MORBUS MACULOSUS WERLHOPII 477 



■ In consequence of these slovenly methods of classification cases of ulcera- 

 tive endocarditis with purulent arthritis and multiple cutaneous and internal 

 hemorrhages finally came to be designated as poliosis rheumatica, and hemor- 

 rhage in the latter disease was assumed to be emholic. But if we leave out 

 of consideration altogether the results of these blunders, we find in literature 

 an increasing number of cases described as peliosis rheumatica which have 

 nothing in common with the original Schonlein clinical picture except the 

 combination of hemorrhages and joint affection. Attention to a particular 

 type of hemorrhage soon ceased, and instead of the isolated, non-confluent, 

 lentil-sized petechise upon the lower extremities, described by Schonlein, we 

 find writers including in their descriptions every form of cutaneous hemor- 

 rhage, of mucous membrane hemorrhage, and of hemorrhage into internal 

 organs. If we attempt to bring order out of the chaos of pathologic entities 

 and clinical pictures described in literature under the name of peliosis rheu- 

 matica we find simple purpura, purpura hemorrhagica and purpura urticans, 

 morbus maculosus Werlhofii, scurvy, true peliosis rheumatica and, finally, 

 erythema nodosum. 



Occasionally we find each of these maladies, running their course with 

 cutaneous hemorrhage, complicated with joint affections, as will be later ex- 

 plained in detail. Hence the decision as to the nature and character of the 

 disease should not depend upon the seat, nor the size, nor the form and confiu- 

 ence of the hemorrhages, nor upon the implication of the mucous membranes, 

 the serous membranes or the internal organs, nor even upon the sequence of 

 the individual symptoms, hut wholly upon the etiology. This, however, in the 

 group of diseases above mentioned, must be looked for in those changes in the 

 blood which we have designated by the term hemorrhagic diathesis. Patients 

 suffering from this disease have a pale, delicate skin which upon the slightest 

 cause shows a tendency to hemorrhage ; they also present the well-known symp- 

 toms of chlorosis and anemia. It is probably due to this vulnerability of the 

 skin, which is also unusually sensitive to changes in temperature, that such 

 individuals are more readily attacked by rheumatoid affections than others. 

 It seems arbitrary to isolate from this great complex of cases which have a 

 common cause, a single group particularly characterized by the behavior and 

 localization of the petechije, and to assign a particular name to it. In any 

 large batch of clinical material many cases will be met with which correspond 

 minutely to the description of Schonlein, with the sole difference that the 

 form of the hemorrhages varies, or that they have their seat in the mucous 

 membranes. How can the latter be reasonably described as peliosis rheu- 

 matica, and the former not? I have a large number of clinical histories which 

 I have been for a long time collecting because I was interested in the ques- 

 tion of the relation between the hemorrhagic diseases and affection of the 

 joints. I shall refer later to the conclusions based on these, and at this point 

 shall only state that I concur in the opinion at which Scheby-Buch arrived 

 after careful study : " The history of peliosis rheumatica is of itself sufficient 

 to show the untenability of the view that it is an independent disease, even if 

 we did not have other weighty reasons for the same conclusion." 



No one would think of designating scurvy combined with arthritic affec- 



