478 THE HEMORRHAGIC DIATHESES 



tion as peliosis rheumatica, yet carefully studied eases of purpura hemor- 

 rhagica with Joint afEection have been described by some writers as peliosis 

 rheumatica, and by others as acute articular rheumatism with hemorrhages. 

 French and English authors were among the first to describe all such cases of 

 extensive hemorrhagic diathesis with articular affection as " acute articular 

 rheumatism with atypical course," and thus to a certain extent constructed a 

 new clinical picture. This example shows what th$ results might be if, with- 

 out the protective guidance of etiology, and solely on the basis of obvious 

 symptoms, one should attempt to classify these cases ! With a sharply defined 

 clinical picture such as scurvy usually presents, only an unusually slovenly 

 habit of mind could make it possible to mistake the relation of the symptoms. 

 But the case is quite different when we attempt to deal with the group of cases 

 last indicated. Some authors describe them as purpura or peliosis rheumatica, 

 according to whether the cutaneous phenomena or the joint affections are 

 more prominent; others call them rheumarthritis, without realizing that the 

 clinical picture does not correspond to Schonlein's conception, and that in 

 acute articular rheumatism cutaneous hemorrhages do not occur except in the 

 presence of certain severe complications ! 



One who has seen much of acute articular rheumatism knows that it has 

 in uncomplicated cases no association with cutaneous hemorrhages, and will 

 not confound this disease with any other. Of great importance is the tend- 

 ency of rheumatism to produce secondary inflammations of the serous mem- 

 branes and of the endocardium, which is absent or extremely rare in the pure 

 form of peliosis and in the hemorrhagic diathesis. Further, the absence in 

 all forms of purpura of the very severe and exhausting sweats of acute rheu- 

 matism, as well as the absence of severe joint phenomena, is important. Cuta- 

 neous or internal hemorrhages (particularly of the retina) occurring in acute 

 rheumatism depend upon a complicating acute endocarditis, as I have explic- 

 itly pointed out in my monograph upon septic diseases.^ Such cases are also 

 to be clearly differentiated from those in which, with a simultaneous septic 

 or so-called ulcerative endocarditis, purulent joint metastases with numerous 

 petechia distributed over the entire skin and retinal hemorrhages appear. 

 The cardinal difference between these groups is that, in the former, acute artic- 

 ular rheumatism introduces the scene and represents the original disease, while 

 in the latter a wound affection (for example, diphtheria of the placental area, 

 etc.) or internal suppuration (such as thrombophlebitis suppurativa of the 

 pelvic veins due to abortion, or of the spermatic veins in the course of gonor- 

 rhea) is the cause. In the last-named group of cases the joint affections are 

 invariably secondary. Many examples of both varieties of cases have been 

 given in my article upon septic disease. (See p. 380 et seq., and p. 588.) 



Having now proven, as I believe, that there is no justification for Schon- 

 lein's clinical picture of peliosis rheumatica, and that the condition was a joint 

 affection combined with a hemorrhagic diathesis, I must mention that there 

 are cases which run a course exactly as described by Schonlein, except that 

 they are due to another cause, namely, gonorrhea. I have used the designa- 



1 Zeitschr. f. klin. Med., Bd. ii, 1881. 



