Source:  Snow, John. Association Medical Journal., n. s. vol. 4, May 3, 1856, pp. 364-365.

Case of purpura hæmorrhagica

By John Snow, M.D., London.

The following case presented an appearance which is not clearly described in the works with which I am acquainted.

CASE. I was called on Aug. 13th, 1855, to see a patient, aged about 45 years. He is a mechanic, in business on his own account. He had formerly a good constitution, and enjoyed good health; but within the last few years he had [364/365] acquired a habit of hard drinking, and has suffered from attacks of dyspepsia and a morbid sensibility of the nervous system. On the present occasion, he had been drinking to excess for two or three weeks, and eating scarcely any food. I was sent for on account of a copious bleeding from his nose, which he had, however, stopped before my arrival, by the application of turpentine on cotton wool. There were large ecchymoses on his arm, hands, thighs, and legs, and some smaller ones on his head. They had appeared at various times within the three previous days, and some of the earlier ones were already fading. In the centre of each patch of ecchymosis there was small hard tumour, over which the skin was quite white. These tumours or nodules felt almost as hard as cartilage, and were proportionate in size to the ecchymosis: where these were as large as the hand, the tumours were as big as a horse-bean; where the purple patches were smaller, so were the tumours. The pulse was bounding but compressible; there was great debility, and the limbs were rather tremulous. He was treated with lemon-juice and decoction of cinchona with dilute sulphuric acid, and was directed to take such nourishing food as his appetite would permit. He improved during the next two days. On the 15th, the patches of ecchymosis had faded considerably, and the nodules were diminished in size.

I was sent for again on the 18th, and found the patient labouring under a rather severe attack of erysipelas of the face and head. He took quinine and nourishing diet; nitrate of silver was applied externally; and on the 26th, he was convalescent.

REMARKS. I consider that the small hard tumour situated in the centre of each patch of ecchymosis consisted undoubtedly of the fibrin of the blood, which had coagulated quickly at the point where it escaped from the ruptured vessel, whilst the serum and globules spread all round in the cellular tissue. The above case of purpura did not differ in any essential particular from that important variety of the disease we call scurvy; and although in some cases of scurvy the blood seems to have lost its power of coagulating, there are other cases in which this fluid coagulates more quickly and strongly than usual. This was remarked by Dr. Milman, who wrote on scurvy in 1782, and attributed the disease to impaired nutrition of blood-vessels. Dr. Budd has since observed that the blood in many cases of scurvy retains its power of coagulating undiminished.

Although I have not observed the above mentioned little tumours in any other case of purpura, I cannot consider this to be a solitary instance of their presence. I think it probable that they may have been passed over, as belonging to what is called purpura urticaria. The tumours, however, have no relation to the wheals of urticaria, and do not

in the least resemble them.

Sackville Street, April 1856.

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