ART. XXXV. - Sanguineous Congestions of the Skin-Purpura. -By PROF. E. YOUNKIN, M. D.

The diseases in which blood is deposited on the surface or within the substance of the skin, or beneath in the cellular tissue, have received different names, according to the character of the sanguineous effusion.

When the blotches are produced by blows, or by local causes, they are denominated ecchymoses; when the effused spots are the size of hemp-seed, and from that to the size of peas, and when associated with some other affection of a more or less serious nature, they are called petechia; and when the congested parts present in streaks they are denominated vibices.

A more general term, which comprehends several forms of hemorrhage in the skin and mucous membrane, is that of purpura.

By purpura we mean a disease characterized by blotches of a dark-red or livid hemorrhagic effusion. The spots are circular and of different sizes; often in stripes or patches, irregularly scattered over the thighs, arms and trunk, with occasional hemorrhage from the mouth, nose, or bowels, and attended with debility and depression. Purpura is not to be regarded as an independent disease, but rather as a symptom of other conditions, the cause of which may be found primarily in the vascular or in the nervous systems.

In almost all cases the appearance of the spots is preceded by great debility, heaviness of the limbs and general uneasiness, either with or without fever, and they are frequent accompaniments of articular disease and scorbutic affections.

The extravasated spots are uncertain in their development, and irregular in duration. The process of effusion is neither uniform nor regular, and hence they may be developing in some places whilst fading out in others.

In the simplest form of purpura the disease almost always commences independently of known causes, and without marked derangement of the principal functions. Nevertheless some patients complain of lassitude and weariness some days before the appearance of the spots.

A much more serious form of the disease is that of purpura hæmorrhagica, which presents sometimes by mere petechia, but often by larger extravasated patches, preceded by great lassitude, debility and pains in the limbs. The body has been seen covered with livid spots similar to those that follow bruises, and blood has been seen exuding from behind the ears and vertex. The disposition to hemorrhage is so great, in some cases, that the slightest pressure upon a part is sufficient to produce an ecchymosis, but the distinguishing feature of purpura hæmorrhagica consists in the hemorrhage from other organs.

First, from the nose. This is the most common of all the varieties, and has been followed by death from sheer loss of blood.

Second, from the throat and mouth.

Sometimes the whole fauces appear of a deep red, and blood issues from every part. The gums are livid and spongy, and the blood exudes from the edges. The inner surface of the cheeks presents blackish spots, and the palate is covered with dark patches. Quite recently, I have seen these conditions associated with diphtheritic membrane on the tonsils, which loosened and came off, after which severe bleeding from the throat, nose and bowels so reduced my patient that it died.

Third, the hemorrhage may come from the stomach. In such cases there is vomiting of blood, accompanied with pain, usually in the left hypochondrium, with increase in the size of the spleen.

Fourth, the patient may pass blood from the bowels; the stools are of pure blood or sometimes blackish-looking.

Fifth, the blood may flow from the urinary passage. The urine is tinged with blood, or the fluid may pass unmixed and partly coagulated. A recent case, under my care, after passing blood from the urinary passage, was taken with suppression of urine, and died in thirty-six hours.

Sixth, there are cases in which hemorrhage takes place from the uterus, vagina, or pudenda. These cases are almost always

serious, and may be mistaken for miscarriage.

From whatever source the hemorrhage springs, if it is abundant, the lower limbs become cedematous, the face pale, the skin a whitish-yellow hue and the purpuric spots of a darker tint. The blood becomes thin, the extremities cold, and the patient grows more and more feeble. If, under these circumstances, another hemorrhage takes place, the patient usually dies of exhaustion.

In my own practice, I have met with a number of cases of purpura in children, some presenting without premonitory signs, and others following chills and fever, some cholera infantum, etc.

Purpura scorbutica is the most dangerous form of the disease, and the cutaneous affection is but a symptom of the general nutitrive derangement. Scorbutic purpura evidently points to the existence of serious blood-dyscrasia. The spots on or within the skin are always preceded by general lassitude, with pains in the limbs and joints. The fever may be high or low, of long duration or short, according to the form of the disease and the condition of the general health. In this form of the disease an unfailing condition is the affection of the gums. They are inflamed, painful, swollen and spongy. They bleed freely, and serious hemorrhage is liable to take place from the internal organs.

This disease is the result of living in confined abodes, impure air, unwholesome food and infectious surroundings. It is found in forts, prisons, hospitals, ships, and even city and country dwellings, where individuals are exposed to vitiated food and surroundings. Once started in a community, it may spread and become epidemic.

In the treatment of purpura the leading indications are to invigorate the vascular system, and to restore the nutritive processes. To accomplish these ends, the older writers depended on the sulphuric acid, iron and bark. The aromatic sulphuric acid, lemon and lime juice may be given. Tinct. ferri mur. may be administered with advantage. In some cases I have relied on the fluid extract of baptisia and the muriate of hydrastia. In cases of hemorrhage from internal organs, hamamelis stands first in importance. Ergotini internally or subcutaneously, in hemorrhage from the uterus especially; carbo-ligni in hemorrhage from the bowels, given in pill form, or an injection of willow charcoal may be used. In hemorrhage from the kidneys, perhaps there is no better agent than galic acid. For the debility, quinine and iron.

Spongy and bleeding gums are also painted with citric acid or dilute chromic acid, and the mouth may be washed with a solution of ratanhy. In purpura, with rheumatic pains in the muscles or joints, cimicifugi and salicylate of sodæ act well.

The cutaneous spots may be removed by increasing vascular tension; these are cured by absorption, and this condition may be promoted by faradization, and the ends accomplished as above indicated. With all, a generous meat and vegetable diet, wine, cider and buttermilk.

ART. XXXVI.-Obstetrics.-BY W. S. BAIN, M. D.

On July 15th, I was called to see Mrs. R., pluripara, æt. 16. The patient stated that she had been confined with her first child about ten months previous. About three or four months after her confinement, she noticed a tumor rising above the symphysis. As she had not menstruated since her confinement, and the time being so short, and there being no symptoms of pregnancy, she did not suppose that it was possible for her to be pregnant at this time, July 15th. She looked to be advanced to about the sixth or seventh month of gestation.

up so high that it was The os was patulous, and

On examination, found the os with difficulty that I could reach it. easily opened with the finger. The abdomen was lacking the ovoid form usually seen in pregnancy where everything is in a

normal condition. No amount of manipulation would produce any fœtal movements or uterine contractions, neither could I hear any sounds that in any way resembled the fœtal heart. I informed the lady that I believed her to be pregnant, but could not say positively. I advised her to wait a short time, and if there were no movements to come to my office, and I would try to set the question at rest as to whether she was pregnant. In about a week, or ten days, she came to the office, stating that she had not felt any symptoms, and said she did not believe that she was pregnant. As she was suffering considerable mental strain about her condition, I decided to ascertain if possible her true condition. I placed her in an operating chair, in dorsal position, and made digital examination, but failed to find the os. I then introduced a speculum, and opened the vagina. By using a depressor, I succeeded in bringing the os in view. There was nothing abnormal about the appearance of the os, it having the appearance of an os at about six or seven months gestation. I then made cold applications to the abdomen, but failed to elicit any movements or contractions. The stethoscope gave negative results as to cardiac sounds. I again informed the lady and husband that I thought she was pregnant, and instructed her to wait until her time was up, or nine months, and if there were still no signs of movement, or other symptoms pointing to pregnancy, I would then examine the cavity of the uterus and see what it contained. With this understanding, she left the office.

The next day after the patient was in my office she visited the city of Greenville, and was examined by two physicians, with the same results as I had obtained. A few days after this last examination I was hastily sent for to see the case. I found the patient in labor. On making digital examination, found the os opening, but could find no membrane protruding. After waiting half an hour, examined the case again. Found os open, and head presenting. As the head was soft and small, I grasped it with my fingers and delivered it, causing the mother but slight pain. It was dark, measured five inches, and well preserved, save the mottled condition of the skin. There was no membrane, nor any signs of any liquor amnii. On examination, found membrane protruding; ruptured the sac and there was a gush