PURPURA ILEj1ORRIIACICA. MORBUS MACULOSUS WERLHOFTI The hwmorrhages occur not only on the external skin and in the subcutaneous cellular tissue, but also in various mucous membranes and in the internal organs.
The affection usually begins quite suddenly without prodromata while patients are in the best of health, by the appearance of blood spots over the en tire trunk and the extremi ties. These spots are partly similar to those in purpura simplex, but most of them are considerably larger up to the size of a small dish and coalesce into large patches. Their contour is irregular, partly round, part ly oval and partly striated; color dark red with bluish or brownish tint; and the body attains quite a pecu liar tiger-like appearance. Here and there the rhages assume the form of subcutaneous infiltrations. In severe cases, where the blood spots coalesce to a considerable extent, the par ticular extremity appears quite dark, and covered with wheals similar to gangrene, except that the odor is absent. Some times the hcemorrha-ges extend over small areas, but invade deeper layers and form coarse knots.
These skin luzemorrhages arc associated with hfemorrhages from all kinds of mucous membranes, especially from the nose. Epistaxis is one of the regular symptoms of the affection. Then there appear blood spots on the mucous membranes of the lips, palate and tongue, less frequently on the conjunctiva or iii the ear. Memorrhages on the mucous membranes of the intestine and the bladder are shown by the excretion of bloody stools and bloody urine, but, like kemoptosis and haematemesis, this occurs only in very rare and very severe cases. The joints, as a rule, remain uninvolved.
There is such a pronounced general tendency to haemorrhage that slight pressure on any part of the body suffices to produce an extrava sation of blood into the skin, the subcutaneous cellular tissue, or the• joints. In slight external injuries occasioned by scratching with the fingernails, injections, punctures in blood examinations, there are Often hemorrhages which may become dangerous on account of the difficulty to control them.
The general condition is sometimes disturbed only slightly but in many cases very perceptibly: the children are ill-humored, fagged out, tired, ask to go to bed, complain of headache and look pale. In severe. cases an almost typhoid condition may be developed. The temperature is not materially elevated as a rule, but under certain circumstances. may rise to 39.5° C. (103° F.) in the evening. Pulse sometimes slow. More serious disturbances of the general condition will then appear, if severe. and frequent epistaxis has caused profuse loss of blood. The debility may then become pronounced.
Course and majority of cases have an acute. course without any actual repetition of the attacks. When the spots. have reached the climax in point of number and extent, which is gen erally the case in about a week, they become paler and change color along with the changes of the blood-pigment. The frequent bleedings. from nose and mouth come to a standstill, feces or urine which may have been tinged with blood, resume normal conditions and after about fourteen days recovery is complete.
Sometimes, however, the onset is slow, and then the affection takes; a much more chronic course. The hannorrhages on the skin, from the nose and gums, etc., are so frequently repeated that many weeks and months may elapse before a cure is effected. In fact, when the inter vals of apparent health are of longer duration, the trouble extends over several years. These are the cases which owing to considerable loss of blood may lead to grave conditions and even death. On the other hand, cases have been reported which in spite of an acute course have ended fatally within a few days. On the whole, however, the termination is favorable.