466 THE HEMORRHAGIC DIATHESES 



Despite the report that by anatomical investigations vascular changes have 

 been found in the ecchymoses of neighboring capillaries as well as in the 

 smallest arterial and venous vessels, in my opinion no clinician will admit 

 these to be a constant etiologic factor in purpura. In order to reject absolutely 

 the theory that the described vascular changes are the cause of such processes, 

 one must have witnessed how the normal skin of the entire body may be 

 covered by hemorrhages in the course of a few hours, so that the entire surface 

 appears spotted like the skin of a tiger or a leopard. I refer here to the 

 illustration I gave in ISTothnagel's " Special Pathology and Therapy," Part III, 

 vol. viii. Such a possibility must be constantly borne in mind. We shall 

 discard absolutely the assumption of a vascular disease distributed over the 

 entire cutaneous surface, if we consider the appearance and disappearance of 

 the affection in the briefest time, the recurrence and repeated recurrence after 

 varying intervals, and the final complete recovery from the disease. That the 

 vessels in the hyperemic areas present the phenomenon of stasis is self-evident; 

 the exit of blood per diapedesin is itself the final and most extreme phenomenon 

 and expression of each extensive stasis. But a purpura hemorrhagica widely 

 distributed over the entire body, appearing acutely, and sometimes involving 

 the mucous membranes and the serous membranes, can never be due to a 

 hyaline vascular degeneration. How could this arise so suddenly and disappear 

 so rapidly? I admit the vascular degeneration as a cause in certain cases 

 running a severe and fatal course, particularly the forms which run a chronic 

 course, in which the cutaneous hemorrhages represent one of the secondary 

 symptoms of the disease, as, for instance, in senile marasmus, peliosis cachec- 

 ticorum or in pulmonary tuberculosis. But the mild cases (ordinary purpura) 

 which run a more or less rapid course, repeatedly appearing and disappearing 

 again, certainly do not depend upon stasis and hyaline vascular degeneration 

 but on internal causes entirely unknown to us at the present time. 



The many microscopic investigations which I have made in cutaneous 

 hemorrhages in all forms of the hemorrhagic diathesis, and particularly my 

 numerous investigations of the blood-vessels of the eye (the optic nerve, the 

 choroid and the retina) in pernicious anemia, leukemia, scurvy, diabetes and 

 sepsis, I must admit have given results which are by no means satisfactory. 

 In many hemorrhages of the retina in these diseases, in spite of the most 

 minute and careful examination of numerous sections so thin that they per- 

 mitted the use of an immersion lens, I have not succeeded in detecting vascu- 

 lar changes in -the arterioles or capillaries supplying them. The conducting 

 vessel was quite intact, and each blood-corpuscle contained in it, as well as 

 the nuclei of the walls, and the patent lumen, could be distinctly recognized 

 almost up to the bleeding point, where frequently a diehotomous division 

 occurred. The two branches given off could be seen for a short distance and 

 were quite intact until they disappeared in the hemorrhage. The eye of the 

 investigator, no matter how practised, is unable to see in the midst of the hem- 

 orrhage which completely covers the arteriole or capillary what has become 

 of the vessel, and especially whether the hemorrhage has occurred per diape^ 

 desin or per rhexin. Hence I must absolutely reject this theory, and can only 

 compliment those observers who were able to demonstrate a vascular change 



