Purpura.
Synonyms:—Hemorrhagic diathesis; hemorrhea petechialis.
Definition:—Under this title are included several varieties of extravasation into or beneath the skin and mucous membranes; a condition symptomatic of a perverted condition of the nutrition or of a serious alteration in the character of the blood.
There are two distinct classes of purpura; primary and secondary. The secondary form is the result of the influence of severe diseases; of the conditions which attend these diseases, upon the character and quality of the blood, upon the circulation and upon the circulatory organs, or upon the nervous influence which governs the circulation. These are the infectious diseases, those which are due to direct blood depravation, as scurvy, hemophilia, or anemia and leukemia, malignant growths, and locomotor ataxia, as well as poisons and muscular strain, and the physiologic influence of certain drugs.
The primary form, known as idiopathic purpura, occurs from causes which are at present unknown. There are three varieties: First, the simple form—purpura simplex—simple purpura; second, the arthritic form—arthritic purpura, purpura rheumatica; and third, the hemorrhagic form—purpura hemorrhagica.
Simple purpura occurs in children as they approach the age of puberty. It will develop during a condition of apparent perfect health, or it may be accompanied only with some apparently simple stomach disorder, or the child may be recovering from an attack of some infectious disease. The hemorrhage occurs in the form of multiple small areas of ecchymoses, the size of a split pea, which gives the skin a finely motted appearance. It appears upon the ankles and over the shins, soon extending to the knees, or it may appear on the arms, or upon the body. The condition may also appear as minute points of extravasation in the hair follicles, or the extravasation may occur across the skin in streaks known as vibices or more general extravasations may appear. The color may be a bright red, or dark purplish red at first but becomes faded later and produces a yellowish green discoloration of the skin and gradually disappear with no increased impairment of the patient's health.
Arthritic purpura is of extremely obscure origin. It occurs among males from twenty-five to thirty-five years of age, seldom being seen in females. It is ushered in with fever, the temperature ranging from 100° to 102.5° F., and an acute affection of the joints characterized by tenderness, swelling, and occasionally quite severe pain.
With this there are ecchymoses or petechial spots over the joints which may extend over the extremities, although they appear usually upon the legs only. There may be edema, or bullae, and hemorrhage may occur from the mucous membranes of the nose and from other localities. The constitutional symptoms may be quite pronounced, and sore throat with derangement of the digestion, or enlarged glands, and albuminuria, may appear. The disorder persists sometimes for months and requires a long time for its complete disappearance.
That form of this disorder which occurs in childhood is known as "Henoch's purpura." It has all the manifestations above described, developing more rapidly and is of a more severe type. It is accompanied with severe pain in the bowels, vomiting and severe diarrhea, and there may be intestinal and reual hemorrhage. The purpura is scantily developed usually. In the hemorrhagic purpura we have more extensive extravasations than in either of the other forms. It is frequently a complication either of infectious disease, or it appears while the patient is in poor health from other cause. It occurs during early middle life, but is frequent in young women of feeble vitality. It occurs with marked symptoms and with considerable abruptness. There is disability, loss of appetite, malaise and headache, with fever, but the temperature seldom rises above 103° F. The pulse becomes rapid and ultimately feeble.
It is observed that small petechial spots have appeared upon the skin and these increase to hemorrhagic ecchymoses or extravasations quite rapidly. Nose bleed mays appear before these have been observed, but usually they appear nearly simultaneously. The epistaxis is difficult of control and soon recurs and persists, and other hemorrhages occur. The patient becomes weak and soon there is marked prostration with pain through the muscular structures and in the joints and limbs, and in the chest. Other hemorrhages soon follow. There may be hematemesis, or hemoptysis; or hematuria, with perhaps nephritis, may follow, or there may be cerebral hemorrhage. The patient becomes pale immediately, and anemia with extreme pallor is an unavoidable result. The conditions continue for ten or twelve days, except in the malignant form which will terminate fatally usually in a few days.
Prognosis:—The prognosis is unfavorable in most cases and should always be guarded. The danger depends upon the extent of the hemorrhages and the amount of blood lost.
Diagnosis:—The sudden appearance of a condition pronouncedly hemorrhagic, without scurvy or other pronounced and plainly marked cause of extravasation and hemorrhage, with acute prostration and anemia, will confirm a diagnosis in this disease.
Treatment:—Purpura simplex should be treated expectantly. No medication may be needed unless to correct stomach disorders, or other attendant conditions, or to quiet the anxiety of the patient or friends. In pronounced and protracted cases the patient should have iron in an easily appropriated form, and the best tonics. The tincture of the chlorid or ethereal tincture of the perchlorid will do well. Arsenic is advised and the strychnin arsenate will prove of service when there is debility of the nervous system with circulatory enfeeblement. Remedies should be avoided which inhibit the coagulating power of the blood, or which act as depressants to the capillary circulation. Ergot and the salicylates are used, but I believe them both to be contraindicated in all forms of the disease because they exercise this depressing or stagnating influence.
The patients should be treated with extreme care and consideration. They should be put to bed and relieved of care and anxiety. The food should be frequently administered in fluid form, and of easy digestion. No depleting or depressing measures of any kind should be used. The hemorrhage should be controlled by erigeron or geranium, or with the inorganic styptics. Rhus aromatic has been extolled and thuja will exercise a beneficial influence. The sub-sulphate or the tincture of the chlorid of iron may be given freely or aromatic sulphuric acid will be available. For their alterative influence the best of our alteratives should be used; hydrastis, echinacea, berberis, burdock, yellow dock and kalmia are advised. The general health of the patient must receive persistent attention and the best of surroundings and an abundance of judicious out of door exercise must be taken.
