ECCHYMOSIB FOLLOWING INSANE EXCITE..l\1ENT.

By "V. R. DAWSON, l\:I.D. t7NIV. DeBL.;

Assistant Medical Superintendent, Farnham House Asylum, Finglas,Dublin;

Late Assistant Physician, Royal Edinburgh Asylum.

[Read in the Section of Medicine, February 22, 1895.1

. NOTWITHSTANDING the large amount of attention that has of

late years been paid to the elucidation of diseases charac­

terised by luemorrhages into or beneath the skin, an attention~ ~

,,~hich has resulted in the gro,ving certainty that thehrenlorrhage in special purpuric disease is due to bacterial

embolisnl, there still retuains a considerable nunlber of cases

,vhich are as yet very inlperfectly explained. Of these, some

of the Inost interesting are the cases ".here hremorrhage

occurs into the skin in the course of disease of the nervous

system, 'vhether functional or organic, and the predonlinen t

factor in the causation of \vhich appears to be nervous

influence, although, as U nna recently stated, it is still

questionable \v hethel" hreillorrhage occurs nlerely froDl the

action of the nervous system upon the blood-vessels. Probably

sey-eral factors combine in the production of such hremor­

rhages, and this I take to have occurred in the case \vhichI have the honour to lay before you this evening.

CASE.-l\frs. A. B., a stout, fair, florid 1VOlnan of fifty years ofage, was admitted to the Royal Edinburgh Asylurn, on August13th, 1890, suffering from delusional melancholia. She is the wifeof a sea-captain, and had made several voyages with her husband,but there is no record of any attack of a malarial natnre. Herfamily history is not quite satisfactory, her Inother having sufferedfrom epilepsy, whUst all the children of one of her sisters had died

B~y DR. ,¥. R. DAWSON. 59

in convulsions. She herself had led a hard-working steady "life,but, though of a kindly disposition, was inclined to be solitary andunsocial, and at the same time was easily excited. Her climacteric,vas late in coming on, and she suffered frorn endometritis anduterine displacement, which gave rise to pains and feelings ofdiscomfort in connection wi th the uterus. The immediate cause ofher mental illness, however, was an attack of influenza, which hadtaken place some five months before her admission-in fact, shewas one of eleven cases of insanity associated with this disorder,published by Dr. Elkins a in ] 893. She first began to take cause...less ill-will against people, and becanle emotional and querulous,lost her sleep, and used to sit up at night ,vriting letters. Herill-will gradually deepened to extreme delusions of suspicion and.persecution, directed against her doctor, whom she accused ofinj uring her with instruments and wishing to poison her, as wellas against her husband and daughters, who, she thought, wereplotting against her. She took violent fits of crying, struck herdaughters at times, and became so noisy and destructive that atlength she had to be sent to the asylum.

On admission she was very miserable, crying loudly and volublybemoaning her fate, and full of suspicious delusions, whilst at thesame time conscious of her illness. In addition to the uterinesensations before alluded to, she complained of giddiness and asensation of weight on the top of her head. rrhe heart's action,vas feeble, the pulse weak and rapid (100), but the temperature wasnormal, nor coulil any further disorder be detected.

'l'he patient improved rapidly at first, and remained better forsome months, though never well enough to leave, and her elnotionalequilibrium was still easily upset-e.g., by a visit from her daughter.She soon, however, relapsed and became noisy and unmanageable, andfor the past four years has remained very much in t.he same condi­tion, physically in fair health and very stout, but delusional and sus­picious, and subject every ten or fourteen days to exacerbations whichmanifest themselves as outbursts of violent indignant grief, duringwhich she is very noisy and abusive and has at times to be secluded.l'he day after such attacks she commonly has to remain in bed,suffering from headache, giddiness, and pain in the chest. Shesometimes prescribes a dose of castor oil for herself, and then forSonle days is quiet and comparatively good-humoured, but gradually

a Influenza as a ca1.t-Se of Insanity. Edinb. Hasp. Rep., Vol. I., 312(Case 3, p. 315).

60 Eccllyrl10sis following Insane EtrciteJnent.

works up to a similar climax again; a premonitory symptoln of thecoming explosion being the writing of voluminous letters, closelywritten and crossed, setting forth her history and wrongs, anddirected to her relations, the asylum officers, or the inspectors.During the attacks alluded to, the hysterical character of which isobvious, the temperature when taken was never found to be raised.

On several occasions during 1890 and 1891 the fits of excite­ment were followed by the appearance of erythematous patches,symmetrical in distribution, and situated mostly on the arms, butalso on the breast. These were, perhaps, merely local accentuationsof a general erythema which was also present. They were notnoticed during the two following years, but may possibly have beenpresent; Mrs. A. B. being a very difficult suhject to deal with onaccount of her suspicions, so that, unless she herself called attentionto the eruption, it might very well pass unobserved.

On or about the 25th April, 1894-i.e., four years from thecommencement of the patient's mental illness-,-an attack of excite­ment having just passed off, there appeared a purpuric eruption ofsmall spots on the chest and back of shoulders, immediately followedby larger extravasations which were situated on one shoulder, bothwrists, and the right thigh, just above the knee, appearances whichthe delusional suspicion of the patient promptly fixed on as evidenceof poisoning. A mixture containing bromide of potassium andantipyrin, and, a few days later, one containing tincture of perchlo­ride of iron, were administered, and there was no return of excite­ment or ecchymosis for over a nlonth. About the 31st Mayor] st June, however, there was another attack of excitement, and onJune 2nd a large black patch-resembling a severe bruise, and inthe centre of which, under a pale spot, was a small hard lump­appeared on the right wrist, from which a slighter degree of dis­coloration spread all over the back of the hand and wrist. Spotsalso appeared on both arms and shoulders. 'fhere were alsoswelling and pain in the discoloured area on the wrist, neither ofwhich existed elsewhere. On this occasion the fits of excitementwere repeated, some four having occurred in the earlier part ofJune, and fresh spots kept coming out on the arms and other parts.All these spots had exactly the appearance of ordinary bruises, andvaried in size from that of a threepenny piece or even smaller upto one large enough to cover, as has been stated" the bac.k ofthe wrist and hand. At the time of this attack some blood wasevacuated by the mouth on one occasion, but I am unable to

Bv DR. W. R. DAWSON.&0

61

About the middle of Junethere were no more spots

give its source, and it never recurred.the excitement had passed away, anduntil after the next fit.

On June 26th, Mrs. A. B., who was of a curious disposition,ventured too near a patient who was struggling with his attendantsin the grounds, and received a kick in the left iliac region. Therewas some blar-kness and pain, but she did not complain much of itat the time. On July 3rd, however, at a picnic which she wasjudged ,veIl enough to attend, she became furiously excited andeven violent, and on the next day a fresh eruption of spots began,of which several eventually appeared on the fronts of both legs,and a small one on the right forearm. But in addition to thesethe iliac bruise extended over the lower left portion of the abdomenand down into the groin, at the same time assuming an intensepurple-brown colour; there was also much stinging pain in theregion, which lasted to some extent for a time, at all events, afterthe discoloration had disappeared. Iron was administered, butthe patient could not be got to take it after a time, asserting thatit was given in order to bring out the spots so that I mightphotograph them! I had attempted to do so a few days previously.About July 24th, slighter excitement was followed by spots on thecentre of the chest, and on the shoulders and thighs; and again inthe early part of August there was excitement, as a result of whicha bruise-like spot about I-in. square appeared in the right palm atthe base of the first finger, extending to the back b~tween it andthe middle finger, and a black patch was observed to the inner sideof the right thigh, and a number of purpuric spots about the lowerpart of both calves and ankles, there being also some soreness inthe latter region. On August 13th a similar fit was followed by avery small spot on the extreme tip of the tongue, which disappearedin two or three days, the gums being at the same time sore, andlooking a little spongy. About the 28th August, after some ex­citement, a spot appeared on the left hand between the little andring finger~, and one on the left breast. Very early in the morningof the 31st there was a faint fit, and the patient was obliged toremain in bed this day, with dizzine~s and "flapping of the heart."A small fresh spot appeared on the left forearm, and there wassome soreness of the left calf. Lastly, a large ecchymosis on theback of the left elbow, and a small one in the middle of the fore­al'm in front, were noticed after another attack in the middle of~eptember.

62 Ecchymosis Jollou'inglnsane EXt~itelnent.

[S'ince the paper ,vas read, the following particulars of thefurther progress of the case were kindly sent me by Dr.

Middlelnass :-

A very violent outbreak occurred about the end of September,on the day following which a number of subcutaneous ecchymoseswere observed, one on the right upper arm being espe~ially darkand well-marked. The excitement gradually p9.ssed off withoutthe eruption of any further spots, and the patient appear8 to havehad no further outburst until February 5th" 1895, being meanwhilewell enough to take part in the Christlnas festivities. On themorning of the 5th she quite suddenly broke out into a fit of ex­citement, and a few hours after a few slight ecchymoses werenoticed. There is, ho\vever, a dou bt whether they appeared afle?'the excitement. From that date there has been so much inlprove­ment as to suggest a hope of her recovery.. Occasional attacks ofexcitement, and ecchyrnoses, have since occurred, but the formerhave been less frequent and severe, and the latter much lessmarked.]

It will thus be seen that every recurrence of excitementafter the end of April up to the close of my record, ,vas

follo\ved by an eruption of spots of ecchymosis. The fits

themselves follo\ved in a general way the type of that before

described-viz., a period of violent angry excitement and.

shouting, followed by a day of headache, giddiness, pain in

the thorax, and sometimes palpitation, which usually com­

pelled the patient to renlain in bed, and on which the spots

appeared first. The spots themselves varied greatly both in

number, size, and situation, appearing on the whole to favour

the extremities. On some occasions there was a decided

symmetry, but most often not. As regards their colour,

they had exactly the appearance of bruises, both when fresh

and as they passed a\vay, being at first of the bluish colour

characteristic of hremorrhage into the deeper layers of the

cutiB~ Only in the- case of the l.arge hremorrhage of trau-

matic origin did the bro,vnish colour indicate that the more

By DR. W. R. DAWSON. 63

superficial cutaneous layers were involved. I only obtaineda sample of blood on one occasion, ~vhich ,vas examined underso great disadvantages that little could be made of it. Thereseemed, however, to be a number of microcytes present. The

patient's temperature whenever taken was founel to be

normal during the period of prostration. The heart ,vas

rather feeble in its action.To sum up 'briefly what seem to me the most pregnant

facts in this case, \ve have here a woman of a florid com­

plexion, with a skin predisposed to erythematous congestion,

and a weak heart, seized with a form of mental affection

(melancholia) in which disease of the circulatory system is

especially common,a and liable to frequently-recurring fits of

excitement of a hysterical type, such as are known to cause

~etive hyperromia of the cutaneous vess~Is, in "Thorn, after

four years, every attack of excitement has come to be fol­

lo"red by hremorrhages of greater or less extent into the

deeper layers of the cutis, these hremorrhages being situated

in almost all regions of the body except the face, apparently

beginning somewhat suddenly, and at times showing a ten­

dency to symmetry. At the same time \ve find the hremor­

rhagic tendency greatly augmented by traumatic injury to

the blood-vessels, and a certain, though slight, anlount ofinlplication of th0 nlUCOUS membranes; ,vhile, lastly, theabsence of high temperature negatives the presence of anyacute specific disorder.

So far as I have been able to examine the literature of the

subject, I have only met with one other case in \vhich the

ha:nllorrhage appeared to be directly due to insane excite­

ment. '!'his \vas the case, published by Drs. Savage andPercy Slnith,b of a man, forty years of age, who was admitted

to Bethlem Hospital in 1886. He had been steady, indus-

a Dr. C. F. Beadles-. Journal of Mental Science. Vol. XLI., p. 33.b Journal of Mental Science. Jan.; 1886. P. 501.

64 Ecclt'!Jrn08is following ,Insane Excitement.

trioDs, and cheerful. Ten days before admission 'he wasseized with a pain in h-is head and neck, became emo­

tional and depressed, and finally maniacal, with, delusions

of suspicion. After admission he was restless, violent, and

,,·eak, dirty in his habits, and required to be fed with the

stomach pump. The temperature gradually rose to over

103°. Nearly three weeks after admission he became uncon.,.

scions, with stertorous breathing, and died about five hours

later. He had manybrnise-like marks on the arms andtrunk on admission, and other patches subsequently came

out, appearing in the night, 'and soon acquiring a bronz-e-like

colour. They were' symmetrically disposed, and, some so

placed that no ordinary bruises could arise in the situation,

were situated about the elbows and arms, over the anterior

superior spines of the -ilia, the sides of the gluteal ,regions,

the knees, and fronts of the legs, and varied greatly in size.

There ,vas also an attack of severe hrematuria, and a gela­

tinous false membrane, with recent clots, was found beneaththe dura mater.

There -are obvious- resemblances in the appearance. distri­

bution, and mode of occurrence of the spots in this case andin that which forms the subject of the present paper, ifallowance be made for the much more acute course of thedisease here. But Savage's case differs in the immediate

appearance·of the purpura, the high temperature, the pre­

sence of other hremorrhages, and, above all, in the muscular

violence, which was very rare in my case. Many of thespots were situated exactly-in positions where a weak, restless

patient 'would be likely to bruise himself.

M.Klippel a"published a case of non-traumatic symnletricalecchymosis of the face in an old 'female dement, which began

at the inner canthi -and gradually overspread all the upper

.. Lancet. 1885. II., p. 815. (Abstract o-f· article in Ann. Medico·cbirurg., No.8).

By DR. W. R. DAWSON. 65

part of the face, passed through the same stages as a bruise,and fina11y· disappeared. There were also two symmetrical

spots on the thighs. No other synlptoms of purpura or:

scurvy appeared, and the telnperature was n.ot raised. Here,

however, the ecchymosisd-oes not seem to have followed anyfit of excitement, and the symptoms of the case as described

are suggestive of locomotor ataxy.

With the exception of a case, noted by Dr. Savage, 8 of

general paralysis, in which a purpuric ernptipnsymmetrically

distributed on the thighs and legs came out some days after

art'injur.r to the left elbow, I have been unaple, to find any

other record of non-traumatic ecchymoses in the insane. Itwill be observed that no- mention has been made of hrematoma

anris; but this omission is due to the fact that the most

recent researches b seem to show this lesion to be probabl.y

due to a degeneration of the auricular cartilage, and not tohave anything to do with the skin at all. Of the ease with

which traumatic cutaneous and subcutaneous effusions of

blood can be produced in the insane there seems to be no

question.

Turning now to ordinary nervous disease, we find thatthere are three principal disorders with which hremorrhage

into the skin has been associated-viz.., epilepsy, locomotor

ataxy, and, most important in the present connection, hysteria.

(Hremorrhage following neuralgic pain is also described.)

In the first the hrenl0rrhages must obviously be due to the

extreme congestion during the seizur~, aided, perhaps, in a

nlanner which we shall presently see, by the tightening of

the skin owing to muscular contraction•. Vascular disease

is excluded by the fact that the hremorrhage has,occurred in

young, healthy persons, with a first attack.c The so-called

• JournoJ of Mental Saience. Jan., 1886. P. 507.b See paper by Drs. Middlemass and Robertson. Edinburgh Med.

Jaurn. Dec., 1894. P. 512.c Crossm8Jln. Med. Times ,and Gazette. 1876. II., p. 723.

66 ECClt!J111OSis folloloing 111sane Exaitelnent.

tab,etic purpura would seem to point to vascular disease. In

hysteria,. however, the occurrence of hremorrhage does not

seem so ea&y to account for, and the conditions here most

closely rese'Inhle those in the present case. Of the occurrence

of· hremorrhage both into and from the skin in hysteria therecan he no doubt, although the subject has been confused with

much imposturE. Gowers, a it is true, will only admit that

',' itis probable that, in rare cases, the vasomotor disturbance

may lead to the occurrence of small hremorrhages into the

skin;" but ROSS,b Striimpel,c &c., state positively that such

occur; and as regards bleeding from the skin-i.e., from the

vessels of the s'weat-glands, cases have been recorded byFranque d and Bourneville e which leave no doubt on thepoint. In the cases alluded to it is important to note that.

in both, the bleeding occurred in connection with hystericalconvulsiolls.

Before trying to draw any deduction as to the probable

mode of occurrence of the hremorrhage in such cases, I must

crave your indulgence if I allude· very briefly to the nlost

recent and authoritative pronouncement as to the patholog'y

of cutaneous and subcutaneous hremorrhage in general-I

mean the very interesting a.nd instructive article on the sub­ject in Unna's recent work on dermic pathology.t

In the first place, he finds that in almost all ski n hremor­

.rhages, from whatever cause, there is really rupture of a

vessel, and only in few and peculiar cases, a diapedesis; but

although the latter can only be present when the hremorrhagesare small, of slow growth, and situa.ted exclusively in thepapillre or epithelium, it no doubt frequently accompanies

a Diseases of the N~rvous System. Vol. IL, p. 1015.b Tr.eatise. on Diseases of the Nervous System. Vol. II., p. 879.C Textbook of Medicine (Eng. ed.). P.76l.

. d Med. Times and Gazette. 1865. I., p. 590. (Abstract from Schmidt'sJ ahr-b. ..1864. No. ·7.)

e Lancet. 1875. II., p. 356. (Abstract.)l Die Hi&topathologie·der Hautkrankheiten. 1894. P. 48

By DR. 'V. R. DAWSO~. 67

rupture. The mechanics of rupture U uua explains veryjno-eniously, and his explanation is well borne out by histo-~

logical facts. The lesion is almost always found to havetaken place in the deepest layer of the cutis, or the most

superficial of the subcutaneous tissue-i.e., at the point

where the delicate yessels running in the firm cutaneous

tissue acquire greatly strengthened coats before entering the

looser underlying material. rrhe rupture is found to be

situated in the thin-\valled portion, and the deduction is

t.hat any cause, such as distellsion of the cutaneous vessels

at a time "7hen the cutis cannot expand, which would cause the

thin-walled portion to expand beyond the shelter of the firm

connect.ive-tissue layer, would be liable to produce rupture.

This altogether disposes of the old theory of hremorrhage

due to changes in the blood itself,. which, in fact, Unna

definitely rejects, as he does, also, the predisposing influence

of ordinary thrombi, of any disease causing thickening of

the vessel-walls, embolism, &c. The only causes of skin

hremorrhage. he says, to be discussed in future are :-

(1.) ~nlbolism with specific hremorrhagic bacteria.

(2.) Congenital defect of the vessel-walls, as in hromophilia.

(3. ) Congestive processes, not alone, but in combination

with each other, or with simultaneous vascular paralysis,

,vhiIst hypostatic congestion, perhaps, plays the Inost ilnpor­

tant preparatoryr6le.

With the first of these causes we have, obviously, nothing

to do, and may pass on at once to the third, which alone can

explain hoomorrhage of nervous origin. On the causation of

this Unna declines to give a positive opinion, for ,vantof

sufficient evidence, but suggests the theory of venous spasnlSwith simultaneous arterial distension as a possible cause.

Probably small hremorrhages, such as those in epilepsy, are.]0 many cases due to diapedesis; but the larger bruise-like

noomorrhages of. rapid occurrence can only be the result of

E

68 EccJI'!Jnlo~i8 following insane Emc.itement.

rupture. . The appearance of those in the case described,

as well as in the reported cases alluded to, would seemto show that the bleeding had taken place at the :levelwhich Unna considers typical-i.e. in the deeper layers of

the cutis and most superficial of the subcutan60us tissue.'Ve must, therefore, suppose some such form of combinedactive and passive congestion to have taken place, and this,in my case, is, I think, not far to seek. In the first place,

the patient was a fair, fresh-complexioned wonlan of the

type in whom cutaneous flushings are apt to occur, she \vas

at a time of life ,,-hen such are common, and subject tomental excitement of a hysterical type, such as is known tocause dilatation of the cutaneous arteries, and which, in point

of fact, did produce an erythema as we have seen. Add tothis, the fact of tardy venous return, due to weakness of her

heart, and we have quite sufficient data to ac.count for very

considerable distension of the cutaneous vessels, which mightquite conceivably lead to rupture. But why did not thisoccu.r until four years after the conditions were established,

the fits not having increased in severity? There can onlybe one answer to this question-viz., vascular degeneration.As regards the character of this, it would be, of course, idle

to conject~re in the absence of any histological investigation,

but I think it quite possible that it may merely consist of alovrered vitality of the vessel-walls, such a lowered vitality

as is known to exist in many or all of the tissues in in­sanity, and which may quite possibly show no indication of itspresence which can be detected with the microscope. That

some forms of degeneration may predispose to hremorrhage

seems pretty clear from the occurrence of the latter spon­taneously in diseases of so degenerative a type as generalparalysis and locomotor ataxy, and, perhaps, the case of M.I{]ippel might also be placed in the same category, while the

liability to severe hremorrhage from traumata, which is so

By DR. '\T. R. DAWSON. 69

common in insanity, certainly seems to indicate the saIne.

Mv view, then, ~f this case would be, that the hremorrharre~ 0

was due to active and passive hyperremia, in combination

with some degenerative process in the vessels; whilst Dr.

Savage's case, so far as it was not due to slight traumata,,,"ould be caused by vascular disease and the vascular dilata­tion of excitenlent.

In conclusion, I have to thank Dr. Clollston for permitting

me to publish the case, and several of the assistants atMorningside, past and present, for various details concerning

it.