General Remarks.
Blood may be effused into the skin under a variety of circumstances. The occurrence may take place as an idiopathic condition spontaneously; or secondarily in connection with other diseases of the skin. The blood-vessels may be ruptured, and so permit the escape of blood, or the blood globules may escape bodily through the actual vessel walls. The usual cause of rupture is traumatic injury. The hemorrhagic spots receive different names according to their size and shape. When they are small, in the form of red points, they are called petechiae; when larger, and more or less linear, vibices; when large in the form of bruises, ecchymosis; and when the blood collects in the form of a distinct tumor, haematoma.
The secondary forms of cutaneous hemorrhage occur in connection with typhus, measles, scarlatina, and variola, the early eruptions of which may severally be more or less hemorrhagic, the hyperaemia being accompanied by actual hemorrhage into the skin. The eruption of several of the ordinary inflammatory diseases of the skin also are sometimes complicated by a certain amount of effusion of blood. Other conditions under which cutaneous hemorrhages arise are altered states of the blood current, such as impurifications by bile products stasis of the capillaries produced in connection with kidneys and heart disease, etc.
It is only to hemorrhage occurring as a primary and independent disease that the term purpura is applied, and this we will now describe.
Purpura.
Purpura is an affection of the skin characterized by the sudden appearance of reddish macules of varying size and on various parts of the body. In a short time they become purplish, the color not being removable by pressure. After they have existed a few days they undergo changes in color similar to those which follow a bruise.
The eruption may appear in either sex, at any age, and in almost any condition of general health; in those who are greatly enfeebled as well as in those in an apparently robust condition.
The eruption may cover the greater, part of the surface, but more frequently is confined to the lower extremities.
A single purpuric, outbreak may be the beginning and end of the trouble, or, as frequently happens, fresh crops may appear at regular or irregular intervals for a considerable period. The affection has been noticed in connection with suppressed menstruation, apparently taking the place of the natural flow. The foregoing features characterize purpura simplex, which, as a rule, is not a serious affection.
Sometimes, however, the hemorrhages are not confined to the cutaneous tissues, but may take place internally as well, and serious loss of blood may result from the rupture of superficial capillaries in the various mucous membranes, and especially those of the gastro-intestinal tract. This form is termed purpura hemorrhagica.
The etiology of purpura is absolutely unknown. It has no connection, however, with the congenital anomaly known as hemophilia, nor with the acquired condition known as scorbutus, or scurvy.
Diagnosis.-The name should be confined to the simple affection we have described, and should not be used in connection with any other distinct disease that happens to be complicated with minute hemorrhagic effusions.
Scurvy should never be mistaken for purpura, or vice versa. In the former disease the limbs are swollen and tense, and the hemorrhages form diffuse patches rather than macules. The gums also are swollen, and ready to bleed at the slightest provocation. Purpuric blotches are likewise met with in spleiosis rheumatica; but the pronounced arthritic symptoms serve as a mark of distinction.
Petrone found single, small, ovoid micrococci in the blood of a young man who was suffering from purpura hemorrhagica rheumatica febrilis. Some of his blood was subcutaneously injected into a rabbit. After two days numerous hemorrhagic spots appeared in the skin of one ear. By this experiment Petrone thinks he has demonstrated the infectious nature of the disease.
Treatment.-Piffard says that one drug stands prominent and alone as an efficient agent in the treatment of purpura, and this is ergot. He advises the use hypodermically of ergotine, or drachm doses of the fluid extract given internally two or three times a day. He also advises against the use of iron, quinine, and similar drugs of the tonic class.
The diet should consist of the most nutritious articles. Malt preparations are useful foods. Outdoor exercise is very beneficial. Locally, hamamelis is one of the best remedies, and when there is much hemorrhage, ice treatment may be resorted to.
Simple purpura responds best to Arsenicum alb., and the hemorrhagic form to Sulph. acid. Other remedies may be indicated as follows:
Arnica.-Yellow, blue and reddish-blue spots; in lying in women.
Baptisia.-Livid spots all over the body and limbs, of the size of a three-cent piece; great languor; desire to lie down; tired, bruised, sick feeling all over the body.
Berberis.-Petechiae on the right shoulder or left humerus, back of the head and wrist. Bruised pain with stiffness and lameness in small of back; renal or vesical complications.
Chloral.-Its continued use internally has caused purpura hemorrhagica, preceded by a bright red blush, erythematous in aspect, but permanent under pressure, followed in two days by deep red spots, mixed with mottled livid patches. The buccal mucous membrane becomes red, raw, ulcerated, and blistered, breath fetid, pulse 120 and feeble. A desquamation ensued, but with bed-sores in some places. In other cases it caused petechiae, vibices, and ecchymoses.
Cocoa.-Dark spots like ecchymoses under the skin, about the size of a pin’s head, on the fingers.
Erigeron.-When apparently well-indicated remedies fail.
Hamamelis.-Hemorrhagic purpura; profuse epistaxis; passive, venous hemorrhages; great lassitude and weariness; in old people.
Lachesis.-Simple purpura; blackish-blue spots; great physical and mental exhaustion; climacteric troubles.
Mercurius.-Bluish-red spots, darker on the margin and lighter in the centre. Other symptoms of Mercurius present.
Phosphorus.-Petechial spots on the skin; bluish-red spots on the legs; purple-like exanthem over the whole body.
Rhus tox.-Simple purpura; dark brown spots on inside of ankles; rheumatism of joints worse during rest; swollen ankles after sitting too long.
Terebinth.-Hemorrhagic purpura; intestinal hemorrhages; hematuria.
Veratrum vir.-Simple purpura; galvanic-like shocks in the limbs; rapid pulse; slow respiration; in plethoric individuals.
