PURPURA.

L. C. Allen, M.D., Hoschton, Ga.

Purpura is a symptom often met with in general practice, and not infrequently the condition is a grave one. The subject has not received the attention from the profession that its importance deserves. Under the name purpura a large number of symptoms, or diseases, which have the common symptom of extravisation of blood under the skin, or mucous membrane, are described. In studying the literature of this subject what most impresses one is the chaotic condition in which this literature is found. Our knowledge of hemorrhagic conditions is, as yet, far from satisfactory. The direct, immediate cause of the hemorrhages we do not know. For instance, we do not as yet know why we should have subcutaneous bleeding in one case of rheumatism, or malaria, and not in another. The exact pathological changes that are present in the blood, or blood vessels, in purpuric conditions need further elucidation.

Purpura is doubtless an eliminative reaction of the system to infection, or some form of toxaemia. This is a modern view. Accepting this view as correct, purpura may be classified, pathologically considered, as follows:

1. Infectious Purpura. This is found in typhoid fever, pneumonia, the exanthemata, septicaemia, pyaemia, malaria, rheumatism and other infectious diseases.

2. Toxic Purpura. After the administration of certain drugs, such, for instance, as quinine, copaiba, mercury, ergot, the iodides, and chloral hydrate, a purpuric. eruption is sometimes seen.

3. Cachectic Purpura. This form is seen in cases of cancer, tuberculosis, Bright's disease, Hodgkin's dis

ease, leucaemia, haemophilia, and the debility of old age, 4. Neurotic Purpura. This form is met with in hysteria, after a fight, or profound emotion, and in various other nervous abnormalities.

Clinically considered, purpura is commonly divided into two varieties: Purpura Simplex and Purpura Haemorrhagica.

In purpura simplex the hemorrhages occur beneath the skin. This form is most commonly met with in children. There is more or less malaise, loss of appetite, some times pain in the joints, and occasionally a diarrhoea.

The prognosis is favorable. The patient usually gets well in a week or ten days.

In purpura haemorrhagica, in addition to the subcutaneous hemorrhages, there is bleeding from the mucous membranes, such as the nose, kidneys, stomach, and other places. This bleeding comes on in the form of an oozing from the mucous membrane. It is most frequently seen during the course of typhoid fever, malaria, the exanthemata, rheumatism, or any serious infection. The purpuric spots vary greatly in size-from the size of a pin head to that of the palm of the hand. Gangrene of the skin has been known to follow extensive ecchymoses. Severe vomiting is common. Pure blood may be puked up. Internal hemorrhages into the brain, and is meninges, or into the lungs, or suprarenal capsule, or from the uterus, may occur. The spleen and liver may be enlarged, and jaundice is not uncommon. The gums may be spongy and bleed, but the teeth are never loosened, as in scurvy.

There is a severe type of purpura haemorrhagica known as acute or fulminating, in which the prognosis is very grave. In this form 75 per cent. of the patients die. There is usually a chill, with the temparture rising to 103 or 105, followed with marked prostration, purpurie spots rapidly appearing, and with bleeding from

mucous membranes. Restlessness, delirium, and stupor supervene, and the patient succumbs to hemorrhages, or dies in a condition of coma within a few days. Hemorrhages into the brain, suprarenal capsule, or other viscera may prove quickly fatal. Purpura occuring in the aged, or in the cachectic, is an ill omen. Purpura is a finger that points to death when it comes on in a case of chronic renal, hepatic or malignant disease. Ocurring in children, or those in middle life, during the course of an infectious disease, the outlook is not so bad.

In the treatment of purpura there are two remedies that I especially recommend, viz: the suprarenal extract, and the chloride of calcium. According to my experience these are by far the best remedies we have for this condition. Aromatic sulphuric acid is probably useful, and turpentine is highly recommended by some writers. Astringents are also recommended by writers, such as alum, lead, tannic and gallic acid. I have little faith in them, except in cases where they may be used locally. Tannic, or gallic acid, or remedies containing them, like hydrastis, might prove beneficial in cases of hemorrhage from the kidneys, or alimentary canal. Ergot is another remedy that may prove valuable.

A word of caution as to the diet. These patients should never be allowed alcohol in any form. All food and drink should be taken in a cool state, and in small quantities. Milk is generally regarded as the most suitable food.

The following case will serve to illustrate a form of purpura often met with, and also the treatment to be employed: Mr. B., aged 30, single, school-teacher, had a moderate case of typhoid fever. Progressed very well up to middle of third week. Temperature ranging from 101 to 103, pulse 100 to 110, some diarrhoea, but easily controlled, tympanitis moderate, some nausea, no delirium. About the 18th day he began to spit up small amounts of blood, but the amount was so small that no special attention was given to it. On the next day this was noticed to be increasing in amount, but still not

sufficient to cause us to think that it required any special treatment. On the third day, however, I was sent for early in the morning, and, on arrival, found that he had vomited up blood in large amounts several times during the night; both nostrils were bleeding slowly, but constantly; he was still spitting out blood, and now every few minutes; he was also passing considerable blood from the kidneys; and purpuric spots about as large as a grain of corn had occurred all over his body. He pulse had run up to 160, and was very weak; temperature, subnormal; still in his right mind, but very much. alarmed, and, as I thought, with good cause. Fortunately, the bowels were quiet. The condition of this patient appeared to be desperate. I proceeded as follows: I first gave him a hypodermic of morphine and atropine, for its stimulating and quieting effect, and because I did not want the bowels to move. Then I took a mixture of equal parts of normal salt solution, warm, and adrenalin chloride solution, 1 to 1000, and with a cotton applicator, made a thorough application to the entire mucous membrane of both nasal cavities. Instructed nurse how to do this, and directed it to be repeated every three hours regularly, and oftener if hemorrhages recurred. This stopped the nasal bleeding at once. I want to call attention to the point that I would have given the adrenalin internally, but I knew that in making the application to such an extensive area of mucous membrane that enough of it would be absorbed to produce decided constitutional effects. This proved to be the case, for it was easy to discover a marked effect upon the pulse in a very few minutes. Next I gave him 10 grains of Chloride of Calcium, in the form of an elixir, and directed this to be repeated every three hours. Also gave him strychnine and digitalis, for the heart. That was all the first day. He vomited blood once more. Never had any return of the nasal hemorrhage, but the adrenalin applications were kept up for three or four days, when they were left off, and the remedy was then

given internally. He continued to pass bloody urine for three or four days, but that was the only loss of blood he sustained. He had a little fever, at irregular intervals, for about ten more days, when it finally left him. Strychnine and digitalis were left off after a few days. but the calcium was continued until convalescence was well established. The recovery was uneventful.