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different arteries with each other; but these are points which scarcely require or admit of general directions.

What has been stated above bears immediately upon the second point which we proposed for consideration, viz. to inquire what condition of the vital powers or of the functions may be supposed capable of producing a distinct and specific effect upon the pulse, and what are the diseases which derive their distinctive characters from the changes consequent on these conditions. Now we shall find that the diseases in which the action of the heart is more immediately or directly concerned are those which we referred to the great class of febrile affections. These may be arranged under the two divisions of fevers that originate in, or are essentially connected with, increased action of the vital powers, and those which originate in a diminished action of these powers; the first constituting what is popularly termed inflammatory fever, the synocha or cauma of systematic writers; the latter the low or nervous fever, the typhus of the nosologists. If to these we add a third class of diseases, which depend upon a directly sedative operation on the nervous system, nearly corresponding to the anesthesia of the nosologists, we shall have three great divisions, to which we may refer all the various changes in the state and condition of the pulse which can be easily reduced to any general principles.

We are now arrived at that part of the subject to which all the rest ought to be subservient, and which alone gives it its value-the practical application of our theoretical principles; yet, important as it is, on this occasion it must necessarily be passed over with a very slight notice. All that can be accomplished in an essay like the present, is to establish and illustrate certain general positions, which may be applicable to each particular disease, or even to each individual case,-a detail which would be inconsistent with the nature and the limits of our article, but which will be amply supplied by the other parts of this work.

The object of the practitioner is to ascertain, if possible, in the first instance, what is the ordinary state of the pulse of each individual, as depending upon his peculiar constitution or habits; and, secondly, how it may be supposed to be affected by the circumstances, either external or internal, which were enumerated above, and which are independent of the disease in question. In the third place, he must ascertain the state of the pulse with respect to its three principal relations of time, force, and equality, considered either simply or in combination, and endeavour to trace their connection with the supposed cause of the disease, and with the derangement which has been induced in the various powers and functions of the system. These he will probably find it convenient to refer to one or other of the three great classes mentioned above, and he must regulate his practice, and form his diagnosis and prognosis by still farther viewing them in connection with the other symptoms of the disease. The result of this process will be, that by referring to the physiological principles which we have attempted to establish, the practitioner will frequently be enabled to explain what would otherwise be obscure and unintelligible; yet it must be acknowledged, on the other hand,

that he will meet with numerous anomalies which
he will find it impossible to reduce to his system,
and which can only be duly appreciated by a care-
ful and diligent observation of the phenomena of
disease, and by steadily preferring the result of
experience to the deductions of any theory, how-
ever plausibly formed or ingeniously supported.
[See on the whole subject of the pulse, Piorry,
Traité de Diagnostic, § 537.]

JOHN BOSTOCK.

PURGATIVES.-See CATHARTICS. PURPURA.—The terms purpura, [or porphyra purpura hæmorrhagica, and hæmorrhag petechialis, are employed to denote that affection which was formerly distinguished in medical writings by the designations of morbus maculosus hæmorrhagicus, petechiae sine febre, phænigmus petechialis, (Sauv.) &c. This disease is characterized by an efflorescence on the skin, occurring independently of primary fever, consisting of red, purple, or livid spots of various sizes, (termed petechiae, vibices, and ecchymoses,) and in its more severe form accompanied by hemorrhage from various parts of the body, chiefly from the mucous membranes. The spots are seldom elevated above the level of the surrounding cuticle; they are unattended by itching or any uneasy sensa tion; and on division of the cuticle by a scalpel they are found to consist of minute effusions of from every form of rash or other cutaneous erup blood. They are therefore essentially different tion; and are properly considered as the result of a cutaneous hemorrhage.

[In consequence of the appearance of the skin, purpura has been commonly classed amongst cutaneous diseases. Willan has treated, under the head of purpura, of the land-scurvy, and of the petechial spots of malignant fever,-petechia contagiosa; yet he has omitted sea-scurvy,-an affection almost identical with land-scurvy. They are all as a general rule-dependent upon = similar depraved condition of the fluids and solids; are true cachexies, in other words; and have accordingly been treated of, by the writer, under Scorbutic Cachexia. (Practice of Medicine, 24 edit. ii. 632, Philad. 1844.)]

Petechiae (a name introduced into nosological language from the Italian petecchia, and supposed to be originally derived from their resemblance to flea-bites) have been long noted as a symptom in continued fevers and other febrile diseases, in which they have been supposed to indicate peculiar malignancy. (See the article FEVER.) From their constant occurrence in certain epidemic fevers, these were considered as constituting a specific exanthematous disease, which was described in nosological systems and practical writings under the names of petechia, febris petechialis, febris purpurata, &c. The occurrence of petechië in continued fever, no less than in small-pox, measles, &c. is now universally allowed to be a contingent symptom, and most commonly arises from the influence of foul air, a hot regimen, the neglect of purgatives, or similar errors in treatment. It is accordingly much less frequent than formerly. Petechial fever is the "purpura" of Sauvages" nosology; a term which had previously been used

in the same sense by Riverius, Diemerbroeck, &c. | cases of the disease, never having met with one By others of the old writers it had been employed which proved fatal. He considered the disease as

to signify affections totally different, viz. various forms of papulous eruptions and rashes, as redgum, lichen, miliaria, nettle-rash, measles, and scarlatina. (Willan on Cutaneous Diseases, p. 452.-Bateman, Synopsis, p. 103, third edit.) We must therefore take care not to apply their observations to what is now termed purpura.

We owe the name of purpura in its present acceptation to Dr. Willan. In his nomenclature of cutaneous affections it is used as a generic term, to include every form of petechial eruption, febrile or non-febrile. He therefore includes under it, as a species, purpura contagiosa, the petechial eruption in continued fevers; a name every way objectionable, as it would tend to perpetuate the ancient errors of the idiopathic nature and specific contagion of those petechiæ. Under the names of P. simplex, P. hæmorrhagica, and P. urticans, he describes " three striking varieties" of petechial eruption independent of primary fever,-varieties which confessedly differ chiefly in degree, and which, under the general name of purpura, form the subject of the present article.

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Purpura, considered by Willan as an affection of the skin, was ranked by him under the order Exanthemata," or rashes, of his arrangement; to which it bears some affinity in external appearance only, but even in this respect does not agree with his definition of the order. Rayer has more correctly classed purpura (under the somewhat quaint name of hémacélinose,-from aiμa, blood, dis, spot, vócos, disease; Rayer, Malad. de la Peau, t. ii. p. 158,) under "Cutaneous and Sub. cutaneous Hemorrhages." But purpura cannot be correctly considered as merely a cutaneous disease, since, as Dr. Watson has well observed, "the effusion of blood (which, strictly a hemorrhage in all parts, takes the form of red or purple spots where the quantity effused is but a drop) is not confined to the skin nor to the subcutaneous tissues, but is observed occasionally on the internal surfaces also, and in the parenchymatous surface of the viscera. The disease, therefore, is properly a hemorrhage, but it is not properly, or merely, a cutaneous hemorrhage."

nearly if not quite identical with scorbutus, and to be combated by similar remedies. These views were disputed by Dr. Parry and Dr. Harty, and were considerably modified by Dr. Bateman in his Synopsis. Since that period a succession of valuable and instructive cases have been published in the Edinburgh Medical and Surgical Journal, and a few in other periodical works. Yet much remains to be done ere the pathology of purpura or its treatment can be considered as satisfactorily fixed on scientific principles. These may

Phenomena of the disease.

be referred to-1. appearances on the skin; 2. hemorrhages; 3. constitutional symptoms; 4. progress and duration of the disease; 5. circumstances noticed respecting the blood and the urine; 6. morbid appearances on dissection.

1. We have already given a general description of the efflorescence on the skin characteristic of purpura. There are three different forms of it, (well represented in plates xxviii. and xxix. of Bateman's "Delineations,") viz. the P. simplex, P. hæmorrhagica, and P. urticans of Willan. The P. senilis of Bateman (figured in his 30th plate) is a nearly local form of ecchymosis, unattended with fever, hemorrhage, or other constitutional symptoms; we shall therefore refer to the "Delineations," and to the third and subsequent editions of the "Synopsis," for his account of it.

In the purpura simplex, the petechiæ are described by Willan and Bateman as occurring with little constitutional disorder. "They are most numerous on the breast and on the inside of the arms and legs, and are of various sizes, from the most minute point to that of a flea-bite, and commonly circular. They may be distinguished from recent flea-bites partly by their more livid or purple colour, and partly because, in the latter, there is a distinct central puncture, the redness round which disappears on pressure." (Bateman, Synopsis, p. 104.) Purpura simplex is chiefly noticed in women and delicate children. It is thus described by Heberden: Cutis puerorum interdùm ubique distinguitur maculis purpureis, similibus earum quæ in febribus nascuntur. Tamen cum his adversa valetudo nulla est, neque præcessit, neque subsequitur. Alia pustulæ (scił. macula) vix sunt semine milii majores, aliæ sunt tres pollices ample. Post paucos dies cunctæ, sine medicamentorum auxilio, suâ sponte plerumque recedunt. In quodam puero sic affecto, si modo digitus leviter cuti imprimeretur, continuo sanguis

Purpura, considered as a hemorrhagic affection, is a most interesting subject of pathological inquiry, and demands peculiar attention from the danger which attends it, and from the obscurity which attaches to its nature and mode of cure. It has, therefore, ever since it was first distinguished from typhoid fever, attracted much notice from medical writers. For its earlier literary history, the reader must be referred to Dr. Willan's work, where he will find it amply detailed. Reference to the old writers can be of little avail for pathological and practical purposes. The first systematic account of the disease, under the name of hemorrhoea petechialis, was given in this country by Dr. Adair, in his thesis published in 1789. ibid. ix. 186. Ibid. xiii. 402.- Combe, ibid. xvii. 83. Dr. Bateman, in his inaugural dissertation pub-Johnston, ibid. xviii. 402. - Duncan (junior), ibid. 405.lished in 1800, described it under the same appellation. The description of purpura by Willan in his Reports of the Diseases of London, and subsequently in his great work on Diseases of the Skin, is given with his usual perspicuity, but he was practically unacquainted with the severer

*Duncan (senior), Medical Cases, Edin. 1781, p. 90.Rogert, Acta Soc. Reg. Med. Hafn. tom. i-Adair, Diss. Inaug. Edin. 1781. Ferris, Med. Facts and Observat. Walker, Annals of Med. vol. ii. (1797.)- Bateman, Diss. 1781. Tattersall, Med. Comment. vol. xx. (1795)Inaug. 1800.- Willan, Reports on Diseases of London.Willan on Cutaneous Diseases.-Bateman's Synopsis.Bateman's Reports on Diseases of London. - Parry, Edin. Med. Journ. v. 7. Bateman, ibid. vi. 224 and 374. Jeffreys, ibid. viii. 435.- Walsh, ibid. ix. 161.- Harty,

Nicholl, ibid. xviii. 540.-Darwall, ibid. xxiii. 53.-Magee, ibid. xxiv. 367.-Kift, ibid. xxvii. 71.-Blackall on Dropsies, p. 150. Yeats, Medical Transactions, iv. 429Gairdner, Edin. Medico-Chirur. Trans. i. 671. Wood, ibid. 680.- Fairbairn, ibid. ii. 157. Latham, Med. Ga zette, i. 544.-Watson, ibid. vol. vii.-Mackintosh's Pract of Physic, vol. ii. Rayer, Malad. de la Peau, tom. ii. p. 158.

Bateman's Synopsis, p. 116.)

ex vasis vicinis exiit, et sugillatio, tanquàm in legs. (Willan on Cutaneous Diseases, p. 461.— collisis, facta est." (Heberden, Comment. cap. lxxviii. de maculis purpureis.) The latter cir- | cumstance is more frequently noticed in the next form of the disease.

In purpura hæmorrhagica "the petechiae are often of a larger size, and are interspersed with, livid stripes and patches, resembling marks left by the stroke of a whip, or by violent bruises. They commonly appear first on the legs, and at uncertain periods afterwards on the thighs, arms, and trunk of the body, the hands being more rarely spotted with them, and the trunk generally free. They are usually of a bright red colour when they first appear, but soon become purple or livid; and, when about to disappear, they change to a brown or yellowish hue; so that, as new eruptions arise, and the absorption of the old ones slowly proceeds, this variety of colour is commonly seen in the different points about the same time. (See Delin. plate xxviii. fig. 2.) The cuticle over them appears smooth and shining, but is not sensibly elevated in a few cases, however, the cuticle has been seen raised into a sort of vesicles, containing black blood.... The gentlest pressure on the skin, even such as is employed in feeling the pulse, will often produce a purple blotch like that which is left after a severe bruise." (Bateman, Synopsis, p. 105.) The nature and seat of the small effusions of blood which constitute the petechia, from which the vibices and ecchymoses differ chiefly in magnitude, are well explained by the anatomical researches of Rayer. "On dissecting the skin," he observes, "it is found that the petechin and ecchymoses do not all occupy the same situation. Some are very superficial, and seated on the surface of the rete mucosum; others occupy the alveoli of the cutis; the largest and darkest-coloured have their seat under the skin in the cellular tissue. In these the blood is found coagulated, but it is fluid in the smaller and more superficial effusions. The vascular ramifications contiguous to these minute ecchymoses are in their natural state. The blood is easily removed by washing or maceration." (Rayer, Malad. de la Peau, ii. 162.)

The variety termed by Willan and Bateman purpura urticans, is comparatively rare. It is characterized by "rounded and reddish elevations of the cuticle, resembling wheals, but which are not accompanied, like the wheals of urticaria, by any sensation of itching or tingling." These little tumours gradually dilate; but within twentyfour hours or somewhat longer, subside to the level of the neighbouring cuticle. They are commonly situated on the legs, where they are intermixed with petechiae; (see Delineat. plate xxix. ;) they also appear on the thighs, breast, arms, &c. The spots are not permanent, but fade, while others appear in succession in different places. The duration of the complaint varies from three to five weeks. Willan never observed it to be attended with hemorrhage or fever; he states that it generally occurs in summer and autumn, and attacks those who are exposed to daily fatigue, &c., or young women who live luxuriously and take little exercise. Some ædema of the extremities usually accompanies it, and it is occasionally preceded by stiffness and pain in the

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2. The hemorrhages attendant on purpura take place from the mouth, nostrils, bronchial tubes, stomach, intestines, bladder, uterus, in short, from every part of the mucous membranes. They also in some cases occur from the skin; at least this singular hemorrhage bears in some cases a close analogy to purpura. In all these cases the effect produced on the system is from the loss of blood; but where the hemorrhage is strictly internal, as from the serous membranes or the parenchymatous substance of the viscera, the mischief is done by the mechanical compression or destruction of the texture of organs essential to life. Both cerebral and pulmonary apoplexy may thus occur and destroy the patient; of which there are several cases on record.

The most frequent hemorrhage, particularly in weak subjects, and where there is an approach to what has been termed the scorbutic diathesis, is that from the mouth. The gums are tender, and easily bleed on being touched. The lining membrane of the inside of the lips and cheeks, the investing membrane of the tongue, and also in some cases that which covers the tonsils and contiguous parts, present dark-coloured spots, which are usually elevated and distended with blood, which they pour out either spontaneously or on the slightest pressure. In some very unfavourable cases, as that related by the late Dr. Duncan, (Edinburgh Med. Journal, vol. ix. p. 405,) these spots degenerate into gangrenous ulcerations.

The tendency to the several kinds of hemor rhage varies at different periods of life: according to Rayer, epistaxis is the most common in children, as might be expected; uterine hemorrhage in women; and pulmonary or intestinal hemor rhage in male adults. The quantity of blood lost is often very considerable; and, as in other cases of hemorrhage, it is very apt to recur, and to become periodical. A case is mentioned where it returned daily at the same hour for a considerable period.

3. We have already stated that the constitu tional symptoms are usually but slight in the varieties of the disease termed P. simplex and P. urticans. In both of these forms, occurring without hemorrhage, considerable febrile excitement has been observed in some cases. With regard to P. hæmorrhagica, the following account of the preceding and accompanying symptoms is given by Bateman: "This singular disease is often preceded for some weeks by great lassitude, faintness, and pains in the limbs, which render the patient incapable of any exertion; but not unfrequently it appears suddenly, in the midst of apparent good health. It is always accompanied by extreme debility and depression of spirits; the pulse is commonly feeble, and sometimes quickened; and heat, flushing, perspiration, and other symptoms of slight febrile irritation, recurring like the paroxysms of hectic, occasionally attend. In some patients, deep-seated pains about the præcordia, and in the chest, loins, and abdomen, have been felt. In others, a cough has accompanied the complaint, or tumour and tension of the epigastrium and hypochondria, with tenderness on pressure, and a constipated or irregular state of the

Dr. Watson asserts that

in many, perhaps in all instances of the disease, in which it can be examined, the blood is found actually to have undergone a change, and not merely a change which may be ascertained by nice or elaborate chemical research, but such an alteration of its sensible qualities as is evident to the eye, and forces itself upon our notice." (Watson's Lumleian Lecture, Med. Gazette, vol. x. p. 499.) The inquiry into the state of the blood is certainly one of the highest interest, both with regard to the pathology of this disease in particular, and as it bears upon the general doctrines of pathological science. But in pursuing it we must be careful to keep in view the causes which, inde

bowels. But in many cases no febrile symptoms | noted in several cases. have been noticed; and the functions of the intestines are often natural. In a few instances frequent syncope has occurred. When the disease has continued some time, the patient becomes sallow, or of a dirty complexion, and much emaciated; and some degree of oedema appears in the lower extremities, and afterwards extends to other parts." (Bateman, Synopsis, p. 107.) This is a very faithful general account; but in several of the cases which have been recorded, the febrile symptoms, and those indicative of internal affections of the congestive or inflammatory kind, have been much more considerable than we should collect from Dr. Bateman's statement. Such af fections are considered by Rayer as always con-pendently of any primitive alteration in the state stituting an "accidental complication" of purpura; and he says that it is only in such cases of accidental complication that he has seen it present the characters of active hemorrhage. (Op. cit. ii. 167.) On the other hand, it is to be observed that the mode of treatment which has been directed to the relief of the internal symptoms, has in several well-marked cases procured the cessation of those proper to purpura; an effect which has also not unfrequently occurred from a profuse eruption of the catamenia, (Bateman, Reports of Diseases of London, p. 130,) or from a hemorrhage which has appeared to be, in the language of the schools, critical. This subject, however, will more properly come to be considered under the heads of pathology and treatment.

4. The purpura hæmorrhagica," observes Willan, "has not any regular or stated termination. It was protracted, in the cases under my own observation, from fourteen days to twelve months and upwards. The disease did not, in any of these cases, prove fatal." (Op. cit. p. 457.) In some cases the disease has proved fatal from internal or external hemorrhage, or the violence of the febrile symptoms, or prostration of the vital powers, in a shorter time, considerably, than the former period mentioned by Willan. In others it has assumed a completely chronic form, and either recurred periodically, or as to some of its symptoms been more or less constantly present. Several well-attested cases are recorded where it has appeared to be linked in an inexplicable manner with the mode of existence of the individual, and put on the character of what are properly called "constitutional hemorrhages." (See HEMORRHAGE.) In such cases, it has existed for years without impairment of the general health. A boy is mentioned by Bateman on the authority of the elder Dr. Duncan, whose skin for several years was constantly covered with petechia, and exhibited vibices or purple blotches on the slightest blow; yet he was in other respects in good health, and capable of active exercise. Pulmonary hemorrhage at length supervened, and carried him off. (Synopsis, p. 108.) A case is related by Adair, where the symptoms of purpura recurred regularly for six succeeding summers. (Diss. Inaug. p. 16.)

of the blood existing as the cause of all the phenomena of purpura, may materially affect the condition of that fluid. The coexistence of fever or inflammation will, of course, give rise to those alterations in the blood which are proper to those morbid states; accordingly we find it stated by Dr. Parry, that in both his cases the blood was highly buffed, the crassamentum firm and cohesive, but bearing a small proportion to the serum.* In other cases where the blood has been examined, there had previously occurred either very profuse or long-continued hemorrhage, which necessarily altered the quality of the blood by diminishing the quantity of the red globules as well as of the fibrine of the blood in proportion to the serum. Our conclusions ought, if possible, to be derived from the examination of blood drawn at the height of the disease, when no excessive hemorrhage has preceded, and in cases where there are no decided marks of inflammation or other disease coexisting with purpura.

Some of the most remarkable results of the examination of the blood in purpura have been the following. In the case of a sea-captain, a plethoric subject with a full pulse, the state of the blood obtained by a second venesection, and when purgatives had been prescribed, and two pounds of blood previously lost by epistaxis, is described by Dr. Jeffreys as follows: "The blood drawn yesterday shows an inflammatory buff on its surface, at least an inch and a half in thickness, firm and yellow, far exceeding any thing I ever saw in rheumatism or pneumonia, but not at all cupped; in fact, the whole serum looks like a corrupted coat of coagulable lymph. The crassamentum appears in a very dissolved state, of nearly a black colour, and much less in quantity than usual." (Edin. Med. Journal, viii. 435.) This patient was again twice bled, the blood presenting the same appearances; he ultimately recovered. In a case related by Dr. Johnston, of decidedly febrile character, and which rapidly proved fatal, the blood did not separate into serum and crassamentum; it had little consistence or tenacity, but traces of coagulable lymph were diffused through it. (Edin. Med. Journal, xviii. 402.) In Dr. Duncan's case, which has been already quoted, the blood, while flowing slowly from the vein, was

5. We have not been able to meet with any account of the chemical analysis of the blood in a case of purpura. Its sensible qualities, how-man, (Reports on Diseases of London, p. 131,) of purpura ever, and mode of coagulation have been carefully

Edin. Med. Journ. v. 8. In a case related by Bateoccurring in a stout farmer, with a sharp and frequent pulse, the blood also exhibited a firm buffy coat.

The chief morbid appearances which have been noticed in the three great cavities have been the following:

observed to be florid and semi-transparent, resemble number of histories, recorded with various bling diluted arterial blood. It slowly formed a degrees of minuteness.* loose coagulum, from which no serum was separated; the coagulum was like jelly, tremulous, transparent, and colourless, the few red globules having subsided to the bottom. In this case much blood had been previously lost by hemorrhage. (Ibid. xviii. 405.) In Dr. Combe's case the blood was pale, coagulated slowly, separated no serum, and was not buffed. (Ibid. xvii. 83.) In Dr. Gairdner's the blood first drawn by the lancet seemed, four hours after, to coagulate very imperfectly into a homogeneous mass, On the following day it resembled a tremulous jelly, the top of which was of a greenish buff colour with brownish spots like tadpoles. What afterwards oozed from the puncture resembled turbid lymph, or a watery fluid containing colouring matter in suspension; the cloths taken from the arm appeared as if stained with bloody water. (Edin. Medico-Chir. Transactions, i. 671.) In Dr. Fairbairn's case the blood first drawn resembled that described by Dr. Duncan and Dr. Combe; on a second bleeding it presented the same appear-morrhagica, besides the impression of petechial ances; but on the third it showed the buffy coat, coagulated somewhat more firmly, and separated a portion of serum. (Ibid. ii. 671.)

[These facts do not accord with the recent views of Andral, (Hématologie Pathologique, Paris, 1843, or translation by Drs. J. F. Meigs and A. Stillé, Philad. 1844,) that the fibrinous element of the blood is probably depressed beneath its normal proportion in every case of purpura hæmorrhagica.]

The state of the urine has been less attentively noticed, or at least less frequently. We possess, however, the accounts of two cases in which the urine has been analyzed. At the conclusion of Dr. Combe's case, which we have just referred to, the results of the analysis of the urine are stated, at the height, during the decline, and after the cessation of the disease. At the height of the disease, and previous to venesection, the urine was found to contain a large proportion of serosity and of the phosphates, no free acid, and but a small proportion of urea. When the force of the disease had been broken, and the hemorrhage had ceased, there was no longer any albuminous matter, but a free acid, and but a small proportion of urea. Finally, when the patient was convalescent, the analysis of the urine detected no ingredients differing from its healthy condition. In Dr. Gairdner's case, also above referred to, the urine, on analysis by Mr. Murray, showed a deficiency of urea and an excess of albuminous matter. For the chemical details we must refer to the original cases. In Dr. Blackall's work on Dropsy, several cases are related "resembling land-scurvy," two of which, at least, are clearly cases of the hemorrhagic purpura, in which the attack was sudden and attended with febrile symptoms. In both these cases the urine was albuminous, and Dr. B. states his opinion that "venesection would have been their appropriate remedy; in the early stage, probably a successful one."

6. The appearances which are exhibited by the skin on examination after death have already been noticed. Of the morbid alterations discovered in the internal organs we possess a tolera

In the head. In a case transcribed by Rayer (Obs. 174,) from Stoll, the meninges of the brain, especially on the left side, were spotted with seve ral large ecchymotic macule; some ecchymoses, resembling clots of extravasated blood, from the size of a lentil to that of a bean, were also found in the convolutions of the brain. The surface of the ventricles, and that of the cerebellum, were covered with innumerable small petechiæ; the left ventricle was distended with straw-coloured serum. The girl who was the subject of this case had died comatose, having previously suf fered severely from headach (which chiefly affected the left side); she had high fever, petechiæ, and hemorrhage from the mouth. In Dr. Walsh's case (Edin. Med. Journ. vol. ix.) of a soldier previously in good health, who died apoplectic on the fourth day from the supervention of purpura he

spots on the pericranium, and an ecchymosis of the right temporal muscle, a considerable coagulum (a table-spoonful) was found pressing on the brain, and the vessels of the pia mater were turgid with black blood. In Mr. Wood's case (Edin. Medico-Chir. Trans. vol. i.,) the pericranium and dura mater were covered with petechial spots, and "in the right temporal region a fine coagulum, floating in bloody serum, had forced its way through the broken-down brain into the ventricle.” Similar effusions of blood on the brain were ob served in two cases by Dr. Watson. (Med. Gazette, x. 502.)

In the chest the following appearances are no ticed by Rayer as characteristic of this disease. " The outer surface of the lungs is commonly speckled with numerous ecchymoses, which are the more distinctly visible, that the surface of the lung in the intervals retains its natural hue. Beneath each of these ecchymotic spots the tissue of the lung is of a uniform brownish-red colour, is firmer in its texture than the surrounding healthy lung, and presents a circumscribed engorgement, from which, on pressure, black blood is squeezed out-a morbid alteration quite analogous to the hemoptysical engorgements described by Laennec." Similar petechial spots are also found on the surface of the heart, on the pleura, &c. The other morbid changes noticed in the thorax are not so characteristic, being common to other diseases. Such are the effusions of serous or sero-sanguineous fluid very commonly found in the cavities of the pleuræ or pericardium, or in the cellular tissue of the lungs. In one case (Dr. Johnston's) the heart is stated to have been smail, pale, and easily lacerable. In some cases it has contained fluid blood, or pink-coloured gelatinous coagula in some of its cavities. The pericardium, in one case, and the inner membrane of the aorta

*Raymann, Acta Nat. Cur. apud Adair, diss. inang. p. 14. Edinburgh Med. Journal, vi. 374. Ibid. ix. 164. Ibid. xiii. 402. Ibid. xiii. 405. Ibid. xxvii. 71. Edsburgh Medico-Chir. Trans. i. 681. Ibid, ii, 161. Malad. de la Peau, tome ii. observ. 171, 172, 173, 174, 175. Cases 173 and 174 are transcribed from Stoll, Rat Medendi.

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