402 THE HEMORRHAGIC DIATHESES 



as well as a great tendency to somnolence, the latter symptom, however, beir 

 by no means relieved by frequent slumber. 



Corresponding to 'the advancing symptoms of the disease, the externi 

 signs of the affection become noticeable. The expression of the face denot( 

 suffering, the lines are ilaccid, the freshness of the complexion gives way to 

 cyanotic pallor, the visible mucous membranes are of a livid color, the ey( 

 are dull, sunken in the orbits and are surrounded by rings. The skin of tl 

 body loses luster and smoothness, it becomes dry and fissured, and occasional] 

 desquamates as in pityriasis of the aged. Upon the skin brownish spots ai 

 observed, similar to the , bronze discoloration in Addison's disease. At ti 

 onset fever is usually absent. With loss in strength advancing emaciatio 

 goes hand in hand. To the same extent the pulse loses in tension and volum 

 and is slow, but becomes for the time full and frequent whenever the patiei 

 makes a comparatively slight bodily exertion. The subjective sensation c 

 palpitation of the heart is combined with this, without, however, either i 

 rest or after movement, any conspicuous change being revealed by physics 

 examination of the heart. 



The constitutional phenomena just mentioned, to a certain extent pre 

 dromes of the disease, may be entirely absent, and the patient be attacked sud 

 denly — without a prodromal stage — with the characteristic symptoms. Usu 

 ally, however, these symptoms precede by a considerable time, the perioi 

 varying between several days, usually from eight to fourteen, and, in exeep 

 tional cases, several weeks. 



The most conspicuous site for the characteristic symptoms of scurvy is th 

 gums, and we must emphasize that only those areas of the gums are attacke( 

 which correspond to points in the jaw in which the teeth are inserted ; so thai 

 for example, in children and in the aged, in those areas in which no teeth hav 

 appeared, or in those from which they have already fallen out, the gums shoi 

 no lesion. Where, however, through carious processes the teeth have partiall; 

 decayed, or where, after disappearance of the crown the alveoli still posses 

 roots, the disease preferably localizes itself. The anterior gums usually, anc 

 especially at the onset of the disease, are decidedly implicated, but not the res 

 of the mucous membrane of the mouth. At first the free border of the gums 

 particularly the bit which projects in the intermediate space between two teeth 

 begins to swell, rising above its surroundings, at the same time assuming f 

 deep bluish-red color. This color is not only the expression of an edematou 

 hyperemia but usually of a hemorrhagic infiltration as well, whereby it diSeri 

 distinctly from other forms of stomatitis. 



The affection of the gums rapidly advances, the swollen areas are fre 

 quently extremely painful, and a very characteristic symptom appears; mod 

 erate pressure, a mere touch, causes profuse hemorrhage. The longer tb 

 duration of the disease, and the more severe its form, the more extensive thi 

 affection of the gums. At the same time, the swelling becomes greater anc 

 greater, so that frequently nothing of the teeth can be seen. 



Simultaneously an intensely disagreeable odor of decomposition proceed; 

 from the mouth, and in the later course of the disease becomes quite unbear 

 able. The inflammatory swelling increases still further, deposits of a dirty 



