472 THE HEMORRHAGIC DIATHESES 



differ from flea-bites by the absence of the circumscribed circular areola, 

 ■which is only seen in acute cases and soon disappears. The face almost always 

 remains entirely exempt. Upon the extremities the extensor areas are invari- 

 ably more markedly implicated than the flexor areas. In form and size these 

 cutaneous hemorrhages usually resemble petechise, i. e., they are of the circum- 

 ference of the head of a pin. Occasionally isolated, more extensive hemor- 

 rhages are observed, which are scarcely larger than a pea. In a short time the 

 hemorrhages change their color, and undergo the well-known alterations in 

 color of extravasated hemoglobin, or may cease quite suddenly, without leavmg 

 any pigmentation. After a few days at the longest, during which time relapses 

 frequently occur, they become pale and disappear, and the disease may be 

 looked upon as having run its course. The patients, who are sometimes a 

 little anemic, convalesce and the disease terminates in complete restoration to 

 health; or one or several relapses of the same mild nature may occur. Never- 

 theless, after the process has run its course upon the skin, it is well to make 

 regular and careful examinations of the urine for albumin. 



The disease designated as purpura hemorrhagica represents a severe and 

 tenacious type in which, besides cutaneous hemorrhages, bleeding also occurs 

 into the mucous membranes. This variety may also develop without pro- 

 dromes, and run an afebrile course. It differs from the previously described 

 form, above all, by the fact that the hemorrhages are more profuse and more 

 extensive, so that the body looks as if it had been sprinkled with blood. Be- 

 sides punctiform hemorrhages, extensive suggillations occur which sometimes 

 reach as deep as the cutis, forming hard infiltrations. Sometimes large con- 

 fluent blood spots, sometimes streaks and globular or concentric figures, or 

 eonfiuent masses of irregular arrangement, are noted. Thus large areas, or 

 the greater part of the entire cutaneous surface, may be implicated so that 

 only small patches of skin between the hemorrhagic spots remain entirely 

 free. The deeply situated strise-like hemorrhages, over which the skin shows 

 all the colors of the rainbow, are very characteristic. These are frequently 

 found in the popliteal space, also upon the upper arm and thighs, occasionally 

 upon the buttocks, and give the impression, by their yellowish green or bluish 

 red color, that they were produced by a blow, a fall, or a contusion. 



Similar discolored cutaneous areas are found in scurvy due to deeply-seated 

 extravasations which have undergone the same changes in color that extrava- 

 sated hemoglobin shows. These extravasations may be deeply situated in the 

 muscles and cause decided hematomata. 



Fever may be entirely absent; if evening rises in temperature occur they 

 are usually slight, the temperature rarely exceeding 101.3° P.; more fre- 

 quently, however, this form runs its course without fever. Occasionally, but 

 by no means always, hemorrhages take place in the mucous membranes. The 

 earliest are in the nasal mucous membrane, and may produce more or less 

 severe epistaxis. 



This is followed by hemorrhages of the mucous membranes of the lips, 

 cheeks, palate, and gums, without, however, as in the case of scurvy, giving 

 rise to loosening of the teeth or to ulcerative processes in the gums ; yet occa- 

 sionally there is a loosening or swelling of the gums and also even hemorrhage. 



