leeches should be applied to the abdomen, followed by warm fomentations or the application of a warm emollient cataplasm, and internally, small doses of a combination of calomel, ipecacuanha, and extract of hyoscyamus, and an occasional dose of castor oil may be given. If, at the same time, there exist much heat and dryness of the surface, some gentle diaphoretic will be proper, with frequent tepid sponging. viij.

R.-Acetat. ammoniæ,

Aq. camphoræ, Zij.
Vin. ipecacuanhæ, 3j.
Tinct. hyoscyami, 3j.

Syrup. limonis, 3ij.-M.

Dose, a teaspoonful every three hours, for a child two years old..

On the formation of vesications, the warm bath and fomentations of an infusion of chamomile, with the sulphate of quinia internally, in conjunction with the mineral acids, if the state of the bowels will permit of their use, should be administered. If the vesications are very large, they should be punctured, and the ulcerated surface which subsequently forms, washed with a very weak solution of the nitrate of silver at the same time the patient should be put upon a mild, but nourishing diet.

In the gangrenous or phagedenic form of the disease, an ointment prepared from the great fig-wort (Scrofularia nodosa) has, we are assured by Maunsell, been found particularly successful in causing the ulcers to assume a healthy condition, and cicatrize. This remedy was introduced by Dr. Stokes, the elder, of Dublin, who found it in popular use among the Irish peasantry. He at first applied a carrot poultice or one of porter and oatmeal, which was kept on for about eight hours. When removed, the ulcerated surface being gently wiped with lint, the ointment of scrofularia, previously melted, was spread over it carefully, by means of a soft feather. The ulcer was then dressed with the ointment, to which an eighth part of wax had been added, the dressing being repeated, in severe cases, every fourth or sixth hour. Dr. Stokes also directed the internal use of yeast, which he believed to be of service.

In a comparatively chronic form of pemphigus, Dr. Maunsell states that the employment of iodine has been found to be attended with the most decided benefit.

18.-Purpura.

Purpura consists in a subcuticular extravasation of blood, occurring without external violence, and not disappearing upon pressure. It is sometimes accompanied with hemorrhage from one or other of the internal organs.

Where the extravasation takes place, the appearance of the skin differs in different cases. It may be covered with minute red, or violetcolored spots (petechia), or with patches of a ruddy violet color, often livid, and sometimes quite black. They are generally of a deeper hue in the centre than at the circumference, and vary in diameter from a few lines to several inches (ecchymoses). Both forms of extra

vasation are very generally observed in all cases of purpura. In some they occur without being preceded by any marked disturbance of health, though usually there is for some days previous to their appearance a state of considerable lassitude, dejection, and fretfulness, with indications of general debility. Purpura is unattended throughout with any degree of febrile excitement (P. simplex).

The subcuticular extravasation may consist entirely of petechiæ, having some resemblance to flea-bites, but not quite so large, unsurrounded by an areola of inflammation, and uneffaceable upon pressure. The petechiae may be intermixed with ecchymoses-occasionally, but very rarely, only the latter are present. The petechia may occur upon particular regions, or they may be disseminated over nearly the whole surface of the body, at one and the same time, or by successive crops during several days-when in place of being all of the same hue, they will vary from a reddish-purple, or brown, to a clear or faint yellow. Petechiae occur principally upon the legs, but often upon the face also, when ecchymoses frequently appear upon the conjunctiva.

The extravasations constituting P. simplex are always unattended with local heat or pain, or any febrile excitement, and occasionally, without the least apparent disturbance of either of the principal functions of the system.

Soon after their formation, the petechiae undergo a change of color, passing from reddish-brown, through various intermediate shades, to yellow. Most commonly, the blood is entirely reabsorbed in twelve or fourteen days. Occasionally, as remarked by Rayer, the spots of extravasation form a slight eminence, of the size of a pin's head, caused by a minute drop of blood being effused immediately beneath the cuticle, which it raises. On the drying of the blood, a small dark crust appears.

When the petechiae are very numerous, they are sometimes, at particular parts of the surface, collected into irregular clusters. In a few rare cases, there is observed, interspersed among the petechiæ, a kind of marbling of a light violet color, like the eruption in rubeola nigra. Occasionally, there are but few or no petechiae, while ecchymoses, in considerable numbers, are disseminated over the body and limbs, particularly over the dorsal surface of the feet and hands, and the inner surface of the extremities. They resemble often the marks left by the strokes of a whip: Their color, which is of a dark or livid blue, fades very slowly. These ecchymoses are, in some cases, succeeded by an exfoliation of the cuticle, particularly when the latter has become detached by the quantity of sanguinolent serum effused beneath it. Sometimes the effusion is to so great an extent as to produce bullæ or phlyctenæ.

In certain cases the blood is effused into the subcutaneous and intermuscular tissues, and then the skin commonly presents a number of broad, slightly prominent spots, dark in the centre, and of a greenish-yellow towards the circumference; they are unattended with pain. Sometimes the backs of the hands are affected with a species of oedema.

The subcuticular extravasation is, in a few instances, preceded by

somewhat prominent, reddish, oval, or circular spots, accompanied by a smarting or tingling sensation, similar to, but not so decided as that of urticaria (P. urticans). These spots, at the end of two or three days, sink to a level with the surrounding skin, and acquire a darkred, or liver color; new spots at the same time making their appearance. They are sometimes intermixed with true petechiæ. P. urticans occurs most frequently upon the legs, which are often at the same time cedematous, or affected with a sensation of stiffness or heaviness. The eruption generally continues for a month, but may be of longer duration. In cases of P. simplex, immediately after the disappearance of the petechiae and ecchymoses, these have been known to return suddenly, in the course of a single night. This may be repeated several times at very short intervals, prolonging thus the duration of the disease to several months.

When P. simplex presents itself under the form of ecchymoses, it is generally a more serious disease than when it appears under the petechial form. The P. urticans is the least important of all the forms of the disease.

A much more serious form of purpura is that accompanied with hemorrhage. The body is often covered with livid spots, similar to those that follow bruises. Actual thrombus occasionally forms under the hairy scalp, and the blood has even been seen exuding from behind the ears, and from the vertex; the subcuticular and cutaneous effusion at the same time covering nearly the whole snrface.

In some patients the disposition to hemorrhage is so great that the mere act of feeling the pulse, the pressure of a loose ligature, or the weight of the body in sitting, leaning, or lying down, is sufficient to cause actual ecchymoses. The slightest puncture, the mere grazing of the skin, is followed by a copious and continued discharge of blood; and most commonly, either from the commencement, or in the course of the disease, hemorrhage occurs, to a greater or less extent, from the nose, bowels, stomach, or lungs (P. hæmorrhagica). In some of these cases, the fauces are of a dark-red color, and blood issues from every portion of the surface. P. hæmorrhagica is sometimes, according to Rayer, complicated with angina membranacea. Occasionally, the gums become livid and spongy, and blood exudes from their surface; the tongue swollen, livid, and blackish; while the inner surface of the cheeks presents some blackish and soft patches, with which the palate is also covered. On all these parts, irregular phlyctenæ, or bullæ appear, filled with dark-colored blood. When these burst, a discharge of blood takes place from the excoriated surface. Deeper ulceration sometimes occurs, with hemorrhage to a much greater extent. Children have been known to die in a single night, from the discharge of blood, in such cases.

When the hemorrhage is very considerable, or recurs frequently, the feet and legs become cedematous, the face blanched, and the surface of the body, generally, of a yellowish, or livid hue; the petechia and ecchymoses increase in number, and acquire a deep brown tint; the blood becomes more and more serous; the temperature of the body, but particularly of the extremities, sinks, the pulse becomes

small and feeble, and the strength of the patient completely prostrated. Convulsive movements, tremors of the whole body, or fainting fits, sometimes occur. The patient finally dies ex-sanguious, unless febrile symptoms, or serious internal disease, should ensue previously to death.

Purpura is occasionally, but very rarely, accompanied by febrile reaction (P. febrilis). The occurrence of petechiae and ecchymoses is then preceded by a sense of extreme lassitude and depression, and by shivering fits, of longer or shorter duration, succeeded by increased heat of the skin, pains in the back and limbs, headache, quickness of pulse, nausea, retching, or vomiting. The subcuticular extravasations appear between the third and sixth days, sometimes with hemorrhage from the mucous membranes, and at others, preceded by exanthematous spots, similar to those of urticaria febrilis. Febrile purpura may be attended with ecchymoses, and occasionally with hemorrhage from the nose, throat, stomach, intestines, &c. In other cases, the latter are unattended with the subcuticular extravasation.

Febrile purpura may present, from the commencement, very serious symptoms, and prove fatal in a few days, in consequence of sanguineous effusion in the lungs, or substance of the brain; or it may terminate in death more slowly, in consequence of the extent of the hemorrhage, or the gradual draining away of the blood.

The causes of purpura are extremely obscure. It is of much more frequent occurrence before than after the period of puberty, and attacks, as remarked by Willan, Graves, and others, most generally, such children as are exposed to the debilitating influence of an impure and confined, or cold and damp atmosphere; who are badly fed, or on improper food, and debarred from sufficient exercise. It is, nevertheless, not unfrequently met with in robust children, of full habits, and apparently in the enjoyment of perfect health. Some children appear to be peculiarly predisposed to its attacks, and this often happens in all the children of the same family, as we have repeatedly observed. It has been supposed, in some cases, to be hereditary. It occasionally occurs subsequent to smallpox, measles, and other acute affections.

To the production of purpura, it has been maintained by Mills, Parry, and Combe, that the presence of venous plethora is necessary. In many cases, it is very certain there exist strong evidences of an overloaded state of the portal system, with more or less derangement of the digestive organs; the bowels are often torpid, or in a state of constipation, and when evacuations are procured, these are often of a most vitiated character. Pain of the epigastrium, or hypochondria, or tenderness upon pressure, with swelling and tension of these parts, are also frequent symptoms of the hemorrhagic cases.

In mild cases of purpura simplex, all that will, in general, be necessary to effect a cure, is to properly regulate the diet and regimen; the use of the warm or tepid bath daily; the administration of a full dose of calomel, followed by castor oil or the citrate of magnesia. When the bowels have been fully evacuated, small doses of calomel, calcined magnesia, and ipecacuanha, in combination, should be given

three times a day; the patient being at the same time freely exposed to a fresh, pure, and mild atmosphere.

In the more severe cases of P. hemorrhagica and P. febrilis, the remedies must be adapted to the circumstances of each case. Where there exist evident indications of hyperæmia, or venous plethora; or much local pain or tenderness, with fulness and tension of the abdomen generally, or at the epigastrium, or hypochondria, a cautious abstraction of blood from the arm, or locally, by leeches, will occasionally be advisable. In young children, bleeding, however, is a remedy not generally adapted to this disease: When leeches are employed, we have often known them to give rise to a long-continued hemorrhage, by which a fatal result was caused, in cases, where, it is probable, had the leeches not been applied, the disease might have been cured; we have known also the loss of a few ounces of blood from the arm, to be followed by so great a degree of exhaustion, as to demand an immediate resort to stimulants, to prevent the death of the patient. Nevertheless, in children over ten years of age, the very best effects have resulted from the cautious abstraction of blood, in' the early stage of the disease, particularly by the lancet.

Our chief attention should in every case be directed to the condition of the bowels. Full doses of calomel, in combination with magnesia or jalap, and followed, in a few hours, by a mixture of castor oil and turpentine, will have the effect, very generally, of bringing away large quantities of vitiated secretions: of unloading the portal system, and exciting a more healthy action throughout the entire extent of the gastro-intestinal mucous membrane. By the continuance of the turpentine in tolerably large doses, with an occasional dose of calomel, we shall soon correct the character of the intestinal evacuations, and at the same time effect a cure of the disease. We have seen the most rapid change produced in all the more serious phenomena of purpura hæmorrhagica, and a striking amendment take place in the condition of the patient generally the moment that large evacuations are procured from the bowels of dark olive-green, and highly offensive

feces.

The drink of the patient may be acidulated with lemon juice; it should be given perfectly cold. The diet should be light and unirritating, and composed of articles of a nourishing kind.

When decided debility exists, the sulphate of quinia, the dilute mineral acids, and a nourishing diet, with, perhaps, in extreme cases, wine whey, or wine and water, or diluted malt liquors, will be demanded; attention being, at the same time, paid to the bowels: In such cases, the spirits of turpentine with castor oil will form the most efficient and appropriate purgative. Care must be taken, however, not to mistake mere oppression of the vital functions for debility, or to commence with tonics or stimulants too early in any case: When this is done, we have repeatedly seen the tonic treatment increase the number of petchiæ, augment the hemorrhage from the mucous membranes, and excite a violent febrile reaction, quickly followed by collapse and death.