744

117 notified cases. The number of revaccinations increased from 156 in 1901 to 8688 in 1902, while the successful

primary vaccinations increased from 1590 in 1901 to 2777in 1902. As will be seen by a statement from our Dublincorrespondent there are 16 cases of small-pox in that cityand on March 8th 1 patient died from the disease in thecorporation isolation hospital.

ANNUAL DEBATE OF THE CHELSEA CLINICALSOCIETY.

THE members of the Chelsea Clinical Society commencedtheir annual clinical debate on March 10th at the Jenner

Institute, Chelsea-gardens, London, S.W. The subject wasDiabetic and Non-Diabetic Glycosuria and the debatewas opened by Dr. W. Hale White, whose remarks will

be found in full in this issue of THE LANCET, p. 714. Dr.

Hale White was followed by Dr. F. W. Pavy who in the

course of his contribution to the discussion defined diabetesas "a more or less persistent defective assimilative actionupon the carbohydrates of food resulting in glycosuria." A

full report of the debate will be published in our next issue.The two other speakers were Dr. R. Saundby and Dr. J. RoseBradford.

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URÆMIC ULCERATION OF THE SKIN AND

WE have recently in an annotation referred to theintestinal lesions of uraemia.1 i The cutaneous lesions of

kidney disease resemble the intestinal ones in that they arealso ill recognised and only in recent years have receivedattention. Erythematous, urticarial, papular, purpuric, andpustular eruptions have been described. In connexion with

a case of uraemic ulceration of the duodenum with haemor-

rhage reported to the Societe Medical des Hópitaux of Parisby M. Barie and M. Delaunay (described in the annotationreferred to), M. P. Dalché and M. Henri Claude reported atthe meeting of the society on Jan. 23rd an analogousand equally interesting case of haemorrhagic ulceration ofthe skin and mucous membranes in uraemia. A woman,

aged 36 years, was admitted to hospital. Eight years beforethere was albuminuria during pregnancy which disappearedafter labour. During the next six years her health was fairlygood. Then began headaches, gastro-intestinal troubles,and fugitive oedema of the legs and eyelids. Dyspnoea,palpitation of the heart, and epistaxis appeared and threemonths before admission ecchymotic spots were observed on

]

the limbs. Hasmorrhages into the mouth, near the anus, andat the umbilicus followed in this order. Haemorrhage in thelast position was present on admission. The disease pro-gressed rapidly and the patient died about a month afteradmission in a state of profound cachexia without havingpresented any acute symptoms of uraemia, but cryoscopyshowed progressive insufficiency of renal excretion. At

1

the necropsy granular kidneys were found. M. Dalcheand M. Claude laid emphasis on the characters of thehaemorrhages and ulcers which gave the case a specialclinical aspect. On the limbs were purpuric spots andecchymoses distributed almost symmetrically. At the

1

umbilicus and anus there was a slight oozing of blood 1

the source of which was not evident. The saliva was con- ]

stantly bloody and haemorrhages occurred from the tongue Cand mucous membrane of the cheeks. The tongue was

C

yellowish white and at its sides were hypertrophied papillae 1

with fissures between them from which blood constantly 1

oozed. A small hsemorrhagio ulcer and some purpuric spots 1

were observed on the right side of the soft palate. On the t

mucous membrane of the cheeks two gangrenous patches I

appeared. Around the anus were small round ulcers with i

1 THE LANCET, Feb. 14th, 1903, p. 458.

slightly elevated borders from which blood issued. In the

week preceding death the buccal haemorrhages became

more and more abundant ; the ulcers on the cheeks

extended and became covered with a false membrane,the attempted removal of which increased the haemor-

rhage. Ulceration gradually took place at the umbilicus,resulting in two bleeding ulcers of the size of a 50-centimepiece with indurated and elevated borders. In the last daysof life they extended to the subcutaneous cellular tissue.

In all the lesions the process seemed to be the same : anextravasation of blood took place in the deeper layers of theskin or mucous membrane and was followed by destructionof the overlying tissues and hoemorrhage. The base ofthe ulcer had the characters of necrosis and not of inflam-mation. Histological examination confirmed this view ;purely necrotic changes were found. Purpura is a well- .

known manifestation of uraemia, but usually is not accom-panied by haemorrhage from the skin. M. Barie in 1889described uraemic stomatitis, but in this affection theulceration differed from that in the present case: it was

inflammatory and painful, the borders of the ulcers were notelevated, there was no haemorrhage, and the tongue was notaffected. It is noteworthy that the ulcers occurred only onparts subject to friction-the tongue, mouth, umbilicus, andanus. In other parts, no doubt in consequence of the re-establishment of the circulation, the haemorrhages were notfollowed by ulceration. The cause of extravasation of bloodin uraemia is doubtful. Amongst others alterations in bloodpressure, in the vessels, and in the coagulability of the bloodhave been proposed. Schonemann has recently examined themucous membrane of persons who died from urasmia andhad epistaxis. He found an increase in the number of the

capillaries, which were so near the surface that some of

them had perforated the basal membrane and insinuated

themselves between the epithelial cells. Thus the capillaryloops would be ruptured by the slightest injury. In the

present ’case the blood showed no loss of coagulability.The necrotic lesions of uraemia described above show an

interesting analogy with diabetes in which such lesions

occur..

STEAM TRAFFIC IN THE STREETS.

IT is difficult of course to define sharply the differencebetween a motor car and a steam engine, but we are con-fident that the Locomotives on Highways Act of 1896 wasnever meant, at any rate in crowded cities, to license the

running of a steam engine little short of the dimensions of arailway locomotive with a string of cars behind it throughthe streets. Yet recently in certain thoroughfares in theWest-end a steam engine drawing a number of cars, the

whole train being much on the same scale as a goods trainon the railway, has been a common spectacle. Even downthe narrow thoroughfare of the Strand at busy times of theday we have seen gigantic-there is no other word for it-steam boilers drawn along by a big powerful steam engine.The time surely has not come when our streets may be usedwith safety to the public as railroads. It seems to us to

be placing a very elastic and audacious interpretationupon the meaning of the Act, which was intended for

motor cars conveying persons in the same way as a

carriage, and not for heavy goods at all. An accidentoccurred this week in which a coachman lost his life

through the starting of a horse at the sight of one of thesehuge engines and its train of heavily loaded vehicles. Ifthis engine and its cars are to be allowed the use ofthe streets without let or hindrance we may confidentlyexpect further disaster. The London County Council, bymeans of its by-laws, should exercise the powers whichit possesses in this matter. We think that such traffic inthe busy streets of London should be prohibited altogether