XANTHO-ERYTHRODERMIA PERSTANS.
By H. RADCLIFFE-CROCKER.
The above provisional clinical title was suggested to me by my coadjutor
at University College Hospital, Mr. George Pernet, for a well-defined
affection of the skin, of which I have met with ten instances during the
last three years, all but one of them in private practice. I am not
aware that the disease in question has been described before, unless it
can be brought under Brocq’s “erythrodermies pityriasiques en plaques
disseminées,” with which it will be closely compared when the cases
themselves have been considered.
A case which I showed at the Dermatological Society of London in
October, 1904, when Drs. Hallopeau, Gastou, Jacquet and Pautrier were
present, was not regarded by them as a case of Brocq’s disease, with
which they were presumably familiar, but as an entirely new affection in
their experience.
The following description is drawn up from nine of the cases, all males,
which, in the main features, closely resemble each other. The remaining
case, a lady, had some important differences which will be discussed
later.
So far, all the cases have been adults, though some of them were young.
The lesions are evolved in patches of a pale pink or yellowish hue on
the limbs and trunk, the uncovered parts, such as the face and hands,
being free or very slightly affected. Generally, the patches come out
very gradually and in small numbers and, in the main, symmetrically, but
as the older patches never go away spontaneously, while fresh ones are
continually evoluting at short or long intervals, large areas are
involved, and in the course of years (in one case, months) the whole
trunk and limbs are crowded with lesions, though there are always spaces
of normal skin intervening, or sometimes completely enclosed by the
diseased process, where the original patches have coalesced. For the
most part the original patches are discrete and enlarge but little after
their formation, unless they merge into adjoining patches, when
hand-sized or larger areas may be formed.
With regard to individual patches, they are usually of oval or elongated
form, arranged symmetrically in oblique lines on the back in the
direction of the ribs, probably in the lines of fission, more or less
horizontal in direction in front, and often, but not always, in vertical
lines on the limbs. On the latter, especially the thighs, they not
infrequently present the appearance of streaks formed by the finger, the
upper part of the stroke being abrupt, and the lower shading off. This
may sometimes also be seen on the trunk. The majority of the single
patches range from one to three inches in their longest diameter; the
borders are not very well-defined nor raised above the rest, but there
is no difficulty in discerning the morbid from the healthy skin. They
are not raised above the surface, but may be rather deep in the cutis.
Infiltration can often be distinctly felt when the patch is pinched up
in comparison with the adjoining healthy tissues, but in the more recent
and smaller patches it is imperceptible, and occasionally they look like
mere stains. Their colour is either pale pink or yellowish; in some
cases the yellowish hue is pronounced, in others absent or nearly so; on
the lower limbs the pink hue predominates. The surface is smooth on the
trunk, but is often slightly rough on the arms and thighs, and below the
knees maybe distinctly rough or even in branny scales. The patches are
never so marked on the upper as on the lower limbs, the palms are always
free, and the backs of the hands are generally unaffected, but sometimes
there are a few small patches below the wrist. The face is nearly always
free, though I have seen faint patches in one case. There is very little
to suggest that the disease is inflammatory, and itching is quite absent
in most of the cases; a few patients said they had some itching when
hot, but only in one case was it really complained of, and that only in
the early evoluting stage of the patches. The initial site for the
lesions varies; the thighs are the most frequently first affected, the
legs next in frequency, and then the trunk. The lower limbs, too, are
generally more crowded with lesions than other parts.
The duration of the disease may be very long. My first case had been
developing for over ten years, others had been only for a few months;
but in the case of a medical man, over 50 when I saw him, he said that
patches first appeared on his legs when he was a house-surgeon, and had
been slowly evolving ever since, so that after thirty years he was
pretty thickly covered, as none as far as he knew had gone entirely
away, though they had temporarily disappeared when he had rubbed in
chrysarobin ointment, but had gradually returned to their old site.
The disease is compatible with perfect health; and even when there was
any departure from the normal there was no reason to suppose that the
abnormality was in any way connected with the skin lesions, while the
majority of the patients had above the average health for their age.
While there appears to be no tendency in the disease to spontaneous
involution, they are not, as the case narratives show, altogether
rebellious to treatment, and in at least two cases a cure appears to
have been effected and in others some improvement, while in a residue no
improvement could be noted. The agents which appeared to have a good
effect are salicin in 15-grain doses at least three times a day, which
by itself entirely cured a recent case (Case 5) of only two months’
duration and of rather acute development, and vasogen iodine 10 per
cent. rubbed in is a useful supplement and materially aided in the cure
of Case 4. In some cases, salicin has failed to make any marked
impression on the lesions, while in others the patient has not gone on
with it sufficiently long to test its merits. As might be expected, it
has been most successful when the disease has been present for a short
time.
The only female case, a lady aged 47 years, resembled the other cases in
its gradual evolution, long duration, absence of itching, in the
persistence of the old patches with continual evolution of new ones, in
its limitation to the covered parts, and in the general good health of
the patient. The differences were in the patches being distinctly scaly
all over the body; though the scales were small and even powdery in most
parts of the body, they were, as usual, rather larger and more abundant
on the legs. The patches were also more decidedly red than in the other
cases; while there was some spontaneous improvement in the summer, in
winter the patches cracked and smarted. This patient, who had been
affected with the disease for ten years, had had the most varied drug
and spa treatment, including cacodylate of soda injections for three
months without any material effect; but after nine exposures to the
Röntgen rays, the part exposed entirely cleared up, while the disease
was unchanged on the inner side of the leg which the rays had not
reached. I intend, therefore, to make use of the rays wherever
practicable.
As regards to _etiology_, it is chiefly negative. There is a large
preponderance of males, and all the cases have been over 20 years old,
while 56 years is the oldest I have met with. In no case could an
exciting cause be made out; two of the patients had had syphilis, but it
did not appear to have any etiological importance, and in one of them
antisyphilitic treatment was tried vigorously for twelve months without
effect.
* * * * *
CASE 1.—Mr. O——, draper, aged 30 years, was first seen by me on March
5th, 1902. The disease had been present ten years. From the commencement
none of the patches had gone away. They appeared simultaneously inside
the arms and thighs. They increased in numbers very slowly for a long
time, and were confined to the limbs until three years ago, when they
attacked the trunk, and during the last year have greatly increased in
number; in fact, most of them have appeared in the last twelve months.
His father was drowned and his mother died of fatty heart at the age of
51 years. When first seen by me the disease was in yellowish patches
which commenced four inches above the nipples, but were not abundant
till the line of the nipples, and they were less numerous below the
umbilicus than above it. They were rather thickly arranged in horizontal
elongated patches from 1 to 3 inches long, and 1/2 inch wide, as if
streaked by the finger, pale, pink, or yellowish in tint, rather
well-defined, but the edges were not sharp, and when the patch was
pinched up a slight infiltration or thickening could be felt in the
skin. The longer patches were formed by coalescence of some of the
smaller ones. The surface was quite smooth. On the sides, the patches
inclined slightly downwards and forwards, but they were practically
horizontal in front. On the back they were sparse, and faintly developed
in the interscapular region, and not nearly so numerous as in front; but
on the lower half of the back and sides they were in the form of
yellowish red stains, without elevation or roughness, and they were more
numerous than on the upper part of the back. Forearms: The patches were
on the inner side chiefly, more numerous on the right side than the
left, and thickly arranged between the wrist and elbow. They were not
elongated, but roundish, oval, or irregular, about three quarters of an
inch in diameter, and somewhat brighter in tint than on the trunk. The
surface was faintly rough, and on pinching up a patch it was slightly
thicker than usual. There were about eight to ten patches on the right
upper arm, while the left was almost free, and there were not nearly so
many patches on the left forearm as there were on the right. On the
thighs: They were most abundant on the inner side, and many more on the
right side than on the left. There were scarcely any patches on the
front of the thigh, but there were a few on the outer side. The patches
sloped downwards and inwards, were oval and broader than the trunk
patches, but still like finger-streaks. The legs were much more densely
covered with coalesced irregular patches, some enclosing healthy skin,
and the surface was rougher than the lesions on the rest of the body. On
the neck, there were a few ill-defined spots about one inch square in
area. There was slight blotchy redness of a not very obvious kind on the
face, scarcely perceptible on the forehead. There was some seborrhœa
capitis, but not so much as formerly, as he uses brilliantine. The
patches seldom itched unless he got very hot. No illness preceded the
eruption; in fact, he has never had any illness; his tongue was clean,
and he looked and has always been perfectly healthy. The general aspect
was somewhat that of a general orbicular seborrhoic eczema, except that
for the most part the surface was smooth.
He has consulted dermatologists and others, but nothing he has taken or
used has done him any good. I only saw him once.
* * * * *
CASE 2.—Mr. H——, aged 37 years, manager of a factory, came to me on
April 2nd, 1902. His general health was very good. The disease had been
present five years, and began on the right fore-arm and a little later
attacked the left. He has never been free since it first appeared, but
thinks some patches have faded and others come out. In the last winter
he had been decidedly worse, for the patches had certainly increased
during the last few months. On the fore-arms, they were nearly
symmetrical, and were quite so at an earlier stage. The lesions were
yellowish or pale red patches; the simple ones were elongated, but the
compound ones irregular in outline; they were from 3/4 to 1-1/2 inches
long. The surface, with a lens, could be seen to be very slightly
roughened, but this was not perceptible to the finger—but when pinched
up there was decided thickening, though they were not raised. There were
no patches on the back of the arms or fore-arms and none on the trunk,
but there were similar patches on the inside of the thighs and on the
legs, some of them larger than the arm-lesions but less distinctly
patchy. There was a large, irregular area on the back of each thigh, and
a few roundish ones scattered about the limbs. The face was quite free,
there was no seborrhœa capitis and there was no itching or other sensory
symptoms in the patches. He was one of ten brothers and sisters who were
in good health, except one who died of syphilitic paralysis. His father
died aged 71 years, and his mother, aged 63 years, was alive and well.
He was given salicin, gr. xv _ter die_, and a lotion of glycerine of
lead and liquor carbonis detergens. I saw him again on July 3rd, when
the eruption had cleared up considerably, much of it having faded,
leaving only a slight stain, but here and there it was still yellow and
slightly rough. He was much better when he took the medicine regularly,
but when he stopped it some of the eruption returned. The salicin was
increased to 20 grains. I did not see him again until July 23rd, 1904.
He then said he took the medicine for three months from July 3rd, 1902,
and then stopped it. He had used the lotion a little longer. On the back
of the legs there were large patches nearly covering the entire area,
but not much in front. It was more distinctly red here than elsewhere,
and there was very little thickening. There were only one or two patches
on the left thigh, but a dozen or more on the left. The trunk still
remained free. The initial patch was on the right wrist seven and a half
years previously, but had disappeared. Some few fresh ones still
developed occasionally. He was told to continue the salicin and rub on
10 per cent. vasogen iodine.
* * * * *
CASE 3.—Mr. H——, aged 56 years, butcher, came to me with skin lesions of
which he had only been aware three weeks, but they may have been there
longer as he had to get up so early to attend the markets that he rarely
saw his own skin. He was a stout healthy-looking man, but he had
syphilis in 1879 and had then suffered from iritis; he was under
treatment for two years. He suffered from constipation and had done so
since he had enteric fever as a young man. Urine had no albumen nor
sugar. He came of a long-lived family, his father having died at 86 and
his mother at 74. He had seven brothers and sisters alive out of
thirteen. The lesions were few in number and situated symmetrically over
the lower ribs on each side, the patches sloping obliquely downwards
from the back to the front. One on each side was 6 or 7 inches long and
compound. There was a single one much smaller (2-3 inches) symmetrically
situated in a line with the large patch, and there were three or four
others above the major patch on the back. There was one distinct patch
over the left scapula and about half a dozen fainter ones about the
back; a few faint ones were present on the back of each arm and forearm.
The lower limbs were free. The patches were erythematous in aspect, the
larger ones brightish red, the others paler. The surface was very
faintly roughened to the touch, and there was very distinct thickening
when the skin was pinched up, but they were not raised above the
surface. The borders of some of the patches were well defined, while
others shaded off gradually.
He was given salicin internally and, to rub in, 10 per cent. vasogen
iodine.
On February 11th there was decidedly less thickening on the left side
but no noticeable difference on the right. He complained of indigestion,
so the salicin was stopped and bicarbonate of soda given him, with
tincture of nux vomica. On March 17th the thickening was much less and
the patch on the left forearm was gone. On May 8th it had all cleared up
and only left slight staining. As he has not come again he has probably
remained well. The resolution of the patches was in this case probably,
to be chiefly attributed to the vasogen iodine.
* * * * *
CASE 4.—Mr. M——, aged 54 years, a gentleman in good circumstances, was
brought to me on June 2nd, 1903, by Dr. Lovell. All his family were
long-lived. His grandfather was killed by an accident aged 93 years, but
his father died of cardiac disease, aged 67 years. The disease the
patient suffered from commenced early in April, _i.e._ two months before
I saw him, on the right leg, and by June had extended all over the lower
limbs and on the trunk, nearly all over the back, but there was scarcely
any on the front. On the forearms, the patches were more on the extensor
than the flexor surface. The eruption consisted of irregular, pale,
erythematous patches from a square inch to the palm in size, with
distinct infiltration in most of them. On the back, they were arranged
symmetrically in the direction of the ribs, _i.e._ sloping downwards and
forwards from back to front. In the early stage, on the back, they could
be traced to commence as minute papules at the hair-follicles, and
gradually the intervals between were filled up until infiltrations with
a uniform surface were formed. Some itched, but none severely, and many
did not itch at all.
Salicin 15 grains three times a day, with 5 minims of tincture of nux
vomica, was prescribed. On June 23rd I saw him again, and there was then
distinctly less thickening on the thighs and legs and the eruption was
somewhat less bright in some parts. The longitudinal patches over the
scapula were still thickened, but there was less infiltration in the
patches on the upper limbs and on the forearms they were yellower.
In response to my inquiry Dr. Lovell wrote me on November 29th, 1904,
that he saw the patient on July 19th, 1903, and the eruption appeared to
be gradually fading away. He next saw him for a sore throat in January,
1904, and the patient told him that the skin affection had gradually
left him. He had had no other treatment than taking the salicin which I
prescribed. This case is the most satisfactory and rapid in its
involution under treatment, as it was also the most rapid in its
evolution, and came earlier under my observation than any of the others.
* * * * *
CASE 5.—Dr. D——, aged 53 years. In 1876, while a house-surgeon, he first
noticed a patch on one calf; since then the patches have gradually
increased in number, and some of them in size. Chrysarobin kills them
down for a time, but they re-form in the same place. In his family
history a sister died of Addison’s disease, and one daughter is slightly
phthisical. His own health is good and he is well nourished.
When seen by me on February 4th, 1904, there was a large irregular
lesion occupying nearly the whole of the interscapular region and
numerous others on the back, abdomen, and thighs. They were of a dull
pale lemon colour; some were distinctly thickened when the skin was
pinched up; in others this was not recognisable. On the thighs, they
were pinkish and slightly roughened. On the body they were smooth,
elongated, oblong, oval, and well defined, symmetrically placed, and on
the back in oblique lines sloping down and out from the spine in the
lines of cleavage, _i.e._ corresponding to the rib slope. They seldom
itched or gave any trouble.
* * * * *
CASE 6.—Mr. H——, aged 37 years, a draper. The disease had been present
two years. When seen on April 26th, 1904, he had numerous patches on the
calves and front of the legs, some three or four inches across, with
distinct thickening. They were round, well-defined, and when pinched up
were hard as compared with the adjoining healthy skin. Besides these
there were more recent superficial irregular patches symmetrically
arranged on both thighs. In the interscapular region and in front under
the breasts were slightly yellowish stains, but no other alteration of
the skin could be seen or felt, the surface being quite smooth. There
was occasionally some itching, but never severe. There was constipation
present, but no other symptom of ill health.
He was ordered fifteen grains of salicin three times a day, and to rub
in ten per cent. vasogen iodine. He was seen again on June 1st, when
there was less thickening in some of the patches, but no other change.
* * * * *
CASE 7.—Mr. D——, aged 34 years, was seen first on November 3rd, 1904, in
consultation with Dr. Payne. He had had a chancre in 1896. He had a
severe sore throat and a rash, which only lasted a short time. He was
treated with mercury for eighteen months.
The present eruption began from three to four years ago, and for the
last twelve months he had been treated by Dr. Payne with the biniodide
of mercury mixture, 1/16 grain three times a day, and also with
mercurial inunctions, but without making any material effect upon the
present lesions. When I saw him the trunk was only slightly affected.
There were a few pale yellow patches below the nipples, elongated and
nearly horizontal. On the back, there were one or two commencing
yellowish spots in the interscapular region, but in the lumbar and
sacral regions they were fairly numerous, and also yellowish and
elongated horizontally. On the thighs, the patches were very abundant in
vertical elongated streaks about half an inch wide, as if the finger had
been wiped down the limb in two- or three-inch pale yellow streaks. On
the legs, the patches were larger, irregular in outline from
coalescence, and of a yellowish-pink colour. The eruption was very
symmetrical, many of them, especially on the thighs, were slightly but
distinctly thickened when pinched up. On the anus and forearms there
were a good many patches, but not so many as on the thighs, where,
arranged in the line of the limb, they were of a paler yellow colour.
The patient said that they itched very decidedly almost always at night
and very often in the day. Sometimes they were sore. They did not itch
when they first came out. The eruption began on the thighs, and although
fresh ones were coming out from time to time, none, so far as he knew,
had faded or gone away.
He was ordered to rub in vasogen iodine and take salicin 15 grains three
times a day. I heard about two months later by letter that there was no
material change, but he had not used the iodine local application.
* * * * *
CASE 8.—Charles C——, aged 32 years, tailor, came to University College
Hospital on October 4th, 1904. He stated that the skin lesions had
commenced four years previously, appearing first on the thighs, then on
the legs, and a little later on the forearms. He did not remember when
the body was first affected. Fresh patches have appeared from time to
time, but none have gone away. The lesions consisted of irregular
patches from half to several inches in diameter symmetrically
distributed over the trunk and limbs. On the back, they were in
elongated or oval patches, symmetrically arranged in oblique lines
corresponding to the direction of the ribs. They are well defined from
the healthy skin, not raised above the normal skin, and the border was
not raised above the central portion either to sight or touch. In front,
there were large areas due to coalescence of several patches, but the
smaller patches were elongated and horizontally placed. On the thighs
near the groin the patches ran obliquely round the limb, but lower down
were vertical. The general colour was yellowish pink, but in some the
yellow, in others the pink predominated. When pinched up, many of the
patches were distinctly thickened, but in the more recent this could not
be felt, and some appeared as mere stains. The surface was smooth on the
trunk, but on the lower limbs there was some roughness of the surface,
more marked below the knee, but not actually scaly. The patches on the
trunk were larger than on the limbs, and healthy areas of skin were
sometimes completely enclosed by the diseased patches. The upper part of
the chest, neck, and face were free, except a small patch on the lower
lip. There were also large spaces of unaffected skin on the thighs, but
only small ones on the upper limbs. On the back of the hands near the
wrists, there were some small patches. The mucous membrane of the mouth
was normal. There was no itching nor other subjective sensation. There
was a history of phthisis in his mother and brother, but the patient was
well nourished and healthy, except that he was liable to bronchitis, and
had some enlarged post sterno-mastoid glands on the left side. He was
put upon salicin gr. xv _ter die_, and vasogen iodine rubbed on the
forearms, but so far no decisive result has been obtained. Mr. Pernet
has obtained a piece of skin from the right forearm, where the lesion
was apparently superficial. His report is appended.
* * * * *
CASE 9.—A gentleman, aged 29 years, in whom the disease has been present
for four and a half years, was seen with Mr. George Pernet, who showed
him at the Dermatological Society of London in November, 1904, and the
notes of his case were published in the December number of the _British
Journal of Dermatology_, vol. xvi, p. 457.
* * * * *
There remains only the case of the lady, which requires separate
consideration.
* * * * *
CASE 10.—Mrs. H—— was sent to me by Dr. Vassie on January 18th, 1902.
She had suffered from the disease for nine or ten years, had seen other
dermatologists, and visited sulphur and other spas. The disease had
begun with a single patch on the arm, and after remaining single for a
few months, had spread and extended almost all over the body and limbs.
When I saw her, the lesions were practically all over the trunk and
limbs with ill-defined pale red patches with powdery roughness and
decided thickening of the whole cutis of the patches, most marked in a
3-inch patch, situated high up on the right loin. The thigh patches were
also thickened, but on the arms and forearms the thickening was less
marked. On the front of the legs, the patches were irregular and more
decidedly scaly, but not like either eczema or psoriasis. The eruption,
as a whole, was like a seborrhoic eczema but less defined, and in parts
the lesions were very pale and shaded off into the healthy skin. The
neck, face, and hands were free. It smarted in cold weather, but did not
itch.
The catamenia were regular, and her general health when seen was
excellent, but a year previously she had had a fibroid removed after it
had begun to be troublesome for a month from hæmorrhage. Before that the
catamenia were twice a month. There was slight seborrhœa capitis.
Salicin, 15 grains three times a day, was given. On July 17th she was
seen again, and the eruption on the legs was somewhat paler, and that on
the arms was much paler, but over the scapula the lesions were thickened
but paler; but she attributed the improvement to the warmer weather
during the last month, as there was generally some improvement in the
summer, while in the winter it fell back, cracked, and smarted. She was
not seen again until May 12th, 1904, having meanwhile had other advice,
but without any improvement, and none of the patches had gone away. At
Wiesbaden she had subcutaneous injections of cacodylate of soda in the
month while she was there, and once a fortnight for twelve weeks after,
but without benefit. It was noted that the leg’s were distinctly red and
scaly. On the rest of the limbs and body the patches were red and scaly
but without thickening, except on the forearms, the patches on the left
being distinctly thickened. The patches were large, many being
palm-sized and in the aggregate covered three fourths of the body, but
the face and hands were quite free, and the neck nearly so. There was no
itching. As every previous treatment had failed, the possibility of the
disease developing into Mycosis fungoides being entertained, although
itching was absent, it was resolved to try the effect of the Röntgen
rays on a portion of one leg. Nine exposures of ten minutes each at a
distance of eight inches were given, and a month after there was slight
improvement where the rays had been used, but it was not very decided;
but on the left arm where vasogen iodine had been rubbed in there was
decided improvement, the lesions being pale, less scaly, and there was
some clearance as compared with the right side, which had not been
treated. I did not see her again until February 7th, 1905, and she then
told me that the improvement where the X-rays had been applied had
continued, and in a few weeks after I last saw her, in August, 1904, the
disease had entirely disappeared from the outer side of the leg below
the knee, and the skin when I examined it was quite white and smooth on
the part exposed and had been so for four months, while the inner side
of the leg where the rays had not reached remained unaltered. She had
not continued the vasogen iodine to the arm, and it had become scaly
again.
General Remarks on the Disease.
From the above description and the cases related in support of it, what
inference may be drawn as to the nature of the disease and its relation
to other skin affections? Frankly, at present I am quite unable to even
conjecture its pathology, or to suggest, with one exception, any
relation to other dermatoses. In my first cases I supposed that it was
an early stage of Mycosis fungoides, though the absence or trifling
character of the subjective symptoms did not lend this any support. I
clung to this theory, however, _faute de mieux_, for a long time, but it
received its _coup de grace_ when I met with a case of over thirty
years’ duration without any such malign development.
At the Dermatological Society of London, where Mr. George Pernet and
myself have shown three cases, among other suggestions, that of a
possible seborrhoïde or Urticaria pigmentosa have been made. Against the
former, the absence of scaliness in a large proportion of the patches,
that the patches are in the skin, not raised above, and that itching is
an exceptional feature, together with the unchanging character of the
lesions, effectually bar the diagnosis of a seborrhoïde. Neither can I
find anything beyond the yellowish tint frequently, but not always,
present to support the idea of Urticaria pigmentosa. The absence of
itching in nearly all the cases of Urticaria factitia, while the patches
are level with the normal skin, and their unchanging character, are all
strongly against such a diagnosis, to say nothing of the extreme rarity
of adult Urticaria pigmentosa and the improbability of one man meeting
with nine cases of it. The histology also negatives this.
I can therefore, at present, only regard it as a dermatosis
_sui-generis_, of which the pathology must be left an open question, as
Mr. George Pernet’s report on the histology of the portion of skin
removed from Case 8 does not throw much light upon the pathology. There
remains only the affection described by Brocq, to which, certainly,
there are closer resemblances than to any other affection.
Brocq[1] divides the group which he calls parapsoriasis into three
groups:
First variety (very closely related to psoriasis), Parapsoriasis
guttata. Jadassohn’s case is probably to be referred to it.
Second variety (intermediate between Lichen and psoriasis),
Parapsoriasis lichenoides, including Parakeratosis variegata of Unna,
and Lichen variegatus (Crocker).
Third variety (closely allied to Seborrhœa psoriasiformis),
Parapsoriasis in patches, corresponding to Erythrodermie pityriasique en
plaques disseminées of Brocq, and of which cases have also been reported
by J. C. White and C. J. White.
It is only with the third variety that comparison need be made, the deep
colour and very small pattern, like a mosaic of the first two, sharply
contrasting with the broad effects as of colour dashed on, in
Xantho-erythrodermia perstans.
For the whole group Brocq gives the following characteristics:
(1) An almost complete absence of pruritus.
(2) A very slow evolution.
(3) A distribution in circumscribed, sharply defined patches, whose
dimensions are from 2 cm. to 6 cm. in diameter, and which are scattered
here and there over the integument.
(4) An almost complete absence of infiltration of the derma.
(5) A pale redness (pinkish coloured).
(6) A fine pityriasic desquamation.
(7) An extraordinary resistance to the local applications usually
employed in the treatment of psoriasiform or pityriasic seborrhœa, in
fact, only yielding slowly and imperfectly to the most energetic
application of pyrogallic acid.
The special features of the third variety he describes as:
(1) Being in patches, circumscribed, sharply defined from 2 cm. to 6 cm.
in diameter.
(2) They are scattered irregularly over the skin without any apparent
system.
(3) The colour varies from a pale red to a brownish or livid red,
according to the part affected.
(4) There is always present a fine pityriasic desquamation more or less
marked in different cases.
(5) There are at times in some of these cases, aggregations of small
flattened papules which may be considered as links connecting it with
the second variety.
(6) There is no infiltration of the integument appreciable to the eye or
touch.
(7) The face is rarely affected, and there is the same extremely slow
evolution, great resistance to local treatment, and few or no subjective
symptoms.
Referring to the whole group, he says: “We know nothing very definite
about the etiology or pathology of these affections. They may appear at
any age, but seem more frequent in youths or adults. He has observed
cases in men and women and in all classes of society. They seem to be
slightly more frequent in women than in men.”
It must be confessed that there are many points of resemblance of this
third variety to Xantho-erythrodermia perstans, and, as regards the
lady, Case 10, it is probably what Brocq has described as “Erythrodermie
pityriasique en plaques disseminées,” although I should say there was
distinct infiltration in a large proportion of the lesions, and many of
the patches far exceeded the limits in size that Brocq lays down.
With regard to the other nine cases, the differences are somewhat more
marked, and they should, at least for the present, be either kept apart
or treated as a distinct variety.
The differences are:
(1) The patches are frequently much larger, 3 and 4 inches or more in
their long diameter, and the margin is not very sharply defined.
(2) A distinct arrangement in lines in direction varying with the
topography is observable in most cases.
(3) The colour is either pale red or distinctly yellowish.
(4) Instead of a fine pityriasic desquamation being always present, this
is only distinct on the legs, sometimes just recognisable on the thighs
and arms, while on the trunk it is absent, the surface being usually
quite smooth.
(5) The presence of papules I have not observed, except at the
commencement of Case 4.
(6) There is distinct infiltration in a large proportion of the patches,
perceptible to the touch, though not to the eye.
The resemblances are: the absence of conspicuous pruritus, and there is
often none; the occurrence in patches; the slow evolution; a pale
redness; in many cases an extraordinary resistance to treatment. These
are not enough to establish identity, but I confess that in my opinion
they show greater resemblance to the affection I am describing than they
do to psoriasis, and certainly my nine male cases would never suggest to
any one a resemblance to psoriasis, and I should strongly demur to class
them under parapsoriasis as a covering term.
Histological Note by George Pernet.
A piece of skin was removed from the extensor surface of the right
forearm of the male case, aged 32 years (a Jewish tailor), where the
more recent patches had appeared. Clinically there was practically no
infiltration to be felt in that situation. The specimen was hardened in
alcohol, cut in celloidin, and stained in various ways. The
microscopical appearances were as follows:
_Epidermis._—The stratum granulosum was either atrophied or absent. The
stratum lucidum was absent except for traces here and there. The
epidermis generally showed a slight amount of œdema.
_Corium._—The vessels were dilated, with some cellular infiltration
about them. The collagen appeared to be normal, with the exception of
slight œdema, but the elastin was apparently reduced in quantity,
especially in the papillary layer, and it was to some extent fragmented
in places. It should be mentioned that the specimen was stretched on a
small piece of cork in the process of hardening. The elastin stained,
however, much as in the normal condition.
Altogether there was little to be gathered from the histology _quâ_
cause, except that the appearances of the blood-vessels perhaps pointed
to a general blood condition.
Dr. Thiele, Pathologist to University College Hospital, kindly
examined the blood and reported: Total red corpuscles per c.mm.,
6,560,000; total whites per c.mm., 21,878. Hæmoglobin, 84%. C.T.,
65. Differential count of whites: Small lymphocytes, 18·2%; large
lymphocytes, 9·4%; neutrophiles, 60·7%; oxyphiles, 1·6%: hyaline
cells, 2·1%.
Footnote 1:
_Amer. Journ. Cut. Dis._, vol. xxi, 1903, p. 315.
IDIOPATHIC MULTIPLE PIGMENT SARCOMA (IDIOPATHIC MULTIPLE HÆMORRHAGIC
SARCOMA) OF KAPOSI.
By F. PARKES WEBER, M.D., F.R.C.P., AND PAUL DASER, M.D.
The patient, Jakob Z——, is a Polish Jew, aged 46 years, from Galicia,
who has lived nine years in England, and says he has enjoyed good
health. There is no evidence of previous alcoholism or syphilis. The
patient was brought by Dr. Weber before the Dermatological Society of
London on February 8th, 1905.
The present illness commenced about three years before, when he chanced
to wound the sole of his right foot with a nail. A pedunculated growth,
about the size of a cherry, arose from the wound. This description
reminds one of the strawberry-like granulation tumours sometimes growing
from small wounds or ulcers on the fingers, which have been termed
“botryomycosis,” or rather “botryomycomata,” because at one time they
were supposed to be caused by the “botryomyces.”[2] The growth was
removed by a doctor. Afterwards small bluish nodules developed from time
to time on the feet and legs. Some of these nodules apparently undergo
the following series of changes: They slowly increase in size, and after
about three months constitute little pendulous tumours, which ultimately
fall off spontaneously or else are knocked off or pulled off by chance;
in this way local healing occurs, but fresh nodules form elsewhere.
Though, as stated, some of the nodules become pedunculated growths,
others appear to atrophy and merely leave brownish pigment in the skin,
whilst others seem to undergo very little change, and, at all events,
persist for a long time in their primitive form, namely, as hard bluish
lumps under the epidermis. Treatment has been as yet without result.
_Present condition_ (January, 1905).—On _the hands_ about the knuckles
and backs of the fingers are a few minute slightly elevated bluish
nodules. On the sole of the _right foot_, especially on the inner part,
there are nodules in various stages of development. The minute ones,
those in an early stage of development, are slightly elevated and of a
bluish colour, similar to those on the hands. Others, further advanced
in development, are small, sessile, or pedunculated hard outgrowths,
without bluish colour and sometimes covered by thickened epidermis.
There is a large patch of pigmented (brown) skin on the dorsal surface
of the right foot, and in the neighbourhood of this pigmented area are
some minute nodules of similar character to those already described. It
is possible that the pigmented skin has been the site of minute growths
which have undergone spontaneous involution, and have, as frequently
happens in Lichen planus, left pigmentation of the skin behind them. The
right thigh and leg are not affected.
The _left lower extremity_ is the part most affected by the disease, and
there is chronic, rather firm, œdema of the left foot and ankle. The
nodules on the left foot are similar to those on the right, but are more
widely distributed, and the left foot differs from the right in the
absence of the pigmented area and in the presence of the œdema to which
we have just alluded. Of the little sessile or pedunculated tumours on
the back of the left foot and in the neighbourhood of the ankle-joint
(see Fig. 1) the biggest are of the size of a large pea. There are
likewise little tumours of various sizes—that is, in various stages of
development—on the inner aspect of the left popliteal region (see Fig.
2) and in the neighbourhood of the patella, the smaller ones being
bluish and slightly elevated, the larger ones being reddish,
lentil-sized, sessile outgrowths.
There are no nodules or growths on other parts of the limbs, trunk, or
head, with the exception of four or five minute purplish or bluish
papules on the _glans penis_ and neighbouring skin.
[Illustration: Figure 1.]
There is no evidence of any disease of the thoracic or abdominal
viscera. The patient is not strongly built, but looks well nourished. He
complains of various pains, but whether these are related to the disease
or not is doubtful.
[Illustration: Figure 2.]
_Microscopic examination._—One of the growths, of the size of a large
pea, was removed from the left ankle, and a smaller one (lentil-sized)
from the left knee. Sections of both were stained with hæmatoxylin and
eosin-hæmatoxylin. The growths are seen to be situated in the corium,
and are circumscribed. The epidermis over one of them is thickened. They
consist of oval and spindle cells, which, in some parts, are more or
less grouped into strands or bundles, and are cut in various directions.
In some parts of the sections there are empty spaces (? lymph spaces)
and in some parts there is homogeneous substance between the cells; in
other parts there is extravasated blood. The cells in the larger and
older of the two nodules are decidedly more elongated and
fibrous-looking than in the smaller and more recently developed one. Dr.
J. M. H. MacLeod is kindly going to make a further report of the
microscopical features.
_Remarks._—It seems to us clear that the case is a typical but
relatively early one of the so-called idiopathic multiple pigment
sarcoma (idiopathic multiple hæmorrhagic sarcoma) of Kaposi and later
writers. For the literature on the subject we refer to the English
summaries of Dr. J. H. Sequeira[3] and Dr. Radcliffe-Crocker.[4] The
patient in our case is a male, as in nearly all other recorded cases of
this disease; he is of the favourite age (between 40 and 50), and it may
likewise be noted that he is a Galician Jew, as the patient of Sir
Stephen Mackenzie[5] and Dr. J. J. Pringle was. The minute bluish
nodules in the corium may be regarded as the primary feature of the
disease. They either remain for a long time without undergoing much
obvious change, or they undergo spontaneous involution and completely
atrophy, leaving behind them only a little brownish cutaneous
pigmentation; or else (thirdly) they may increase in size, become much
elevated, and form definite sessile tumours, which, later on, become
pedunculated, and finally drop off. This is the cycle in regard to the
development of the little pendulous tumours which constitutes one of the
most characteristic features of the disease. Another characteristic
feature of the disease, probably sooner or later present in every case,
is the œdema which occurs in the parts most affected, especially in the
lower extremities. It is persistent œdema, and results in an
elephantiasis-like condition. It is well marked in the left foot and
ankle of our case. The striking blue or purple colour of the small
nodules (which is absent in the pendulous tumours) seems, as in other
cases, to be due to the venous blood contained in the blood-vessels or
extravasated. What pigment there is in the growths is probably derived
from blood. In our patient there is no evidence of gout as in certain
cases described by Mr. Hutchinson.[6]
The prognosis in the present case is not altogether unfavourable,
considering that the patient’s general health is good, that the disease
is probably seldom of itself fatal, and that in some cases improvement
or spontaneous care has, apparently, occurred after the disease has
lasted twenty years or more.
Footnote 2:
_Vide_ X. Delore, _Lyon Médicale_, July 16th, 1899, p. 376; J.
Sabrazès and A. Laubée, _Arch. Gén. de Méd._, Paris, November, 1899,
p. 515; R. von Baracz, _Wien. klin. Wochenschr._, 1901, No. 14; G.
Carrière and G. Potel, _Presse Médicale_, Paris, May 17th, 1902, p.
471; and L. Legroux, “La Botryomycose,” _Thèse de Paris_, 1904. The
botryomyces appears to have owed its supposed existence to a mistaken
interpretation of microscopic appearances. H. Bichat (_Arch. Gén. de
Méd._, February 2nd, 1904, p. 281) thinks there is nothing specific in
the growths, but V. Ball (_Arch. Gén. de Méd._, August 2nd, 1904, p.
1921) concludes that that botryomycosis, though it owes its name to an
error, is nevertheless a pathological entity and is a special
staphylococcal affection. Dr. Weber possesses a microscopic section of
one of these little growths, which was removed from the finger (close
to the nail) of a woman in 1890, when he was a house-surgeon at St.
Bartholomew’s Hospital for Sir William Savory. It was a typical
strawberry-like “botryomycoma” with quite a narrow pedicle. Dr. J. M.
H. MacLeod, who has kindly examined the section in question, tells us
he regards such growths as “septic granulomata,” septic organisms
producing very various effects according to their degree of virulence
and naturally according to the nature of the living soil on which they
grow.
Footnote 3:
_British Journal of Dermatology_, June, 1901, p. 201.
Footnote 4:
_Diseases of the Skin_, third edition, 1903, p. 963.
Footnote 5:
_British Medical Journal_, June 4th, 1890. Amongst foreign accounts
_vide_ Radaeli’s report of five cases in _Lo Sperimentale_, December,
1904, p. 1023.
Footnote 6:
_Archives of Surgery_, vol. v, p. 237, and vol. vi. p. 132. See also
Mr. Hutchinson’s _Smaller Atlas of Clinical Surgery_, Plate 61, where
he refers to the case figured by Hebra and Kaposi as “Sarcoma
melanodes”; also his remarks on “Sarcoma melanodes” in the _British
Medical Journal_, January 7th, 1905, and the case shown by him at the
Polyclinic in December, 1904, which was also shown by Dr. Ormerod at
the Dermatological Society of London, July 8th, 1903.
SOCIETY INTELLIGENCE.
THE DERMATOLOGICAL SOCIETY OF LONDON.
An Ordinary Meeting of the above Society was held on March 8th, 1905, at
5.15 p.m., Dr. J. H. STOWERS in the chair.
The following cases were demonstrated:
* * * * *
Dr. JAMES GALLOWAY showed the case of a young lady presenting an
eruption on the left arm of unusual character. The lesion in some
respects resembled those of granulomatous origin, but no definite
diagnosis was given. This case will be subsequently noted in full.
* * * * *
Dr. T. J. P. HARTIGAN (introduced) showed a case of _atrophy of the
nails_, a description of which will be found on page 147.
* * * * *
Dr. GRAHAM LITTLE showed: (1) A case of a _corymbose syphilide_ in a man
aged 44 years, with a history suggestive of a double infection with
syphilis. The patient had been in the Army and had contracted syphilis
in India, twelve years ago. He then had a chancre on the top of the
glans penis, the scar of which was still visible. He was taken into the
Military Hospital and treated for exactly ninety-seven days, his
treatment ceasing entirely after this period. He had no secondary
eruption and no further symptoms. Eight years later he had another
chancre, also on the glans penis, but near the frænum. This was,
according to his description, a deep ulcer, which was seven weeks in
healing. He had no bubo following and no secondary eruption. Ten weeks
ago he began to have the present eruption, which was the only general
rash he had ever had. With the exception of the treatment during the
actual presence of the two chancres, he had had no specific treatment
whatever.
The eruption as seen on exhibition consisted of numerous groups of
fairly large papules arranged in a somewhat herpetiform manner, with
here and there a central larger papule surrounded by smaller ones, in
the manner described as corymbose, but for the most part the groups were
composed of papules equal in size; these groups were scattered over the
back especially, the chest, the arms, the thighs, and the face, with
individual large papules here and there upon the arms and legs. The
mucous membranes were not affected.
The history seemed to point to a double infection, the interval between
the two chancres being eight years.
(2) A case of _dermatitis artefacta_ in a young lady, a private patient,
who gave the following history. She was bitten by an old collie dog
twenty-three days ago on the calf, through her dress. She was not seen
by a doctor until a week or more later, and when seen by him she had a
circular “patch upon the calf of vesicating erythema, surrounding the
bite, with a vivid erythematous non-vesicating ring, about half an inch
broad, surrounding the central patch, and separated from it by an
intervening band of healthy skin, about a quarter of an inch broad.”
Four days later an exactly similar condition was noted on the lower part
and inner aspect of the same leg, “a patch of vesicating erythema the
size of a florin, surrounded immediately by healthy skin and then a ring
of vivid erythema half an inch wide.” The patient did not appear to be
in any way neurotic. There was no apparent animus against the owners of
the dog, who were old and intimate friends, and no breach of relations
between them had taken place. She led a healthy active life and was, in
fact, in robust health at the time. The ointment used in the first
instance was obtained from a chemist; her doctor had prescribed carbolic
ointment. The method of production was not ascertained and no adequate
motive could be assigned.
(3) A case which was shown as _syringomyelia_ with trophic ulcers on the
upper arm and shoulder in a woman who had been under Mr. Ernest Lane’s
care for about twelve years, and had had numerous operations performed
for a continually ascending necrosis of bone accompanied by trophic
ulcers on the skin.
Some divergences of opinion were expressed as to the diagnosis, and
this being at any rate a rare and interesting case, a more detailed
report will be subsequently submitted for publication in this
journal.
* * * * *
Dr. J. M. H. MACLEOD showed a case of _grouped comedones_ associated
with acneiform lesions on the chest of a boy aged 2 years. The comedones
were present chiefly on the sternal region, but several isolated groups
occurred around the nipple and umbilicus. Only a few of the comedones
had become inflamed or transformed into acne pustules. The mother had
noticed the comedones about a month before exhibition. There was a
definite history of local irritation in the case, for since the child
was a few months old he had worn a piece of flannel over the chest in
the affected region, and as the mother believed that he had a delicate
chest the flannel had been frequently saturated with camphorated oil.
The exhibitor intended to make a bacterial examination of the lesions
with the object of trying to find the acne bacillus, and hoped to report
the result at a subsequent meeting of the Society. Another point of
interest in connection with the case was the fact that it occurred in a
boy, as the large majority of reported cases have been in boys. Dr.
MacLeod referred also to another case in an infant boy of about a year
old, which he had seen on the afternoon of the meeting, but
unfortunately had been unable to bring up, in which the comedones were
grouped on the forehead and cheeks and in which there was no history of
local irritation to account for the lesions.
* * * * *
Mr. MALCOLM MORRIS showed a case of early _Parakeratosis variegata_, a
full report of which will be published in a future issue of the journal.
* * * * *
Dr. ORMEROD showed: (1) A case of _Lupus erythematosus telangiectodes_.
The patient was a woman, aged 44 years, who stated that she had suffered
from an eruption on the cheeks for the last eighteen months. On
exhibition, there was a large red area situated symmetrically on either
check, the redness being due to dilatation of the small vessels. Within
these areas there were islets of paler and shiny skin, which showed
superficial atrophy. A small area in each patch was covered with a crust
which was difficult to remove, and when detached showed little tags and
prominences on the under surface. The appearance of the eruption had not
materially altered since the patient was first seen fourteen months ago.
All the members present agreed with the diagnosis of the exhibitor.
(2) A woman, aged 38 years, suffering from a curious _eruption
associated with obscure nerve symptoms_. The history showed that four
years ago she had suffered from some chest affection, accompanied by the
expectoration of blood and offensive matter. She was ill three months,
and during her convalescence she scratched her right thumb, and a
lymphangitis of the arm, with axillary abscess, resulted. She next
developed a painful swelling of the right elbow, which was opened and
drained, and she thought a piece of bone came away; the arm was put up
in splints. The right elbow had been stiff since that time, and during
its healing she had developed pricking sensations in the fingers, which
became contracted. There was then an interval of nine months’ good
health, after which, two years ago, she developed an abscess in front of
the right thigh, which eventually broke, and laid her up for four
months. Subsequently, about eighteen months ago, the rash appeared, at
first round the site of the abscess, then spreading towards the buttock
and loin, and finally extending down the leg.
On exhibition, the patient showed an extensive anæsthetic area over the
right side extending up into the axilla, curving down both in front and
behind at the level of about the sixth rib, and embracing the whole of
the right arm and leg, with the exception of small islands on the palm,
sole, and gluteal region, where sensation still persisted. The rash
followed a similar distribution, but did not affect the arm, and tailed
off on the leg with the appearance of isolated spots. The rash
developed, according to the patient’s history, in the form of red spots,
on which a blister full of clear fluid formed. The fluid then became
mattery, and an ulcer resulted. The development of an ulcer was heralded
by a pricking sensation. On exhibition, the striking characteristics
were the presence of patches of excoriated skin and white scars,
surrounded by pigmentation. The patches were oval in shape, with the
long axis running down the limb or transversely on the trunk. The more
recent lesions consisted of red, raised papules with an excoriation on
the summit. In spite of bandaging with boric acid ointment in the
hospital a few lesions formed beneath the dressings, though more
appeared outside. Examination of the supposed affected joints showed
nothing abnormal; the reactions of the atrophied muscles to electricity
were also normal. The anæsthesia was shown to be of psychical nature,
and the exhibitor therefore considered most, if not all, of her
disabilities to be of an hysterical nature. He asked the opinion of the
Society as to the nature of the eruption.
Most members, including the exhibitor, considered that the eruption
was artificially produced by the patient.
* * * * *
Dr. J. J. PRINGLE Showed a case of _Lupus erythematosus associated with
Raynaud’s disease_ in a highly neurotic woman, aged 44 years. The
symptoms of Raynaud’s disease apparently first manifested themselves in
1895, but were first recognised as such in 1896. Associated with the
typical phenomena of recurrent local syncope and asphyxia of the
extremities, more especially of the hands, there were attacks of severe
griping abdominal pain. The exact nature of these attacks had never been
accurately determined, but there were evidences of some chronic
intestinal obstruction, which could not, however, be located. The
exhibitor had witnessed several occurrences of typical Raynaud symptoms
in the hands, and the nutrition of all the fingers was impaired, their
tips being stumpy and atrophied, but no gangrene had ensued. The first
manifestations of Lupus erythematosus showed themselves in 1900, in the
temporal regions and scalp. They were regarded as “gouty psoriasis,” and
were treated by a physician professing the cult of homœopathy by
repeated painting with pure oil of cade (!), under which they progressed
rapidly, but in the wrong direction. She was also advised to winter in a
high, cold, and dry locality, but she suffered terribly from this
experience, which was carried out last winter in Switzerland.
The Lupus erythematosus was of severe inflammatory type and occupied a
great portion of the scalp, denuding it of hair, and giving rise to a
large atrophic scar which was the seat of peculiarly obstinate recurrent
attacks of suppuration, probably referable to a dirty toupet, worn for
cosmetic purposes. Symmetrical patches were also present behind the
ears, inside the pinnæ, and in the zygomatic regions, while there were
present over the whole face a large number of telangiectatic spots
averaging nearly the size of a pea. The nasal and buccal mucous
membranes were healthy. The urine contained neither albumen nor
blood-pigment, nor was there any history pointing towards
hæmoglobinuria. The exhibitor asked the experience of members as to the
value of treatment of such a condition by Finsen’s method, X-rays, and
especially by high-frequency currents, which he was inclined to try as
of possible value in both the associated conditions present.
Dr. Pringle’s suggestion, that treatment by high-frequency currents
afforded the best prospect of benefiting the patient, especially
with regard to the Raynaud phenomena, was generally accepted.
Dr. DORE was of opinion that the disease would thereby be
considerably ameliorated and possibly even arrested, but the
attitude of the majority of members present was somewhat sceptical.
* * * * *
Dr. H. RADCLIFFE-CROCKER showed a case of _tuberculous gummata_ (or
gummatous tuberculides). The patient was a well-grown and
well-nourished, healthy-looking girl, aged 18 years, who first came
under observation on February 17th, when the following notes were made:
The disease began at the age of 7 years, when a crop of lesions made
their appearance. One of these occurred on the abdomen, near the right
ilium, where a large scar, about 3 inches (over 7 centimetres) in
diameter, was present. This condition lasted for a few months. Then very
few lesions appeared up to the age of 15, when they became more numerous
and had gone on ever since without any interval of freedom. For three
years the patient had been subject to flat circumscribed infiltrations
of the skin varying from a shilling to a crown in size. These lesions
all broke down more or less into superficial ulcers, which healed in
from two to three weeks. On the legs and thighs up to the crest of the
ilium there were a large number of more or less circular scars varying
in size, but most of them about as large as half a crown (3
centimetres). On the thighs, however, some were over 2 inches in
diameter (about 5 centimetres). On the right thigh near the knee there
was a recent lesion (two weeks old), which was about 2-1/2 inches by 1
inch (6 centimetres by 2 centimetres), dull red, with great thickening;
it presented on its surface a pea-sized ulceration, which had formed
within twenty-four hours of the time when the patient was first seen. A
similar lesion, with a more advanced ulceration, on the right calf, had
been present three weeks. Below the left knee there was a flat
infiltration, slightly raised and well defined, about the size of a
shilling (about 2 centimetres). On the right temple there was a small
circular scar of 1/4 inch, which had resulted from a similar lesion to
those already described. The patient’s lungs were unaffected, but the
history was strongly tuberculous on the father’s side, a large number of
his relations having died of consumption, whilst some others were dying
of the same disease at the present moment. The patient had lost one
sister, aged 21 years, of phthisis, and a brother and another sister of
“consumption of the bowels.”
* * * * *
Dr. SEQUEIRA showed a case of _Lupus vulgaris_ to illustrate the value
of Dr. A. E. Wright’s recent work upon opsonins. The patient, a Jewess,
aged 20 years, was first seen at the London Hospital in the summer of
1900. The whole of the face and part of the neck were then much
infiltrated and in parts ulcerated. The feet also were affected, parts
of several toes having been destroyed. Owing probably to the fact that
she was unable to walk, the patient was not seen again until February,
1905. Fortunately, photographs of the condition in 1900 were preserved,
and these showed that the disease had extended very little in the four
years and a half, although the patient had had no treatment whatever in
the interval. The general health had improved, but the lupoid
infiltration of the face and neck were well marked and there was still
considerable ulceration, the ulcers being covered with dirty scab. The
destructive ulceration of the toes had slightly increased. There were no
physical signs pointing to tuberculosis of the internal organs. The
glands were slightly enlarged, but this was not a marked feature.
Dr. Sequeira took the patient into the hospital, intending to use
tuberculin. Before doing this, the blood was examined by Dr. Wm.
Bulloch, who found that the opsonic index was 1·3, normal blood being 1.
A high opsonic index, it may be mentioned, has been found by Dr. Bulloch
in a certain proportion of the cases of Lupus attending the London
Hospital, and particularly in the chronic cases doing well under the
light treatment. As the opsonic index was already high in this case, it
was deemed unnecessary to raise it by the injection of tuberculin, and
fomentations were applied to the affected areas, to bring the opsonins
to the diseased parts. The result was very striking. In a few days the
lesions were paler, flatter, and clean. When shown at the meeting, after
a fortnight’s treatment with fomentations, the infiltration had markedly
diminished, the raised margin being flatter and paler, and the ulcerated
areas healed up, except upon the stumps of the toes.
The fomentations were of boracic lint soaked in hot water and covered
with oil silk frequently changed. It may be mentioned that the
improvement was much more rapid than had been seen in similarly
extensive cases treated by fomentations, the only known difference being
the high opsonic index. The case is of importance as supporting Wright’s
work, and also as showing the value of examining the blood before
injecting tuberculin. It also explains why some apparently severe cases
do well under simple treatment.
Dr. GRAHAM LITTLE was able to confirm Dr. Sequeira’s observations in
this case from one at St. Mary’s Hospital, in which a similar
improvement had been noticed with fomentations in a patient whose
opsonic index was as high as 2.
* * * * *
Mr. GERALD SICHEL (introduced) showed, on behalf of Sir Cooper Perry:
(1) The boy, aged 8 years, who was shown at the February meeting as a
case for diagnosis, and in whose case the chronic nodular annular
patches had gradually increased in size; fresh, hard, painless, and but
slightly tender, shotty nodules had also developed in the periosteum of
the left temporal region. Dr. Galloway recognised the case as identical
with one he had described in this journal as _Lichen annularis_. Dr.
Pringle also had seen similar cases.
(2) A boy, aged 13 years, presenting symmetrical, painless
_callosities_, covering in size an area of between a shilling and a
two-shilling piece, on the back of each heel, and which he had noticed
for the past eight or nine months.