July 1,
1873.]
NOpS^N
SKIN DISEASES.?BY W. J. PALME!?.
not of kind ; such difference, however, being at the same time so great, that the milder cases show but little tendency to assume
ROUGH NOTES ON THE cb^MON FORMS OF SKIN DISEASE MET WITH IN CALCUTTA.
By Surgeon \V.
the more severe form. Impairment of sensation,
J. Palmeb, M.D. and F.ll.C.S.L.
IV.?NEUROSES. Under this head is grouped a class of diseases where nerve action certainly localizes, and perhaps causes the skin affection. A case is reported by Mr. Hutchinson where section of the median nerve caused first redness and great heat of the fingers, followed by the formation of blebs or bullae; and a similar?very remarkable one occurred at the dispensary during the past year, where flattened, ragged-edged shot had become imbedded in both the median and ulnar nerves of the and an unbearable burning right-arm, causing great redness, heat in the fore arm and hand, which ultimately spread in a of the whole side right body ; the burning less degree to the was so intense, that the patient could not exist without constant cold wet applications on the affected parts. These symptoms subsided almost entirely after the shots were removed, and before the skin affection had time to assume the form of blebs or ulcers seen in the former case. Tumours again, when pressing on trunks of nerves, not unfrequently give rise to an eruption of herpes over the distal branches ; and cases of long-continued pains in the feet and toes, attended with formication, and leading to senile-gangrene, without any appreciable disease or alteration in the blood vessels of the part, are by no means ; the root disease being in such cases most probably alteration in the nerves which preside over the nutrition of the part.
uncommon an
leprosy (Elephantiasis Graecorum),
both
tubercular and anaesthetic?most of those classed under the "
"keloid of Addison," as well as many head of " inorphaea, of those called "scleroderma ;"also "herpes," and "urticaria"? are so far associated with nerve distribution or alteration, that they may be conveniently classed together under the head "neuroses." The first
peculiarity
that strikes
in Calcutta, is the relative cases which would be called
an
observer of skin diseases of the occurrence of
frequency morphooa,
keloid of
Addison,
or
scleroderma, in London, where these diseases are by no means of such frequent occurrence. "Whenever the disease in such cases, as seen here, is very extensive, and the nerves leading to the affected parts are so placed that they can be distinctly felt, as is the case with the uln^r inside the elbow, and the posterior tibial at the inner malleolus, they are found to be thickened, attaining to as much as three times their normal bulk?some of the fingers or toes
being in such cases, not unfrequently, permanently contracted. (a.) Leprosy [Elephantiasis Gracorum).?Patients affected with fully developed tubercular leprosy do not, as a rule, apply at the dispensary for relief, being persuaded either that medical treatment will not alleviate their sufferings, or that the leper hospital is the proper place for them. Of the 88 cases registered in the jlispensary records as leprosy, therefore, a very large proportion belonged to the anaesthetic or earlier form of the disease. In addition to these 88 cases, there were 26 in which the disease was either so limited in extent, or so imperfectly developed, that some hesitation was felt in pronouncing such patients to be
impaired sensibility of the affected part was in constant symptom, they were simply recorded as anajsthesia," leaving the real nature of the primary root disease, an open question.
lepers; and, all such cases
as
cases a "
of
lesion,
or
universally admitted that the anaesthetic form is earlier stage of the true leprosy ; and the impression produced upon me, by the observations of the last two years, is that the difference between these cases classed as anaesthesia It is
only
now
an
and the anaesthetic form of
leprosy,
is
only
to more
gradually increasing
or
less
in the affected parts, is the distinguishing character of these milder forms. Patches of leucoderma exhibit alterations in color to a still greater extent; but both the remain normal in these epidermis and true skin with its
complete insensibility
(Continued from page 118.)
All the cases of true
173
one
of degree and
glands
in every respect except color. Patches of lichen, with raised edges, and hardened sub-cuticular deposit, sometimes might be mistaken, at first sight, for this milder form of leprosy,
cases
they never exhibit any great alteration either of colour or sensibility. The subject of leprosy in India has been so fully discussed in the report to the College of Physicians, an admirable analysis of which, by Surgeon N. 0. Macnamara, appeared in the Indian Medical Gazette at 1866, that only such cases as appear to afford but
illustrations of the transition above referred
to
will be noticed
here. Case I.?W.
Pereira,
a
Eurasian,
Calcutta,
native of
was
admitted into the Presidency General Hospital, April 10th 1871, with large patches of skin on different parts of his body, which had altered much in colour, and were without any sensation
pinched or pricked. History.?Has been healthy until the present attack; never had syphilis. Has had a large patch of tinea versicolor on his neck for three years; this however has never given him any uneasiness or trouble of any kind. His present disease commenced eight months ago as a circular, raised spot, of a dark red colour, on the dorsum of the left foot; his slciu being naturally of a yellowish-brown colour; the raised border continued to encroach on the surrounding healthy skin, while the centre gradually lost its bright colour, becoming both paler in colour and harder in texture; the sensibility remained good up to the time of this condensation of tissue, after which it gradually decreased, until the prick of a pin could no longer be felt. While these changes were progressing on the foot, other similar patches appeared on the legs, thighs, trunk, arms, and head successively ; the tendons on the dorsum of the foot, and other places where they could be seen, also gradually became thickened. These discoloured and hardened patches are now scattered all over his body, occurring equally on the flexor and extensor surfaces, without any tendency to be quite symmetrical. There is one spot near the middle of the forehead, the size of when
florin
a
or
is
rupee, which commenced about
a
month ago.
It
quarter of an inch above the surrounding surface; dark red, port-wine colour; sensitive when the finger is
is raised a
pressed
a
upon
it;
and its surface is covered with
a
thin
layer
of
fine, branny, glistening scales. There is another spot on the face, which commenced about half months ago, which involves the skin of the a of the left lower eye-lid, and upper-lip, extending also the ear; the encroaching edges of over the malar bone, as far as this spot are still raised, red, and sensitive; the central portions having become depressed, of a pale, dirty white colour, and of a somewhat glistening aspect; they are still sensitive, but two and nose,
less
so
The
than the edges. larger and older
patches
on
the
thighs
are
quite
insensi-
tive ; of a dull, dirty yellowish-white colour, in the midst of which the mouths of sebaceous follicles appear, as black points, surrounded by elevated skin, the whole being of a brawny,
leathery, in
or
or
parchment-like hardness,
beneath the
true
from
condensed
deposits
skin.
These older patches appear to be what would be called scleriasis or scleroderma, while the newer ones are more like what is described as morpliaja, or the keloid of Addison. The ulnar and posterior tibial nerves in this case can be felt to be much thickened; and although the toes still preserve their
THE INDIAN MEDICAL GAZETTE.
3_74
natural shape and form, both ears are considerably thickened, as well as the skin over the eyebrows. There is, therefore, but little reason to doubt that this is a case of true leprosy in the earlier
or
Case IT.?Denonath Dass, aged 28 years, applied at the dispensary on April 22nd, 1871, suffering from leprosy and
scabies. he had
History.?Says
was
a
chancre about sixteen years ago,
not followed
by
any secondary symptoms. just before or just after, he appeared in the skin of his followed by other similar spots in different
About the same time, but whether does not remember, a circular spot
loins, which was soon parts of the body.
are now many patches scattered body, which so exactly resemble those described in the former case, that they need only be referred to here, in order to note their association with pudding-shaped" toes, which were insensible to pain, but had not yet begun to ulcerate.
Present condition.?There
over
the
III.?Jetoo, coachman, aged 45 years, applied at the dispensary in April 1871, suffering from patches of discolouration, with diminished sensibility, all over his body; he also had permanent contraction of the little and ringfingers of either Case
hand, which had existed for
History.?Had
a
sore
on
some
months.
penis thirty years ago, but never Five years ago, two somewhat circu-
the skin feels
brawny
and
thick,
when
up between the finger and thumb, it has not yet advanced to that stage when it conveys the impression of being
pinched
leathery
or
parchment-like.
The ulnar nerves, as they pass the elbow joint, may be felt to be much thickened; but neither the eyebrows, ears, or toes, appear much affected in this case. Case IV.?Sree Hurry, 40 years of age, applied at the on the 6th May 1871, having suffered for many
dispensary
years from symptoms of leprosy. There were pale coloured, insensitive, thickened patches of skin all over his body; the skin between these patches being so dry and coarse, that distinct furrows were left when a pencil or the finger nail His lace presented the characteristic was drawn across it. leonine expression; his nose and ears were thickened and
left nodular; his ulnar and posterior tibial nerves were also thickened; and his fingers and toes had already become pudding-shaped," the latter being deeply ulcerated. "
Case
V.?Asradi, aged 20 years, applied at the dispensary on April 1871, with irregular shaped, discoloured, more insensitive, and thickened patches of skin, like those
the 22nd or
less
(5.) Herpes.?Nearly 200 casus are recorded as licrpes in tlie dispensary books; they occurred as shingles (herpes zoster), or
of tough vesicles on a hardened base; or oval of similar vesicles. It is probable that some of these 200 cases might have been more correctly classed under eczema, but
spray-like clusters
of them presented any peculiarity or feature of interest deserving of record here. (c.) Urticaria, depending sometimes on nerve alteration, and sometimes on blood poisoning, may be also passed over
none
without remark.
(*) Truritus.?Forty-four cases appear in the dispensary records, classed under this head. The itching in most of' these cases was strictly confined to the limits of the scrotum (pruritus scroti) : in many, a slight amount of sub-cuticular uniform thickening could be felt, but the cuticle, however, remaining normal; while in some few remaining cases no structural alteration whatever of any kind could be detected, though the itching was terribly severe. The former class generally occurred amongst natives, and were probably cases of imperfectly developed eczema, or perhaps of the initial stage of scrotal tumour; but the latter, most frequently seen amongst Europeans, were probably due to nerve disorder of kind. The form
some
so
the
any secondary symptoms. lar spots of more or less discoloured skin appeared over the fifth, sixth, and seventh ribs on the right side; these were followed by other similar patches on the trunk, legs, arms, and feet. Sensibility, greatly diminished, is not yet entirely lost in any of these
though parts; and although
1S73.
masses
anaesthetic form.
which however
[July 1,
above described. One was situated over the upper half of the left scapula and shoulder-joint; another on the front of the left fore-arm, and back of the wrist; and another involved the whole of the back of the right-arm and fore-arm. There was an entire absence in this patient of the leonine expression; the cars, aloe of the nose, fingers, and toes, were also quite normal; but he was only twenty (20) years old.
Case'N I. Rugonath, aged 18 years, applied at the dispensary on the 27th Hay 1871. He had only one spot, which commenced about a year ago ; and this was situated on the right-arm?was about two inches in and had
passed diameter, through the several stages, ending in condensation and loss of colour in the skin, with almost complete loss of sensation in the centre of the affected part.
frequently
Europe, The
of
itching with papules,
associated
called
prurigo senilis, body-lice in
with the presence of
is not common in Calcutta. skin affections, not
having yet been satisfactorily associated with any definite diathesis, will be arranged according to their anatomical seat:? I. Affections of the epidermis.?Sudctmina, miliaria, and corns, remain to be noticed. Notwithstanding the profuse perspiration caused by the hot climate, the two former affections are not seen more frequently in Calcutta than in London; while the last, or corns, are unknown, except amongst the well-to-do natives, who have unfortunately adopted tho barbarous European custom of pinching up their feet in tight shoes, until thenatural shape of/the foot is replaced by an unsightly deformity. (To be continued.J remaining
\
1873.]
NOpS^N
SKIN DISEASES.?BY W. J. PALME!?.
not of kind ; such difference, however, being at the same time so great, that the milder cases show but little tendency to assume
ROUGH NOTES ON THE cb^MON FORMS OF SKIN DISEASE MET WITH IN CALCUTTA.
By Surgeon \V.
the more severe form. Impairment of sensation,
J. Palmeb, M.D. and F.ll.C.S.L.
IV.?NEUROSES. Under this head is grouped a class of diseases where nerve action certainly localizes, and perhaps causes the skin affection. A case is reported by Mr. Hutchinson where section of the median nerve caused first redness and great heat of the fingers, followed by the formation of blebs or bullae; and a similar?very remarkable one occurred at the dispensary during the past year, where flattened, ragged-edged shot had become imbedded in both the median and ulnar nerves of the and an unbearable burning right-arm, causing great redness, heat in the fore arm and hand, which ultimately spread in a of the whole side right body ; the burning less degree to the was so intense, that the patient could not exist without constant cold wet applications on the affected parts. These symptoms subsided almost entirely after the shots were removed, and before the skin affection had time to assume the form of blebs or ulcers seen in the former case. Tumours again, when pressing on trunks of nerves, not unfrequently give rise to an eruption of herpes over the distal branches ; and cases of long-continued pains in the feet and toes, attended with formication, and leading to senile-gangrene, without any appreciable disease or alteration in the blood vessels of the part, are by no means ; the root disease being in such cases most probably alteration in the nerves which preside over the nutrition of the part.
uncommon an
leprosy (Elephantiasis Graecorum),
both
tubercular and anaesthetic?most of those classed under the "
"keloid of Addison," as well as many head of " inorphaea, of those called "scleroderma ;"also "herpes," and "urticaria"? are so far associated with nerve distribution or alteration, that they may be conveniently classed together under the head "neuroses." The first
peculiarity
that strikes
in Calcutta, is the relative cases which would be called
an
observer of skin diseases of the occurrence of
frequency morphooa,
keloid of
Addison,
or
scleroderma, in London, where these diseases are by no means of such frequent occurrence. "Whenever the disease in such cases, as seen here, is very extensive, and the nerves leading to the affected parts are so placed that they can be distinctly felt, as is the case with the uln^r inside the elbow, and the posterior tibial at the inner malleolus, they are found to be thickened, attaining to as much as three times their normal bulk?some of the fingers or toes
being in such cases, not unfrequently, permanently contracted. (a.) Leprosy [Elephantiasis Gracorum).?Patients affected with fully developed tubercular leprosy do not, as a rule, apply at the dispensary for relief, being persuaded either that medical treatment will not alleviate their sufferings, or that the leper hospital is the proper place for them. Of the 88 cases registered in the jlispensary records as leprosy, therefore, a very large proportion belonged to the anaesthetic or earlier form of the disease. In addition to these 88 cases, there were 26 in which the disease was either so limited in extent, or so imperfectly developed, that some hesitation was felt in pronouncing such patients to be
impaired sensibility of the affected part was in constant symptom, they were simply recorded as anajsthesia," leaving the real nature of the primary root disease, an open question.
lepers; and, all such cases
as
cases a "
of
lesion,
or
universally admitted that the anaesthetic form is earlier stage of the true leprosy ; and the impression produced upon me, by the observations of the last two years, is that the difference between these cases classed as anaesthesia It is
only
now
an
and the anaesthetic form of
leprosy,
is
only
to more
gradually increasing
or
less
in the affected parts, is the distinguishing character of these milder forms. Patches of leucoderma exhibit alterations in color to a still greater extent; but both the remain normal in these epidermis and true skin with its
complete insensibility
(Continued from page 118.)
All the cases of true
173
one
of degree and
glands
in every respect except color. Patches of lichen, with raised edges, and hardened sub-cuticular deposit, sometimes might be mistaken, at first sight, for this milder form of leprosy,
cases
they never exhibit any great alteration either of colour or sensibility. The subject of leprosy in India has been so fully discussed in the report to the College of Physicians, an admirable analysis of which, by Surgeon N. 0. Macnamara, appeared in the Indian Medical Gazette at 1866, that only such cases as appear to afford but
illustrations of the transition above referred
to
will be noticed
here. Case I.?W.
Pereira,
a
Eurasian,
Calcutta,
native of
was
admitted into the Presidency General Hospital, April 10th 1871, with large patches of skin on different parts of his body, which had altered much in colour, and were without any sensation
pinched or pricked. History.?Has been healthy until the present attack; never had syphilis. Has had a large patch of tinea versicolor on his neck for three years; this however has never given him any uneasiness or trouble of any kind. His present disease commenced eight months ago as a circular, raised spot, of a dark red colour, on the dorsum of the left foot; his slciu being naturally of a yellowish-brown colour; the raised border continued to encroach on the surrounding healthy skin, while the centre gradually lost its bright colour, becoming both paler in colour and harder in texture; the sensibility remained good up to the time of this condensation of tissue, after which it gradually decreased, until the prick of a pin could no longer be felt. While these changes were progressing on the foot, other similar patches appeared on the legs, thighs, trunk, arms, and head successively ; the tendons on the dorsum of the foot, and other places where they could be seen, also gradually became thickened. These discoloured and hardened patches are now scattered all over his body, occurring equally on the flexor and extensor surfaces, without any tendency to be quite symmetrical. There is one spot near the middle of the forehead, the size of when
florin
a
or
is
rupee, which commenced about
a
month ago.
It
quarter of an inch above the surrounding surface; dark red, port-wine colour; sensitive when the finger is
is raised a
pressed
a
upon
it;
and its surface is covered with
a
thin
layer
of
fine, branny, glistening scales. There is another spot on the face, which commenced about half months ago, which involves the skin of the a of the left lower eye-lid, and upper-lip, extending also the ear; the encroaching edges of over the malar bone, as far as this spot are still raised, red, and sensitive; the central portions having become depressed, of a pale, dirty white colour, and of a somewhat glistening aspect; they are still sensitive, but two and nose,
less
so
The
than the edges. larger and older
patches
on
the
thighs
are
quite
insensi-
tive ; of a dull, dirty yellowish-white colour, in the midst of which the mouths of sebaceous follicles appear, as black points, surrounded by elevated skin, the whole being of a brawny,
leathery, in
or
or
parchment-like hardness,
beneath the
true
from
condensed
deposits
skin.
These older patches appear to be what would be called scleriasis or scleroderma, while the newer ones are more like what is described as morpliaja, or the keloid of Addison. The ulnar and posterior tibial nerves in this case can be felt to be much thickened; and although the toes still preserve their
THE INDIAN MEDICAL GAZETTE.
3_74
natural shape and form, both ears are considerably thickened, as well as the skin over the eyebrows. There is, therefore, but little reason to doubt that this is a case of true leprosy in the earlier
or
Case IT.?Denonath Dass, aged 28 years, applied at the dispensary on April 22nd, 1871, suffering from leprosy and
scabies. he had
History.?Says
was
a
chancre about sixteen years ago,
not followed
by
any secondary symptoms. just before or just after, he appeared in the skin of his followed by other similar spots in different
About the same time, but whether does not remember, a circular spot
loins, which was soon parts of the body.
are now many patches scattered body, which so exactly resemble those described in the former case, that they need only be referred to here, in order to note their association with pudding-shaped" toes, which were insensible to pain, but had not yet begun to ulcerate.
Present condition.?There
over
the
III.?Jetoo, coachman, aged 45 years, applied at the dispensary in April 1871, suffering from patches of discolouration, with diminished sensibility, all over his body; he also had permanent contraction of the little and ringfingers of either Case
hand, which had existed for
History.?Had
a
sore
on
some
months.
penis thirty years ago, but never Five years ago, two somewhat circu-
the skin feels
brawny
and
thick,
when
up between the finger and thumb, it has not yet advanced to that stage when it conveys the impression of being
pinched
leathery
or
parchment-like.
The ulnar nerves, as they pass the elbow joint, may be felt to be much thickened; but neither the eyebrows, ears, or toes, appear much affected in this case. Case IV.?Sree Hurry, 40 years of age, applied at the on the 6th May 1871, having suffered for many
dispensary
years from symptoms of leprosy. There were pale coloured, insensitive, thickened patches of skin all over his body; the skin between these patches being so dry and coarse, that distinct furrows were left when a pencil or the finger nail His lace presented the characteristic was drawn across it. leonine expression; his nose and ears were thickened and
left nodular; his ulnar and posterior tibial nerves were also thickened; and his fingers and toes had already become pudding-shaped," the latter being deeply ulcerated. "
Case
V.?Asradi, aged 20 years, applied at the dispensary on April 1871, with irregular shaped, discoloured, more insensitive, and thickened patches of skin, like those
the 22nd or
less
(5.) Herpes.?Nearly 200 casus are recorded as licrpes in tlie dispensary books; they occurred as shingles (herpes zoster), or
of tough vesicles on a hardened base; or oval of similar vesicles. It is probable that some of these 200 cases might have been more correctly classed under eczema, but
spray-like clusters
of them presented any peculiarity or feature of interest deserving of record here. (c.) Urticaria, depending sometimes on nerve alteration, and sometimes on blood poisoning, may be also passed over
none
without remark.
(*) Truritus.?Forty-four cases appear in the dispensary records, classed under this head. The itching in most of' these cases was strictly confined to the limits of the scrotum (pruritus scroti) : in many, a slight amount of sub-cuticular uniform thickening could be felt, but the cuticle, however, remaining normal; while in some few remaining cases no structural alteration whatever of any kind could be detected, though the itching was terribly severe. The former class generally occurred amongst natives, and were probably cases of imperfectly developed eczema, or perhaps of the initial stage of scrotal tumour; but the latter, most frequently seen amongst Europeans, were probably due to nerve disorder of kind. The form
some
so
the
any secondary symptoms. lar spots of more or less discoloured skin appeared over the fifth, sixth, and seventh ribs on the right side; these were followed by other similar patches on the trunk, legs, arms, and feet. Sensibility, greatly diminished, is not yet entirely lost in any of these
though parts; and although
1S73.
masses
anaesthetic form.
which however
[July 1,
above described. One was situated over the upper half of the left scapula and shoulder-joint; another on the front of the left fore-arm, and back of the wrist; and another involved the whole of the back of the right-arm and fore-arm. There was an entire absence in this patient of the leonine expression; the cars, aloe of the nose, fingers, and toes, were also quite normal; but he was only twenty (20) years old.
Case'N I. Rugonath, aged 18 years, applied at the dispensary on the 27th Hay 1871. He had only one spot, which commenced about a year ago ; and this was situated on the right-arm?was about two inches in and had
passed diameter, through the several stages, ending in condensation and loss of colour in the skin, with almost complete loss of sensation in the centre of the affected part.
frequently
Europe, The
of
itching with papules,
associated
called
prurigo senilis, body-lice in
with the presence of
is not common in Calcutta. skin affections, not
having yet been satisfactorily associated with any definite diathesis, will be arranged according to their anatomical seat:? I. Affections of the epidermis.?Sudctmina, miliaria, and corns, remain to be noticed. Notwithstanding the profuse perspiration caused by the hot climate, the two former affections are not seen more frequently in Calcutta than in London; while the last, or corns, are unknown, except amongst the well-to-do natives, who have unfortunately adopted tho barbarous European custom of pinching up their feet in tight shoes, until thenatural shape of/the foot is replaced by an unsightly deformity. (To be continued.J remaining
\
