IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I 1^ in IIM 1^ lii£ III ^'^ U£ us us U£ III 2.0 >^ ., luuu mm 1-25 1.4 1.6 ^ 6" ► <^ 7J ^^ A. "T j^ /. o B "%^ / /A Hiotographic Sciences Corporation 23 WEST MAIM STREET WEBSTER, N.Y. 14S80 (716) 872-4503 k ^ ■3> CIHM/ICMH Microfiche Series. CIHM/ICMH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques Tnohnical and Bibliographic Notes/Notes techniques et bibliographiques The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographically unique, which may alter any o/ the images in the reproduction, or which may significantly change the usual mbthod of filming, are checked below. Coloured covers/ Couverture de cculeur I I Covers damaged/ Couverture endommagde □ Covers restored and/or laminated/ Couverture restaur^e et/ou pellicul^e n Cover ti^le missing/ Le titre de couverture manque □ Coloured maps/ Cartes gdographiques en couleur □ Coloured ink (i.e. other than blue or black)/ Encre de couleur (i.e. autrA nna hiana »•• »»: Encre de couleur (i.e. autre que bleue ou noire) Coloured plates and/or illustrations/ Planches et/ou illustrations en couleur Bound with other material/ Reli6 avec d'autres documents D D D Tight binding may cause shadows or distortion along interior margin/ Lareliure serrde peut causer de I'ombre ou de la distortion le long de la marge intirieure Blank leaves added during restoration may appear within the text. Whenever possible, these have been omitted from filming/ II se peut que certaines pages blanches ajout6es tors d'une restauration apparaissent dans le texte, mais, lorsque cela 6tait possible, ces pages n'ont pas dt6 filmdes. Additional comments:/ Commentaires suppldmentaires; L'Institut a microfilmd le meilleur exemplaire qu'il lui a 6t6 possible de se procurer. Les details de cat exemplaire qui sont peut-dtre uniques du point de vue bibliographique, qui peuvent modifier une image reproduite, ou qui peuvent exiger une modification dans la m6thode normale de filmage sont indiqu6s ci-dessous. r~n Coloured pages/ Pages de couleur Pages damaged/ Pages endommagies Pages restored and/oi Pages lestaur^es et/ou pelliculdes I I Pages damaged/ I I Pages restored and/or laminated/ y Pages discoloured, stained or foxed/ Pages d^colordes, tachet^es ou piqu6es □ Pages detached/ Pages d^tachdes 0Showthrough/ Transparence □ Quality of print varies/ Qualitd indgale de I'impression □ includes supplementary material/ Comprend du materiel supplementaire □ Only edition available/ Seule ddition disponible □ Pages wholly or partially obscured by errata slips, tissues, etc., have been refilmed to ensure the best possible image/ Les pages totalement ou partiellement obscurcies par un feuiilet d'errata, une pelure, etc., ont 6t6 filmdes d nouveau de facon d obtenir la meilleure image possible. This item is filmed at the reduction ratio checked below/ Ce document est film* au taux de r6duction indiqu6 ci-dessous. JOX 14X 18X 22X lix 16X 20X 26X 30X J 24X 28X 1 32X Th« copy filmed her* has been reproduced thanks to the generosity of: Medical Library McGill University Montreal The images appearing here arm the best quality possible considering the condition and legibility of the original copy and in keeping with the filming contract specifications. Original copies in printed paper covers an fflmed beginning with the front cover and ending on the last page with a printed or illustrated impres- sion, or the back cover when appropriate. All other original copies are filmed beginning on the first page with a printed or illustrated impres- sion, and ending on the last page with a printed or illustrated impression. The last recorded frame on each microfiche shall contain the symbol —^(meaning "CON- TINUED"?, or the symbol V (meaning "END"), whichever applies. Map: plates, charts, etc.. may be filmed at different reduction ratioa. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand comer, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: L 'exemplaire filmA f ut reproduit grice A la g^nirositi de: Medical Library McGill University Montreal Les Images suivantes ont «t« reproduites avec le plus grand soin. compte tenu de la condition et de la nettet* de I'exemplaire film*, st en conformity avec les conditions du contrat de fllmage. Les exemplaires originaux dont la couverture en papier est imprim«e sont film«s en commenqant par le premier plat et en terminant soit par la derniAre page qui comporte une empreinte d'impression ou d'illustration, soit par le second plat, selon le cas. Tous les autres sxamplaires originaux sont fiimte en commenqant par la premiere page qui comporte une empreinte d'impression ou d'illustration et en terminant par la derniire page qui comporte une telle empreinte. Un dee symboles suivants apparaitra sur la demiAre image de cheque microfiche, selon le caa: le symbols — ♦ signifie "A SUIVRE" le symbols V signifie "FIN". Les cartes, planches, tableaux, etc., peuvent dtre filmte A dee taux de reduction diffirents. Lorsqus le document est trop grand pour itrm reproduit en un seul cliche, il est film* i partir de I'angle supArieur gauche, de gauche d droite. et do haut en bas, en prenant le nombre d'Images nteessaire. Las diagrammes suivants illuatrent la m^thode. 32X 1 2 3 1 2 3 4 5 6 "^t. c 9 tl ^. A Remarkable Case of Purpuric Frup- tion ending in Gangrene, apparently caused by Sodium Salicylate. BY Francis J. Shepherd, M. D., Surgeon to the Montreal General Hospital, and Lecturer on Dermatology, McGill University, Montreal. kefrinted from the Journal op Cutaneous and Ghnito-Urinarv Diseasks FOH January, 1896. If I', f '!l [Reprinted from the Journal op Cutaneous and Genito-Urinary Diseahbs for January, 1896.] A REMARKABLE CASE OF PURPURIC ERUPTION ENDING IN GANGRENE, APPARENTLY CAUSED BY SODIUM SALICYLATE.* By FRANCIS J. SIIEPHERP, M. D., Surgeon to the Montreal General Hospital, and Lecturer en Dermatology, McGill University, Montreal. HAVING had under my care during tlie past summer a very unusual case of skin eruption, supposed to be caused by the ingestion of sodium salicylate, I tliouglit a report of it would interest the members of this association. I am indebted to my house surgeon, Dr. Byers, for the careful notes taken of this case. William B., hotel porter, aged thirty-two, was admitted into the Mon- treal General Hospital, May 8, 1805, complaining of pain and swelling in the left knee-joint. Patient is a well-made man of medium stature, somewhat addicted to talcohol. Had typhoid fever six years ago, and a year later several severe attacks of renal colic, for which nephrotomy was performed. He never had sy])liilis, gout, or rheumatism. Two days before entrance into hospital, had received a severe blow on the knee, which vvas followed almost immediately by swelling, pain, and heat in the joint. On examination the left knee exhibited all the characteristics of an acute synovitis. As there was no history of gonorrhoea or any other condition tending to a synovitis, the diagnosis o^' traumatic synovitis was made and appropriate treatniLMit adopted. Witli the exception of the knee-joint lesion the patient was perfectly healthy. The next day after admission the patient's temperature, which had previously been normal, ruse to 100° F., but there was no aggravation of the knee symptoms. Three days after entrance the heat, swelling, and pain disappeared from the left knee, l)ut now the right knee was becoming affected. It was slightly swollen, red, and very painful. Thinking the case was one of acute rheumatism, and waiting his transference to the medical wards, the house surgeon ordered twenty-grain doses of sodium sali- cylate to be taken three times a day. After three doses had been * Read before the nineteentli annual meeting of the American Dermatological Association September 18, 1895. Oopthioht, 1H90, by D. Appleton and Company. I 2 Original Communioationb. taken (one drachm), un eruption appeared on the body and extremi- ties looking very mucli like urticaria. Distinct wheals 'wore seen, but there was not much itchiness. Successive crops of these urticarial Fig. 1. spots coming out, the administration ot the drug was discontinued. The spots now became petechial, an J were raised above the surface ! Case of Purpuric Ernptinn evdhvj in Gangrme. 3 ami cormiderably ind.irufe.l (Fig. 1). TI.e Kpots went throngl. the usual diromatio cliangos following extravasati..ti of blood, and coinddently tlin induration altogether disappoarod. At a fi'w points the hjemor- rhagic extravasation was so groat that the vitality of the skin was destroyed, and a deep slough resulted, which on separating left a well- marked ulcer which was very slow to heal. The erui)tion afiected all Buperhcial parts ..f the body except the palms of the hands and soles ot the feet. In additi(»n to this the mouth, soft palate, tongue, pharvnx, and larynx were all the seat of the eruption, which caused a great deal ot oHlernatous swelling and led to alarming svmptoms of impending suffocation, and for some days the patient was" unable to swallow any- thing but li(jnid food, and that in oidy very small (piantities. Mvalgic and arthralgia pains accompanied the eruption The heart was normal throughout the course of the ease, and once oidv was a trace of albu- min found in the urine. There was never any blood or pus in the urine, iK.r was there any disturbance of the bowels. The whole period occupied by the disease from the onset to the disappearance of the eruption was thirty-three days. Such is tlie general account of the case, as to the distribution of the eruption and its appearance. As was noted, ahnost every part of the surface of the bodv except the palms (»f the hands and the soles of the feet was affected at some tune or other during the course of the disease. The eyelids were so swollen that the |)atient culd not see out of his eyes, and the prepuce was much enlarged, discolored, and (edematous. "The tongue, mouth, and [)harynx were similarly affected, large extravasations occurred in the soft tissues of the palate and pharynx, and many sloughy spots were seen as the result of the severe haemorrhage. This gave'rise to difficulty and severe pain in swallowing. The^ larvnx, owing to the condition of the mouth, could not be examined with^he laryngoscope, but the voice was much altered and severe dvspncea occurred at times, showing that the conditions existing in the mouth were also present in the laryn.x. The eruption first appeared on the right leg, thigh, left leg, and left elbow. Then the trunk became affected, and the backs of the arms, the face, and mouth. The shoulders next were the sites of the eruption, and here it was more severe than anywhere else (Fig. 2). About the neck, shoulders, and upper arms the extravasation f(i]low- ing the urticarial wheals was so great that large sloughs were formed. The eruption was much more extensive on the posterior than the an- terior surface of the body. The scapular region antl nape of the neck, backs of arms, back, buttocks, backs of thighs, and calves of legs were 4 Orioinai. Communications. especially aftected ; imiccMl, in every part where tliero waH much pres- sure the raKh was thickly (lirttrihutcd'. On the anterior surface the only parts affected were the face, upper part of thorax, shoulders, tln'frhs. Fid. 2. and dorsum of ri^^ht foot, and in no place was the eruption very abun- dant. Over the shoulders and arms the eruption was most violent, the extravasations leading to necrosis of the skin. Several crops of erup- tion came out from time to time, but none was so severe as the first. When the spots first came out they had exactly the appearance of urticaria, the wheals varyinj,' in size from a ten- to a fifty-cent piece and elevated above the surface of the skin. At times they were slightly itchy, and the patient complained of stinging sensations. Soon I '• Cam of Pnrpuric kruptuyv ending in Gangrene. 6 alter their appenrntice the npots hecaine miirkcvllj infiltrated, and tlio Burroinuh'ng tiesiie was slif^'iitly iiMleniatuiiri, In riome rej^'ions, the arms especially, the Hwellin^r wan acute and asHociatcd with teiidernerts and pain, prohahly due to the tension. Within twelve hours the infiltrated spots showed Mood extravasation. They had at first a pinkish color, witli here and there a central spot of a darker shade. In some instances the whole spots became dark from extravasated blood. In another forty-eijrht hours the infiltration had disappeared, and the color changes in the spots had commenced. These were very strikiii^r, the body be- inj; covered with brown, red, and coffee-colored" s|)ots. In many i)]ace8, where several wheals had run to were intensely itchy, and Hotne were the size of a fifty-cent piece. They occurred on the hack at first, Imt afterward spread to the breast, shonhhirs, upper anus, hips, and thighs. After cifxlit (hiys the spots hccanio pah;r, and tlie epidermis dmiiuiniated in large scales. Of course, Home might cjntend that my case waa not one of drug erup- tion, hut one of those rare forms of peliosis rheumatica known as erythema purpuricum. Hutchison calls it purpura thromhotica. (n some of these cases the lui'morrhage is severe enough to destnty the skin and cause a slough. It is said that the rash of this atiection occurs chieHy in the legs, and is more often seen in women. The pains in the Iind)s, the swellings in the joints, and the duration of the case would perhaps render this diagnosis ]>rol)able, hut still the fact remains that until the drug was administered no sign of any skin affection was seen, and the purpura was preceded by a well-niarked urticarial rash. Again, the hiemorrliagic condition existed in the mu- cous membranes or under the skin. Still, tiiere is no doubt much to be said in favor of the diagnosis of peliosis rheumatica, and since the case occurred I have been daily more inclined to come to the conclu- sion that the erupti(»n was not due to the sodium salicylate alone.