emphasis to tax his mind on this point and on a pad he wrote, "I have not bled a teaspoonful in thirteen years, and in that time have twice had this condition in my throat"-meaning quinsy. There was no history of malaria, rheumatism or gout. His habits were exemplary, and he had never used stimulants or tobacco. There was no history of scorbutus. After the cessation of hem

orrhage I began to nourish him by giving liquid food at two hours intervals. Iced milk was freely given during that night, and this varied with other food stuffs in liquid form, was continued until his death. The next day, March 14th, I began the tincture of chloride of iron, ten drops every three hours, with brandy one drachm every two hours. The temperature ranged from 98.6 to 100.2, the pulse from 96 to 112. At no time did examination of urine show casts. Albumen was present, due to presence of blood. Urine, normal in color, was voided in sufficient quantity. There was oozing of bloody saliva constantly from mouth. Digital examination showed the clot to occupy a portion of the auropharynx and lower naso-pharynx, and extending about two-thirds across the palatine arch. It was necessary to occasionally pass a bent probe with a swab of cotton through the open portion to allow of respiration and deglutition. As the patient had not slept for sometime, fearing exhaustion, I administered a hypodermic of morphia gr. 1-4, atropine, gr. 1-150. He rested quietly after this for about four hours. This brings us to 2:30 a. m. March 15th, when I noticed for the first time, bleeding from the left. side of the nose, bright arterial hemorrhage. I at once packed the nose tightly with iodoform gauze, and hemorrhage from this point was arrested, except a slight oozing through the gauze. It also became necessary to pack the right side

of the nose subsequently. The temperature during March the 15th ranged from 97.8 to 99.6, pulse 112 to 136, respiration 22. I began giving ergot in one drachm doses every four hours, and after three doses in one-half drachms every two hours. Dr. Wallace Johnson was at this time asked to remain with the case in my absence and a trained nurse was installed. The afternoon of March 15th, Dr. Taber Johnson met me in consultation and at his suggestion the infusion of digitalis was begun and continued at intervals of from two to three hours, in doses from two drachms to four drachms through the illness. Dr. Frank Baker was with us frequently in consultation. At 10:30 a. m. of March 15th, swallowing caused severe choking and a portion of the clot was carefully removed and relief ensued. This time my attention was drawn to the first purpuric spot, situated immediately above the orbital ridge of left side. These gradually made their appearance over the entire body, and at 6:30, the evening of March 15th, the first bloody urine was passed. The same treatment was continued during March 16th, and during the entire illness, except the introduction of dilute sulphuric acid, given in fifteen drop doses every two hours to control nausea, and fearing the possibility of malarial infection, thirty grains of quinia were given in suppository every twenty-four hours. Bleeding from the kidneys and bladder varied in amount, at times so profuse as to form large clots in the vessel. Hemorrhage from the kidney was shown by the presence of methæmoglobin in urine-by reddish brown color. Hemorrhage OCcurred from bowels as shown by tarry stools and clots. Bleeding from nasopharynx required the introduction of compress. This was accomplished with some difficulty, owing to the clot in throat. On March 16th a marked dila

The

swallow very well, and he had not eaten anything. The abscess was very large and almost entirely filled the pharynx: it was high up and easily reached. pus was green showing that it was old.. I made the smallest possible puncture with the pen knife, so that there was no possibility of severing an artery. What vessel could have been cut there? It must have been due to a slough. However, an impression went forth from that house (by what means I do not know) that I did cut an artery, and that death was due to that cause. I am indebted to Dr. Compton for the kind words he has spoken to-night.

In regard to this disease: I have seen quite a number of cases within the last five years, but I never saw a typical case until after we had the grippe. The first marked case that I saw was that of a gentleman who was sent to me by a spe cialist who examined his throat and found that there was a purpuric tendency there. He had one or two spots on the soft palate and one on the side of the tongue. When I saw him I found that he had spots on the breast and arms, which were quite small and of a hemorrhagic nature. I gave him a mercurial purge, followed by a saline, and had the stools and urine retained to see if there was any tendency to hemorrhage from the bowels or bladder. The next morning I found that there was no hemorrhage from these parts, but the throat was literally covered with spots, and there were spots also all over the body, as well as on the conjunctiva. There was a mild hemorrhage from the nose, and later there was hæmaturia. In this case I considered it the result of the grippe, and I put him on treatment which I had been giving for that disease. In a few days he was very much better, and in a week he was entirely relieved of the symptoms.

The other case was that of a child who was taken in the same way. There was constant bleeding from the gums and posterior nares. There were several purpuric spots on the body and tongue. I gave sulphuric acid in this case and he also got well. I saw one other case in consultation with Dr. Prentiss, which he thought was scurvy.

acter.

to

I want Dr. J. W. Chappell said: mention a case which came under my notice which evidently was of this charIt occurred in a baby a week or more old. After the cord dropped off there was a small ulceration left, which in a few days began to bleed. I applied alum and other styptics, but the bleeding kept on. Then I applied a plaster of Paris compress, which effectually stopped the bleeding at the navel, but shortly afterwards blood began to ooze through the skin of the external ear. I applied a plaster of Paris compress to this also, but the bleeding did not stop until the compress was thoroughly saturated with blood and the body had become very weak. I do not recall just now how long the little fellow lived, but after a short time there appeared purpuric spots which rapidly spread all over the body before death. I came the conclusion then that it was due to probable infection through the cord. Dr. Compton, in his paper, spoke of the differential diagnosis from scrobutus, but said nothing of hæmophilia. This disease I believe runs in families, but I could get no history of similar trouble from either branch of the family in this

case.

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Dr. J. Foster Scott said: I saw, last December, a very interesting case of purpura hemorrhagica. The case had been diagnosed as multiple sarcoma under the skin. When I saw the case the serum had evidently been absorbed and the pigmented appearance of the skin had disappeared. There was no sarcoma, and it soon was evident that she had purpura hemorrhagica. She passed enormous quantities of blood from the bowels, and hemorrhage spots appeared on her limbs and all over her body. to the treatment: lamb's ribs with the meat scraped off, and then chopped up fine and made somewhat similar to small sausages: patients thus get the marrow of the bone which is favorable to formation of new blood. As she was dying we tried hypodermoclysis or injections of normal salt solution, but without effect.

As

boy about ten years old who had a few spots over his body. He had a tooth extracted, and soon afterwards I was summoned because the bleeding could not be checked. I saw the same thing in an infant, who was born apparently healthy and remained so up to the fourth week. He was circumcised on the eighth day, but no hemorrhagic condition showed itself until he was four weeks old, when he accidentally scratched himself on the lip, causing an uncontrollable hemorrhage. Dr. Roberts, who was living at that time, was called in, and cauterized the wound, but it went from bad to worse. I was called in the next day and fastened a sponge over the wound, but without avail.

of my cases died. Up to now all the remedies suggested have done no good in aggravated cases.

Dr. Rupert Norton: In regard to what Dr. Scott has said about bone marrow, I wish to remind him that it has been used for the past two or three years in all varieties of blood diseases with little or no effect. So far as I know it possesses value only in chlorosis, where its effects seem to be due to the amount of iron in the marrow, for sometimes it does apparently improve patients with this disease. In pernicious anæmia it seems to have no effect at all. We know so little about the formation of the blood that we cannot be sure of any good results from the use of bone extracts. Thyroid extract is different, for the thyroid gland does secrete something which has a certain marked effect, but bone does not secrete any fluid, as far as

we now know. We know positively little or nothing as to where the red or white blood corpuscles are formed.

Dr. Compton said, in closing the discussion: Dr. Stone seems to have had remarkably good results in his treatment of this disease, but I think he must have been dealing with purpura simplex and not purpura hemorrhagica. Purpura simplex is, as its name implies, much less grave and much more amenable to treatment than the hemorrhagic form. All forms of purpura are hemorrhagic. I am sorry the gentlemen who have had cases of Werlhoff's disease have not noticed the bronze hue of the skin which was so marked in this case. It was well marked, and in looking up the records I found only one man-Letzerich-who makes any mention of it. Osler says

that as yet we have no drug which can be relied on in these cases. I believe this was a true case of Werlhoff's disease because of profusion of hemorrhage, which occurred in skin, from mucous surfaces, kidney, bladder and intestine. In purpura simplex the spots generally appear first on the lower extremities, but in this case they appeared first on the head and went downwards. They varied in size from a pin head to a thumb nail. Another peculiar feature was the typhoid condition which this case sssumed. He was in a state of coma vigil about three days, during which time, although he appeared to be unconscious, he was alive to everything going on about him. Those cases of marked success in treatment appear to be open to the suspicion of a mistaken diagnosis.

APPENDICITIS:

Private John Burke, battery "G", 4th artillery, 23 years old, enlisted at Harrisburg, Penn., January 21, 1896. Was admitted to sick report February 3, 1896, at three o'clock, p. m.; complaining of pain and tenderness in right iliac region; was put to bed and had hot fomentations to vicinity of pain. Temperature 99.8°. Temperature 99.8°.

Feb. 4th. Temperature 99° in the morning, normal in the evening. Given magnesia sulphate which operated readily and freely. Fomentations continued.

Feb. 5th. Temperature normal; fomentations continued; saline repeated. Feb. 6th. Temperature normal; admitted, what he had previously denied,