/ ^ jy^ '^^ .0^, ^''^y.^ IMAGE EVALUATION TEST TARGET (MT-3) // ^/ .»» LL 1.25 ■tt Uii §22 :.tt|2o ■luu 6" ^^ ^ ^ J^ ^^? .V ■/y Photographic Sciences Corporalion \ <> 23 WIST MAIN STRUT WIBSTH,N.Y. USm (716)«7a-4503 '^ CIHM/ICMH Microfiche Series. CIHIVI/iCIVIH Collection de m Canadian institute for Historical IMicroreproductions / institut Canadian da microraproductions historiquas Tachnieal and BibHoflraphic Notaa/Notas taehniquaa at bibliographiqiiaa Tha Inatituta haa anamptad to obtain tha baat oriqinal copy availabia for filming. Faaturaa of thia copy which may ba bibllographieaMy uniqua, which may altar any of tha imagaa in tha raproduetion. or which may aignificantly changa tha uaual mathod of filming, ara (liaekad balow. HColourad covara/ Couvartura da coulaur r~~| Covara damagad/ Couvartura andommagia □ Covara raatorad and/or laminatad/ Couvartura raatauria at/ou pallicuMa □ Covar titia miaaing/ La titra da couvartura manqva □ Colourad mapa/ Cartaa gtegraphiquaa an coulaur □ Colourad ink (i.a. othar than blua or black)/ Encra da coulaur (i.a. autra qua blaua ou noira) D D D D Colourad plataa and/or illuatrationa/ Planchaa at/ou illuatrationa an coulaur □ Bound with othar matarial/ Rali4 avac d'autraa documants Tight binding may cauaa ahadowa or diatortion along intarior margin/ Laraiiura aarria paut cauaar da i'ombra ou da ia diatoralon la kmg da la marga intiriaura Blank laavaa addad during rastoration may appaar within tha taxt. Whanavar poaaibla. thaaa hava baan omittad from filming/ II aa paut qua cartainaa pagaa blanchaa aJoutAaa lora d'una raatauration apparaiaaant dana la taxta. mala, iortqua cala 4tait poaaibla, caa pagaa n'ont paa «ti film4aa. Additional commanta:/ Commantairaa aupplAmantairaa: L'lnatHbt a microf llmA la maillaur axampiaira qu'il lui a 4tA poaaibla da aa procurar. Laa ditaiia da cat axampiaira qui aont paut-4tra uniquaa du point da vua bibliographiqua, qui pauvant modif iar una imaga raproduita. ou qui pauvant axigar una modlfteatlon dana la m4thoda normala da f ilmaga aont indlquto cl-d aaa oua. D Colourad pagaa/ Pagaa da coulaur □ Pagaa damagad/ Pagaa D andommagiaa raatorad and/oi Pagaa raataurAaa at/ou pallicul4aa Pagaa dlacolourad. atainad or foxa< Pagaa dicoioriaa. tachatiaa ou piquiaa Pagaa datachad/ Pagaa d4tach4aa Showthroughy Tranaparanca Quality of prin Quallt* inigala da I'impraaaion Inciudaa aupplamantary matarii Comprand du matArial aupplAmantaira Only adition avaikibia/ Sauia Mition diaponibia r~l Pagaa raatorad and/or laminatad/ r~n Pagaa dlacolourad. atainad or foxad/ r~| Pagaa datachad/ pn Showthrough/ F~| Quality of print variaa/ r~1 Inciudaa aupplamantary matarial/ rn Only adition availabia/ Pagaa wholly or partially obacurad by arrata alipa, tiaauaa, ate., hava baan rafilmad to anaura tha bast poaaibla imaga/ Laa pagaa totalamant ou partiailamant obacurciaa par un fauillat d'arrata. una palura. ate. ont Ati filmiaa i nouvaau da fa^on i obtanir ia maillaura imaga poaaibla. Thia itam ia fiimad at tha raduction ratio chackad balow/ Ca document aat film* au taux da reduction indiqui ci-daaaoua. 10X 14X 1IX 22X 2SX aox ', y 12X 16X 20X a4x 2SX 32X Th« oopy filmMl han haa bMn r«produe«d thanks to tha ganaroalty of: MMinl Library MoGill Uniwnity MontTMl quairty lagibllity tha Tha imagaa appa a riwg haia ara tha poaaibla eonsidaring tha oondltion of tha original copy and in Icaaping fHming contract tpaclflcatlona. Original copiaa In printad papar covara ara fHmad baginning with tha front cover and anding on tha last paga wHh a printad or IHuatratad Impraa- •ion, or tho back cover whan appropriate. All other original coplee are fllmed beginning on the firat paga with a printad or Uluatrated Impree- sion, and anding on the !aat page with e printed or liluatrated tmpreaaton. L'axemplaire fHm4 fut reproduit griee i la g4nirotlti do: MmHmI Library MoQill Univanity Lee imegee aulvantae ont M reproduitea evee le plua grand aoin. compte tenu do ie condition et do le nettet* do I'exenipleire film*, et en conformiti evoc lee condMona du contrat da fllmege. Lee OKemplelree orlgineiix dent !e couverture en pepler eet imprim^e eont fHm4e en commen^nt par la premier plat et en termlnent aoit par la daml^ r e pege qui comporte une empreir .e dimpreaaion ou dlHuatration. soH par le eecond plot, aelon le cea. Toua lee eutree exemplelree orlgineux aont fNmia en commen^ent per le premMre pege qui comporte une empreinte dimpreaeion ou dIHuetretion et en termlnent per le demlAre page qui comporte une telle The leet recorded freme on eech microfiche •hell contein the aymbol -^ (meening "CON< TINUED"). or the eymbol ▼ (meening "END"), whichever eppHea. Un dee eymboiea auhrants apparettre sur ia damMre image do cheqfjo microfiche, aelon le cee: le symbole -»> ilgnlfie "A 8UIVRE", le aymbole ▼ aignifie "FIN". Mepe. pletee, cherts, etc.. mey be filmed et different reduction retkM. Thoae too lerge to be entirely included in one expoeure are fllmed beginning in the upper left hend comer, left to right end top to bottom, aa many framee aa required. The following diegreme IHuetrete the method: plenchee, tebleeux, etc., peuvent Atre fllmAe A dee taux da rMuctlon dIffArants. Loraque la document eet trop g"«nd pour Atre reproduit en un soul clichA. il eet fllmA A pertir do I'engle supArleu/ geuche, do geuche A droite, et do heut en bee, en prenent le nombre dlmegee nAcesseire. Las dbigrsmmes suivents INuatrant le mAthode. 1 2 3 1 2 3 4 5 6 m U OBSODKE USE OF PORPURi liElORRHlGIM VITH HPECTIOI BI ' THE BACOIUS AESOGEIES CAPSUUTUS. BT W. P. HAMILTON, M.D. Assistaat Physician to the Royal Victoria HospitaL AND H. B. YATES, B.A., M.D., Assistant Demonstrator of Bacteriology, McGill University. ?5S (Rented from Montreal Medical Journal, Augutf, 1897«) ^ I^ACULTY ^KBIT'S W. p. HAMIITON, 1891 and H. B. YATES . 1893. V AN OBSCURE CASE OF PURPURA HiEMORRHAGICA WITH INFECTION BY THE BACILLUS AEROGENES CAPSULATUS. BY W. F. Hamilton, M.D. Assistant Physician to the Royal Victoria Hospital ' and H, B. Yatbs. B.A., M.D. Assistant Demonstrator of Bacteriology, McGiU University. It may be said that the great majority of cases of purpura are obscure. While we may observe the clinical aspects of such cases and classify them according to outstanding features presented by this case or by that, yet there come, and these not infrequently, caoes conform- ing to no type. On the other hand a given case manifests classifying points of a variety of cases during the course of its development. Obscure must they remain until by the aid of added research some setiological factors are discovered, some certain basis of classification established. The case which is here reported h£is some of the clinical features of those described and designated by Henoch as " purpura f ulminans " but it differs from them in its duration and in its hsemorrhagic feat- ures. T. S., set. 22, student in arts at McGill University, was admitted to the Royal Victoria Hospital on the morning of Nov. 7th, 1896, com- plaining of spitting of small quantities of blood and of spots over his body. He was a well developed and a well nourished young man. He had never resided outside his native province, Quebec. His health had been good with the exception of sickness due to measles, mumps, whooping-cough and chicken-pox in his childhood. Besides the erup- tions due to these diseases he described a bright red itchy papular eruption which came out in the spring of 1895. This became pustu- lar in part and disappeared at the end of four weeks. The history is altogether negative, touching the points of haemophilia, malignant disease, previous attacks, rheumatism, venereal disease, use of drugs, alcohol, tobacco and privation. It seems probable from his statements concerning his family that tuberculosis affects one brother. Beyond recurring haemoptysis in this member and an attack of haeraatemesis in a paternal aunt there wets no evidence of hsemorrhagic diathesis. History of onset and condition of patient. — On Nov. 2nd, without any premonitory malaise, a few bright red spots of the size of a pin's head were first noticed about the left ankle. From this time until the next evening they became numerous over both the lower extremities. Three days afterward a few spots were observed on the arms, then the chest showed similar areas, the abdomen remaining free until ufter the 7th. A slight knock at any part induced the appearance of extensive and severe bruising. So far as can be ascer- tained the patient was not feeling ill or weak during these four days, but in the night of the fourth day he was awakened by flowing of blood from mouth and with coughing and spitting up blood. On the afternoon of the following day, 7th, he lost large quantities of blood, from nose, mouth and throat, and for the first time felt weakness, rawness of the throat and slight pains in the knees. Examination of surfaces. — There ^ere the spots already referred to, which were distinctly hsemorrhagic. Besides these small haemorr- hages, which were most numerous on the lower extremities, there were those of similar size on the face, neck and trunk, the abdomen possess- ing least. Here and there appeared larger purpuric areas varying in size and colour. In a Irrgedark red patch on the left arm two nodules about the size of a pea were noticed. The conjunetivse presented a few haemorrhages. The nose was slowly but constantly bleeding. The lips were of good colour. The gums were not spongy. On the soft palate and left tonsil hsemorrhagic areas were seen. The pharynx was congested ; there was no glandular enlargment except at the angle of jaws. T!ie constitutional condition. — Mentally the patient was clear: Temperature 1021, pulse 100, respiration 24. The blood, etc. — Cultures on agar-agar and in broths were negative microscopically. A few (1 or 2) days before death, the blood showed lymphocytes as the chief form of leucocyte, but one polynnclear cell being fouud in a search over three sides. Blood count r. c. 4,840,000, w. c. 6,000, haemoglobin 87%. The circulatory, respiratory and diges- tive as well as urinary systems were all negative at the primary examination. Ocular fundi negative. Progress of case. — The patient was under observation for five days, during which a constant and remarkable increase in the gravity of the case was noted — in the varying temperature, quickening and weakening pulse, in the persistent and intractable haemorrhages, both sub-cutaneous and from the mucous membranes, in the occurrence of heematuria, haemoptysis, hasmatemesis and melaena, and in the sloughy appearance about the palate and cedema about the conjunctivae and eye lids. Finally delirium supervened a short time previous to death, which occurred on the morning of Nov. 13th, eleven days after the first spots bad been noticed about the ankles and seven days after the occurrence of nasal hsemorrhage and admission to the hospital. The treatment consists in largo doses of fluid extract of ergot at first and then the B. P. solution of chloride of lime. These measures did not seem to influence the hseraorrhages in any way. The clinical points which present chief interest in this case are : 1. The extreme severity of the disease. 2. The febrile temperature. 3. The similarity of the clinical picture to one of an acute infection. The severity of the case is manifest in the degree of prostration and the early fatal termination, for, from the loss of good health_till the time of his death, but eight days elapsed. Of the whole temperature cjurse we are not able to speak positively but its range was from 99° to 104° and when admitted on the first day of mucous membrane haemorrhages it was found as high as 102.4*. Such a temperature, while it may suggest the presence of some specific fever, may certainly be accounted for by the course of purpura hsemorrhagica alone. But apart from the temperature curve we wish to observe that here the primary event was the occurrence of hcemorr- hages, spontaneous haemorrhage as already recorded, being first observed about the ankles and right elbow, the young man meanwhile going about without feeling weakness or illness. Then the constitu- tional symptoms supervened, fever, prostration, delirium. The striking similarity that such forms of purpura haemorrhagica bear to that of an acute infectious process has been long since recog- nised and numerous clinical observers have commented upon it while pathologists have investigated several cases with this thought before them. There is this, however, to be noted, as is well known, that in infectious fevers and exanthemata proper the appearance of the char- acteristic eruption follows rather than precedes the febrile and con- stitutional symptoms. In this case the autopsy was made within 10 hours after death. The body presented the general appearances of death. An extensive purpuric eruption was observed with large areas of subcutaneous haemorrhages looking like bruises. Some of these measured from 11 c. m., to 17 c. m., in length, while others were about the size of a ten cent piece. There were no ry^^H. a{)pts. Ji'he petechiae bore no special relation to the hait Mlicles. " ' -" --" The head was not examined. The heart showed numerous small ecchymotic areas as well on the visceral ay on the parietal pericardium* while fresh blood-stained fluid to the amount of 30 c. c. was found in the pericardium. The vessels on the surface of the heart were injected with air, giving the ventricle a peculiar glistening appearance. There appeared to be some interstitial emphysema as well. The right auricle espec- ially was distend(!d with gas. The right ventrit^le was flabby and somewhat dilated. The left ventricular muscle showed areas of necrosis and subendocardial hsemorrhages were observed. The aorta was small and relatively thin. The valves were normal while the great vessels showed mixed clots which were frothy. The lungs presented sub pleural ecchymoses, both recent and old with several interstitial haemorrhages. The vessels of the lungs con- tain air mixed with blood. But little gas escaped on opening the abdomen. The intestines were greatly distended with gas. The mesentery of the lower part of the ileum contained a hsemorrhaglc area. In the gastric mucosa numer- ous haemorrhages were seen while the contents of the stomach were bile- and blood-stained. The duodenum was intensely injected and the rugae swollen, the remaining portion of the small intestine presenting an appearance much the same. Peyer's patches showed no changes. In the lower part of the ileum a few patches of congestion were seen with one large area about 7 c. m. long covered by a false mem- brane with ecchymoses both within and about it. This area corres- ponds to the area of ecchymosis noticed on the peritoneal surface in the mesentery, as above described. The caecum and transverse colon were greatly congested. In this part as well as in the rest of the colon were extensive submucous ecchymoses. The contents of this viscus were blood-stained and of the consistence of porridge. The rectum presented submucous haemorr- hages. The liver floated easily in water ; it was friable in places, emphy- sematous and somewhat spongy at parts. The surface was smooth except where air bullae were plainly visible. The gall-bladder con- tained thick black bile. The spleen was small, dry and flabby. Air was seen within the vessels and it floated just beneath the water surface. The pancreas was congested though not visibly haemorrhagic. The suprarenals were of fair size with softened medulla. The left kidney sank slowly in water. Its parenchyma was some- what degenerated. There were a few subcapsular ecchymoses. The right kidney floated In this organ more degenev^itiyn was seen and « v the hflsmorrhagic areas were more numerous. The bladder contained some frothy urine. There were seen numerous submucous hsemorr- hages. The walls were thin. Coverslip preparations made from the blood in the inferior vena cava showed the presence of enormous numbers of a large encapsu- lated bacillus undistinguishable from the Bac oerogenes capsulatus, which seemed to be in pure culture. Cultures were made at the time of the autopsy from the various organs. From the blood deep lactose agar cultures showed gas forma- tions at the end of 36 hours and the presence of the B. aerogenes capsulatus. Smear cultures on agar of heart, spleen, kidney and liver gave the staphylococcus pyogenes aureus, while cultures from the spleen gave a bacillus smaller than the colon bacillus, whose length was generally about four times its breadth but presenting considerable variability, sometimes appearing as a small diplo*bacillu8. Sections of the various organs showed abundant collections of the B. aSrogenes capsulatus. In the kidney and liver rarer minute bacilli, correspond- ing to that isolated from the spleen, were to be recognised. A pure culture of this small bacillus injected into the rabbit (1 cm. intra- venously) led to death in 14 days. For several days previously the animal was noticed to be becoming more and more emtvciated ; then paresis set in, beginnins; in the hind limbs and becoming general. Already by the fifth day the hind limbs could not be used. During the last twenty-four hours the animal showed fairly frequent convul- sions. Pure cultures from the peritoneal cavity of the rabbit into a white mouse (0*25 cm.) led to death of the animal in forty-eight hours. However, neither in the rabbit nor in the mouse were there any ecchyinoses or signs of a purp'jric condition. Conclusions : — 1. From the history and the course of the case it is hardly possible that the bacillus aerogenes capsulatus was the primary infection. 2. It is quite possible that the staphylococcus pyogenes aureus was primary. There is no conclusive evidence of such however, since examination of the tissues showed no large collection of the cocci in any of the organs, nor again were there any typical abscesses any- where. On the other hand we know that this form is a frequent inhabitant of the intestines and thfs, like the bacillus sarogenes capsulatus may invade the tissues from the erosions in the intestinal mucosa. 3. Concerning the third form again nothing definite can be said, for while somewhat similar forms have been described occurring with purpura, inoculations of pure cultures into lower animals in this case. while leading to their death were entirely unassooiated with any evidences of purpura. While this case is interesting as showing a somewhat unusual com- plication of acute purpura hflemorrhagica and while so little is known of the ntiology of this form of disease that every case deserves to be placed on record, yet it cannot be said that this careful bacteriological study leads us any further or throws any light on the causation of the condition. The chief and apparently the oldest area of disturbance internally was the area of diphtheritic inflammation in the ileum. But never- theless it may be doubted from clinical history whether this was the primary seat of the disease, for the history shows that for two or three days the patient had subcutaneous haemorrhages with scarcely any disturbance of the general health. Then it was only with the appear- ance of mucous membrane haemorrhages that the temperature became elevated and from this point it would appear that the secondary infec- tion may be truiCed which ended evidently by affording a point of entrance to the bacillus lerogenes capsulatus with the resulting tissue changes in the heart and other organs as above described. The question whether cases of morbus maculosus are cases of haemorrhage due to some specific origin is unanswered, and the rela- tion between the various forms of purpura hitherto classified as idiopathic must yet remain in obscurity. In preparing this report we have been greatly helped by Prof. Adami who furnished us with a report of the autopsy and directed the bac- teriological study. / ;