480 THE HEMORRHAGIC DIATHESES 



therefore regard this not as a special form of purpura but as a special mani- 

 festation of the same transitory hemorrhagic diatheses which in all cases have 

 one and the same pathogenetic cause. 



According to v. Dusch and Hoche the affection occurs especially in youth. 

 In earliest childhood, from the first to the third year, and in advanced age, 

 beyond the forty-sixth year of life, no case is known; after the third year 

 the number of cases gradually increases to its maximum between the ninth 

 and twelfth years. The frequency then remains about the same up to the 

 twenty-fourth year. Beyond this age the affection again becomes quite rare. 



Males are more frequently attacked than females ; of forty patients whose 

 sex is mentioned 33 were males and 7 females. These reports regarding age 

 and sex differ decidedly from those of other authors. Eegarding sex, I have 

 noted a decided preponderance of the affection in males. 



As predisposing causes, besides recovery from a previous acute rheumatic 

 attack, unfavorable hygienic conditions, damp dwellings and insufficient nutri- 

 tion are sometimes noted, but among the cases there are also patients who have 

 not been subjected to these influences. It is necessary to emphasize this, as 

 purpura is still occasionally spoken of as a disease of the proletariat, and as 

 the expression of a certain general cachexia. 



With more or less disturbance in general health of varying duration, accom- 

 panied by headache, lassitude, anorexia, etc., rheumatoid pains appear which 

 are drawing or tearing in character, not strictly localized, but in various parts 

 of the body, having their seat particularly in the lower extremity and in the 

 back. At times there is a transitory edematous swelling in the affected regions. 



Some of the patients now take to bed, others continue to follow their ordi- 

 nary pursuits. Soon, however, severe pains occur in one or more joints, usu- 

 ally without any perceptible external change in the affected area; in other 

 cases one or more joints begin to swell, the skin reddens, becomes hot, and 

 in the surrounding areas edematous infiltrations appear, quite as in acute 

 articular rheumatism. In this stage sometimes mild fever is noted ; tempera- 

 tures reaching 101.3° F. are rare, as are high temperatures in the later course 

 of the disease. 



As a rule, the pains and immobility of the joints cause the patient to send 

 for a physician, and frequently he is the first to note the purpuric areas, which 

 are at the onset isolated, arising without any subjective symptoms. IJsually 

 the eruption causes itching only when it begins with urticaria. Generally 

 a period of several days intervenes between the occurrence of the joint pains 

 and the appearance of the first eruption of purpura. 



The purpura itself, in the beginning usually bright red and consisting of 

 small, irregular and isolated spots, or groups formed of these, gradually 

 coalesces into larger, irregular areas, which in the course of a few days show 

 a change in color and become bluish or yellow or dark brown. 



From the lower leg (where they frequently but by no means always appear 

 first) they distribute themselves gradually by continuity, or in jumps to the 

 upper thigh, buttocks and gluteal regions. New eruptions appear upon both 

 arms, or upon the trunk, so that sometimes the entire body, particularly the 

 region of the larger joints, appears covered with purpuric spots. 



