MORBUS MACULOSUS WERLHOFII 483 



proboscis. This prominence is due to a deep hemorrhagic suffusion of the 

 mucous membrane beginning at the border of the lip, almost 3 c.c. in breadth, 

 and reaching posteriorly almost to the gums. The mucous membrane in 

 this area appears eroded and covered with thick crusts, upon the removal 

 of which the base of a superficial ulcer of bad color is seen. The mucous 

 membrane around the border of the ulcer is in the form of rolled-up 

 shreds. The gums are bluish red, swollen, in part hemorrhagically infiltrated. 

 The lips are covered with sordes, and from between them a blood-stained 

 mucus exudes. Under the conjunctivae of both eyes there are circular fiat- 

 tened hemorrhages. The skin is smooth and dry. The color is chiefly 

 yellowish, but is modified by a great number of pale to dark violet, 

 irregularly shaped hemorrhages, which appear partly as small spots and 

 partly as flat extravasations. In some areas these flakes disappear on pres- 

 sure; at most points, however, they persist. Aside from these spots the 

 skin, on account of stasis and uneven filling of the vessels, assumes a mar- 

 bled appearance. 



Upon the lower extremities quite large suffusions are found which attain 

 an area of several square inches, and also hemorrhages which almost give the 

 impression of being of traumatic origin. Upon the external surface of the 

 thigh they are quite symmetric; there is also a certain symmetry upon the 

 back. In the joints of the feet, and upon the dorsum of each foot, there are 

 extensive suffusions, reddish blue in color, almost the size of a silver dollar. 

 Upon the right lower leg, and upon the dorsum of the left foot there are also 

 large suffusions besides ulcers covered with crusts. The sensorium shows 

 coma; there is no reaction upon deep pricks with a pin. The apex of the 

 heart cannot be felt; cardiac dulness is not increased; heart sounds clear. 

 Lungs normal. Spleen moderately enlarged, reaching 3 cm. beyond the ante- 

 rior axillary line. In the eye-ground the arteries and veins are dilated, the 

 papillary limits obliterated. N"o retinal hemorrhages. Temperature reaches 

 106.9° P. 



Evening, eight o'clocTc. Patient is comatose with closed eyes, moaning, and 

 assumes the dorsal decubitus. Eespiration increased (32 per minute) and 

 stertorous. Patient very restless. The muscles markedly contracted. There 

 is anesthesia of both cornea. 



Half-past eleven at night. Complete unconsciousness. Marked prostra- 

 tion. The face is covered with sweat and feels cool, whereas elsewhere the 

 skin is dry and burning hot. Temperature 107.6° F. Upon the left thigh, 

 situated externally, a single hluish red suggillation the size of two hands, which 

 has resulted from the confluence of a number of smaller foci. When I saw the 

 patient three hours earlier, about eight o'clock, the individual points of the 

 eruption were still separated by large intervening areas of healthy skin. Since 

 eight o'clock, several fresh, bright red hemorrhages have appeared, among 

 them one the size of a silver dollar. Eespiration greatly increased, loud, 

 snoring in character; the pulse very small and soft, 120 per minute. Paresis 

 upon the right side affecting the face and extremities. Ptosis of the right 

 eyelid. In the eye-ground nothing abnormal. Sedes inscice. Urine acid, 

 contains much albumin and numerous broad casts. 



