DIAGNOSIS FOR HEMORRHAGIC AFFECTIONS The recognition of fairly pronounced cases is easy. The strict diagnostic separation of the various forms of purpura is without practi cal importance; in case of need a review of the points mentioned on page 172 in regard to the uniformity of the various forms of purpura ought to be sufficient. An early recognition of haemophilia would be important, as the life of the patient may thereby be prolonged for years; but unless there is a bleeder family in the case, the diagnosis is difficult and probably only possible after the first serious hemor rhage. Frequent recurrence of "rheumatic" pains in limbs and joints requires careful observation if it occurs in a member of a bleeder family, as the pains may exist for a long time as the only expression of a latent haemophilic diathesis. Considering that these articular affec tions represent so to speak a noli me tangere, it is necessary to differen tiate them from other similar affections. They are most easily confused with tuberculous white swelling, from which they may be distinguished by the rapid appearance and disappearance of the exudates and by the absence of any considerable thickening of the capsule.
Haemophilic articular affections as well as articular swellings in rheumatic purpura arc distinguished from articular rheumatism by the larger swelling in the latter, the local development of heat, the moist skin tending to perspiration and fever. It should be understood that in haemophilia there are hemorrhages into the joints, that in purpura there is oedematous swelling of the periarticular parts, that in rheuma tism there is inflammatory swelling and effusion into the joints and their neighborhood, that in tuberculous arthritis there is granulation which always considerably involves the adjacent bones. In all these
cases X-ray examination ?vill prove a most excellent aid in diagnosis.
Morbus Maculosus and two affections are dif ferent in their very onset. In the former it is more or less sudden, in the latter after slow preparation of the soil. Although in the course of purpura hemorrhagica a severe disturbance of nutrition may set in, it is always a secondary occurrence and never present simultaneously with the first appearance of the other manifestations; such however is the case in scorbutus, in which along with early disturbed nutrition, there is a characteristic tendency to ulceration and inflammation. The af fected gums in scorbutus are known by their dark red swelling, their spongy consistency, the loosening and sensitiveness of the gums, all manifestations which are absent in purpura.
The urine in licematurig is distinct from that in lurninglobinuria by its lake-colored appearance and the percentage of the red blood corpus cles; in the latter disease attention should be paid to the paroxysmal occurrence in conjunction with the effect of cold. H:ematuria occurs, aside from hemorrhagic diatheses, when there are stones in the bladder, the renal pelvis or the kidney, a condition generally associated with considerable secretion of mucous and inflammatory products in the uri ne.