MORBUS MACULOSUS WERLHOFII 471 



peliosis, dysentery, all these would be considered, and formerly would unques- 

 tionably have been diagnosticated. 



Yet we know now, from careful investigations, that all of these symptoms, 

 apparently so different, may run side by side within the conception of a 

 severe purpura. 



Which qualifying adjective we attach to the purpura in this case — " rheu- 

 matica," " intestinalis," "hemorrhagica," or perhaps, on account of the im- 

 plication of the gums, " scorbutica " — is quite immaterial ; now one, now 

 another symptom-group may assume greater prominence among the phenom- 

 ena. As we shall see, however, all of the symptoms which have been men- 

 tioned may, and occasionally do, appear in purpura. 



The second case also is a characteristic example of the diagnostic difficulties 

 which may arise under some circumstances. Besides the extensive cutaneous 

 hemorrhages which were of paramount interest, there were repeated multiple 

 and painful joint swellings, appearing and disappearing suddenly, and re- 

 lapses which almost always occurred if the patient attempted to leave the 

 bed. Symptoms on the part of the digestive apparatus, colic, bilious and 

 hemorrhagic vomiting, and hemorrhagic diarrhea were also present. There 

 can be no doubt that the case was one of so-called purpura rheumatica. 



Cases with extensive cutaneous hemorrhages and multiple arthritic affec- 

 tions are often described in literature as " anomalous " articular rheumatism. 

 Occasionally these are combined with inflammation of the serous membranes, 

 particularly with pericardial exudates presumably of a hemorrhagic nature. 

 A conspicuous feature of these cases is that the joint affection runs a more 

 rapid and more favorable course than it ordinarily does in pure acute articular 

 rheumatism. As similar cases originated during the period when the favor- 

 able action of salicylic acid and its salts upon diseased joints was unknown, 

 it must be suspected that the authors in question failed to recognize the much 

 more rapid and more favorable course of the arthritic affections in purpura. 

 This should have attracted their attention to the fact that they were not 

 dealing with genuine articular rheumatism "with an atypical course," but 

 with a complication of purpura. 



Another complication of purpura which met with tardy recognition ex- 

 hibits phenomena on the part of the stomach and intestines, such as intense 

 colicky attacks with vomiting and hemorrhagic diarrhea. 



The simplest and mildest forms of purpura are those in which isolated 

 hemorrhagic spots frequently appear in the form of minute petechijE upon 

 the surface of the skin and are the only clinical symptom. These sometimes 

 occur very suddenly without being preceded by prodromes. More often this 

 eruption is accompanied by gastric disturbance, loss of appetite, epigastric 

 pressure, lassitude, vomiting and slight fever. The affection sometimes lasts 

 but a few hours, sometimes for a few days, and, exceptionally, from one to 

 two weeks. The cutaneous hemorrhages usually present themselves in the 

 form of numerous small and large dusky red or bluish red circular spots; 

 they appear particularly upon the lower legs and feet, often also upon the 

 abdomen and the arms, and frequently exhaust themselves in a smgle crop. 

 In fresh cases, they do not disappear upon pressure with the finger, and they 



