MORBUS MACULOSUS WERLHOFII 493 



the absence of a tendency to profuse sweats and endocardial or pericardial 

 implication, and, finally, by the fact that -very frequently the Joint phe- 

 nomena are quite transitory and appear much milder than in the other affec- 

 tion, although this cannot be designated as a constant, invariable rule. 



The relation of the arthritic affection to the hemorrhagic disease appears, 

 apart from the arthritic hemorrhages, to be by no means clear. It becomes 

 somewhat less obscure if we consider that in the hemorrhagic diathesis the 

 serous membranes are especially liable to attack and we know from the analogy 

 of other arthritic affections that the serous membranes bear a certain relation 

 to the joints, so that both are often attacked at once. 



It is hard to decide whether the implication of the joints of the knee and 

 of the foot, so frequently observed, can be explained by the suggestion that 

 the general predisposition to purpura would naturally fall heaviest on those 

 joints whose function it is to carry the weight of the body, and which for 

 this reason are particularly exposed. Of course this explanation should be 

 similarly operative in other multiple joint affections. 



I suppose that the sum of our positive knowledge is this : There is an ana- 

 tomic relationship between the joint cavities with the serous membranes ; hem- 

 orrhages into these occur under the influence of the hemorrhagic diathesis. Yet, 

 as regards the arthritic affections in purpura hemorrhagica and in morbus 

 maculosus Werlhofii, it appears to me by no means so firmly established as in 

 the analogous joint disease in scurvy and hemophilia that these are invariably 

 and absolutely hemorrhagic. The clinical symptoms, results of occasional 

 Joint-puncture and the autopsy findings in the Traube-Leuthold case (already 

 mentioned three times) are all opposed to this. 



Of the intestinal symptoms in severe and complicated forms of the disease 

 painful colics are the most characteristic. These resemble the form seen in 

 chronic lead-poisoning. The seat of pain is referred to the region of the navel, 

 from which it radiates to various places. Although at the autopsy hemorrhagic 

 infiltrations of the intestine with ulcer formation in various areas have 

 repeatedly been found, v. Dusch advises caution in the interpretation of 

 reports from the patient : " Bloody vomiting occurred," or, " Tarry hemor- 

 rhagic discharges occurred." He is of the opinion that such reports prove 

 nothing, and especially not that the seat of hemorrhage is actually within the 

 intestinal canal. It must be remembered that in small children, in sleep, 

 and in comatose patients who maintain the dorsal decubitus considerable 

 quantities of blood may flow unnoticed from the nose into the stomach and 

 be discharged by rectum. I cannot suppress the opinion that this explanation 

 seems very forced and artificial, and I do not doubt that in the cases of severe 

 colic actual enterorrhagia often occurs, a view which is more firmly founded 

 upon the fact that the colics decrease decidedly in severity after profuse hem- 

 orrhage from the intestine. 



Albuminuria is by no means a rare complication in the course of the vari- 

 ous forms of the hemorrhagic diathesis, for the most part without an inflam- 

 matory condition of the kidneys. In some cases I have seen the excretion of 

 albumin in every attack, and occasionally it extends into the intervals. In 

 other cases the excretion of albumin lasts for ten months and longer, but 



