When pains in the joints are complained of, there may be some ten derness and considerable swelling. This symptom is often spoken of as "rheumatism," and the disease is then called purpura rheumatica. It seems probable, however, that sometimes, at any rate, the lesion is due not to rheumatic inflammation but to hmmorrhage into or around the joint. If it arise from this cause the articular affection is more chronic than a rheumatic joint lesion, and remains confined to the part first attacked. There is no necessary discolouration of the skin.
During the progress of the complaint the general symptoms are often indefinite. The appetite may be good or more or less impaired. A _cer tain amount of thirst is usually to be noticed. The liver may become much swollen from congestion, and the bowels are often confined. Usually, until the loss of blood has produced anaemia, the child complains only of aching and feeling tired. The temperature is often normal, but sometimes there is irregular pyrexia. The febrile heat does not, however, appear to bear any relation to the haemorrhage. I have not found it to precede or follow in any regular manner the flow of blood.
A robust little boy, six years of age, was in his usual health when he suddenly began to bleed from the eyes, nose, and mouth. During the next month he continued to bleed every morning from the gums, and on three separate occasions had copious attacks of haemorrhage from the eyes and nose. An accidental cut on the finger also bled profusely for two hours. During all this month the boy was very thirsty, drinking any fluid he could get, even dirty water.
On admission into the East London Children's Hospital the child seemed to be well nourished and had a healthy appearance, with a fair amount of colour in his face. His gums were not spongy. His face, body, and limbs were thickly covered with purpuric spots of a brownish-red colour, which did not fade on pressure. There were in addition large bruises on the right arm, the trunk, and the left thigh. There was no enlargement of the liver or spleen. The urine had a density of 1.029. It was clear, without sediment, and contained no albumen. The heart beat in the fifth interspace in the nipple line. At the apex the sounds were healthy but muffled, and a loud anmmic murmur was heard at the base.
While in the hospital the patient had frequent hemorrhages from the nose, the mouth, the bowels, the kidneys,•and into the skin. On one oc casion he repeatedly retched and vomited large black clots of blood. He also complained much of abdominal pain, and passed large quantities of black blood from the bowels. This may, of course, have been blood poured out by the nasal fossee and swallowed ; but the haemorrhage was at any rate copious, and caused a marked blanching of the skin and much feebleness and languor. The boy's temperature varied considerably dur ing his illness. He had irregular attacks of fever during which the tem perature would rise to 101° or even higher, but the pyrexia did not always precede the gush of blood. If, however, there was fever when the haemor rhage occurred, the first effect of the flow was to reduce the bodily heat to a subnormal level.
The boy was treated first with iron, which seemed to have no effect upon the hmmorrhages ; then with aperients, which produced at first a. marked improvement ; later with iron and arsenic combined, under which he became rapidly convalescent.
When anaemia occurs, the ordinary signs of debility are noticed. The child is pallid and feeble. He is restless and complains of headache, and his pulse is frequent and irritable. A systolic murmur can usually be de tected at the base of the heart, and a loud venous hum is not uncom monly heard at the upper part of the sternum.
There may be some oedema of the ankles, and even of the limbs and face. In very severe forms of the disease the child may die from syncope or exhaustion, and sometimes death occurs in an attack of convulsions. Convulsions are due in rare cases to hemorrhage into the cranial cavity. Mr. Hallowes has reported the case of a boy between three and four years. old, who had lived in a good air and been well fed. This lad, after being languid for one day, developed bruise-like patches on different parts of the body, and died on the third day after a convulsive attack followed by rigidity. At the autopsy extensive hemorrhage was found to have oc curred into both ventricles with laceration of the brain substance. No rup tured vessel could be found.