SEBORRHCEA NIGRICANS, AN UNUSUAL HYSTERICAL DISORDER. BY JOHN K. MITCHELL, M.D., OF PHILADELPHIA. PROM THE PHILADELPHIA MEDlfcAL JOURNAL, 1898. [Reprinted from The Philadelphia Medical Journal, January 15,1898.] SEBORRHCEA NIGRICANS, An Unnsnal Hysterical Disorder. By JOHN K. MITCHELL, M.D., of Philadelphia. The patient, Miss S., aged 24, was born in New York of Jewish parents. As a child her health was always good until she was sixteen years old, when, after an effort in swimming, she felt a pain from the right side of the back running into the right leg, and down the inside of the leg to the knee. This was momentary, and soon passed away. Ever since this time she has had a great deal of trouble from very obstinate constipation, which sometimes lasts for a week. Dr. Lange, who was consulted about this, found a floating right kidney, which probably had something to do with causing the constipation. He operated and fixed the organ, from which time the constipation improved, and she grew better in other ways. When she was about 19 years of age, a series of deaths in her family affected her very deeply, and she began to have a return of the headaches which had seriously annoyed her as a child, and at this time she first noticed the beginning of a dark coloration on the lower lids of both eyes. From this date to the present she has never been in good health, though her illnesses have been trifling. She was once five weeks in bed from mere weakness. She suffered with cramps in the abdomen, apparently hysterical in character, and had semi-conscious attacks, with fixation of the eyes, and loss of knowledge of her surroundings. The discoloration, too, began to grow darker and more extensive. At the timie of Ifarvttfiber, 2 1893, it extended, as shown in the sketch, around both eyes, on both lids, above the eyebrows, on the forehead a little way, and beyond the canthus on both temples, at times even reaching as low as the alae of the nose. Notes taken at this date and soon after describe the dis- tribution and variation of the coloration as follows: “ The pigmentation is not increased by excitement nor by ordinary exercise, but is sometimes worse after the occurrence of an unusually painful menstrual period. If she is exhausted by exercise, or by any other sort of fatigue, the color becomes deeper and is more widespread. As to other symptoms, her eyes are weak, and frequently ache and burn. She has a nerv- ous cough. The heart and lungs are negative, with this marked exception, that respiration is almost always extremely rapid, sometimes as high as 50 or 60 a minute, a fact of which she is herself unaware. There is no fulness of the thyroid. The urine on analysis is negative. Blood-examination shows 90 per cent, of hem- oglobin and 4,725,000 red corpuscles, an excellent state- ment for a city-bred subject, and quite contradicting the appearance of a somewhat sallow and colorless skin. The microscopic study of the blood reveals no abnor- mality. “Further observation of the pigmentation shows that the color is never so marked on the upper lids as on the lower. It is increased by extremes of heat and cold, and changes to a certain extent from day to day. It is not affected by pressure. On attempting to wipe it off, it gives to the cloth used in wiping a look of smutti- ness, as if fine lead-pencil dust were upon it. It can be washed off if some force is used and pretty hard scrubbing, but when washed off is renewed in a few hours. After washing in this way, the skin is found somewhat sensitive, and a little flushed where the color- ing has been removed, but probably this is in part the 3 effect of the rubbing. If she is kept entirely at rest for a few days, making no exertion whatever, the discolored area lessens, and the hue is somewhat less deep.” A minute examination of this patient’s condition was made, but the most careful study revealed no facts but those which have been already detailed. It did not seem to be a case calling for treatment beyond the care- ful regulation of her life, so that she should lead a thor- oughly wholesome existence. A schedule was ordered for her, accordingly, as follows : On waking, at 7 in the morning, she took a cup of cocoa, followed by a cold sponge-bath, and thorough rubbing with a rough towel. After this, she had breakfast in bed, and rested quietly for an hour, going out for a walk later in the morning. Massage was applied, and Swedish movements given daily ; two ounces of malt before meals was ordered, and full doses of iron, with a laxative when needed. No 4 attempt at local treatment of the discolored area was at first tried. The limit of the pigmentation was painstakingly measured from day to day, and found to reach from 1|- in. to If in. below the nasal margin of the lower lid. The color was always less on the upper lids than on the lower. Very small differences in her health and con- dition at once determined differences in the extent and depth of the pigmentation. After two or three weeks of treatment, several efforts were made to remove the deposit from the skin. It must be said that at first no little doubt was felt as to whether the patient did not use some means to produce or deepen the colora- tion ; but very careful watching by an observant nurse led to the conviction that this was not so. The first attempt to remove it was by the application of hot water with mild friction, daily repeated. The skin be- came very tender under this treatment, and it was soon seen that in the course of an hour or so after the use of water of a temperature practically almost scalding, a new deposit of pigment became visible, which could readily be rubbed off with the finger, and imparted a slightly greasy feeling, not unlike soot. In six or eight hours, the deposit had returned about the same as be- fore removal. After some days of this, an astringent application was used after the washing, hoping to so affect the skin as to lessen the deposit or secretion. To this end, a solution of ferric sulphate was ordered, using first weak, and then stronger solutions. A strong solu- tion of this, however, seemed rather to set than to re- move the discoloration, and quickly made the skin very tender. After two or three efforts, its use was discon- tinued. The patient suffered with a bilious attack in January, after two months of treatment, and had several days of headache, with indigestion, nausea, slight jaundice, and loss of appetite. During this time, there was an evi- dent increase in the amount of pigment upon the sur- face ; but in February it began to improve, and from this time there was always somewhat less, although if the patient suffered in any way with headache or indi- gestion, the depth of the discoloration was greater. She grew better, however, in other ways, and when she went home in March, the extent of the deposit was usually about an inch, instead of, as previously, an inch and a half or more, and it was much less dark than it had been. I had later an opportunity of seeing her again, and learned that after her return home the illness of her sister had made it necessary for her to undertake the charge of the househould, with some added strain in the way of nursing, and the pigmentation had promptly increased. There can be no doubt that this case had all its symp- toms modified by the presence of an hysterical tendency. The menstrual functions were disturbed; she suffered with dyspepsia; she had several of the stigmata of hys- teria, including that very distinct sign of hysterical dis- order, rapid breathing. There was no possible reason for suspecting simulation, or the use of any artificial means to deepen the pigmentation; and this opinion, formed without any knowledge of other cases of the same kind, was only strengthened when the subject was further studied. The first case of this kind which I can anywhere find reported is in the Philosophical Transactions of the Royal Society for the year 1709, where Mr. James Yonge, of Plymouth, reports very briefly the case of a girl 16 years of age. She had, he says, “ about the end of April, a few hot pimples rise on her cheeks, which bleeding and a purge or two cured. She con- tinued very well till about a month after, when her face suddenly turned black, like that of a negro. This sur- 6 prising accident much frightened the girl, even to dis- traction, when my assistance was required. By the arguments I used, and some composing anti-hysterical remedies, the violence of her fits was much abated. I also directed a lotion for her face, which took off the discoloration ; but it returned frequently, though not regularly, sometimes twice or thrice in twenty-four hours; sometimes five or six times. It comes on in- sensibly, without pain, sickness or any other symptoms of its approach, excepting a little warm flushing just before it appears. It easily comes away, and leaves the skin clear and white, but smuts the cloth that wipes it from the face; it feels unctuous, and seems like grease and soot or blacking mixed. It has no taste, which seems very strange, that a fuliginous exu- dation should be insipid. She never had the menses ; is thin but healthful; the blackness appears nowhere but in the prominent part of her face.” Baron Alibert, in his Monographic des Dermatoses, published in 1835, relates a case that he had himself seen at the Hopital St. Louis, in which almost the whole of the body had become of a dusky black, notunlike a negro’s. The author attributed this trouble to the worry and suffering which the patient had undergone. The face was darkish, but not black; the hands and the lower legs and feet were almost exempt from the coloration. This unfortunate individual was afflicted also with “ an immense number of fleas,” and these affected particularly those parts of the body which were darkest in color. The patient died of pulmonary tuberculosis in the Charite, and a careful post-mortem was made by Chomel. It was found from sections of the skin in different regions of the body, that the blackness was owing to a layer of this color which was interposed be- tween the derm and the epiderm, to which latter it was very closely adherent, so that it was entirely impossible 7 to separate it by any means. “It is,” says Chomel, “the mucous tissue which appears to he the exclusive seat of this color, in which the other layers do not participate.” This is not a case apparently, of the same character as that of our patient, but rather a melanosis, like the coloring of certain sarcomata and some other tumors. Mr. Teevan, in the 28th volume of the Medico-Chi- rurgical Transactions of London, reports a case which had also been previously reported by Dr. Read of Bel- fast, of a girl of 15, who, beginning with a deranged and insufficient state of the catamenial secretion, had, after a time, “ a complete blackness ” settling around both of her eyes, and partly upon her forehead. The disease commenced with irritation of the brow and eye-lids, which lasted for about ten minutes, and then there ensued an exudation of a “ blackish fluid, which gave these parts the appearance of being smeared with Indian ink.” This secretion was removable by wash- ing with a sponge in water, but returned in the course of a few hours. On trying to wash it at first the surface of the skin was found to be so sensitive and painful that the patient desisted from the attempt; but the medical men in London who were consulted, think- ing it a case of deceit, insisted on thoroughly washing it, which readily removed the whole of the black mat- ter, and left the skin perfectly clear and unstained. In a few hours the exudation re-commenced, and in five or six hours covered, as before, the entire forehead and the upper and lower lids of both eyes. The discolora- tion eventually disappeared when the general health was restored by constitutional treatment, and the dis- ease never after returned. It is mentioned in this case, that on at least one occasion the child vomited a quan- tity of liquid exactly resembling the color on her face. The case was seen by Sir Benjamin Brodie and others, 8 who were entirely unable to make up their minds as to its causation. Dr. J. Moore Neligan, in the Dublin Quarterly Jour- nal of Medical Science, 1855, reports as follows : Eliza D., aged 21, unmarried, suffered from amenorrhea. During the 11 or 12 months in which this suppression of the menses continued, the patient had at every return of the monthly period, a large erysipelatous patch on the right side of the body, each eruption as it appeared be- ing ushered in by fever, malaise and sickness, and gradually subsiding after three or four days. When this erysipelatous blush disappeared at the regular period, a black vomit took its place, and after several months of this a dark, bluish-black stain was observed for the first time at the inner canthus of the left eye, which rapidly spread without congestion or swelling. The dark patches remained under both eyes, extending somewhat, and becoming of a deeper black color, at each monthly period. The skin was excessively tender to the touch. The girl was much emaciated, highly hys- terical, nervous and excitable. During the following year the dark stains spread, covering the whole of the upper lid of the right eye, and partly that of the left, the under lids of both eyes, and extending upon the skin of the cheek. “On examining the dark patches with a lens, it was at once evident that the stain was not of equally deep color throughout, but was dotted over the surface of the skin, the dark dots corresponding to the orifices of the sebaceous glands.” The surface of the skin was so tender that she could not bear the most gentle pressure of the finger. The report of this case to the College of Physicians in Ireland brought out a history from Professor Law (quoted by Neligan in his article, but not elsewhere re- ported so far as I can find) of a somewhat similar case which had been under his care. The rest of the history 9 of Dr. Law’s case was very like that reported by Dr. Neligan. Irritability of the stomach and derangement of the uterine functions were present in both, and also occasional vomiting of dark matters from the stomach. Dr. Neligan’s case did not do well, and, when seen a year after the first note, was growing worse, both in the color- ing and in her general condition. A very good litho- graph of the appearance of this patient accompanies Dr. Neligan’s communication. Erasmus Wilson and Dr. Neligan united in giving to this trouble the title of “ Stearrhoea Nigricans.” Le Roy de Mericourt gave the same disease the title of “ chromhydrosis,” and reported two similar cases in 1857. In a later work he enumerated 28 authentic observations by various persons. De Mericourt had the same trouble in convincing people that his patients had not simulated the coloration that had fallen to the lot of Neligan; and a committee of the Societe Medicale des Hopitaux concluded that the patient whom they had examined had simulated the coloring of the eye- lids, using soot for producing it, and thereupon asserted their disbelief that any such disease as chromhydrosis existed. De Mericourt returned, however, to his work, and in a very complete and convincing memoir united all the known facts, discussed the observations and opinions of the committee and added thereto descrip- tions of the examinations of the secretion, showing its special character. De Mericourt’s paper was published in the Annales d Oculistique, in 1863. He quotes the cases which I have already mentioned, and follows them with a number of others of his own, and of numerous French and German observers, some of which were seen by Hardy, Larrey, and others, as well as himself. Of the 28 cases 24 were in women and almost all of the women suffered with various forms of menstrual 10 irregularity. In every case in both sexes there was a preceding history either of nervous disturbance or of profound depression from some cause. In a number of the women, the history is of an affection distinctly hys- terical in character. In the Annales d’ Oculistique for 1864, Dr. Warlomont reported a case even more distinctly hysterical in its general symptoms than any of those included by de Mericourt or the previous observers. The rapidity with which the color returned in this case Avas very re- markable. There should be no difficulty in the recognition of this disease. The character of the exudation, both microscopically and chemically, is very distinct. The small dark-colored fragments of matter, seen upon the surface of the skin with a lens, when removed present no characteristic of organized matter. They are in irreg- ular lamellae or granular masses, exactly as described in the paper of de Mericourt just cited. In the present instance the matter removed Avas found to be soluble in acids and insoluble in ether, shoAV- ing that it was not a “ fatty exudate as Neligan had supposed. The bluish-black color which is presented in the case I have reported is the one most commonly seen. It may vary in either direction toward blue or black. Very excellent illustrations of the appearance of the different patients are to be found in the report of Neligan’s case in the Dublin Quarterly and of Read’s and Teevan’s case in the Medico-Chirurgical Transac- tions of London. In a feAv of the cases described, nothing is said about the habitat of the patients, but it is to be noticed that in almost every instance where it is mentioned, the place of residence Avas near the sea. ' De Mericourt even thinks that some causal relation may exist between this sea-board situation and the diseased state. 11 A full report on the substance removed from the skin by scraping, and on the possibility of using various matters to simulate such a color, is appended to de Mericourt’s paper by Professor Charles Robin. To this it is only necessary for me to add that besides the microscopic examinations in the present case, and some repetition of the chemical examination made in de Mericourt’s cases, I have submitted a portion of the substance removed to examination by Professor A. C. Abbott, of the Laboratory of Hygiene of the University of Pennsylvania, who was kind enough to report as follows: “We have examined the matters from dis- colored portion of the skin of your patient, Miss H. both microscopically and by bacteriological methods and fail to find anything to account for the most pecu- liar condition. Microscopically we could detect noth- ing but amorphous masses that resemble only bits of blackened dirt, and the results of bacteriological inspec- tion were only those that were usual from normal skins, viz: a few cocci that to all appearances are the or- dinary white-skin cocci and have apparently nothing to do with the condition. We regret that we cannot afford you more light on the subject, but are, neverthe- less, under many obligations to you for giving us the chance to see this very remarkable case.” The Philadelphia Medical Journal 1420 CHESTNUT ST., PHILADELPHIA A WEEKLY JOURNAL WITH A MINIMUM CIRCULATION OF 10,000 COPIES $3.00 Per Annum This, one of the largest of American Weekly Medical Journals, contains more literature of value to practitioners than oth- ers, and at about one-half the usual price. Short, crisp editorials. All the very latest literature of the world abstracted and classified. Original articles from the leaders of American Medicine. 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