Case of Vitiligooidea, with remarks. By W. H. Ranking, M. D.
(Cantab.) Norwich.—In the summer of 1850, the following case pre-
sented itself to my notice, and a very brief inspection was sufficient to
lead me to believe that I had encountered a disease, of which no distinct
account had been given by writers on dermatology. I took notice of
the case at the time, with reference to publication, but other occupa-
tions interfered with my intention, and the circumstance had all but
escaped my recollection, when I met with the description of this dis-
ease, by Dr. Gull, under the term vitiligooidea, the identity of which
with my own case could not fail to be recognized. The instances of
this curious malady hitherto put on record do not amount to more
than five. I have accordingly endeavored to give a succinct account
of wffiat is known thereupon.
My patient, MaryB--------, a married woman, aged twenty-nine, consult-
ed me, in June, 1850, for obstinate and severe jaundice. Inquiry into her
history elicited the facts that her health had been good until three years
previously, when, after an attack of dyspepsia, jaundice supervened, and
had continued till the time of her visit to me, uninfluenced by treatment,
including several salivations. At this time she was universally and
deeply jaundiced; but the appearance which immediately and morestrong-
ly attracted my attention, was a peculiar deposit on the skin surrounding
the eyes, and which, on further investigation, I found to be abundantly
distributed over other portions of the body. She informed me that
about twelve months ago, spots of this peculiar deposit first appeared
on the shoulders, and have since shown themselves on the face, arms,
hands and lumbar regions. In the face, it has assumed a symmetrical
disposition, extending along each eyelid, and down the side of the
nostrils. On the shoulder the spots are circular and distinctly elevated.
Along the inside of the elbows, and on the hands, the deposit follows
the flexures of the joints, being flat and linear on the palmar aspect,
and more tubercular and rounded on the dorsal. The color of this de-
posit is of a whitish-yellow, resembling more nearly than anything else
the atheromatous patches so commonly found in the aorta. On the
face and palms of the hands it is but little elevated; and, as in athe-
roma, appears to be deposited immediately under the epithelium. On
the shoulder and in the dorsal region the spots are circular and promi-
nent, bearing no inconsiderable resemblance to split peas.
At the time of my seeing this ease the peculiar affection was still on
the increase, fresh spots showing themselves almost daily. They were
tender to the touch, and were the seat of a burning sensation, which
prevented the patient using her hands without acute suffering.
The history of the jaundice pointed to the conclusion that it de-
pended upon permanent occlusion of the common duct. The woman
died soon after my seeing her, under the care of another practitioner,
and, as far as I could learn, from severe and rapid peritonitis.
The only references to this singular cutaneous disease which I have
been able to meet with are contained in a paper published in “Guy’s Hos-
pital Reports/’ for although Willan alludes to a rare disease under the
term vitiligo, which has some points of resemblance, the full compari-
son of the two is unfavorable to the notion of their identity. The
term used by Willan has, however, led Dr. Gull to give to the disease
in question the name vitiligooidea. The cases narrated by him are four
in number. The first is that of a married woman, aged forty-two, who
had been deeply jaundiced for two years. At the end of fourteen
months this pecnliar change in the integument began to show itself on
the eyelids, assuming a perfect symmetrical form, as well as in the
palms of the hands, where, as in my case, it followed accurately the
flexures of the joints. The disease remained stationary till her death.
A second patient was admitted into Guy’s Hospital, laboring under
diabetes; but in this instance the eruption was so far different in its
aspect that I cannot think Dr. Gull justified in associating it with the
former case.
The third instance is that of a married woman, like the first, the
subject of jaundice. The skin diseases commenced at the end of four-
teen months, appearing first on the hands and subsequently affecting
the eyelids. This case is now, I believe, under treatment, but the dis-
ease shows a tendency to increase rather than diminish.
The fourth case described by Dr. Gull is, in every respect, similar,
both as to the prior existence of jaundice, and the distribution of the
cutaneous deposit.
I have ventured to call attention to the above singular disease,
chiefly on account of its singularity, and not with the expectation
of being able to offer any elucidation of its pathology or treatment.
To speculate on the former might, until further experience is af-
forded, be an unprofitable exercise; nevertheless, it is impossible
to overlook the important fact of some connextion between the
cutaneous deposit and jaundice of an aggravated degree and pro-
longed duration. In every case reported, obstinate and severe
jaundice had existed for several months prior to the appearance of
the skin malady. Can it be that, like the cretaceous deposits of gout,
this was an attempt at elimination of noxious matter necessarily con-
tained in blood, in which was suspended the elements of bile ? I re-
gret much that I had no opportunity of instituting a microscopic ex-
amination of the deposit; but its prima facie resemblance to athe-
roma would warrant the idea that, like the latter exudation, the pe-
culiar deposit in question contained cholesterine, a principle which
is well known to enter largely into the composition of the biliary se-
cretion.
This explanation of the composition and the pathological significance
of the vitiligoid deposit is, as we have premised, simple hypothesis;
but, such as it is, I would offer it, in order to elicit observations.
Respecting treatment, nothing can be said. If, as I imagine, the
affection is but a symptom of prolonged retention of bile, or its elements
in the blood, nothing in the way of amendment can be anticipated,
unless the original malady be removed, when possibly the absorbents
might spontaneously remove the deposit. In the cases hitherto re-
ported no decided amendments followed any of the means adopted.—
London Lancet, Feb., 1853.