Pruritus and its Management*

This state of affairs continued for 17 days, during which time the dose of A.C.T.H. was gradually reduced from 40 mg. six-hourly to 15 mg. twice daily, as supplies were running out. Her temperature rose to 1010 F. (38.30 C.) and she had a haemoptysis of 12 oz. (340 ml.). A fresh supply of A.C.T.H. was obtained and her condition improved, but the drug was running short by October 3, and was tailed off and discontinued on October 7. Three days later her temperature, which had been rising, reached 1020 F, (38.90 C.); she had a haemoptysis of 16 oz. (450 ml.), and several smaller ones. Her condition became critical. Her pulse rate rose to 140 a minute, and her blood pressure fell from its normal level of 130/80 to 90/50. The bleeding from her lungs was stopped by two transfusions of 2 pints and 1 pint (1,140 and 570 ml.) of blood respectively, but she remained desperately ill. The next day A.C.T.H. was again obtained and 30 mg. was given intramuscularly with a further pint (570 ml.) of fresh blood. Two hours later her general condition was better, her colour improved, and her pyrexia began to settle. The A.C.T.H. was continued in doses of 15 mg. six-hourly, and a week later, on October 19, her blood count showed the first sign of improvement; haemoglobin, 72%; red cells, 3,890,000; white cells, 3,000 (60% polymorphs); 60 nucleated red cells per c.mm.; platelets 10,000. The figures of her blood count remained round about the same level and on November 6 A.C.T.H. was stopped. On this occasion after withdrawal of A.C.T.H. her temperature did not rise or her condition deteriorate and her blood count had remained substantially the same, although transfusions of 2 pints (1,140 ml.) were required every two to three weeks instead of weekly. Her bone marrow on November 9 appeared completely aplastic, but the drop in cells was mainly in the red-cell series, her white blood count being constant at 2,000-3,000 and her platelets 10,000-50,000 per c.mm. Her condition appeared to improve for a time, but remained precarious throughout. The haemorrhagic incidents became more frequent. She was admitted for a further transfusion, developed a cerebral haemorrhage, and died before any effect of a new supply of cortisone could take place. She died on December 28-that is, 139 days after the onset of her blood disorder. Post-mortem examination revealed a pale and fatty bone marrow, the presence of petechial haemorrhages in most organs, and a cerebral haemorrhage on the right side. Bronchiectasis, fatty degeneration of the liver, and deposition of haemosiderin in the liver and spleen were found. No significant histological changes were present in the endocrine organs. Discussion It is the experience of several workers that marrow function usually returns spontaneously in about a week after discontinuing the offending drug (Hutt and Lee, 1953). We felt at first that both cortisone and A.C.T.H. were of no value in the management of this case, but, as the aplastic condition of her marrow persisted and she did not deteriorate clinically, we began to think that it might be having a life-saving effect. Coincidentally with the reduction in the dose of A.C.T.H. to an ineffective level she developed on two occasions a pyrexia and severe haemoptysis, and on the second was desperately ill. On both occasions when an effective dose of A.C.T.H. was restarted her general condition improved in a matter of hours. We found no evidence that cortisone and A.C.T.H. had any effect in hastening recovery of normal marrow function. Sternal marrow puncture was not used throughout as a guide to the amount of regeneration, as daily blood counts showed no signs of recovery and the patient was having to endure many but inevitable needle pricks and discomforts. We felt, however, that we were giving cortisone and A.C.T.H. a proper trial, as they were not begun until 11 days after the onset of purpura and the discontinuation of carbimazole. We suggest that these drugs would have produced signs of regeneration of the marrow after a course lasting 72 days if they were capable of bringing about such an effect. Summary