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Internal cancer should be suspected and investigated in the presence of certain cutaneous manifestations which include among others {a) flgurate erythema {h) melanin spots on the lips and oral mucosa and sometimes other areas and (c) symmetrical papillary hypertrophy of the skin (most commonly in the axillae) with varying degrees of pigmentation.

IN April, 1960, one of us (J.C.B.) received a letter from Dr. Euth Eauschkolb from Cleveland, OMo, in wMcli slie described the case of a 29-year-old white woman who stated that she had a brown mole on the sole of her left foot when she was at high school. About three years previously a brown mass appeared on the left thigh above the knee. This was widely excised and found to be malignant, so the left inguinal nodes were removed. At this time she had a fist-sized purple tumour in the middle of the anterior aspect of the left thigh, surrounded by about 50 flesh-coloured nodules. There were palpable masses in the left groin and a mass in the left breast and axilla. She was admitted to the Cleveland Clinic under Dr. K. H. Burdick (who also wrote to J.C.B. in January, 1961) with inguinal, cervical and pulmonary metastases as well as a number of metastases to the skin of the trunk and head. Dr. Burdick (1961) first injected the largest skin tumour with live vaccina virus and found the patient showed an accelerated reaction. He then proceeded to inject smallpox vaccine diluted in normal saline into individual metastic nodules in the skin. Initially he commenced with three vials of vaccine diluted with 0-2 c.c. of normal saline. The dosage was gradually worked up to a total of five vials. As she improved the time between doses was increased to as long as a month.. Some four hours after the injection the patient would have a toxic reaction characterized by nausea, vomitiag and fever which lasted four hours. The smaller nodules disappeared in four weeks, and the larger ones were injected again, also any new lesions.. : ,, All cutaneous metastases disappeared except the large one in the thigh, which regressed considerably in size. The primary site on the sole of the foot was very little affected. The treatment did not prevent the occurrence of further metastases. ... ; The patient was also given 25 mg. of nitrogen mustard and 15 mg. of thio-tepa into the femoral artery in the early stages. It is interesting to note that the skin metastases did not respond to this intra-arterial therapy, but did respond to the injections of live vaccinia virus.. . .. In a recent letter (August, 1961) Dr. Burdick states : "It seems that the larger cutaneous lesions do not do as well as do the small lesions. Anything over 1 cm. in diameter seems to do rather poorly with the vaccina." He also makes the observation " It would seem that the individuals who obtaia the best response from the vaccina virus are those who also obtain a toxic type of reaction to the injected vaccina virus ".In addition he states that from the few histological studies he and his associates have made on tumour lesions and a number of malignant melanoblastomas in the hamster, it would seem there is a very definite cell necrosis caused by the vaccinia virus.

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