400 THE HEMORRHAGIC DIATHESES 



ever, hemorrhages have occurred, more or less extensive ulcerations of the cap- 

 sule of the joint, hemorrhagic effusions between the bones and the cartilage, 

 and hemorrhagic softening of the epiphyses are noted. Corresponding to the 

 clinical symptoms, we find between the periosteum and bones effusions of blood 

 in different stages of coagulation or decomposition, ulceration of the periosteum, 

 wasting and even suppuration of the cartilage of the joint, and necrotic changes 

 in the bones. Sometimes the insertions of the muscles are loosened by these. 

 In the interior of the bone also, particularly in the. spongiosa, hemorrhagic 

 effusions take place. 



In the bone-marrow lymphoid transformation has not infrequently been 

 observed. 



In infantile scurvy an epiphyseal separation is occasionally observed, and 

 in about 45 per cent, of the cases rickets also is present. 



Very important changes occur in the digestive tract. The mucous mem- 

 brane of the mouth, except that of the gums, is but slightly altered ; now and 

 then hemorrhagic areas and erosions are noted. The gums are invariably 

 swollen, moderately reddened, and completely permeated by red blood-corpus- 

 cles. In older cases there is a coarse thickening as the result of proliferation 

 of the connective tissue. Frequently the surface is ulcerated or necrotic. 

 Babes differentiates microscopically five layers in a sequence from without 

 inward which he describes as follows: 1. The upper -layer for the most part 

 is denuded of epithelium, moderately thick, pale, resembling a diphtheritic 

 membrane, and permeated with but few nuclear fragments and by various 

 bacteria, particularly streptococci; 2. A layer about 0.1 mm. in thickness, 

 without structure ; upon staining with Loffler blue it is seen as a film of bent, 

 extraordinarily fine bacilli, often showing long wavy forms which may reach 

 the deeper tissues and the superficial layer in the form of sheaves or lines, 

 and in the latter form they permit the recognition of granular decomposition; 

 3. Mononuclear and polynuclear round cells; 4. Mucous membrane tissue with 

 edematous swelling, and a granular exudate with numerous bacilli of the 

 variety described under 2. In the walls of the vessels and in their surround- 

 ings swollen spindle cells with reticulated protoplasm which may be well 

 stained by methylene-blue ; 5. Markedly dilated larger vessels with large spindle 

 cells in their walls. 



Upon the gastric and intestinal mucous membranes infiltrations of blood 

 are frequently found ; also ulcerative losses of substance, besides necrotic and 

 diphtheritic changes. In those cases which run their course with bloody diar- 

 rhea, special pathological processes are found in the colon. The mucous mem- 

 brane is swollen, friable, and covered with a hemorrhagic mass which may be 

 readily peeled off. The tissue lying beneath is softened or completely decom- 

 posed. 



Cases are also noted in which the follicles show pathological changes, and 

 in which the alterations have been limited to these. They are frequently ulcer- 

 ated, surrounded by dense hemorrhagic infiltration. 



In the large glandular organs of the abdomen, the liver and the pancreas, 

 no special changes are found except hemorrhages and fatty degeneration. The 

 spleen is usually enlarged, soft, even fluctuating, and occasionally exhibits 



