MORBUS MACULOSUS WERLHOFII 459 



tions, is identical with purpura, so that the latter has been designated as the 

 milder and more acute form of scurvy. This view, as we have shown, is 

 incorrect, even though there is occasionally a mild affection of the gums in 

 Werlhof's disease. Often the symptoms of purpura hemorrhagica appear dur- 

 ing convalescence from severe infectious diseases, particularly after enteric 

 fever and malaria. 



In rachitic children, as well as during pregnancy and in labor, the affection 

 has- also been noted. Isolated reports have been given of toxic forms of pur- 

 pura. The affection has also been observed after the inhalation of poisonous 



In the ecchymoses which are distributed so numerously over the entire 

 body it is often possible to demonstrate, in the substance which occludes the 

 capillary vessel, the cause of the entire affection. In the multiple capillary 

 hemorrhages of septic affections, which show to the naked eye white centers 

 in the midst of the effused blood, occlusion of the capillaries and capillary 

 veins with emboli of micrococci may frequently be determined. So in hemor- 

 rhagic smallpox bacteria are found in the hemorrhagic and purulent foci 

 of the external skin and in the internal organs, the spleen, kidneys and lungs. 

 In the retinal hemorrhages of metastatic ophthalmia, I was also able to find 

 masses of bacteria in the occluded vessel, centrally or removed from the foci, 

 whereas in other cases which were evidently of septic nature, this proof could 

 not be demonstrated. This attempt to find thrombi in the vessels has failed 

 entirely in many cases of hemorrhagic exanthems. In many other diseases 

 and intoxications the most important clinical symptoms of which consist of 

 hemorrhagic conditions (cholera, plague, yellow fever, anthrax, poisoning from 

 snake-bite, petechial typhus, etc.) occlusion of the capillaries in the sur- 

 roundings or in the center of the ecchymoses have not been manifest, and we 

 have been forced to the conclusion that zymotic substances, ferment bodies, 

 ptomains or toxins produce the hemorrhagic diathesis. 



How this occurs, whether they alter the blood directly and thus cause occlu- 

 sion of the capillaries, or whether they affect the walls of the vessels in their 

 structure, or in their functions as muscular and nervous apparatus, we do not 

 know. 



Whether in morbus maculosus, that is, purpura hemorrhagica, microorgan- 

 isms or their toxins circulate in the blood, exerting a deleterious effect upon 

 it or upon the membranes of the vessel, and lead to the multiple ecchymoses 

 which are typical of this disease, has not been ascertained with certainty, 

 although such a view is likely. The facts at hand are not generally accepted. 



Few authors have found well-characterized microorganisms as the cause 

 of purpura. Ajello, who in a case of purpura demonstrated methemoglobin in 

 the spectrum of the blood, assumes that purpura hemorrhagica may arise by 

 autointoxication from the intestinal tract as the result of absorbed products 

 of proteid decomposition; Schwab also believes an action of toxins to be the 

 cause of this disease. In other forms of purpura which arise in connection 

 with infectious diseases, the blood has been examined for bacteria, only in 

 part with a positive result. Earlier authors, such as Batemann and Grisolle, 

 have looked upon certain forms of purpura as infectious and contagious ; and. 



