MORBUS MACULOSUS WERLHOFII 473 



Severe gastric conditions, or decided pain and swelling of the joints are more* 

 rarely noted, at most in 40 per cent, of the cases. But the process may last 

 a long time (six to fifteen months) owing to repeated relapses, and may cause 

 great debility. Severe grades of anemia combined with palpitation, vertigo 

 and syncope are not infrequently observed in such cases. 



The debility is markedly increased when the disease runs its course with 

 fever and albuminuria. It is to be mentioned that in bed-ridden patients re- 

 lapses take place as soon as the patients attempt to leave the bed ; it is at this 

 time also that joint affections are apt to appear or recur. The severe cases of 

 purpura hemorrhagica with gastric symptoms will be considered later on. 



Purpura urticans has been described by authors as a special variety in 

 which, besides cutaneous hemorrhage, there is an urticarial eruption of the 

 external skin, the individual wheals of which appear to be hemorrhagic. 

 Occasionally these urticarial eruptions occur simultaneously with petechias, in 

 other cases the two conditions alternate. 



Strictly we should use the term " purpura urticans " to designate only 

 such cases of urticaria as leave behind them true petechisE or purpuric areas. 

 I have observed such cases in which each time, after the patient had left his 

 bed, new patches of urticaria alternating with purpura appeared, and in which 

 the urticarial eruption invariably left purpuric areas behind. Such cases last 

 for many weeks, or even for months. Gastric symptoms are often present in 

 purpura urticans, as in true urticaria. 



The forms of purpura which I have described thus far (including the 

 milder forms of the so-called erythema nodosum — ^boil-like, deep infiltrations 

 with hemorrhages) usually appear without conspicuous prodromata, and with- 

 out other local disturbances. In contrast with these forms of " pure " purpura 

 are others in which, a few days prior to the appearance of the hemorrhagic 

 phenomena, mild prodromes of an indefinite nature, lassitude, headache, an- 

 orexia, may be observed. Finally a drawing sensation in the limbs and pain 

 in the joints may usher in the malady; then moderate fever, lasting several 

 days, with pain in the joints, particularly of the lower extremity, appear and 

 last until the outbreak of the true purpuric affection. Thus we reach the 

 form which has been designated peliosis or purpura rheumatica. It is to 

 Schonlein's credit that he first recognized the unquestionable and intimate 

 relation existing between the hemorrhagic diathesis and certain arthritic affec- 

 tions ; but he did not discern that this connection is a very general one. On 

 the contrary, he declared it to be only a limited one, and thus he failed to 

 apprehend the true nature of the hemorrhagic diathesis, the proper under- 

 standing of which was delayed for a long time. 



The designation peliosis (v TreAiwo-is) is first found in the works of 

 Hippocrates and signifies " blood under the skin." As is well known, Schon- 

 lein appropriated this term as a designation for the clinical picture, and added 

 to it the epithet " rheumatica." 



According to Schonlein's well known lectures, which were published by 

 " some ©f his pupils," the following are the main symptoms of peliosis rheu- 

 matica- "The areas never coalesce. The patients have either formerly suf- 

 fered from rheumatism, or then exhibit rheumatic phenomena, mild periodic 



