470 THE HEMORRHAGIC DIATHESES 



an attempt to classify these hemorrhagic diseases in accordance with the usual 

 reports and designations. 



For example, we will take a case of purpura with joint affection and intes- 

 tinal hemorrhage. Purpura with Joint affection, provided it is not also com- 

 plicated by intestinal hemorrhage, would ordinarily be designated as peliosis 

 rheumatica. As most authors mention neither internal hemorrhage in pelio- 

 sis rheumatica nor joint affections in purpura hemorrhagica, embarrassment 

 would surely ensue as to the category in which to place the case if the teachings 

 of these authors were followed. But it is absolutely certain that such a case 

 should be included in the great group of the hemorrhagic diatheses. 



According to the classic descriptions of the clinicians of the middle of the 

 previous century, it was generally accepted that purpura simplex, purpura 

 hemorrhagica, and peliosis rheumatica were to be viewed as entirely different 

 diseases, that in peliosis rheumatica no internal hemorrhages occurred, and 

 further, that in the different forms of purpura no joint affection was observed. 



I need only mention here the revered names of Eayer, AVillan, Wunderlich, 

 Schonlein, Hebra and Cannstatt. The last, in complete imanimity with 

 Wunderlich and Hebra, teaches that in purpura hemorrhagica, in contrast to 

 peliosis rheumatica, no joint affection occurs, and, moreover, that the absence 

 of joint affection is an important diagnostic point in the differentiation 

 between purpura and scurvy. 



A differential sign between purpura simplex and purpura hemorrhagica, 

 according to the previously named authors, is the presence of large ecchymoses 

 upon the external skin and the occurrence of bleeding from the mucous mem- 

 brane and in the internal organs in the latter affection. 



Accurate observation of typical cases among a great number of patients 

 has shown the unreliability of all of these views, and has demonstrated espe- 

 cially that the points in the history of the individual case regarding the form, 

 extent and seat of the hemorrhages, as well as in regard to the implication 

 of the joints, hitherto held to be diagnostic, can no longer be so regarded. 

 As we shall have to consider more minutely these important questions which 

 dominate the situation, I will only, at this point, demonstrate by some typical 

 examples to what confusion it would lead if, upon the basis of such purely 

 external symptoms and signs, the cases of hemorrhagic diathesis were to be 

 classified. I shall now show that other complications may occur in hemor- 

 rhagic diseases by which the external picture of the affection may be appar- 

 ently changed, while its essential nature remains the same. 



I shall first mention two cases that came under my own observation: In 

 the first there were recurring paroxysms of petechiae, large ecchymoses and 

 suggillations (particularly in the extremities) with painful arthritic swellings, 

 which passed rapidly away; besides these, there were severe gastric disturb- 

 ances with bilious vomiting, attacks of colic and recurrent hemorrhagic diar- 

 rhea. The gums were swollen and bled readily, the teeth were loosened. 



With what were we dealing? Without practical experience, it would be 

 very difficult to recognize the condition among the earlier classifications, and 

 we should lose our way in the devious paths of complicated and apparently 

 non-related symptom-complexes. Purpura, acute rheumatic fever, scurvy, 



