8 b. On 8th Jan. last, Mr. F. again called upon me in alarm, insisting that, this time certainly, he exhibited the evidences upon his skin of a fresh explosion of syphilis. Upon examination, I discovered that the surface of the scalp, face, ears, neck, chest, dorsum, abdomen, and extremities, including the palms and soles, was covered with an eruption of strictly disseminated vesicles, nowhere arranged in groups, in various stages of development.
8 c. Dr. L. A. Duhring, of Philadelphia, recently described, in a clinical lecture delivered at the Hospital of the University of Philadelphia, the peculiarities of a bullous eruption, due to the iodide of potassium, occurring in a patient affected with eczema. The description given of the lesions is admirably exact, and it is interesting in this connection to note the points of resemblance and dissimilarity between the induced phenomena in the two cases. In the following particulars the eruption in the case of the two patients displayed similar features: the vesicles were generally elevated above the surface of the skin from one – half to two lines, were roundish in shape, tensely distended by their contents, and contained a clear serous fluid, no blood or pus. They were, when mature, well – formed, persistent, showed no disposition to rupture, even when firmly pressed upon, and were yellowish – gray in colour, having a glistening look due to the external surface of the capsule of each. They were implanted upon a slightly reddened base without peripheral areola, and existed in every stage of development to complete maturity. When ruptured (some had been purposely ruptured by the patient himself), a moderately large drop of clear serum exuded. The integument upon which they were seen was neither oedematous nor infiltrated. But in the following particulars the eruption in the case of the two patients differed: in that here reported, the lesions varied in size from pin – point to small split – pea, and were in no case larger. They did not coalesce so as to form bullae; indeed, were not closely packed, as interspaces of a diameter of two inches could be occasionally observed. There were hence no coalition septa, nor were puncta to be seen imbedded in any, like boiled sago grains. They were slightly acuminate rather than flattened, and in no instance umbilicated. When first examined, none were in phase of retrogression, and were thus neither shrivelled nor macerated. The incipient lesions were not suggestive of miliaria – the condition in which minute vesicles appear upon the surface, like scattered seed – pearls. On the contrary, the papular origin of each was quite distinct, many papulo – vesicular forms showing upon the lower extremities. The eruption was symmetrical, but yet more abundantly developed upon the upper than upon the lower segment of the body.
8 d. When the eruption subsided, as it did to a marked degree in a few days without treatment, the vesicles shrivelled without bursting, and left neither ulcer nor scab, merely a light desquamative crust of yellowish – red hue, which left, after falling, a transitory hyperaemia of the surface. The patient complained of a moderate degree of itching, which in no sense compared with that from which he suffered when affected with the pruriginous boutons described above. He readily controlled the effort to scratch, and even complained, when his scalp was handled, of a certain degree of tenderness and soreness there. Here, as also upon the legs, palms, and soles, were many abortive lesions, but several fully – developed vesicles could be seen upon the scalp. The facial vesicles presented a peculiarly livid appearance during the time of his examination. It was due to the intense mental agitation of the patient, the surface of the skin of the face being engorged with blood. He had not forgotten his old syphilitic papules in the same locality, which betrayed his secret to many unskilled observers.
8 e. The disease was readily differentiated from eczema by the fact of the permanent character of the vesicles, and the absence of any evidence of dermatitis. The failure to recognise the ” boiled – sagograin ” appearance, and the absence of sweating, excluded dysidrosis – the disease which Drs. Fox, Liveing, Tay and Tweedy have of late been vigorously discussing in the British Medical Journal. The absence of concentric arrangement, as pointed out by Dr. Duhring in his case, forbade confusion with herpes. The absence of fever and failure of development into pustules excluded the supposition that the disease of the skin had been induced by either variola or varioloid, though unquestionably there are forms of the last – named disease, such as the so – called ” horn – pox,” which it would be difficult to differentiate, especially in cases where there had been no precedent febrile state. The straw – coloured ” stuck – on ” scabs of impetigo contagiosa were not observed. Uniformity of lesion, absence of itching with nocturnal aggravation, and the extent of the disease, were not characteristic of scabies, while the distribution of the lesions precluded the possibility that they were induced by zoster. 8 f. An important question remained: Were the lesions produced by syphilis? I had no hesitation in deciding that the eruption was in no way associated with the syphilitic diathesis undoubtedly present in this case, although I am aware of the fact that my position on this point will probably be disputed by many. My reasons for this decision may be briefly given as follows:
(1) Vesicular lesions are rare in syphilis. Lancereaux, in his voluminous treatise, devotes but little more than one page to their consideration. Bassereau observed, in all, but twelve cases. I can recall but two cases of distinctly and purely vesicular syphilis, observed during more than fourteen years’ experience of the disease, and in neither of these were the lesions similar to those described above.
(2) The character and behaviour of the vesicles in this patient were not those peculiar to the specific forms. In the three varieties described in most of the text – books (” varicellar,” “eczematous,” and ” herpetic ” inexact terms at the best) there is usually a history of either faint umbilication, transformation into pustular lesions, areolae of congestion or inflammation, segregation into groups, localisation in or about the hair follicles, indurated and copper – coloured base, sequence of scabs, scales, ulcers, or cicatrices, or obscurity of cause. Without particularising, it will be seen that these were not phenomena noted in the case under consideration.
(3) The patient in this instance had survived that period of syphilis in which we look for superficial, symmetrical, and short lived cutaneous manifestations. It is true that Wilson has described a corymbiform vesicular syphilide, occurring as a late symptom in tertiary or neoplastic stages of the disease. But in his patients the lesions were small red papules, vesicular at the summit merely, occurring in patches made up of more or less concentric segments of circles.
8 g. For these reasons it seemed to me that the eruption in this instance could have been produced only by some of the irritant ingesta. The patient had not taken the potassium iodide for several months before the occurrence of the disorder. Just prior, however, to the discovery of the lesions of the skin, a friend had given him, for the purpose of relieving pain in the chest, two of the gelatine – coated granules manufactured by Messrs. McKesson and Robbins, of New York, containing each a half grain of the extract of cannabis indica. He had taken these in the evening, and soon after, commencing to feel drowsy, he had retired to bed. He passed the night in a heavy, dreamless sleep, having been much exhausted during the previous day by necessary attention to his business. In the morning the eruption was perceptible over the surface of his body.
8 h. In a few days, as has been already stated, without the administration of other remedies than a gentle laxative, the eruption entirely disappeared. The patient remained at rest in his house for three days, merely dusting some finely powdered starch over those portions of the skin exposed to the air or undue friction of the clothing. (J. N. Hyde, N. Y. Medorrhinum Record May 11th, 1878.)
9. In the course of the m. I had prescribed for a gentleman of the age of 48 a mixture containing twenty minims of the Pharmacopoeial tincture of cannabis indica for migraine and lassitude. He was of an excitable temperament, nervous about himself, and particularly anxious not to be laid up just then, on account of some important business engagements. In the early afternoon I received a telegram, asking me to see him at his residence as soon as possible, and then learnt that after leaving my house he had gone to the city, had had the prescription made up, and had taken ” a dose.” Very shortly afterwards he had felt giddy and faint, and had had great difficulty in reaching the underground railway even with assistance. He had complained of much palpitation and anxiety, and said he was almost unable to stand. After telegraphing to me, he had gone to bed and fallen into a deep sleep. When I saw him he was excited and nervous, although saying he felt better than on going to bed; the pulse was still rapid and compressible, but there were no indications of any other disturbance of the nervous system; upon being reassured about the cause and prognosis, he speedily became quieter, and complained of hunger, got up, dressed, and went down to dinner. I was at first much puzzled at such marked effects from an ordinary dose, but upon asking to see the medicine bottle found the explanation. Having no glass at hand when taking the medicine, he had recklessly drunk from the bottle and had swallowed about two doses and a half, equivalent to about fifty minims. He has since taken the ordinary dose on several occasions, not only without any toxic effects, but with marked relief of migraine and of the ordinary symptoms of business worry. (Nestor Tirard, Lancet, 1890, i, 723.)
Hughes was a great writer and a scholar. He actively cooperated with Dr. T.F. Allen to compile his 'Encyclopedia' and rendered immeasurable aid to Dr. Dudgeon in translating Hahnemann's 'Materia Medica Pura' into English. In 1889 he was appointed an Editor of the 'British Homoeopathic Journal' and continued in that capacity until his demise. In 1876, Dr. Hughes was appointed as the Permanent Secretary of the Organization of the International Congress of Homoeopathy Physicians in Philadelphia. He also presided over the International Congress in London.