A CASE OF BILATERAL HERPES ZOSTER
1
749 A CASE OF BILATERAL HERPES ZOSTER. BY E. R. C. WALKER, B.A. CAMB., M.B., CH.B. EDIN., RESIDENT PHYSICIAN, THE ROYAL INFIRMARY, EDINBURGH. IN the following case the patient could not recall any previous illnesses, and did not remember being in con- tact with any case of herpes zoster or of chicken-pox. He was a general labourer, aged 29, of Irish nationality. For about two months before the onset of acute pain he had occasionally experienced a tingling sensation on the upper part of his chest on both sides. About a fort- night before the appearance of the rash he had a stabbing pain about two inches above the left nipple. Ten days later Showing distribution of lesions on the back after the vesicles had broken down. The photograph was taken by Dr. W. D. Small. a similar pain developed on the right side at a somewhat lower level. Two days later the rash appeared on both sides. The patient thought it appeared first on the left side, but was not certain. The distribution was as follows : Right side : from ninth, tenth, and eleventh dorsal vertebrae spreading round the chest to midway between the umbilicus and ensiform cartilage in front. Left side : from fourth, fifth, and sixth dorsal vertebrae spreading round underneath the shoulder, above the nipple to fourth and fifth costal cartilages in front, and also down posterior fold of axilla and back of arm. ’ Condition on Admission.-When, on Feb. 2nd, 1924, he was admitted to hospital, seven days after the appearance of the rash, the temperature was 98-2°F., respirations 24, pulse 120. There was a slight rise of temperature in the evening, but this subsided during the night, as did also the respirations and pulse. Wassermann reaction was negative. Urine normal. Bowels slightly constipated. He made a complete and rapid recovery. The unusually long history may perhaps be due to the patient’s nationality. He was somewhat vague as to facts, and his native courtesy made him very willing to oblige in the matter of remembering early symptoms. He was, however, quite definite about the pain above the nipple a fortnight before the appear- ance of the rash. I have to thank my chief, Prof. Jonathan Meakins, for leave to publish the case. KENT COUNTY OPHTHALMIC HOSPITAL, MAIDSTONE. The annual report of this institution stated that the accounts were satisfactory, but owing to the transition state of the hospital, due to building and rebuilding operations, it was difficult to make any comparison with past years. The total sum realised by the Extension Fund Appeal amounted to over .615,000. The board expressed its deep ’I gratitude to Mr. Wheler Bennett for his handsome contribu- tion of 10,000 to the hospital. The importance of the I Weekly Subscribers’ Fund was shown by the fact that four I years ago this fund amounted to 2192 and had now increased to .87925. There were at the moment 206 cases I awaiting admission. Medical Societies. NORTH OF ENGLAND OBSTETRICAL AND GYNECOLOGICAL SOCIETY. A MEETING of this Society was held in Liverpool on March 14th, with Dr. A. DONALD, the President, in the chair. DISCUSSION ON PRIMARY PULMONARY THROMBOSIS. The discussion on the paper read by Prof. E. Glynn,l postponed from the meeting held on Jan. 18th, was opened by Prof. BLAIR BELL. He said that to gynaecologists the question of primary pulmonary thrombosis was of special interest, as in all gynoeco- logical clinics throughout the world this disaster had occurred with greater frequency than in the clinics of the general surgeons. Prof. Glynn would, however, be the first to disclaim any suggestion that the idea of primary pulmonary thrombosis was a new one. It had frequently been discussed during the last 50 years, during which time there had been a considerable division of opinion not only as to whether primary thrombosis in the pulmonary artery was commoner than embolus of the vessel, but also concerning the relation of thrombosis in the systemic veins to clots in the pulmonary vessels, and, moreover, whether clotting in the pulmonary artery was centripetal or the reverse. Nevertheless, Prof. Glynn’s name would always be associated with the pathology of the subject because he had based his views on strict pathological investigation, a method not adopted by the earlier writers. Prof. Blair Bell thought that the main pathological contentions submitted by Prof. Glynn could hardly be controverted. Prof. Glynn stated that he had performed 35 consecutive autopsies on cases of pulmonary embolus and thrombosis ; and in 30 (85 per cent.) of these he had found that the fatal lesion was primary pulmonary thrombosis. He adduced as evidence of primary thrombosis not only the presence of blood-clots, which might be found in all lobes of both lungs, but also proof that they were of ante-mortem formation, for age changes, such as deposition of blood-pigment, were demonstrated in nearly all, and commencing organisation was found in the clot in one-third of the specimens-conditions that could not possibly have developed in the few minutes generally supervening between the onset of the lethal seizure and death. The question of pulmonary embolus did not require special considera- tion, for the cause and mechanism were easily under- stood. Moreover, embolism was comparatively rare. The discussion of Prof. Glynn’s paper really centred on the problem of the causes and prevention of primary pulmonary thrombosis, and it was probable that the greater frequency of this condition after gynaecological operations was attributable to two causes: (a) injury to large veins; (b) proximity of large vessels to septic foci. With regard to the first, injuries might be produced in several ways, the chief of which were the temporary application of compression forceps to big vessels like the ovarian, and the stripping free of large veins from the surround- ing tissues, in which circumstances actual clotting or pre-clotting changes might more readily be produced in the blood contained within the lumen of the vein. The proximity of large vessels to septic foci was no less important. The proximity of large vessels to a septic area was conducive to changes in the blood- stream by the passage of toxins or organisms through the vessel walls. If the sepsis was severe actual thrombosis might occur in the pelvic veins, in which case a pulmonary embolus was a contingency to be remembered and avoided by suitable measures, such as rest. If the sepsis were mild, local thrombosis did not occur, but the toxins which reached the blood- stream were predisposing factors of pulmonary thrombosis. 1 THE LANCET, Feb. 23rd, 1924, p. 390.
Transcript of A CASE OF BILATERAL HERPES ZOSTER
749
A CASE OF BILATERAL HERPES ZOSTER.
BY E. R. C. WALKER, B.A. CAMB., M.B., CH.B. EDIN.,RESIDENT PHYSICIAN, THE ROYAL INFIRMARY, EDINBURGH.
IN the following case the patient could not recall anyprevious illnesses, and did not remember being in con-tact with any case of herpes zoster or of chicken-pox.He was a general labourer, aged 29, of Irish nationality.
For about two months before the onset of acute painhe had occasionally experienced a tingling sensation on
the upper part of his chest on both sides. About a fort-night before the appearance of the rash he had a stabbingpain about two inches above the left nipple. Ten days later
Showing distribution of lesions on the back after the vesicleshad broken down. The photograph was taken by Dr. W. D.Small.
a similar pain developed on the right side at a somewhatlower level. Two days later the rash appeared on both sides.The patient thought it appeared first on the left side, but wasnot certain. The distribution was as follows : Right side :from ninth, tenth, and eleventh dorsal vertebrae spreadinground the chest to midway between the umbilicus andensiform cartilage in front. Left side : from fourth, fifth,and sixth dorsal vertebrae spreading round underneath theshoulder, above the nipple to fourth and fifth costal cartilagesin front, and also down posterior fold of axilla and back of arm.
’ Condition on Admission.-When, on Feb. 2nd, 1924, hewas admitted to hospital, seven days after the appearanceof the rash, the temperature was 98-2°F., respirations 24,pulse 120. There was a slight rise of temperature in theevening, but this subsided during the night, as did also therespirations and pulse. Wassermann reaction was negative.Urine normal. Bowels slightly constipated.He made a complete and rapid recovery.The unusually long history may perhaps be due to
the patient’s nationality. He was somewhat vagueas to facts, and his native courtesy made him verywilling to oblige in the matter of remembering earlysymptoms. He was, however, quite definite about thepain above the nipple a fortnight before the appear-ance of the rash.
I have to thank my chief, Prof. Jonathan Meakins,for leave to publish the case.
KENT COUNTY OPHTHALMIC HOSPITAL, MAIDSTONE.The annual report of this institution stated that the accountswere satisfactory, but owing to the transition state of thehospital, due to building and rebuilding operations, itwas difficult to make any comparison with past years.The total sum realised by the Extension Fund Appealamounted to over .615,000. The board expressed its deep ’Igratitude to Mr. Wheler Bennett for his handsome contribu-tion of 10,000 to the hospital. The importance of the IWeekly Subscribers’ Fund was shown by the fact that four
Iyears ago this fund amounted to 2192 and had nowincreased to .87925. There were at the moment 206 cases Iawaiting admission.
Medical Societies.NORTH OF ENGLAND OBSTETRICAL AND
GYNECOLOGICAL SOCIETY.
A MEETING of this Society was held in Liverpool onMarch 14th, with Dr. A. DONALD, the President, inthe chair.
DISCUSSION ON PRIMARY PULMONARY THROMBOSIS.The discussion on the paper read by Prof. E. Glynn,l
postponed from the meeting held on Jan. 18th, wasopened by Prof. BLAIR BELL. He said that togynaecologists the question of primary pulmonary
thrombosis was of special interest, as in all gynoeco-logical clinics throughout the world this disaster hadoccurred with greater frequency than in the clinicsof the general surgeons. Prof. Glynn would, however,be the first to disclaim any suggestion that the ideaof primary pulmonary thrombosis was a new one.It had frequently been discussed during the last 50years, during which time there had been a considerabledivision of opinion not only as to whether primarythrombosis in the pulmonary artery was commonerthan embolus of the vessel, but also concerningthe relation of thrombosis in the systemic veins toclots in the pulmonary vessels, and, moreover, whetherclotting in the pulmonary artery was centripetal orthe reverse. Nevertheless, Prof. Glynn’s name
would always be associated with the pathology of thesubject because he had based his views on strictpathological investigation, a method not adoptedby the earlier writers. Prof. Blair Bell thought thatthe main pathological contentions submitted by Prof.Glynn could hardly be controverted. Prof. Glynnstated that he had performed 35 consecutive autopsieson cases of pulmonary embolus and thrombosis ;and in 30 (85 per cent.) of these he had found that thefatal lesion was primary pulmonary thrombosis.He adduced as evidence of primary thrombosis notonly the presence of blood-clots, which might be foundin all lobes of both lungs, but also proof that they wereof ante-mortem formation, for age changes, such asdeposition of blood-pigment, were demonstrated innearly all, and commencing organisation was foundin the clot in one-third of the specimens-conditionsthat could not possibly have developed in the fewminutes generally supervening between the onsetof the lethal seizure and death. The question ofpulmonary embolus did not require special considera-tion, for the cause and mechanism were easily under-stood. Moreover, embolism was comparatively rare.The discussion of Prof. Glynn’s paper really centredon the problem of the causes and prevention ofprimary pulmonary thrombosis, and it was probablethat the greater frequency of this condition aftergynaecological operations was attributable to twocauses: (a) injury to large veins; (b) proximityof large vessels to septic foci. With regard to thefirst, injuries might be produced in several ways,the chief of which were the temporary applicationof compression forceps to big vessels like the ovarian,and the stripping free of large veins from the surround-ing tissues, in which circumstances actual clottingor pre-clotting changes might more readily be producedin the blood contained within the lumen of the vein.The proximity of large vessels to septic foci was noless important. The proximity of large vessels toa septic area was conducive to changes in the blood-stream by the passage of toxins or organisms throughthe vessel walls. If the sepsis was severe actualthrombosis might occur in the pelvic veins, in whichcase a pulmonary embolus was a contingency to beremembered and avoided by suitable measures, suchas rest. If the sepsis were mild, local thrombosis didnot occur, but the toxins which reached the blood-stream were predisposing factors of pulmonarythrombosis.
1 THE LANCET, Feb. 23rd, 1924, p. 390.
