Part 4

Mr. SPENCER HURLBUTT showed a _case for diagnosis_. The patient was a delicate-looking woman, aged 22 years, with a symmetrical eruption affecting both legs. The disease first appeared three months ago as a brownish-coloured spot on the outer side of the right calf, which was followed at intervals by similar ones on each leg, and these had gradually enlarged until the present time. There were now ten to twelve patches of varying sizes up to that of a florin situated upon the back and outer surface of the legs. The lesions consisted of fairly well-defined, non-indurated, circular, dull-red patches, with thin adherent scales, their general appearance being suggestive of psoriasis which had undergone treatment. The usual situations affected by that disease were, however, free from the eruption, and severe itching, especially toward night-time, was a prominent symptom.

The general opinion was that this was a case of seborrhœic dermatitis of a psoriasiform type.

* * * * *

Dr. GRAHAM LITTLE showed (1) a case of _Tinea cruris_ in a private patient, a Japanese gentleman, an exponent of the art of ju-jitsu. The patient had noticed the eruption for about a month and a half, but could not be certain that he had not the first trace of it before he left Japan, six months ago. He was engaged in teaching the national form of wrestling, and in his exercises had to strip almost entirely, so that he might well have contracted the disease from a pupil. There were now large patches of scaly dermatitis occupying the perineum and groins with extensions on to the scrotum. On the left side of the cheek there was a circinate patch the size of a florin, having a somewhat intricate whorled pattern, suggesting tropical ringworm. On the outer side of the ankle just below the external malleolus there was a small patch the size of a sixpence, which was fading. No treatment had been applied to any of the lesions. There was no history of infection among his pupils, with the exception of one, a friend, who stated that he had some patches on his skin which he noticed while on the voyage from Japan. The patch on the groin was scraped, and in the scales thus obtained a very large-spored mycelium with unusually long branches was demonstrated.

(2) A case of _Pityriasis rosea_ in a girl aged about 12 years, with very characteristic pale pink patches, in size about one quarter by half an inch, appearing first upon the upper part of the trunk above the clavicles, and arranged in lines directed obliquely from the summit of the shoulder to the clavicle. Upon the back in the intervertebral groove there were numerous similar patches and also smaller papules, round and faintly scaly. The eruption had made its appearance two days previously, and it was not now present upon the limbs or lower upon the body than the groin. It itched slightly. There was no similar eruption in any member of the family. This was the second case the exhibitor had seen of the disease this week, and it was probably true that the malady was an exanthem occurring in epidemic form during certain periods of the year.

Dr. WILFRID WARDE agreed as to the epidemic character of the disease, and he remarked upon the general good health of the patients. He thought that the so-called “herald-patch” was frequently missed, both by the patient and the physician.

(3) A case of _Lupus vulgaris_ of the nose and cheek in a little weakly East-end child who had had a remarkably complete series of tubercular affections, commencing with a tubercular ulcer upon the right conjunctiva and cornea for which the eye had been enucleated eight years ago. Six years afterwards she developed lupus of the nose, which had run a very acute course and had speedily ulcerated, producing considerable loss of tissue in the cartilaginous portion of the nose. She was treated at first with cod-liver oil and thyroid extract for some months, and later with X-rays, which had been continued for many months with apparently no good effect. After several months of this treatment sudden improvement took place up to a certain stage, but there it stopped, the nose being still the seat of active disease. The application of Finsen light by the Finsen-Reyn lamp was then tried, and, in all, sixty exposures had been given of an hour and a quarter at a sitting, at daily intervals. The result had been satisfactory beyond belief to those who had seen the case at its worst. It was also an interesting fact that this patient had been the subject of an acute attack of typical Lichen scrofulosorum of the trunk, and she had been shown with this eruption at the Dermatological Society of London, in the _Transactions_ of which it was fully recorded.[7]

All the members agreed upon the excellent results which had been obtained in the treatment of this case.

(4) A case of _Linear lichen planus_ in a middle-aged woman, who had been under observation since August of last year. At that time she presented herself with no symptoms of the disease except a broad, linear patch running vertically across the popliteal space on the left side. This patch was of a violaceous tint, and the skin was thickened along its course and was intensely irritable. But there were no papules distinctive of _Lichen planus_ on any part of the body, until about a month ago, when she began to develop an acute attack of the disease. It was interesting to observe that new papules continued the line of the original streak from the popliteal space up the back of the right thigh as far as the buttock in an almost unbroken line, other papules being distributed extensively upon the body, but without any linear arrangement. She had well-marked lesions of Lichen planus upon the buccal mucous membrane, which had also developed within the last few weeks. The itching was a very severe symptom, and it kept the patient awake at night.

(5) A case of _syphilis_ in a man, aged 25 years, with an affection of the upper lip which it was a little difficult to classify, the question being whether it was a primary or a tertiary ulcer. The whole of the lip was greatly swollen, and at each angle of the mouth there was a deeply-excavated ulceration scabbed over, the intervening portion of the lip being occupied by a papillomatous infiltration resembling the appearance of frambœsiform syphilis. The man absolutely denied previous lesions of any kind; there was no scar upon the penis or upon any portion of the body, and no history of a secondary rash at any time. But the uvula bad been apparently destroyed by ulceration and was now merely rudimentary, and there was a deep ulcer upon the back of the pharynx very suggestive of tertiary disease. The absence of primary and secondary symptoms was peculiar. It should be mentioned that there was no pronounced enlargement of the glands in connection with the deep ulcers of the lip, which, it might be considered, precluded the diagnosis of primary sores here.

Mr. ARTHUR SHILLITOE suggested the possibility of the case being an instance of tertiary symptoms in a patient the subject of congenital syphilis, but the teeth and physiognomy generally did not confirm this possibility. The general opinion supported the diagnosis of tertiary syphilis.

* * * * *

Mr. GEORGE PERNET showed a case of _superficial scarring and telangiectases of the left side of the face and neck following an X-ray burn_. The patient, aged 28 years, was treated three years ago in the provinces for what was said to be a tuberculous lesion upon the left side of the chin. As far as she recollected, the affected part was exposed on eight occasions to the X-rays for about ten minutes at a time, the eyes only being protected, but not the adjacent parts of the face and neck. The patient stated that as a result the face was dressed and bandaged for three months. The parts now exhibited the well-known characteristic features following such burns. The original lesion for which she had been treated appeared to be healed.

* * * * *

Dr. V. H. RUTHERFORD showed microscopic sections from the case of _multiple sarcoma cutis_ which he had exhibited at the previous meeting of the Society:

(1) An early nodule—the size of a pea—over which the skin still retained its natural colour, displayed chiefly fibrillary bundles with a small number of cells in various stages of development, some being round, others elongated with fine protoplasmic processes, and others again with irregular outlines.

(2) In a later nodule—the size of a bean—over which the skin had become red, the bundles of fibres were replaced by typical small round cells (lympho-sarcoma). The sections were stained with hæmatoxylin.

A post-mortem examination was made on Monday, February 20th, when a considerable growth was found in the mediastinum (probably primary), pressing upon the right bronchus, and smaller growths sparsely distributed in the pleura, lungs, retroperitoneal glands, etc.

Footnote 7:

_British Journal of Dermatology_, 1903, p. 210.

CURRENT LITERATURE.

ON THE QUESTION OF BLASTOMYCOSIS OF THE SKIN AND ITS RELATION TO “FOLLICULITIS EXULCERANS SERPIGINOSA NASI” (KAPOSI.) BRANDWEINER. (_Archiv f. Derm. u. Syph._, August, 1904, p. 49. One plate.)

This paper is based on a case which occurred in Dr. Matzenauer’s clinique in Vienna. The patient was a shoemaker, aged 37 years, who suffered from a papillated crusted lesion on the lower part of the left side of the nose. The diseased patch occupied the ala nasi, and extended up as far as the bridge, where it faded into the surrounding skin. It was reddish-brown in colour, raised and irregular in shape, and covered with yellowish inspissated pus. It had been noticed first about a year before. On histological examination the stratum corneum was found to contain numerous unicellular organisms of from 4 to 10 µ in diameter, which stained with polychrome methylene blue, were doubly contoured and were believed to be blastomycetes. The epithelium had proliferated and presented small necrotic pustules containing these organisms. There was a round-celled infiltration in the corium in which the blastomyces was also detected. An attempt to cultivate the organisms and to inoculate them in lower animals was unsuccessful. On the ground of this not quite convincing case the writer took the opportunity of reviewing the literature on the subject. He referred in detail to several cases described by Kaposi with the title of “Folliculitis exulcerans serpiginosa nasi,” which he regarded as most probably identical with “blastomycosis.”

J. M. H. M.

A NOTE ON THE TREATMENT OF SYPHILIS. JONATHAN HUTCHINSON. (_The Practit._, August, 1904, p. 145.)

In this short communication the writer refers at the outset to the remarkable fact that mercury obtained its reputation in the treatment of syphilis almost immediately after the introduction of that disease into Europe, and “the pills—which were known as Barbarossa’s, and of which a large quantity was furnished for the treatment of Francis the First—were probably essentially the same as those which Messrs. Burroughs Wellcome and Co. now supply by the million.” In opposition to a number of writers, especially on the Continent, the writer is a strong advocate of the early use of mercury, and of what has been called the “suppression treatment.” He commences mercurial treatment immediately the syphilitic character of the sore is definite. The prevention of late or tertiary phenomena being the most important aim in the treatment of the disease, efforts should be made to this end, and he considers that the immediate use of mercury, which may prevent the secondary stage from developing, has also the effect of reducing the possibilities of the development of the late stage. With regard to the length of time the patient should continue to take the mercury the writer strongly believes in the efficacy of prolonged and continuous treatment. He does not see the object of intermitting the course and giving the specific virus any chance of renewing its activity unless the mercury is interfering with the health of the patient. The plan of treatment usually adopted by the writer is as follows: “A pill is prescribed containing one grain of grey powder and one of Dover’s powder, and this the patient is to take after meals, and only three times a day at first. If no diarrhœa follows, the pill is to be given four, five, or six times a day.” The diet is regulated, and the patient is told that the treatment must be continued without intermission for a year at least. An alum mouth-wash is ordered to prevent ptyalism. If there is debility, a grain of quinine is added to the pill. In using the iodides he considers that the iodides of mercury are much less manageable than the two separated, and prefers to give the iodide of potassium in a fluid dose along with the mercurial pills.

J. M. H. M.

URANIUM IN THE TREATMENT OF LUPUS: A PRELIMINARY NOTE. NORMAN WALKER. (_The Scot. Med. and Surg. Journ._, September, 1904, p. 207.)

The method of applying the uranium which was adopted by the writer was to prepare an oxide of uranium from the nitrate, incorporate it with a negative base such as bees-wax, and spread this on leather to form a plaster of the usual thickness and the required extent. The plaster is enclosed in waxed paper gummed at the edges. The uranium plaster was applied at first in cases where the limbs were affected with lupus and later on the face. Exposure for three days and three nights to an affected arm was followed by no reaction, but on the face it was found that a slight reaction followed in cases where the exposure exceeded twenty-four hours. The plaster may be worn only at nights and removed in the morning. The results have been encouraging, and the risks appear to be negligible. The treatment is cheap, since the cost of making the plaster has been estimated at about one shilling, and experiments have shown that the plaster remains active after four months. This short paper is illustrated by reproductions of four skiagraphs, one taken by thorium and the other three by uranium plasters. These demonstrate the fact that the radio-activity of the uranium salt is much greater than that of thorium.

J. M. H. M.

OBSERVATIONS ON THE USE OF EUCAINE B. AND ADRENALIN AS A MEANS OF INDUCING LOCAL ANÆSTHESIA. GEORGE L. CHIENE. (_The Scot. Med. and Surg. Journ._, September, 1904, p. 215.)

In this communication the writer makes some interesting and instructive observations on the value of combining adrenalin with encaine or cocaine as a local anæsthetic for minor operations. Satisfactory results were obtained by employing a mixture of a 2 per cent. solution of eucaine B. and 1-5000 adrenalin chloride, thirty minims of the solution being injected. The chief drawback to the method was the fact that adrenalin solutions did not keep well, and readily became inert and contaminated. This difficulty has now been obviated to a large extent by the introduction by Messrs. Burroughs Wellcome and Co. of a new preparation of the supra-renal gland called “Soloid Hemisine,” which is said to represent the hæmostatic principle of the supra-renal gland in a more stable form. The writer has had compound soloids prepared by the same firm which when dissolved in 10 c.c. give a solution of 1 per cent. eucaine B. and 5 minim. of adrenalin (1-1000.) By injecting this a carbuncle the size of the palm of the hand was excised without pain or discomfort, and at a later date the surface was skin-grafted, the same anæsthetic being used. The writer believes that the addition of the adrenalin not only increases the efficiency but also the safety of the eucaine or cocaine as local anæsthetics.

J. M. H. M.

DERMATITIS FRAMBŒSIFORMIS. F. SAUERBERGER (_Archiv f. Derm. u. Syph._, October, 1904, lxxii, p. 3).

In this contribution the writer describes an unusual case which occurred in Professor Janovsky’s clinic at Prague. The patient was a coal-miner, aged 18 years. At the age of 14 he began work in a mine and soon afterwards he suffered from a severe attack of furunculosis, which persisted for a year. As it got steadily worse he had to leave his work for a time. When he was able to work again he got employment in another mine. After some time he went to the original mine and the furunculosis returned rapidly and he was again compelled to leave work. He blamed bad drinking-water as the cause of it. Several other miners in the same pit were similarly affected and among them was the patient’s father. Soon after leaving work for the second time the pustular lesions began to be replaced by raised papillomatous masses which were especially well-marked about the face and neck. The eyelids, forehead, tip of the nose, nasal orifice, lips, chin, and left side of the cheek became covered with crusted papillomatous lesions. A few similar lesions developed on the body in the inguinal regions, and both the cervical and inguinal glands were enlarged. A microscopical examination of one of the lesions showed a proliferation of the interpapillary processes, and a dense cellular infiltration in the papillary and sub-papillary layers, consisting chiefly of leucocytes and mast-cells and dilatation of the capillaries. The lesions did not react well to local treatment, but eventually with tonics and by persevering with local remedies a cure resulted. There was no history or evidence of syphilis. The disease was similar in many respects to tropical frambœsia or yaws, and corresponded closely to a case which Lewin described as sporadic frambœsia.

J. M. H. M.

ON THE RADIO-THERAPEUTICS OF RINGWORM. SABOURAUD. (_Ann. de Derm. et de Syph._, July, 1904, p. 577.)

In a previous paper (published in January, 1904, in the _Annales de l’Institut Pasteur_) Sabouraud had proposed a method of treating ringworm with X-rays, which he sums up as follows: “The application in one sitting upon a given point of the scalp of a quantity of X-rays equal to 4-1/2-5 H-units of Holzknecht is made; fifteen days later a complete epilation will occur on the region treated, healthy as well as diseased hairs being shed. New and healthy hair will commence to grow ten weeks after the treatment, and will be completely restored within ten weeks. The infectivity of the disease will cease with the fall of the last diseased hair, within twenty-five days at latest of the treatment.” This formula, Sabouraud maintains, has been amply proved to be true by his experience of the six months which have intervened since his paper of January, 1904. Some very striking results are quoted. Thus while in six months before this treatment was adopted 57 patients were discharged as cured, in the past six months 134 such patients were discharged; moreover, a very large number of patients were treated without admission and also cured. An entire section of the hospital, consisting of one hundred beds set apart for favus cases, has been closed and will be converted to the uses of general medicine, as being no longer required for its former purpose.

Certain additional knowledge has been afforded by the experience of the past six months, which may be stated in the following practical rules: The penetration of X-rays is proportional to their number; the more penetrating they are, the more numerous they are. The danger of X-rays is proportional to their penetration; it is thus more dangerous to handle X-rays of 8°-11° (on Benoist’s radio-chromometer) than rays of 3°-5°. Now tubes change progressively with use and these changes are marked by colour changes in the glass. At first, after about ten hours’ use, the tubes take a violet coloration; with this there is no impairment of function. But with further use, after about thirty hours, a brown tint becomes marked, and the tube is said to be “smoked.” With this change it becomes increasingly difficult to obtain rays of a low degree of penetration. For epilation rays of all degrees of penetration serve equally well; rays of 3° are as effective as rays of 11°, but the treatment must be for a longer time. Thus a tube working at 3° caused an epilation in twenty-five minutes. The same epilation would result in eleven minutes from a tube at 8°-11°; and if one used the latter tube for twenty-five minutes, a dermatitis would result. This is entirely unnecessary for epilation and is attended by mischievous consequences, even when quite slight, and must be avoided. All forms of dermatitis, except that of transient erythema, produce permanent baldness. Permanent alopecia may also result without dermatitis in cases where the amount of X-rays given has been insufficient to cause epilation, and a second _séance_ has been necessary. In this case certain hairs will have received a dose beyond the maximum for safety, and these will be permanently destroyed. For safe working, it is necessary to have a measure of the rays coming from the tube at any given time; and the measure must be constant for every variety of tube. This is obtained by certain colour changes taking place in specially prepared substances, these changes being proportional to the amount of X-rays derived from the tube. The pastilles of Holzknecht have been used for this purpose, but they are a secret preparation, expensive, and not everywhere procurable. Sabouraud has devised small discs made of paper which is the same as that used for screens and is coated with a preparation of platino-cyanide of barium. These discs change in colour in a fixed manner, comparable from time to time with test-colours, and their use makes it impossible, with care, to overstep the limits of safety.

E. G. L.

SYPHILIS AND CANCER. ETCHEVERRY. (_Ann. de Derm. et de Syph._, August-September, 1904, p. 797.)

This research was undertaken in Audry’s Clinique at Toulouse, and the consideration of the connection between these two diseases was directed to the occurrence of lesions on the tongue and buccal mucous membrane. These facts are grouped in three classes, according as: (1) cancer supervened, in syphilitic patients, upon a preceding leucoplakia; (2) without leucoplakia, but in the presence of other local syphilitic lesions, such as gummata, scars of gummata, or of hard chancres; and (3) in the absence of all local signs of syphilis. Thirteen cases of epithelioma developing upon syphilitic leucoplakia are detailed under the first heading. This sequel is relatively frequent. In the second group twenty-two cases are noted. In the third group no direct transformation of syphilitic into epitheliomatous lesions could be established, but the fact of previous syphilis was ascertained in all the fifteen cases quoted. Etcheverry, struck with the singular frequency of association of the two diseases, speculates whether there may not be some direct predisposition in syphilitic patients, as such, to develop cancer. In epithelioma of relatively young patients he states that syphilis may almost always be found as a previous accident. The greater frequency of cancer of the mouth in men than in women coincides with the greater frequency of syphilis in men; according to Fournier, syphilis is eight times more common in males. Etcheverry hazards the suggestion that the cachexia produced by syphilis may be a directly provocative cause of ensuing cancer. As regards the treatment of these mixed cases of syphilis and cancer, the administration of mercury, preferably by injections of calomel, influences favourably the syphilitic element of the disease, and occasionally, as a temporary effort, the epitheliomatous development is checked by this drug. On the other hand, iodides are distinctly mischievous to the malignant growth, and should not be given.