-< THE Medico- Chirurgical Rev iew, N? LXIX. [No. 29 of a Decennial Series.] APRIL 1, to JULY 1, 1841. Practical Remarks on the Discrimination and Appear- ances of Surgical Disease; with an Appendix, containing the Descriptive Catalogue of the Author's Collection in Pathological Anatomy; and the Hunterian Oration for 1833. By John fiowsnip, Surgeon to Uliaring L,ross nospuai, occ. juohuou : John Churchill, 1840. Tins work must be considered as possessing an additional interest and claim upon us, from the demise, since its publication, of the author. Mr. ttowship has always evinced great zeal in the cultivation of pathology, and rnany of his papers have been highly valuable. If we do not owe to him j^rnarkable discoveries, we are his debtors for useful facts, and the volume ?re us contains, if we mistake not, a considerable share of them. *v e do not know how we can better present an epitomized view of its contents than by referring to the introduction. In that, the author tells Us: ^at the first affection adverted to, is a peculiar description of chronic ^e head ; and here discrimination at once confers the power of ordmg immediate relief. Derangement or disease in the maxillary an- um introduces some interesting illustrations. The next subject is inter- _1 1Jd or ulcerative absorption of the bones of the cranium ; and here the ery first illustration is calculated to give an instructive lesson, on the ne- cessity for understanding the principles as well as practice of Surgery, that e may proceed with judgment and pursue a right course. The last case f .ced under this title is extremely curious, and, in a physiological point view, very important, on several accounts, especially as exhibiting the operation of a most curious law in the system, that where atrophy of the ain induces a diminution of its volume, the cranium generally follows its ntents, by a correspondent change of external form; although M. Cru- t1.]Ter> in his admirable work on Pathological Anatomy, gives a very Qf excePti?n to the rulc- The remarks next in order, regard fracture the l^sis-cranii, in which we see the advantage of watching and noting fu ?^"ect-s of accident for a series of years; a habit, which now and then TK s^U(^en^ with a diagnosis not otherwise to be acquired, niu 6Se corQments are followed by remarks on specific disease in the cra- tiss^' an^ con^en^s- Scirrhous tumours in the diploe or in the fibrous ditt^ the dura mater. Fungoide tumour in the eye and orbit, or in the v ma.ter > illustrating the different modes in which disturbance or des- No. LXIX. B 2 Medico-chirurgical Review. [July 1 traction of the substance of the brain may take place, from absorption, or disorganization. Next come a series of remarks on the phenomena and causes of congestion of the brain, including the powerful influence of mind in its production. Several of the cases may be truly said to possess great practical interest, in reference to the discrimination and treatment of this disease. The consideration of deficient development or subsequent wast- ing of the limbs, next follows; from affection of brain or of some part of the nervous system, leading on to a number of interesting and various practical illustrations. The next condition of brain noticed is that of serous effusion ; a con- dition, which may almost always be distinguished during life; and here it is satisfactory to observe, that where the existence of the disease is most clear, and where its progress has induced obvious enlargement of the cra- nium, a prompt recourse to active treatment may be attended with perfect and permanent recovery. Injury of the head from the passage of the electric fluid through the brain, comes next in order ; and here is drawn a curious and close parallel between the symptoms of concussion, extravasation, inflammation, and effusion, as induced by this cause, and as brought on by the more ordinary modes of external violence. Inflammatory affections of the brain offer some interesting distinctive features ; and it may be remarked, that, when the excitement is superficial only, the symptoms may differ essentially, with the tissue principally involved, whether venous or arachnoide. The occa- sional and curious influence of abscess in the brain, near the origin of the olfactory nerve, in giving rise to a false sensorial impression is noticed, and practically illustrated. The formation of a large abscess in the lateral ven- tricle, without its having excited the least mental disturbance, is curious; but the production of several large abscesses in the substance of the brain (two of which abscesses are distinctly and demonstrably seen to be situated one within the other) is still more so. The formation of hydatids in the brain may present symptoms by which this complaint may be distinguished from ordinary serous effusion, which it most resembles. Ramollissement of the brain should excite much close consideration and interest in the practitioner, from the discordance of opinion which still exists as to its cause, and consecfhently its treatment; while even its diagnostic symptoms are by no means uniformly admitted or generally understood. The practical illustrations under this title may, it is hoped, be regarded as affording some useful and important light. Effusion of blood within the head is next considered ; and whether from an internal or external cause may generally be discriminated. The severely painful affection, tic doloureux, was long supposed to affect only the nerves of the face; but experience has shewn the more extensive range of its in- fluence ; and the cases demonstrate its direct power of deranging not only the nerves of sensation in the body and limbs, but the various ganglia and organs supplied by the sympathetic system, the nerves of sense, and even the sensorium itself. The discrimination of the causes of compression of the spinal cord in the neck is important, and the agency of some of these causes obscure; several of the illustrative remarks on their operation will be found interesting and rare. Tumour of the thyroide gland is not subject to much variety; it is oc- J 841] Mr. Howship on Surgical Diseases 3 casionally liable to common inflammation and abscess, but very rarely in- deed to scirrhus. The extent of infiltration into the cellular tissue, in the first case of bronchocele, is very extraordinary. Chronic ulceration of the epiglottis, or larynx, easily distinguished, but nor easily relieved, is in fact one of the most distressing and embarrassing cases that can occur ; the misery induced by this disease can be understood only by referring to the annexed illustrations. The remarks on scrofulous disease in the cervical vertebra may serve to illustrate, in some degree, the symptoms and appearances. Malignant disease of the face, or of the tongue, is noticed principally to establish its diagnosis. Spasmodic stric- ture in the oesophagus furnishes several interesting practical remarks and illustrations : as simple spasm, as inflammatory spasm, and as occasionally incurring a state of stomach no less serious than the complaint itself. The observations on malignant disease in the same part may much assist in the discrimination of these complaints. Abscess in the oesophagus is shewn sometimes to prove fatal, but the illustrations also demonstrate that it may terminate favourably. Affections of the heart and circulation next follow. Adhesion between the heart and pericardium ; enlargement or hypertrophy ; aneurism ; rup - ture of the heartare each practically illustrated. Of the formation of polypus in the heart, independent of the comments, two cases are given, "which appear to prove most clearly, not only that these concretions may form during life, but occasionally cause death. On disease in the valves of the heart, the illustrative remarks and appearances may, it is hoped, be regarded with interest and advantage ; urging the importance of the ste- thoscope, demonstrating the fatal result of the disease, and pointing out the means by which its early progress may be detected and checked. Aneurism of the thoracic aorta presents an important subject for study, "With a view to its discrimination; the practical illustrations here adduced are calculated to throw some interesting light on the symptoms, appear- ances, and treatment. Abdominal aneurism also offers some valuable prac- tical illustrations; in three of the cases aneurism was cured, in one by an ?peration, in the two others by the natural process ; one case is added, not ?f aneurism, but of disease simulating aneurism so closely as to defy all power of discrimination. The consequences of tumour formed in the poats of the aorta, near its origin, are shewn in two curious and interest- cases. Where the course of the circulation is interrupted by oblitera- tion or obstruction of the aorta, the facility and efficiency with which the collateral circulation may be established, is most admirable and astonishing. Jext follow remarks on obstruction from varicose enlargement, or from in- flammation, of the veins ; the discrimination of these complaints being as- sisted by a variety of practical illustrations. Obstruction to the circula- 10n from local disease of viscera, gives rise to much interesting illustration ?f various kinds. The first case mentioned of soft white tubercles sur- r?nnding the large vessels of the heart, is believed to be of rare occur- ence. th remar^s on the symptoms and discrimination of inflammation in i e lungs, and its consequences, in various forms of effusion, may, it is |J0Ped, be found useful at the bed side ; they are illustrated by examples ydrothorax, empyema, abscess, or ulceration with haemorrhage, haemor- 4 Medico-chirurgical Review. [Juty * rhage witliout ulceration, and, lastly, tubercular disease. Then come tlie symptoms and discrimination of disease in the liver, commencing with in- flammation, acute and chronic, abscess, purulent hydatid cyst, and serous hydatid cyst. Irritation from biliary calculi introduces several exceedingly curious and interesting practical illustrations; among which may be mentioned the enormously enlarged ducts within the liver, in the absence of a gall-bladder; the detection of permanent spasm of the gall-ducts; the escape of calculi by ulceration; and the large fungoid tumor, with a collection of calculi in its centre. These are followed by affections of stomach, spasm, inflammation, effu- sion, ulceration, mortification, hfjemorrhage, and organic or specific disease. Then succeed the diseases of the intestinal canal; altered action of the mucous exlialants, separating albumen, pus, or blood; deranged muscular action or spasm, with the means for more efficiently detecting its existence and precise seat, noticing certain very peculiar symptoms, probably the result of reflex irritation, obstruction, and intus-susception, inflammation and ulceration of the mucous tissue, and occasional influence of ulceration on the nerves of the lower extremities, abdominal abscess, and specific disease in the bowels. In the last place are described the various forms and appearances of hernia, some of the illustrations of which are believed to be very rare ; the case of thyroideal hernia, especially, presenting a diagnostic symptom that appears not to have been before observed. In a work made up of miscellaneous facts, like the present, a systematic analysis would be impossible. All that can be done is to select those ob- servations that are likely to be useful or are novel, and lay them before our readers. The genius of medical literature in this country, and the practical tastes of the profession are not altogether repugnant to works of this description. On Chronic Pain in the Head relieved by Incision. There are, says Mr. Howship, certain cases of chronic pain in the head, occasional or constant, from injury or otherwise, generally seated in one spot, over which the scalp is painful, tender, and somewhat tumid; in which medicine is of little or no use. In these cases, a division of the scalp, by an incision, carried across the spot down to the bone, will prove the most efficient treatment. The relief experienced from this operation is such as can only be ex- plained in the light atforded by pathological anatomy, which enables us to see that, in many chronic affections of the scalp, the membranes of the brain, and especially the dura mater, participate; inducing pain, and all the ill consequences of congestion of the brain. Mr. Howship relates two cases. The first was that of a lady aged 31, who had suffered from pain in the head, for years, in spite of all medical treatment. Division of the tumid and tender scalp gave immediate and permanent relief. The second case is still more interesting. H. D., a coachman, a sober man, complained of severe pain in the head, distressing him many years, 1841] Mr. Hoivship on Surgical Diseases. 5 and of late so severe that he was scarcely able to sit on the box ; and when up, dreaded the attempt to get down. Medicine useless; nearly dis- tracted, and tired of his life. He said that, sixteen years before, he struck his head, by a fall, upon some soft meadow ground; that from the con- fusion that followed he soon recovered, but became subject to pains in the head, especially in the seat of the injury, over the left parietal bone, where the scalp was still sore, painful, and puffed. Mr. Howship cut through the scalp and thickened pericranium, down to the bone, which was uneven and rough, but not carious. The night before this operation he had not slept five minutes, from severe pain, but said he felt relief the moment the bone was exposed, and the following night rested better than for months before, getting three or four hours' refreshing sleep. The wound nearly healed in a month ; the old pain partially returned, with a sense of numbness in the side of the face, as before the operation ; but the wound again suppurating, remained open several months longer, and then healed permanently. From this time he lost all his complaints ; continued well; and some years afterward told Mr. H. he never was in better health than he then enjoyed. On Ulcerative or Interstitial Absorption of the Cranium, from Irritation or Injury. Mr. Howship was consulted by Mr. B., a gentleman who stated that, thirty-two years previously, he had suffered severely under the removal ?f nearly the whole necrosed right, and part of the left, parietal bones, from syphilis. He recovered his health, and for very many years remained Well, with a large depressed cicatrix, beneath which was a smooth expan- sion of new bone, deposited in the granulations from the dura mater. Lately, he had been rendered extremely uneasy, by a part of the cica- trix spontaneouslv ulcerating, without local pain or other sign of ill health. The ulceration extending, a few thin, small scales of new formed bone came away. Within a fortnight he was attacked, for the first time, with gout. The ulceration healed, although his gradual recovery occupied several months; but there was no subsequent return. Mr. Howship conceives that it was the irritation of the latent gout that gave rise to the inflammation. We are not so sure of this. Disease of ^e bones, after syphilis (probably mercurial), is very apt to recur without ai*y ostensible cause, and it might as well give rise to the gout, as the g?ut to it. Occasionally," says Mr. II., "from external injury, in young children, some extent of the skull has been removed by interstitial absorption. If blood .eeffused beneath the scalp, leeching may lessen its quantity: but if not, should be let out?and when ? Art early opening may add a second irritation to the :irst; and any delay in letting it escape may perhaps operate to induce absorp- .]on of the subjacent bone. As a rule, I think it best to make an early open- s' 7. H. relates two cases that occurred in children. We shall introduce one. 6 Medico CHiuuitGicAL Review. [July 1 Case.?T. G., aged three years, fell down an area, struck the back of his head, and was taken up senseless. Under proper treatment he re- covered ; but a month after, a considerable tumour remained just above the lambdoidal, and over the sagittal suture. The elevated scalp soft and yielding ; the pulsation of the brain was distinctly perceived in the tumor, even by the eye ; so that any opening incautiously made through the scalp might have injured the dura mater or brain, and destroyed life. The opening in the skull was three inches long and one broad; the ossific margin in parts presenting a raised and compact, or slightly tuberculated edge. Neither is this liability to absorption from external injury confined to an early period of life. In one instance, Mr. H. detected a small opening produced in the vertex of the skull, through which the brain pulsated, in an aged woman ; the consequence, she said, of a bruise from a blunt iron, many months before ; yet productive of little pain or inconvenience. Mr. Howship mentions the particulars of a curious Case of Extensive Absorption and Necrosis of the Cranium, with Atrophy of the Brain. 11. H., aged 36. who stated that she had never had syphilis nor used mercury, had suffered for the last fourteen years from extensive necrosis of both parietal bones ; the separation of numerous pieces from both jaws, with or without teeth ; portions of the left frontal bone ; the angle of the right lower jaw ; and more recently the mastoide process of the right temporal bone, which came away by the mouth, while the attachment of the sterno-mastoide muscle nevertheless remained undisturbed. On the superior part of the right side of the head, the brain appeared to have been adequately defended by a formation of new bone beneath the extensive cicatrix upon the scalp, where pulsation, formerly obvious, could not now be felt. The most curious point, however, in this case is, that although the de- ficiency of bone in the cranium is partially supplied, the form of the skull has undergone an astonishing though slowly progressive change. The right side of the cranium has sunk to a much lower level than the left, the corresponding hemisphere of the brain having sunk also, in conse- quence of progressive atrophy of its substance; for the configuration of the head demonstrates that in this direction the cerebrum must have un- dergone absorption of a part of its mass, nearly or quite equal to one pound weight. It is remarkable, also, that in this case the deficiency in the cerebrum being principally on the right side, the defective condition of the nervous and muscular powers of the limbs is on the right side also. The superior part of the frontal region has at the same time sunk ex- tensively on both sides, completely changed the aspect of the profile. The mental operations are remarkably disturbed. The only medicine that has been of any service in relieving the extreme feelings of irritation that exist about the head is sarsaparilla. " This extremely interesting and curious change in the frontal bone, I mentioned to a gentleman well known for his distinguished labours in phrenological science. I supposed it new ; but he immediately pointed to a cast demonstrative of a similar change in a late illustrious personage, 1841J Mr. How&hip on Surgical Diseases. 7 who, in the decline of intellectual power, sustained a great diminution in the volume of the anterior lobes cerebri; the sinking of the cranium, in- sensibly following the declension beneath it, from absorption of the brain; as proved by the casts taken." Fracture of the Basis Cranii not fatal. _ There can be no question that fatal as this accident usually is, it occa- sionally does not prove so. Mr. Howship relates two interesting cases of recovery. One we shall introduce. Case.?T. C., 68, fell down stairs, upon his head. Blood flowed freely from the mouth and ears, through the night; the discharge from the ears subsequently becoming purulent. Symptoms of concussion were soon relieved. Six months after, with much pain at the back of the head, he could obtain sleep only with the back of his head on a pillow, but not on either Slde ; and was often obliged to sit up in bed all night, holding his head With his hands. Occasionally he was delirious and rambling, but never violent, with severe pain in the night, always less in the day. Two years after the accident, this man still rested very badly ; subject to stupor and giddiness, even in the day, and often starting suddenly up ln the night, as if delirious, when not so. One night he jumped up in bed, and began talking strangely ; his wife accused him of being light- headed, but he said no, he was perfectly awake, and sensible. " appears to me, then, that where a patient, under injury of the basis of the cranium, may have partially recovered; by the presence of the symptoms just noticed; bleeding and suppuration, in one or both auditory passages; congestive and uneasy feelings, about the basis of the brain; want of power to bear pres- sure on the head, and the mild nocturnal delirium ; the practitioner may be in- structed to give a guarded and cautious opinion, as to any eventual restoration to Perfect health." 15. Temporary Amaurosis, from Affection of the Omc Nerve. It would appear probable, says Mr. H., that a temporary amaurotic blindness may, now and then, arise from a transitory suspension of power the optic nerve, in which, from the undisturbed state of the organ of Y^ion, on the one hand, and the absence of any sign of congestion or af- fection of the sensorium on the other, we seem obliged to admit that the defect must be confined to the optic nerve ; the temporary character of the attack at the same time forbidding the inference of existing organic dis- ease. Case.?Mr. F., aged 30, mentioned to Mr. Howship a curious affection ? s^ght to which he was liable, about six years before. He had a feeling dumbness in the right eye, and, within a minute, total loss of sight,, so ]. ^ c?nld not perceive the flame of a candle when held to it. 1 his ed three or four minutes, and then gradually subsided ; at first he ?u ^ see the light without distinguishing objects, and in ten or fifteen 8 Medico-chirurgical Review. [July 1 minutes was quite well. This attack, which returned twenty or thirty times in the space of six months, was never attended, preceded, or followed by pain or other complaint in the head. He had requested a medical friend, more than once, to look at the eye during the attack and compare it with the other, but he could discern no difference between the two. On Deficient Development of Parts. Mr. Howship alludes to a series of cases having one character in com- mon, that of deficient growth or development, or a wasting of the mus- cular structure of the limbs, in consequence of affection of the brain from which the nerves proceed, or of disease in the vicinity or course of these nerves. These complaints are all essentially characterized by an inadequate transmission or unequal distribution of nervous influence. Mr. Howship relates two cases of paralysis and deficient development of the limbs, arising from the cerebral congestion produced by teething. We quote one. Case. E.F., a healthy child, eighteen months old, from the irritation of dentition, suddenly lost the use of the left side ; she was no longer able to stand on the leg or move the arm, which, if raised, fell powerless. Mr. H. directed a blister to be kept open on the neck, and the bowels to be cleared. In a week she was able to stand a little; the improvement more slow in the arm, the fingers could only be partially moved in a month. In three months apparently recovered ; in six months the blister was allowed to be healed. It was curious to observe, during subsequent growth, the deficient sym- metry in the two sides. At thirteen years, the left arm was much smaller, and one inch and a quarter shorter than the right; a similar deficiency also existing in the leg. At eighteen, the left arm measured one inch and a half less in length than the right; and the left leg, only two-thirds the circumference of the right, was two inches shorter than the other. She was still unable perfectly to extend the fingers of the left hand, but could walk firmly and freely. Mr. H. also gives a case of deficient development of the right arm and leg from congestion of the brain, produced by fever. From these he passes to cases of another sort. 1. Case of deficient Development from External Injury.?E. T. 14. Fell down stairs when four years old, and bruised the hip. She subsequently had repeated abscesses about the hip-joint, followed by slow retraction of the limb. The retraction eventually subsided, but the deficiency in growth remained. Mr. H. found, on examination, the hip-joint sound, but the affected leg much emaciated, very weak, and, when measured, four inches shorter than the other. 2. Case of deficient Growth, from Cold, by sitting on Damp Grass.? C. C., jet. 20, when two years old, was carelessly laid on the left side upon 1841] Mr. Hows/up on Surgical Diseases. 9 some damp grass. She took cold, her left leg became weak, and some time after was observed not to keep pace with the other in growth, be- coming thinner, smaller, softer, and shorter. On comparing the limbs together, Mr. H. found the left leg and thigh very much smaller and Weaker, and three inches shorter than the right; and as to power, she was not able to walk more than a quarter of a mile a day. " In several cases of chronic dysentery, I have seen lameness and wasting of the lower limbs; in one particularly, in a young man, the patient became per- fectly and permanently helpless, the thighs drawn up, the legs completely re- tracted and incapable of motion. In these affections the diagnosis will be suffi- ciently easy : the absence of any organic disease in the limbs and the presence of symptoms demonstrative of dysenteric irritation in the bowels, cannot fail to ex- plain the character of this complaint." 32. Air. Howship adds, that the mere act of volition, unequally exerted, the mere habit of using one limb more freely or frequently than the other, may lead to the same result; as in the following case. Case.?J. C. a strong, healthy man, applied for a high-heeled shoe, his left leg being shorter than the right. He said he was very well till bound apprentice to a turner, he found that standing constantly on the left leg, und working the treadle as constantly with the right, pain often distressed his left knee, and the limb gradually declined in growth. On comparing the limbs, Mr. H. found much enlargement about the left trochauter, apparent shortening of the neck of the femur, and a degree of stiffness, at first appearing to arise from anchylosis. The left, just three ^ches shorter than the right leg, was extremely thin and deficient com- pared with the right, which was muscular, large, and vigorous. Effusion of Serum within the Head. . Mr. Howship remarks, what we confess gives rise to some misgivings lQ our mind, that?" There is an occasional symptom especially diagnostic ?f external hydrocephalus or effusion between the membranes; when Present, I should say it is impossible to mistake the seat of the deposit. Yne of the cases in which I observed this symptom most distinctly was the following." ^rs. D., 53, with hydrothorax and anasarca, was for years subject to ?ccasional attacks in the head, in which, always disposed to doze, her Senses were observed by all her family to be yet awake to the lightest and e.ast impression ; but the peculiar symptom was this, that, whether in the ^ght or day, she would be at one and the same time light headed, yet Penectly sensible ; speaking to herself incoherently, yet, if spoken to, flswering clearly and rationally. On examination, Mr. H. found abun- ant serous effusion between the membranes, but no accumulation in the Utricles. ~ Dryness of the Pia Mater. * r- Howship has never witnessed but one case of this. c?se.-?j. s., 37, of sober and silent temper, complained of violent pain 10 Medico-chirurgical Review. [July 1 in the head and loins; the latter arose from red gravel, which was occa- sionally passed with the urine. The violence of head-ache made him stagger and affected his sight, yet he could get no sleep. In dressing his horses, it was often expected he would get kicked, for he frequently went to the heels instead of the head, not seeming to know what he was about. Mr. S. visited him before his death, to draw off his urine; the eyes in- sensible to light, the pupils dilated, and the mental and physical powers entirely oppressed. The next day he died. On laying aside the dura mater, Mr. H. found the arachnoide and pia mater unusually dry, just as if exposed for twenty-four hours in a warm air, so dry as to feel positively firm and crisp. The ventricles contained about four ounces of serum ; the medullary substance of the brain was so firm, that the cavities did not even partially collapse on the escape of their contents. On Injury by Lightning. " In my Course of Lectures on Surgery, I am in the habit of comparing con- cussion of the brain from external violence with the impression induced by the electric shock; but, on following out the parallel, it becomes extremely doubtful whether concussion should be selected in preference, when so many widely different results also arise from this peculiar description of injury. It may be supposed scarcely necessary to devote much pains to ascertain the cause when so active an agent has been concerned, for these phenomena loudly proclaim themselves; and if instant death was the invariable result in every such case, it might be an inquiry of comparatively little importance; but when we find that all the various effects of injury from other causes are occasionally produced by lightning, we see the evident and high importance of considering and discrimi- nating as correctly as possible, not so much the cause, as the precise changes of condition to which it may have given rise, in order that we may thence be enabled to decide with advantage upon the most appropriate treatment." 41. Mr. Howship adds that, as the injury sustained depends not on the quantity but the intensity of the electric fluid, the influence of one and the same shock will occasionally induce strange diversities of effect, ac- cording to the position of individuals or the conducting power of sub- stances near them at the moment of the accident. One of the most remarkable circumstances regarding the effects of the electric shock on the living body is this; that while the mildest power incurs only a slight, sudden, contraction in the muscles, with sense of pain in the nerves, ligaments, and joints, and a more severe shock excites vio- lent convulsive action, the most severe shock, demonstrating the greatest intensity of power, is productive of effects of a diametrically opposite character. The rapidity of thought is proverbial, and the quickness with which the convulsion responds to the passage of the ordinary electric shock, is sufficiently remarkable, but under the greatest intensity of power, the passage of the electric fluid seems too quick even for the nerves them- selves ; for instead of the body being most violently disturbed, it is not moved at ail; and if the person was sitting by the fire, or asleep, he so remains to all appearance, until discovered to be dead. Where sudden death is thus produced, it appears that the transmission of the shock through the body at once exhausts the vital power, and com- 1841] Mr. Howship on Surgical Diseases. 11 pletely destroys the living principle ; and this takes place with such incon- ceivable rapidity as to effect its purpose before even the nervous system can take the alarm ; and that the living principle is instantly destroyed, in the solids and fluids, is evinced by the muscles not stiffening, the blood not coagulating, and the whole body sinking almost immediately into putre- factive decomposition. Mr. H. relates several cases?one of slight injury from lightning, which Merely produced red marks in the skin of the back, of a delicate arbores- pent character, not painful or elevated, but slightly heated?another case, lri which a stroke of lightning gave rise to all the symptoms of concussion of the brain?a third case, in which, after a lightning stroke, concussion, followed by violent tremors and febrile excitement, terminated in purulent effusion between the membranes of the brain?and finally, several other cases in which the effects were such as would ensue from rupture of a blood-vessel in the cranium. Mr. Howship relates some interesting cases of Abscess in the Brain, "Without, however, we are afraid, rendering our diagnosis much more certain. Speaking of Hydatids in the Brain, he observes (we wish we c?uld be so confident):?The distinguishing symptom here appears to be occasional attack of convulsion or insensibility, which scarcely disturbs, 111 the least degree, the intellectual functions; from which attack, where the case presents in its most simple form, the patient is absolutely restored t? his activity of body and clearness of mind almost in an instant, the at- tack coming on and going off suddenly. On Ramollissement of the Brain. Mi\ Howship makes some observations on the causes and on the treat- ment of this serious affection. After noticing the inflammatory hypothesis Lallemand, and the opinion of llostan, that it depends on a morbid state ?f the cerebral vessels, he remarks:? ? / % ?wn opinion is with M. Rostan, that ramollissement may arise as an ac- C1(fental consequence of inflammation, yet that it certainly does often occur with- out any evidence of preceding inflammatory excitement. But I also believe that may take place without inflammation on the one hand, or disease of blood-ves- sy ?n the other. The importance of this opinion, if correct, must be at once ^Jrmtted, seeing that it presumes the disease to be, in certain cases, so far more in u-n reach of relief, than was before supposed. I feel assured it may arise this way, and that in two cases to be presently related, it did so arise, from ex- 0^SsiVe mental fatigue, inducing long continued congestion of the brain; and in e ?f these cases it will especially be seen, that the adoption of an antiphlogistic c J?rse would soon have destroyed life, but that a watchful attention to the indi- an l?nS t^lat presented, and the persevering direction of the most powerful tonics patientynCS' Provec* obviously efficient means of saving and restoring the 0r^r" howship criticises the sentiments of M. Rostan on the incurability, ac S0Tnething very like it, of ramollissement, and then presents us with an vatiQlnt the symptoms as they have occurred under his own obser- 12 Medico-chirurgical Review. [July 1 "We now then come to the symptoms, by which ramollissement may be dis- criminated. As I have seen them, they may be said to include the following. Occasional pain, uneasy feelings or giddiness in the head, the impressions through the senses disturbed, the least sound insupportably agonizing, moderate light dis- tressing, the feelings now and then so acute, that the lightest touch extorts most piteous cries, the sentient nerves in the extremities deranged, with feelings of numbness, or of a sandy sensation about the toes and fingers, stiffness in the limbs, rendering the walk unsteady or unsafe, the temper of mind changed to extreme impatience, uncontrollable dejection, or absolute indifference, total want of sleep, or, when dozing, disturbed by most frightful dreams, the mental faculties invariably affected, perception slow, judgment difficult, memory feeble or false, imagination gone, ideas confused, the patient dreads and perhaps cannot endure the least conversation, or if for a few minutes exposed to it, subsequently sinks into the most alarming state of exhaustion. As the disease advances, the patient, especially under the least mental occupation or excitement, is liable to a sudden attack, something between coma and convulsion, in which, although de- prived of utterance, and to appearance near death, he is perfectly conscious of his state. From this attack he revives, and after an uncertain interval sustains a re- turn, more severe than before, perhaps with paralytic symptoms, imder which he at length sinks. These then are the leading symptoms. They rarely all occur in the same in- dividual, but the presence of any two or three of them would be sufficient to enable the attentive practitioner to discriminate this most fearful disease. If, for example, the sensations described in the head occurred in connection with the morbid acuteness of sensation in the skin or in the ear, together with any of the other symptoms, they would offer a combination, which, regarding its steady permanence, could scarcely be supposed to be the consequence of inflammation, hysteria, or any disease we yet know of, except that now under consideration." 60. Mr. Howship relates several cases of fatal ramollissement, and two instances of cure. We shall introduce the shorter of the two, and leave it to our readers to decide what degree of credit they will attach to the belief that the affection was really cerebral softening. Case.?Mr. F. 50, a gentleman in the law, long subject to uneasy feel- ings in the head, had to visit Chester. Anxious occupation through the preceding week, in considering and arranging the various causes for trial, had made him much worse ; and when in court, in the midst of his duties he fainted outright, sunk down completely powerless, and slightly con- vulsed, yet conscious, hearing all that was said, although unable to speak. Dr. Thackery saw him, and directed aperients, spare diet, and quietude. A relative went down, brought him to London, and Mr. Howship found him complaining of frequent returns of violent shootings through the right temple, and faintings ; also a sense of numbness all through the right side, with sandy feelings in the hands and feet. Dr. Hooper visited him with Mr. Howship ; his bowels were kept freely cleared, which, with an occasional gentle opiate at night, light diet, and the most perfect quietude, were beneficial. The fainting fits and feelings of exhaustion became less frequent and less severe. The pulse, never excited, was now soft and small, at sixty. The strength and power in the limbs, in the course of a month, much improved ; and the preceding distortion of the features and closing of the left eyelid, had quite disappeared. He still walked with a stiff and awkward gait, the soles of his feet not seeming to himself to feel A 1841] Mr. How ship on Surgical Diseases. 13 the floor ; and so weak, that one morning he fainted on the night-chair, and being alone, fell to the ground. As to the previous affection of sight, he told Mr. H. first came the double sight, then the sickness without vomiting, and then the fainting in court. The double sight was not strictly so, but a multiplying of one ?hject to many. Or, if he took a pen and put it down on the paper, it "Was placed half an inch away from where he intended; and when he had Written, he found it was in the wrong place. He observed there was the same error in kind now, only much diminished in degree. There was also a little flickering in his sight still; but otherwise he felt quite as well, and even better now, than before he left town. For many subsequent weeks, this gentleman was directed the vinum ferri, the shower bath, a nutritious diet, and wine; the bowels being con- stantly attended to. Under this plan, he so far recovered as entirely to lose all his complaints, except that he had still a very slight sense of occa- sional sandiness in his hands, a peculiarity in feeling which remained so ^te as six years subsequent to the attack. We certainly know of no positive reason why ramollissement of the hrain should not in its earlier stages be curable. The difficulty is to say When the affection really exists, or, rather, when such a morbid lesion has bee?i cured. We pass over several subjects, to pause at two, not very common cases, ?ne of inflammation, the other of abscess of the thyroid gland. Case.?Inflammation in the Thyroid Gland.?J. D., 16, took a severe c?ld, the submaxillary glands becoming somewhat, and the left lobe of the thyroid gland more, enlarged. Mr. H. found the latter swelling firm and ^ard ; the skin covering it dry and hot. The tumor, closely attached to the base of the larynx, moved with it in deglutition. For a day or two, With heated skin, quick pulse, and white tongue, stinging and shooting pains were severe. A grain of calomel, ter die, in a few days subdued the symptoms, and he was relieved from all uneasiness; the indurated and ?rny feel of the swelling subsequently, but slowly, subsiding. Case.?Inflammation and Abscess in the Thyroid Gland.?A mail guard, exposed to a deep snow, took cold, felt poorly and stiff about the jaws; lnflammation settling with much heat and tumor about the larynx and trachea, impeding respiration to an alarming degree. The tumor, heated and red, was firm as horn, with feverish disturbance. Although the larynx ^as nearly fixed, it was evidently enough inflammation of the thyroid S^and. Poultices and fomentations, assisted by tonics, in a few weeks in- Uced suppuration, and the abscess broke and discharged several ounces of PUs, to his relief and comfort. He now breathed more freely, and rapidly ^proved in appetite, spirits, and strength ; the abscess healing in about thr<* weeks. UppURATIO>r IN THE SUB-MUCOUS CELLULAR TlSSUE OF THE LARYNX. ^ e notice the following case for reasons that we shall state immediately. 14 Medico-ciiirurgical Review. [July 1 Case.?A. B., 30, had a succession of acutely painful, and actively sup- purating boils, on the thigh, forearm, and back of the hand. When the ulcer on the forearm, which had discharged portions of fascia and tendon, had been open nine or ten days, the secretion of pus suddenly diminished, and in two days ceased entirely; and on the same day he felt uneasiness in his throat. In a few days, respiration became impeded, from some cause, situated evidently in the larynx. Towards evening, the difficulty in breathing was alarming, his features betraying most extreme anxiety and distress. Supported in bed, a consultation was immediately called ; antispasmodics directed, and a blister laid on the chest; at six a.m. he expired. Post mortem.?The cause of death was confined to the thyroide catilage, the space within which had been so restricted as to produce suffocation. The cartilage divided, the cellular tissue connecting the mucous membrane to the cartilage was inflamed, thickened, and diseased, especially just be- neath the arytenoide cartilages, where it formed a spongy, elastic cushion, projecting from each side, and closing the passage into the trachea. This spongy substance, cut into, numerous globules of a thick purulent matter started forth; the colour and consistence of the pus, and other cir- cumstances of this case, presenting a strong analogy to the character of carbuncle. We draw particular attention to this case, because it is the representa- tive of a class. It is, unfortunately, far from uncommon for a patient to complain of what seems and is treated as a simple sore-throat, and sud- denly to be cut off. On examination after death, suppuration is discover- ed in the sub-mucous cellular tissue of the larynx. It is hard to lay down any diagnostic signs of this affection. But when the symptoms seem severe beyond their apparent cause, and the expression of distress is disproportioned to it, we should recollect the possibility of suppuration and beware. Stricture of tue (Esophagus. " In the detection and treatment, the superiority of the silver ball and elastic curved wire, over the ordinary instrument, the bougie, cannot be too much in- sisted on, exciting much less irritation, and conveying much more information, as to the state of the pharynx, the precise extent of the contraction, and exact condition of the oesophagus below." 93. The following case is not devoid of interest:? Case.?Inflammatory Spasmodic Stricture of the (Esophagus.?" Mrs. E., G3, from severe cold and sore throat, had great and increasing difficulty in swallow- ing. Afraid of losing a desirable situation, she concealed her complaint, and foolishly neglected her health, until, from want of support, she became emaciated, typhoide, and so weak that she could not stand. In this state I found her, with black and parched tongue, small rapid pulse, hot skin, and thirst. With diffi- culty I persuaded her to let me introduce the smallest silver ball to a contraction at the bottom of the pharynx, which the instrument would not pass. Unable to take medicine, incapable of taking food, and evidently perishing from want, she was nevertheless sufficiently obstinate to throw away still more valuable L 1841] Mr. Hows/iip on Surgical Diseases. 15 tune, in resisting for several clays her daughter's entreaty and my persuasion, to allow the instrument to be again introduced. She then did submit, and I soon passed the stricture, so that now she could get down small morsels of meat. But now another difficulty arose, for although the food passed fairly down, it was almost directly rejected again. It appeared that the stomach, so long inactive, had become so irritable and contracted, as to be scarcely capable of relaxation ; a difficulty in which medicine appeared likely to be of little service. She was therefore enjoined to persevere in taking nourishment, solid or fluid, in small quantities, frequently repeated, notwithstanding its rejection. This she did, and soon began, very gradually to improve. The feverish excitement slowly sub- sided, the power of retention returned, the strength was restored, and she per- fectly recovered." 96. We are induced to believe that patients are occasionally treated for stricture of the oesophagus, as for stricture elsewhere, without any just occasion. Nor is the mistake always a harmless one. Bougies in the hands of those unaccustomed to them are sometimes dangerous weapons, nay, they may be so even in good hands. Sir A. Cooper used to relate a case which occurred to Sir E. Home and himself. He had found a diffi- culty in passing an instrument down the oesophagus ; Sir E. Home was called in. He took the instrument, passed it in good style, and injected through it milk and water into the stomach. Violent symptoms soon set 1n, and in a few hours the patient died. On examination, the milk and Water were found in the posterior mediastinum ! and we have seen a bou- gie take the same route in overcoming a stricture which was not in ex- istence. Malignant Disease in the (Esophagus. . ' The discrimination of malignant disease in the oesophagus may, under some Circumstances, be doubtful, but where the complaint has existed some time, and ne symptoms are considered with care, the seat and cause may almost always ? determined with precision. In some few cases, exhibiting every peculiarity o scirrhous structure, the characteristic pains have not been apparent; but ^exceptions are extremely rare. I he presence of the peculiar heat and darting pains of scirrhus, may be held _ y to establish the existence of this disease, while their absence only leaves the jlUestion doubtful. The discrimination of soft cancer, or fungoide tumour, may e assisted by recollecting, that the constitutional tendency in this disease is ^'ays to irritation; a condition, the presence of which will always render its -ystence probable ; and, if seated in the upper part of the oesophagus or plia- x> there may even be the peculiar darting pains along the eustachian tubes served in scirrhus." 97. ^ e confess that we have witnessed cases of malignant disease in the ^sophagus, more particularly of the fungoid kind, unattended with pain, of an^ ot^ier symPtom than difficulty of swallowing. In one or two ^ these cases their real nature has been dubious, and the diagnosis mainly Unin^ ?n ^h0 Pecu^ar aspect of the patient. The following case is not JtSE-?Stricture from Fungoid Tumour in the Pharynx. Mrs. H., 36, been some years subject to aching pain and difficulty in swallowing, 16 Medico-ciiirurgical Review. [July 1 whenever she took cold, a complaint first felt in a severe sore throat. The small silver ball would not pass an obstruction at the lower part of the pharynx, from whence a ropy mucus was freely excreted. The throat ex- hibited no appearance of disease, but externally, the right side, opposite the larynx, felt rather full, soft, and tender to the touch. Although the
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