TWO CASES OF NON-ULCERATING " OBIENTAL SOBE " 201 



At certain points the infiltration of the epidermic layers by the round-culled ^'rowth 

 was evident, but at most points there still persisted a considerable layer of the rete. 



We could find no evidence of actual necrosis, nor were giant cells visible. It was 

 not until we consulted the recent French work on tropical medicine by Jeanselnie and 

 Eist that we found a description of anything like the condition seen in the sections of 

 the first small growth observed. There, however, we came across an excellent account 

 of the histo-pathology of " Bouton d'Orient." These authors state that the dominant 

 change consists in a thickening of the rete Malpighi (hyperacanthos and an incomplete 

 keratinisation of the corneal layer [parakeratose]). The prickle cells are separated one 

 from the other by an interstitial cedema, and perinuclear vacuolation occurs. They go on 

 to describe the state of the sub-epidermic tissue in much the same way as other writers, 

 but lay stress on the foci of necrosis and the presence of giant cells. Their diagrams, 

 both of skin sections and of the periphery and centre of a typical inflammatory nodule, 

 are very instructive, and, save for the absence of cell nests and the presence of the giant 

 cells, might apply to our sections of the small growth first removed and studied. 



It is then, we think, evident that the skin disease under consideration is an example 

 of what is called oriental sore, but it appears to be a type not prone to ulceration.' The condition 

 In this case some of the growths have been present for two years, and, even when 'j''™ *, ^. , 



" ^ J ' ' identical with 



punctured, tend to scab and heal iumiediately.- In the father's case the tiunours have that described 

 persisted unchanged, save as regards size, for six years, in the sister's case for four and ^ ° . 



'- . . observers, but 



a half years. The patient has been very closely questioned on these points and is very ofa type not 

 definite in his replies. P™"<= '° 



ulceration 



Has such a condition been previously reported '? With one exception we can find 

 no record of such being the case. Some writers speak of the papules persisti^ig for a 

 long period (Cardamatis'* mentions one of two and a half months) and others of chronic 

 papules which abort, but in no instance is any indication given that growths may attain 

 the size they have done in this case without showing any sign of breaking down."* 



The exception mentioned is given by Canibillet,'' who recently described the case 

 of a small native boy in Algiers, who presented, on the right cheek, a tumour, which, to 

 judge from the photograph given, must be almost identical with the face growth in our 

 case. It commenced as a small papule, increased in size until, at the time the pajjer 

 was written, it measured three centimetres in diameter, and showed no sign of ulceration 

 or discharge. It had persisted for a year in this state. On puncture it yielded blood 

 and " de petits (jruvieatix blancs," and in smears Leishniania tropica was found. He 

 concluded that the case was one of "Bouton d'Orient," and certainly this term is much 

 more applicable to his case and ours than that of oriental sore. The latter, in any 

 case, is a misnomer, as instances have been described from Bahia by Juliano Moreira, 

 and recently from Bauru in Brazil, by Lindenberg," who found Leishman bodies present. 

 His work has been confirmed by Carini and Paranhos.^ We think cases of this kind 



■ Is it not possible that the result depends upon the reaction of the tissue to the virus? If this lie 

 strong the epidermic layers thicken; if weak they are destroyed. It may be so, or si^ecial forms of 

 Leishmania may produce their own specific results: or again, symbiosis, with cocci or bacteria, may play a part. 



■-■ A portion only of the small growth showing the cell nests was excised. The wound healed rapidly, 

 and now the nodule presents much the same aspect as it did before part of it was removed. 



■' Cardamatis, J. P. Inc cit and (July 21, 1909), "Observations microscopiques sur un bouton d'Orient 

 non ulcere." Bull. Soc. Path. Exof. Paris. 



* See, however, note at end of this paper. 



■■• Cambillet, — (July 21, 1909), " Un cas dc bouton d'Orient a Flatters (Alger)." Hid. 



" Liudenberg, A. (May 12, 1909), " L'ulcere de Bauru on le bouton d'Orient au Bresil." Ibiil. 



' Carini and Paranhos, U. (May 12, 1909), " Identification de I'Ulcere do Bauru avec le bouton 

 d'Orient." Ibkl. 



