CLASS III—HEMORRHAGESPURPURA

Synonyms.—Hæmorrhœa petechialis; Fr., Hémorragies cutanées; Ger., Blutfleck-
enkrankheit.

Definition.—A hemorrhagic affection characterized by the appear­
ance of variously sized, usually non-elevated, smooth, reddish or pur­
plish spots or patches, not disappearing upon pressure, and generally
accompanied by systemic disturbance of slight or severe nature.

Various grades of the disease are encountered, from mild and in­
significant to profoundly grave, both as to the cutaneous lesions and
the constitutional symptoms. It is customary, for the sake of con­
venience, to divide the cases into three classes or varieties, denoting
respectively the mild, moderate, and severe grades: purpura simplex,
purpura rheumatica, and purpura hæmorrhagica. This division is,
however, to a great extent a purely arbitrary one, as merging cases
are not uncommon. Insignificant cutaneous lesions are sometimes seen
in association with more or less severe constitutional disturbance, and
in rare instances the integumentary hemorrhage may be quite profound
and the systemic involvement relatively slight. Nevertheless it is not
improbable that the various grades may have a different or mixed etiology.
In some of the more severe cases soreness of the throat, of varying
degree, precedes the cutaneous outbreak.

The lesions are variously designated, according to size, etc., petechiæ,
vibices, ecchymoses, and ecchymomata. Petechiæ are the spots usually
seen in the mild type, and are generally rounded or ovalish in form, and
from a pin­point to a dime in size; vibices may be described as simply
hemorrhagic streaks, of varying length from a small fraction of an inch
to an inch or more; ecchymoses are the larger, non-elevated lesions, and
may be rounded or irregularly shaped; an ecchymoma (also called hema-
toma) is large in size, similar to the last, but the extravasation of blood
has been sufficiently great to produce slight or pronounced elevations
or tumors.

Symptoms.—The essential symptom in purpura is the cuta­
neous hemorrhage—hemorrhage into the integumentary tissues, and
which does not disappear upon pressure. The lesions thus produced
are pin-head, pea- to bean-sized or larger, appear suddenly, and are
noted to be of a bright-red or purplish-red color. Their brightness
gradually fades, the color usually changing to a bluish, bluish-green,
bluish- or greenish-yellow, dirty yellowish, yellowish-white, and finally
disappearing. In the smaller lesions these changes are scarcely per­
ceptible, the spots becoming fainter and then fading away; in the large

492

PURPURA

493

ecchymotic lesions the various changing tints are quite pronounced,
resembling in many respects the changes observed following a bruise.
As a rule, the lesions are not visibly elevated, but in extreme cases in
which there may be considerable effusion, slightly raised flat, tumor-like
formations result. The most common sites are the lower extremities,
and especially from the middle of the thighs downward, although the
upper part, and also the forearms, not infrequently share in the dis­
tribution. In other cases, and especially of the more severe type, the
lesions may be seen over the trunk, and rarely upon the face as well.
Exceptionally the trunk is the seat of most of the spots or patches.

As a rule, there are no subjective symptoms in uncomplicated cases,
although occasionally slight soreness is complained of, and less frequently
mild itching. In some instances other skin-lesions, such as those of
urticaria and erythema multiforme, are associated, to be referred to
later. Other accidental and general symptoms will be referred to under
the particular varieties or subdivisions.

Purpura Simplex.—This, the mild grade of the disease, is rarely
accompanied by any systemic disturbance, in some cases possibly slight
malaise, loss of appetite, etc. It usually manifests itself quite suddenly,
the spots appearing in numbers, pin­point­ to pea- or bean-sized, bright
or dark red in color, and most frequently limited to the lower extremi­
ties, although it is not uncommon to see lesions on the forearms as well.
In other cases their appearance is gradual, coming out in distinct, crop-
like exacerbations. Once its acme is reached, they begin in most cases
gradually to fade, and at the end of a few weeks or longer have entirely
disappeared. It is not unusual, however, for new lesions to appear
either irregularly or in crops at irregular intervals for several weeks to
several months; and in exceptional instances the tendency may persist
for one, two, three, or more years. In a case of a young girl under my
care the eruption persisted in this manner, with irregular, but usually
short, periods of quiescence, for five years, and was still appearing when
the patient withdrew from my observation several years ago; there were
no subjective or general symptoms, and the child, aged about twelve,
was apparently in good health. Such extremely prolonged cases are
rare, but cases lasting in this irregular manner for a year or two are not, I
believe, so uncommon as is generally thought.¹

• In rare instances the lesions may be circulate, with clear center,
as in a case reported by Duhring² and one by myself;³ the eruption in
my case was chiefly limited to the trunk. Subjective symptoms are
scarcely ever noted; in some instances, however, there is an urticarial
element, and it is noted that the hemorrhagic spots, here and there,
become the seat of wheals—purpura urticans; most of these cases are,

¹ Meachen, Brit. Jour. Derm., 1903, p. 459, showed a somewhat similar case before
the Derm. Soc‘y of Great Britain and Ireland, a girl of eighteen, who had been continu­
ously subject to the malady, with varying intensity, for four years, her general health
being good; Osier, Jour. Cutan. Dis., 1903, p. 297 (with colored plate), reports a case of
“Chronic Purpuric Erythema,” lasting eight years, with pigmentation of the skin and
enlargement of the liver and spleen; patient died of pernicious malaria.

² Duhring, Med. and Surg. Reporter, Aug. 3, 1878.

³ Stelwagon, Jour. Cutan. Dis., 1887, p. 370 (with illustration).

494

HEMORRHAGES

however, examples of urticaria, with hemorrhagic tendency in the lesions.
Very exceptionally there may be associated some irregularly scattered
but scanty efflorescences of erythema multiforme; these are, however,
rare—much more so than in cases of purpura rheumatica.

A variety (purpura senilis) of apparently an entirely different and
innocent nature is observed in people of advancing years, although
occasionally also in younger individuals; purpuric spots appear on the
legs, usually about the ankles and on the leg just above, which last a
variable time, sometimes almost indefinitely, and leave behind pigment
stains. New spots continue to reappear at irregular intervals. This
condition seems to be of purely local nature, and is usually observed
in association with sluggish circulation and often with varicose veins.

Purpura rheumatica or arthritic purpura presents itself in several
varieties. The most common, and in fact the usual one, is that with
cutaneous lesions, as in purpura simplex, with the addition of rheumatic
pains and sometimes swellings about the joints. There is generally
slight passing, sometimes more or less prolonged, febrile action, and the
outbreak is often ushered in with the other usual symptoms of constitu­
tional disturbance. Its behavior and course, although more severe,
are practically like average cases of purpura simplex.

Another variety of the rheumatic form is that known as peliosis
rheumatica, or Schönlein's disease. It is rare. In its most marked
expression it may be said to be made up of a combination of symp­
toms—those of rheumatism, purpura, and erythema multiforme, often
with here and there considerable edematous swelling. Occasional urti-
carial lesions are also associated, and exceptionally some of the efflores­
cences may become vesicular or bullous. The disease frequently begins
with symptoms of sore throat. In one case observed by me there was
marked edematous swelling of the legs, with both purpuric patches and
ecchymoses, and pronounced rheumatic symptoms of the main joints,
together with hemorrhagic lesions and swellings of the lips and throat.
Such extreme examples have been well termed febrile purpuric edema.
The constitutional symptoms are often alarming, the temperature
elevated, the urine often diminished, and occasionally endocarditis and
pericarditis, and in rare instances, as in 2 cases observed by Osier,¹
necrosis and sloughing of a portion of the uvula. In the single example
of this severe type under my care recovery took place. Osier states
in fact, that cases usually do well, and that a fatal result is rare. Recur­
rence is noted, in some instances, at yearly intervals for several years—
in this respect corresponding to erythema multiforme.

Somewhat similar to peliosis rheumatica is that known as Henoch's
purpura, observed principally in children, in which, however, the ery­
thema multiforme aspect is more pronounced, and the purpuric charac­
ter, as to the integument, less conspicuous; edematous swelling is also
often noted, suggestive of a combination of purpura and angioneurotic
edema, as in the cases reported by Bowen² and others. In addition

¹ Osier, Practice of Medicine.

² Bowen, “The Association of Purpura and Acute Circumscribed Edema,” Jour.
Cutan. Dis., 1892, p. 434 (report of 2 cases and references to allied literature).

PLATE XVIII.

Purpura.

PURPURA

495

there are gastric and intestinal symptoms and hemorrhages from the
mucous membranes. Osier¹ states its characters to be: (1) Relapses
or recurrences extending over several years; (2) cutaneous lesions, which
are those of erythema multiforme rather than of simple purpura; (3)
gastro­intestinal crises—pain, vomiting, and diarrhea; (4) joint pains
or swelling, often trifling; (5) hemorrhages from the mucous membranes.
A variable amount of albumin is usually found in the urine, while in the
most aggravated cases there were all the symptoms of acute hemorrhagic
nephritis. He further states that any one or two of these symptoms
may be absent; the intestinal crises, with enlargement of the spleen,
may be present and recur for months before the true nature of the trouble
becomes manifest. In 61 cases collected, of which 11 are reported by
Osier, there were 13 deaths. In these are included the large number
collected by Dusch and Hoche.² Apparently the dermatologist rarely
gets sight of these peculiar cases, which, according to this writer, are
more common than generally thought.

Purpura hæmorrhagica (also known as morbus maculosus Werlhoffi
and land scurvy) may begin as a simple purpura without preceding con­
stitutional disturbance or with mild systemic symptoms, the integ-
umental lesions being small, scanty, or numerous; and there may sub­
sequently develop the characteristic symptoms of this type of purpura,
such as more or less grave constitutional involvement, hemorrhages
from the mucous membranes, and also considerable hemorrhagic effusion
into the skin, producing large areas or tumor-like ecchymoses (ecchy-
momata). On the other hand, the disease may begin suddenly, with
severe systemic disturbance, and assume its serious character from the
start. Purpuric patches are usually noted upon the mucous membrane
of the mouth and throat. The cutaneous lesions in this variety may
appear anywhere, beginning either on the extremities or trunk. In
many cases, although the symptoms are somewhat alarming, recovery
after several weeks or a few months finally results. Extreme cases are
met with in which there is a combination of profound cutaneous dis­
turbance, and hemorrhages from the mouth, stomach and intestinal
symptoms, with general symptoms of collapse and a rapidly fatal ending
—purpura fulminans.

Etiology.—The disease is not uncommon, and is met with in
both sexes and at all ages, being most frequent between the ages of ten
and forty. Its subjects, as regards the state of the general health, vary
from those in seemingly good condition to those profoundly cachectic.
No one cause can, in the state of our present knowledge, be set down as
essential in all cases. Various factors seem capable of bringing on that
unknown condition which results in hemorrhagic effusion. It is known
that the ingestion of certain drugs (see Dermatitis medicamentosa),

¹ Osier, loc. cit., and (interesting paper, reporting 11 cases—3 deaths) in Amer.
Jour. Med. Sci., Dec, 1895, p. 816; see also valuable contribution by S. Mackenzie
(on the relationship of purpura rheumatica and erythema multiforme), Brit. Jour.
Derm., 1896, p. 116; and Weber (case report with remarks on the visceral complica­
tions of purpura), Brit, Jour. Derm., 1900, p. 77.

²Dusch and Hoche, Festchrift Eduard Henoch, Berlin, 1890, p. 379

496

HEMORRHAGES

notably potassium iodid, salicylates, and chloral, have provoked it.¹
Malarial poison is not infrequently to be assigned as an important factor,
as in cases reported by Tyrrell² and others.³ Syers,⁴ who has had ample
opportunities of observing the disease in children, is inclined to consider
it somewhat allied to scorbutus and due in many cases to poor, unhy­
gienic life conditions and insufficient or poor food. It is likewise some­
times seen in the course of or following grave systemic disease,⁵ more es­
pecially profound anemia, scorbutus, hemophilia, variola, pyemia, typhus,
syphilis, grip, nephritis, etc Rheumatism has long been discussed as
etiologic, but the rheumatic symptoms in this disease are doubtless
merely a part of a symptom-complex due to some unrecognized cause.
It has also been observed along with gonorrheal rheumatism, in which
the latter could scarcely be considered the exciting factor. Doubtless
in some of the gonorrheal cases the purpuric manifestation has been the
result of drug administration; copaiba has been known to produce it.
Nervous disorders, both of a functional and organic character, visceral
diseases, and other similar factors have all seemed to be of etiologic
import in some instances, the eruption occurring in association with
hysteria, myelitis, locomotor ataxia, etc It is probable that circulatory
disturbance, especially when associated with debility or cachexia, with
resulting blood impoverishment, anæmia etc may likewise be occasion­
ally responsible.

Micro-organisms have been also looked upon as causative, at least
in the more grave cases, and have been found by Martin de Gimard,⁶
Letzerich,⁷ Hanot and Luzet,⁸ Kolb,⁹ Burch,¹⁰ Howard,¹¹ and others,
but there is a great deal of diversity in the findings, and in some instances,
as in the case of Mossé and Iversenc,¹² several bacterial forms are to be

¹ Knowles, “ Purpura Caused by the Ingestion of the Iodid,” Jour. Amer. Med.
Assoc, July, 9, 1910, p. 100 (with review and references). Selling, “Purpura Hæm-
orrhagica Due to Benzol Poisoning,” Johns Hopkins Hospital Bulletin, Feb., 1910
(in workers where benzol was used freely; 14 cases; 3 cases described, 2 of which were
fatal, had all the symptoms of idiopathic purpura).

² Tyrrell, Pacific Med. and Surg. Jour., June, 1876.

³ Engmann, “Paludides, with the Histopathology of a Case of Malarial Purpura,”
Jour. Cutan. Dis., 1903, p. 489 (with references).

⁴ Syers, Lancet, Feb. 12, 1898.

⁵ Among recent cases may be mentioned that by Colcott Fox, London Clin. Soc‘y,
Lancet, June 3, 1899 (developing toward the end of Bright‘s disease); Poynton, ibid.,
Oct. 28, 1899 (with pernicious acute rheumatism); Frankenhäuser, St. Petersburger
med. Wochenschr., 1899, No. 4, and Glendenning, Philada. Med. Jour., May 6, 1899,
vol. iii, p. 968 (following the grip); Londe, abs. in Jour. mal. cutan., 1899, p. 770 (at
the decline of typhoid fever); see also interesting and suggestive paper (with references)
by Graham Little, “Cases of Purpura Ending Fatally, Associated with Hemorrhage
into the Suprarenal Capsules/’ Brit. Med. Jour., 1901, p. 445. Rolleston and Molony,
British Jour, of Children's Diseases, Jan. 1912, p. 1, records that in a series of Too
cases of infective diarrhea, out of 67 fatal cases 16 developed purpura.

⁶ Jules L. A. Martin de Gimard, Du Purpura hemorrhagique primitif, Paris, 1888.

⁷ Letzerich, Untersuchungen über die Aetiologie und die Kenntniss des Purpura hœm-
orrhagica, Leipzig, 1889.

⁸ Hanot and Luzet, Arch, de méd. cxper., 1890, No. 6, ii.

⁹ Kolb. Arbeiten aus der Kaiserlichen Gesundheitsamte, 1891, vii, p. 60 (with refer­
ences, and 4 plates, presenting 13 cuts of bacillus cultures and inoculated animal tissue
sections).

¹⁰ Burch, Medical News, 1899, vol. lxxivi, p. 427.

¹¹ Howard, Jour. Exper. Med., 1899, No. 2, vol. iv.

¹² Mossé and Iversenc, Jour. mal. cutan., Nov., 1898.

PURPURA

497

found, which may, as they suggest, mean that the primitive infection
opens the door to secondary infection. The bacillus described by Kolb,
Letzerich and Burch, and some others, however, seems to be closely
similar or identical. Most of these investigations have been with hem-
orrhagic or grave types. Martin de Gimard, Letzerich, and Kolb all
succeeded, in experimental inoculations in animals from pure cultures,
in producing the malady. Microbic infection is, therefore, doubtless
the causative factor in some of the grave cases; and it is not impossible
that the initial sore throat often noted indicates the port of entrance.

Summarizing, I agree with Johnson,¹ who, from a careful study,
believes that the causative factors may be divided, in general, into
several classes—vasomotor, toxic, and infectious; and some of those of
toxic origin, probably as Breton's² observations lead him to conclude,
arise from an auto­intoxication starting from the intestinal tract. There
seems, too, an affinity or connection between certain cases of erythema
multiforme and some cases of purpura rheumatica, and Osier is inclined
to include with these angioneurotic edema and urticaria, and suggests
the possibility of as yet an unknown poison, possibly the result of faulty
metabolism, which, according to individual and dosage, may provoke
one or the other of these several manifestations.

Pathology.—While it is customary to designate almost all cases
with hemorrhagic cutaneous lesions purpura, it is, nevertheless, beyond
question that this manifestation is simply a symptom of probably
widely diverse conditions.³ It is difficult to reconcile the mild, insig­
nificant cases with those examples, apparently infectious in origin, and
rapidly fatal, except upon such assumption. It is probable, too, that
cases differ somewhat as to the pathology, of the lesion, whether the
toxic agent or the pathogenetic factor, whatever it is, acts primarily
upon the nervous centers, peripheral nerves, on the blood itself, or on
the vessel-walls. There may be simple transudation of blood coloring­-
matter, or the blood may find exit through a rupture of the vessel-wall
or by diapedesis; the second method is probably the most usual. Ac­
cording to Hebra, in the first formation of the lesion there is slight
accompanying hyperemia, which soon disappears, and Kromayer⁴ states
that since his attention was called to this point he has found, from careful
observation, that there is a prodromal hyperemic spot, sometimes slightly
elevated, which immediately precedes the hemorrhage. Excepting these
two, I believe no one else refers to it or has confirmed it. Inasmuch as
in most instances the lesions are on dependent parts, blood stasis is
doubtless a contributing factor; thus, in a case recorded by Bruce and
Galloway,⁵ a man aged twenty-nine, the purpuric spots on the legs

¹ Johnson, N. Y. Med. Jour., Oct. 7, 1890.

² Breton, Jour, des practiciens, 1899, No. 3.

³Török, “Les Purpuras,” Jour. mal. cutan., April, 1903, forcibly contends that all
purpuras have a similar origin—some infective or toxic or autotoxic agent acting upon
the vascular walls and reaching the parts affected by the blood­stream; these agents may­
be various, and can produce the same clinical and histopathologic picture; clinical dif­
ferences are merely of degree; the differences in histopathologic findings by various
investigations are assumed to be due to accidental conditions.

⁴ Kromayer, Allgemeine Dermatologie, Berlin, 1896, p. 77.

⁶ Bruce and Galloway, Brit. Jour. Derm., 1898, p. 6.

32

498

HEMORRHAGES

gradually vanished after rest in bed, the eruption recurring as soon as
the patient was allowed to get up. Or there may be sudden obstruction
of the vessel, due to thrombosis or embolism, and in some of the grave,
and doubtless infectious, cases, the obstruction may consist of accumula­
tion of micro-organisms, as Cheyne, Letzerich, Martin de Gimard, and
others have found. Most investigations have been with hemorrhagic
cases. Martin de Gimard¹ ascribes the disease conjointly to a mechan­
ical obstruction of the vessels and to inflammation of the vessel-walls
from the presence of colonies of micrococci, rupture occurring spon­
taneously or as a result of movements on the part of the patient. I have
noted the effect of this latter in many cases; while the patient remains at
relative or complete rest there is but little disposition to the appearance
of new lesions, but if at all active, an exacerbation is immediately
noted; this is probably an element also in such cases as that of Bruce
and Galloway, just referred to. Letzerich, from his investigations,
was led to conclude that the bacilli or their products exerted a chemical
influence on the albumin of the blood, changing it into a gelatinous
substance, which produces disturbance of circulation leading to ex­
travasations. The blood changes have, however, been found to be
somewhat varied by different observers and in different cases. In grave
types there is usually great diminution in the red corpuscles; in 2 fatal
cases recently reported by Dziehiszek² and by Cureton³ this was especially
noticeable; in the latter‘s case three days before death numbering
1,680,000 and rapidly going down to 310,000. Duke⁴ found in his cases
the blood-platelet count was below 10,000, and, as a rule, below 1000.

Anatomically (Robinson), the effusion has its seat in the corium,
especially the papillae, and sometimes in the subcutaneous tissue as
well; the involved blood-vessels are usually dilated and filled with red
blood-corpuscles.

Diagnosis.—But little difficulty, as a rule, need be experienced
in the recognition of so well marked a symptomatology which most
cases present. The lesions are not inflammatory, are purely hemor-
rhagic, and do not disappear under pressure. In rare instances, it is
true, the border­line between purpura and erythema multiforme is
closely approached, but in uncomplicated purpura there are no ery-
thematous lesions. In fact, the disease to be differentiated is scurvy.
In this latter, however, the condition is observed usually in one de­
prived of all vegetable food and fruits, and is generally preceded or

¹ Martin de Gimard (loc. cit.), cited by D. J. M. Miller, Medical News, Aug. 8,
1891, who reports a fatal case—I have not been able to see the original.

² Dziehiszek, Gazette Lekarska, 1898, vol. xviii, 648—abs. in Jour. Cutan. Dis.,
1898, p. 502.

³ Cureton, Lancet, Feb. 25, 1899.

⁴ Duke‘s (“ The Pathogenesis of Purpura Hæmorrhagica with Especial Reference
to the part played by Blood-platelets,” Arch. Intern. Med., Nov., 1912, x, p. 445, with
review and references; and “ The Behavior of the Blood-platelets in Toxæmia and Hem-
orrhagic Diseases,” Bull. Johns Hopkins Hosp., May, 1912, p. 144) observations and
experiments seem to indicate that the malady may be caused by any agent which
reduces the blood-platelet count to a sufficient degree. He found in experiments on
animals that subcutaneous injections of benzol, diphtheria toxin, and tuberculin, the
platelet count was in some instances sufficiently reduced to bring about symptoms
of purpura, only, however, in those having an extremely low count.

PURPURA

499

accompanied by softening and sponginess of the gums, which bleed
easily, and often loosening of the teeth; moreover, the hemorrhagic
lesions are, as a rule, limited to the legs in almost all cases, and most
frequently about the ankles, with often some brawny swelling of the
parts and a tendency to break down into ulcerations. The lesions
which are produced by flea-bites are often, after a day or two, of slight
purpuric character, but their origin is usually recognized, and in the
beginning they are encircled by a slight erythematous halo, and they
are not, moreover, usually seen in numbers, nor do they appear in crops.

Prognosis.—While it is generally believed that various types of
purpura are of diverse nature and etiology, nevertheless cases which
appear as mild in character after a time become, in some instances,
quite serious. The prognosis should always be expressed with a certain
amount of caution, although it can be said that almost all those of mild
or moderate character terminate favorably. As to the length of time
for such to come to pass, however, no definite statements can be given.
Most cases end in three to six or eight weeks; others, even though mild
in type, may persist with remission for some months. Those presenting
alarming symptoms, especially those of the type purpura hæmorrhagica,
must always be considered grave, and a fatal ending often occurs, some­
times in several days or a week. In cachectic patients the outlook is
always less favorable. Hyde and Montgomery¹ state that in a case
under their care a purpuric eruption was the first evidence of hemophilia,
which subsequently showed itself.

Treatment.—Except in the mildest types the patient should be
kept at absolute rest, and preferably in bed, in the horizontal position,
or with the legs on a higher, slightly inclined plane; and in more severe
cases light compression, as with the roller bandage, may also be used,
as advised by Besnier. In the graver forms occasional disinfection of
the throat and mouth (possible port of entrance of the disease) is advis­
able. Outside of the use of several special remedies, treatment depends
upon the possible etiologic factor. Quinin is to be given, and in full
doses, where malaria is suspected. The special remedies which have
been extolled from time to time are iron, especially the tincture of the
muriate, ergot, oil of turpentine, oil of Canada erigeron, aromatic sul­
phuric acid, and silver nitrate. Poulet² was especially favorable to
silver nitrate, in dosage of about ¹/₆ grain (0.0108) two or three times daily,
and records recoveries from its use in what appeared to be grave cases;
he believes its favorable action due to its modifying influence on the
capillary circulation through an impression on the vasomotor nerves.
Crocker strongly indorses oil of turpentine, both internally and by in­
halation. Recently Wright³ has advised a trial of calcium chlorid in
15- to 30-grain (1.-2.) doses three times daily, basing its possible value
upon its service in urticaria and hemophilia, etc., in which lessened

¹ Hyde and Montgomery, Diseases of the Skin, seventh edit., p. 485.

² Poulet, Bull. gén. de thérapeutique, May 3, 1889—abstract in Jour. Cutan. Dis.,
1889, p. 331.

³ Wright, “On the Treatment of the Hemorrhages and Urticarias which are asso­
ciated with Deficient Blood-coagulability,” Lancet, Jan. 18, 1896, p. 153; also papers in
Brit. Jour. Derm., 1896, p. 82; and (on calcium salts) Brit. Med. Jour., Dec 19,1891.

500

HEMORRHAGES

blood coagulability had seemed, from his investigations, to be the direct
etiologic factor. The remedy should not be given, however, for more
than several days, as its continued use finally diminishes the coagula­
bility. In suspected cases, probably rare, of syphilitic etiology, the
proper treatment should be instituted; in a recent case by Kornreich,¹
of moderate but persistent type, which showed no improvement under
ordinary remedies, rapid recovery ensued upon the administration of
potassium iodid and mercury. Frick² commends antirheumatic reme­
dies, stating that such treatment had succeeded in cases rebellious to
other plans, and he is inclined to believe that this is suggestive of a com­
mon or allied cause for these affections. The most valuable remedies
in my experience have been quinin, iron, and ergot, the last in grave forms
by subcutaneous injection. It is possible, in these alarming cases, the
injection of artificial serum might be of service; Boulloche³ had success
in a case of fulminating type, in which this seemed to be the therapeutic
agent in promoting rapid recovery—an injection of 120 cc was used.
MacGowan⁴ highly commends full doses of adrenalin chlorid.

External treatment is rarely called for. Duhring, in the graver
types, thinks well of ice applied frequently to the parts. If there is
any. itchiness, very occasionally noted, the ordinary antipruritic lotion
of carbolic acid can be prescribed.

Purpura Scorbutica (Synonyms: Scurvy; Sea scurvy; Scorbutus),
—In its cutaneous symptoms scurvy is closely similar to purpura, and
by some writers is considered of allied nature. In the general characters
and features, however, the diseases are more or less dissimilar. Scurvy
is due to long-continued deprivation of proper food, especially fruits
and vegetables, and its development is also favored by other bad hygienic
conditions. Its subjects are usually sailors or others taking long voy­
ages, although it is occasionally observed in those on land, and both
Starr and Crozer Griffith, as well as others, have also noted it in im­
properly or insufficiently fed infants and young children. A peculiar
constitutional state is developed, characterized by emaciation, general
febrile and asthenic symptoms, sometimes with also swelling of one or
more joints, and a moderately or markedly swollen, turgid and spongy
and even gangrenous condition of the gums; and concomitantly, or
sooner or later, by the appearance, usually upon the lower portion of the
legs only, of dark-colored hemorrhagic patches or blotches. Sometimes,
instead of more or less diffused discoloration, it may consist of a variable
number of small or moderately large spots, in close proximity or crowded
together; or these will be seen in the neighborhood of or just outlying
large or confluent plaques. In fact, the cutaneous lesions may, as to
size and ordinary characters, be essentially similar to the petechiæ,
ecchymoses, and ecchymomata of purpura, and these several grades of
hemorrhagic lesion may exist at the same time; but they never have the

¹ Kornreich, Med. Record, Feb. 26, 1898.

² Frick, “Purpura Rheumatica,” Kansas City Med. Index, 1896, p. 159.

³ Boulloche, Bull, et mêm. de la soc. med. d. hop. de Paris, 1899, vol. xvi, p. 809.

⁴ MacGowan, “The Use of Adrenalin Chlorid in Hemorrhages and Angioneurotic
Diseases of the Skin,” Jour. Cutan. Dis., 1905, p. 72.

PURPURA

5OI

bright-red color of the latter malady, but are usually dark sluggish red
from the beginning, and generally of a dull purplish hue. While its
common and often sole seat is about the ankle and the immediately
adjacent part, it sometimes is also seen higher up, and occasionally on
other parts as well. The skin of the affected region often becomes
swollen, brawny, and slightly scaly, and not infrequently breaks down
and ulcerates. The tumid gums in well-marked cases show a more or
less irregular or fungoidal surface, give off an offensive secretion, and
bleed readily. Indeed, in advanced cases hemorrhages from the various
mucous surfaces, slight or grave, may also take place. Under unfavorable
conditions, in those instances in which the same bad hygienic surround­
ings and the ingestion of improper food are continued, death finally
results.

While scurvy can be said to be closely allied to purpura, it clinically
differs somewhat from the latter, mainly by the asthenic and emaciated
general condition and the peculiar puffy, spongy state of the gums, as
well as by the diffused character of the cutaneous manifestation and its
usual limitation to the ankle region or lower part of the legs. Moreover,
unlike many cases of purpura, scurvy is, as a rule, readily remediable,
and usually rapidly so, although in some instances recovery is tedious.

The treatment consists in giving the patient the advantage of hy­
gienic living, proper food, with an abundance of vegetables. Lemon­ or
lime-juice has always enjoyed a reputation in the management of this
malady, and deservedly, as it is especially valuable, and is to be taken
freely. In some cases tonics are also required, such as the ferruginous
preparations, quinin, strychnin, and, in weak digestion, the ordinary
stomachic bitters, such as gentian. In grave cases stimulants are some­
times needed. The tumid, spongy, and possibly ulcerated condition
of the gums often demands treatment, and of great service is frequent
rinsing of the mouth with water, first tepid, later moderately cool. In
addition astringent and antiseptic mouth-washes are to be employed,
such as a weak solution of potassium chlorate, 2 or 3 grains (0.13 5-0.2)
to the ounce (32.), with 5 or 10 minims (0.35-0.65) of tincture of myrrh.¹
A boric acid lotion with a little tincture of myrrh is also useful. The
skin condition in most cases requires but little if any treatment, but if
extensive, a roller bandage to give support to the parts may be used. If
brawny and scaly, a mild ointment can also be applied, and if ulcerations
have resulted, they are to be treated upon general principles—cleanliness,
mild antiseptic lotions, and ointments, with the roller bandage support.

¹ Coplans (Jour. Trop. Med., 1904, p. 98), who from observations of the disease in
South Africa, believes the disease of bacterial rather than of dietary origin, places the
greatest stress upon rigorous and frequent mouth antisepsis, and believes that cases seen
early can be cured by this treatment alone.

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