624

artery and vein. 2. That immediate ligature (i. e. beforethe collateral channels have had time to enlarge) of boththe femoral artery and vein, and especially of the commonfemoral vessels, is liable to be attended with gangrene,although this risk is probably less than has generally beenassumed. 3. That ligature of both vessels when, in con-sequence of pressure, as of a tumour, the collateral circula-tion has become established, is attended with much less riskof gangrene. 4. That when the femoral artery and vein arewounded, ligature of the artery and pressure on the vein, ifthe wound of the latter vessel is a mere puncture, is a safetreatment, provided that the nature of the injury allows ofreasonable prospects of the external wound being kept asepticand uniting by the first intention. 5. That. when the woundin the vein is too large to permit of treatment by pressure,the walls may be safely nipped up and a ligature thrownaround them without obliterating the calibre of the vessel;but that this procedure should only be resorted to, as in theformer case, when there is a reasonable prospect of thewound healing by the first intention. 6. That consideringthe grave risks of gangrene that attend the sudden oblitera-tion of the common femoral vein, the lateral ligatureshould in this situation, for all small and moderate-sizedwounds that require immediate ligature, be the treatmentadopted. - Mr. HULKE had ligatured simultaneously intwo cases of cancerous ulceration the external iliac arteryand vein without any apparent ill results following.There was a great difference between aneurysmal varlxand varicose aneurysm; in the former an elastic bandagemight almost do away with its evil effects. A case

was mentioned of a pistol-shot wound, in which the femoralartery and vein were bruised ; the necropsy, ten days afterthe accident, showed that in a little more time the escharbetween the lumen of the artery and vein would have givenway and led to a direct communication between artery andvein. He had obtained good results in cases of lateralligature of such veins as the internal j ugular and longitudinalsinus.-Mr. HARRISON CRipps commented on the difficultyof discovering whether both vessels were injured, and hesaid he was disappointed with the title of the paper. Heremarked on the great value of pressure in the treatment ofwounded vessels; but this pressure must be done very ,,

systematically and intelligently, the most effective way I,being first to bandage the limb, and next to apply compresses ’’,above, below, and on the wound, with the pressure so ’,arranged as to be easily shifted on to different parts asrequired. He did not place much reliance on statisticsdrawn from published cases. - Mr. THOMAS SMITHnarrated the case of a boy in whom both vessels werewounded, and led to an aneurysmal varix, and inwhich systematic treatment by pressure ended in a cure.-Mr. PEARCE GouLD narrated the case of a lad under Mr.Lawson’s care in which it was found advisable to ligaturethe artery, and with a very good result. Wounds in thearteries should, he considered, be treated in the same way,regardless of the situation of the artery. He did not feelsure of the value of delay, and pointed out some of the evileffects of pressure, making one hesitate about waitingbefore cutting down and securing both ends of the artery.-Mr. WALSHAM, in reply, could not agree with the remarksof Mr. Cripps on pressure, which bad been tried in his owncase with, he thought, the approval as to method of Mr.Cripps. He agreed with Mr. Gould that if there was muchextravasation into the tissues Guthrie’s rule should be fol-lowed, but not otherwise. No harm could result from waitinga few days and trying pressure.

CLINICAL SOCIETY OF LONDON.

Hyperpyre,ria Treated by Cold.-Gall-stones causingSuppuration; operation; recovery.

AN ordinary meeting of this Society was held on the23rd inst., Dr. W. H. Broadbent, M.D., F,R.C.P., President,in the chair.

Dr. WILLIAM M. ORD read a paper on a case of Hyper-pyrexia in Acute Rheumatism treated by Ice-pack. The

patient was a man aged thirty-two, a heavy beer drinker,who had contracted, three weeks before admission to St.Thomas’s Hospital, a sharp attack of acute rheumatism, re-ferred to exposure to cold. On admission, he was found tohave acute inflammation of many joints, marked signs ofpericarditis and slighter signs of endocarditis, with some

pleurisy. His temperature was 1024°; the respirations werequickened; the urine contained one-sixth ot albumen andvery little chloride. He was slightly delirious. Twodayslaterthe delirium had increased to such a degree that it wasnecessary to remove him from the large ward to a single-bedded ward. He was very violent, had hallucinations anddelusions, and was with difficulty kept in bed. The deliriumstrongly suggested the existence of hyperpyrexia, but thetemperature was only 1014°. After this the temperaturerose steadily, till at 4 A.M. on the morning of the fourth dayfrom admission it reached 108’40, while the patient had falleninto a state of restless unconsciousness, with tremors. Theice-pack was now applied, and was maintained for fourhours, at the end of which the temperature was 100°, thepatient had recovered consciousness and spoke sensibly, andthe pulse had fallen from 160 to 100. During the next fewdays the temperature, after a rise to 1034°, kept between1000 and 101°. The signs of pericarditis disappeared, butthose of endocarditis remained. The joint affection hadgreatly decreased, and the albumen had disappeared from theurine. On the seventh day after admission the temperatureagain began to rise, and at 2 P.M. on the morning of theeighth day was 1054°, the patient having passed throughdelirium into restless unconsciousness. The ice-pack wasagain applied. At 5 A.M. the temperature was 100°, and thepatient had recovered consciousness. After this the patientmade a steady recovery, and was discharged six weeks afteradmission in good general health and without sign of lungor heart disease. The treatment was effectively carried outby Dr. Ord’s house physicians, Dr. Wheaton and Mr.Macevoy. Dr..Ord brought the case before the ClinicalSociety, not because it presented anything new or original,but with the intention of emphasising the value of coldapplications to the surface of the body in hyperpyrexia. Heurged that, notwithstanding the acknowledged value of thevarious antipyretic drugs in pyrexia, their use in hyper-pyrexia was comparatively unsafe, large and frequent dosesbeing required, whereby toxic symptoms were often pro-duced. He admitted that the bath treatment was not ofuniversal applicability, but pointed out that it involved nopoisoning, and had a remarkable effect, not only in reducingtemperature, but in restoring the nervous system to anatural condition. The rapid disappearance of inflamma-tion in the thoracic viscera and joints was also noteworthy,

Dr. C. J. ARELE read notes of two cases of Hyperpyrexiasuccessfully treated by Cold. The first case was that of arailway clerk, aged twenty-seven, married, who was

admitted into University College Hospital on Sept. 21st,1887, with an ordinary attack of rheumatism. Previoushealth and habits good. Had syphilis nine years ago. Hismother died after an attack of acute rheumatism. His sisterwas rheumatic. On admission he was treated with largedoses of salicylata of soda. The night after admission hebecame very delirious, the joint pain disappeared, the skinwas hot and burning, and the temperature went up to 1104°.After employing the ice-cold bath for forty minutes thetemperature fell to 97°, but ran up four hours later to 107’2°,while taking antifebrin. The bath was repeated for twenty-five minutes, after which the temperature fell again andshowed no further tendency to run up excessively. Therewas no visceral lesion. The patient was ultimately dis-charged cured. The second case was that of a marriedwoman, aged thirty. She had rheumatic fever eighteenyears ago ; no complications. There was no family historyof rheumatism. Had been ailing with joint pain for a weekbefore she was seen by a medical man. Temperature at middayon Oct. 9th, 1887, was 1025°, at 10.30 the same night 1l0’io,Patient violent and delirious. No bath was available, soshe was treated with ice-cold packs. The temperature fellin one hour later to 101°. For the next twenty-four hoursit averaged 103° ; then fell to normal under salol and ali-cylate of soda. Was discharged well on Oct. 27th. Shewas readmitted with another attack of acute rheumatismand pericarditis, but was now convalescing. Dr. Arkle saidthat these cases show the value of the cold bath and packas antipyretics. Both belong to the type in which thetemperature, after maintaining for one or two days amoderate level, suddenly rises to an excessive height, Inboth cases the temperature was very tractable, and hadlittle tendency to run up repeatedly. The cases threw nolight on the etiology. One was a male, and the other afemale; one a first attack, and the other a second. Bothseemed mild, uncomplicated attacks. In both there wascessation of sweating, and in one disappearance of articular

625

pain. In both the delirium accompanied the hyperpyrexia,and was of the same violent character. Both patients hadmarked retraction of the head, and one severe or persistentopisthotonos.Dr. MACLAOAN concurred in the treatment. As to the

physiology and pathology of the hyperpyrexia, he arguedthat the metabolism of the tissues was interfered with

through the nervous system, there being a kind of paralysisof the inhibition which normally kept the tissue changeswithin bounds. He drew a distinction between the pyrexiaand hyperpyrexia, especially in rheumatic fever. The resist-ance orinhibition of the heat centres being removed, hyper-pyrexia resulted, and this was therefore of nervous origin,and afforded the reason for salicylates being useless in truebyperpyrexia. Cold increased the inhibition of the heat centres,and did not act simply mechanically or physically. Coldacted on the heat inhibitory centres pretty much in thesame way as digitalis did on the cardiac nervous centres.Cold therefore not only relieves the fever, but cures thenervous cause of the fever.-Dr. COUPLAND thought thatthe distinction between pyrexia and byperpyrexia washardly justified; for pyrexia is due as much to nervous de-rangement as hyperpyrexia, and in both cold acted as aremedial agent. lIe called attention to the marked nervoussymptoms which heralded the rise of hyperpyrexia inDr. Ord’s case. Prodromal symptoms were very generallyobserved.-Dr. BROADBENT considered that the delirium andcoma were not due merely to the high temperature, butwere rather to be partly attributed to nerve disturbance ofthe same order as caused the hyperpyrexia. In relapsingfever nervous symptoms were sometimes observed precedingand accompanying great rises of temperature. He" hadobserved in rheumatic cases delirium of the hyperpyretictype, but hyperpyrexia did not occur always. Both caseswere treated by salicylates, and both ended fatally. Besidesthe abstraction of heat, an impression was made on thenervous system by the cold, and this enabled the heatcentres to resume control over the heat-producing processes.- Dr. BASIL G. MORISON mentioned the case of an infantfourteen days old, whose pulse, consequent on over-feeding,fell to 30 per minute, the skin becoming cold. A drachmof tincture of belladonna was injected into the rectum,whereupon the pulse rose to 180 and the temperature to103°. The child’s life appeared to be in danger. Ice wasapplied and the pulse and fever fell. The heart stopped fora few beats. The child recovered. As an illustration of theaction of cold, the case was thought to be interesting.-Dr. ANGEL MONEY said that the expression used by thepatient in Dr. Arkle’s first case afforded an illustration ofthe principle of dissolution as expounded by IIughlingsJackson.--Dr. BARLOW described a method he had practisedof employing cold water, which chiefly consisted in pouringwater from a height on to the patient lying in bed inclineddownwards from the head, a mackintosh being arranged tocarry the water off into a vessel at the foot of the bed.He had treated cases successfully on this plan, which couldeasily be carried out at the patient’s home, and made thefriends less timid than did the employment of the whole bath.- Dr. ORD, in reply, pointed out that Dr. Maclagan’s theoryof hyperpyrexia being due to paralysis of the heat inhibitoryapparatus was supported to some extent by Dr. Buzzard’sview’s as to rheumatic fever being due to an affection of themedulla, in which the heat centre was supposed to belocated. He argued that the effect of the cold was notmerely mechanical, and recalled some experiments which hemade a year ago on the effect of cold baths on the dead. Hehad found that a bath which in the living would bringdown the temperature several degreas had very little effecton the dead body. He considered that although the mechanismof the production of pyrexia and hyperpyrexia might be thesame, the same stimulus wiich in one man would cause anormal reaction (fever) gave rise in another to an exaggerated ’,reaction (hyperpyrexia). He advocated recourse to preventivemeasures wherever the temperature exceeded 105°. He addedthat he attributed the delirium accompanying pericarditisnot to this affection, but to the effect of arising temperature.He preferred the graduated bath as less uncomfortable andless dangerous.-Dr. ARKLE, in reply, said that informationwas wanting with reference to prodromal symptoms in histwo cases, especially the latter.Mr. PEARCE GlouLn read notes of a case of Gall-stones ex-

riting Suppuration, treated by operation, with recovery.Toe patient was a gentleman aged thirty-eight, who badsymptoms of gall-stones two years before he consulted Mr.

Gould for an abscess in the abdominal wall at the junctionof the epigastrium and right hypochondrium. The abscesswas opened, and 140 small biliary calculi were removed,together with pus. The sinus that was left was long in beal-ing. No bile was discharged through it at anytime. Manyof the calculi showed eviaence of spontaneous fracture of alarger calcu]m..Mr. Gould mentioned that he had foundreference to thirty-five other cases of gall-stones makingtheir way through theabdomin d wall, but this was the onlyone in which the diagnosis appeared to have been made priorto the abscess bursting. The abscesses have pointed atvarious places in the abdominal wall, most often above andto the right of the umbilicus. As a rule no bile has escapedwith the stones, and these latter have generally beennumerous. There appeared to be lacking any satisfactoryexplanation of the very different results of biliary calculiin different cases.-Dr. ORDsaid he had never had an oppor-tunity of investigating the disintegration of urinary cal-culi. In biliary calculi the disintegration might result fromtwo very different sets of circumstances: it might be fromthe difference of consistency of the layers, or by contact oflarge calculi with one another. Further, while biliarycalculi in the first instance were formed of a mixture ofcholesterine and bile pigment, these subsequently crvstal-lised out into different layers. A change into a differentmedium would facilitate disintegration.-Dr. MACLAGANreferred to a case of his, in which post mortem they founda hundred and eighty small calculi in the peritoneum,many of which were disintegrated. He suggested that thedisintegration might be due to contraction of the walls ofthe gall-bladder when distension began.-Mr. GOULD, inreply, said it was rather remarkable that so few cases ofdisintegrated calculi had been recorded. All the specimensin the London museums were beautifully facetted stones,very different from the fragments handed round. Hequestioned the suggestion of Dr. Maclagan as to the possiblecause of the disintegration, seeing that in many cases ofsevere renal colic, when great pressure must have beenexerted during the passage of the calculi along the duct,no such disintegration occurred.

MEDICAL SOCIETY OF LONDON.

Lupus of Mouth.-Injury to Epipn,.tJsis of Ulna.-OpMkal-moptegia.-Gunshot Injury of Knee Joint.-Tl’epkiningfor Meningeal AY6-,moi-rhage. - Ch’1rcot’s Disease.-Obliterating Arteritis.-Removal of Penis.- Carcinoma" en cuirasse."

THE meeting of this Society on March 26th was a " clinicalevening"; a large number of interesting cases were exhibited,and there was a considerable attendance of Fellows. Mr. J.

Knowsley Thornton, M.C., Vice-President, was in the chair.Dr. ORWIN exhibited a case of Lupus of the Mnuth,

Pharynx, and Larynx, in a girl aged twenty-one. In 1886 hefirst saw her with lupus of the nose of seven years’standing,with perforation of the nasal septum; there was then nodisease of the pharynx or larynx. Fifteen months ago heexhibited to the Society a case of primary lupus of thelarynx. In the present instance he thought the disease hadspread from the nose to the palate through the lymphaticchannels, and that the pharyngeal and laryngeal complicationmight have resulted from absorption of the nasal secretion.He proposed to repeatedly apply the actual cautery if the casedid not yield to ordinary remedies, and Dr. Semon had pub-lished a case in which he effected a cure by many hundreds ofapplications of the thermo-cautery.-Mr. LENNox BROWNEhad recorded eleven cases of lupus of the throat, and inalmost every instance it had been associated with lupus ofthe face. Tertiary syphilis usually attacked the palate fromthe nasal surface, whereas lupus did so from the buccalaspect. Lupus attacked cartilage rarely, and bone never,and was often associated with crowding of the teeth. Thedistinctions between lupus and tubercle were mainly sym-ptomatic ; in lupus, patients rarely complained of theirthroats, and attributed the hoarse voice to nasal disease.He thought lupus of the throat would be mOTe frequentlyfound if oftener looked for.-Dr. OuTTBRSON WOOD inquiredif there were a family history of syphilis.-Dr. ORWIN saidthere was no such history. If the case were syphilitic, bethought it would have spread more rapidly.

Ma,. EDMUND OWEN brought forward a case of injury tothe Lower Epiphysis of the Ulna, in a girl aged eighteen,

N 2