ON PURPURA HÆMORRHAGICA. By E. M. HODDER, Esq., M. D., Toron to. Proceedings of the Toronto Medico-Chirurgical Society. Mary Osborne, æt. nearly four years, of light complexion, and delicate constitution, complained of being unwell on the 27th March, and in the evening became somewhat feverish. Her friends, supposing that it would shortly pass off, gave her only a little castor oil. On finding that the fever still continued, and was on the increase, I was sent for on the 30th March, when I found her labouring under symptoms of derangement of the mucous membrane of the stomach and bowels. Her tongue was loaded with a whitish fur, she had no appetite, great thirst, bowels rather confined, motions slimy, offensive, and of a light colour, skin generally hot, particularly over the abdomen, a quick pulse, and constant irritation and picking of the nose. Ordered-A mild aperient immediately; warm bath, and some powders, composed of hydr. c creta, rhu. et ipecac. [No. 1 chia was not elevated, but those which appeared to contain blood, were as large and as much raised as the half of a small pea, some of which having burst, had stained the linen with the blood they contained. The constitution at this time did not appear to suffer much; there was no fever, no thirst, the pulse was 100 and soft (weak, if anything). She had no pain in any part of the body, appetite bad, tongue moist with a slightly brown fur upon it, and, with the exception of her temper which was irritable, the child was playing about, and appeared nearly well. Ordered-Hydr. submur. pulv. jalap, comp. et rhu. immediately, and repeated to-morrow morning. The surface of the body to be sponged with vinegar and water night and morning. April 21st. Much the same as yesterday, except that the tongue is somewhat cleaner and moist. Bowels have been acted upon two or three times; motions light in colour. Ordered-A perient powders to be continued occasionally; potass. chlorat. and hydrochloric acid mixture every four hours. April 22d. The child appears listless, the tongue In a day or two the tongue began to clean, and the appetite returned; and all the other symptoms were either gone or much relieved; the same plan of treatment rather more brown, no fever, pulse 106, soft. Aperient was continued until 5th April, when the child only ap- powder immediately, beef tea, and continue the mixpeared to want strength to restore her to her usual ture. health. April 24th. The child is worse to-day in every reShe continued well until the 18th, when she again spect. The surface of the body is pallid; the petechia complained, and on the 20th I was called in, when I are larger and more numerous; blood has been voided found her labouring under well marked symptoms of by stool. Yesterday evening she complained of soreness Purpura Hæmorrhagica. of the throat, and, upon examining it this morning, I The whole surface of the body and the extremities found the back part of the fauces much swollen, dark, were more or less covered by small petechiae of a bright livid, and almost gangrenous in appearance; a large red colour, interspersed with some of a larger size and sloughing ulcer occupied the right tonsil and the root of livid hue; the mucous membrane lining the mouth and the uvula; the tongue was black, but moist; and the air passages was also studded with them, two or three breath extremely fœtid. Pulse 130, small and weak; of which were of a large size, and appeared as if filled countenance sunken; a slight cough. No pain in any with black fluid blood, some having burst, giving rise to part of the body except the throat. She was ordered hæmorrhage from the mouth and nose. wine every hour until seen in the evening, the hydroThe conjunctiva was also spotted. Besides the pete-chloric acid gargle, and sulph. quinine with excess of chiæ on the body and extremities, there were several sulph. acid every four hours. stripes and patches or ecchymoses, as if produced by bruises and the cuts of a whip. 6 P. M. Continues much the same, with the exception of vomiting, which came on at 5 P.M. Matter vomited The cuticle over these patches and the smaller pete-like dark coffee grounds, mixed with thick mucus. In On Purpura Hæmorrhagica. the act of vomiting the uvula came away, throat gangrenous, breath intolerably 'fætid. She could not use the acid gargle. Ordered-Wine to be continued in larger quantities; continue the mixture; alum gargle for the throat. 25th. Passed a restless night; all the symptoms much as yesterday; pulse 140, very feeble. By some accident the wine was not given to her throughout the night. Vomiting returned occasionally, same sort of matter; evacuations dark, tarlike, and semifluid. Continue as before. 26th. Continues the same in every respect. 27th. Aggravation of all the symptoms; extreme pallor of the surface of the body; evacuations copious and of the same appearance as before; pulse 160, small, weak, and indistinct; tongue quite black; stomach rejects every thing taken into it; breathing thick and heavy, almost amounting to stertor; approaching coma. Dr. O'Brien kindly visited her this evening, and suggested the use of the hydrochloric acid gargle again; the mixture to be continued, with the addition of a few drops of Tr. opii. The foramen ovale was not completely closed, several circular openings still existing. In the stomach there was some ropy mucus, with a small quantity of dark-coloured fluid, and its villous surface presented innumerable small bloody points, Externally the intestines generally exhibited a deep purple surface, particularly the ilium, cæcum, and part of the colon; and on slitting them open they were found completely filled with blood of a tarlike colour and consistence. Their mucous surface appeared gorged with blood, which could not be removed or lessened by repeated washings, and being wiped with a sponge. The urine was very turbid, but did not contain any blood, The examination was here brought to a close, in consequence of the friends objecting to the head being opened. June 2, 1845. In drawing the attention of this Society to Purpura Hæmorrhagica, (which in its most severe form is undoubtedly a rare disease), I am induced to do so from She continued to linger until about 4 A.M., of the 28th, the great danger which attends it, the obscurity in which when she died completely comatose. Sectio Cadaveris, 26 hours after Death. The body externally was every where dotted with dark and circumscribed livid spots, varying in size from a millet seed to a silver threepenny piece. There were also several stripes of a bluish colour, and the appearance of numerous bruises as above described. The livid colour was deeper at the centres of the large spots, becoming of a more dusky red hue towards the circumference. On making the usual incision from the sternum to the pubis, the same purpurous spots were discovered on the pectoral and abdominal muscles, as well as on the fascia covering them. Almost every organ in the cavities of the thorax, abdomen, and pelvis, presented a similar appearance, the lungs, heart, pleura costalis, and thymus gland (which was of very large size), being all covered with the same ecchymosed patches. Nor were they confined to the surface, for on cutting into their substance they were found equally numerous, and of precisely the same character. The lining membrane of the trachea and bronchi were, however, quite free from them. The heart it is veiled as to its causes and means of cure, and because, to the pathologist it offers a wide and interesting field for experiment, which it is the duty of every Practitioner to avail himself of, so far as his time and opportunities will allow. It appears to be the opinion of most modern pathologists, that this disease is occasioned by a depraved or attenuated state of the blood, exhibiting diminished vitality, and an alteration in its composition and vital properties. I regret that I have not been able to meet with any account of the chemical analysis of the blood in Purpura Hæmorrhagica-its sensible qualities, however, and mode of coagulation have been carefully noted in several cases Dr. Watson (Lumleian Lecture, Med. Gaz. vol. x) asserts that, "in many, perhaps in all instances of the disease, in which it can be examined, the blood is found actually to have undergone a change, not merely a change which may be ascertained by nice or elaborate chemical research, but such an alteration of its sensible qualities as is evident to the eye, and forces itself upon our notice." The following are some of the most remarkable results of the examination of the blood in this disease:-1st, case of Dr. Jeffreys'-blood taken from a plethoric subject contained no blood whatever; the walls of the ventricles with a full pulse-2d. bleeding, after purgatives, and a participated in the appearance observed in the other viscera. In the upper part of the septum common to the two auricles, and above the fossa ovalis, there was an interstitial deposit or extravasation of blood, extending throughout its whole extent. previous loss of two pounds of blood by epistaxis. “The blood drawn yesterday shows an inflammatory buff on its surface, at least an inch and a half in thickness, firm and yellow, far exceeding any thing I ever saw in Rheumatism or pneumonia, but not at all cupped, in fact the more slowly than the other constituents, and that after repeated bleedings the blood may become so impoverished and deprived of its globules as to be unable to arouse and keep up the vital action in the animal economy. Under these circumstances then, bleeding should only be thought of when the disease has been of short duration, the patient plethoric, with a sharp hard pulse, fixed pain, or symptoms denoting local congestion. Dr. Macintosh informs us that he lost a patient some hours after she was bled. whole serum looks like a corrupted coat of coagulated globules and fibrine are deficient, and when the serum is lymph. The crassamentum appears in a very dissolved in larger proportion than natural, with a diminution of the state, of nearly a black color, and much less in quantity quantity of the salts held in solution, that the specific than usual." This patient was again twice bled, the weight will be less than natural, as is seen in chlorosis, blood presenting the same appearances; he ultimately typhus and yellow fever, and in all probability in Purpura. recovered -2d. Dr. Johnston relates a case of decidedly Should the above theory hereafter prove correct, or febrile character, and which rapidly proved fatal, the even to approach the truth; it will be one essential step blood did not separate into serum and crassamentum; it gained towards the true pathology of this obscure disease; had little consistence or tenacity, but traces of coagulable and we may hope that in due time we may discover a lymph were diffused through it :-3d. In Dr. Duncan's more successful mode of treatment than has been hitherto case, the blood, while flowing slowly from the vein, was adopted. observed to be florid and semitransparent, resembling In the treatment of this disease in its severe form, diluted arterial blood. It slowly formed a loose coagulum, venesection must be looked upon as a hazardous remedy, from which no serum was separated; the coagulum was requiring great discrimination as to the causes and period like jelly, tremulous, transparent and colourless, the few of the disease in which it may be employed with safety. red globules having subsided to the bottom. In this case We know that by repeated bleedings or hemorrhages the much blood had previously been lost by hemorrhage. mass of circulating fluid is diminished and rendered poorer In Dr. Combe's case the blood was pale, coagulated by being deprived of its red globules, and the salts held slowly, separated no serum, and was not buffed. In Dr. in solution; we also know that these are reproduced Gardner's case the blood first drawn by the lancet seemed, four hours after, to coagulate very imperfectly into a homogeneous mass. On the following day it resembled a tremulous jelly, the top of which was of a greenish buff colour with brownish spots like tadpoles. What afterwards oozed from the puncture resembled turbid lymph. (See Cyclopædia Pract. Medicine, Article Purpura.) In two cases which I saw some years since, the blood of the first, a delicate child about eight years of age, did not separate into serum and crassamentum, but the whole mass was soft, not retaining its shape when turned out of the cup, the upper surface flat, and pale in colour, the under, dark and of the consistence of tar. The second, a woman of about fifty years, the blood separated as usual, but the crassamentum was semifluid, dark and not buffed, the serum was of a dirty green colour, and in a very large proportion to the clot. It is very evident To whatever conclusion the pathologist may arrive, it from the foregoing cases that the blood in purpura differs cannot be denied that purpura is sometimes connected much from its natural condition: we find that the serum with a state of the system generally, or of some particular generally bears a much larger proportion to the crassamen-organ or organs, which requires blood letting for its cure; tum than in the healthy state, that the red globules (to but, I think it equally certain, that in the more seve e which the blood owes its power of arousing and keeping up forms of Purpura Hæmorrhagica, when there is prostration vital motion in the animal economy) are deficient, and per- of the vital powers, a pale cachectic complexion, with a haps altered in composition, and I have no doubt that a small, weak, and quick pulse, a diminution of heat on the future analysis will show, that, from the dark colour of surface of the body or extremities, and hæmorrhage the blood in all the cases, the saline matters which exist taking place from several of the mucous surfaces, it would n the natural and healthy serum, will be found greatly be as unphilosophical to bleed, as it would be in the latter diminished, or in some cases altogether wanting in pur-stages of any malignant or typhoid fever. purous blood. Dr. Fairburn's case, though a strong man in the prime of life, never rallied after the third bleeding. In the case of the child above alluded to, death followed a moderate bleeding in less than 24 hours, although the symptoms were never extreme and in the aged woman, who was bled in consequence of severe headache, never rallied, but died in about three days afterwards. The neutral saline medicines have been strongly recommended by Dr. Sevens, not with a view to purge, but to correct the deteriorated state of the blood. When the specific weight is increased, it is generally owing to a deficiency in the proportion of water, as in the blood of Cholera and Diabetes, sometimes to increase of Dr. Belcombe has also employed them with success fibrine, and red particles, as in Plethora, Gout, and Rheu-in three cases, one of which appears to have been of a matism; we may naturally infer then, that, when the red severe form. Dr. B. like, myself, used the Chlorate of Ergot of Wheat.-Ammoniacal Ointment. Potassa. I should not again feel disposed to use saline cease to perform their destined functions. To do this the medicines in the most severe forms of the disease, in con-blood must be supplied with what it has lost, and I can sequence of the lowering effects of these remedies on see no more speedy manner of restoring that deficiency the system. than by injecting the healthy blood of a stout and plethoric individual into the veins of the sinking patient. Whatever our present theories may be, “much yet remains to be done ere the pathology of Purpura or its treatment can be considered as satisfactorily fixed on scientific principles." Toronto, July 1845. Ergot of Wheat.-In a private letter from Dr. Reynolds of Bro ckville, the writer observes: Mr. Geo. Gulliver, F. R. S., (Surgeon to the Royal Horse Guards) in a paper "on the formation of the buffy coat of the blood" read before the Royal Medical and Chirurgical Society of London, in February last, asks, "whether the well known utility of saline medicines in inflammation may not be explained by their effects in preventing or destroying the aggregation of the red corpuscles, and in preventing or lessening the buffy or inflammatory condition of the blood. Purgatives sufficient ly active to unload the bowels, and frequently repeated, have been strongly recommended, and from the benefit I send you a small specimen of Ergot of Wheat, and which temporarily followed their exhibition in the case regret that I could not procure a quantity of it. One of our farmers, two years ago, imported some Spanish above related, their can be no doubt of their great utility. Wheat, to try whether it would be sufficiently forward They should consist principally of the warm aromatic or to escape the fly, but found last year that it was atresinous drugs. Various tonics, the vegetable and min-tacked with a disease similar to that so common in the eral acids, and astringent, have all their supporters, but are only applicable in the latter stages of the disease, after the use of purgatives. An interesting case is related by Dr. Sutherland, in the Montreal Medical Gazette for May 1844, of a lad aged 15, who was treated successfully by large doses of acetate of lead (15 grains every 2 or 4 hours) frequently repeated. Quinine and some of the preparations of iron will probably be found amongst the most useful of the tonic remedies. The diet should consist principally of light and easily digested animal food in the solid form, with perhaps a little wine occasionally. Those articles should be selected which will yield to the debilitated system the largest amount of red globules and fibrine. There is one remedial agent which has been often resorted to in hæmorrhages arising after child birth, serious wounds, or compound fractures, in cholera, &c. &c., but which I am not aware has ever been proposed or adopted in Purpura Hæmorrhagica-I mean Transfusion. In suggesting the propriety of performing this operation in an extreme case of Purpura, I would do so, not with any very sanguine hope of success, (nor should I attempt it until all other remedies had failed, and that death was inevitable without some speedy change taking place) but with a view to support the sinking powers of life, to stimulate the various organs, to arouse healthy action, and if possible gain a little time. Brockville, January 21, 1846. Rye, producing the Ergot, and rendering the flour a dangerous article of food, should the grain before grinding, be not carefully freed from this variety of smut. I tried the effect of this Ergot in an obstetric case-where the os uteri was well dilated; the woman had been for several hours without pains, notwithstanding a recourse to the usual treatment to induce them, &c. I gave about drachm in the form of infusion, and in course of fifteen minutes strong pains came on, and the patient was delivered of a fine boy, making the usual noisy entrance into life; so that in medicinal the Ergot of Rye. properties it would seem to have similar effects with Very truly yours, THOS. REYNOLDS, M.D. AMMONIACAL OINTMENT A SUBSTITUTE FOR The ammoniacal ointment, when properly prepared, action renders it preferable to the other preparations used causes vesication in about ten minutes. This rapidity of for producing vesication, which seldom act until after the Care should be taken that the ointlapse of several hours. imperfect. The formula for its preparation recommended by ment is properly prepared, or its operation will be slow and M. Gondret, the inventor, is as follows:-Hogs lard, 32 parts; oil of sweet almonds, 2 parts; melt at a very gentle heat, and pour the compound into a bottle with a wide mouth: then add strong solution of ammonia (at 25 per cent.?) 17 parts. Keep the contents of the bottle well The common cause of mixed by shaking them until cold. the ointment failing, is that the mixture of lard and oil is over heated. If the lard is too liquid or too warm when the ammonia is added, a portion of this is rapidly lost by evaporation; and the strength of the compound is impaired. If we are correct in supposing this formidable disease When well prepared and kept in a cool place, in a well to arise from an attenuated or depraved state of the blood closed bottle, the ointment will preserve its vesicating proin which the red globules are deficient, and perhaps alter-perties for more than a month.-Journal de Pharmacie, Janvier, 1846. ed in composition, surely there is nothing irrational in proposing to infuse into the system that principal of vitality without which the heart and brain would soon It would be better to melt the lard with the oil, by immersing the vessel containing them in water, the temperature of which is gradually raised." |