MORBUS MACULOSUS WERLHOFII 467 



in " every " case. At this point, I wish to refer to my later investigations 

 of the vascular changes in the retinitis of Bright's disease, which are soon 

 to be published. 



The conditions are not very dissimilar in hemorrhage, occurring as the 

 result of general septic disease, although they really do not belong to the same 

 category. There is no doubt that in cases of sepsis and malignant endocarditis, 

 m the midst of cutaneous hemorrhages, occasionally a white center is seen 

 which is analogous to the same processes in the retina. Although I have 

 sometimes succeeded in recognizing these white centers as small infarcted 

 blood-vessels filled with micrococci, this finding is not constant, and cannot 

 be proved to be a process which occurs during life; under no circumstances 

 can conclusions be drawn from this to explain the multiple cutaneous hemor- 

 rhages in the various forms of purpura. 



How far an infection may be assumed to cause the disease in these latter 

 cases must remain an open question until it is proven whether, and to what 

 extent, the bacillus purpuras or some other pathogenic microbe is a constant 

 finding in the blood of patients suffering from morbus maculosus. If later 

 investigations should substantiate this, the view would also be permissible 

 that the toxins or ptomains circulating in the blood lead to an extensive stasis 

 formation in the capillaries and small veins, or that they directly alter the 

 blood, thus causing occlusion of the capillaries, or, finally, that they affect 

 the vascular walls in their structure or in the functions of their muscular 

 and nervous apparatus so that, for example, a stasis as the result of paralytic 

 dilatation of the smallest vessels might take place. 



That the severest cases of this disease, designated as purpura fulminans, 

 terminating fatally in the briefest time, are of an infectious character, and are 

 probably due to the entrance of pathogenic microorganisms which have a very 

 deleterious effect, I believe to be true beyond doubt, although, unfortunately, 

 this has not as yet been proven. 



As a rule the disease is not frequent ; females, according to reports, appear 

 to be somewhat more predisposed than males. An age limit does not exist, 

 but at middle life attacks appear to be most numerous. The aged and nurs- 

 lings are very rarely affected. Nevertheless, the report that prior to the fifth 

 year of life scarcely any cases occur is incorrect. I have certainly seen quite 

 a number of cases which occurred between infancy and the fifth or sixth year. 

 These cases were either pure " purpura simplex " or " purpura hemorrhagica," 

 or such forms as are complicated with disease of the joints (peliosis rheu- 

 matica), or, lastly, forms in which not only cutaneous hemorrhage but intes- 

 tinal symptoms, particularly vomiting, intestinal colic, and watery or hemor- 

 rhagic diarrhea, are prominent. In quite a large number of cases which 

 occurred in rachitic children in the second, third and fourth years of life 

 the only symptom was attacks of cutaneous hemorrhage, and after repeated 

 relapses these children made a complete recovery. Here also the female sex 

 was in the majority. 



Immediate causes can be determined only in the rarest cases. The disease 

 seems to appear " spontaneously and primarily," and either to exhaust itself 



