Acta
Derm Venereol 1948;28(3):295- 324
By
C. Lennhoff
The investigations, on which I am
going to report, date in parts as far back as 20-25 years. I was obliged to
abandon my notes pertaining to this work when fleeing from
In 1914 I had published, in
Zeitschrift für Chemotherapie, a paper dealing with a method of demonstrating Tr.
pallidum by means of arsphenamine. For this visualization of spirochaetes I
made use the powerful reducing property of the arsphenamine. As reduction
indicator I used a mixture of potassium ferricyanide and ferric chloride, from
which
Furthermore, it was found that the spirochaetes
of relapsing fever and anthrax bacilli can be stained with arsphenamine;
the latter is a specific remedy for each disease. Simultaneously I reported
that by using quinine microscopical demonstration is possible of malarial
plasmodia by means of the thalleoquin reaction. In this connection it should be
mentioned that in 1926, at the Mitteldeutscher Dermatologen-Kongress in
Magdeburg, I was able to show in co-operation with Dr. KAGELMANN that the fungi
of sporotrichosis can be made visible with iodine. In addition Tr. pallidum
was made visible by using iodine and gold. Initially in co-operation with Dr.
KAGELMANN, I devised a procedure for staining smears containing Tr. pallidum
with mercury and bismuth. With arsphenamine and bismuth, but not with mercury,
microscopical demonstration is successful if the films covering the slides are
delicate. When working, with bismuth we used Nadisan and Neonadisan
respectively, the bismuth absorbed by the spirochaetes being demonstrated by
Legère's test or with ammonium sulphide. As regards mercury, a demonstration
of the organisms in smears is successful only when working with thick-drop
preparations, and in this case a colloidal layer of a certain thickness seems
to be imperative. It is also necessary to use a dissociated mercury salt. At
present I employ exclusively a 1 per cent aqueous solution of mercuric
chloride. Further, it is important to maintain a temperature optimum of
between 50-
Briefly, the procedure for staining
spirochaetes in thick drops on glass slides is as follows:
Demonstration of
spirochaetes in thick-drop and klatsch preparations.
I) Dry in air.
II) Immerse for 10
minutes at 56° C in 1 per cent mercuric chloride.
III) Pour off the fluid
(do not rinse).
IV) Dry with filter
paper.
V) Immerse for 20
minutes in well saturated solution of ammonium sulphide (preferably with the
slide standing upright in a cuvette).
VI) Pour off the fluid.
VII) Rinse. Dry.
Optimal visualization will be obtained by following the above directions. If, however, it is only a matter of a practical demonstration of the spirochaetes, the periods of time specified, especially that of the ammonium sulphide treatment, may be considerably abbreviated. On the other hand, the specimens may quite well be exposed for several hours without injury at. 56° C to the action of the mercuric chloride solution.
From the time I spent in Magdeburg I
still possess specimens, in which spirochaetes were demonstrated in thick drops
of material taken from cases of tertiary syphilis. However, it was first here
in Stockholm I recognized that this method of demonstrating Tr. pallidum
is quantitatively superior to the dark-field technique, though of course it is
no substitute for observing the organisms in motion. Here we met with 12
instances of primary lesions, in which no spirochaetes could be found on
dark-field examination, whereas their presence was disclosed by the above
procedure. In these cases we proceeded by first taking serum for dark-field examination,
then for the thick-drop stain, and finally again for: darkfield examination.
These latter examinations were carried out by at least
Moreover, my researches here in
Stockholm on this thick-drop procedure yielded results that were quite useful
in yet another way. As you will hear presently, I was able to establish the
presence of elements resembling spirochaetes in appearance in quite a
considerable number of aetiologically obscure conditions. These spirochaetes
are susceptible to staining if a glass slide is lightly touched with the dermal
surface of an excised piece of skin, or with another tissue specimen, or vice
versa (klatsch technique). In this manipulation pressure should be avoided,
otherwise numerous fibrils and filaments are apt to be stained as well, which
would render recognition of the spirochaetes difficult or, in occasional
instances, actually impossible. The best results are obtained, e.g. in lichen
ruber, if after contact with the specimen a droplet of tissue fluid remains
on the slide. Naturally this klatsch procedure is not so conclusive for
determining the pathogenicity of a given spirochaete as one that discloses the
position of the organisms within the tissues. The technique, however, is simple
and does not require much time. For demonstrating Tr. pallidum at an
autopsy the method seems to be definitely useful.
Before proceeding to discuss the
experiments performed on animals with bismuth and mercury, I should like to
mention a preliminary investigation. If a rabbit is injected first
subcutaneously with mercuric chloride solution,
and immediately afterwards intravenously with a solution of sodium
thiosulphate, a dark, smoky discoloration will presently appear at the site of
the sublimate injection, due to the presence of an active sulphur compound,
such as e.g. sulphuretted hydrogen, into which compound the sodium thiosulphate
is rapidly turned even in the alkaline system. Many years after this
experiment, during my stay in Oslo, I learned from a paper by OPPENHEIM that as
early as in 1896 the pharmacologist FAUST of Vienna had by another method of
approach arrived at the result that sodium thiosulphate is instantaneously
transformed within the system. When he injected a lethal dose of potassium
cyanide together with sodium thiosulphate into mice, the animals survived. If a
syphilitic rabbit presenting a chancre teeming with spirochaetes is given an
intravenous injection of sodium thiosulphate, the organisms will, on dark-field
examination, have disappeared immediately, i.e. after the minimum time required
for preparing the specimens. After some time spirochaetes may again be seen,
thus showing - and this I ask you to bear in mind for the following discussion
- that sulphur is an antisyphilitic, as had formerly been pointed out by other
investigators as well; its curative action upon syphilis is, however, not a
lasting one, i.e. if any conclusion at all may be drawn from the above
experiment. If a syphilitic rabbit is injected intravenously with Nadisan or
Neonadisan and subsequently with sodium thiosulphate, and then serum is taken
from the chancre at short intervals, spirochaetes that are stained black will
be found, the black stain being due to bisulfide having been absorbed by the
organisms in the system of the rabbit. If my memory does not fail me, we have
carried out corresponding experiments with Neonadisan and sodium iodate
administered intravenously.
Experiments with mercury, which
could only be carried out on rabbits, proved difficult. Obviously, there are
certain differences between, on the one hand, the action of arsphenamine and
bismuth and, on the other, that of mercury. I am, however, not able to give
details.
If Salyrgan, a colloidal mercury
preparation, is injected into the chancre of a rabbit and immediately followed
by an injection of sodium thiosulphate into a vein, spirochaetes stained black
will be found in the serum subsequently taken from the chancre. If my memory
does not deceive me, it was recorded that we found spirochaetes showing the
black stain as early as 2 minutes after the sodium thiosulphate injection. If a
syphilitic rabbit is injected intravenously with Salyrgan and sodium iodide,
then I seem to recall that the spirochaetes can be seen stained red, i.e. by
mercuric iodide. Unfortunately, I am unable to give details of these experiments
carried out so long ago, as pointed out in the introduction to the present
paper.
The possibility of demonstrating
spirochaetes with mercury has hitherto attained the greatest importance. With
the assistance of Miss KOEHNE in Magdeburg, I had 'evolved a mercury impregnation
method for spirochaetes situated in the tissues. Though as yet not free from
considerable imperfections, it still seems capable of demonstrating not only
the spirochaetes susceptible to the silver stains, such as Tr. pallidum,
but in addition other spirochaetes hitherto unknown.
Before considering ,this method I
will try to give you an idea of the reasoning that led me to it. The
starting-point of my investigations constituted my endeavours to find an
avenue of approach to the pathogenesis of psoriasis. Round about
In 1921, at the Mitteldeutscher
Dermatologen-Kongress in Halle, I had demonstrated a crystal violet stain
which, owing to a misapprehension of my manuscript, was stated by HOFFMANN and
HOFFMANN in Jadassohn's handbook to be unstable. Using this stain I also had
found elements resembling spirochaetes in smears prepared from a psoriasis
cuticle. However, since fibrin was also made visible with this method and
since, in addition, it failed to yield information as to the position of the
elements observed within the tissues, I regarded these findings as of minor
importance. Yet when in Oslo, in 1940, I found again among my papers the
sketches made from my preparations by Dr. KAGELMANN in 1920 or 1921, I felt
that I had before me spirochaetes identical with those I had later demonstrated
in the tissues. A series of examinations of psoriasis lesions for spirochaetes
carried out with the conventional silver stains failed to give any
particularly significant results.
Especially encouraging to me in my
endeavours was the observation that a considerable proportion of psoriasis
cases heal under treatment with mercurous iodide (the Hydrargyrosum jodidum
of the Swedish Pharmacopoeia). This fact I had mentioned briefly in a
discussion at the Leipziger Naturforschertag in 1922. To quote the expression I
used on that occasion, »the trees will not grow skyhigh», that is to say, only
in a proportion of the cases is a cure brought about, and relapses occur as
with all the other methods; on the other hand, the number of cases cured by
mercurous iodide exceeds that of the responses to arsenic. This therapeutical
experience was supplemented by the discovery of the corymbose psoriasis,
presented. by myself at a meeting of the Magdeburg Medical Society, and
reported by KAGELMANN in Archiv für Dermatologie, vol. 146. These observations
constituted a very strong incitement to attempt a demonstration of spirochaetes
by means of mercury, in view of the parallelism between therapeutical action
and microscopical visualization. Since I in co-operation with Dr. KAGELMANN
succeeded in demonstrating Tr. pallidum with the thick-drop procedure,
it seemed desirable to evolve a method of visualization in the tissues, which
was done with the assistance of Miss KOEHNE.
As with silver staining, thin tissue
specimens are immersed in concentrated solutions of mercuric chloride in
absolute alcohol. Here in Stockholm we prolonged the alcohol treatment as
compared with our previous procedure, the specimens now being kept for 6-9
months in this concentrated alcoholic mercuric chloride solution. Naturally,
great care must be exercised in preventing the solution from evaporating
during this long period. For this purpose the flasks are closed with
well-fitting, paraffined corks and periodically examined for the formation of
precipitates. Subsequent to the mercuric chloride treatment the specimens are
rinsed in running water for 15-21 hours and afterwards immersed for 6-9 hours
in an aqueous solution of ammonium sulphide. Here also the flasks must be
tightly closed. Prior to being used.with tissue specimens, each fresh batch of
the ammonium sulphide is tested as to its efficacy with thick-drop preparations
of syphilitic chancre serum on glass slides. The reagent is then stored under
paraffin in a refrigerator. It will now retain its applicability for at least
a month. If stored for longer periods, the ammonium sulphide will deteriorate
and assume a brownish tinge. The reagent must possess a satisfactory quality
to ensure the success of the visualization. In Magdeburg the drug was ordered
from a firm of chemical manufacturers, here it has been supplied to us of late
by the Chemical Department of Karolinska Institutet. In order to ensure
complete saturation of the ammonium sulphide solution, hydrogen sulphide is
bubbled through an ammoniacal solution for 8-9 hours. After having been
treated with ammonium sulphide the specimens are immediately immersed in
absolute alcohol, which as a rule is twice changed, and as quickly as possible
transferred into paraffin via xylene. If the specimens have been left in the
mercuric chloride solution for too short a time, the mercury with which the
spirochaetes are impregnated may be dissolved by the ammonium .sulphide, or the
stain may be destroyed during the process of embedding.
In this connection I wish especially
to point out a technical error I occasionally made here in Stockholm. As
already emphasized, very thin slices of tissue should be taken for examination.
At the out-patient department I had removed pieces of skin by shallow excision
with a scalpel, subsequently spreading these upon a coverglass or a piece of
filter-paper in order to prevent the margins from doubling up. Even if the
specimens are separated from these supports after the lapse of only a few
minutes, the staining of the spirochaetes in the dermis will be found to be
less satisfactory, if not completely destroyed, within the areas that were in
contact with the support. The specimens should therefore be transferred into
the alcoholic mercuric chloride solution without employing a support of this
type. By using a 5 % aqueous mercuric chloride solution instead a concentrated
alcoholic mercuric chloride solution the period of treatment can be extended up
to 3-6 months. With this modification, however, fibrils and filaments are apt
to stain too, thus obstructing examination. Even the alcohol method fails to
afford complete protection against the coincidental staining of fibrils. This
applies particularly to specimens of facial skin undergoing senile
degeneration,. and was especially noted when examining lesions of
erythematodes. The 5 % aqueous solution has proved very useful in demonstrating
spirochaetes in cases of eruptive fevers, particularly rubella, which had
initially given rise to considerable difficulties. However, when a biopsy
specimen, taken from a rubella patient on the first day of the eruption, was
kept for 6 months in concentrated alcoholic mercuric chloride solution, i.e.
longer than at the start of the investigations, the presence of spirochaetes
was disclosed by this solution also. Attempts to accelerate considerably the
action of the mercuric chloride solution by employing higher temperatures about
50° C., have resulted in a fairly satisfactory, and sometimes excellent,
visualization of. the spirochaetes in a number of cases without producing
consistently reliable results. I will, however, refrain from discussing these
experiments. Even our alcoholic mercuric chloride procedure still needs improvement.
A serious drawback with regard to skin lesions is that the spirochaetes
situated within the epithelium are stained only in the marginal zones or in
those areas where the epithelium is partly broken up by the morbid process. In
some cases we have therefore scarified the epithelium with the scalpel; in
Magdeburg - this .modification was not used by us in Stockholm - we had also
achieved visualization in the epithelium by omitting to embed the specimens,
Instead, these were dipped for a moment in distilled water subsequent to the
mercuric chloride treatment. Frozen sections were then made which were stained
on the slide with ammonium sulphide. In this procedure the sections should be
carefully dried on the slides with filter-paper, as they otherwise are apt to
fold up when the ammonium sulphide solution is applied. This procedure sometimes
met with certain technical difficulties; in such cases it was modified as
follows: The wet frozen section is placed upon a slide, which is laid, with the
section facing downwards, on a cuvette-cover containing ammonium sulphide. Care
is taken that the cuvette-cover is well closed by the slide. The period during
which the solution, or vapours, of ammonium sulphide are allowed to act on the
specimen, is 3-20 minutes. - Briefly summarized, our tissue procedure
principally used at present is the following:
Demonstration of
spirochaetes in tissue specimens.
I) Immerse the thinnest
possible tissue pieces for about 6-9 months in:
Mercuric chloride 25.0,.
Absolute alcohol 75.0
(close flask with paraffined cork).
II) Rinse for about
15-21 hours in running water.
III) Immerse for about 9
hours in ammonium sulphide.
IV) After rapid transfer via alcohol and xylene, embed in paraffin. Frequently we employ counterstaining with haematoxylin and van Gieson's solution.
In addition to the examination of tissue specimens in Magdeburg, we attempted to demonstrate the spirochaetes of psoriasis, seborrhoic eczema, lichen ruber and pityriasis rosea with the aid of the dark-field procedure. As it is not possible in these diseases to obtain serum for dark-field examination in the same way as in syphilis, we evolved the following technique:
When dealing with psoriasis,
seborrhoic eczema and pityriasis rosea, we collected a liberal amount of scales
or, as was most often done in cases of lichen ruber, tissue material.
The material obtained was ground in a sterile mortar, suspended in saline and -
in order to remove coarser particles of tissue - strained through a single or
double layer of sterile fine linen, occasionally also through a Seitz filter.
The filtrate was centrifuged for 20-45 minutes at 3,000 revs/ min, and the
supernatant fluid then drained off by means of a water-jet pump, with the
exception of a minute amount covering the bottom of the tube and kept for
dark-field examination. As regards psoriasis, I remember the figures quoted in
the records: the number of spirochaetes found in a given case was small in
spite of lengthy mostly 6-7, in exceptional instances only 2, and at the utmost
30. The organisms were coarse and moved in a characteristic, transversely
wabbling fashion. According to the records, we have found spirochaetes in
92 of 96 psoriasis cases. with the procedure described..
I am unable to recall the actual
figures for seborrhoic eczema, lichen ruber and pityriasis rosea. As far
I know, we examined about 15 cases each of these diseases with the darkfield
technique, with positive findings in 12-14 cases of each disorder. In these
examinations we were unable to distinguish between the spirochaete of
seborrhoic eczema and that of psoriasis. In accordance with its appearance
in stained sections, the spirochaete of lichen ruber is delicate, and moves
gracefully, i.e. without displaying the so-called »twisting» motion of Tr.
pallidum. The spirochaete of pityriasis rosea moves with extraordinary
velocity, often tumbling head over heels in its motion, and is in this state
not recognizable as a spirochaete; when the organism has resumed its horizontal
position however, its true character of a spirochaete will be revealed.
Hitherto we have not been able to take up work with the tedious procedure of
dark-field examination as no centrifuge has been available. However, we have
carried out a few preliminary experiments using the simplified technique by
scraping a small amount of tissue material from the dermal surface of the
excised specimen into a drop of saline. Thus we were able to find spirochaetes,
which in various instances were demonstrated to several gentlemen, in 13 cases
of psoriasis, 5 of pityriasis rosea, 1 of seborrhoic eczema, 2 of lichen
ruber, 3 of erythema exsudativum multiforme, and 1 of erythema nodosum.
Further, in Magdeburg, we had
succeeded in growing the spirochaetes of psoriasis, lichen ruber and
pityriasis rosea on culture media. The organisms were grown in a refrigerator at 5-8° C on two media
introduced by REITER and HODER respectively; growth was arrested at 37° C; the
optimal temperature was not ascertained. However, when dealing with other
spirochaetes, the temperature most conducive to growth should generally be
considered of interest, as this might prove capable of explaining the presence
of particularly large numbers of spirochaetes in the skin, and of illuminating
certain clinical aspects, e.g. in cases of eruptive fevers. When I was
compelled to resign my appointment, the oldest psoriasis strain was at the
28th subculture. The transfers had been made at fortnightly intervals, the
purity of the strain having been controlled in the 8th or 9th subculture.
Cultivation had been carried out by Miss RILKE. Recently we resumed cultivation
in a refrigerator in co-operation with Docent HOLLSTRÖM; hitherto we have
obtained first cultures grown in HODER'S medium from cases of psoriasis and
pityriasis rosea, also from those of erythematodes and erythema multiforme, the
organisms of which have not been grown previously. In these experiments we used
a medium prepared with rabbit-serum broth and rabbit liver thrice subjected to
fractional sterilization (HODER, Z. Immun. Forsch. .1930).
Hitherto, I have mostly been
concerned with demonstrating spirochates in tissue specimens, but I must
refrain from discussing details. However, I wish to stress the fact that
careful attention was paid as to whether or not the elements interpreted by us
as spirochaetes were situated in loco morbi. Below, the term
spirochaete will be used to design elements presenting the morphological aspect
of spirochaetes, whether the living organisms have been studied in the
dark-field or not. Firstly, I propose to give a tabulation of the diseases in
question:
Psoriasis, seborrhoic eczema, lichen
ruber, pityriasis rosea, erythematodes, erythema multiforme, erythema nodosum, zoster, varicella, morbilli,
rubella, dermatitis herpetiformis, pemphigus, mycosis fungoides, parapsoriasis,
lymphadenosis cutis benigna, lymphogranuloma inguinale,
lymphogranulomatosis maligna, lymphogranulomatosis benigna, erythema migrans,
acne necroticans, acne vulgaris, endocarditis and leucaemia.2
We have examined about 240 cases of
psoriasis in all. In Magdeburg, on examination of skin sections, 72 out of 80
cases were positive, in Stockholm all the 52 examined cases were positive. This
also applies to material obtained from Koebners phenomena. In addition, there
were in Magdeburg 96 cases with dark-field examination, 92 of which were
positive; in Stockholm we obtained 13 positive dark-field findings. When
stained in the tissues, the spirochaete is as a rule rather coarse, with
occasional delicate specimens. Therapeutically, psoriasis responds top
spirochaeticides, arsenic and mercurous iodide, as I have mentioned earlier;
furthermore gold, bismuth and iodine have been recommended for treatment.
Following the administration of arsphenamine and gold, psoriasiform eruptions
have been observed.
Of seborrhoic eczema altogether 27
cases were examined. Therapeutically, in addition to ammoniated mercury
ointment sulphur is used principally; the latter is a spirochaeticide.
In lichen ruber another
delicate spirochaete is present, which is distinguishable from that of
psoriasis not only on dark-field examination but also in sections. In the
spirochaete observed in cases of lichen ruber the coils are generally
somewhat wider and more shallow than in Tr. pallidum. The characteristic
spirochaete was demonstrated in about 60 cases in all, among which there was
one showing occasional organisms in a Koebners phenomenon, and one organism was
found in a lymph gland forwarded for examination by Docent HOLLSTRÖM. In
addition, there were 2 further cases which, in my opinion, are of general
significance. In each of 2 eruptions resembling lichen ruber, which had
developed subsequent to the administration of arsphenamine and mercury
respectively, I found spirochaetes identical with those otherwise observed in
cases of lichen ruber. I addition to the lichen ruber caused by
the use of arsphenamine and mercury, lichen ruber is also known to
develop especially after chrysotherapy, as gold is also a spirochaeticide. Lichen
ruber may be to be cured by arsenic, mercurous iodide and bismuth, i.e. by
spirochaeticides, but may also be provoked by spirochaeticides. As is
well-known, considerable credit is due to Milian for having pointed out, in
general terms, the significance of the provocation of a latent microbism.
Apparently this factor plays an especially important role, in the field of
dermatology, as regards the spirochaeticides that simultaneously exert a
curative action on the conditions concerned.
The total of pityriasis rosea cases
examined amounts to about 80, practically all of them being positive. As a
rule, the spirochaete is delicate in shape with narrow coils, both shape and
size, however, being subject to considerable variations: there exist also
fairly large and coarser forms, and organisms with quite shallow coils as well
as such forming arcs and circles are comparatively frequent. Previously it had
been contended by SAALFELD that pityriasis rosea is cured by arsenic; here it
was established that a prompt cure results from bismuth and arsphenamine. A
report on this observation will be given by Docent HOLLSTRÖM. the first to have
treated pityriasis rosea with bismuth. Evidence is on record of pityriasis
rosea being provoked by gold and arsphenamine.
Of erythematodes we have examined 60
cases in all, consistently with positive spirochaetal findings. In addition
there are 3 cases, of which cubital lymph glands were forwarded for examination
by Dr. THYRESSON. The lesions clear up after administration of gold,
arsphenamine, bismuth and also mercurous iodide, as has been established by us
here in Stockholm in experiments extending over a considerable period.
According to MARTENSTEIN and GRANZOW the luetin reaction is positive in 75 per
cent of the cases, i.e. as frequently as in tertiary syphilis. The Wassermann
test is not infrequently positive in the acute cases, being positive in
chronic cases if the amount of antigen is doubled. The relation between
erythematodes and tuberculosis or streptococcal infection might possibly be
interpreted on the basis of provocation of a latent microbism, which also
applies to erythema nodosum. Again, the occurrence of tuberculosis subsequent
to morbilli has been known for a long time. Parenthetically, I should like to
mention that once in a case of erythematodes presenting symptoms of arthritis,
I found spirochaetes in an endocarditic heart valve; I am unable to
state whether in this case the endocarditis was due to the erythematodes, or
was merely a case of (so-called rheumatic endocarditis). Furthermore, I once
demonstrated spirochaetes in a valve in a case of rheumatic endocarditis, and
twice in lymph glands. of patients suffering from rheumatic polyarthritis. I am
not aware, nor have I investigated, whether salicylic acid arts as a
spirochaeticide. I have examined 27 cases of erythema multiforme in addition to
one case examined in Magdeburg. Among these, the findings were negative in
sections in one case, doubtfully positive in another case, and positive in the
remainder. One case of erythema multiforme with sparse nodular lesions
following on the administration of sulfathiazole was positive. Besides
salicylic acid, potassium iodide is recommended for treatment and, in relapsing
cases, arsenic; possibly also provocation occurs brought about by salicylic acid,
arsenicals and mercury.
8 cases of erythema nodosum have
been examined (tissue specimens), with positive findings, and I demonstrated
the organisms in the dark-field in one case to several colleagues. In addition,
there were 7 cases of erythema nodosum after the administration of
sulfathiazole, which were positive. As is well-known, MASSINI reported a long
time ago that on darkfield examination in a case of erythema nodosum he had
found spirochaetes which he was unable to stain whichever method he employed.
I have examined 34 cases of zoster,
yielding positive results by me. Provocation has been described as being due to
arsenic and its derivatives, potassium iodide, bismuth, mercury and Chrysolgan.
Varicella infection from arsenic zoster has both been observed .and
experimentally produced. Provided the virus is the same in both diseases, the
transfer, of the arsenic zoster and its manifestation in the form of varicella
may be considered to support the conception of the provocation of a latent
microbism.
I have examined 15 varicella and 7
morbilli cases. In a case, in which Docent HOLLSTRÖM consulted me on the first
morning of the morbilli eruption, I found four spirochaetes with peculiar,
twisting movements in the blood after a dark-field search of about 45 minutes.
SALIMBENI and KERMORGANI, of the Institut Pasteur, stated that they were able
to culture at 32° C spirochaetes from morbilli blood collected prior to the
development of the rash; they failed, however, to obtain a pure culture. As
regards provocation, MILIAN has reported a case of morbilli after arsphenamine
entailing infection of other persons.
I have examined altogether 13 cases
of rubella. Prior to being able to examine sections, I had made a klatsch
preparation showing definitely peculiar spirochaetes with which I was
unfamiliar. 1 mentioned this at the time when demonstrating the preparation to
Professor HELLERSTRÖM, Docent RINGERTZ and other gentlemen. This was the first
and only instance that I seemed to have identified a new spirochaete solely on
the basis of a klatsch preparation. In addition to the findings discussed
above, I have met with a case of rubella after sulfathiazole and another one
after arsphenamine, each of them positive. In the latter case typical
lymphoglandular enlargement was noted in the occipital triangle. I am not aware
of benign eruptive fevers having been treated with spirochaeticides. I was not
afforded the opportunity examining cases of scarlet fever.
I have examined 7 positive cases of dermatitis
herpetiformis. Also in this disease I consider provocation by spirochaeticides
possible. There are cases in which the condition develops for the first time in
previously healthy subjects after the administration of iodine or mercury and
takes a course exactly identical with that observed in dermatitis
herpetiformis, arising without any known excitive factor. As far as I know,
there is no evidence of a reaction of supersensitiveness with such a course.
Should it emerge on continued investigation that the local responses to iodine
and mercury respectively are due to provocation, this observation would be of
considerable interest.
I shall not discuss these conditions
as I have examined only a few cases. The common feature is the therapeutical
use of spirochaeticides. To my knowledge this is at present not known to apply
to erythema migrans.3
I have examined 10 cases, of acne
vulgaris but these were not exhaustively investigated; in the first place, the
objection can be raised that positive spirochaetal findings might be due to a
seborrhoic eczema conductive to the origination of the acne. Of lymphatic
leucaemia I have collected 6 cases with positive findings, in one of which a
positive klatsch preparation was obtained from bone marrow. Of myeloid
leucaemia, there are 2 cases, one of them with a positive klatsch preparation
of bone marrow. Therapeutically, arsenicals should be taken into consideration.
Possibly also the leucaemoid reaction to mercury results from provocation.
Further more, I would like to
mention that I have found spirochaetes in closed cancerous tumours; I do not
propose, however, to discuss this observation until further thorough investigations
have been made. 4
In one instance we found spirochaetes
in a horny scale covering a soft naevus, and in another in a scale adhering to
a lipoma, in neither case, however, in the tissues. Spirochaetes were not demonstrated
in allergic eczema, Besnier's prurigo, lupus vulgaris, a case of glandular
tuberculosis, mycotic lesions, a case of Recklinghausen's disease, nor in a
case of pseudomyxoma peritonei and one of glomerulonephritis. These constitute
some few controls, but naturally the range of control examinations must be
considerably extended. At the present moment the observations indicate that
spirochaetes are not present in all conditions, nor at all stages of their
development.
In summarizing I should like
especially to emphasize the following. On the basis of the parallelism between
therapeutic action and microscopical visualization, a procedure was evolved
whereby, with the aid of mercury. Tr. pallidum and new, unknown
spirochaetes could be demonstrated. As to Tr. pallidum, the thick-drop
procedure seems to be quantitatively superior to the dark-field technique,
though naturally incapable of replacing the latter. The spirochaetes previously
known are susceptible to the silver
stain, that is to say, they are
argentum-positive; but it has been occasionally suggested that even this group
includes argentum negative forms (HOLLANDE, HOFFMANN and KARRENBERG). The
new, apparently very numerous spirochaetes are (generally?) argentum-negative. This
is probably one of the reasons for their hitherto having escaped observation;
another one is perhaps the fact that when dealing with the conditions in
question, serum for dark-field examination cannot be obtained by so simple a
procedure as that with which we are familiar in the examination of syphilitic
lesions.
In the diseases, in which
spirochaetes are present, treatment with spirochaeticides and provocation by
the same seems to play an important part. Many observations suggest that toxicodermas
presenting the aspect of idiopathic diseases are actually identical with the
conditions they simulate.
It is generally known that
identification of the spirochaetes depending entirely on morphological
characteristics as displayed in the fixed condition is as a rule impossible;
however, the spirochaete of psoriasis can be distinguished from that of lichen
ruber even in tissue specimens. The new spirochaetes hitherto examined
with the dark-field technique are distinctive for the various diseases. In
Magdeburg the spirochaetes of psoriasis, lichen ruber and pityriasis
rosea have been cultured in a refrigerator. Recently, in co-operation with
Docent HOLLSTRÖM first cultures have also been obtained from psoriasis,
pityriasis rosea, erythematodes and erythema multiforme. The organisms of both
the latter diseases have not previously been grown.
As for the majority of the
conditions examined, it is at present more or less likely that spirochaetes are
of aetiological significance. In my opinion, as regards psoriasis, lichen
ruber, pityriasis rosea and erythematodes, the aetiologic evidence for
these being spirochaetoses is largely established; in the case of erythema
multiforme I consider this highly probable. However, it should be strongly
emphasized that as yet only the foundation is laid for further necessary
investigations.
I have now come to the end of my
thesis but before concluding I wish to express my deeply-felt gratitude to my
former .associates. In the first place, my sincere thanks are due to Professor
FELIX PINKUS, who after a long interval of involuntary leisure has given me
highly valuable advice and assistance at a preliminary general survey of my
previous specimens during our simultaneous stay in Oslo. From that period also
dates my gratitude towards Professor VICTOR KAFKA, who has encouraged me by
taking especially keen interest in my work. - Here in Sweden, I am first and
foremost greatly indebted to Professor SVEN HELLERSTRÖM, who immediately
welcomed me to his clinic and facilitated my work in every respect, as well as
to the Prosectors of the Pathological Institute of St. Göran's Hospital, Dr.
FREDRIK WAHLGREN and Dr. NILS RINGERTZ, who afforded me the opportunity of
working in their institute and continually gave me their support. Furthermore,
I proffer my thanks to Physician-in-Chief Docent Bo TARRAS-WAHLBERG and to all
the other gentlemen who extended their kind help to me. However, in all
probability I would not have been able at all to express my gratitude, had not
Sweden received us refugees and afforded us the opportunity of working. To
Sweden, therefore, our heart-felt thanks are addressed.
At the 11th Meeting of the Northern
Dermatological Society, on June 9th, 1946 the following original preparations
were demonstrated under the microscope:
I) Tr. pallidum,
thick-drop preparation.
II) Spirochaetes in a
papilla, psoriasis.
III) » in a vesicle, lichen ruber
bullosus.
IV) » in the dermis, pityriasis rosea.
V) » in the epithelium, erythematodes.
VI) » at the lower epithelial margin,
erythema multiforme.
VII) » in a lymph gland, myeloid
leucaemia.
Author's address: Karolinska Institutets Dermatologiska Klinik, Karolinska Sjukhuset, Stockholm 60, Sweden.
TABLES 1-10.
When not stated that the pictures were taken from frozen sections, material embedded in paraffin had been used.
Table 1. - Figs. 1-3. - Drawings by
Professor FELIX PINKUS. Compo oc. 4. Apochrom. imm. 2 mm. Figs. 4-23 are photomicrographs.
Fig.1. - Psoriasis: Spirochaetes in a horny scale..
Fig. 2. - Psoriasis: Spirochaete between parakeratosis and epithelium.
Fig. 3. - Psoriasis: Spirochaete beneath the stratum corneum.
Table 2. - Fig. 4. - Psoriasis: Spirochaete in the epithelium. Frozen section. X 600.
Fig. 5. - Psoriasis: Spirochaete in a papilla. X 600.
Table 3. - Fig. 6. - Psoriasis: Spirochaetes in the dermis. x 600.
Fig. 7. - Psoriasis:
Spirochaete in a papilla (case from which the oldest culture was obtained). x
600.
Table 4. - Fig. 8. - Psoriasis: Spirochaete in a micro-abscess. X 1,000.
Fig. 9. - Pustular psoriasis: Spirochaete in a pustule. X 600.
Table 6. - Fig. 10. - Pustular psoriasis: Spirochaete, and perhaps
spirochaetal debris, in a pustule. X .600.
Fig. 11. - Pustular psoriasis: Spirochaetes in a pustule. X 600.
Fig. 12. - Same area as in Fig. 11. X 1,000.
Table 6. - Fig. 13. -
Psoriasis: Spirochaete In a vesicle wall. The black mass within the vesicle is
precipitated mercuric sulphide.
Fig. 14. - Seborrhoic eczema: Spirochaetes adjacent to a hair follicle.
X 600...
Table 7. - Fig. 15. - Lichen ruber: Spirochaetes in the
epithelium. Frozen section. X 600.
Fig. 16. - Same area as in Fig. 15. X 1,000.
Table 8.- Fig. 17. - Lichen ruber: Spirochaete in an
infiltrate. X 600.
Fig. 18. - Lichen ruber bullosus: Spirochaetes- in a vesicle. X
600.
Fig. 19. - Same area as in Fig. 18. X 1,000.
Table 9. - Fig. 20. - Pityriasis rosea: Spirochaetes in the epithelium.
Frozen section. X 600.
Fig. 21. - Pityriasis rosea: Spirochaetes in the dermis. X 1,000.
Table 10. - Fig. 22. - Morbilli: Spirochaete in the dermis. X 600.
Fig. 23. - Zoster: Spirochaete in the dermis. X 1,000.
(pictures omitted – they were
unfortunately photocopied too dark)
1 Addendum to proofs. Since reading
this paper before the meeting, I have examined material obtained by lymph node
aspiration in cases of various skin diseases. These finding. will later be
reported elsewhere.
2 Addendum to proofs: In addition,
granuloma anulare and bromoderma (?).
3 Addendum to proofs: subsequently
3 cases of erythema migrans received bismuth treatment, 2 of which with
striking success; the third case, which is still under treatment fails to show
a rapid improvement.
4 Addendum to proofs: Since the time
of the Meeting the number of examinations has increased. I refrain, however,
from giving data as to these continued investigations in correcting the proofs.