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 Gallowayshowed 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 ofatrophy of the nails, a description of which will be found on page 147.
Dr.Graham Littleshowed: (1) A case of acorymbose syphilidein 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 ofdermatitis artefactain 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 assyringomyeliawith 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. MacLeodshowed a case ofgrouped comedonesassociated 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 Morrisshowed a case of earlyParakeratosis variegata, a full report of which will be published in a future issue of the journal.
Dr.Ormerodshowed: (1) A case ofLupus 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 ofthe 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 curiouseruption 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 onthe 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. PringleShowed a case ofLupus erythematosus associated with Raynaud’s diseasein 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 zygomaticregions, 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.Dorewas 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-Crockershowed a case oftuberculous 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.â€
Dr.Sequeirashowed a case ofLupus vulgaristo 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 bringthe 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 Littlewas 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 asLichen annularis. Dr. Pringle also had seen similar cases.
(2) A boy, aged 13 years, presenting symmetrical, painlesscallosities, 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.