406 THE HEMORRHAGIC DIATHESES 



some painful, some painless, some acute and accompanied by fever, some grad- 

 ual in onset and afebrile in course. 



Hemorrhages from the mucous membranes are decidedly less frequent, 

 but they may cause death or hasten death by inanition. We must mention 

 hemorrhages from the nose, hematemesis, enterorrhagia, hematuria, metror- 

 rhagia and hemoptysis. For a long time, severe epistaxis has been greatly 

 dreaded; it is, however, not very frequent, but can rarely be stopped without 

 packing, and sometimes causes death. These hemorrhages rarely occur spon- 

 taneously, but are usually the result of slight injuries to the nasal mucous 

 membrane; they may follow strenuous blowing of the nose. The fact that an 

 external cause is usually required to produce the hemorrhages which are so 

 characteristic of scurvy, Immermann believes will explain the circumstance 

 that the gums are usually the seat of these symptoms. He is of the opinion 

 that the stomatitis marginalis of scurvy is also secondary, inasmuch as the 

 gums, considering the delicacy of their histologic structure, are so frequently 

 and decidedly exposed to mechanical, chemical and thermic irritations — ^par- 

 ticularly as the development of the affection of the gums is always appar- 

 ently associated with the presence of teeth in the ]aw, and therefore with the 

 process of chewing. It may also be here emphasized that the gums are not 

 exclusively the seat of the disease, nor are they the first typical points, but 

 severe cases may run their course without an implication of the gums, and in 

 general the sequence of the individual symptoms and the number of the impli- 

 cated organs may be very variable. 



Hemorrhage from the mucous membranes of the stomach and intestines is 

 decidedly more rare than from the mucous membrane of the nose, and is prone 

 to occur when the bowel is stimulated to decided peristalsis ; as, for example, 

 after the administration of purgatives. Its development may, therefore, be 

 compared with epistaxis after violent blowing of the nose. In rare cases dys- 

 entery is simultaneously present. Hemoptysis occurs only occasionally owing 

 to a coexisting tuberculosis or a fibrinous pneumonia, the latter disease then 

 having its starting point in a hemorrhagic pulmonary infarct. 



Besides these hemorrhages which appear upon the surface, or from organs 

 with an external outlet, others may occur in the internal cavities, or there 

 may be bleeding even into the organs themselves. These represent a severe 

 form of the disease ; they cause extreme debility or may even be the immediate 

 cause of death. Among these we must mention first the pleural and peri- 

 cardial hemorrhages some of which may be looked upon as forms of non- 

 inflammatory hemothorax which occasionally leads to an inflammation of the 

 serosa, some as inflammatory hemorrhagic effusions which, by compression of 

 the lungs or paralysis of the heart, decidedly increase the danger to life. 

 That these effusions into the serous cavities (which may also occur in the 

 peritoneum) are susceptible of absorption is unquestionable. 



Meningeal hemorrhages have also been observed, and may be diagnosticated 

 by pain, paresthesia, spasms, contractures, paralyses, and apoplectiform attacks. 

 In some cases death occurs with the symptoms of apoplexy, but actual cases 

 of true cerebral hemorrhage appear to be extraordinarily rare. More frequent 

 are scorbutic changes in the eye. Hemorrhages and inflammation of the con- 



