that a young person should die with apoplexy, death is probably due to such an aneurism, which has ruptured after its formation. Occasionally, aneurism produced in this way has come under surgical treatment for the cure of the disease; but it is well to remember that the condition is an indication of the existence of the worst possible form of disease of the valves of the heart, one usually associated with embolism in many of the organs, and with hectic fever. It is nearly always fatal within a few weeks; and there is hardly scope for treatment other than palliative.

CHAPTER XLV.

PURPURA-HÆMOPHILIA-SCURVY-ANÆMIA, ETC.

CERTAIN other diseases may be noticed in connection with the heart, though, strictly speaking, they are probably blood diseases rather than diseases of the circulatory system.

Purpura is one of these. It is by no means uncommon in children of the lower classes as the result of bad feeding or bad living. It may be met with in all degrees, from scattered petechia in the skin, of small size, and which might easily be mistaken for fleabites, or larger and more profusely spread, up to considerable extravasations into the subcutaneous tissue, or to bleeding from the nose, gums, stomach, bowels, and kidney. Purpura when confined to the skin is sometimes called simple; when affecting mucous membranes also, purpura hæmorrhagica, or morbus maculosus. Purpura is a condition which is found associated with many diseases, such as rickets, rheumatism, blood-poisoning of various septic kinds, or ulcerative forms of heart disease, and it is produced in some subjects artificially by the administration of drugs, such as iodide of potassium. Many of these forms, however, are allocated to the distinct disease, and we have thus purpura rheumatica, the petechia of scarlatina and small-pox, and the purpura of heart disease. These are not generally included in the term purpura, but only such cases as originate, often without fever, without any more definite cause than prolonged failure in nutrition, dietetic or other. Even extreme cases of this kind are not uncommon, and they usually speedily get well upon

proper diet. I have, however, met with one case which was associated with fever and severe intestinal lesions, which speedily proved fatal. The intestine was found in this case in a spongy, tufted condition, not unlike the gums as seen in bad cases of scurvy.

in purpura.

Hemorrhage occasionally occurs about the fundus oculi This lesion has of late been frequently described; but, so far as I know, it has no special importance attaching to it. A girl, æt. four, was admitted on July 31, 1877. She had been languid and fretful, suffering from stomatitis for three days, and two days before admission the body became covered with purple spots. The gums commenced to bleed on the morning of admission, and blood had also came from the right ear, from which for two years there had been an occasional discharge of pus. The child by nature was of a dark, sallow complexion, but had enjoyed good health. It had been noticed that since her birth any scratch or cut would bleed freely. The child had been well fed, was fond of vegetables, and had had plenty. The mother was of dark complexion, and believed that she had had a similar attack when a child. The gums were much

swollen, greyish looking, and fungating. All parts of the body were covered with small petechia but no bruises. The child lay feeble and exhausted, with a temperature of 99.8°, pulse 134, respiration 20. The urine was normal. The thoracic and abdominal viscera also. Gallic acid, in six-grain doses, was administered three times daily, and green vegetables, milk, and beef-tea were ordered. The bleeding from the gums becoming serious, they were painted with tincture of perchloride of iron. She vomited blood twice only; passed none in the evacuations and none in the urine. The bleeding from the gums gradually ceased, and the spots faded from the skin, and she left the hospital well after about three weeks' stay.

During her illness the fundus oculi was examined for hemorrhage, and on the right side, above and internal to the optic disc, and at some distance from its margin, a large dark round blotch was seen, with a haze over it, and a white margin surrounding it. Near it was a large vessel. The appearances were those of hemorrhage into the choroid, with either atrophy around it or the white margin of a displaced retina. Both discs were whitish, and the chorodial pigment was very unevenly distributed-some parts of the choroid looking white by contrast with others.

The child was seen again some months later, and, the pupils being dilated with atropine, the fundus was fully examined. No trace of the former hemorrhage existed, and the uneven distribution of pigment so marked before was now hardly noticeable.

Five cases of purpura that have been under my care in the Evelina Hospital have all been of the female sex.

Of the pathology of purpura nothing is known; the blood has been examined, without result; the bloodvessels also, with no decided bearing. All that is known is the practical fact that it depends often upon deprivation of particular kinds of food, and quickly disappears when these are supplied.

It is indeed but seldom fatal, although, in severe cases, the amount of bleeding from the nose, the bowels, or the kidney, may give rise to some anxiety.

Treatment.-Rest in bed is necessary if there be any severity about the attack; and to stay the bleeding some gallic acid may be given in honey, or some turpentine in syrup. The body should be kept cool, and ice may be applied if necessary to the head or spine, or even placed in the rectum. Plenty of good milk should be given, and orange, lemon, or lime-juice, with green vegetable diet and underdone meat or beef juice.

Hæmophilia.-Purpura-the just detailed case in particular-with its history of a tendency to bleed to excess on slight scratches, etc., leads naturally to the consideration of hæmophilia, or the hæmorrhagic diathesis. It is a disease which is strongly hereditary, and it is far more common in males than in females, the proportion being about eleven to one. As regards its transmission, there is this curious fact about it, that it passes to the males through the females, the mothers remaining quite healthy whilst passing on the disease to their sons, and fathers who are bleeders but rarely transmitting it to their sons. The females in bleeder families, according to Dr. Wickham Legg, from whom I am condensing this account, are, unfortunately, remarkably fertile.

Symptoms. The subjects of hæmophilia differ in no appreciable respect from other people. They are usually healthy. The symptoms usually show themselves soon after birth, within the first year or two of life, and are characterized either by bleeding from the nose or mouth or spontaneous ecchymoses in the skin. In the extreme cases, found usually only in the males, the bleeding arises spontaneously, or from the most trivial causes, and occurs not only in the skin and from mucous surfaces, but large extravasations take place into the subcutaneous tissue and intermuscular septa, and into the cavities of the larger joints. To this escape of blood into the joints is due the obstinate swellings of the joints, particularly of the knee, which characterize this dis

ease.

Of the few cases that have come under my own notice, one was a boy, aged four, who had persistent epistaxis after some slight injury. Another, a boy, aged nine, with epistaxis to blanching, whose brother suffers also from frequent epistaxis. A third, a male, of eighteen months, I am uncertain about, from the possible existence of rickets. He had had convulsions, and his head was large; but he looked in