I carried out a similar procedure in this instance.

The test ointments were

covered with gauze and then secured with a loosely applied roller bandage.
Within a short time the patient complained of burning at all the test areas. The
applications were of course removed at once, with the use of warm mineral oil.
Except for the fact that the dermatitis seemed more acute, nothing of note was
recorded.
To permit the subsidence of the dermatitis accentuated by the test ointments,
the patient was instructed to return in three days, having applied nothing to her
skin and having refrained from washing" during the interval.
On her return three areas of dermatitis were selected and bandaged with several
layers of sterile gauze so that on each area there was the product of a different
manufacturer. Within ten minutes burning was experienced at all the areas, and
on the removal of the gauze dressings the observation of a noticeable increase in

redness testified to the veracity of the patient's complaint.

Similar gauze patch tests were now applied to normal-appearing cutaneous
surfaces and left in place for forty-eight hours. No reaction was noted at the end
of this period at these sites.
I believe that accentuation of dermatitis as a result of sensitivity to gauze may
occur more often than is generally suspected, as no one had called my attention to it.

631 Jenkins Building (22).

COMPOUND BENZOIN TINCTURE IN TREATMENT OF VESICULOBULLOUS

LESIONS OF MUCOUS MEMBRANES
HENRY HARRIS PERLMAN, M.D.
PHILADELPHIA

It often happens that the dermatologist is concerned with vesiculobullous lesions

of the mucous membrane of the oral cavity that tax all his skill as a therapeutist.
Treatment with compound benzoin tincture has given excellent results in these
cases, and, as there are no references to it in recent dermatologic literature, I wish
to bring it to the attention of dermatologists.
Benzoin is one of the ancient drugs of pharmacy and has enjoyed its popularity
under a masquerade of many romantic names, among them Turlington's balsam,
friars' balsam, Wade's balsam, balsam de malthe, Jesuit's drops, St. Victor's
balsam, Persian balsam, Swedish balsam and Jerusalem balsam. It is official in the
United States Pharmacoepeia and the British Pharmacopeia under the title tinctura
benzoini composita. It is prepared by the maceration of a mixture of benzoin, aloe
in the form of a moderately coarse powder, storax and tolu balsam in strong
alcohol for three days. Then the mixture is filtered and enough alcohol added so
that the tincture contains 74 to 80 per cent by volume of alcohol. Because of this
strong alcoholic content the preparation is irritating to broken tissues. Downing
and Stoklosa 1 developed a nonirritating ointment in which the compound tincture
evaporated to the consistency of an extract is incorporated in a zinc oxide base.
The antiseptic effect of the tincture is probably dependent on the benzoic and
cinnamic acids contained in the benzoin and storax, two of the active ingredients
of the compound, while the strong alcoholic content of the pharmaceutic preparation

1. Downing, J. G., and Stoklosa, M. J.: Compound Tincture of Benzoin in

Ointments, Arch. Dermat. & Syph. 54:714 (Dec.) 1946.

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 possibly has some additional antiseptic and dehydrating effect on the edematous
tissue.
In the following report, the application of compound tincture of benzoin to the
oral lesions resulted in the elimination of pain and the improvement of the lesions
after the failure of many other indicated methods.

REPORT OF A CASE

L. C, 19 years of age, a college student, suffering from recurrent episodes of

blisters in her mouth, was referred to me in October 1947. In November 1945
gingival lesions involving her throat and buccal areas developed. The temperature
rose at night (101 to 103 F.) but receded in the morning. The gingival lesions,
which principally were gray vesicles, healed without scarring. But they spread
over the buccal surfaces, tongue and fauces. There was submaxillary adenitis.
Treatment consisted of the use of salicylates and sulfonamide drugs and the
intramuscular injection of 300,000 units of penicillin. The temperature became
normal in a week, and the patient was well in two weeks. All laboratory tests
(including the smear for Vincent's angina) had negative results. Alkaline mouth
washes and dyes had been used without effect.
Two months later there was another attack, which commenced with a small
ulcer, resembling aphthous stomatitis, under the upper lip. It spread rapidly,
involving the whole mouth, with vesicles and small bullae that changed into crusts,
especially on the vermilion border of the lip. There was edema of the lips and
mouth, conjunctivitis and photophobia. The condition responded well to large
intravenous injections of preparations containing the vitamin B complex. The
patient was ambulatory and became well in six weeks.
On about May 25, 1946, the patient acquired an ulcer under the upper lip which
spread rapidly until the tongue, cheeks, vermilion border and most of the oral
mucosa were involved. There was conjunctivitis, and the edema of the pharynx
and the oral mucosa was so severe that eating and swallowing became very difficult.
The condition did not respond to treatment with 300,000 units of penicillin and 15
grains (1 Gm.) of methenamine, the latter administered three times daily. The
patient had to be hospitalized. The temperature, blood picture and blood chemistry
were normal. The Wassermann reaction of the blood was negative. Treatment
consisted of intravenous injections of methenamine, 15 grains each, for three days,
and two whole blood transfusions. The patient was discharged in nine days in
good condition.
In April 1947 the patient experienced another attack similar to the preceding
one. Five doses of 15 grains of methenamine were given intravenously over a ten

day period. Simultaneously vaccinations with smallpox virus w-ere performed with¬
out their achieving a "take." The episode was aborted, and the patient remained
ambulatory.
On Oct. 17, 1947, vesicular lesions developed on the mucous membranes of the
upper and lower lips. They spread until the entire oral mucosa was involved.
The conjunctivas and the skin remained free of lesions. The vesicles ruptured and
formed crusts. The patient remained afebrile but was unable to take food by
mouth because of great pain. Even the sipping of milk through a tube was
very painful. There was no "take" to vaccination with smallpox virus. Intravenous
injections of methenamine were given as before. The mouth was given a cleansing
with a potassium permanganate solution ( 1:2,000) followed by a wiping of the
lesions with liquid petrolatum. No relief was obtained. Then full strength com¬
pound benzoin tincture was applied with a cotton applicator. There was almost
immediate relief from pain, and within a few hours there was a noticeable decrease

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 in edema of the lips. The patient was able to take food, and in a few days the
lesions in the mouth subsided. During those few days the patient kept applying
the compound benzoin tincture herself every few hours. There has been no
recurrence since that time.

I ha\ e used compound benzoin tincture with excellent results in treatment

of herpes simplex of the lips, aphthous stomatitis and lesions of so-called "trench
mouth" in infants and Vincent's infection. Although I have had no experience
with its use in treatment of oral lesions of pemphigus and epidermolysis bullosa
I think it would be of help. It has given relief of pain in a case of lingua
geographica in a 6 year old white boy.
SUMMARY AXD CONCIA SI0NS

A of erythema multiforme exudativum, characterized by recurrent episodes

case

of vesiculobullous lesions on the lips and oral mucosa, is reported. Topical therapy
consisting of the use of various alkaline mouth washes and dyes and local applica¬
tions of silver nitrate failed to improve the lesions of the lips and the oral mucosa.
The aforementioned vesiculobullous lesions promptly responded to topical
applications of compound benzoin tincture U. S. P.
Some of the commoner dermatologie entities affecting the mucous membranes of
the lips and mouth in which the topical application of the official compound
benzoin tincture has proved of value are listed.
1726 Pine Street. ;

LICHEN PLANUS HYPERTROPHICUS

Possiible Clue to Etiology

CHARLES C. DENNIE, M.D.

AND
FRANCIS P. COOMBS, M.D.
KANSAS CITY, MO.
A.H., a 58 year old married woman, was first seen by us on Nov. 4, 1947,
and diagnosis of lichen planus hypertrophicus of the anterolateral surface of the
a

left thigh was made. Pronounced varicose veins of both legs were found. The
lesions had first appeared one year previous to the patient's first visit. Leading
from the area was a moderately large varicose vein, tortuously running toward
the saphenous vein at the junction of the upper and the middle third of the thigh.
This varix had been present for some time previous to the appearance of the
lesions. Biopsy showed typical lichen planus hypertrophicus.
Microscopic observations were as follows : The keratin layer was thickened.
One follicle was widened, with decided keratotic plugging. Relative and absolute
hyperkeratosis, an increase in the stratum granulosum, acanthosis, slight liquefactive
degeneration of the basal cell layer and mild lymphocytic infiltration in the upper
portion of the cutis, with some histiocytosis around the keratinized follicle,
were seen.

The patient related that in 1940 she had had a patch of identical lesions on.
the anterior surface of the lower part of the left leg, also associated with a varicose

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