A RARE CASE OF PURPURA HqMORRHAGICA OCCURRING AFTER SCARLATINA ANGINOSA

H KETTLE
1866 The Lancet  
65 back of the leg a semicircular line of demarcation had formed as high as the popliteal space, beneath which space, at the flexure of the knee, was to be seen the marks of a wound, extending completely across the leg, and having several sutures in it. A longitudinal incision was made, so as to examine the joint (which was as carefully dissected as the disintegrated state of the parts would admit), when a quantity of grumous serum escaped, and the following parts were found to be tornnamely,
more » ... to be tornnamely, both heads of the gastrocnemius, tendon of biceps, popliteal artery, crucial ligaments, and part of the external semilunar cartilage; but neither of the cartilages had been entirely detached, and they looked quite healthy. The popliteal and peroneal nerves looked as if they had been much stretched, but were not torn. Further the leg was not examined, the principal object being to ascertain the state of the parts implicated after so severe an injury. For two or three days after the operation the patient seemed to do well, with the exception of pain in the stump, which looked unhealthy, though not gangrenous, and discharged a quantity of grumous-looking secretion. From this time he got weaker and weaker, and died on the seventh day after the operation, or the eleventh after the accident. I fully believe that if this man had been operated on at the time of the accident, the case would have added one more to the list of recoveries after amputation in the thigh for compound dislocation of the knee. , an exceedingly well developed little girl, aged about four years, y,ras attacked with the usual symptoms of scarlatina on the 18th of November, 1865. The throat was much inflamed, and diarrhoea, persistent throughout. About the sixth day erysipelas appeared around the left eye, and terminated in suppuration. After a most severe attack she slowly approached convalescence, but could only with great difficulty be induced to take small quantities of stimulants and nutriment. At nine of Dec. 10th, she was suddenly attacked with vomiting of blood, with bleeding from the nose and the abscess beneath the eye. From the loud rale heard in respiration, there was also evidently haemorrhage from the'lungs. The faeces were bloody; but the urine could not be examined. Haemorrhage continued with slight intermissions, in spite of all treatment, for more than seven hours, when death closed the scene. There appeared numerous but rather small ecchymoses upon the chest, abdomen, and back; but none upon the extremities. No post-mortem examination was allowed. There had been no dropsy or nephritis in this case. I have never seen, heard, or read of a similar case, although I am aware that it has occurred after typhoid and other fevers of low type. SmaUneath, Birmingham, Dec. 1863. FELLOWSHIP OF THE COLLEGE OF SURGEONS.—We pointed out recently the extreme imperfection of the examinations for the Fellowship of the College of Surgeons. We learn that this representation has not been without its e9ect, and that it has been resolved in Council to apply to the Secretary of State for authority to make such alterations in the bye-laws as will allow these examinations to be considerably extended and improved. We know too well the difficulties of carrying any change whatever into Council, and the especial horror which the senior members have of any profane hand being laid upon their chartered privileges, not to be aware that this is very significant; and the profession will receive this intimation with MMisfaction. It is, however, but a very small instalment of what is needed. The imperfect and fragmentary nature of the examination for membership, which is a passport to siirgical practice, is the standing disgrace of the College. It is undoubtedly the most deceptive diploma which exists in this kingdom ; and the College is bound to institute, either by co-operation with the College of Physicians or singly, an examination which shall be more complete and satisfactory. Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum, tum proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus, Morb., lib. iv. Procemium. THE two cases of aneurism which we publish this week may be advantageously considered together, for they are striking examples of the difficulty which often attends the diagnosis of such arterial lesions. They may be compared also with Mr. Heath's case at the Westminster Hospital, which appeared recently in our columns ("Mirror," Dec. 30th, p. 724), as well as with a case narrated by Dr. Davies in the "London Hospital Reports," vol. i. We had frequent opportunities of observing Sir William Fergusson's patient. It was interesting to note that, with a ,large pulsating tumour bulging up from the supra-clavicular region, and threatening at any moment to burst and destroy him, the man appeared to suffer very little inconvenience. He was rather surprised indeed at being kept in bed, and was disappointed at not being allowed to go and see "King John" at Drury-lane Theatre. Mr. T. Howells, house-surgeon, has been good enough to give us some account of the patient's history. M. W— aged forty-three, a seaman, fell overboard on October 1st, 1864, striking the "bowsprit shrouds" in the fall. On arrival in port, his clavicle was found fractured about two inches from the sternum, and there was a small pulsating tumour about two inches above the sternal end of the clavicle. This tumour steadily increased in size. On his return to England he was admitted into the hospital on October 24th, 1865, twelve months after the accident. On admission, the tumour is now about four inches in diameter, pulsates strongly, and bulges from the clavicular region of the right side of the chest, extending from the second rib to half way up the neck, and from the acromium to the sternoclavicular joint. The skin over the tumour is of a light-red tint; but in one spot on a level with the clavicle, and about two inches to the right of the sternum, it is of dark purplish colour, and the aneurism appears to "point" at this part, under which a portion of bone may be felt. There is very little cedema ' of right arm. There is no cedema of the neck or face, no hoarseness or other alteration of voice, no difficulty of swallowing, and but little affection of breathing or cough. The vision is unimpaired, and the pupils of both eyes are equal; there is ' no arcus senilis. The hearing is unaffected. No bruit audible over the cardiac region, and the sounds of the heart are normal both at apex and base, but they can be distinctly heard over the tumour in the situation of the right sterno-clavicular joint. Ordered two grains of acetate of lead and a quarter of a grain of gum of opium in a pill three times a day. Nov. 7th.-Aneurism increasing in size; more cough and : difficulty of respiration. 30th.—With a view of supporting the gradually thinning . skin, gutta-percha dissolved in chloroform was painted over the tumour, so as to form a thick layer on its surface. Dec. 14th.-From increased size of tumour the gutta-percha ' coating has come off. The skin is ulcerating at the part where the aneurism points. 16th.-Complains of great pain in arm and shoulder. : 21st.-Great difficulty in swallowing and breathing. 28th.-Tumour increasing over shoulder in front and behind. Jan. 2nd, 1866.-Aneurism burst at six P.M. at the thin point. Not much blood lost, and bleeding was stopped by tincture of muriate of iron and graduated compresses. C,
doi:10.1016/s0140-6736(02)52687-8 fatcat:pjft6krcobbxlfqauofmvshcoy