Class III.—Hemorrhages

Purpura.

Define purpura.

Purpura is a hemorrhagic affection characterized by the appearance of variously-sized, usually non-elevated, smooth, reddish or purplish spots or patches, not disappearing under pressure.

Name the several varieties met with.

Three—purpura simplex, purpura rheumatica and purpura hæmorrhagica; denoting, respectively, the mild, moderate and severe grade of the disease. The division is, to a great extent, an arbitrary one.

Describe the clinical appearance and course of an individual lesion of purpura.

The spot, which may be pin-head, pea-, bean-sized or larger, appears suddenly, and is of a bright red or purplish red color. Its brightness gradually fades, the color changing to a bluish, bluish-green, bluish- or greenish-yellow, dirty yellowish, yellowish-white, and finally disappearing; varying in duration from several days to several weeks.

Describe the symptoms of purpura simplex.

Purpura simplex, or the mild form, shows itself as pin-point to pea- or bean-sized, bright or dark-red spots, limited, as a rule, to the limbs, especially the lower extremities; fading gradually away and coming to an end in a few weeks, or new crops appearing irregularly for several months. There is rarely any systemic disturbance, and, as a rule, no subjective symptoms; in exceptional cases an urticarial element is added—purpura urticans.

Describe the symptoms of purpura rheumatica.

Purpura rheumatica (also called peliosis rheumatica) is usually preceded by symptoms of malaise, rheumatic pains and sometimes swelling about the joints; these phenomena abate and frequently disappear upon the outbreak of the eruption. The lesions are pea- to dime-sized, smooth, non-elevated, or slightly raised, and of a reddish or purplish color; the eruption may be more or less generalized, most abundant upon the limbs, or it may be limited to these parts. It may end in a few weeks, or may persist for several months, new spots appearing irregularly or in the form of crops.

As somewhat allied to this is another form (Schönlein's disease), quite alarming in its symptoms. It is rare. It is characterized by symptoms partaking of the nature of rheumatism, purpuric spots, blotches and ecchymoses, erythema multiforme, and often associated with considerable edema. The throat is also usually invaded, and indeed the first symptom is commonly in this region. Considerable constitutional disturbance, of a threatening character, is commonly observed. Recovery usually takes place.

Henoch's purpura, observed chiefly in children, resembles the above, with the erythema multiforme character and the œdematous swellings more pronounced, while the actual purpuric symptoms are less conspicuous. Gastric and intestinal symptoms and hemorrhages from the mucous membrane are commonly noted. It is fatal in about 20 per cent. of the cases.

Describe the symptoms of purpura hæmorrhagica.

Purpura hæmorrhagica (also called land scurvy) is characterized usually by premonitory, and frequently accompanying, symptoms of general distress, and by the appearance of coin to palm-sized, red or purplish hemorrhagic spots or patches, smooth, non-elevated or raised. Hemorrhage from the mouth, gums and other parts, slight or serious in character, may occur. New lesions continue to appear for several days or weeks; and in exceptional instances, repeated relapses take place, and the disease thus persists for months. It may end fatally.

State the etiology of purpura.

In most instances no cause can be assigned. The disease occurs at all ages from childhood to advanced life, and in individuals, apparently, in good and bad health alike. The hemorrhagic type is oftener seen in subjects debilitated or in a depraved state of health. A microörganism is also looked upon as a factor by some observers, especially in the grave type of disease.

State the diagnostic characters of purpura.

The appearance, irregularly or in crops, of bright-red or purplish spots, evidently of hemorrhagic nature, and not disappearing upon pressure, and as they are fading, going through the several changes of color usually observed in any ecchymosis.

How does scurvy (scorbutus) differ from purpura?

Scurvy, which may resemble the severe grade of purpura, has a different history, a recognizable cause, usually a peculiar distribution, and is accompanied with general weakness and a spongy, soft and bleeding condition of the gums.

What is the pathology of purpura?

The lesion of purpura consists essentially of a hemorrhage into the cutaneous tissues. The blood is subsequently absorbed, the hæmatin undergoing changes of color from a red to greenish and pale yellow, and finally fading away.

State the prognosis

The milder varieties disappear in the course of several weeks or months, and are rarely of serious import; the outcome of purpura hæmorrhagica is somewhat uncertain; although usually favorable, a fatal result from internal hemorrhage is possible. The variety known as Schönlein's disease is alarming, but seldom fatal. Henoch's disease is, however, always of grave import.

What is the treatment of purpura?

Hygienic and dietary measures, the administration of tonics and astringents, and, in severe cases, by relative or absolute rest.

The drugs commonly prescribed are: ergot, oil of erigeron, oil of turpentine, quinia, strychnia, iron, mineral acids, and gallic acid. External treatment is rarely called for, but if deemed advisable, astringent lotions may be employed.

Scorbutus.

(Synonyms: Scurvy; Sea Scurvy; Purpura Scorbutica.)

Describe scorbutus.

Scurvy is a peculiar constitutional state, developed in those living under bad hygienic conditions, and is characterized by emaciation, general febrile and asthenic symptoms, a more or less 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. The skin of the affected part may become brawny and slightly scaly, and not infrequently may break down and ulcerate. Hemorrhages from the various mucous surfaces, slight or grave, may also take place.

State the etiology of scurvy.

It is due to long-continued deprivation of proper food, especially of fruits and vegetables. Other bad hygienic conditions favor its development. It is seen most commonly in sailors and others taking long voyages.

How is scurvy to be distinguished from purpura?

By the asthenic and emaciated general condition and the peculiar puffy, spongy state of the gums. The cutaneous manifestation is more diffused, forming usually large palm-sized patches, and, as a rule, limited to the region of the ankles or lower part of the legs.

Give the prognosis of scurvy.

The disease is remediable, and usually rapidly so. In those instances in which the same bad hygienic conditions and the ingestion of improper food are continued, death finally results.

What treatment would you advise in scurvy?

Proper food, with an abundance of fruit and vegetables. Lemon or lime juice is especially valuable, and is to be taken freely. If indicated, tonics and stimulants are also to be prescribed. For the relief of the tumid, spongy condition of the gums, astringent and antiseptic mouth washes are to be employed.

The cutaneous manifestations, when tending to ulceration, are to be treated upon general principles.