THE CAUSATION O F BLUE TOES. 423

naphthylamine. When boiled in water it not only dissolves out in a purple colour, but also a solid sediment of dark colour is washed out of the stocking. When treated with dilute acids, various colours of bright blue or peacock blue appear according to the acid used, etc. It is thus a mixed dye.

SOCIETY INTELLIGENCE.

DERMATOLOGICAL SOCIETY O F LONDON.

A MEETING of this Society was held on Wednesday, October 8th,

The following cases and specimens were demonstrated :- Dr. DORE showed (1) a case for diagnosis. The patient was an

antEmic weakly-looking boy, aged 6 years. The greater part of his body was covered with a patchy, finely scaly eruption of a brick-red colour. The general aspect of the eruption resembled psoriasis. On the trunk it was composed of slightly scaly papules and patches, closely aggregated, and leaving only narrow areas of intervening healthy skin, the whole having a mottled if not definitely retiform appearance. The patches had a crinkled surface like that some- times seen in seborrhoic eczema, were diffusely outlined, only slightly scaly, and did not specially affect the favourite sites of psoriasis. On the forearms and legs the papular element was more marked, the irregular-shaped, flat, shining papules bearing a close resemblance to those of Lichen planus. There were a few scattered papules on the forehead and one or two round the mouth, but with the exception of these the face was unaffected.

The palms and soles and scalp also escaped and the mucous membranes of the mouth were not attacked. On the back of the neck there was some mottled pigmentation, dark patches alternating with light ones. There were no subjective symptoms. The eruption appeared on the backs of the thighs about a month after an attack of scarlet fever two years ago, and gradually spread over the whole body.

The condition had resisted treatment with strong tar, sulphur and resorcin ointment since June of the present year, when the

Dr. STEPHEN MACKENZIE in the chair.

VOL. XIV. I d L

424 SOCIETY INTELLIGENCE.

patient first came under observation, the only effect being to sliglitly reduce the scaliness. His father and mother were healthy and tliere was no other sliin-disease ill the fitniily. He was one of a family of eight, of vhom four had died. The facts that the palms, soles and face were unaffected, together with the resistance of the disease to treatment and the peculiar nature of the eruption, had led to the tentative diagnosis of I’arakeratosis rariegata, and this was sup- ported by some of the members present.

The disease affected the lumbar and sacral regions, both thighs and legs. It was most marked on the feet and legs, where the condition was apparently aggravated by the severe and extensive varicosity of the veins. Typical Lichen planus papules were seen, but these had mostly coalesced to form small scattered circular or irregular-shaped patches, some of which showed central atrophy and pigmentation. The disease dated from February (seven months ago), and was said to have followed a severe attack of vomiting. The lesion’s mere of a very inflammatory type. The buccal niucous membranes were affected.

On either side of the nose and extending nearly to the inner canthi tliere were smooth, slightly raised, yellowish patches of Xanthomn planum. The ears were affected, the lobules and external meati and surrounding skin being involved on both sides. There was also a large patch made up of an aggregation of sizlall nodules on the Ieft side of the neck. The patient had suffered a good deal with “ bilious attacks,” before the patches made their appearance.

(4) A specimen of a cutaneous horn removed from a woman, aged 68. It began t o grow soon after her change of life in 1884. The growth was very slow for the first three years, when it was said to have been accelerated by the shock consequent upon the death of her husband. After this the horn grew rapidly for over two years. I t then ceased to grow and began to loosen at the roots. It was quite loose when it was removed by her medical man in 1892, although a good deal of bleeding followed the operation. I t mas situated “ about 2 inches above the forehead on the left side of the parting.” Her inotlier is said to have had a siiiiilar grov th at the back of her head, about the

(2) A case of Lichen &anus in a woni~11, aged 44 years.

(3) A case of X a n t h n a in a woman, aged 64 years.

The condition had lasted for two and a half years.

I n other respects she was healthy.

SOCIETY INTELLIQENCE. 425

size and shape of a small nut, which was removed at an early stage of growth. The horn exhibited was about 3 inches in length, roughly pointed at the distal and tuberous at the proximal end, and had three spiral twists.

Dr. W. T. FREEMAN showed a case of pigmentation of the lower extremities. The patient was a male, aged 22, a clerk, who attended the evening educational classes of the Reading College.

It commenced about the inner ankle and progressively spread up the leg from that point. It was at first of a reddish-brown colour, but for some months had been of its present yellow ochre colour. It occurred in small sheets surrounded by individual lesions of the size of a pin’s head. In places these were simply groups of individual macules like cayenne pepper, arranged in corymbose fashion.

There were no subjective symptoms, and he said that he had never really had any such symptoms. It was nowhere raised above the skin, and there was no scaling ; no infiltration of skin. To get rid of the objectionable eruption on his legs he had for six months previously to September 4th used Clark’s ointment, and taken the world-famed blood-mixture.

Since September 4th Dr. Freeman had prescribed for him a 1 in 3,000 perchloride of mercury lotion with good results.

In the opinion of most of the members the case was one of mild eczema, accompanied by pigmentation especially affecting the follicles.

The present eruption had existed for fully one year and a half.

Dr. GRAHAM LITTLE showed (1) a case of Dermatitis herpeti$ormis in a girl, aged 10 years. Ninnie H. was admitted into the Children’s Hospital from the skin department on June 30th, with the following history :-

She had an attack of “ blisters ” on her arms and feet four months ago. She was taken into an infirmary and kept as an in-patient for nearly four months. During the time she was in the infirmary the eruption improved, so that at the date of her discharge she was quite clear of it. It returned, however, within a fortnight of her being sent home. She was brought up to the hospital a few days after and admitted.

L I, 2

426 SOCIETY I N T E L L I G E N C E

State on Admission.--She was a well-nourished girl. There was no point of importance in the family or personal history. She had very numerous vesicles and bulla: over the greater part of the body. There were a few incipient vesicles on the face, but the scalp was free, and there were no lesions on the niucous membrane of the mouth. There were large bull= on the arms varying in size from an eighth to half an inch in diameter. The skin immediately surrounding the bulla was reddened slightly, but there was no considerable erythema, the bulla appearing on healthy skin and not apparently being preceded by papules. The contents were quite clear, and when withdrawn with a sterile hypodermic needle gave no culture on serum-agar a t 37" even after ten days. The lesions mere most numerous and largest on the arms, especially on the flexor surfaces, but they also occurred on the back of the body, on the front of the thighs, and, as small vesicles, on the inner and posterior surfaces of the thighs. There mere numerous early vesicles on the buttocks, on the fronts of the knees, and about the ankles and at the base of the toes. There were further many small scars scattered about the body, and said to be the remains of the earlier eruption. The temperature was normal throughout her stay in hospital.

There was no itching whatever a t any time, and no constitutional illness, the appetite and sleep being perfectly normal. There was nothing to note in the condition of the urine, and it was passed in normal quantities. An examination of the blood was kindly under- taken by Dr. Clive Riviere, the Pathologist to the hospital, who gave the following report :-

Red cells, 4,940,000. Colourless cells, 9,000.

Polymorphonuclear, 34%. Small mononuclear, 53%. Large mononuclear, 7%. Eosirtopkiles, 4.7%. Myelocytes, .7%. Basophiles, '7%.

Thus it m s seen that there was only a very sliglitly increased proportion of white to red cells, but a definite increase of the eosino- philes, the normal ratio of these being one or two per cent. (Ehrlich,

SOCIETP INTELLIGENCE. 427

quoted by Leredde). The treatment adopted was the internal administration of arsenic in alkaline mixtures, and the puncture, and subsequent dusting with an antiseptic powder, of each individual vesicle or bulla. Speedy improvement resulted, and the patient waa transferred, within a fortnight, to the Bognor Convalescent Home, perfectly clear of the eruption.

The patient returned to the hospital on August 6th, having been discharged from the seaside convalescent home in connection with the Children's Hospital on July 31st. Three days after this dis- charge the mother noticed that blebs were forming on the feet, hands, arms and groins. The child complained at the same time of a feeling of numbness in the feet, with tingling, formication, and general malaise. She was again admitted to the hospital on August 6th. The temperature on admission was normal, but rose in the evening to 101" ; she appeared ill, and her tongue was thickly coated with a brown fur. She had large blebs on the toes, filled with serous and purulent effusion. Several of these had burst, leaving red excoriated surfaces which mere exceedingly painful. There were a number of papules and bulls on the abdomen, the arms and legs, the labia majora, the chest, and the under surface of the chin.

Several fresh bulls had appeared on different parts of the body, but the child was in better general condition. On the 12th no fresh lesions had appeared, and the older ones had mostly healed. She was discharged perfectly free from the eruption on September 1st. About ten days later she returned to the skin department with a fresh crop of papules and bullae, chiefly on the arms and legs. She had been an out-patient under Dr. Little's observation since that date, and new places had been affected continuously up to the present time. Itching, moderete in degree, was then for the first time noticeable.

The blood was examined during her second detention in the hospital, and on this occasion was found to be normal. The contents of a clear vesicle and of a purulent bulla were examined by the pathologist to the hospital. In the first instance the culture praved sterile ; in the second a diplococcus was isolated which was morpho- logically indistinguishable from the pneumocdccus, but its biological characters were, at the time of exhibition, under investigation.

The physical signs in the chest were normal. On the 8th the temperature was normal.

428 SOCIETY I N T E L L I G E N C E .

(2) A case of Urticaria pigrncntosa of the macular type. The patient was a boy aged 3 years. The affection dated from birth, having been noted a t the first washing of the child. Macules varying from one to three-quarters of an inch in size were very thickly distributed over almost the whole surface of the body, but were especially thick on the back and front of the trunlr. They were less numerous on the thighs and did not occur below the level of the calf. The face, scalp, hands and backs of the arms were free. The macule was of ;I deep yellowish-brown. It was flush with the skin but became turgescent when scratched, and the brown colour became a dusky pink. The eruption was distinctly itchy, and there was factitious urticaria. He was the only member of the family affected.

This was a very abnormal case as regards the number, elevation and size of the pigmented tumours which made up the eruption, but the diagnosis seemed inevitable. The patient was a boy aged 4 months. The tumours seemed to have been first observed about a month after birth, a t any rate as regards the geiieralised eruption seen on exliibi- tion, but the mother said that " some marlis " dated from birth, and were thought by the doctor in attendance to be birth-marks. There were very numerous yellowish-brown tumours, the colour being several shades lighter than was the case in the previous patient. They were for the most part tense, shiny swellings, about half an inch long and a quarter of an inch wide, the long axis being usually transverse, and the tumours following the segmental lines of the body in the manner noted by Hallopeau in the case pictured in the St. Louis Atlas. The eruption was thickest on the trunli, face and scalp, but there were numerous lesions on the limbs also. Fresh ehments appeared from time to time and commenced as an almost flat macule, which became turgescent when scratched. The older, more deeply pigmented nodules also swelled and became flushed when scratched. There were no bull= or pustules. There was no itching. There was no family history of importance and the child seemed in other respects to be thoroughly healthy.

There w s in the part of the skin corresponding to the elevation a marked focal accumulation of cells in the papillary zone of the corium, with very large nuclei and surrounded by granules staining bluish-red with polychrolllo

(3) A case of Urticaria pignzewtosa of the nodular variety.

Sections from this case were demonstrated.

SOCIETY INTELLIGENCE. 429

methylene blue, the nuclei staining red. The granules thus did not stain quite characteristically for mast-cell granules, but they were nevertheless probably mast-cells which for some reason did not stain well. Between these cells there were very numerous polynnclear leucocytes.

The child had suffered from the eruption from earliest infancy, with never an interval of freedom, and was in a deplorable state of generaliwd prurigo. There was remarkable lichenification of the skin in the lower limbs and in the neighbourhood of the joints, to such a degree, in fact, as to impede the movements of the joints, and to render the boy averse to getting about. The glands of the groin formed copspicuous prominences to two inches below the line of the groin. The parents appeared to be healthy country-folk of pure English stock.

Dr. LITTLE also showed a culture from a case of ringworm of the beard which on French maltose-agar had grown a violet fungus identical in appearance with the culture shown by Dr. Colcott Fox from a case of ringworm also of the beard. The naked-eye appear- ances of the case gave no indication of any peculiarity in the fungus, and unstained microscope specimens showed nothing remarkable except a peculiarly large-spored fungus. There was no suppuration with the ringworm when seen at the time the preparation was made.

(4) A case of Prurigo of Hebra in a boy of 4 years.

Mr. GEORGE PERNET* showed two unusual cases of Lupus erythe- matosus.

(1) Generalized Lupus Erythematosus.-The patient was a young man, aged 18, a plumber, who attended at the University College Hospital Skin Department for the first time on August 29th. Altogether the disease had been present for two years on the face, but for the last three months it had attacked other parts of the body. It began on the face, in the summer-time, in a ( ( butterfly ” arrange- ment (and had been called (( butterfly erysipelas ”), and then spread successively to the ears, neck, front of chest, and lastly to the hands and feet. He stated the face had got much better up to a fortnight previously, when it all came back again. When first seen by Mr. Pernet, the greater part of the face was affected in a diffuse way, the

* Mr. Pernet was indebted t o Dr. Radcliffe-Crocker for these two cases.

430 SOCIETY I N T E L L I G E N C E .

eyelids and the parts about the mouth having alone practically escaped. It was bright red in hue over the bridge of the nose, and of a duller red beyond. On the forehead it finished off in small reddish spots from a hemp-seed to a lentil in size; this was also the case about the angles of the jaws and under the chin. Behind the ears and at the sides of the izeck the borders of the erythema were well-defined, with a few spots beyond as regards the former. I n the two last situations it was also redder than in the more central parts of the cheeks. Below the limit of the reddened parts under the chin there was a transverse band of normal skin, but beyond this again the redness extended en nappe over the anterior part of the neck, becoming more mottled in appearance as it reached the front of the chest, where it extended down nearly to the margins of the ribs in front, including the nipples and a little beyond laterally. Here and there on the abdoirien there were a few little finger-nail sized spots. On the back there were also some lesions, which had formed a patch, situated in the median line, just below the vertebra prominens. There were some scattered small reddened spots between the inferior angles of the scapiilze. In the middle line, over the lumbar vertebrze, and about the liips and brcttocks, there were also some scattered spots. There were reddened areas about the axillre.

The dorsum of the right liand presented characteristic bright red areas over the knuckles, especially of the first and middle fingers, and over some of the phalaiigeal joints. The back of the left hand was somewhat similarly and symmetrically affected, but to a less extent. There was marked general redness and swelling of both palms, with flaking of the horny layer; the latter was sodden and raised up en masse in some parts. On the extensor surface of the right forearin there were a few scattered pin-head to $-inch spots, but the left forearm was practically free in the corresponding situation. On the arms, about the deltoid insertions on both sides, there were twenty to thirty punctate, reddened spots.

The outer halves of the soles of both feet were markedly affected, of a livid red tint, sodden and exfoliating in a more or less massive way.

The tongue was furred on either side with prominent papill%, but in the centre there was an oval red, denuded area. There was also

SOCIETY INTELLIGENCE. 43 1

redness about the middle line of the hard and soft palate, and diffuse redness of both conjunctivae, with some pain about the eyes, especially the right.

On the scalp there was some slight redness here and there, with a little scaly crusting in parts.

The urine was acid. On testing it, there was a distinct cloud of albumin, but no sugar.

The patient was put on salicin mixture, gr. xv. t. d. s., p. c., and a morning saline aperient as the bowels were constipated.

On September 2, that is four days after Mr. Pernet first saw him, the erythematous condition had greatly improved everywhere ; the swelling of the palms and soles had subsided. Desquamation was taking place over the front of the chest and on the face.

On September 2'3, the urine was again examined and no albumin found. All the skin-symptoms greatly improved, but, as he felt a little sick, mist. sod. effervesc. was substituted for the mist. salicin.

When shown on October 1 there was not much to be seen except two small areas on the right cheek and another on the left, with some duskiness of the akin of the face, but very little in the body.

There was.no history of consumption in the family. (2) Telangiectic Lz~pus erythematosus in a young woman of 27.

It had been going on for five years, and started with burning of the face, first about the left malar area, and two years after attacking the corresponding part of the right cheek. When first seen on August 22, at University College Hospital, both cheeks were florid, presenting on closer examination numerous telangiectases. Over the malar prominences there was a certain amount of superficial scarring, more or less encircled by a zone of dilated vessels. On the left upper eyelid there was a little finger-nail sized patch, with dilated vessels and slight scaling, also a rather smaller patch on the lower eyelid on the same side. There was a very slight amount of superficial scarring about the rim of the ears. She had a poor circulation and was subject to chilblains about the hands in the winter, but there was no Lupus erythematosus about these parts. The face was liable to swell when exposed to wind or sunlight. She had had various kinds of treatment before coming under observation. She had improved since she had attended. There was no history of con- sumption in the family, the members of which were long-lived.

The scalp was free.

432 SOCIETY INTELLIGENCE.

Dr. H. RADCLIFFE-CROCKER brought forward a case of Elepkantiasis Gnmonm on account of an X-ray burn of the face. The patient was a woman of 43, who had been under his care some years ago.*

She had been lost sight of for some three years. In the spring of 1901, she attended the London Hospital, where the X-rays were employed, with a certain amount of improvement. In July, 1902, she attended University College Hospital again, when she was found to have developed a number of large nodules, especially about the brows, the lobes of the ears, the wrists and forearms, with considerable thickening about the lips and mouth.

She again attended the hospital at the end of July, 1902, with a severe S.ray burn of the central parts of the face. She had had eighteen consecutive exposures of half an hour each. Her lips, nose and chin were in a condition of blistering, yellowish in colour, much swollen, and looking as if there were fluid beneath. The rest of the face was of a deep purple red. She was admitted because of her general weakness and the severe pain of the lsuriit parts. She gradually improved under treatment, and at the present moment the result was a great improvement of the parts which had been exposed to the X-rays, so much so that the patient was desirous of further treat- ment by this method.

Dr. T.TTHITFIELD showed a middle-aged woman, of about 40 years of age, suffering from a symnietrical seawing cmption. The history given was that the disease had commenced about twenty years previously on the right shoulder. Soon afterwards the left shoulder had become similarly affected, and a good many gears later the right buttock. Quite recently a new patch of the dieease had begun to form on the right buttock below the older one.

The condition noted was as follows :-On the posterior part of the right shoulder over the deltoid region rrere two large patches, lying more or less parallel to one another, and occupying areas about four inches long and three-quarters of an inch wide. On the left shoulder in a similar position was a single patch of identical shape, but slightly smaller. On the right buttock again was another similar but smaller patch, and below this was a very small atrophic scar which the patient said was the early stage of the disease. The

* For details of her case see Lancet, August 8, 1896.

SOCIETY INTELLIGENCE, 433

patches were formed of a central area of atrophic and slightly puckered scar which affected the skin quite deeply, and seemed adherent to the subcutaneous tissue. It mas of a white colour and showed no enlargement of veins or thickening of the skin. At each end of this band-like scar there was definite infiltration, red in colour, fading almost entirely on pressure, and having a moderately firm consistency. The infiltration seemed to be about a quarter of an inch thick with a convex outline towards the normal skin beyond it, and a slightly nodular but not claw-like edge. The surface of this infiltration was neither shiny nor telangiectatic, but rather suggested that the infiltration lay in the deeper part of the coriurn. Subjective symptoms were pricking and burning. All the patches were exactly similar with the exception of the newly forming one which showed the atrophic scarring, but not the infiltration. As the diagnosis seemed to be obscure Dr. Whitfield had taken out a small piece from the edge of the infiltration on the right shoulder, and the small wound thus caused had closed by first intention, and up to the time of exhibition showed no thickening. The histological appearances showed a rather cellular fibrous new growth with very little elastin present, lying in the middle part of the corium and not affecting the papillary layer. There was practically no inflammatory reaction present, nor any suggestion of granulomatous formation ; in fact, the picture suggested a rather deep form of sclerodermia. This was the diagnosis offered on account of, first, the symmetry, secondly, the consistency of the new tissue formation, thirdly, the normal appearance of the surface, and, lastly, the absence of any of the usual claw-like extensions found in keloid. There was considerable discussion of the case, some members believing it to be keloid, others agreeing with the diagnosis offered by the exhibitor. Dr. Whitfield said that he would try to keep an eye on the patient and note the result of the biopsy. There was no sign of keloid in the scar made by it at present, but it might help the diagnosis in the future if such changes took place later.