468 THE HEMORRHAGIC DIATHESES 



in one attack or to extend through several relapses. In isolated cases the 

 duration of the attack may be many months or even years. 



Chilling or wetting of the body, damp dwellings and insufficient food are 

 cited as causes, but without sufficient reason. Since unfavorable circumstances 

 of life and unhygienic surroundings reduce the bodily resistance and increase 

 the predisposition to all diseases, this is naturally the case also in the hemor- 

 rhagic diathesis. We see poorly nourished individuals with poor constitutions 

 forming by far the great contingent of sufferers from this disease, but we also 

 find the disease in millionaires who live in luxurious palaces, and who can 

 command all the advantages of life and the best of care. 



The aifection always occurs sporadically and as an isolated disease, never, 

 as in the case of scurvy with which it is often confused, showing an endemic 

 or epidemic distribution. 



In isolated cases intoxication with marsh gas has been reported, but prob- 

 ably this is erroneous. On the other hand, it appears to be absolutely proven 

 that in convalescents from enteric fever and malaria, or after these diseases 

 have run a prolonged course, purpura sometimes follows. I have also observed 

 purpura as a sequel of scarlatina and measles, as well as in the late course 

 of diabetes mellitus and in pulmonary phthisis. Bright's disease also belongs 

 to those affections in the course of which cutaneous hemorrhages occasionally 

 occur. Evidently the conditions are here somewhat more complicated. I 

 should like to refer to Mathieu's view that the purpura which is seen quite 

 .frequently in Bright's disease is of vital importance, and develops under the 

 same conditions as uremia. We must recognize the absolute untenability of 

 this assumption. Purpura arises in all forms of nephritis, but especially in 

 interstitial nephritis; during the course of the latter it often recurs (a few 

 spots or a great many), and again disappears without being of decisive 

 importance in prognosis. 



I shall revert later to the views of Bamberger, a very careful observer, but 

 here I may mention my own opinion based upon numerous observations. Pur- 

 pura and renal affections appear to me to bear double and varying relation- 

 ship. The evidence of this is the fact that after long continued, frequently 

 relapsing purpura, we often observe albuminuria (usually not exceeding 0.1 

 per cent.) with or without a very scant number of casts. After a shorter 

 or longer duration these signs gradually disappear without developing into 

 chronic nephritis. In a second group of cases the relation is unquestionably 

 the opposite, inasmuch as with a contracted kidney, repeated attacks of sim- 

 ple or hemorrhagic purpura occur. But in such cases the prognosis does not 

 assume a more serious character. 



Dohrn once observed a child born of a woman suffering from purpura, the 

 child also being attacked by the disease. If this was not really a case of 

 hemorrhagic diathesis as a result of septic infection, the conclusion is justified 

 that the vascular system (blood and vessels) of mother and child suffered from 

 the same deleterious influences. 



In conclusion, we must mention that in individual cases as an immediate 

 consequence of severe nervous shock, pain, fright and fear,, severe cases of 

 purpura arise. In this connection I shall mention the case of Lebreton, who 



