MORBUS MACULOSUS WERLHOFII 485 



septic diseases, and in acute leukemia also, extensive cutaneous hemorrhages 

 occur. 



To the forms of the hemorrhagic diathesis which have been described we 

 must add still another disease which lately has become quite prominent, and 

 which by some authors is looked upon as infantile scurvy. Yet it differs 

 from the latter affection in many important peculiarities. The disease was 

 described in 1857 by Moller in Konigsberg as "acute rachitis" and was par- 

 ticularly studied by Barlow in 1883, since which time it has been called by his 

 name. In the last few years this affection has been repeatedly the subject of 

 close investigation, and particularly on account of the increasing frequency of 

 the disease among the children of families of the better class, has become 

 important. It occurs exclusively in children between the middle of the first 

 year and the third year of life. The onset is often, but not always, acute. 

 After a few days of general ill health, occasionally following an attack of diar- 

 rhea, sensitiveness and difficulty of movement in one or both lower extremities 

 appear, with sensitiveness to touch. The children are usually found with 

 their limbs extended or retracted upon the abdomen, immovable in bed. Either 

 active or passive motion is painful. Very soon a spindle-shaped, sensitive, 

 smooth, white tumor of elastic consistency is noted in the course of the diaph- 

 ysis of one or both thighs, rarely of the lower leg or of the upper extremities. 

 Occasionally crepitation is noted in the epiphysial border, which is due to a 

 loosening of the latter. 



This deeply situated subperiosteal or subperichondrial tumor in the tract 

 of the long tubular bones is the pathognomonic, peculiar sign of this disease, 

 compared with which the rachitic or scorbutic symptoms are entirely secondary. 

 Neither clinically, by puncture or incision, nor after death, has pus ever been 

 found under the periosteum of the diseased bones, but invariably pure blood, 

 and there is no case on record in which it has ever been observed that the cap- 

 sule of the joint, in spite of its close proximity, was implicated in the process. 



To these previously mentioned symptoms frequently, but by no means 

 always, the symptoms of the hemorrhagic diathesis, of scurvy and of rickets, 

 are added. To the latter has been attributed the great tendency to sweating, 

 particularly of the occiput, as well as the swelling of the epiphyses. Scurvy 

 is thought to explain the loosening and spongy swelling of the gums with 

 fetor, and the tendency to hemorrhage, especially in the cases where teeth 

 are already present. Fever and gastric symptoms are frequent. Occa- 

 sionally purpura, hemorrhages into the mucous membranes, and albuminuria 

 occur; Henoch mentions hemorrhages under the periosteum of the frontal 

 bone, into the eyelids, and into the retrobulbar tissue with exophthalmos. 

 The 'appearance of the children is anemic, but very rarely, either by hemor- 

 rhage or other complications, does death occur. 



Eegarding the etiology of this important and interesting disease, it has 

 been maintained more and more lately that improper nourishment is respon- 

 sible. While by some authors the too great uniformity of the nutrition has 

 been looked upon as the cause, others emphasize the absence of fresh food^ In 

 the exhaustive American collective investigation (Boston Med. and Surg. Jour- 

 nal, 1898), and in a great number of individual observations, it has been 



