312

The following is an example of "

simple " peripheralneuropathy (perhaps due to vitamin-B1 deficiency) withcomplete achlorhydria.Case 8.-A man, aged 60, in Maroh, 1951, immediately

after two months’ persistent diarrhoea, developed whatappeared to be a mild simple peripheral neuropathy (motorand sensory) unaccompanied by any evidence of involvementof pyramidal tracts though he had recently noticed someincreased frequency and urgency of micturition. A peri-pheral blood-count was normal. A test-meal showed hista-mine-fast achlorhydria. The patient was treated with

vitamin-B1 tablets and Marmite ’ and steadily improved.Ten months after the onset there were no longer any motoror sensory abnormalities in the limbs, and micturition wasnormal. There has been no sort of recurrence in the two

years since then.

Whether his neuropathy was the result of a nutritionaldeficiency or of an infection is unknown, but in spite ofthe achlorhydria the clinical course seems to excludedeficiency of vitamin B12. This case is mentioned to showthat, although the combination of histamine-fast achlor-hydria and peripheral neuropathy, even in the presenceof a normal blood-count and a normal marrow-count,must always arouse a suspicion of vitamin-Bi2 deficiency(pernicious-anæmia/subacute-combined-degeneration syn-drome), the neuropathy may sometimes have a differentcause. r

The diagnosis may remain in doubt in some cases ofalcoholic peripheral neuropathy associated with hista-mine-fast achlorhydria and in other neurological condi-tions where the clinical picture has been confused byinjudicious liver or vitamin therapy. In recent yearsgastric biopsy has been used to obtain further informationin such cases. As a diagnostic technique this procedurehas yet to justify itself fully, and some of the histologicaldistinctions are relative rather than absolute.Doig et al. (1950), however, have found that all

patients with subacute combined degeneration of thecord and/or pernicious anaemia show considerable

atrophy of the mucosa of the body of the stomach(much more than is generally found in chronic gastritis),and from these and other observations they considerthat the nature of the biopsy fragments is a valuable aidto the correct diagnosis. This may be of importance incases of subacute combined degeneration of the cordwithout obvious changes in the blood or in the bone-marrow, for it is these patients in particular who needearly treatment.

Hyland et al. (1951) have shown that the most strikingrecoveries in the nervous system are seen when theinterval between the onset of neurological disease and theinstitution of therapy is less than six months. Failure to

improve on adequate therapy was-found only in patientswith neurological symptoms of long duration. The

recognition of early neuropathy due to vitamin-B,,,deficiency in the absence of changes in the blood or evenin the bone-marrow is therefore very necessary.

SummarySubacute combined degeneration of the cord may be

associated not only with a normal peripheral blood-countbut also with a normal sternal marrow.

5 cases of subacute combined degeneration withinsignificant changes in the peripheral blood and withnormoblastic bone-marrow are described.

In the 1st case there was no initial treatment withvitamin B12, and changes characteristic of perniciousanaemia were found one year later in the peripheral bloodand bone-marrow. In the 2nd case a small amount ofvitamin B12 was given (somewhat injudiciously) for twoweeks only. Thereafter the patient remained well forthree years, at the end of which changes characteristicof pernicious anaemia were found in blood and bone-marrow.

Pernicious anaemia, did not develop, the neurologicalsigns did not advance, and there was symptomaticrecovery in the 3 other patients, who received adequatetreatment with vitamin Bi2. In 2 of these 3 cases giantmetamyelocytes were seen in the bone-marrow; thismay be one of the earliest indications of the developmentof pernicious anaemia,.

2 patients (cases 6 and 7) are described, in whom peri-pheral neuropathy was associated with histamine-fast achlorhydria and a normal peripheral blood-count.In 1 of these, minimal changes in the sternal marrowalso suggested the beginning of pernicious anaemia.

Patients with histamine-fast achlorhydria are in varyingdegrees liable to develop manifestations of vitamin-B12deficiency (peripheral neuropathy, subacute combineddegeneration, and pernicious anaemia), but the relativesusceptibility of the peripheral nerves, spinal cord, andbone-marrow is unpredictable. Early treatment ofneurological manifestations is essential, and such patientsshould be kept under prolonged observation. ’

Although always suspect, some cases of peripheralneuropathy with histamine-fast achlorhydria and withoutanaemia are due to causes other than vitamin-B12deficiency.

It is suggested that the inappropriate terms " perniciousanaemia" and " subacute combined degeneration -of thecord " now be dropped in favour of the more compre-hensive designation " vitamin-B12 deficiency." This maybe qualified, if desired, by adding " megaloblasticanæmia" and/or " neuropath " (whether cerebral,spinal, or peripheral) as appropriate.

I would like to thank the several pathologists for their readycooperation, and also Dr. M. G. Ashby who originally drewmy attention to the sequels in the first 2 cases.

REFERENCES

Dcig, R. K., Motteram, R., Robertson, E. G., Wood, I. J. (1950)Lancet, ii, 836.

Foy, H., Kondi, A., Hargreaves, A. (1950) Ibid, i, 1172.Greenfield, J. G., O’Flynn, E. (1933) Ibid, ii, 62.Hughes, R., Wells, C. (1951) Ibid, i, 939.Hyland, H. H., Watts, G. O., Farquharson, R. F. (1951) Canad.

med. Ass. J. 65, 295.Leichtenstern, O. (1884) Dtsch. med. Wschr. 10, 849.Lichtheim, L. (1887) Neurol. Zbl. 6, 235.Meyjes, F. E. P. (1947) See Lancet, ii, 400.Monrad-Krohn, G. H. (1947) Ibid.Russell, J. S. R., Batten, F. E., Collier, J. (1900) Brain, 23, 39.Suzman, M. M. (1931) Trans. Amer. neurol. Ass. 57, 339.Thomson, M. L. (1944) Lancet, ii, 688.Ungley, C. C., Suzman, M. M. (1929) Brain, 52, 271.Whitby, L. E. H., Britton, C. J. C. (1953) Disorders of the Blood.

7th ed., London.Wilson, S. A. K. (1940) Neurology. London ; vol. II, p. 1340.Wilson, T. E. (1942) Med. J. Aust. i, 513.Woltman, H. W. (1919) Amer. J. med. Sci. 157, 400.Young, R. H. (1932) J. Amer. med. Ass. 99, 612.

TREATMENT OF PLANTAR WARTS WITHCARBON-DIOXIDE SNOW

K. D. CROWM.B. Lond., M.R.C.P.

ASSISTANT TO THE SKIN DEPARTMENT, ST. THOMAS’S HOSPITAL,LONDON

O. L. S. SCOTTM.A., M.B. Camb., M.R.C.P.

CONSULTANT DERMATOLOGIST, GUILDFORD AND REDHILL

HOSPITAL GROUPS AND WEMBLEY HOSPITAL

IN our experience the treatment of plantar wartswith carbon-dioxide snow has proved very reliable andcan be used equally easily in hospital, surgery, or

patient’s home.The ideal method of treating these lesions should be

rapid, needing only one or two visits to the physician,and it should be relatively painless and easy to apply.Destructive therapy of some kind or another, therefore,is the only form which is likely to be satisfactory.

313

Treatment with adhesive strappin,g; with or without25% podophyllin and with trichloracetic, carbolic,or salicylic-acids has the disadvantage of requiringseveral treatments, while X-ray treatment, even if one

accepts its safety and reliability, can be administeredonly at certain hospitals where the apparatus is available.Freezing with liquid nitrogen is not reliable (Morgan1962), and it is difficult to obtain the substance. Curet-

tage followed by cauterisation is the method most widelyused, with local or general anopsthesia. It has a highcure-rate but requires the provision of sterile instru-ments and dressings. Other disadvantages are the oftenconsiderable pain, tenderness, and disability caused

by the treatment.Freezing with carbon-dioxide snow appeared to us

to satisfy every criterion, but it had long since falleninto disrepute because of its unreliability, the cure-ratebeing only about 50%, even when freezing was appliedfor an adequate length of time. Furthermore, manyhave believed that severe pain is inevitable if it is usedproperly. In view of its possible advantages, however,we decided to reinvestigate its use.We soon noted that freezing for a,n insufficient length

of time was not the only cause of failure. for in a shortseries of patients whose warts were frozen for five orsix minutes about half recurred. When, however, thethick hyperkeratotic cap of the wart was removed beforefreezing, the cure-rate immediately rose and became

comparable to that achieved by curettage and cauterisa-tion. The pain was surprisingly slight, did not increaseas the freezing-time increased, and compared veryfavourably with that after curettage.

- Method

The technique is very simple, but it is essential that alldetails be strictly adhered to.All patients over the age of 5 years are given two tab.

codein. co. B.P. forty minutes before treatment, tominimise any pain which may be felt during the freezingand thawing. The skin is cleaned and, with a sharpscalpel which need not be sterile, the hyperkeratoticcap of the wart is pared down. This paring should bedone thoroughly because it is essential for success, andit should continue until the minute bleeding points of theexposed papillae appear. When the wart has been pared,a circle should be inked round it 5 mm. outside its borders.This allows one to see the exact position of the stick ofsnow during the freezing. The stick is then made, andits diameter should be slightly larger than that of thewart. That made by the ’ Sparklet ’ apparatus shownin the accompanying figure is large enough to treat thevast majority of warts. If larger quantities are neededfor larger moulds, a second cylinder may be dischargedinto the sparklet apparatus and the double content ofsnow transferred to the other mould. This apparatus issimple and cheap.Freezing is- continued with firm pressure for five

minutes, care being taken that the stick is held per-pendicularly in the centre of the inked circle. Whenthe stick is removed, a round button-like area of frozentissue is seen, and this is covered with a small dressing.The patient is warned that some pain may be experiencedfor five or ten minutes during thawing. This is usuallyslight or absent, and can be predicted by the disøomfortthat has been felt during freezing. It is advisable togive patients an analgesic to take home, in case theyshould experience pain later.Within four days a blister appears--although, if it

contains only a little fluid and is thick-walled and deep,it may be difficult to see. After seven days the blistertop, part of which includes the wart, is removed, and anadhesive dressing is applied. A red granular surface isexposed, in the centre of which may appear what seemsto be the remains of a wart, although its presence does not

Apparatus for making and applying carbon-dioxide snow, showingsparklet apparatus and two larger wooden moulds.

indicate failure. The raw surface heals painlessly withina few days, and infection very seldom occurs. When oneor more tiny seedlings are present in addition to the mainwart, they are marked with a pen and frozen for forty-five seconds, and a cautery is plunged into the solidan;p"t heti8ed spot.The treatment of single warts already described

needs only to be slightly modified for multiple lesions.Two warts may be frozen simultaneously with two sticks,and grouped lesions may be treated with a larger stickto cover them all. Sometimes it is advisable to treat

multiple lesions at intervals, but this is a matter ofcommon sense. Pain does not seem to be any greaterwith freezing larger than with smaller areas.

Results

1-nder local or general anaesthesia 67 unselected patientswere treated by curettage and cauterisation ; 200

similarly unselected patients were treated by freezingwith carbon-dioxide snow as outlined above. Manyof the patients had multiple warts, and all were followedup for at least six months.

Of the 200 patients 136 were female and 64 male.They were treated at four widely separated hospitals,and it was thought unlikely that there was any particularbias in favour of selection of a preponderance of girlsover boys in the nature of 2 to 1. The warts had beennoticed for periods averaging sixteen weeks but rangingfrom one week to ten years. The average age was 16-7

years (range 5-65). ,The results of the two methods of treatment are

compared in table i. Of those treated by curettage andcauterisation the warts were cured in 54 (81%) andrecurred in 13 (19%). Of the group treated by freezingwith carbon-dioxide snow they were cured in 186 (93%)and recurred in 14 (7%). This difference is statisticallysignificant.More important than the better cure-rate achieved by

freezing are the better results so far as disability isconcerned (table II). The figures were difficult to assessin the case of those treated by curettage, since most of thepatients had been advised to rest for five to seven daysafter operation. However, 16 patients (24%) were

quite unable to walk for an average of twelve days (rangetwo to thirty-five days) after operation because ofsevere pain and tenderness, and there is no doubt thatmore patients in this group would have been similarlydisabled had they tried to walk. On the other hand,

TA]3]LE I-COMPARISON OF RESULTS AS REGARDS CURE

Method of treatment

CO 2 ,mow......Curott-ago and cautery ..

No. ofpatientstreated

i

20067

I Heaults

Cured for atleast U raos.least (j mos.

- .

18(! (93%)54 (81 ’Yo)

Iteeitrredwitliin û mos.

14(7%) )13 (19%)

X-8-5. 11 ;001.

314

of 142 patients treated by freezing 13 (9%) were unableto walk for an average of four days (range two tofourteen days).

ComplicationsFew complications were found in the 200 patients

treated by freezing. 4 patients developed large hsemor-rhagic blisters, but these did not interfere with progress.Unusually large tense blisters caused no trouble, sincethe patients were told to prick them if necessary. Onlyone blister become secondarily infected, and healingwas not slower on that account. An unusual complica-tion, seen in 3 patients, was the appearance of a cluster

TABLE II-COMPARISON OF RESULTS AS REGARDS DISABILITY

Method of treatment

C02 snowCurettage and cautery :

No. ofpatientstreated

14267

Results

No. able Ito walk

within 24 hr.

129 (91%)51 (76%)

No. unableto walk

within 24 hr.

13 ( 9%)16 (24%)

x2 = 80. P<0 01.

of small seedlings, several months after treatment, inthe area of the blister. These patients responded rapidlyto soaking with 5% formaldehyde solution.

Discussion

Our figures confirm the clinical impression that

freezing with carbon-dioxide snow is the method ofchoice in treating plantar warts. Compared with curettageand cauterisation-the only other rapid and reliablemethod-its advantages are fewer failures, less pain,less and shorter disability, and simplicity of operation.The treatment is suitable for all except children underthe age of five years and a few hypersensitive adults whoneed general anaesthesia no matter how small the opera-tion. Contrary to the general impression, prolongedfreezing for five or six minutes will produce no more dis-comfort than freezing for a much shorter time. Further-more, the degree of pain experienced by most peopleis very much less than is widely imagined, and usuallyamounts to little more than discomfort. This comparativefreedom from pain and disability is the outstandingadvantage of the method. Sleep is rarely interfered withand most children return to school the next day.There need be no hesitation in refreezing the few warts

which recur, since in every case in which this was doneit proved successful. Small recurrences respond veryrapidly to daily soaks in 5% aqueous formaldehyde.

It is now our practice to treat these all-too-commonplantar warts (but not warts elsewhere) by this techniquein the course of the ordinary outpatient session. Thissaves an immense amount of time and trouble to patientsand staff.

SummaryA rigid technique is described for treating plantar

warts by freezing with carbon-dioxide snow.In the series reported the results of this method were

better than those of curettage and cauterisation, and thepain and inconvenience less.

Freezing with carbon-dioxide snow is the method ofchoice in treating plantar warts.

All these patients were treated in the skin departmentsof Charing Cross Hospital, London ; Redhill County Hospital,Surrey ; St. Luke’s Hospital, Guildford, Surrey ; andSt. Thomas’s Hospital, London. The photograph was takenby Mr. T. W. Brandon, of St. Thomas’s Hospital. The’

Sparklet ’ apparatus is obtainable from Sparklets, QueenStreet, London, N.17, and the wooden moulds from Messrs.Allen & Hanburys, Wigmore Street, London, W.I.

REFERENCE

Morgan, J. K. (1952) Brit. J. Derm. 64, 55.

THE OXYGEN TREATMENT OFASCARIASIS

F. F. TALYZINM.D. Moscow

PROFESSOR OF BIOLOGY AND PARASITOLOGY AT THE FIRST

MOSCOW MEDICAL SCHOOL, U.S.S.R.

THE use of santonin in ascariasis is not always freefrom unpleasant complications, and a search for othermore harmless methods of treatment was thereforeundertaken in the Soviet Union. One of the methodswhich proved successful and is now widely used istreatment with oxygen, recommended by N. P. Kravetz.The treatment is as follows. The patient is given an

enema before breakfast. After the bowel has beenevacuated, a duodenal tube is introduced into thestomach (preferably through the nose) and oxygen ispassed into it under slight pressure in the course of7-15 minutes (with slight intervals). Very soon theoxygen reaches the small intestine. This is shown byborborygmi in the middle of the abdomen and by asensation of increasing fullness and moderate pressure.The patient must be told that he should experience no

unpleasant sensations. Should belching, nausea, or painsupervene the oxygen is stopped at once by turning offthe stopcock ; the tube must on no account be removed.After a minute or two the administration of oxygen isrestarted and continued until a uniform distension andtympanites spread over the whole abdomen. The usualdose for an adult is 1-2 litres of the gas.A saline aperient, such as magnesium sulphate, is given

after 2 hours. After a further 3 hours the patient mayhave a normal meal. The ascarides are passed dead in thestool usually on the 2nd or 3rd day, more rarely duringthe 1st and rarer still on the 4th day.We use the following equipment : (1) an oxygen

cylinder, which fills (2) an oxygen pillow ; (3) two wide-mouth aspirator bottles, joined by rubber tubing 1 metrelong ; and (4) a duodenal tube. Bottle no. 2 (whichhas a capacity of 2-5-3 litres) is partially filled withoxygen as shown in fig. 1. The stopcock at its neck isthen closed and attached to a 20 cm. length of-duodenaltube which is passed into the nose or mouth ’t:lig. 2).When the stopcock is opened and bottle no. 1 (capacity3-4 litres) is raised to a higher level, oxygen passes intothe duodenal tube. (A double attachment at the neckof bottle no. 2 is a convenience, for then the connectionto the oxygen pillow need not be removed when thebottle is connected to the duodenal tube.)

Fig. I.-Filling battle no. 2 with oxygen.