TWO CASES OF DERMATITIS VENENATA PRODUCED BY WEARING FUR

1677 One reason for scarcely be doubted that it is a case of aneurysm of the the heart itself much less is seen. this is that part of the heart is situated directly in aorta, the tumour probably springing from the descending front of the spinal column, and so is necessarily obscured part of the arch. I may add that since this examination was made a diastolic from view, and another reason is on account of the oblique the base position which the heart takes upandin the thorax,while the backwards, being directed slightly upwards apex points downwards and forwards. On the left of the spine a definite shadow is seen with a well-marked external border; this corresponds to the left ventricle. To the right of the middle line a smaller shadow of less intensity appears, which chiefly corresponds to the right auricle. The appearance of the shadows will be seen in Fig. 1. 2 and it is necessary to be quite familiar with this appearance on the screen before anything abnormal can be detected. When taking a tracing of this back view it is useful also to mark in the lowest points of the angles of the scapulse which are normally The on a level with the lower border of the seventh rib. following is a case in which examination by the rays materially assisted in making a diagnosis. A man aged forty years was first seen in June, 1896, by Dr. A. Wheeler. He then complained of pain in the left side and also occasionally in the back, which he had had since March. Shortly afterwards he was seen by Dr. Sidney Coupland, who agreed with Dr. Wheeler in suspecting the possibility of an aneurysm. At this time the physical signs consisted of some impairment of resonance in the interscapular region and a blowing systolic murmur was to be heard all over this region, but with its point of maximum intensity to the right of the vertebral column. The patient was informed of the probability of the presence of a deep-seated aneurysm, but wishing for further corroboration he consulted another physician, who did not think the evidence sufficient to warrant such a I diagnosis being made. The case was in this doubtful position ’,

htg: III

Back View of heart, shewing

.Aneurism situated above

murmur

has

developed

.

in addition to the

mentioned, thereby adding still

more

systolic one above confirmatory evidence

in favour of the diagnosis. Since the above was written I have had an opportunity of examining two other cases of aneurysm, with equally satisfactory results. Queen Anne-street, W.

Clinical Notes : MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL. TWO CASES OF DERMATITIS VENENATA PRODUCED BY WEARING FUR BY ROBERT J. CARTER, M.D. LOND., ASSISTANT PHYSICIAN TO THE WESTERN SKIN HOSPITAL.

showing

when Dr. Coupland kindly sent him to me and we together examined him by the x rays. From the front it was noticed that the heart was a little hypertrophied, and just above the point of junction of the left border with the sternum a faint indefinite shadow was seen (Fig. II., A), from which, however, nothing decided could be made out. On looking at the back we were more successful. The shadow of the heart appeared as usual, but just above it was a very definite shadow seen on both sides of the spinal column and about on a level with the fourth dorsal vertebrœ (Fig. III., A and B). On the right side the border was convex and could be distinctly seen to pulsate, while its intensity was about equal to that of the heart, but, on the whole, a little lighter. On the left side the shadow was only faint and its margins could not so definitely be made out. This, then, was

important piece of evidence, which, added to the physical. signs already obtained, removes the case from a doubtful one to one the nature of which is practically certain, for it can

an

: .

.

In the figures the bones which of course in have not been shaded to avoid confusion.

early

on

an undefinite Shadow above the left border.

2

winter of last year I was consulted by a account of a rash attended by much irritation patient which had appeared on her neck and was spreading. On examination it was found that the skin of the neck, except the nape, extending downwards as far as the clavicles and upwards just over the inferior maxilla, was the seat of an acute dermatitis. The whole area was bright red, infiltrated and papular, with here and there excoriations produced by scratching; the margins were ill-defined, the inflammation gradually losing itself in the healthy surrounding skin. As it appeared obviously due to some external irritant a few questions revealed the cause. The eruption, which had been present one week and had commenced simultaneously on both sides over the prominences of the sterno-mastoid muscles, only showed itself after wearing for the first time a new sable collarette, which had been worn for some hours every day during that week. Some calamine lotion and a silk handkerchief in place of the fur speedily produced a cure. A few weeks ago another patient presented herself with a similar dermatitis, and in this case also it was elicited that the rash was noticed immediately after a new sable collarette had been This latter case was not so severe worn for the first time. and had only been present three days, but similar treatment IN the

Frolct taclew oflzeai-t in. the Fig .&bgr;.case of Aneurism

reality appeared dark,

’

1678 proved ellectual.

For the benefit of the uninitiated it may be mentioned that these collars are composed of the fur of an entire animal, which is stuffed after dressing the skin. The modern methods of treating furs and skins are various, but I believe arsenic is used in many cases, and the appearance of the dermatitis was suggestive of arsenic or of some chemical irritant which might have been present in the skin as a preservative. Acacia-road, N.W.

procedures give results showing

a

greatly diminished death-

rate. Sieur3 collected 18 cases of extra-peritoneal rupture in which an operation was performed, and of these 10 recovered; this gives a mortality of 44 per cent. H. Schlange44 gives 7 recoveries out of 10 cases. In rupture of the bladder, where it is uncovered by peritoneum, no method of operation can give results to be compared with those of suprapubic cystotomy. By this method the extent of the injury can be clearly seen and the wound can be plugged or sutured as may seem best. In the case we record below a noteworthy

was inflicted. Forcible catheterisation has at times had its advocates, but WILLIAMS, L.R.C.P. LOND. its results have been always disastrous in a very large proportion of cases. The most frequent cause of death has been Tj)H following case because of its rarity is, I believe, sepsis, but bœmorrbage, though not actually profuse, is ’ nearly always present. In this case the prostate seems to worthy of being placed upon record. In the early morning of Nov. 20th I was hurriedly have escaped completely, the catheter leaving the urethra called to see a man aged seventy-one years. I went almost at its apex. For the notes of the case we are indebted to Mr. II. H. Cheesman. immediately, but found him lying on his back dead in bed. A man aged sixty-three years was admitted on May 22nd, A few minutes before I was summoned he had awakened his 1896, suffering from retention of urine and free haemorrhage wife by his noisy breathing and directly afterwards from the urethra. Twenty-five years ago he had gonorrhcea expired. The previous history is not very precise. His and had been troubled from time to time by a stricture. He wife stated that of late years he had suffered from slight had been in the habit of passing a catheter for about eight dyspeptic symptoms and a " weak heart," but had never been years. During the day there had not been much difficulty in medically attended for these; otherwise he had enjoyed passing urine, but at night he was always compelled to use fairly good health. At the necropsy I found the pericardial a catheter. The difficulty in micturition became suddenly cavity distended with fluid blood and clots, and on exa- worse on May 21st, and for the first time the passage of the mining the heart a triradiate rupture (about 1 in. in length instrument failed to draw off urine. During the passage of externally and ¼ in. internally) was seen on the anterior a silver catheter by a medical man the patient felt acute pain surface of the left ventricle near to the septum. The heart and at the same time felt the catheter leave the middle Its cavities line and noticed that it passed an unusual distance. was considerably enlarged and weighed 18 oz. were dilated and both auriculo-ventricular valves thickened. Blood at once flowed copiously from the urethra. The The heart muscle itself was extremely friable, breaking down patient was then told he must go at once to the hospital. on the slightest pressure of the finger, and in a state of fatty In the cab blood ran freely from the urethra, and on his degeneration. The thoracic aorta and coronary arteries arrival at the hospital clots of considerable size were found were atheromatous. With the exception of some slight in his trousers and he was in a collapsed state from loss of emphysema of the lungs and a small cyst on the surface of blood and acute pain. On admission the bladder was found the left kidney all the other organs were natural. to be enormously distended vertically and laterally. It reached Mansfield-road, N.W. about an inch and a half above the umbilicus and was unusually hard, giving no thrill on percussion. It was evidently f full of blood-clot. The prostate was found much hypertrophied, especially on the right side. Suprapubic puncture being useless in such a condition a cystotomy above the was performed. Considerably over a pound of solid pubes OF clot was turned out, and then, on inserting the fingers into the bladder before it had contracted, an irregular rent sufficient to admit the tips of two fingers was found at the base of the bladder and on the right side of the prostate. MeanBRITISH AND FOREIGN. while, bright blood was oozing from the laceration. The N alla autem est alia pro certo noseendi via, nisi quamplurimas et mor- wound in that place was, therefore, stuffed with gauze from borum et dissectionum historias, tum aliorum tum proprias collectas the suprapubic opening and the bladder sutured to the habere, et inter sa comparare.-MORGAGNI De Sed. et Caus. Morb., abdominal wall, thus leaving an aperture above the lib. iv. Prooemium. pubes for free drainage of urine. The patient’s progress toward recovery was rapid, and on the seventh day after WESTMINSTER HOSPITAL. operation a softcatheter was passed per urethram and the A CASE OF EXTRA - PERITONEAL RUPTURE OF THE wound allowed to heal. He has since presented suprapubic BLADDER ; SUPRAPUBIC CYSTOTOMY ; RECOVERY. himself at the hospital and now has very little difficulty in (Under the care of Mr. THOMAS BOND and passing his urine. Mr. A. H. TUBBY.) Remarks.-In the attempt to pass a silver catheter EXTRA-PERITONEAL ruptures of the bladder are by no it is possible that the instrument entered an old false passage and that then the catheter was pushed means common, though opinions differ considerably as to on regardless of the pain it caused and of the change in their frequency. There can be little doubt, however, that in its direction until it ruptured the base of the bladder on the majority of cases of rupture of the bladder the peri- the right side. The prostatic urethra had not been traversed. toneum is involved. Some of the cases of rupture in which F’rom the large amount of haemorrhage a vessel of conthe peritoneum is not involved present no other lesion, and siderable size, probably the inferior vesical, had been torn these may be due to bullet wounds and stabs, but on the across. That no extravasation of urine occurred was due to whole the most serious cases are those which are associated the fact that suprapubic cystotomy was performed within an with, and due to, fracture of the bones of the pelvis, and of hour or two of the accident. The patient’s uninterrupted these a large number never come to operation, as the other recovery and the rapid resumption of the normal functions of the bladder are worthy of note. injuries are sufficiently severe to cause death, and in many cases the injury to the bladder is only recognised after death. This fact may account in part for the differences in BRISTOL GENERAL HOSPITAL. opinion as to the frequency of the lesion. W. Rivington1 mentions 60 cases of extra-peritoneal rupture out of a total A CASH OF HERNIA IN WHICH IRREDUCIBILITY WAS DUE of 225 fatal cases of ruptured bladder, while out of TO THE PRESENCE OF A MESENTERIC CYST. 10 cases reported by Prescott Hewett 8 were extra(Under the care of Mr. CHARLES A. MORTON). peritoneal.2 The mortality in any form of ruptured MESENTERIC cysts are sufficiently rare to warrant a record bladder has always been very high, but if only cases of made suitable for operation be considered recent operative being every case met with, but the occurrence of a

A CASE OF RUPTURE OF THE CARDIAC MUSCLE.

point is the method by which the injury

BY J. W.

t

( ’

A Mirror

HOSPITAL

PRACTICE,

--

2

Transactions of the

Pathological Society,

vol. ii.,

p. 227.

4

3 Revue de Chirurgie, March, 1894 Archiv für Klinische Chirurgie, vol. xliii., p. 23,

1892.