It is frequently connected with, and directly dependant upon, plethora, or venous congestion about the head, and is relieved by cupping and general blood-letting. But, in a variety of cases, giddiness has for its exciting cause indigestion; and occasionally giddiness accompanies an attack of dyspepsia through its whole course, and constitutes the leading feature of the complaint for many successive weeks. Under such circumstances vertigo is to be treated in the manner already directed for the management of dyspeptic headache.

CLASS VI.

CHRONIC DISEASES OF THE THORAX.

CHAP. I.

BRONCHOCELE.

Nature of the Affection. Symptoms and Progress of the Disease.

Speculations concerning its Cause.

Treatment. By Medicine, Influence of Iodine. By surgical Operation.

BRONCHOCELE, or the goitres, is a chronic indolent enlargement of the thyroid gland, occasioning swelling of the fore part of the neck, often to such an extent as to produce great deformity. The tumour, however, is quite free from pain, and does not appear to give rise to any degree of constitutional disturbance. There is no malignity in the disease, nor any disposition in the tumour, except from accidental circumstances, to take on inflammatory action.

The precise nature of the swelling which constitutes bronchocele has been a frequent object of investigation. The section of a thyroid gland affected by this disease exhibits a congeries of cells containing a transparent viscid fluid.* The size of these cells differs in different cases; although externally the tumour shows the same character. It varies even in different parts of the same gland. Some of these cells are sufficiently large to contain a pea; the generality are smaller. Reasoning from the change of structure thus observed, Dr. Baillie conjectures that bronchocele may depend upon an increased and vitiated secretion from the gland, which gradually distends its cells, and forms the swelling characteristic of the disease.

Doubts have been entertained, whether there are not different species of this disorder. Distinctions have been drawn * Vide Baillie's Morbid Anatomy, fifth edition, page 91.

between the sanguineous and the sarcomatous, the common and the scrophulous bronchocele; but these are probably of no real importance. If any essential differences do exist in the morbid changes of structure which the gland undergoes, the appearances presented on dissection are not sufficiently uniform to warrant us in characterizing them with precision.

There are, it is true, some slighter variations in the affection, which have always been acknowledged. The tumour varies, for instance, in point of consistence. It is hard and unyielding, or soft and spongy. In some cases, the whole body of the gland is involved in the disease, while in others the swelling is partial, affecting one lobe of the gland only, or portions of it, so as to occasion tumours that project irregularly over the anterior part of the neck.

In all cases of bronchocele there are grounds for believing that an unusual determination of blood to the gland takes place. There is very often a sensible throbbing of the tumour during life. After death, too, the blood-vessels connected with the gland, both arteries and veins, are found enlarged, and this enlargement is made particularly apparent by injecting them.

The size which the tumour acquires after a lapse of years is often enormous, and its mere weight produces no inconsiderable inconvenience. The adjacent cellular membrane and lymphatic glands in process of time participate in the disease, and the whole neck becomes enlarged. That this should exist without prejudice to the life or general health of the patient, is more surprising than that it should occasionally give rise to alarming symptoms, and be the immediate cause of death. The tumour itself becomes in some instances painful, the veins of the neck enlarge, there is hoarseness and headache, and that long train of evils is felt which inevitably results from obstructed respiration.

Causes. The causes of bronchocele are involved in great obscurity, and have given rise to much discussion. It has been the object of authors to discover some one cause to which every case of bronchocele may be traced; but such an expectation is neither reasonable nor warranted by pathological analogies. Like swelling of the liver or spleen, bronchocele may arise from many causes, differing essentially from each other. For all practical purposes it is sufficient to inquire