708THEBRITISHMEDICAL_OURNAL.[MayI8,1878.ofthenervecentres,andperhapsal - PDF document

708THEBRITISHMEDICAL_OURNAL.[MayI8,1878.ofthenervecentres,andperhapsalso,Iwouldadd,ofthenervesin-volved.Itapparentlycorrespondswiththetransitoryparalysisinducedbyphysiologistsintheloweranimals,bypassingastronggalvaniccurrentthroughthespinalcordormotornerves;or,inaminordegree,withthefatiguethatfollowsunwontedandexcessivevoluntarymuscularexercise.5.Itseemsprobable,fromthefactthattheseverepainwhichaccom-paniedtheconvulsionswasfollowedbyephemeralanaesthesiaintheaffectedmembers,thatthecentreforsensation,andpossiblyalsothecorrespondingsensorynerves,wereinastatesimilartothoseformotion.Thisassociationisanalogoustowhatisobservedinhemi-plegiaduetoorganiclesion,and,justasinit,thesensorydefectwasevenofshorterdurationthanthelossofmotorpower.6.Itisworthyofbeingrecalledthatanaloguesofconvulsionswithexcessivepain,followedbytemporarypalsyandanaesthesia,existinthesphereofspecialsensation,asinacaserecordedbymeintheBR1-TISHMEDICALJOURNAL(Aprili8th,I874),inwhich,atthebeginningofanepilepticseizure,aballofredfirewasseenbythepatient,whoforsomehoursafterwardswasunableproperlytorecognisethatcolour.AndIthinkwealsoseeananalogousconditioninthesphereofmindinthedegreeofdementiawhichordinarilyfollowsanattackofacutemaniabeforerestorationoffullmentalpower.ONTHETREATMENTOFPUERPERALHYPER-PYREXIABYCOLD.ByALFREDWILTSHIRE,M.D.,F.R.C.P.Lond.;JointLectureronMidwiferyandtheDiseasesofWomenandChildrenatSt.Mary'sHospital;Vice-PresidentoftheObstetricalSocietyofLondon.DR.PLAYFAIR'Scaseofpuerperalsepticamia,withhyperpyrexia,treatedbythecontinuousapplicationofcold(recordedintheJOURNALforNovember17th),opensupfordiscussionthepracticeoftreatingsuchcasesbytherapidabstractionofheat,aremedywhichhasprovedofinestimablevalueinothergravemaladiesaccompaniedbyhyper-pyrexia.AsIamabletocontributeparticularsoftwocasessimilarlytreatedbyamethodwhichappearstopossesssomeadvantages,IavailmyselfoftheopportunitynowaffordedbyDr.Playfair'scommunica-tiontolaythembeforethereadersoftheJOURNAL.ThecaseswerebrieflynarratedatameetingoftheSouth-EasternBranchonDecembergth,I875(seetheJOURNALforDecember25th,I875);butnoparticularshaveuntilnowbeenpublished.Intheautumnof1873,IsucceededmyfriendandcolleagueDr.Edisinthechargeofthein-patientsoftheBritishLying-inHospital,aninstitutiontowhichIwasthenphysician.Ingivingthepatientsintomycharge,Dr.Edisremarkedthattherewassomethingwrongabouttheplace;fornoneofthemothershadatemperatureunderIoodeg.Fahr.,uponwhichIobservedthatIshouldfeelcompelledtoclosethehospital,ifthingscontinuedinanunsatisfactorystate.Iregrettosaythatclosureimmediatelybecamenecessary,onaccountoftheserioussymptomswhicharoseintwonewlyadmittedpatients.AdayortwoafterItookcharge,twohealthyyoungwomen,primi-parae,weredeliveredinthehospital.Bothweremarried,wereagedrespectively23and26,andhadfairlygoodlabours,therebeingnothingabnormalineithercase.Ihadthetemperaturewatched,ashasnowformanyyearsbeenmycustom,andveryspeedilyitattainedhighfigures.Therewasnolocalconditionineithercasetoaccountforthisabnormalelevationoftemperature,anditappearedtobeonlytooclearlyduetotheunhealthysurroundingsofthepatients.Findingthatquinineinlargeandrepeateddoses,intra-uterineirrigations,purges,andsoon,wereineffectualforthereductionoftheexcessivelyhightemperature,whichineachcaseexceededio6deg.;andfeelingpersuadedthatsuchhyperpyrexiawasincompatiblewithlife,iflong-continued,Ibadthepatientspackedroundwithvesselscontainingice;hotwater-tins,soda-waterandotherbottles,beingfilledwithbrokenice.Thisdrycoldmethodwasselectedbecauseitobviatedthenecessityofremovingtheprostratepatientsfromtheirbeds:apointwhichhasalwaysseemedtometobeofmuchimportanceinthetreatmentofhyperpyrexiabycold,sincethepatientsforwhomitisnecessaryareusuallyextremelyexhausted.Thetemperatureineachcasewaspromptlyreduced,butitroseagain,afteravariablefashion,whenthecoldwasremoved,andoccasionally,Iamboundtosay,apparentlyinspiteofit.Still,inthemain,whenitwascarefuilyandassidu-ouslyapplied,theeffectofthismethodofreducingtemperaturewasdistinct,andthereliefexperiencedbythepatientswasattimesgreatandpalpable.Theonlyinconveniencearisingfromitsusewastheinabilityofthepatientstosleepduringitsapplication.Chillingoftheskinappearedtobeattendedbyincreasedvascularsupplytothenervouscentres,andconsequentwakefulness.Thismightdoubtlesshavebeenobviatedifwehadthenhadatcommandtheefficientmeanswenowhaveforcoolingthehead;viz.,theice-cap.Asitwas,soundsleepspeedilyfollowedtheremovalofthecold;thecerebralvesselsbeingobviouslyrelievedbytheflushingofthoseoftheskin.Formanydays,awearyfightwaskeptupwithflactuatingsuccess,thetemperatureoccasionallyremainingnormalforseveralhours.Ultimately,oneofthepatientsrecovered,andtheother,tomygreatregret,sank.Unfortunately,nonecropsywasobtainable.Ibelievethat,couldwehaveremovedthepatientwhosecaseendedfatallyfromthebuilding,shealsowouldhaverecovered;for,againandagain,hertemperaturefelltonormalornearit,andsheappearedtobeonthevergeofconvalescence;sheseemed,however,togetfreshdosesofpoisonandrelapsedaccordingly.Whattendstoconfirmthisviewisthefactthattheotherpatient,whooscillatedinlikemanner,onlyrecoveredonbeingremoved,thoughatsomerisk,toherhomeatCroydon.Inneithercasewasthereanypurulentcollectionorotherabnormalcondition,exceptthat,intheonethatendedfatally,therewasatonetimeslighttendernessoftheuterus.Bothwerewhatmightbecalledichorrhaemiccases;theywerepoisonedbytheiren-vironments,thepoisonexertinginthempowerfullyphlogogenouseffects.Thisisbyfarthemostfatalformof"puerperalfever";inmyexperience,itismuchmorerapidlyandcertainlyfatalthanwhere"puerperalfever"isaccompaniedbysuppuration.Someweeksafterwards,onattendingameetingoftheSouth-EasternBranchatCroydonastheguestofDr.AlfredCarpenter,IfoundthesurvivingpatientintheCroydonHospital,whithershehadbeentakenshortlyafterherremovaltoherhome.Herappearanceinterestedmegreatly;for,fromaplumpblondewithplentyoffairhair,asshewaswhenIfirstsawher,shehadchangedtoathindusky-skinnedwomanwithscarcelyanyhair.Herappearanceshowedplainlytheseverityofthestruggleshehadgonethrough:herepidermicstructuresgenerallyhadwithered,asusuallyhappensafterpostpartuminflamma.tions.Inboththecasesjustrelated,theskinwasoccasionallyspongedwithcoldwater.Therewasonenoteworthydifferencebetweenthem,inas-muchasonlyoneofthepatientsperspired,andthatwasshewhore-covered.Theother'sskinwasobduratelydry,anditisobviousthatherpowerofradiatingheatwascorrespondinglydiminished.Effortsweremadetoinducesweating,butunsuccessfully.Herfriendssaidtheyhadneverknownhertoperspire.Theadvantageofapplyingcoldtohyperpyreticpatientswithoutmovingthemisobvious.Itisespeciallyuseful,forexample,inacutearticularrheumatism,andincasesoftyphoidfeverwhereperforationofthebowelfromulcerationisdreaded,sincemovementfromthebedtoabath,orviceversd,mightprecipitatebursting.Thisplanhasalreadybeenattemptedwithpartialsuccessbywetpackingandsoon;butthepackingaroundwithvesselscontainingiceinadditiontothewetsheetorspongingappearstobeareadyandpowerfulmeansofabstractingheatwithoutundulydisturbingthepatient.Besidesitsvalueinpuerperalcases,asillustratedbyDr.Playfair'scaseandbytheforegoing,Ihavealsofounditofgreatvalueafterovariotomy.Duringthepastyear,Iuseditinconjunctionwithanotherandsimilarmethod,alsoveryvaluable-theice-cap-in,amongothers,twocasesofovariotomyattheWestLondonHospital.Bothpatientsrecovered,andIbelievetheyowetheirrecoveryinnosmalldegreetothepromptabstractionandsubsequentcontrolofheatbythecontinuousapplicationofcold.Myownobservationsenablemetoconcurfullyintheopinionthatthecontrolofabnormallyhightemperaturesbytheapplicationofcoldisnotonlylargelyfeasible,butthatitisatherapeuticagentofimmensevalueinagreatnumberofcases.Imeanthat,bytherapidreductionofhyperpyrexia,notonlydoweremoveexcessiveanddangerousheat,butalsothatprobablywe,atthesametime,hinderitsproduction:aresultofenormousimportance.Iam,therefore,quiteatonewiththosewhoconsiderthatweoughtnottowaitforfoudroyantmanifest-ationsofhyperpyrexia,butthatalarmshouldbetakenearly,andeffortsmade,ifpossible,tosuppressitsgenesis.Therearedoubtlessstillunusedmethodsofdoingthis,anditwillwellrepaythosewhoarecalledupontoemploycoldtodevisemeanssuitabletodifferentcases.Forexample,wherethepatientcanbearremovalfromthebedtoabathofcoolwaterwithoutrisk,nothingcanbebetter;butnumbersofpatientscouldonlybesomovedatgreathazard,andthensuchmea-suresaswater-bedsandcushionsfilledwithcoldwater,vesselscontain-ingice,ice-caps,spongingwithcoldwater,wetpacking,exposuretocoldair,andsoon,mightbeadopted.Wetpackingmay,inamodifiedway,beadvantageouslycombinedwithice-packing;and,asbothareapplicablewithoutunduedisturbanceofthepatient,theyare Mayi8,1878.]THEBR1IISHMEDICAL7OURNAL.o09valuableauxiliariesincasesofmarkedprostration.Moisteningtheskinandallowingfreeevaporationnotonlyfavourstheradiationofheat,butisalsoextremelygratefultofeveredpatients.Ihaveadoptedthecombinedplanwithdecidedadvantage.Ihavemorethanoncestated,attheObstetricalSocietyandelse-where,thatquinineappearstoexertmuchlessinfluenceoverhyper-pyrexiaofichorrhbemicoriginthanoverthatassociatedwith,ifindeeditbenotdependentupon,suppuration;andIwouldventuretosuggesttheprobabilitythattheichorrhaemiccaseswhichshowthehighesttem-peraturesandarethemostrapidlyfatalmaybemorefavourablyinflu-enced,ifnotentirelycontrolled,bytheassiduousapplicationofcoldthanbytheadministrationofquinine,valuableasthatdrugdoubtlessisinothercases.Thebrilliantresultswhichhaveattendedthead-ministrationofsalicylicacidanditssaltsinacuterheumatism,usuallyanon-suppurativedisease,leadonetohopeforsimilarresultsinpuer-peralsepticoemiaunaccompaniedbvsuppuration.Icannotforbearre-markingthatourpresenttherapeuticalresourcesencouragethebeliefthatwearebetterabletocopewith"puerperalfever"initsvariousformsthanheretofore,moreespeciallywhentheiremploymentisnotundulydelayed.Itonlyremainsformetosaythatthefurtheradmissionofpatientsintothehospitalwasimmediatelysuspendedontheappearanceofun-favourablesymptomsinthetwopatientswhosecasesIhavejustre-lated;andthat,oninspection,quiteenoughwasfoundtoaccountfortheunhealthystateofthebuilding.Thoroughmeasureswereresortedtowithmarkedsuccess,andtherecommendationthatthehospitalshouldbeclosedperiodicallyforthoroughcleansinganddisinfectionwasadoptedbytheauthorities.Thisplanhasbeenattendedbymarkedsuccess;andIlearnfromthematron(Mrs.Freeman)that,atthepresenttime,theconditionofthepatientsismostsatisfactory,althoughothermetropolitanlying-inhospitalsarenotsofreefrommis-chiefascouldbewished.Theactingmatron(Mrs.Thompson)de-servesawarmacknowledgmentoftheintelligentskillwithwhichsheattendedtothetwopatientswhosecasesarerelatedabove.TWOCASESOFHYPERPYREXIATREATEDBYTHECOLDBATH.ByA.T.H.WATERS,M.D.,F.R.C.P.,PhysiciantotheLiverpoolRoyalInfirmary.THEfollowingcasesmayperhapsbeconsideredworthpublishing.Theirpublicationhasbeendelayedbytheunsuccessfulendeavourtorecoverthelostnotesofathirdcase-oneoftyphoidfever-treatedonsimilarprinciples.CASEi.-IwassummonedonMay15th,I876,toseeapatientwhowasunderthecareofDr.JohnstoneofUpholland,anditiswithhisconsentthatIpublishthecase.Thepatientwasamarriedladytwenty-sixyearsofage,ofstrumousaspect,sufferingfromanattack(thefirst)ofacuterheumatism,withpericarditis.HerattackhadcommencedonMlay8th,andshewasfirstseenbyDr.Johnstoneontheioth,whenthetemperaturewasIO4deg.Duringthefourfollowingdays,thetemperature,whentaken,rangedbetween104deg.and105deg.Isawthepatientat5P.M.onMayiSth,abouttheeighthday.Thecasewasoneofsevererheumaticfever,andthephysicalsignsofpericarditiswerewellmarked.Thepatientwasrestless,butfreefromdelirium.Thepulsewas120,andthetempera-ture104.2deg.Theurinewasveryacid.ThetreatmentwhichhadbeenadoptedbyDr.Johnstonewastheadministrationofbicarbonateofpotash,withbarkandopium,andfourouncesofbrandydaily.Ire-commendedthatthetreatmentshouldbecontinued;thedoseofpotash,however,tobeincreased,andthatofopiumdiminished.Ifurtheradvisedthat,shouldthetemperaturerisetoIO6deg.,thepatientshouldbeputintoabathat95deg.,tobecooleddownto75deg.or70deg.Onthefollowingday,atIP.M.,Dr.Johnstonefoundthetemperatureio6.-2deg.,accompaniedwith"furiousde-lirium".Dr.Johnstonesays:"Ihadherputintoabath(tepid),whichwasquicklycooleddowntoperfectlycold.(Icannotgiveyouthetemperature,butthewaterwascoldfromthepump.)"Thepatientwasinthebathhalfanhour.Thedeliriumsensiblydecreasedduringthistime.Shesleptalittlethenightafterthebath,and,onthefol-lowingday,shesleptprofoundlyfortwoorthreehours,andafterthistherewasnodelirium.At10.30P.M.ofthei6th-viz.,betweeneightandninehoursafterthebath-thetemperaturewas102.6deg.OntheI7th,at9A.M.,itwas103deg.;at3.30P.M.,102.8deg.;andat10P.M.102.8deg.Dr.Johnstonesays:"Beyondthis,Ihavenofurtherrecord.Icanonlysaythatherprogresstowardsrecoverywasuninterrupted.ShelefthomeabouttheendofJunefoide,feelingperfectlywell,butwithaslightsystolicmurmur.'CASEii.-E.W.,adomesticservant,nineteenyeaadmittedintotheLiverpoolRoyalInfirmary,underNovember2ISt,I876,sufferingfromtyphoidfever.Shehnfinedtoherbedforaboutaweek,buthadnotbeenuntreatment.Therehadbeenslightloosenessofthebowels,utcideddiarrhoea.Shewasorderedmilkandbeef-tea,andeffervescingmixture,threetimesaday.Onthemorningofthe22nd,thedayafteradmission,thetemperature(thenandafterwardstakenintheaxilla)wasIOIdeg.,andintheeveningI04.6deg.Onthe23rd,itwasioI.8deg.inthemorning,and104.6deg.intheevening.Threeouncesofbrandywereorderedonthisday.Onthemorningofthe24th,at9.30,thetemperaturewas105.6deg.;at12.15,IO6.4deg.;andat1245,whenIpaidmyvisittothehospital,ithadrisentoio6.8deg.Therewasnodelirium;butthepatientwasrestless.BeingunabletoremainattheInfirmary,Igavedirectionsthatthetemperatureshouldbetakeneveryquarterofanhour,andthat,ifitroseto107deg.,thebathshouldbeused.AtI.15,thetemperaturewasfoundtobe107.2deg.,andthepatientwasputintoabathatioodeg.,whichwasgraduallyreducedto75deg.Thepatientwasinthebathanhourandfiveminutes,andonremovalhertemperaturewas99.6deg.At3P.M.,tengrainsofquinineweregiven,andwerevomited;at3.35,fivegrainsweregiven,andretained.Thetempera.turebegantorisesoonafterthebath,andat5.15itwasIO5.6deg.,andthebathwasagainused;thetemperatureofthewaterbeing99deg.atthebeginningand76deg.attheend.Thepatientwasinthebathanhour,hertemperatureonremovalbeingioo.8deg.At6.30,fivegrainsofquinineweregiven.Thetemperatureagainroseafterthesecondbath,andat8.I5itwasIO3.8deg.;andthehouse.physicianthoughtitbesttousethebathagain.Thepatientremainedinithalfanhour,thetemperatureofthewaterbeing97deg.atthebeginningand76deg.attheend.Onremoval,thepatient'stem-peraturewas99.8deg.Shewasputtobed,andIsawherimme-diatelyafterwards,andorderedfivegrainsofquininetobegiveneveryfourhours.Shesleptduringthenight,and,at9.30A.M.onthe25th,thetemperaturewas99deg.andthepulseIOO.Shehadperspiredfreely,andhadtakensixdosesofquinine,withagooddealofmilkandbeef-tea,andnineouncesofbrandy,sincethefirstbath.Thequininewasnoworderedtobetakeneverysixhours.Thehighestrecordedtemperatureofthisdaywasatmidnight;viz.,104.2deg.;butitsoonfell,and,at9A.M.ofthe26th,itwas100.4deg.,andintheevening102.4deg.Onthe27th,greatpainwascomplainedofintheleftside;butnosignsofpleurisyoranyinflammationcouldbedetected.Thepaincontinuedforsomedays,andwasrelievedbysub-cutaneousinjectionsofmorphia.Thequininewasdiminished,andthepatienttooknothingbutmilkandbeef-tea,withamoderatequan-tityofbrandy.Therewasnodiarrhoeathroughout,andonlyafewcha-racteristicspotsappeared.Forafewdays,thetemperatureremainedverymoderate,andtherewasnocomplication;but,ontheeveningofDecember2nd,thetemperaturewasfoundtobeIO4.8deg.,havingrisenfrom99deg.sincethemorning.Thepatientwascarefullywatched,andfive-graindosesofquinineweregiveneverysixhours.Thetemperaturesoonbegantofall,and,ontheeveningofthenextday,itwasIOOdeg.Withtheexceptionofariseofthetempera.tureto102.5deg.onDecemberioth,andofI03.5deg.onthe13th,therecoverywasuninterrupted.ShewasdischargedfromthehospitalonJanuary5th,I877,thetemperaturehavingbeennormalforafort-night.NOTESONACASEOFMULTIPLEEXOSTOSES.*ByTHOMASJONES,M.B.,F.R.C.S.,SurgeontotheChildren'sHospital,Manchester.THEconditionofseveralexostosesdevelopedinthesameindividualisasufficientlyrareoccurrencetoinducemetoplaceonrecordthefollowingremarkablecase.Wm.S.,aged9,anativeofWarrington,wasadmittedintotheChildren'sHospitalonJuly3rd,I877.Theimmediatecauseoftheparentsseekingadvicewasalargetumourspringingfromtheposteriorsurfaceoftherightlegabouttwoinchesbelowtheknee.Thismass,ofirregularshapeandfirmconsistence,wasfoundtospringfromibothbones.Theskinoverthetumourwasofnormalcolourandfreely,movable.Afurtherexaminationoftheboyresultedinthedetectionofanumberofbonyoutgrowths,ofvarioussizesand*ReadbeforetheSectionofSurgeryattheAnnualMeetingoftheBritishMedicalAsociationinManchester,Augustz877.