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CLINICAL SOCIETY OF LONDON. FRIDAY, OCT. 11TH, 1872.
562 is of the necessary thickness. The splint is then soaked in the mixture and immediately applied. Cysts of the Spermatic Cord.-Tbe patient had a somewhat large cyst on each cord, so that the scrotum seemed to contain four testes. One of the cysts was punctured with a trocar in our presence. The liquid presented the appearance peculiar to spermatic cysts, and on microscopical examination was found full of living spermatozoids. A solution of tincture of iodine was injected.
paration
Naso-phai-lingeaZ Polypus in a girl of fifteen.-This was quite an unusual case of naso-pharyngeal polypus in a female.
’
Dr. Labbe said he did not know of any other case on record. We saw the polypus operated on. The galvano-caustic knife was used, and the soft palate was slit neatly and quite clean. The tumour was then seen bulging forward, and was immediately removed by the galvano-caustic wire. No hasmorrhage took place. The patient bore the operation very bravely. The growth was of the size of a small hen’s egg.
Medical Societies. CLINICAL SOCIETY OF LONDON. FRIDAY, OCT. 11TH, 1872. SIR WILLIAM GULL, BART., M.D., F.R.S., IN THE CHAIR. DR. SOUTHEY read ACUTE
a
paper
RHEUMATISM WITH
on
CEREBRAL
SYMPTOMS AND HIGH TEMPERATURE TREATED UNSUCCESSFULLY BY COLD AFFUSION.
The author related the case of a well-built man, aged thirtyfive, of highly nervous temperament, in the habit of drinking wine and beer, but not intemperate. This was his first attack of acute rheumatism. The rheumatic articular inflammations were not established until after he had been ailing for fourteen days, with a temperature ranging between 100° and 102’5°. The rheumatic symptoms were well marked. The invasion of several joints with swelling and redness, the tongue, the pulse, and the sweating, were highly characteristic. On the eighteenth day of illness pericarditis set in, the joint inflammation suddenly subsided, and delirium of a peculiar kind, preceded by head pain and obscurity of vision, presented itself; the temperature now ranged between 104° and 105° in the axilla for ten days, while twelve grains of quinine, from six to ten ounces of brandy per diem, and various opiates, as well as chloral, Bronchial were administered with little sedative effect. symptoms now ensued, with great failure of power, although food and stimulants were freely taken. Delirium, akin to coma vigil, still continuing, and his temperature marking 105°, the patient was immersed in a bath quickly cooled down from 96° to 71°. The effect was immediate dissipation of delirium, with reduction of temperature to 1005°, followed by short repose ; but, the bodily temperature quickly rising again, he was wrapped in a wet sheet and exposed to a temperature of 65° for an hour. After this his temperature fell, and remained between 101° and 102° for two days. Some rest was now obtained, the pulmonary symptoms were relieved,and respiration fell from 36 to 28 per minute. Subsequently the wet sheet was frequently employed on four occasions, as often as three times in the twenty-four hours, with invariable relief as to the delirium and subsultus. From the eighteenth day of his illness up to I the fortieth quinine was given, in doses varying from twelve ’, to twenty-four grains in the twenty-four hours, as well as from four to ten ounces, without noticeable good or ill effect. On the thirty-third day of his illness his temperature fell spontaneously to 1005°; he was then quite rational for twelve hours, and there was a slight return of the rheumatic pains in the joints, which lasted, however, only for a few hours. The patient gradually sank with low broncho-pneumonic symptoms on the forty, second day of his illness. The post-mortem examination revealed that swollen condition of the glandular viscera ordinarily discovered after all acute febrile diseases, but no tubercle was discovered anywhere in the body, and no apparent mischief in the brain or its membranes. The author of the communication considered the case one of cerebral rheumatism, and thought that the cold-water treatment had prolonged life and relieved the delirium.
brandy,
The PRESIDENT asked if, at the post-mortem examination, the bronchial system was found to have been involved, asit appeared to him that the matter had been overlooked. Dr. BUZZARD asked the author whether it was not probable that the patient had been a hard drinker, and that hence some of the symptoms may hfive been those of delirium tremens; and Dr. SouTHET replied that he did not believe the patient drank to excess, inasmuch as a little alcohol affected him considerably. Dr. WILSON Fox, in commenting upon the relations of delirium tremens to temperature, could speak only of fatal cases. He remarked, for the purpose of eliciting opinion, on the low temperature at which the cold affusion was used. He thought that the treatment should be adopted exclusively as an extreme measure, and the question was, should you wait until the temperature has attained what may be called at present a fatal height., say till it reaches 106° or 107°. He did not believe in fatality in acute rheumatism unless indeed 109° was reached ; but it appeared that a case of Dr. Murchison’s, with a temperature of 106-5°, is the highest recorded in which recovery naturally took place. He doubted very much whether death often took place from pericarditis, and thought, therefore, it was best,. except in extreme cases, to watch the patient through the disorder, believing that the cold affusions did no good, and might cause bronchial complications. Dr. WEBER thought the case before the Society different both from those of Dr. Fox and those that he (Dr. Weber) had met with, for the temperature was not at first high101° to 103-5°, but suddenly rose to 108° and 109°, ending in recovery after a single relapse. The delirium also was different, and, he thought, if cerebral complications did not exist, the wet sheet was a good and successful plan of treatment. Dr. THEODORE WILLIAMS said he had tried the cold affusion in three cases of phthisis without any subsequent symptoms of bronchitis, the water being heated at first to 85° and reduced to 72°, and the patient kept in the bath twenty-five minutes. The PRESIDENT inferred that the case was one of typhoid rheumatism, and suggested that the sudden rise of temperature indicated an association with delirium tremens, as distinguished from acute rheumatism, which elicited from the author of the paper that his patient was in the habit of taking beer for breakfast. A MEMBER remarked that successful cases had occurred with higher temperature than that recorded, and Dr. WEBER said that usually the affection of the joints was slight before the head symptoms commenced, and increased in intensity as the latter diminished. The PRESIDENT quoted the case of a lady, aged thirty-two, in which, with a temperature of 107’5°, a bath at 90°, cooled to 42°, was given, which brought the temperature down to 97.5°. The mind became clear, the joints were much relieved, the bath was repeated, and the patient is now convalescent. Dr. GREENHOW also read elaborate notes of an interesting case of acute rheumatism with high temperature unsuccessfully treated by cold water. Dr. WILSON Fox opined that we had yet a great deal to learn in the matter, for as prominent symptoms we had, firstly, a sudden rise of temperature, with little else, and secondly, a rheumatic pyrexia, ending fatally. He suggested that the best plan was to prescribe cold affusion as a means of conquering hyperpyrexia, waiting for the result; and that it was a moral duty to treat thepatient with cold water when the temperature reached 107°. The real question, of course, to be decided is, do we avert death by cold affusion?2 Mr. HULKE thought the treatment rough, and that cold air might be more easily applied. He had always, in surgical cases of hyperpyrexia, given large doses of quinine with good effect. Dr. ANSTTE also asserted his belief in large doses of quinine in reducing temperature, and Mr. COOPER FoRSTER subscribed cordially to this plan of treatment in pyæmio hyperpyrexia. Mr. GEORGE LAWSON said that patients usually died, although the temperature was lowered, and Dr. GREENHOW, in reply, reiterated his faith in the cold and said that, according to his belief, quinine did not
merely
baths,
affect temperature.
paration
Naso-phai-lingeaZ Polypus in a girl of fifteen.-This was quite an unusual case of naso-pharyngeal polypus in a female.
’
Dr. Labbe said he did not know of any other case on record. We saw the polypus operated on. The galvano-caustic knife was used, and the soft palate was slit neatly and quite clean. The tumour was then seen bulging forward, and was immediately removed by the galvano-caustic wire. No hasmorrhage took place. The patient bore the operation very bravely. The growth was of the size of a small hen’s egg.
Medical Societies. CLINICAL SOCIETY OF LONDON. FRIDAY, OCT. 11TH, 1872. SIR WILLIAM GULL, BART., M.D., F.R.S., IN THE CHAIR. DR. SOUTHEY read ACUTE
a
paper
RHEUMATISM WITH
on
CEREBRAL
SYMPTOMS AND HIGH TEMPERATURE TREATED UNSUCCESSFULLY BY COLD AFFUSION.
The author related the case of a well-built man, aged thirtyfive, of highly nervous temperament, in the habit of drinking wine and beer, but not intemperate. This was his first attack of acute rheumatism. The rheumatic articular inflammations were not established until after he had been ailing for fourteen days, with a temperature ranging between 100° and 102’5°. The rheumatic symptoms were well marked. The invasion of several joints with swelling and redness, the tongue, the pulse, and the sweating, were highly characteristic. On the eighteenth day of illness pericarditis set in, the joint inflammation suddenly subsided, and delirium of a peculiar kind, preceded by head pain and obscurity of vision, presented itself; the temperature now ranged between 104° and 105° in the axilla for ten days, while twelve grains of quinine, from six to ten ounces of brandy per diem, and various opiates, as well as chloral, Bronchial were administered with little sedative effect. symptoms now ensued, with great failure of power, although food and stimulants were freely taken. Delirium, akin to coma vigil, still continuing, and his temperature marking 105°, the patient was immersed in a bath quickly cooled down from 96° to 71°. The effect was immediate dissipation of delirium, with reduction of temperature to 1005°, followed by short repose ; but, the bodily temperature quickly rising again, he was wrapped in a wet sheet and exposed to a temperature of 65° for an hour. After this his temperature fell, and remained between 101° and 102° for two days. Some rest was now obtained, the pulmonary symptoms were relieved,and respiration fell from 36 to 28 per minute. Subsequently the wet sheet was frequently employed on four occasions, as often as three times in the twenty-four hours, with invariable relief as to the delirium and subsultus. From the eighteenth day of his illness up to I the fortieth quinine was given, in doses varying from twelve ’, to twenty-four grains in the twenty-four hours, as well as from four to ten ounces, without noticeable good or ill effect. On the thirty-third day of his illness his temperature fell spontaneously to 1005°; he was then quite rational for twelve hours, and there was a slight return of the rheumatic pains in the joints, which lasted, however, only for a few hours. The patient gradually sank with low broncho-pneumonic symptoms on the forty, second day of his illness. The post-mortem examination revealed that swollen condition of the glandular viscera ordinarily discovered after all acute febrile diseases, but no tubercle was discovered anywhere in the body, and no apparent mischief in the brain or its membranes. The author of the communication considered the case one of cerebral rheumatism, and thought that the cold-water treatment had prolonged life and relieved the delirium.
brandy,
The PRESIDENT asked if, at the post-mortem examination, the bronchial system was found to have been involved, asit appeared to him that the matter had been overlooked. Dr. BUZZARD asked the author whether it was not probable that the patient had been a hard drinker, and that hence some of the symptoms may hfive been those of delirium tremens; and Dr. SouTHET replied that he did not believe the patient drank to excess, inasmuch as a little alcohol affected him considerably. Dr. WILSON Fox, in commenting upon the relations of delirium tremens to temperature, could speak only of fatal cases. He remarked, for the purpose of eliciting opinion, on the low temperature at which the cold affusion was used. He thought that the treatment should be adopted exclusively as an extreme measure, and the question was, should you wait until the temperature has attained what may be called at present a fatal height., say till it reaches 106° or 107°. He did not believe in fatality in acute rheumatism unless indeed 109° was reached ; but it appeared that a case of Dr. Murchison’s, with a temperature of 106-5°, is the highest recorded in which recovery naturally took place. He doubted very much whether death often took place from pericarditis, and thought, therefore, it was best,. except in extreme cases, to watch the patient through the disorder, believing that the cold affusions did no good, and might cause bronchial complications. Dr. WEBER thought the case before the Society different both from those of Dr. Fox and those that he (Dr. Weber) had met with, for the temperature was not at first high101° to 103-5°, but suddenly rose to 108° and 109°, ending in recovery after a single relapse. The delirium also was different, and, he thought, if cerebral complications did not exist, the wet sheet was a good and successful plan of treatment. Dr. THEODORE WILLIAMS said he had tried the cold affusion in three cases of phthisis without any subsequent symptoms of bronchitis, the water being heated at first to 85° and reduced to 72°, and the patient kept in the bath twenty-five minutes. The PRESIDENT inferred that the case was one of typhoid rheumatism, and suggested that the sudden rise of temperature indicated an association with delirium tremens, as distinguished from acute rheumatism, which elicited from the author of the paper that his patient was in the habit of taking beer for breakfast. A MEMBER remarked that successful cases had occurred with higher temperature than that recorded, and Dr. WEBER said that usually the affection of the joints was slight before the head symptoms commenced, and increased in intensity as the latter diminished. The PRESIDENT quoted the case of a lady, aged thirty-two, in which, with a temperature of 107’5°, a bath at 90°, cooled to 42°, was given, which brought the temperature down to 97.5°. The mind became clear, the joints were much relieved, the bath was repeated, and the patient is now convalescent. Dr. GREENHOW also read elaborate notes of an interesting case of acute rheumatism with high temperature unsuccessfully treated by cold water. Dr. WILSON Fox opined that we had yet a great deal to learn in the matter, for as prominent symptoms we had, firstly, a sudden rise of temperature, with little else, and secondly, a rheumatic pyrexia, ending fatally. He suggested that the best plan was to prescribe cold affusion as a means of conquering hyperpyrexia, waiting for the result; and that it was a moral duty to treat thepatient with cold water when the temperature reached 107°. The real question, of course, to be decided is, do we avert death by cold affusion?2 Mr. HULKE thought the treatment rough, and that cold air might be more easily applied. He had always, in surgical cases of hyperpyrexia, given large doses of quinine with good effect. Dr. ANSTTE also asserted his belief in large doses of quinine in reducing temperature, and Mr. COOPER FoRSTER subscribed cordially to this plan of treatment in pyæmio hyperpyrexia. Mr. GEORGE LAWSON said that patients usually died, although the temperature was lowered, and Dr. GREENHOW, in reply, reiterated his faith in the cold and said that, according to his belief, quinine did not
merely
baths,
affect temperature.