On April 17th I was requested to visit Mr. C, of this city. A stranger to me, he showed himself to be a inau of considerable intelligence, of excellent physique, well formed, of medium height, good weight, and nervous temperament. Upon inquiry I learned that he had always enjoyed excellent health, had been accustomed to observe unusual regularity in all his habits of life, and had never been addicted to the use of stimulants or tobacco in any form. His occupation was such that he spent most of

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... he daytime iu the open air and required considerable active exercise. He was nicely housed, and in comfortable circumstances in all respects. So far as could be ascertained at the time there appeared to be no hereditary, congenital, or acquired disposition to disease in any form. He had experienced his usual excellent health until a few days or a week prior to the date upon which I was consulted for the first time. During that interval he had complained of some languor and inability to attend properly to his customary routine duties. Without experiencing any chill or even any sensation of chilliness, observing no symptoms of fever, he soon noticed pain iu his ankles, followed in a day or two by tenderness and swelling of these joints. Subsequently both knee joints became similarly affected. When he first came under my observation, he was in bed, pulse 100, temperature 100,6°P., respiration normal. General appearance somewhat pale and careworn, considered to be due, in a great measure, to loss of sleep and anxiety on account of the interruption of his business, in addition to the pain from which he had suffered. There had been sleeplessness, loss of appetite, and general deterioration of strength, but the ordinary functions appeared to have been well performed. The beforementioned joints were painful on pressure, somewhat swollen, and slightly reddened. The surface of the body generally was warm, but not moist. The lower extremities, below the knees, were cooler to the touch than the rest of the body. Examination of the thoracic and abdominal organs showed nothing abnormal. No analysis of the urine was made at the time, but inquiry elicited nothing unusual concerning it. The diagnosis of rheumatism, probably subacute, was readily made. I recommended that the affected joints should be enveloped with cotton batting, aud prescribed salicylic acid iu the usual way. Ou the following day I learned that my directions had been carefully observed, that the ordiuary effects of the acid had been experienced during the night, that the pains had been relieved considerably, aud that he had had some sleep ; pulse 98, temperature 98.6°F ., respiration easy and regular, heart sounds normal. I advised a continuance of the acid for a day or two, five grains every six hours, and also of the cotton wool dressings, to he replaced subsequently by flannel, and also a resumption of ordinary diet. April 21st, three days later, I was requested to visit the patient again, when I learned that, during the preceding night, there had occurred what he considered 1 Read before the Boston Society for Medical Improvement, November 28, 1881. 68 to be a return of the symptoms which had existed at my first visit. I found the joints presenting about the same appearance as before, and the temperature lud again increased to 100.4°F. The acid had been stopped the preceding morning. I advised its resumption, and gave general directions similar to those given at my first visit. I heard nothing more from my patient until May 2d, eleven days later, when I was summoned to him in great haste to relieve a very profuse and obstinate epistaxis, which already had continued several hours, and had become more violent in spite of the vigorous use of ordinary household remedies. Upon my arrival, the blood was flowing freely from both nostrils and the mouth. The patient's face was blanched, the general surface, as seen at a hasty glance, was pale. Both lower extremities, below the knees, were enlarged, apparently cedematous. The wrists and hands were in a similar condition. These parts, especially the lower extremities, were thickly studded with purpuric spots, some of them the size of a bean, or a little larger. The pulse was rapid and weak, but its exact frequency was not determined. I resorted to compression of the facial artery and to the use of various styptics, and finally succeeded in controlling the haemorrhage by cotton wool tampons soaked in a solution of subsulphate of iron. In the mean time I was informed that since my previous visit the condition of the patient had improved somewhat, that is, the pains had subsided and his strength had returned to some extent. He had been able to sleep tolerably well, especially in the sitting posture. The swelling of the joints, however, had continued without perceptible change (they had not noticed the enlargement, apparently cedematous, of the lower limbs and hands), and having misunderstood my directions, he had continued to take the salicylic acid during the interval for the purpose of reducing the swellings. As near as I could estimate, he must have taken in all about three hundred grains. No immediate cause could be assigned by the patient or his wife to explain the haemorrhage. Upon inquiry I was unable to learn that any of his family were " bleeders," or that he had been liable to attacks of haemorrhage of any kind. He had never had a tooth extracted, and the only fact of any importance in this direction which I did ascertain was that he never made use of a stiff tooth-brush, because it was liable to make his gums bleed a little. Before leaving him I examined him quite carefully. The pulse was rapid and weak, but regular. The respiration was a little hurried and somewhat labored. Nothing abnormal could be detected in the thoracic or abdominal cavities. The joints presented about the same appearance as at my first visit, the lower limbs pitted on pressure, as also did the hands, and the purpuric spots were present, as they have before been described. I ordered tincture digitalis and ergot with perfect rest and simple, unstimulating diet. On the following morning I was again summoned in haste, on account of a recurrence of the epistaxis. Upon my arrival I found the blood issuing copiously from the mouth, obviously from the posterior nares, and oozing from the gums, which, however, on being cleansed, displayed the clear, glistening membrane peculiar to the tissues of the oral cavity, without any appearance of spongiuess or inflammation. The blood was also making its way outside the styptic tampons, which were removed and fresh ones substituted ; but The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SAN DIEGO (UCSD) on June 22, 2016. For personal use only. No other uses without permission. From the NEJM Archive.