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A CASE OF HÆMOPHILIA ILLUSTRATING THE VALUE OF CALCIUM CHLORIDE AS A LOCAL STYPTIC.
DR. T. W. PARRY : HÆMOPHILIA: CALCIUM CHLORIDE AS A LOCAL STYPTIC.
516
occurred and blood had leaked through it, causing a limited of the fibrous coat of the aorta. The intima had thus lost the support of the fibrous coat and some slight exertion had led to a sudden enlargement of the openinga tear, in fact, which would be immediately followed
bulging
FIG. 1.
by the bursting of the fibrous saccule and fatal heamorrhage into the pericardium. The aorta itself, even in. the vicinity of the opening, was perfectly normal, and
as well as the There were no action of microvegetations or other organisms. The lungs and air passages were natural. The heart had been repeatedly examined during life with th& special object of excluding ulcerative endocarditis, and there had never been a murmur at any part of the cardiac area. There had been no impulse over the sternum, and the superficial and deep areas of dulness had been normal. The apex beat had been in its normal position. Many questions arise in the endeavour to explain th& occurrence of an opening into a child’s intra-pericardial aorta. Was it traumatic ? Had the boy received a blow, or had he fallen and a stray pin or nail entered his aorta ? was no history of any such occurrence and no sign of Moreover, the object must any skin wound or puncture. have penetrated his sternum, since the swelling was situated immediately behind the sternum. The inner aspect of the sternum was examined most carefully and there was not the least roughness or irregularity of any sort. One naturally looks for some connexion between this aortic perforation and the middle-ear trouble for which the boy was under treatment. The occurrence of an effusion into the left knee seemed to, show that there had been some dissemination of septic material into the general circulation. The suggestion arises that there had been a small septic ulcer in the aorta the base of which had given way. In that case it is hardly possible that the aortic and mitral valves, the cavities of the heart, and the rest of the aorta with its main branches should have remained entirely healthy. Dr. Tooth considers the aneurysm to have been undoubtedly of pyaamic origin, and the knee trouble to have been of the same nature. The suggestion that the middle-ear suppuration was the beginning of the train of events seems to him the only reasonable one. The specimen has been placed in the museum of St. Bartholomew’s Hospital. Dr. F. W. Andrewes, pathologist to the hospital and curator of the museum, regards it as an acute infective aneurysm and suggests that, in the absence of any other evidence as to its causation, it may have originated as a localised septic aortitis, possibly due to a minute pyasmic embolus in one of the vasa vasorum. An embolus of this nature might occur in any small artery ; in the present case it happened to occur in a very unusual situation and apparently in this one situation only. I publish these notes in the hope that they may bring to the mind of some reader a parallel instance or an explanation which will throw light on the present case. Leadenhall-street, E.C.
the valves and heart muscle,
cavities of the heart,
were
quite healthy. signs of the
There
A, Sacculated swelling with linear rupture. aorta. C, Reflexion of pericardium. laid open. E and F, Great vessels.
D,
B, Ascending Pulmonaryartery
FIG. 2.
A CASE OF HÆMOPHILIA ILLUSTRATING THE VALUE OF CALCIUM CHLORIDE AS A LOCAL STYPTIC. BY T. WILSON PARRY, M.A., M.B., B.C. CANTAB. IN the early morning of Sept. 4th I was called to a boy, aged seven years and four months, who was bleeding from the mouth. On examination, blood was seen to be welling
A,
Triangular perforation in ascending
lunar valves, ventricle. D, ,
vessels.
c, Muscle
Pulmonary
aorta. B, Aortic semiand endocardium of the left laid artery open. E and F, Great
up between the left lower first permanent molar and the temporary molar lying immediately in front of it, the latter being decayed on its distal surface. Both of these teeth were firmly fixed. There was rapid oozing from the cleft and judging by the considerable clot that had been already evacuated from the mouth as well as by what still remained, there had evidently been continuous bleeding during the night. So profuse and persistent did the hæmorrhage eventually become that the likelihood of there being more than one bleeding point was suspected and, accordingly, in consultation with my partner, Dr. D. MeB. Greig, a careful examination of the child’s mouth and throat was made under an anassthetic but no other source of bleeding than that already mentioned could be found. The inter-dental fissure from which the blood flowed was so small that it was with great difficulty that the smallest fragment of wool could be packed into it. During the next four days, however, I plugged it as efficiently as possible with minute pledgets of ’wool steeped in styptics of unimpeachable repute, to wit,
517
CLINICAL NOTES.
alum, tannic acid, turpentine, perchloride of iron, and be swallowed than is perhaps justifiable ; and calcium adrenalin chloride. The bleeding would sometimes stop chloride if swallowed in reasonable doses is the very drug for a quarter of an hour after the little cavity had been one would prescribe. It is into the hands of the great body but would soon burst out afresh as vigorously as of general practitioners that trying and anxious cases as the The best result was undoubtedly obtained from present one recorded first fall, and it is for such of these who adrenalin chloride (1 in 1000, Parke, Davis and Co.), the may be, as I was myself, unaware of the unquestionable bleeding being diminished during its employment but not superiority, at least in this instance, of calcium chloride as a arrested. On the evening of the 8th, when the boy had local styptic over other styptics of more familiar name and been, bleeding almost continually for five days and nights repute, that I take the liberty of publishing this case. and had become anaemic and restless, yawning and sighHornsey-lane, N. with a variable sometimes at times, pulse irregular ing in character and at other times as rapid as 120 per minute, I asked Mr. Bilton Pollard to meet me in consultation. On hearing of the various styptics already employed Mr. Pollard suggested a trial of calcium chloride. AND A small pledget of wool was steeped in some of this THERAPEUTICAL. solution (30 grains to an ounce) and then inserted into the little cavity. This was shortly removed and replaced by another, and yet again by several others, until the removed INTRA-UTERINE FRACTURE OF THE SKULL. plug showed no blood-stain whatever. A final plug was, of course, left in situ. The cessation of bleeding was now BY G. W. KILNER CROSLAND, M.R.C.S. ENG., complete. The nurse in attendance was then ordered to L.R.C.P. LOND. moisten the inserted plug with some fresh solution every 20 minutes. We left the house shortly after 8 P.M. and this FRACTURES occurring in newly-born children are chiefly treatment was continued for two hours, when the boy fell and did six on not wake till the o’clock asleep following interesting in their medico-legal aspect. The following case morning, there being no return whatever of the hæmorrhage. shows particularly well what a great amount of injury can When I saw him in the morning the plug was gone, but be sustained by the child in utero without serious conthere was not the slightest return of the bleeding. I bade the nurse continue painting the gums for three days in case sequences to the mother and without premature labour a fresh outbreak might manifest itself, but this, however, taking place. The patient was a multipara and was pregnant to term, of fortunately, did not occur, no bleeding whatsoever taking place since the first employment of the calcium chloride. her fifth child. The message was urgent, and upon arrival The family to which the patient belonged was of pure I found that a precipitate labour had taken place and that a Scotch descent and consisted of two boys and a girl. The little patient was the eldest, then came his brother, aged dead female child had been born, the mother having been five and a half years, who also was afflicted with haemophilia, delivered in-a kneeling position upon the floor. She informed and lastly a girl, aged four and a half years, who, as might me that four days previously she had fallen down the cellar be expected, was free from the disease. On the mother’s steps, striking and severely bruising her back (the sacral side-and it is, of course, through this branch of the family region) ; at the time of the accident she felt very faint and that we search for a history-there was evidence of the direct the thought passed through her mind that her child was heredity of this pitiful complaint, one of her brothers having injured ; there was no escape of either liquor amnii or of died from haemorrhage, at the age of five years and four blood from the vagina. Four days later labour pains commonths, after extraction of’a tooth. Till then there was no menced and rapidly progressing the labour took place as suspicion that he was afflicted with this malady and it was a stated above. On examining the child a very curious and unusual condistanding puzzle how it was that he always "bruised"so easily and sometimes without any apparent cause. The tion was present: she was dead, maceration and post-mortem first evidence of any kind in the present case that the change having commenced to take place. There was slight parents had of their elder son’s bleeding propensity was cedema of the feet and of the umbilical cord, the abdomen six months. He was circum- was flaccid, and the cuticle was commencing to peel away in when he was at the age cised at that time and the bleeding was only stopped places. On the left parietal region there seemed to be a after several days’ duration with some difficulty. Directly cephalhydrocele, but on examination this turned out to be a he began to walk bruises began to appear, before that fracture or rather separation of the left parietal and the At the age of two and a squamous portions of the temporal bone from one another time none having occurred. half years he cut his tongue with a tin toy, and again when and from the rest of the skull. They were both displaced or tilted outwards and the violence which had caused this had a little older he slightly severed the frasnum of his upper lip with a piece of hard sharp toast, both of these slight injuries also displaced the brain in the same direction. The lower giving rise to haemorrhage of a troublesome kind. As lately jaw was fractured on the right of the symphysis. There as six weeks previously to this present attack he had some was on both sides extensive orbital and subconjunctival obstinate hæmorrhage, lasting 11 days, in the course of ecchymosis. It was evident that the severe injuries which shedding an upper central incisor tooth. This was partially had caused the death of the child were due to the head, arrested by removing the extremely loose tooth and touching resting in the normal position, being forcibly jammed as it the gum with the actual cautery. There was slight oozing were between two opposing sides of the pelvic brim, probably after this for some time which, the mother said, appeared to the sacral promontory and the pubic bones. There were no His younger brother, signs of syphilis, so-called fcetal rickets, or defective subside gradually of its own accord. like himself, is nearly always covered with large and painful ossification, which are said to be predisposing causes of this bruises. He was circumcised at the age of three months and condition. when a little older injured the fragnum of his tongue, both Injuries to the bones which are discovered in newly-born of these trivial wounds giving rise to annoying and some- children may be classified under three heads : (1) those what obstinate bleeding. occurring before labour has commenced due to criminal or Summing up this case I would not have it thought that I accidental violence ; (2) those occurring during labour due to - consider calcium chloride to be an unknown or untried local (a) disproportion between the child and the pelvis, (b) strong styptic, although, at the same time, from questions which I uterine contraction, and (0) unskilled assistance at birth ; have put to several practitioners of undeniable experi- and (3) those occurring after birth, caused by (a) criminal ence, it appears to be far less generally appreciated in this violence and (b) accidental violence from precipitate labour, use than as an internal remedy. But when it succeeds inattention, &c. Cases which come under all these headings and perchloride of iron and adrenalin chloride fail there are described by various authorities on forensic medicine shoold be every reason for its being considered superior to, who seem to agree that those in the first group and affecting -and preferred in ordinary usage to, either of these two the cranial bones are very uncommon. Casper, in his handwell-known styptics-to the former on account of its book, after mentioning two cases, says : " They compel us to intrinsic cleanliness and to the latter on account of its assume that the child may be killed in utero by injuries to greater safety. Frequent applications to any part of the its cranium produced by violence inflicted directly upon the mouth, especially in a child, naturally render it liable body of the pregnant woman " ; and, further,I I Death from cause is one of the rarest phenomena." for a larger dose of whatever drug may be employed to Taylor, in his
plugged,
ever.
Clinical Notes:
MEDICAL, SURGICAL, OBSTETRICAL,
of
this
516
occurred and blood had leaked through it, causing a limited of the fibrous coat of the aorta. The intima had thus lost the support of the fibrous coat and some slight exertion had led to a sudden enlargement of the openinga tear, in fact, which would be immediately followed
bulging
FIG. 1.
by the bursting of the fibrous saccule and fatal heamorrhage into the pericardium. The aorta itself, even in. the vicinity of the opening, was perfectly normal, and
as well as the There were no action of microvegetations or other organisms. The lungs and air passages were natural. The heart had been repeatedly examined during life with th& special object of excluding ulcerative endocarditis, and there had never been a murmur at any part of the cardiac area. There had been no impulse over the sternum, and the superficial and deep areas of dulness had been normal. The apex beat had been in its normal position. Many questions arise in the endeavour to explain th& occurrence of an opening into a child’s intra-pericardial aorta. Was it traumatic ? Had the boy received a blow, or had he fallen and a stray pin or nail entered his aorta ? was no history of any such occurrence and no sign of Moreover, the object must any skin wound or puncture. have penetrated his sternum, since the swelling was situated immediately behind the sternum. The inner aspect of the sternum was examined most carefully and there was not the least roughness or irregularity of any sort. One naturally looks for some connexion between this aortic perforation and the middle-ear trouble for which the boy was under treatment. The occurrence of an effusion into the left knee seemed to, show that there had been some dissemination of septic material into the general circulation. The suggestion arises that there had been a small septic ulcer in the aorta the base of which had given way. In that case it is hardly possible that the aortic and mitral valves, the cavities of the heart, and the rest of the aorta with its main branches should have remained entirely healthy. Dr. Tooth considers the aneurysm to have been undoubtedly of pyaamic origin, and the knee trouble to have been of the same nature. The suggestion that the middle-ear suppuration was the beginning of the train of events seems to him the only reasonable one. The specimen has been placed in the museum of St. Bartholomew’s Hospital. Dr. F. W. Andrewes, pathologist to the hospital and curator of the museum, regards it as an acute infective aneurysm and suggests that, in the absence of any other evidence as to its causation, it may have originated as a localised septic aortitis, possibly due to a minute pyasmic embolus in one of the vasa vasorum. An embolus of this nature might occur in any small artery ; in the present case it happened to occur in a very unusual situation and apparently in this one situation only. I publish these notes in the hope that they may bring to the mind of some reader a parallel instance or an explanation which will throw light on the present case. Leadenhall-street, E.C.
the valves and heart muscle,
cavities of the heart,
were
quite healthy. signs of the
There
A, Sacculated swelling with linear rupture. aorta. C, Reflexion of pericardium. laid open. E and F, Great vessels.
D,
B, Ascending Pulmonaryartery
FIG. 2.
A CASE OF HÆMOPHILIA ILLUSTRATING THE VALUE OF CALCIUM CHLORIDE AS A LOCAL STYPTIC. BY T. WILSON PARRY, M.A., M.B., B.C. CANTAB. IN the early morning of Sept. 4th I was called to a boy, aged seven years and four months, who was bleeding from the mouth. On examination, blood was seen to be welling
A,
Triangular perforation in ascending
lunar valves, ventricle. D, ,
vessels.
c, Muscle
Pulmonary
aorta. B, Aortic semiand endocardium of the left laid artery open. E and F, Great
up between the left lower first permanent molar and the temporary molar lying immediately in front of it, the latter being decayed on its distal surface. Both of these teeth were firmly fixed. There was rapid oozing from the cleft and judging by the considerable clot that had been already evacuated from the mouth as well as by what still remained, there had evidently been continuous bleeding during the night. So profuse and persistent did the hæmorrhage eventually become that the likelihood of there being more than one bleeding point was suspected and, accordingly, in consultation with my partner, Dr. D. MeB. Greig, a careful examination of the child’s mouth and throat was made under an anassthetic but no other source of bleeding than that already mentioned could be found. The inter-dental fissure from which the blood flowed was so small that it was with great difficulty that the smallest fragment of wool could be packed into it. During the next four days, however, I plugged it as efficiently as possible with minute pledgets of ’wool steeped in styptics of unimpeachable repute, to wit,
517
CLINICAL NOTES.
alum, tannic acid, turpentine, perchloride of iron, and be swallowed than is perhaps justifiable ; and calcium adrenalin chloride. The bleeding would sometimes stop chloride if swallowed in reasonable doses is the very drug for a quarter of an hour after the little cavity had been one would prescribe. It is into the hands of the great body but would soon burst out afresh as vigorously as of general practitioners that trying and anxious cases as the The best result was undoubtedly obtained from present one recorded first fall, and it is for such of these who adrenalin chloride (1 in 1000, Parke, Davis and Co.), the may be, as I was myself, unaware of the unquestionable bleeding being diminished during its employment but not superiority, at least in this instance, of calcium chloride as a arrested. On the evening of the 8th, when the boy had local styptic over other styptics of more familiar name and been, bleeding almost continually for five days and nights repute, that I take the liberty of publishing this case. and had become anaemic and restless, yawning and sighHornsey-lane, N. with a variable sometimes at times, pulse irregular ing in character and at other times as rapid as 120 per minute, I asked Mr. Bilton Pollard to meet me in consultation. On hearing of the various styptics already employed Mr. Pollard suggested a trial of calcium chloride. AND A small pledget of wool was steeped in some of this THERAPEUTICAL. solution (30 grains to an ounce) and then inserted into the little cavity. This was shortly removed and replaced by another, and yet again by several others, until the removed INTRA-UTERINE FRACTURE OF THE SKULL. plug showed no blood-stain whatever. A final plug was, of course, left in situ. The cessation of bleeding was now BY G. W. KILNER CROSLAND, M.R.C.S. ENG., complete. The nurse in attendance was then ordered to L.R.C.P. LOND. moisten the inserted plug with some fresh solution every 20 minutes. We left the house shortly after 8 P.M. and this FRACTURES occurring in newly-born children are chiefly treatment was continued for two hours, when the boy fell and did six on not wake till the o’clock asleep following interesting in their medico-legal aspect. The following case morning, there being no return whatever of the hæmorrhage. shows particularly well what a great amount of injury can When I saw him in the morning the plug was gone, but be sustained by the child in utero without serious conthere was not the slightest return of the bleeding. I bade the nurse continue painting the gums for three days in case sequences to the mother and without premature labour a fresh outbreak might manifest itself, but this, however, taking place. The patient was a multipara and was pregnant to term, of fortunately, did not occur, no bleeding whatsoever taking place since the first employment of the calcium chloride. her fifth child. The message was urgent, and upon arrival The family to which the patient belonged was of pure I found that a precipitate labour had taken place and that a Scotch descent and consisted of two boys and a girl. The little patient was the eldest, then came his brother, aged dead female child had been born, the mother having been five and a half years, who also was afflicted with haemophilia, delivered in-a kneeling position upon the floor. She informed and lastly a girl, aged four and a half years, who, as might me that four days previously she had fallen down the cellar be expected, was free from the disease. On the mother’s steps, striking and severely bruising her back (the sacral side-and it is, of course, through this branch of the family region) ; at the time of the accident she felt very faint and that we search for a history-there was evidence of the direct the thought passed through her mind that her child was heredity of this pitiful complaint, one of her brothers having injured ; there was no escape of either liquor amnii or of died from haemorrhage, at the age of five years and four blood from the vagina. Four days later labour pains commonths, after extraction of’a tooth. Till then there was no menced and rapidly progressing the labour took place as suspicion that he was afflicted with this malady and it was a stated above. On examining the child a very curious and unusual condistanding puzzle how it was that he always "bruised"so easily and sometimes without any apparent cause. The tion was present: she was dead, maceration and post-mortem first evidence of any kind in the present case that the change having commenced to take place. There was slight parents had of their elder son’s bleeding propensity was cedema of the feet and of the umbilical cord, the abdomen six months. He was circum- was flaccid, and the cuticle was commencing to peel away in when he was at the age cised at that time and the bleeding was only stopped places. On the left parietal region there seemed to be a after several days’ duration with some difficulty. Directly cephalhydrocele, but on examination this turned out to be a he began to walk bruises began to appear, before that fracture or rather separation of the left parietal and the At the age of two and a squamous portions of the temporal bone from one another time none having occurred. half years he cut his tongue with a tin toy, and again when and from the rest of the skull. They were both displaced or tilted outwards and the violence which had caused this had a little older he slightly severed the frasnum of his upper lip with a piece of hard sharp toast, both of these slight injuries also displaced the brain in the same direction. The lower giving rise to haemorrhage of a troublesome kind. As lately jaw was fractured on the right of the symphysis. There as six weeks previously to this present attack he had some was on both sides extensive orbital and subconjunctival obstinate hæmorrhage, lasting 11 days, in the course of ecchymosis. It was evident that the severe injuries which shedding an upper central incisor tooth. This was partially had caused the death of the child were due to the head, arrested by removing the extremely loose tooth and touching resting in the normal position, being forcibly jammed as it the gum with the actual cautery. There was slight oozing were between two opposing sides of the pelvic brim, probably after this for some time which, the mother said, appeared to the sacral promontory and the pubic bones. There were no His younger brother, signs of syphilis, so-called fcetal rickets, or defective subside gradually of its own accord. like himself, is nearly always covered with large and painful ossification, which are said to be predisposing causes of this bruises. He was circumcised at the age of three months and condition. when a little older injured the fragnum of his tongue, both Injuries to the bones which are discovered in newly-born of these trivial wounds giving rise to annoying and some- children may be classified under three heads : (1) those what obstinate bleeding. occurring before labour has commenced due to criminal or Summing up this case I would not have it thought that I accidental violence ; (2) those occurring during labour due to - consider calcium chloride to be an unknown or untried local (a) disproportion between the child and the pelvis, (b) strong styptic, although, at the same time, from questions which I uterine contraction, and (0) unskilled assistance at birth ; have put to several practitioners of undeniable experi- and (3) those occurring after birth, caused by (a) criminal ence, it appears to be far less generally appreciated in this violence and (b) accidental violence from precipitate labour, use than as an internal remedy. But when it succeeds inattention, &c. Cases which come under all these headings and perchloride of iron and adrenalin chloride fail there are described by various authorities on forensic medicine shoold be every reason for its being considered superior to, who seem to agree that those in the first group and affecting -and preferred in ordinary usage to, either of these two the cranial bones are very uncommon. Casper, in his handwell-known styptics-to the former on account of its book, after mentioning two cases, says : " They compel us to intrinsic cleanliness and to the latter on account of its assume that the child may be killed in utero by injuries to greater safety. Frequent applications to any part of the its cranium produced by violence inflicted directly upon the mouth, especially in a child, naturally render it liable body of the pregnant woman " ; and, further,I I Death from cause is one of the rarest phenomena." for a larger dose of whatever drug may be employed to Taylor, in his
plugged,
ever.
Clinical Notes:
MEDICAL, SURGICAL, OBSTETRICAL,
of
this