CLASS II – HEMORRHAGES [Class II -Haemorrhages]
Definition. – A non-traumatic extravasation of blood into the skin, which does not disappear on pressure.
While purpura is not a distinct disease but rather a symptom of many diseases, like pruritus, it merits separate consideration. Hemorrhages in the skin according to size taken the form of (1) petechiae, which are pin-point to finger nail in size, non-elevated muscles; (2) vibices, similar lesions occurring in streaks or lines; (3) ecchymoses, large non-elevated, round or irregular shaped lesions; (4) ecchymomata (hematomata) which are still larger in size, appearing as pronounced elevations or tumor-like effusions; (5) papules (lichen lividus) when the effusion is at the mouth of a hair-follicle. Hematidrosis or blood sweat will be considered under diseases of the sweat-glands. The generally accepted division of purpura of mild, moderate and severe grades into purpura simplex, purpura rheumatica and purpura hemorrhagica is retained for the sake of simplicity.
Symptoms- The characteristics of most purpuric lesions are their sudden appearance, unchanging size (except by fresh hemorrhage), the non-disappearance of color on pressure, and the presence of bruise-like spots which progressively change in color from the early bright red or purplish red to the later blue, green, brown, yellow and yellowish-white tints.
Purpura simples is the usual clinical type, often preceded by moderate systemic disturbances with few if any subjective sensations. The lesions are pin-head- to pea-sized, round or oval, bright or dark red macules. Appearing suddenly, they are circumscribed, smooth, non-elevated and symmetrically distributed and are frequently limited to the legs but may appear anywhere. Fresh lesions appear in crops so that an attack may last from two or four weeks, each crop passing through the gradations of color before mentioned.
Purpura rheumatica (peliosis rheumatica; Schonlein’s disease) is frequently described as a separate inflammatory disease, but its lesions and etiology are so similar that it seems best to discuss it here. It is always introduced by fever, malaise, insomnia and rheumatic pains in the legs, especially in the joints of the knees and feet which are frequently swollen and tender. The eruption consists of slightly raised well defined papules and macules, split-pea to finer-nail in size. The favorite sites are the knees, calves, ankles, wrists, elbows, and least of all, the trunk. The pains generally subside at the development of the eruption, but it may be otherwise. While a bright red at inception, the lesions soon change in color as in other purpuras and disappear by absorption in ten to fifteen days. The whole disease process may last a few weeks or persist with relapses for several months. There have been many cases reported that were closely allied to visceral, arthritic, and gastrointestinal conditions and these complications must constantly be borne in mind. In fact cutaneous, arthritic and gastrointestinal symptoms are evident in most cases, but usually one group is pre-eminent. The close relation of some cases of this disease to erythema multiforme is clearly marked.
Purpura hemorrhagica (land scurvy; morbus maculosus Werlhoffii) may follow the simple form, from which it differs chiefly in degree or may appear without antecedent symptoms. It is usually preceded by rheumatoid leg pains, lassitude, debility, headache and fever. The hemorrhagic patches come out suddenly in considerable numbers, appearing first on the lower extremities and contiguous parts of the trunk, but later the entire surface may be invaded by new crops. Hemorrhages take place into the inner structures or cavities of organs and bleeding may occur from the mouth, nose, throat, stomach, intestines, bladder, etc. The duration of an attack is seldom more than two or three weeks. Death intervenes from rapid exhaustion. The size, shape and color of the hemorrhagic lesions are not uniform, these features depending largely upon the location, duration and general condition.
There are a number of minor purpuric conditions which need mention. Hemophilia (bleeder’s disease) is characterized by free and persistent bleeding form slight traumatisms and is often hereditary.
Hematomata (blood tumors) vary in size, consistency and shape. There may be superficial or deep seated. All but one of my own cases occurred in infants or children suffering from infantile scurvy (Barlow’s disease).
Purpura scorbutica (scurvy) occurs principally in those long deprived of proper food such as fruit and fresh vegetables and from poor hygienic surroundings and lack of exercise. Systemic depression, swelling of the joints, variable fever, with petechiae, ecchymoses and ecchymomata are the main symptoms.
Purpura papulosa is occasionally seen in the form of small, projecting lesions at or about the hair-follicles usually on the legs of aged, scrofulous or cachectic individuals.
Purpura medicamentosa results from some idiosyncrasy to a drug or drugs and will be found outlined under dermatitis medicamentosa.
Etiology and Pathology. – The tendency to purpura may be hereditary as in cases of hemophilia but it is more often acquired through influences which change the quality of the blood, interfere with the integrity of the blood-vessels, or produce temporary derangement of the vasomotor nerves. It is common in both sexes and at all ages, although the usual limits are between ten and forty years. The hemorrhagic effusion apparently may be caused by many and various factors such as certain drugs, notably the snake poisons, bromides, iodides, salicylates and chloral. It has been noted in the course of, or following, malaria, septicemia, scorbutus, variola, typhus, pyemia, syphilis, influenza, rheumatism, nephritis, or functional and organic nervous disorders. While microorganisms have been discovered and may be causative in grave cases, there is much diversity of opinion concerning the findings. Osler regards erythema multiforme, urticaria, angioneurotic edema and purpura as expressions of faulty metabolism. In fact, the causative features might be divided for study into vasomotor, toxic, and infectious groups. Whatever the toxic or pathogenic factor acting primarily on the nerve centers, the peripheral nerves, the blood itself or the blood-vessels, there is a deposit of blood or blood coloring matter in the true skin. It may be a simple transudation of blood coloring matter or blood itself from the rupture of a small blood vessel or by diapedesis.
Diagnosis – Contusions are distinguished by their location on exposed parts, their non-occurrence in crops, and the history of an accident. Erythema multiforme presents inflamed lesions which appear on pressure. Scurvy will give a history of deprivation of vegetable food and fruits and is accompanied by softening and sponginess of the gums, while the hemorrhagic lesions usually found about the ankles show a tendency to swelling and ulceration. Flea bites may become slightly purpuric but do not appear in crops and a central punctum is usually seen surrounded by an erythematous halo. Drug eruptions may be eliminated by inquiry as to their use.
Prognosis and Treatment. – The outlook is good for Purpura simplex and for most cases of the rheumatic type, but it is impossible to determine the evolution of an attack. An internal hemorrhage or Purpura in the new born, in the old and feeble, or during pregnancy will commonly lessen the chances of recovery. The outcome of purpura hemorrhagica is less favorable.
Treatment will depend upon the possible etiological factors, hence improved nutrition by diet, fresh air, sunlight and other physiological means is often indicated. The chief treatment in scorbutic states is the special improvement of diet. Rest in bed should be insisted upon except in very mild cases while in the severe forms, bed treatment is essential after the hemorrhages have ceased. Local applications of astringents or ice, together with supporting bandages upon the dependent parts are advisable if the case is severe. Of all the specific internal medication such as the tincture of the muriate of iron, ergot, oil of turpentine, silver nitrate (1/6 grain t.i.d.), calcium chloride (15 to 30 grains t.i.d.), and adrenalin chloride (1 : 1000), only the last in full dosage commends itself to us. Potentized remedies are very valuable and usually all sufficient; see Arnica, Arsenicum,Berberis, Bryonia, Carbo veg., China, Chlorum, Coca., Copaiva, Crotal., Kali iod., Lachesis, Nat. mur., Phosphorus, Rhus tox., Secale, Sulphur acid, Terebinth., and Vipera.