So far, all the cases have been adults, though some of them were young. The lesions are evolved in patches of a pale pink or yellowish hue on the limbs and trunk, the uncovered parts, such as the face and hands, being free or very slightly affected. Generally, the patches come out very gradually and in small numbers and, in the main, symmetrically, but as the older patches never go away spontaneously, while fresh ones are continually evoluting at short or long intervals, large areas are involved, and in the course of years (in one case, months) the whole trunk and limbs are crowded with lesions, though there are always spaces of normal skin intervening, or sometimes completely enclosed by the diseased process, where the original patches have coalesced. For the most part the original patches are discrete and enlarge but little after their formation, unless they merge into adjoining patches, when hand-sized or larger areas may be formed.
With regard to individual patches, they are usually of oval or elongated form, arranged symmetrically in oblique lines on the back in the direction of the ribs, probably in the lines of fission, more or less horizontal in direction in front, and often, but not always, in vertical lines on the limbs. On the latter, especially the thighs, they not infrequently present the appearance of streaks formed by the finger, the upper part of the stroke being abrupt, and the lower shading off. This may sometimes also be seen on the trunk. The majority of the single patches range from one to three inches in their longest diameter; the borders are not very well-defined nor raised above the rest, but there is no difficulty in discerning the morbid from the healthy skin. They are not raised above the surface, but may be rather deep in the cutis. Infiltration can often be distinctly felt when the patch is pinched up in comparison with the adjoining healthy tissues, but in the more recent and smaller patches it is imperceptible, and occasionally they look like mere stains. Their colour is either pale pink or yellowish; in some cases the yellowish hue is pronounced, in others absent or nearly so; on the lower limbs the pink hue predominates. The surface is smooth on the trunk, but is often slightly rough on the arms and thighs, and below the knees maybe distinctly rough or even in branny scales. The patches are never so marked on the upper as on the lower limbs, the palms are always free, and the backs of the hands are generally unaffected, but sometimes there are a few small patches below the wrist. The face is nearly always free, though I have seen faint patches in one case. There is very little to suggest that the disease is inflammatory, and itching is quite absent in most of the cases; a few patients said they had some itching when hot, but only in one case was it really complained of, and that only in the early evoluting stage of the patches. The initial site for the lesions varies; the thighs are the most frequently first affected, the legs next in frequency, and then the trunk. The lower limbs, too, are generally more crowded with lesions than other parts.
The duration of the disease may be very long. My first case had been developing for over ten years, others had been only for a few months; but in the case of a medical man, over 50 when I saw him, he said that patches first appeared on his legs when he was a house-surgeon, and had been slowly evolving ever since, so that after thirty years he was pretty thickly covered, as none as far as he knew had gone entirely away, though they had temporarily disappeared when he had rubbed in chrysarobin ointment, but had gradually returned to their old site.
The disease is compatible with perfect health; and even when there was any departure from the normal there was no reason to suppose that the abnormality was in any way connected with the skin lesions, while the majority of the patients had above the average health for their age.
While there appears to be no tendency in the disease to spontaneous involution, they are not, as the case narratives show, altogether rebellious to treatment, and in at least two cases a cure appears to have been effected and in others some improvement, while in a residue no improvement could be noted. The agents which appeared to have a good effect are salicin in 15-grain doses at least three times a day, which by itself entirely cured a recent case (Case 5) of only two months’ duration and of rather acute development, and vasogen iodine 10 per cent. rubbed in is a useful supplement and materially aided in the cure of Case 4. In some cases, salicin has failed to make any marked impression on the lesions, while in others the patient has not gone on with it sufficiently long to test its merits. As might be expected, it has been most successful when the disease has been present for a short time.
The only female case, a lady aged 47 years, resembled the other cases in its gradual evolution, long duration, absence of itching, in the persistence of the old patches with continual evolution of new ones, in its limitation to the covered parts, and in the general good health of the patient. The differences were in the patches being distinctly scaly all over the body; though the scales were small and even powdery in most parts of the body, they were, as usual, rather larger and more abundant on the legs. The patches were also more decidedly red than in the other cases; while there was some spontaneous improvement in the summer, in winter the patches cracked and smarted. This patient, who had been affected with the disease for ten years, had had the most varied drug and spa treatment, including cacodylate of soda injections for three months without any material effect; but after nine exposures to the Röntgen rays, the part exposed entirely cleared up, while the disease was unchanged on the inner side of the leg which the rays had not reached. I intend, therefore, to make use of the rays wherever practicable.
As regards to etiology, it is chiefly negative. There is a large preponderance of males, and all the cases have been over 20 years old, while 56 years is the oldest I have met with. In no case could an exciting cause be made out; two of the patients had had syphilis, but it did not appear to have any etiological importance, and in one of them antisyphilitic treatment was tried vigorously for twelve months without effect.
Case 1.—Mr. O——, draper, aged 30 years, was first seen by me on March 5th, 1902. The disease had been present ten years. From the commencement none of the patches had gone away. They appeared simultaneously inside the arms and thighs. They increased in numbers very slowly for a long time, and were confined to the limbs until three years ago, when they attacked the trunk, and during the last year have greatly increased in number; in fact, most of them have appeared in the last twelve months. His father was drowned and his mother died of fatty heart at the age of 51 years. When first seen by me the disease was in yellowish patches which commenced four inches above the nipples, but were not abundant till the line of the nipples, and they were less numerous below the umbilicus than above it. They were rather thickly arranged in horizontal elongated patches from 1 to 3 inches long, and 1/2 inch wide, as if streaked by the finger, pale, pink, or yellowish in tint, rather well-defined, but the edges were not sharp, and when the patch was pinched up a slight infiltration or thickening could be felt in the skin. The longer patches were formed by coalescence of some of the smaller ones. The surface was quite smooth. On the sides, the patches inclined slightly downwards and forwards, but they were practically horizontal in front. On the back they were sparse, and faintly developed in the interscapular region, and not nearly so numerous as in front; but on the lower half of the back and sides they were in the form of yellowish red stains, without elevation or roughness, and they were more numerous than on the upper part of the back. Forearms: The patches were on the inner side chiefly, more numerous on the right side than the left, and thickly arranged between the wrist and elbow. They were not elongated, but roundish, oval, or irregular, about three quarters of an inch in diameter, and somewhat brighter in tint than on the trunk. The surface was faintly rough, and on pinching up a patch it was slightly thicker than usual. There were about eight to ten patches on the right upper arm, while the left was almost free, and there were not nearly so many patches on the left forearm as there were on the right. On the thighs: They were most abundant on the inner side, and many more on the right side than on the left. There were scarcely any patches on the front of the thigh, but there were a few on the outer side. The patches sloped downwards and inwards, were oval and broader than the trunk patches, but still like finger-streaks. The legs were much more densely covered with coalesced irregular patches, some enclosing healthy skin, and the surface was rougher than the lesions on the rest of the body. On the neck, there were a few ill-defined spots about one inch square in area. There was slight blotchy redness of a not very obvious kind on the face, scarcely perceptible on the forehead. There was some seborrhœa capitis, but not so much as formerly, as he uses brilliantine. The patches seldom itched unless he got very hot. No illness preceded the eruption; in fact, he has never had any illness; his tongue was clean, and he looked and has always been perfectly healthy. The general aspect was somewhat that of a general orbicular seborrhoic eczema, except that for the most part the surface was smooth.
He has consulted dermatologists and others, but nothing he has taken or used has done him any good. I only saw him once.