hier. Since his publication a large number of cases have been recorded. Many of the earlier ones occurred in syphilitic patients, and not unnaturally the cause of the purpura was as frequently thought to be the syphilitic taint as the drug administered. Indeed, Spencer Wells (Medical Times and Gazette, 1856, 2, p. 611) advised the administration of potassium iodide as the treatment for such cases. It is undoubtedly true that some of the cases were truly syphilitic purpuras, as Fox (British and Foreign Medico-Chirurgical Review, 1865) claimed in his case, though he admitted the possibility of iodic purpura, quoting Virchow's observation of this condition in a case of cancer. Baelz (Arch. f. Heilkunde, 1875), Behrend (Berlin. Klin. Woch., 1878), Stephen Mackenzie (Medical Times and Gazette, 1879), and Zeissl (Lehrbuch. d. Syphilis, 2, p. 92) are among earlier writers who described undoubted cases of syphilitic purpura; but it is not my purpose to deal extensively with this form of purpura. I mention the references just quoted only in explanation of my acceptance of syphilis as a sufficient cause for purpura, and as an evidence that this element has been taken into consideration in the cases of syphilitics who developed purpura while taking iodide of potash. In most of these the rôle of the iodide was disclosed by the prompt effect of withdrawal and repeated administration of the drug. This is instanced in the report of Fournier (Rev. Mens. d. Méd. et Chir., 1877, i, 653), one of the earlier discussions of the subject. He records three cases in which the eruption speedily followed administration of the drug, only to subside and again appear on discontinuance and resumption of the medication. The same recurrence of the rash was observed by Mackenzie (loc. cit.) in one of his cases, and by von Janovsky (Monatschrift für Praktische Dermatologie, 1886, v, p. 445), who reports the case of a woman of twenty-two, a syphilitic, who took 30 grains of potassium iodide daily. After ten days, headache, coryza, fever, epistaxis, and purpura upon the arms and legs, appeared. The purpura gradually increased until the iodide was stopped, when the eruption disappeared in ten days. When the drug was again tried, after three weeks, the purpura reappeared when she had taken 75 grains, but without fever. Similar recurrences of iodic purpura have, however, been repeatedly observed in non-syphilitic patients. Among such cases that of Duffey (Dublin Journal of the Medical Sciences, April, 1880), which occurred in a patient suffering with mitral heart disease, that of Paul Raymond (La France Méd., 1889, i, p. 389) in a woman under treatment for arthritis deformans, that of Vidal (Journal of Cutaneous and Venereal Diseases, 1886, iv, No. 3) in a patient with cardiac disease and ancient syphilis, and that of Bradbury (British Medical Journal, 1871, i, p. 120) in a rheumatic, are in stances. Character of the Eruption.-The character of the eruption varies very much. In some instances there is simply the appearance of minute ecchymoses without any other affection of the skin and without constitutional symptoms. Mackenzie (Illustrated Medical News, 1888, i) states that "the form of purpura that most commonly results from iodide of potassium consists of a number of minute circumscribed hemorrhages on the lower extremities, chiefly confined to the fronts of the legs. They resemble cases of rheumatic purpura in position and in that they usually come out in crops, but they differ from this disease in the almost entirely painless character of the attack. The spots disappear when the medicine is discontinued." This description agrees in a general way with that given by Pignot (Dictionnaire des Sciences Médicales, 4 s. 16, p. 345), who states that the eruption occurs upon the legs, face, and body, more generally on the legs. It is discrete, petechial, and miliary, round or oval, from a pin-head to a millet-seed in size. There is no pain, nor any functional disturbance as a rule. It is very rarely attended with constitutional symptoms, then only in grave cases. Other recorded cases, however, differ widely from these in the character of the eruption as well as in the associated symptoms. In the case of Duffey referred to before there was slight redness with itching of the dorsum of the feet, purpura of the legs, and acne of the forehead and of the region of the left shoulder. In Thin's case (Medico-Chirurgical Transactions, 1879), as well as in Elsner's, the purpura was associated with bullous lesions, and the same association has been noted by others. In numerous instances the purpuric affection of the skin has been accompanied with hemorrhages from the mucous membranes or other purpuric manifestations. In the case of Virchow, referred to, there were hemorrhages from the gums and genitalia; and in one case reported by Mackenzie himself there were marked purpuric phenomena in addition to the discrete eruption of the skin. The case was that of an infant of five months, with hereditary syphilis, to whom 21⁄2 grains of potassium iodide were given. Three-quarters of an hour later the mouth and chin began to turn black, and the discoloration soon spread to the orbits and lips. The purpuric eruption visibly increased while being watched, until in an hour or so both the scalp and face were covered. The eyelids were closed and discolored, lips and chin were swollen and deep purple in color, while the bright red of the tongue and mucous membrane of the mouth presented a striking contrast. The cheeks showed numerous small spots of purpura, in which pressure showed no change. There were also a few spots on the upper arm, but none elsewhere. The next day hemorrhage in the hard palate was noted, and eczema behind the ears. Then the purpura spread over the deltoid to the upper arm. The spots were scattered over the forearm. The thighs and legs were covered with large and small purpuric spots. Two days later the eruption began to fade. The child died sixty-eight hours after the onset of the purpura. The autopsy showed purpuric hemorrhages in the skin of the face, ulcers in the cæcum with hemorrhages, and hemorrhages in the left suprarenal capsule and the testes, especially the epididymis. In Abbé's case epistaxis complicated the last two of the six attacks; in von Janovsky's epistaxis preceded the purpura of the skin; while in Elsner's there were hematemesis and melena, as well as ecchymoses and bullæ in the skin. In some instances the repetitions of the purpura have been numerous. In Ricord's case there were three distinct attacks; in one reported by Abbé (Archives of Dermatology, 1878, iv, p. 131) there were six attacks; Fournier mentions frequent recurrences; and other authors also refer to repeated eruptions without specifying their number. Associated Symptoms. - Among the recognized symptoms of iodism a metallic taste in the mouth, swelling and tenderness of the gums, increased salivary secretion, nausea, coating of the tongue, and coryza make their appearance early and in the milder cases. The same symptoms may accompany or precede the purpuric eruption. Severe symptoms, and especially nervous manifestations, such as intense headache, neuralgic pains, and even paralyses, have been recorded in more profound intoxications. Certain peculiar symptoms giving the condition a resemblance to exophthalmic goitre or thyroidism will be discussed below in connection with the case reported. Joint Manifestations.—Mackenzie made especial mention of the painlessness of the attacks, which in other respects resemble purpura rheumatica, but the case I am reporting and other instances in the literature show that the resemblance may be completed by the occurrence of swelling of the joints and severe pains. In Duffey's case there was purpura of the legs with severe pains in the knees, wrists, and shoulders, all of which symptoms subsided when the iodide was withdrawn. In Raymond's case (one of arthritis deformans) generalized pains accompanied the eruption, and in Vidal's there was severe pain in the legs and ankles. In the majority of cases, however, it is true that pain has not been a symptom of the attack. Fever. The occurrence of fever as one of the symptoms of iodism is not generally acknowledged, as it usually does not become pronounced, and is therefore easily overlooked if temperature records are not preserved; and from the nature of the cases in which iodide of potash is administered in large doses and continuously, it is unlikely that accurate observations of the temperature will be recorded throughout the treatment. There are, however, a number of instances reported in the literature of fever occurring in association with purpuric iodism. In one of Wilson Fox's cases (British and Foreign Medico-Chirurgical Review, 1865) there was purpura and a temperature as high as 102.2°. Pellizzara (Archives of Dermatology, 1881) refers particularly to the occurrence of fever with iodic eruption, and quotes from Zeissl and Fischer (Wien. Med. Woch., 1859, No. 29), who mentioned elevation of temperature of the skin. In the case of von Janovsky the temperature rose as high as 1011⁄2° at the time of the epistaxis and purpura. With these exceptions, however, I do not find specific references to elevation of the temperature as one of the symptoms of iodism of the purpuric or any other form. In most instances no reference is made to the temperature, and I assume that in many of the cases no record was preserved. In some cases, however, it is clearly stated that the temperature was normal. Amount of Iodine Necessary to the Production of Iodism.-The symptoms of iodism here referred to generally attend subacute or even chronic intoxication. They may recur very frequently, and sometimes after the administration of exceedingly small doses of the drug. Robinson (Lancet, 1893, i, p. 471) records a case of a man who was taking one grain of potassium iodide three times daily. After six doses he complained of dryness in the throat, and six days later minute purpuric spots appeared on the arms and legs, especially near the elbow and thigh. The symptoms came on after the fourteenth day. Fox (loc. cit.) records the case of a man of thirty years with tubercular syphilides and recent rheumatism who was treated with iodide of potash in doses of five grains three times daily. After the second dose purpura appeared on the legs and arms, and other symptoms of iodism set in. These cases, however, are exceptional. In most instances the symptoms of iodism have not appeared until the patient had taken a number of doses of five or ten grains, repeated three or four times daily. Withdrawal of the drug has generally been followed by immediate improvement in the symptoms, with reappearance rather more easily on a second exhibition of the drug. In a few cases the purpura has developed more readily with the potassium salt than with other iodides. In one case sodium iodide was given without causing recurrence of the iodic purpura after this had subsided upon withdrawal of the iodide of potash. Ammonium iodide, however, caused a recurrence of the purpura; in other cases the ammonium, sodium, and potassium salts behaved exactly the same. The following case illustrates the febrile purpuric type: Mr. A. G., aged twenty-three, was admitted to the University Hospital January 5, 1901. The following history is recorded: His mother is hemiplegic, having suffered an apoplectic seizure, and one sister died of a brain trouble. His father died of kidney disease. He does not recall any of the illnesses of childhood, excepting mumps and croup, the latter of which he had a number of times. In March, 1895, he fell a distance of 25 feet, striking the base of the skull, and after this was in bed for three months. For some time he was in a dazed condition; he recognized persons, but afterward remembered nothing of events. Has had repeated colds every winter since he was five or six years old. A year ago polyps were removed from his nose. There is no venereal history. He has lived a correct life in every way, using alcohol and tobacco moderately. The present trouble began about five years ago, when he was attacked with a cold that lasted for three months. He was taken with attacks of asthmatic breathing, coming on twice a day at times, and lasting for a part of the day and then subsiding. There were intervals of entire freedom from these attacks for as much as several months, with subsequent recurrences. The attacks at first came on in the middle of the night · and would last for about an hour. At first they were frequently attended with vomiting, but during the last four years he has not vomited in the attacks; and after the first six months the attacks ceased their exclusive nocturnal character, and occurred at all times of the day. The paroxysm is typically asthmatic. It comes on suddenly after a prodromal feeling of choking that lasts about an hour. Occasionally he has expectorated a little blood. On admission the temperature was 98°, the pulse 84, and the respirations 20. There was a little cough with mucous expectoration, and a few râles were heard over both lungs. Examination of the blood showed a moderate leucocytosis (11,840), but otherwise practically normal conditions. The examination of the urine was entirely negative. There was no albumin, sugar, nor any other abnormal constituent. Physical examination: Well nourished; skin normal; pupils equal; conjunctivæ slightly injected, eyes otherwise normal; lips and ears slightly cyanosed; tongue coated, pharynx slightly injected; neck short and thick; thyroid normal; sternomastoid slightly prominent; glands palpable in axillary, inguinal, and cervical regions. Chest: Supraclavicular fossæ deep; infraclavicular fossæ also more pronounced than normal. Breathing costoabdominal; better expansion on right than left. Pulmonary resonance vesiculotympanitic. Little change on forced inspiration. The lungs extend one and a half to two fingerbreadths above clavicles. A few piping râles and prolonged expiration on auscultation. Heart: Superficial area slightly smaller than normal; deep dulness a little enlarged to the right. Auscultation: Second heart sound accented at base. Abdomen normal excepting that the liver extends a fingerbreadth below the costal margin. Reflexes normal. An attack of asthma occurred shortly after admission to the hospital, and subsequently repeated attacks took place. Examination for Curschmann's spirals was negative at first, but subsequently positive. There was moderate eosinophilia. Polyps were discovered in the nose and several removed. During his stay in the hospital, in January and February, he had one or two slight attacks of fever which were regarded as due to acute bronchitis or influenza. On one occasion his temperature for a short time reached 104°. On February 12, potassium iodide, grains 5 t. i. d., was begun. On February 23 it was increased to grains 8 t. i. d. During the early part of March he seemed to be growing worse instead of better. There was continuous bronchitis, and at the same time the temperature rose to 101°, and then continued at this height or even higher. On March 19 the patient had several small hemorrhagic spots in the skin of the legs. The cause of the continued bronchitis and the elevated temperature was not determined. Previously all attacks of fever had been very temporary, lasting only a few days at the most. On this occasion it continued and steadily grew worse, and at times reached 102°, 103°, or 104°, never falling to the normal. At the same time the patient's condition was rapidly growing worse, and on March 20 he began to complain of pains in his knees. A note at the same time reads that "the cardiac condition does not seem to be changed." This note was made because a suggestion of a systolic murmur was audible and ulcerative endocarditis was suspected. On March 21 he complained of pains in his left elbow and right foot. On this date, examination of the sputum showed Curschmann's spirals, bronchial casts, and streptococci, but no influenza or tubercle bacilli. The petechiæ of March 19 rapidly faded; on March 22 numerous hemorrhages appeared on both legs below the knees, and a few above the knees. The left forearm was also involved. These spots varied in size and were quite decidedly infiltrated and consequently elevated. On the posterior surface of the right calf there were several dark-blue patches of discoloration, but in other places the spots were bright-red andwere peculiar in showing a tendency to at clustered character. They were raised above the surface and appeared in crops, so that those that had appeared a few days. before were considerably faded. The gums. were very tender and spongy and showed a bluish cyanosed line near the teeth. The breath was fetid. The leucocyte count was 21,280. The cardiac sounds were unaltered. On March 23 the note states that the spots were very numerous, clustered as before, the individual petechia varying in size from a line to two lines in diameter. The clusters, however, were in places quite large from confluence of neighboring spots. The left forearm, to a less extent the right forearm, and both feet showed a considerable uniform swelling of the skin with erythematous redness and rather marked tenderness. The purpuric spots in these situations were slight as compared with the region of the calves and sides, where the eruption was much more marked, but the skin between the lesions showed no redness at all. The joints were probably slightly infiltrated, though there was some difference of opinion as to actual involvement of these parts. At one time it was suspected that the swelling around the joints was purely superficial. The patient was in a state of great suffering and prostration. The skin was leaky and bathed with a warm perspiration. The patient was apathetic and irresponsive. The thyroid gland which had been noted as slightly enlarged before now became decidedly enlarged. The pulse was rapid and small, the rate being 120. No changes were discovered in the auscultatory phenomena of the heart. There was marked tremor of the hands and other parts. Examination of the saliva showed abundance of iodine. On March 22 the patient was given salicylate of soda, but when I saw him on March 23 I ordered a discontinuance of this treatment, and also withdrew the iodide of potash and ordered a mouth-wash of chlorate of potash with thymol. On March 24 the eruption was fading; the patient felt considerably better; the gums were still tender; the fever was less; and the pains in the feet and other joints had subsided. On March 25 the eruption was very much paler and the infiltration less. The only pain was a slight one in the left fore of other cases in which iodide of potash had been given more or less continuously. It happened that at the time of the occurrence of the purpuric case there was in my wards a patient with spinal syphilis who was receiving large doses of iodide of potash. His temperature was taken as a routine morning and evening, and I found that it was then running a mild febrile course; the highest elevations being about 100° and the depressions about 98° to 99%°. There was no explanation for this continued febricula in the man's general condition. As an experiment the iodide of potash was withdrawn, and within a few days the temperature subsided and remained normal so long as the iodide was withheld. Another case of which I have a record is the following: S. F., a servant-girl of twenty-four, was admitted to the hospital with symptoms of cardiac disease. She stated that eight years before, while lifting a heavy weight, she was seized with pain in the left side, was unconscious for several hours, and she had not been altogether well ever since. Two years before admission she began to suffer with palpitations, shortness of breath, and distress after eating. The gastric symptoms subsequently became the most pronounced. The cardiac outline was practically normal. Over the apex, which was vigorous in action, there was heard a presystolic murmur and a highly accentuated first sound, and on palpation could be felt a slight systolic thrill. There was a diastolic shock over the pulmonary region, and a distinct systolic murmur was heard in that situation. The same murmur was transmitted to the aortic area. The patient was treated in a routine way by being put at rest and receiving digitalis and nitroglycerin. Subsequently she complained greatly of nervousness, shortness of breath, and palpitations, and also of the gastric symptoms. For some time. there was almost daily vomiting with occasional streaks of blood. The Paquelin cautery was used with good effect. Sodium bromide eight grains and tincture of aconite two drops, three times daily, were administered, and the pulse-rate was reduced. The respirations, however, remained unchanged. This treatment was begun April 25, 1894. She had been complaining of much headache. This was improved by the treat ment. On July 3 potassium bromide ten grains and potassium iodide three grains, t. i. d., |