1156 T

A CASE OF DESQUAMATIVEERYTHEMA.

BY ATHELSTANE NOBBS, M.D. EDIN.

THE following case, which I assume was purely of thetype known as erythema scarlatiniforme desquamativum,presents one or two points of interest that may be helpfulnot only in determining its position as a simple erythema-which has occasionally been questioned-and not a

dermatitis, but also as possibly indicating, if not actuallythe elucidation of its etiology, at least a suggestion as to itscausation.

Briefly, it occurred in the case of an old patient of mine, aman, aged 62 years, a mechanical engineer by profession. Iam perfectly satisfied that syphilis could safely be eliminatedin this connexion and the usual queries as to the possibilityof contact with any case of scarlet fever, the incidence oftoxic elements, such as fish, tinned foods, sausage, or therecent use of drugs, such as antipyrin, atropine, and soforth, elicited negative replies. The family history wasgood, as was also his own. Practically no cause was

ascribable. During the whole illness, which lasted forabout six weeks from the day when he first complained ofmalaise until the soles of his feet were shed practicallyen masse, there was absolutely no rise of temperature, themercury for the most part hovering in the neighbourhood of97° F. There was no albuminuria and no glandular enlarge-ment, save notably a slight fulness of the thyroid,coupled with some tenderness on pressure of that organnot to be confounded with, nor mistaken for, sub-

maxillary lymphangitis. The course of the disease was

typical, the "boiled-lobster" rash speedily following theprodromal symptoms, commencing on the abdomen and thenrapidly invading the rest of the trunk and eventually theextremities. Desquamation, which ensued about the eighthday, was profuse, varying in character from the consistencyof powdery squamules as it fell from the trunk, neck, andlimbs to scales of the saurian type such as one sees inichthyosis. This latter condition was most marked on theforehead and the flexor surfaces of the forearm, and again onthe extensor surfaces of the legs and ankles. The treatmentwas rest, with milk diet, then vegetarian regimen, andeventually a return to ordinary fare, and by way of a

medicinal standby sodium phosphate in laxative doses.There never was any itchiness, though the patient com-plained of feeling as if his skin would burst, which, indeed, thedying epidermis ultimately did, and for the first week therewas "tenderness" in swallowing, tobacco irritated the

tongue, and there was some photophobia. As the mucosaswere involved in the general congestion of the epiblastictissues this was only to be expected, but it is noteworthythat despite the universal vascular disturbance of the surfaceof practically the whole body there was no sign of cerebralirritation nor yet of the faintest degree of hyperaemia of theendothelial structures.

In such a short sketch as this it is idle to adducea variety of arguments but the following points certainlyoccurred to me. Firstly, if this case was simply one oferythema, as I fully believe it was, either it should beclassified as a benign exanthem, by which I mean a non-

contagious one, or else as a symptom of some diseased con-dition, of which the primal cause is as yet undetermined.In any case I deprecate the use of a misnomer with anI itis " suffix, such as dermatitis exfoliativa, which lacks twoat least of the cardinal points relating to inflammation-namely, pain and heat-though connoting them. Secondly,there seemed to my mind to be some connexion between thedisturbed condition of the thyroid gland and that of the cutismost noticeable, as it was, during the desquamative process.We all know that dried horny scales of the cutis are more orless perpetually being shed whether one is ill or well; butalthough I know it is illogical to attempt even to argue froma special point to a general rule, I cannot divest myself ofthe idea that the activity of the gland alluded to was sym-pathetic and that it may have, and did have, an influence asmuch in the nature of cause as of effect and was probablymore incidental than accidental. The disease, lastly, is saidto be rare even in adults, but I cannot help wondering howmany such find their way to the wards of the feverhospitals.London.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

UNIVERSITY COLLEGE HOSPITAL.A CASE OF FEMORAL ANEURYSM; EXCISION; CURE.

(Under the care of Mr. BILTON POLLARD.)

Nulla autem est alia pro certo noscendi via, nisi quamplnrimas etmorborum et dissectionum historias, tum aliorum tum propriascollocias habere, et inter se comparare.—MoBaAajri De Sed. et Cazcs.DTorb., lib. iv., Prooemium. -FOR the notes of the case we are indebted to Mr. P.

Maynard Heath, late surgical registrar.A man, aged 37 years, complained of weakness and

swelling of the left leg and a throbbing tumour in the leftgroin. The swelling in the groin first appeared in 1901. It

gradually increased in size and became very painful, whilethe leg became swollen. About two months after the firstappearance of the swelling he was admitted to the CivilHospital, Hong-Kong, where the external iliac artery wasligatured. The pulsation in the tumour ceased for about afortnight and then reappeared. The ligature was said tohave slipped and an anaesthetic was again administered andthe artery was said to have been religatured. In 1904 theaneurysm had become as troublesome as it had beenoriginally. He had had syphilis ten years previously andhad been treated for two months.On admission to University College Hospital on Sept. 22nd,

1906, he was found to be a heavily built, well-nourished man.In the left groin was a swelling which filled Scarpa’s triangleand on the surface of this just below Poupart’s ligament wasa prominence the size of a walnut. The latter was ill-defined above but sharply outlined elsewhere. The skin overit was normal. There was slight but definite expansile pulsa-tion in the superficial prominence but no pulsation could bedetected in the main mass of the swelling. The pulse in theartery below was weaker than on the right side and was

slightly delayed. Pressure on the external iliac artery led todiminution in the pulsation of the aneurysm but it was im-possible completely to control it. Immediately above

Poupart’s ligament was the oblique scar of the previousoperation. The oedema of the leg had subsided as the resultof rest in bed, but the whole of the left thigh was muchbigger than its fellow. -No other aneurysms could be found.The heart’s impulse was very weak and a double murmurwas present at the apex. The second sound was considerablyaccentuated. A moderate degree of arterio-sclerosis was

present. On Oct. 4th continuous digital compression of theexternal iliac artery was carried out for eight and a halfhours. No effect on the aneurysm was perceptible. On the19th a vertical incision was made downwards from the oldscar for about nine inches. The surface of the aneurysm was

exposed and cleared and it was then found that the abovenoted prominence was a secondary dilatation of the largemass which lay more deeply. The mass was first cleared onthe outer side, the anterior crural nerve being exposed andheld aside. The parts surrounding the aneurysm were greatlymatted together and after a prolonged dissection the deep cir-cumflex iliac artery was found and ligatured and the externaliliac artery was recognised. In the process of clearing it thedeep epigastric artery was wounded. It was ligatured, theexternal iliac artery being secured above its point of origin.The superficial femoral artery was then exposed andligatured below the aneurysm. Even after this stage theaneurysm still pulsated. It was then found that the femoralvein was closely incorporated with the sac of the aneurysmon the inner side. Part of the sac was therefore cut awayand left attached to the vein, and the aneurysm was rapidlyturned downwards and removed. Several large vessels wereinvolved at the back of the sac but they were readily con-trolled by forceps. It was then found that a longitudinalwound about three-quarters of an inch in length had beenmade in the femoral vein. The rent was closed by a con-tinuous suture of fine silk. Immediately below this wounda large vein, probably the profunda, entered the main vein.All divided vessels were then ligatured and the skin woundwas partly closed, a drainage-tube being introduced.

1157

The operation was prolonged. The patient’s radial pulse s

became very irregular but was fairly forcible. The circula- ftion in the foot of the affected limb seemed to be fairly good e

though the pulse in the dorsalis pedis artery could not be s

felt. After the operation the limb was massaged in an c

upward direction for a short time every hour so as to aid the a

venous circulation. On Oct. 20th the wound was dressed tand the drainage-tube removed. The limb was a good colour Iand quite warm. Slight fulness was noted on the inner side tof the ankle and there was some numbness present on the s

inner side of the leg. On the 23rd the condition of the limb cwas very satisfactory and the rubbing was discontinned. eThe wound healed readily except for necrosis of a small (

area of skin. The temperature reached its highest point r

(100’4° F.) on the 26th and fell next day to normal. The (

man was discharged on Nov. 9th. E

The aneurysm after removal measured three and a half inches (

in its vertical diameter and three inches in its greatest trans- (verse diameter. It involved the common, superficial, and deep (

femoral vessels. The external iliac artery above the point of 1origin of the deep epigastric branch was entirely occluded, ras was the superficial femoral artery at the point of ligature. 1The deep epigastricand profunda arteries were dilated, and icoming off the back of the aneurysm were three vessels,probably the external and internal circumflex and the first 1

perforating arteries. The interior of the aneurysm was

partly filled by laminated clot. 1Remarks by Mr. BILTON POLLARD.-Excision is, in my c

opinion, the best treatment for all aneurysms situated in accessible positions and no aneurysms are more suited to that Imethod of treatment than femoral aneurysm. With cautious 1

dissection it is not difficult to isolate and ligature all thevessels supplying the aneurysm before they are divided. In ithe case now reported the aneurysm, which filled Scarpa’striangle, involved the common and superficial femoral ;arteries, and to some extent the deep femoral artery also. IThe external iliac artery had been tied some years before thepatient came under my care, but pulsation returned soonafter the operation; and immediately before I took charge ofthe case compression of the external iliac artery had Ibeen tried without success. The failure of both thesemethods was clearly due to the free supply of bloodto the aneurysm from other vessels than the externaliliac. The profunda femoris, the external and internal Icircumflex and the first perforating arteries all appeared toarise separately from the sac of the aneurysm and, althoughthe external iliac artery was occluded, blood wa3 stillentering the aneurysm from the deep epigastric artery. Theanterior crural nerve and its branches and the femoral veinwere the only important structures endangered by theoperation. The anterior crural nerve was defined just belowPoupart’s ligament and there was not much difficulty in

separating it and its branches from the aneurysm. It was

quite otherwise with the femoral vein, for it was so

incorporated with the wall of the aneurysm as to be quiteunrecognisable for about three inches of its course. Thevein was isolated above and below, but the line of the inter-vening portion had to be guessed at. Whilst this part ofthe vein was being dissected from the sac a slit about aninch in length was made into it. The bleeding was com-pletely controlled by a fine continuous silk suture and nofurther trouble resulted from the accident. The patient

_

made a rapid recovery and when last seen six months afterthe operation the cure was perfect. The size of the patient’sthigh was decreasing and he was no longer troubled byeither weakness or swelling of the leg.

TORBAY HOSPITAL, TORQUAY.(1) A CASE OF STRANGULATED FEMORAL HERNIA ; HERNI-OTOMY FOLLOWED BY RESECTION OF BOWEL AND CIRCULAR

ENTERORRHAPHY; AND (2) A CASE OF FRACTURE OFTHE PELVIS FROM SLIGHT VIOLENCE, WITH NIPPINGOF SMALL INTESTINE BETWEEN THE FRAGMENTSCAUSING ACUTE INTESTINAL OBSTRUCTION AND

GENERAL PERITONITIS.

(Under the care of Mr. GILBERT J. ARNOLD.)CASE l.-On Dec. 31st a woman, aged 38 years, was sent

into hospital by Dr. F. T. Thistle for operation. On admissionthe patient stated that for some years she had noticed a smalllump in the right groin which had hitherto been painless.She was quite well on the previous day until 7 P.M., when

he began to experience great pain in the groin and this wasollowed by severe vomiting and a sleepless night. Onexamination there was found a small tense hernia of the;ize of a Tangerine orange, occupying the right femoral;anal. Mr. Arnold saw her when she entered the hospitalmd did not employ taxis but had her prepared for opera-tion, which was commenced one hour after admission and19 hours from the onset of ileus. Local infiltration anses-

ihesia was employed, a 2 per cent. isotonic novocainesolution containing suprarenin being used. The sac was

lusky in colour and contained a loop of small intestine andi small piece of adherent omentum. The bowel was dark andcongested, with loss of polish, but by no means gangrenous.fhe narrow tightly constricting neck of the sac was

cautiously nicked with a blunt bistoury sufficiently to relievestrangulation and to enable the bowel at the seat ofconstriction to be drawn down and examined. Imme-

iiately this was done a slight leakage of the liquid intestinalcontents was seen at the point where the bowel was com-pressed against the sharp edge of Gimbernat’s ligament.The parts were cleansed with hot saline solution andthe small necrotic opening in the softened friable bowel wasinvaginated and closed with a few Lembert’s sutures.

However, the appearance and behaviour under stimula-tion with hot saline solution of the involved three-inchLoop of small intestine contrasted badly with the healthybowel beyond and Mr. Arnold had no hesitation in

deciding that it was unsafe to return it. The strangulatedknuckle was divided through its centre and two small-sized Paul’s glass tubes were tied into the open ends, theparts being carefully isolated with sterile gauze and theoperation concluded by one or two sutures which served tosecure the intestine and glass tubes in the wound. The

patient vomited a considerable quantity of fsecal fluid duringoperation, but there was no shock during or after its progress.Three hours later, as the amount of intestinal drainage thathad taken place through the glass tubes was small, Mr.Arnold passed into the intestine by means of a catheterand funnel some warm normal saline solution, and this wasquickly followed by a free discharge from the tube in theafferent piece of bowel which was received into an attachedwaterproof bag.A second operation was performed on Jan. 2nd (two

days after the herniotomy), the patient having greatly im-proved and taken a fair amount of nourishment. Mr. Arnoldremoved the Paul’s tubes and inserted some gauze within theopen ends of the bowel, and again operating under the samelocal analgesia the femoral wound was enlarged into theinguinal canal by division of Poupart’s ligament. The-affectedloop of small intestine, together with healthy bowel beyond,was then readily brought outside the abdomen and surroundedwith sterile gauze. Healthy bowel was then occluded by doubleligatures of rubber drainage-tube four inches on each sidebeyond the open ends. Its mesentery was ligated withsterile catgut and approximately eight inches of smallintestine were removed. An end-to-end anastomosis wasthen effected by an inner row of interrupted sutures ofNo. 0 catgut, not including the serous coat, the sutures beingtied with the knots within the lumen of the bowel and par-ticular care being taken of the mesenteric border. An outerrow of fine Lembert’s sutures, using fine silk and cambricneedles, completed the union, which was accomplished with-out narrowing. The ligatured mesentery was folded on

itself and secured thus with a few stitches in order that nohole should be left at the site of the anastomosis and

possibly give rise to future trouble. The bowel was returned.The divided Poupart’s ligament and the femoral canal werethen methodically sutured and the wound was closed rounda small gauze drain. Recovery was quick, complete, anduneventful.CASE 2.-A woman, aged 76 years, was seen on Jan. 8th, in

consultation with Dr. J. U. Huxley, and immediately sent intohospital as a private patient. She had recently been througha dangerous illness under Dr. Huxley’s care suffering frombronchitis and a weak heart. She had formerly worn a trussfor a right femoral hernia. Two days prior to admission shewas discovered by her daughter on the floor in her bedroom.The patient, who had been confined to her bedroom whenthe accident occurred, stated that she had tripped over theleg of a chair. There were no bruising and no evidence ofinjury to the femur or hip-joint. Severe abdominal pain withfrequent vomiting rapidly set in. On admission the conditionof the patient was extremely bad. Her thin abdomen was

greatly distended and did not move with respiration. There