[Reprint from The Tri-State Medical Journal, St. Louis, Mo., January, 1896.] VITILIGO; ITS CAUSE AND TREATHENT. A. H. Ohmann-Dumesnil. Professor of Dermatology and Syphilology in the Marion-Sims College of Medicine, St. Louis. VITILIGO is far from being so uncommon a disease as is generally sup- posed. It is observed to occur in individuals of all races and, as it is entirely devoid of any subjective symptoms, it is not often that those subject to it apply for relief. On this account statistics of dermatologists, dealing with the frequency of the trouble, are fallacious and the non-recog- nition of cases which are not well marked has led many to the erroneous conclusion that it is comparatively rare. Those who readily recognize the trouble, and who are at all observant, can readily recall a large number of cases which have come under their notice. Whilst, in well-marked cases, the process is a curious one, a study of its pathology shows it to be a very interesting one which is still enshrouded in a great deal of obscurity so far as its etiological factors are concerned. It must not be forgotten that viti- ligo and albinism look alike but differ essentially in the fact that the former is acquired, whereas the latter is a congenital defect. Before entering into a further consideration of these questions it may not be uninteresting to say a few words on the general appearance of the trouble and give the description of a rather marked case which came under my observation a few years ago. Vitiligo, or achromia acquisita, is 2 essentially an atrophy or deficiency of the cutaneous pigment. The trouble is made manifest by the appearance of greater or smaller areas of the skin which are lighter in color than the unaffected portions. In Caucasians the spots are of a milky color and more manifest in summer, when the integument has been rendered darker from the effect of the sun’s rays. In dark races, such as the African, the contrast between the achromic areas and the normal integument is very marked. Absolutely these patches are not whiter in the negro than in the white races. The majority of authors, in fact, all of them state that there is an absolute loss of pigment in the affected spots. This, however, can be easily shown to be erroneous by careful examination. For, if the affected skin be carefully examined, it will be found, as many of the mod- ern writers in dermatology contend, that there is, in reality, a centrifugal displacement of pigment. This is most easily demonstrated in a white skin. If a patch be closely observed and its edge isolated from normal integument, located some two or three inches beyond, it will be found that this periphery is much darker than the normal skin, so that vitiligo should really be denominated a centrifugal displacement of pigment rather than atrophy. Another fact which militates against the atrophic theory is that there does not exist an atrophy of the other elements of the skin as may be seen by referring to Fig. 1. Moreover, sensation, both general and tactile, does not seem to suffer as the esthesiometer and the electric tests easily demonstrate. It would be reasonable to suppose that an atrophy which would implicate such deep-lying structures as pigment cells, would certainly affect the others to some extent at least. Moreover, individuals affected by this disease are otherwise perfectly healthy, and both young and old suffer no inconvenience except in so far as cosmetic appearance is con- cerned. Case.—Some few years ago I had occasion to observe a rather marked example of vitiligo occurring in a rather old negro woman who was at the St. Louis City Hospital at the time. She was rather feeble and in a poor state of health. The disease had begun some years before and had steadily gone on, the white patches increasing in size. Some two years ago I acci- dentally met the woman and her vitiligo had increased. I was not able to secure any photographs on this last occasion, much to my disappointment, as they would have been most interesting for the purpose of estimating the comparative rapidity of growth of the leucodermic spots. A brief descrip- tion of the appearance presented, when the patient was photographed, may not be uninteresting. It may be premised that the leucoderma was not as complete in some portions as in others. When viewed from in front, the general appearance presented was that shown in Fig. 2. The white maculae occurred in a narrow strip across the forehead, with a few above the eyebrows at the top of the nose and around the mouth. Then, lower down a large patch about the vast part of the neck extending across over the clavicles and down on the sternum. At a point about three inches above the xiphoid cartilage down to the level of the nip- Fig. i. Case of Vitiligo Viewed from the Back. pies a broad streak extended, and this stretched over both mammae. An interesting point to observe is the fact that neither areola nor nipple was involved. Across the abdomen an irregular band stretched, which has since become entirely white. The umbilicus was also affected. The arms had a few small patches, and the hands were involved to a greater extent, the dorsum of the left being entirely implicated. A few isolated patches Fig- 2. Case of Vitiligo Viewed from in Front. existed on the legs. Viewed from behind the affected areas differed some- what, as may be seen by reference to Fig. 3. Here the neck was involved with the exception of a very small patch in the central line. Three small 5 isolated macules existed on the left side just above the scapula and towards the central line. Over the right shoulder a patch three inches wide passed backwards and downwards along the line of the spinal column, gradually widening until it arrived to the upper part of the internatal fold. A few isolated small spots also existed over the scapular region of the left side. The left elbow had a large patch. The thighs were also the seat of the disease, a few patches appearing in the popliteal spaces. Finally, each external malleolus exhibited the presence of vitiligo in a more or less marked degree. From what has been mentioned it will be noted that one of the charac- teristics of vitiligo is that it is progressive. It will occasionally happen, however, that a sudden cessation of the spread of the patches will occur. On the other hand I have observed a few cases—negroes and mulattoes—in whom the progress was rapid and they promised to eventually become entirely white. As a rule the progress is very slow, but easily observed from the fact that the seat of predilection resides in the face, neck and hands. It is not an unusual thing to observe the scalp affected, and whenever this occurs, the hairs of the implicated area become white. A peculiarity in connection with the distribution of the discolored por- tion is that, in many cases, a symmetrical distribution is observed. In the case which has just been described this rough symmetry is plainly observ- able. On the other hand I have had occasion to observe perfect symmetry in a case which I reported in 1884.* Again, in the case reported it will be noted that, along the spinal column, the absence of pigment occurs on both sides of the mesial line for about an equal distance. I have observed three negro children who presented a similar conformation upon the scalp. Con- trarily vitiligo may be distinctly unilateral as in a case at present in this city. The subject is a colored waiter in a very popular restaurant and one- half of his face is white. The central line of derinarkation is very sharply drawn and exactly limited to the median line except the nose, where it overlaps this. The pathology of this disease, considered from a pure microscopical point of view, is very simple. It will be found, on examination, that there is a partial, marked or total loss of pigment cells and granules in the skin and connective tissue of the affected area, as shown in Fig. 1. In the parts surrounding the achromic spot a larger quantity of pigment will be found than is the rule in the contiguous normal skin. The distribution of this increased quantity of pigment, however, offers no particular features of interest. It simply occurs in an exaggerated degree in those portions in which the pigment is naturally found, and its disposition in the tissues is the same. Au interesting point in connection with the causation of vitiligo is as *St. Louis Medical and Surgical Journal, Jan., 1884. 6 to the role played by the nervous system as a possible factor. Some years ago I considered this subject in a paper1, but it may not be uninteresting to mention a few words in connection with this and with reference to some more recent works which have since appeared. Duhring* thinks that the disease seems to be due to some disturbance of innervation. Leloir and Chabrier3 found marked changes in the peripheral nerves in a case of vitiligo, and Dejerine4 also made researches upon this subject, and he noted quite marked alterations of the peripheral nerves of the skin. Leloir’prosecuted his researches and found the same alterations in subsequent cases, so that he concludes with quite a degree of certainty that such alterations are very frequent if not constant. Crocker" states that there are strong grounds for regarding the disease as due to a tropho-neurosis, and Morris7 is of the opinion that there can be Fig. 3. Cross Section of Skin in Vitiligo. little doubt that it is a disease of neurotic origin. These opinions will be found much strengthened when we take into consideration the fact that most pigmentary changes and disturbances of the skin have a direct or remote neurotic basis, and from the further fact that in many cases of viti- ligo nervous perturbations of some sort have been found to precede the onset of the disease. That the underlying cause is purely trophic has not been satisfactorily demonstrated, but that the nerve terminals of the skin are probably implicated is further confirmed by the peculiarity of distribu- tion observed in cases. 'The Role of the Nervous System in the Causation of Vitiligo. Alienist and Neurologist, April, 1886. ®Diseases of the Skin, 1881. 3Comptes Rendues de l’Academie des Sciences, 1879. 4Notes sur les Alterations des Nerfs de la Pean dans un Cas de Vitiligo. Progrfes Medical, 1881. 5Recherches Chirigues et Auatomo-Pathologigues sur les Affections Cutanees d’origine Nerveuse, 1882. 6Diseases of the Skin, 2d Ed. 1893. 7Diseases of the Skin. 1894. 7 To further add to the contention of the probability of the cause of viti- ligo being neurotic in character we need but refer to the results of treat- ment in some cases. For, whilst it is considered incurable, cases have improved under treatment and have even been cured, and, in a few isolated instances, a spontaneous cure has been noted. Bulldey1 says that he has seen marked benefit from the use of phosphide of zinc and nux vomica. I have had one case recover, and another improve, under the action of a gal- vanic current. Piffard2 has suggested this, but merely from the assumption that there might possibly be nervous derangement. However, so far as the neurotic origin of vitiligo is concerned, I do not propose to discuss the sub- ject, having already done so on a previous occasion3 (1886). Suffice it to say that the majority of cases are very stubborn to treatment, and those subject to vitiligo are not endowed with sufficient patience to submit to the lengthened course of treatment, which is absolutely necessary to procure any satisfactory result. To those who will submit hopes may be held out and an improvement may be looked for in a reasonable space of time. Under other circumstances it is best not to attempt any treatment whatever. No attempt has been made to give a complete resume of the opinions of even the principal dermatologists upon the probable cause of vitiligo and its pathology. Those who have pushed their investigations on this subject are very nearly of one mind, but the subject is one which is far from being settled, and it offers a large field for original research. Cases are certainly numerous enough to furnish an abundance of material for such a purpose. The minute investigation of the finer nerves will no doubt ultimately lead to a solution of the question. 'Manual of Diseases of the Skin, 1884 3Materia Medica and Therapeutics of the Skin, 1881. 3 hoc cit.