Treatment. In symptomatic purpura attention should be paid to the conditions under which it occurs, and measures should be employed to increase the strength and to restore a normal blood condition. Tonics, good food, and fresh air meet these indications. In the simple purpura of children, or that

CHART XX.-ILLUSTRATES THE RAPIDITY WITH WHICH ANÆMIA IS PRODUCED IN PURPURA HÆMORRHAGICA AND THE GRADUAL RECOVERY.

associated with slight articular trouble, arsenic in full doses should be given. No good is obtained from the small doses, but the Fowler's solution should be pushed freely until physiological effects are obtained. In peliosis rheumatica the sodium salicylate may be given, but with discretion. I confess not to have seen any special control of the hæmorrhages by this remedy.

Aromatic sulphuric acid, ergot, turpentine, acetate of lead, or tannic and gallic acids, may be given, and in some instances they seem to check the bleeding. Oil of turpentine is perhaps the best remedy, in 10 or 15 minims doses three or four times a day. Wright, of Netley, advises the use of calcium chloride in 20-grain doses four times a day (for three or four days) to increase the coagulability of the blood. In bleeding from the mouth, gums. and nose, the inhalation of carbon dioxide, irrigations with 2-per-cent gelatin solution, and adrenalin should be tried. The last remedy has often acted promptly.

HÆMORRHAGIC DISEASES OF THE NEW-BORN.

1. Syphilis Hæmorrhagica Neonatorum.-The child may be born healthy, or there may be signs of hæmorrhage at birth. Then in a few days there are extensive cutaneous extravasations and bleeding from the mucous surfaces and from the navel. The child may become deeply jaundiced. The post mortem shows numerous extravasations in the internal organs and extensive syphilitic changes in the liver and other organs.

2. Epidemic Hæmoglobinuria (Winckel's Disease).-Hæmoglobinuria in the new-born, which occasionally occurs in epidemic form in lying-in institutions, is a very fatal affection, which sets in usually about the fourth day after birth. The child becomes jaundiced, and there are marked gastro-intestinal symptoms, with fever, jaundice, rapid respiration, and sometimes cyanosis. The urine contains albumin and blood-coloring matter-methæmoglobin. The disease has to be distinguished from the simple icterus neonatorum, with which there may sometimes be blood or blood-coloring matter in the urine. The post mortem shows an absence of any septic condition of the umbilical vessels, but the spleen is swollen, and there are punctiform hæmorrhages in different parts. Some cases have shown in a marked degree acute fatty degeneration of the internal organs-the so-called Buhl's disease.

3. Morbus Maculosus Neonatorum.-Apart from the common visceral hæmorrhages, the result of injuries at birth, bleeding from one or more of the surfaces is a not uncommon event in the new-born, particularly in hospital practice. Forty-five cases occurred in 6,700 deliveries (C. W. Townsend). The bleeding may be from the navel alone, but more commonly it is general. Of Townsend's 50 cases, in 20 the blood came from the bowels (melæna neonatorum), in 14 from the stomach, in 14 from the mouth, in 12 from the nose, in 18 from the navel, in 3 from the navel alone. The bleeding begins within the first week, but in rare instances is delayed to the second or third. Thirtyone of the cases died and 19 recovered. The disease is usually of brief duration, death occurring in from one to seven days. The temperature is often elevated. The nature of the disease is unknown. As a rule, nothing abnormal is found post mortem. The general and not local nature of the affection, its self-limited character, the presence of fever, and the greater prevalence of the disease in hospitals, suggest an infectious origin (Townsend). The bleeding may be associated with intense hæmatogenous jaundice. Not every case of bleeding from the stomach or bowels belongs in this category. Ulcers of the oesophagus, stomach, and duodenum have been found in the new-born dead of melana neonatorum. The child may draw the blood from the breast and subsequently vomit it. In the treatment the external warmth must be maintained, and in feeble infants the couveuse may be used. Camphor is recommended, ergotin hypodermically, and the suprarenal extract.

V. HÆMOPHILIA.

Definition. A constitutional fault, hereditary or acquired, characterized by a tendency to uncontrollable bleeding, either spontaneous or from slight wounds, sometimes associated with a form of arthritis. The coagulation time of the blood is usually much retarded.

The fact that fatal hæmorrhage might occur from slight, trifling wounds had been known for centuries. Fordyce, in 1784, recognized the hereditary nature, and early in the last century described the American bleeder families. Buel, Otto, Hay, Coates, and others in America published similar reports. The disease is considered at length in the monographs of Legg and Grandidier, and recently by Stempel.

Etiology. In a majority of cases the disposition is hereditary. In the Appleton-Swain family, of Reading, Mass., there have been cases for nearly two centuries; and F. F. Brown, of that town, tells me that instances have already occurred in the seventh generation. Atavism through the female alone is almost the rule, and the daughters of a bleeder, though healthy and free from any tendency, are almost certain to transmit the disposition to the male offspring. The affection is much more common in males than in females11:1, Legg; 4:1, Stempel. The tendency usually appears within the first two years of life. It is rare for manifestations to be delayed until the tenth or twelfth year. Families in all conditions of life are affected. The bleeder families are usually large. The members are healthy-looking, and have fine, soft skins. The Anglo-German races are chiefly attacked; of 209 cases collected within the ten years 1890-1900 by Stempel, 96 were German, 95 English or American, only 16 French, Hungarian, or Russian. Steiner has reported from my clinic instances occurring in a negro family.

Morbid Anatomy.-No special peculiarities have been described. In some instances changes have been found in the smaller vessels; but in others careful studies have been negative. An unusual thinness of the vessels has been noted. Hæmorrhages have been found in and about the capsules of the joints, and in a few instances inflammation of the synovial surfaces. The nature of the disease is unknown. An increase in the number of the red blood-corpuscles-erythrocythæmia-with a peculiar frailty of the blood-vessels, has been supposed. A deficiency of the leucocytes and a diminution of the blood-plates have been noted, though in a case from my clinic, studied by Steiner, these structures were normal. Wright has found the coagulation time much retarded, as long as twenty-three and forty-five minutes.

Symptoms. Usually hæmophilia is not noted in the child until a trifling cut is followed by serious or uncontrollable hæmorrhage, or spontaneous bleeding occurs and presents insuperable difficulties in its arrest. The symptoms may be grouped under three divisions: external bleedings, spontaneous and traumatic; interstitial bleedings, petechia and ecchymoses; and the joint affeetions. The external bleedings may be spontaneous, but more commonly they follow cuts and wounds. In 334 cases (Grandidier) the chief bleedings were epistaxis, 169; from the mouth, 43; stomach, 15; bowels, 36; urethra, 16; lungs, 17; and in a few instances bleeding from the skin of the head, the tongue, finger-tips, tear-papilla, eyelids, external ear, vulva, navel, and

scrotum.

Traumatic bleeding may result from blows, cuts, scratches, etc., and the blood may be diffused into the tissues or discharged externally. Trivial operations have proved fatal, such as the extraction of teeth, circumcision, or vene section. It is possible that there may be local defects which make bleeding from certain parts of the body more dangerous. D. Hayes Agnew mentioned to me the case of a bleeder who had always bled from cuts and bruises above

the neck, never from those below. The bleeding is a capillary oozing. It may last for hours, or even many days. Epistaxis may prove fatal in twenty-four hours. In the slow bleeding from the mucous surfaces large blood tumors may form and project from the nose or mouth, forming remarkable-looking structures, and showing that the blood has the power of coagulation. The interstitial hæmorrhages may be spontaneous, or may result from injury. Petechia or large extravasations-hæmatomata-may occur, the latter usually following blows.

Joint Affections.-The knees and elbows are chiefly involved, but the small joints may be attacked. The onset is usually acute, with slight fever and swelling and pain, and sometimes redness. In other instances there is hæmorrhagic effusion without fever. König recognizes three stages: first, hæmarthrosis; secondly, an inflammatory process, with fever and spindle-formed swelling, which is apt to be mistaken for tuberculosis; and, lastly, there may be extensive organic changes, which may even resemble those of arthritis deformans. There are cases with spontaneous hæmorrhages into muscles and joints without (for years at least) external bleedings. The greatly deformed joints may be thought to be tuberculous.

Diagnosis. In the diagnosis of the condition the family tendency is important. A single uncontrollable hæmorrhage in child or adult is not to be ranked as hæmophilia; but it is only when a person shows a marked tendency to multiple hæmorrhages, spontaneous or traumatic, which tendency is not transitory but persists, and particularly if there have been joint affections, that we may consider the condition hæmophilia. Such conditions as epistaxis, recurring for years-if no other hæmorrhage occurs-or recurring hæmaturia from one kidney, which has been spoken of as unilateral renal hæmophilia, have no association with the true disease. There is a remarkable form of hereditary epistaxis with multiple cutaneous nævi-telangiectases. The bleeding comes from the dilated spider nævi in the nose, or on the lips, tongue, or cheeks (J. H. H. Bull., 1901). Peliosis rheumatica is an affection which touches hæmophilia very closely, particularly in the relation of the joint swellings. It may also show itself in several members of a family. The diagnosis from the various forms of purpura is usually easy.

Prognosis. The patients rarely die in the first bleeding. The younger the individual the worse is the outlook, though children rarely die in the first year. Grandidier states that of 152 boy subjects, 81 died before the termination of the seventh year. The longer the bleeder survives the greater the chance of his outliving the tendency; but it may persist to old age, as shown in the case of Oliver Appleton, the first reported American bleeder, who died at an advanced age of hæmorrhage from a bed-sore and from the urethra. The prognosis is graver in a boy than in a girl. In the latter menstruation is sometimes early and excessive, but fortunately, in the female members of hæmophilic families, neither this function nor the act of parturition brings with it special dangers.

Treatment.-Members of a bleeder's family, particularly the boys, should be guarded from injury, and operations of all sorts should be avoided. The daughters should not marry, as it is through them that the tendency is propagated.

When an injury or wound has occurred, absolute rest and compression

should first be tried, and if these fail the styptics may be used. In epistaxis ice, tannic and gallic acid may be tried before resorting to plugging. Internally ergot seems to have done good in several cases. Legg advises the perchloride of iron in half-drachm doses every two hours with a purge or sulphate of soda. For the epistaxis the inhalation of carbon dioxide through the nostrils is recommended by A. E. Wright. He also advises a solution of fibrin ferment and chloride of calcium as a styptic. Dried suprarenal gland, 1 part to 10 of water, freshly prepared, may be applied to the part, or the active principle, epinephrin or adrenalin, may be tried. Gelatin in 5-per-cent solution is warmly recommended. Venesection has been tried in several cases. Transfusion has been employed, but without success. During convalescence, iron and arsenic. should be freely used.

VI. SCURVY (Scorbutus).

Definition. A constitutional disease characterized by great debility, with anæmia, a spongy condition of the gums, and a tendency to hæmorrhages.

Etiology. The disease has been known from the earliest times, and has prevailed particularly in armies in the field and among sailors on long voyages. It has been well called "the calamity of sailors."

From the early part of the last century, owing largely to the efforts of Lind and to a knowledge of the conditions upon which the disease depends, scurvy has gradually disappeared from the naval service. In the mercantile marine, cases still occasionally occur, owing to the lack of proper and suitable food.

In parts of Russia scurvy is endemic, at certain seasons reaching epidemic proportions; and the leading authorities upon the disorder, now in that country, are almost unanimous, according to Hoffmann, in regarding it as infectious.

In the United States scurvy has become a very rare disease. To the hospitals in the seaport towns sailors are now and then admitted with it. In large almshouses outbreaks occasionally occur. A very great increase of foreign population of a low grade has in certain districts made the disease not at all uncommon. In the mining districts of Pennsylvania the Hungarian, Bohemian, and Italian settlers are not infrequently attacked. McGrew has recently reported 42 cases in Chicago, limited entirely to Poles. He ascertained that in a large proportion of the cases the diet was composed of bread, strong coffee, and meat. Occasionally one meets with scurvy among quite well-to-do people. One of the most characteristic cases I have ever seen was in a woman with chronic dyspepsia, who had lived for many months chiefly on tea and bread. Some years ago scurvy was not infrequent in the large lumbering camps in the Ottawa Valley. In Great Britain and Ireland it has become very rare; only 302 cases were admitted to the Seaman's Hospital in the twenty-two years ending 1896 (Johnson Smith). Judging from the Report of the American Pædiatric Society, we must infer that infantile scurvy is on the increase in this country.

There are three theories of the disease:

(a) That it is the result of an absence of those ingredients in the food which are supplied by fresh vegetables. What these constituents are has not