426 THE HEMORRHAGIC DIATHESES 



tion and without tendency to hemorrhages. A far more decided hereditary 

 taint was noted in the nervous system; the father was a person easily upset 

 by the slightest psychical irritation, e. g., if he were going upon a journey, 

 vomiting and marked agoraphobia would occur. He died of heart disease. 

 One sister of the father suffered from hysterical spasms, and another was 

 very "nervous." Among the children, one daughter cannot walk upon the 

 street without an attendant, and the patient in question suffers from cardiac 

 palpitation and an ill-defined feeling of fear unless accompanied by her 

 brothers and sisters. In this patient's twelfth year the first marked hemor- 

 rhage occurred after the extraction of a tooth; a few months later menstru- 

 ation began, at first quite regular and not especially profuse. A year later, 

 after exertion in walking, upon the fourth day of the period, the first prolonged 

 metrorrhagia occurred, with syncope, palpitation of the heart, nervous attacks 

 of fear aud excitement; the menses now became irregular, very profuse and 

 prolonged. During her attendance at school attacks of epistaxis were first 

 noted, and these were repeatedly followed by spasms. In the year 1869 the 

 patient was bedridden almost the entire summer, using iron waters, whey and 

 baths. She was in bed most of the time in 1870 on account of frequent 

 epistaxis and severe uterine hemorrhages; for the first time marked ederda 

 of the feet was present. Toward the end of the year epistaxis was again 

 severe. In 1872 there were frequent attacks of epistaxis, but injections of 

 ergotin checked the hemorrhages for from six to eight weeks. In the next 

 year, after a trifling wound of the finger, hemorrhages occurred, lasting for 

 several weeks. Uterine bleeding was almost continuous. Ergotin was of no 

 avail. In 1874 hemorrhage occurred after the extraction of a molar. Two 

 years later, following a very severe attack of dysentery with hematemesis and 

 enterorrhagia such a severe epistaxis occurred that it was necessary to keep 

 a tampon continuously in the nose. Later, bleeding from the nose lasted 

 several hours. Galvanization of the sympathetic, combined with ergotin treat- 

 ment, temporarily improved the general condition. In the year 1881, for the 

 first time, large purpuric spots with decided, painful swelling appeared upon 

 the left upper arm. Menstruation lasted uninterruptedly from Kovember of 

 the same year until February, 1882. Vaginal tampons were continuously 

 necessary. In March, 1882, for the first time, and then very frequently, there 

 was hemorrhage from the uninjured tip of the finger. During January of 

 the next year several intact fingers and the nose bled daily. Subcutaneous 

 hemorrhages followed, the blood in large areas of the right thigh and of the 

 left upper arm finding its way through the skin. In 1884 there was profuse 

 diarrhea, with frequent vomiting accompanied by massive hemorrhages, and 

 prolonged elevation of temperature which lasted for months. The urine be- 

 came exceedingly scant, one-eighth to a quarter of a liter in twenty-four hours ; 

 it was pale, free from albumin, of very low specific gravity (1.002 to 1.005. 

 The average loss of blood in twenty-four hours amounted to one pound (358 

 grams). Galvanic baths decreased the number of hemorrhages. Improvement 

 was brought about exclusively by treatment based upon the decreased amount 

 of urine and an energetic diaphoresis was persistently carried out for over three 

 years; injections of pilocarpin which for a time were substituted by packs 



