484 THE HEMORRHAGIC DIATHESES 



March 24:th, nine o'clock in the morning. But little change in the clin- 

 ical picture. Complete insensibility. Temperature 106.9° P. Upon the skin 

 many new hemorrhages have appeared. To retain the picture of the skin, I 

 asked the artist, E. Eyrich, to paint a -water-color of the case. He began upon 

 the morning of the 24th at a time in which the hemorrhages were so close 

 together that the individual flakes upon the arms, which he had already indi- 

 cated in contour, assumed an entirely different size and configuration from 

 those I had previously seen. While he was working on his picture the indi- 

 vidual flakes coalesced and enlarged. As this condition appeared extremely 

 strange to Mr. Eyrich, he sent for me in order that I might note the coales- 

 cence and enlargement of the individual areas. What, however, lent a pecul- 

 iar character to these hemorrhages was the circumstance that the larger ones 

 were grouped in concentric circles, and that each of these circles showed an 

 entirely different color tint. This peculiar arrangement was caused by the 

 striking rapidity with which the individual areas developed and enlarged. The 

 older center appeared much darker than the fresher peripheral hemorrhage; 

 I myself observed this change in different areas. Thus, areas developed in 

 concentric arrangement which consisted of three to four rings of different col- 

 ors. The development of these hemorrhages occurred with such enormous 

 rapidity that the change in color from the brightest red to the darkest brown- 

 ish red could be noted in the course of a few hours. 



Evening, eight o'clocTc. Patient in collapse. The investigation of the eye- 

 grounds shows in the right a small centrally situated retinal hemorrhage, and 

 in the left two more. 



12.30 A.M. Death. The temperature taken post mortem showed a rise 

 to 108.8° P. 



The result of the autopsy was very unsatisfactory. The changes worthy of 

 mention were the following : 



Cloudy swelling of the liver, spleen and kidneys. White striae of the 

 medullary substance of the kidneys. Very slight deposits of the finest ex^ 

 crescences upon the free border of the mitral leaflet. Multiple hemorrhages 

 in all serous membranes. 



The microscopic investigation of the skin gave an entirely negative result; 

 there were neither vascular emboli nor microorganisms inside the vessels.. 

 Enormous masses of streptococci were found in the glomeruli and in the inter- 

 tubular capillaries of the kidneys as well as in the deposits upon the mitral 

 valve. 



That the diagnosis in such a case is not a very simple one, and that 

 great diagnostic errors are liable to occur, is taught by a case of hemor- 

 rhagic variola in which the clinical symptoms closely resembled those of 

 the case just described, and only late in the course of the disease several dis- 

 tinct umbilicated pustules appeared which in a brief time broke down, leaving 

 ugly ulcers. •■ 



The diagnosis of hemorrhagic smallpox, if the latter runs its course without 

 pustule formation, and appears during a period in which other cases of small- 

 pox have not occurred, may give rise to great difficulties on account of the sim- 

 ilarity to the clinical picture of purpura fulminans. In the course of severe 



