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A STICK IN THE EXTERNAL ILIAC VEIN
819
The staphylococcus isolated post mortem from the abscesses was, like that of the first blood-culture, Does this mean that the resistant to penicillin only. antibiotics were not reaching those abscesses. Novobiocin has been recommended by Lubash et al.
(1956) for to other
use
in infections
by staphylococci
resistant
antibiotics, but Garrod and Waterworth (1956)
have shown that staphylococci rapidly develop resistance to novobiocin in vitro. Anderson (1954) reported a staphylococcus resistant to five antibiotics, but our organism, unlike his, was at all times fully coagulase-positive and continued to produce
pigment. Our thanks
are
due to Dr.
Mary Barber,
of St. Thomas’s confirmR. E. 0. Colindale, for the
Hospital, for the supply of novobiocin and also for ing the sensitivity of the staphylococcus, and to Dr. Williams, of the Public Health phage-typing.
Laboratory,
REFERENCES
Anderson, K. (1954) J. clin. Path. 7, 148. Garrod, L. P., Waterworth, P. M. (1956) Brit. med. J. ii, 61. Lubash, G., Van Der Meulin, J., Berntsen, C., Tompsett, R. (1956) Antibiotic Med. 2, 233.
A STICK IN THE EXTERNAL ILIAC VEIN G. E. DUNKERLEY M.B. Lond., F.R.C.S.E. ASSISTANT
ORTHOPÆDIC
SURGEON,
PORTSMOUTH
was about 3/4 inch in diameter, and soft clot was felt surrounding the foreign body in its lumen. The external iliac vein was ligated proximal to the end of the stick, and the femoral and great saphenous veins were ligated distal to its protruding end. The wood was then safely withdrawn and the damaged portion of vein removed. Attention was next directed to the arteries. The external iliac artery was pulsating weakly, but the femoral artery was in spasm and pulseless. The foreign body had been pressing on it firmly. The artery was dissected free from its surroundings and 2% procaine injected into the adventitia. Pulsation in the femoral artery
The vein
restarted shortly afterwards. The wound was closed in layers, with drainage at the site of the stab wound, and pulsation was felt in the right dorsalis pedis artery on the boy’s return to the ward. The colour of the limb remained normal thereafter, but the limb has continued to be somewhat swollen. Postoperatively the stitches were removed on the tenth day, when the wound was soundly healed and the boy was allowed to get up. Three weeks after the incident he had no symptoms, but his right leg and right testicle were somewhat swollen. There was induration deep to the scar in the groin and
right thigh. This case illustrates the value of thorough exposure before the removal of objects which have inflicted, and remain in, stab wounds. This is all the more important when the wound is in the vicinity of vital structures and when there are signs of damage to large vessels.
HERPES OPHTHALMICUS
HOSPITAL
T. N. FISON
GROUP
THIS case is reported because of the unusual nature of the wound and to emphasise the importance of leaving penetrating weapons in the body at first. They can be removed later under favourable conditions for dealing with any emergencies that may arise.
Case-report
boy, aged 10 years, was admitted to hospital with a piece of dirty wood 1 inch square protruding about 1 inch from his right thigh, 2 inches below the middle of Poupart’s ligament, and running proximally and medially. The boy said later that lots of blood ran out when he was wounded, but his blood-pressure was 110/70 mm. Hg on admission. He had been pushed by another boy and had fallen on to a jutting out piece of wood which pierced his groin and broke off. Apart from the wound and foreign body the right lower limb looked normal on admission but during a few minutes’ stay in the casualty department it became progressively more cyanosed and swollen. On examination half an hour after admission the boy was pale and shocked with guarding and tenderness in his right iliac fossa. His right leg was visibly swollen and cyanosed, the foot was pale, and the toes were almost white. The right popliteal, posterior tibial, and dorsalis pedis arterial pulsation was absent, and there was anaesthesia below the right ankle. Treatment with antitetanic serum, penicillin, and a blood-transfusion was started. Operation.—It was thought that the right femoral artery had been severed, and after a short period for resuscitation an operation was done under general anæsthesia (Dr. W. P. Lee). A longitudinal incision was made in the line of the femoral vessels, starting2 inches distal to the wound, crossing the middle of Poupart’s ligament, and running up to a point an inch medial to the anterior superior iliac spine. The external oblique aponeurosis was divided, in the direction of its fibres, down to the external abdominal ring, and the spermatic cord was identified and protected during the remainder of the operation. The internal oblique muscle was divided across its fibres, and the transversalis fascia divided in the same line. It was then possible to strip the peritoneum back towards the midline. A small opening was made in the peritoneum and the absence of blood in the peritoneal cavity demonstrated. This opening was then closed. As the peritoneum was stripped medially, it was discovered that the stick, which was 41/2 inch long and tapered at the tip to a diameter of less than 1/2 inch, had entered the femoral vein at the level of Poupart’s ligament and that its end was lying within the external iliac vein at the middle of the pelvic brim. A
M.A., M.D. Camb. GENERAL
PRACTITIONER, SIDMOUTH,
DEVON
HERPES ZOSTER and concurrent generalised rash has been previously reported (Roxburgh and Martin 1926, Hewitt 1954) ; but there is considerable doubt whether herpes zoster can be disseminated or whether such cases are a combination of herpes zoster and varicella. The following case is therefore important. Case-record A retired business man, aged 76, with chronic myocardial disease and no previous history of varicella, on Nov. 2, 1954, began to have shooting pains over the left side of the scalp ; and on Nov. 7 her-
petiform vesicles with surrounding of erythema areas were present on the left forehead, scalp, and left side of nose. Nov. 9: Severe conjunctivitis of left eye. Nov. 12 Profuse eruption ofsmall vesicles with a ring of erythema on the trunk and limbs. Extensive hæmorrhagic necrosis of scalp area (left) with severe toxsemia. Nov. 16:Keratitis of left eye, .corneal ulceration, and
:
hypopyon. Dec. 14 : Rash on trunk and limbs
healed, leaving depressed brown pigmented scars. , Dec. 21 Separation of scalp eschar, leaving a patchy Fig. I—Hæmorrhagic
necrosis of rash elsewhere.
scalp
raw
and ’
area.
granulating
The staphylococcus isolated post mortem from the abscesses was, like that of the first blood-culture, Does this mean that the resistant to penicillin only. antibiotics were not reaching those abscesses. Novobiocin has been recommended by Lubash et al.
(1956) for to other
use
in infections
by staphylococci
resistant
antibiotics, but Garrod and Waterworth (1956)
have shown that staphylococci rapidly develop resistance to novobiocin in vitro. Anderson (1954) reported a staphylococcus resistant to five antibiotics, but our organism, unlike his, was at all times fully coagulase-positive and continued to produce
pigment. Our thanks
are
due to Dr.
Mary Barber,
of St. Thomas’s confirmR. E. 0. Colindale, for the
Hospital, for the supply of novobiocin and also for ing the sensitivity of the staphylococcus, and to Dr. Williams, of the Public Health phage-typing.
Laboratory,
REFERENCES
Anderson, K. (1954) J. clin. Path. 7, 148. Garrod, L. P., Waterworth, P. M. (1956) Brit. med. J. ii, 61. Lubash, G., Van Der Meulin, J., Berntsen, C., Tompsett, R. (1956) Antibiotic Med. 2, 233.
A STICK IN THE EXTERNAL ILIAC VEIN G. E. DUNKERLEY M.B. Lond., F.R.C.S.E. ASSISTANT
ORTHOPÆDIC
SURGEON,
PORTSMOUTH
was about 3/4 inch in diameter, and soft clot was felt surrounding the foreign body in its lumen. The external iliac vein was ligated proximal to the end of the stick, and the femoral and great saphenous veins were ligated distal to its protruding end. The wood was then safely withdrawn and the damaged portion of vein removed. Attention was next directed to the arteries. The external iliac artery was pulsating weakly, but the femoral artery was in spasm and pulseless. The foreign body had been pressing on it firmly. The artery was dissected free from its surroundings and 2% procaine injected into the adventitia. Pulsation in the femoral artery
The vein
restarted shortly afterwards. The wound was closed in layers, with drainage at the site of the stab wound, and pulsation was felt in the right dorsalis pedis artery on the boy’s return to the ward. The colour of the limb remained normal thereafter, but the limb has continued to be somewhat swollen. Postoperatively the stitches were removed on the tenth day, when the wound was soundly healed and the boy was allowed to get up. Three weeks after the incident he had no symptoms, but his right leg and right testicle were somewhat swollen. There was induration deep to the scar in the groin and
right thigh. This case illustrates the value of thorough exposure before the removal of objects which have inflicted, and remain in, stab wounds. This is all the more important when the wound is in the vicinity of vital structures and when there are signs of damage to large vessels.
HERPES OPHTHALMICUS
HOSPITAL
T. N. FISON
GROUP
THIS case is reported because of the unusual nature of the wound and to emphasise the importance of leaving penetrating weapons in the body at first. They can be removed later under favourable conditions for dealing with any emergencies that may arise.
Case-report
boy, aged 10 years, was admitted to hospital with a piece of dirty wood 1 inch square protruding about 1 inch from his right thigh, 2 inches below the middle of Poupart’s ligament, and running proximally and medially. The boy said later that lots of blood ran out when he was wounded, but his blood-pressure was 110/70 mm. Hg on admission. He had been pushed by another boy and had fallen on to a jutting out piece of wood which pierced his groin and broke off. Apart from the wound and foreign body the right lower limb looked normal on admission but during a few minutes’ stay in the casualty department it became progressively more cyanosed and swollen. On examination half an hour after admission the boy was pale and shocked with guarding and tenderness in his right iliac fossa. His right leg was visibly swollen and cyanosed, the foot was pale, and the toes were almost white. The right popliteal, posterior tibial, and dorsalis pedis arterial pulsation was absent, and there was anaesthesia below the right ankle. Treatment with antitetanic serum, penicillin, and a blood-transfusion was started. Operation.—It was thought that the right femoral artery had been severed, and after a short period for resuscitation an operation was done under general anæsthesia (Dr. W. P. Lee). A longitudinal incision was made in the line of the femoral vessels, starting2 inches distal to the wound, crossing the middle of Poupart’s ligament, and running up to a point an inch medial to the anterior superior iliac spine. The external oblique aponeurosis was divided, in the direction of its fibres, down to the external abdominal ring, and the spermatic cord was identified and protected during the remainder of the operation. The internal oblique muscle was divided across its fibres, and the transversalis fascia divided in the same line. It was then possible to strip the peritoneum back towards the midline. A small opening was made in the peritoneum and the absence of blood in the peritoneal cavity demonstrated. This opening was then closed. As the peritoneum was stripped medially, it was discovered that the stick, which was 41/2 inch long and tapered at the tip to a diameter of less than 1/2 inch, had entered the femoral vein at the level of Poupart’s ligament and that its end was lying within the external iliac vein at the middle of the pelvic brim. A
M.A., M.D. Camb. GENERAL
PRACTITIONER, SIDMOUTH,
DEVON
HERPES ZOSTER and concurrent generalised rash has been previously reported (Roxburgh and Martin 1926, Hewitt 1954) ; but there is considerable doubt whether herpes zoster can be disseminated or whether such cases are a combination of herpes zoster and varicella. The following case is therefore important. Case-record A retired business man, aged 76, with chronic myocardial disease and no previous history of varicella, on Nov. 2, 1954, began to have shooting pains over the left side of the scalp ; and on Nov. 7 her-
petiform vesicles with surrounding of erythema areas were present on the left forehead, scalp, and left side of nose. Nov. 9: Severe conjunctivitis of left eye. Nov. 12 Profuse eruption ofsmall vesicles with a ring of erythema on the trunk and limbs. Extensive hæmorrhagic necrosis of scalp area (left) with severe toxsemia. Nov. 16:Keratitis of left eye, .corneal ulceration, and
:
hypopyon. Dec. 14 : Rash on trunk and limbs
healed, leaving depressed brown pigmented scars. , Dec. 21 Separation of scalp eschar, leaving a patchy Fig. I—Hæmorrhagic
necrosis of rash elsewhere.
scalp
raw
and ’
area.
granulating