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glands in addition to other mediastinal structures but i

perhaps distantly also to that of other solids in touch withthem. The practical value of an investigation of thisdulness in a great variety of intrathoracic diseases, and par-ticularly in scrofulous children and other subjects liable to I

glandular enlargements, needs only to be mentioned.THE LEFT AURICLE DULNESS.

The post-cordial dulness is of obvious importance to thephysician. It confirms the results of our anterior examina-tion and it enables us to demonstrate the absence of anygreat cardiac changes which would alter the normal area ordegree of dulness. Lastly, a familiarity with the exactoutline is our only means of discriminating from the post-cordial dulness those mediastinal and spinal dulnesses whichwe might in our ignorance have attributed to the heart. Thedistance which intervenes between the dorsal surface andthe ventricles and right auricle would seem to be an

insuperable obstacle to any accurate definition of their size.This is not, however, the case, and modifications in the sizeof the heart are capable of being identified by careful dorsalpleximetry. It is obvious, however, that the most definiteresults will be yielded by that part of the heart which mostclosely approaches the spine, and any information that wemay gain concerning it might be regarded as speciallyreliable. The part in question is the left auricle.Had I been guided by a different method-that of ana-

tomical surface markings as a preliminary to percussion-arecognition of the left auricular dulness would have been oneof my earliest results. The method adopted has been through-out the opposite-the tracing of outlines irrespectively of anyanatomical guide and their subsequent verification by dis-sections. It thus happened that the fact that it is easy topercuss out the left auricle was one of my latest results.Although to attempt it appeared at first sight almost toogreat a refinement of percussion the outline of the leftauricle is really, owing to its superficial position, the mostlikely portion of the post-cordial dulness to be obtained withease and accuracy. (Cf. Fig. 4.) ,

The normal left auricle dulness is of semilunar shape,convex upwards, placed almost symmetrically across themiddle line, sometimes extending a little further to theright than to the left, resting on the hepatic line as a baseand extending vertically from about the eighth to the ninthspine. It is surrounded above and on both sides by themuch less marked dulness belonging to the rest of thecardiac area. The resonance of the eighth and ninth spinesis considerably affected by it and the ninth spine in

particular is always comparatively dull. I can confi-

dently recommend students to practise this percussion, forwhosoever has once succeeded in identifying the left auriclewill experience no trouble in always finding it, its dulnessbeing greater than that of any other part of the post-cordialoutline. The value of this examination is great, for the leftauricle is liable to considerable variations in size and inmitral stenosis to great dilatations.

Curzon-street, W.

DERMATITIS EXFOLIATIVA NEONA-TORUM OR RITTER’S DISEASE.

BY K E D A R N A T H D A S, M.D. CALCUTTA,MEDICAL AND SURGICAL REGISTRAR, CALCUTTA MEDICAL COLLEGE

HOSPITAL.

THIS rare disease of the newly born, which is characterisedby hypersemia and excessive epidermic exfoliation and

accompanied at times by the formation of vesicles or bullsehas received scant recognition in text-books. As far as I

know no case has yet been reported in England. I am surethat cases do occur, but they are diagnosed as acute ’

pemphigus. The following case which came under myobservation only recently supplied the text of this paper.A Hindu male infant, 12 days old, suddenly developed

patches of diffuse redness over the face and neck. On thenext day the trunk became affected and there were large blebshere and there. On the day following the extremities werered. I saw the infant on this day and the large blebs gaveme the impression that it was a case of pemphigus. Whennext seen, two days afterwards, I found large flakes of

epidermis peeling off which drew my attention to the true

nature of the case. There was slight irritation of thebowels. There were no other complications. The tempera-ture remained normal except once on the second day when it.rose to over 103° F. The father and mother were healthy.There was no history of syphilis. The child recovered.Treatment consisted of the application of vinolia creamand putting the infant on a large pad of cotton-wool. Thechild is now (at the time of writing) suffering from an attackof furunculosis.The following description of the disease, chiefly drawn

from Elliot’s masterly contribution on the subject, will,I think, be useful in recognising it.

.SMy.—Ritter von Rittershain was the first to carefullydescribe the disease and to him belongs the credit ofestablishing the existence of it. It is claimed that othershave described it, but they had apparently confounded itwith pemphigus. Ritter observed 279 cases from 1868 to-1878. Since 1878 only a few more cases have been reportedin Germany. In America only six cases had been reportedup to 1892. An example of it was presented before theDermatological Society of Paris in 1892. No cases have beenreported in England.

Etiology.-Little is yet known of the etiology of thedisease. Recent researches show that it is probablyparasitic.

! SY1nptoms and clinical cozirse.-The disease generallyoccurs between the second and fifth week of life, rarelybefore the end of the first week. The process develops sud-denly under the form of a diffuse redness usually locatedupon the lower half of the face, about the mouth, but it mayoccur on some other portion of the body or it may even beuniversal. The byperasmia generally spreads rapidly andcontinuously but it may appear in patches, becomingultimately universal in a short time. As a rulethe extremities are attacked the last of all. Withthe extension of the hyperasmia exfoliation of the

epidermis begins upon the surface first attacked. Theexfoliation may occur without any exudation, the epidermisbeing slightly thickened, wrinkled, dry, and fissured intmpieces of all sizes, loosened at the edges, and removeable byany slight mechanical action, and underneath them a thinlayer of new epidermis will be found. On the other handthe exfoliation may be preceded by an outbreak of smallvesicles or large, irregularly-shaped, flaccid bullse.. These

may burst or on being rubbed off may leave a raw-lookingsurface. In such cases the body at the height of discomfortpresents a most pitiable appearance, as though it had been.scalded, the epidermis on some portions being wrinkled andsodden-looking, on others peeling off in large raggedflakes, while large areas may be entirely denuded, therete alone remaining. The buccal and nasal cavitiesare affected and fissures are very apt to form atthe corners of the mouth. The conjunctivse are

usually injected. Deep ulceration of the cornea has beennoticed. The process of regeneration is very rapid. Usuallythe disease runs its course in from seven to 10 days. Unlesssome internal complication exists the process is unaccom-

panied by either fever or systemic disturbance. Relapsesare occasionally observed, but are usually mild. As sequelsfurunculosis may be mentioned as the most common butabscesses with consecutive sepsis and gangrene may occur.

Pathology and morbid anatomy.-Ritter held that it was a,form of pyaemic infection, but this opinion, I think, is un-tenable. Bohn held that it was a dermatitis. Caspary regardsit as an epidermolysis of unknown nature with secondaryhypersemia of the cutis-possibly an acute disturbance of

inutrition in those external layers of the skin which do not con-l

tain blood-vessels. Kaposi and Bobn think that it representsa great increase in the physiological desquamation, but whilethe latter regards it as a pemphigoid eruption the former

f agrees with Ritter in separating it entirely from pemphigus.Brocq considers it to be a peculiar form of pemphigus, but

; more recently Riehl has discovered a fungus with long thin-

mycelium and concludes that this is the cause of the disease., This parasitic theory is the most satisfactory, though it

requires corroboration.1 IJ’iagnosis.-When once the disease is studied the diagnosis3 offers no difficulty. The only disease with which it can bemistaken is pemphigus simplex acutus neonatorum. Though0pemphigus appears during the first few weeks of life itusually develops earlier, commonly between the fourth and1 the eighth days, rarely after the fourteenth day. It does not

f begin with diffuse redness, but with an eruption of discrete3 bullpg upon an uninfiltrated erythematous base. These appear

269

in successive crops for a week or more but rarely after thefirst month of life.

1’rognos-is.-The general prognosis of the disease is un-favourable. The mortality of Ritter’s cases was 48’82 percent. The cause of death in some cases is the intensity ofthe attack ; in others it is exhaustion, secondary septicaemia,marasmus or loss of animal heat. Inanition is a frequentcause, as is also the development of some secondary andcomplicating disease.

’

Treatment.-The vital powers of the infant should be sus-tained by proper nourishment and tonics should be admin-istered. Externally fats and oils, with some antiseptic suchas boric acid, resorcin, or ichthyol, are recommended, as wellas the enveloping of the patient in wadding or in absorbentcotton. Ichthyol being a parasiticide and also a kerato-plastic agent would be peculiarly indicated.

Calcutta.

SIX CASES OF OPERATION FORAPPENDICITIS.

BY HORATIO P. SYMONDS,SURGEON TO THE RADCLIFFE INFIRMARY, OXFORD.

THE following series of consecutive cases of operation forappendicitis have been under my care in private practiceduring the last few years.CASE 1. -A young man, aged 21 years, was first seen

by me in February, 1896, when he was suffering froman acute attack of appendicitis. ’ There were pain in theright iliac region, an irregular temperature, and constipation.There was also a feeling of resistance in the same region anddulness the extent of which varied considerably. This dulnesswas no doubt due to a faacal accumulation in the cascum,for when the bowels were relieved it disappeared almostimmediately. The treatment which I prescribed was rest inbed, a slop diet, small and frequent doses of saline aperients,and soap-and-water enemata. The acute stage of theattack lasted a week, when the symptoms gradually subsided.The patient remained well for some months but had asimilar attack in the month of July while he was away fromOxford. In November another attack of a similar characteroccurred and I advised that when it quieted down theappendix should be removed. The patient consented to thisand the operation was performed on Nov. 24th. A curvedincision was made about an inch internal to Poupart’sligament, commencing a little above the level of the anteriorsuperior iliac spine. After some little exploration theappendix was found lying in a number of not very firmadhesions below and behind the cascum. It was ligaturedoff as close to its origin as was possible and removed. In itwas a small calculus which was on the point of ulceratingthrough. The patient made an uninterrupted recovery andhas been in good health ever since.CASE 2.-A man, aged 25 years, suffered in November,

1897, from a slight attack of appendicitis, with pain, hightemperature, and constipation. The condition, however,passed off in a few days. Realising the danger which heran he himself raised the question of operation and hedetermined to have the appendix removed. This was doneon Jan. 17th, 1898, when an incision was made as in Case 1and the abdominal cavity opened. The appendix was easilyfound lying free behind the cascum. There were no

adhesions. The peritoneal covering was much inflamed,evidently from the remains of the acute attack, and theterminal inch of the organ was tensely distended. A con-striction existed so close to the cascum that it was difficultto get a stump to ligature and therefore the appendix hadto be cut very close to the bowel. What stump was left hada circular ligature applied to it and in addition the mucousmembrane was invaginated and the two peritoneal surfacesthus brought into contact were sewn to each other, theprinciple being practically that of Lembert’s sutures. Theexternal wound was stitched up in the usual way. The

patient made an uninterrupted recovery and has sinceremained quite well.CASE 3.-A man, aged about 38 years, was seen by

me on Feb. 19th, 1899, suffering from pain in the rightiliac region, sickness, and constipation of two or threedays’ duration. The temperature on that day ranged about104° F. and a distinct swelling was present in the

region of the pain. The patient was very ill and onthe following day was very much worse, all the symptomsbeing aggravated and the condition of the gravest descrip-tion. An operation was therefore undertaken. An incisionin the same situation as that in the two previous cases

was made and an abscess containing a large quantity offoetid pus was evacuated. It was apparently incompletelycut off from the general peritoneal cavity, coils of bowelcovered by recent lymph presenting at the wound. It wasnot considered advisable to explore for the vermiformappendix and the latter was therefore not seen. Twodrainage-tubes were inserted into the abscess cavity whichwas douched out with sterile boric acid solution. Thepatient was very much collapsed after the operation andfor some hours was in a most critical state. Thewound was repeatedly dressed and douched with warmboric lotion. For several days the condition of the patientwas most serious, but about the third day the temperature,which all through varied between 102° and 104°, began tofall and gradually returned to the normal. The bowels wererelieved by small doses of salines repeated every two hourstill an action took place. During recovery a piece of smallintestine persistently protruded from the wound and all

attempts by graduated compresses, &c., failed to maintain itin position within the abdominal cavity. A few weeks afterconvalescence had been established a small faecal fistulaformed in it. An operation was undertaken for the relief ofthis. The knuckle of gut concerned was freed from itsadhesions to the anterior abdominal wall. The edges of thefistula were invaginated and sewn over, the skin wound beingagain sewn over this. Recovery was now uninterrupted andthe patient is now quite well.CASE 4.-A strong, healthy, young farmer was seen by

me in consultation on Sept. llth, 1898. On the 8th, fourdays previously, he had had a long day’s shooting and wasextremely fatigued. During that night he began to feelgreat pain in the right iliac region and on the following dayhe was seen by his medical adviser who found him sufferingfrom pain, sickness, considerable fever, and constipation.He continued getting worse during the next 48 hours and aswelling also appeared in the right iliac fossa. Agreeingwith the diagnosis of vermiform mischief with abscessformation I recommended operation which was performed onSept. 11th. On cutting down over the swelling an abscesswas opened which contained a large quantity of foul-smelling discharge. With some difficulty the appendix wasfound. It was in a state of intense inflammation amountingalmost to necrosis and was on the point of rupturing.It was removed. Two indiarubber tubes were placed inthe abscess cavity and the wound was partially stitched up.Although at the time of operation the patient was in a veryserious condition he began to improve from the moment itwas completed. The pain disappeared and the generalcondition became better. The wound was douched everyfour hours. The temperature commenced to fall very shortlyafter the conclusion of the operation. A piece of intestinepresented at the wound and gave some trouble sub-

sequently, but it was finally retained in position bythe application of a deep suture. About three weeksafter the operation the patient suffered from slight drypleurisy on the right side which, however, becamequiescent, though he continually complained of slight painin the side and had a short hacking cough. Towards theend of October the temperature began to rise a little towardsevening and it was then found that effusion was taking placeinto the right pleural cavity. The temperature continuingto go up an exploratory aspiration disclosed the existence ofan empyema. This was therefore evacuated on Nov. 1st anda large quantity of pus was evacuated. To admit of betterexpansion of the lung portions of ribs were removed. Therecovery from this empyema was tedious in consequence ofthe tendency of the cavity to fill up in pouches with pus, butultimately complete closure of the wound took place and thepatient is now quite well.CASE 5.-A woman, aged about 40 years, was seen by me

in consultation in October, 1898, suffering from pain in theright iliac region, slight fever, and constipation. I diagnosedvermiform inflammation and recommended removal of theappendix. The abdomen was opened by the usual incisionand the appendix was easily found. There were no adhe-sions and the appendix was removed as in Case 2. The

patient made an uninterrupted recovery.CASE 6.-A young woman had had four slight attacks of

appendicitis and as their constant recurrence was a source