PURPURA HEMORRHAGICA RHEUMATICA. (PELIOSIS RHEUMATICA; MORBUS MACUI.OSUS WERHOLFH.) BY D. W. PRENTISS, M.D., PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS IN COLUMBIAN UNIVERSITY, WASHINGTON, D. C. REPRINTED FROM THE TRANSACTIONS OF THE ASSOCIATION OF AMERICAN PHYSICIANS, MAY, 1890. PURPURA HEMORRHAGICA RHEUMATICA. (Peliosis Rheumatica ; Morbus Maculosus Werholfii.) By D. W. PRENTISS, M.D., PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS IN COLUMBIAN UNIVERSITY, WASHINGTON, D. C. Eddie D., aged thirteen years. Previous health good. His first attack was in March, 1889, and began with a swelling of all the joints, pain, especially in the knees and ankles, a purpuric eruption over the entire body, pain in the stomach, and vomiting. The pain in the knees and ankles was excruciat- ing. He was put on a diet of milk and Mellin's food, and recovered in two weeks. This attack followed prolonged exposure and excitement at the base- ball grounds-the boy, being infatuated with the game, was frequently all day without food, except ginger cake, pie, and peanuts, and sat on the rough benches of the ball grounds in cold winds, in rain, or in heat. The second attack was in September, 1889, and was similar in character, except that the swelling and eruption were confined to the right half of the body. He had then been exposed to scarlatina. The treatment up to this time had been acids, iron, and quinine, and, to relieve pain, morphine. The third attack was on November 15, 1889, and was similar to the preced- ing, but more severe. Pain in the abdomen and left side of chest was intense. In addition to the purpuric eruption there were hemorrhages from the bowels and bladder, and, in large patches, into the skin. No hemorrhage from the nose or lungs. There had been very little fever during the attacks, the temperature seldom rising above 100°. In the third attack he was delirious, and had dyspnoea, swelling of the forehead, and conjunctivitis. Arsenic, which he had been taking for several weeks, was discontinued. On December 17, 1889, and on February 27, 1890, he had relapses. After this to the present time relapses recurred at intervals of a month or six weeks, but were less severe. During the interval he is not perfectly well, though comparatively comfortable and free from pain. Since the beginning of the disease the purpuric eruption has never been absent. 2 PURPURA HEMORRHAGICA RHEUMATICA. The urine was examined from time to time, and, excepting the presence of blood, was found normal. On one occasion, however, there was a greatly diminished amount and much albumin, evidently due to acute nephritis. Dr. Theobald Smith, Bacteriologist to the Government Agricultural Department, was kind enough to examine the blood, but discovered nothing abnormal, as will be seen by the accompanying report: " January 21, 1890. The blood from the finger was dried on a cover-glass, and stained with alkaline methylene blue. Some of the preparations were decolorized in one per cent, acetic acid. There was no change in the size or form of the red corpuscles. Occasionally isolated corpuscles were observed, which retained the stain faintly. These forms are probably young corpuscles. The leucocytes were slightly increased in number; otherwise the blood elements appeared normal." Dr. Smith also sent the following interesting note of a hemorrhagic disease that occurs in guinea-pigs: "Among guinea-pigs kept for experimental purposes, a disease occasionally appears which usually ends fatally and may carry off the greater number of those living together. The disease seems to be due to the exclusive use of dry food, such as grain of various kinds. When the food is changed, and vege- tables, fruits, etc., are given, the disease is checked and disappears. That it is a food disease I feel quite certain. The examination of the dead animals reveals, as a rule, extensive subcutaneous and intramuscular ecchymoses, limited chiefly to the limbs. Occasionally they are found on or in the muscles of the chest and abdomen. The internal organs contain no bacteria." The characteristic symptoms in this case of peliosis rheumatica are: Swelling and pain in the large joints, closely resembling rheumatism, but coming and going sometimes within a few hours. The character- istic ecchymoses of true purpura are present. There are hemorrhages into the bladder and bowels, but none from nose or lungs. Of particular interest in this case was a peculiar hemorrhage into the true skin-apparently between the epidermis and true skin-which destroyed the skin by gangrene. The most marked of these ecchymoses were in the skin of the abdomen-two patches, each the size of the palm of the hand, one on the left, the other on the right of the navel. These ecchymoses appeared within half an hour, and were at the beginning perfectly black and painless patches of true gangrene. In a few days a line of demarcation formed, and in due time the dead tissue sloughed, leaving a granulation surface which healed slowly, forming scars which can still be seen. PURPURA HEMORRHAGICA RHE UJI A TIC A. 3 The boy formerly had a tight phimosis, for which I intended circum- cising him, but one of these sloughs appeared on the under surface of the prepuce and cured the phimosis. Among the symptoms were frequent vomiting and violent pains in the abdomen. The abdominal pain at times was so violent that I thought there was a peritonitis from a hemorrhage into the peritoneum, but the absence of tenderness and the rapid disappearance of the pain rendered this view improbable. The attacks, as stated, are remittent in character; exacerbations occurring at intervals of one or two months. The latter attacks have been less prolonged than the earlier. As to treatment, the medicine that appears to have done the most good is arsenic-and possibly salol given for relief of the rheumatic symptoms. DISCUSSION. Dr. I. E. Atkinson : It is difficult to say whether these cases of purpura represent any essential disease, or whether they compose a symptom-complex that may be an expression of quite a number of different diseases. Rheuma- toid symptoms may occur either in purpura simplex or purpura hemorrhagica, and in either case may be fitly classed as peliosis, or purpura rheumatica. The rheumatic or rheumatoid tendency may extend through the entire series of purpuric disorders, and is marked in that related disorder, erythema nodo- sum, in which the hemorrhagic element is often pronounced. The abdominal pains noted in Dr. Prentiss's case are quite frequently observed, often associ- ated with evidences of implication of the nervous system to such an extent that one or two authors have proposed, as a further subdivision of the disorder, purpura nervosa. The truth is, that the various forms of purpura shade into each other so gradually that no lines of demarcation can be drawn between them, and the descriptive terms can only serve to designate preponderating characteristics, but not essential differences. Within the past two months I have had under treatment a case of otherwise extremely mild purpura, which could only be considered purpura hemorrhagica in consequence of a most trivial epistaxis, but in which a decided cerebral hemorrhage had occurred with pronounced, but incomplete, hemiplegia. Such results are not extremely rare. A correct conception of purpura admits no distinction, in essential nature, between the most trivial form of purpura simplex and fatal forms of purpura hemorrhagica, or morbus maculosus Werholju. 4 PURPURA HEMORRHAGICA RHEUMATICA. Dr. A. Jacobi : I am glad to see that the several forms of hemorrhages of this kind are brought together under one head. I have never been able to find a reason why we should have so many separate expressions in our nomen- clature referring to probably the same subjects. We always have to fall back on the disordered condition of the structure of the walls of the bloodvessels. It is not the condition of the blood, but of the bloodvessel walls. As far as the condition of the bloodvessels is concerned, it is probable to my mind we might introduce scurvy under the same head too. It is only a year ago that a German author contended to have found the bacillus in the bloodvessel walls of purpura hemorrhagica. Whether it will be confirmed by further experience remains to be seen. At all events, there must be some change in the structure of the bloodvessel walls. So I have come to the conclusion, if we mean to treat such things, particularly of a chronic character, we have to pay the principal attention to the anatomical structure of the bloodvessels. Then we have to give tissue-builders. We have no better tissue-builders than arsenic and phosphorus. The dose for such a boy as Dr. Prentiss has brought before us would be of a grain of phosphorus three times a day, dissolved in oil or whatever you please, for two or three months or longer. I am positive, in a large number of cases, I have extinguished a tendency to purpura hemorrhagica by such treatment. In the first preparation which has been recommended the phosphorus is probably the efficient factor. Dr. D. W. Prentiss: In regard to the treatment, I commenced to treat with acids and iron tonics, but it appeared to produce no effect whatever, and seemed to disorder the stomach ; and finally, I gave arsenic, which has done more good than anything else. I have not tried phosphorus. I would like to ask Dr. Atkinson, if, in any of these cases, he has found sloughing followed by hemorrhage into the skin? It seems to be a characteristic appearance in this case. Dr. I. E. Atkinson : I have never observed any case where it has gone through the skin. There has been superficial loss of structure. I believe there are cases on record where such gangrene taken place. Dr. A. Jacobi: Such sloughs will take place when the hemorrhage is extensive. This boy has scars of sloughing over the larger portion of the abdominal integument. This boy has no heart disease, no enlarged liver; but he has peritonitis. He ought to go to bed and have cold applications made, I think the doctor's diagnosis of peritonitis is a correct one. Dr. James Tyson : I have seen similar sloughing of the skin of the arm in a case under my care.