492 THE HEMORRHAGIC DIATHESES 



Besides small hemorrhages, not infrequently other forms of deeply situated 

 hemorrhages take place in the subcutaneous tissues; indurated, reddish or 

 bluish, scarcely movable suggillations and infiltrations appear between the 

 periosteum and the external skin (for example, upon the tibia and the vault 

 of the skull), also in areas in which no bones lie just beneath the so-calledN 

 erythema nodosum. These larger and smaller infiltrations, over which the 

 skin shows a bluish discoloration and is but slightly movable, are found par- 

 ticularly in areas upon which external pressure has been exerted for some 

 time. These are found occasionally in the course of purpura with and with- 

 out arthritic affection, but they do not make the slightest impression upon the 

 course of the disease. 



Eegarding the seat of the peteehise, the lower leg is most frequently 

 attacked ; next, the abdomen, the back and the upper extremities ; most rarely, 

 the face and the mucous membrane of the mouth. 



I must not omit to mention that in undoubted simple purpura the gums 

 are sometimes very decidedly affected, while, as is well known, cases of scurvy 

 occur without disease of the gums. But we should judge very superficially if 

 we drew from this the conclusion that the latter is a mild form of scurvy, or 

 the former a severe purpura. In this connection I will refer to the descrip- 

 tion of scurvy (see page 402), and will here simply state the fact that in 

 the course of purpura disease of the gums occasiona,lly occurs, and may lead 

 to severe changes therein with fetor but without the sponginess and ulceration 

 and destruction of the gums or the loosening of the teeth which is so common 

 in the case of scurvy. 



The number of successive hemorrhagic eruptions on the skin varies within 

 wide limits from one to twenty attacks ; on an average, four attacks have been 

 mentioned. 



The relation between the time of the appearance of cutaneous hemorrhages 

 to the other symptoms is a very changeable one; usually, it is true, the former 

 is the earlier symptom. But in children, according to the descriptions of 

 V. Dusch, this rule does not hold and very frequently attacks of severe intes- 

 tinal phenomena without the simultaneous appearance of purpura are ob- 

 served, or vice versa. An infianimatory effusion is present in one or more 

 joints which, on account of its long existence, may remain until several crops 

 of purpura have appeared and disappeared. An effusion of this type in one 

 or another joint is somewhat more rare in children than in adults, in whom it 

 appears in about 50 per cent, of the cases ; edema in the surroundings of the 

 affected joint is met with particularly in adults. 



The effusion is rarely very marked, never becomes purulent, and leaves no 

 disturbances of motion behind. The visible swellings are preceded in almost 

 all cases by arthritic pains or by sensitiveness upon pressure and movement. 

 The joints of the lower extremities are most often attacked, after this the 

 joints of the hands. The differential diagnosis between purpura rheumatica 

 and purpura gonorrhoica may be very difficult under some circumstances, espe- 

 cially if the patient denies a preceding gonorrhea. The prognosis of the former 

 is usually favorable. Peliosis rheumatica differs from acute articular rheu- 

 matism in its entire clinical picture, in the course of its fever, particularly in 



