192 



TWO CASKS OF NON-l'LCERATINO " OHIENTAIi SOKE ' 



Two of IhL- 

 palionl's 

 ininietliatc 

 relatives 

 affected 



The papules 

 considered 

 " unclean " by 

 the natives 



Thu two youngest sisters are 

 An iiunt, aj^od 75, is hcaltliy. 



Brothers : One brother and one step-brother. Neither is affected. Tlu^ former, at,'ed 

 about 40, would appear to be phtliisical. 



Sisters : Six in number and all unaffected save one. Eldest, aged about 35. Youngest, 

 about 12 years. The eldest sister is married and has three girls, all healthy. The second 

 sister has two children, a boy and a girl, both healthy, the third sister has one girl who is 

 healthv, hut the lutiHirr hns for the pant four and a half ijetirs suffered front the same skin 

 diseage us her Imtther. She became infected when living at home, and in iier case tlic 

 tumours are about as numerous as in the brother's. Her husband shows no sign of 

 the disease. 



The fourth sister has one girl, who is healthy. 

 unmarried. 



A paternal uncle died of phthisis four years ago. 

 Patient's grand-parents are dead, cause of death unkiiowii. 



Personal history. — -As a child, patient liad sniall-pox. Thert' is no history of any 

 venereal complaint. No history could be obtained as regards the presence of insect 

 parasites in his house or village. 



History of present illness.— The growths, which, as will be seen, occur for tiie most 

 part in groups (Fig. 41), began to appear first of all upon the left side of the neck, two 

 years ago, when he was living in his native village. Tlien the left side of the face 

 became infected eight months ago, followed by the right shoulder and right upper arm 

 six months ago. Four months ago the neoplasms appeared on the outer surface of the 

 left forearm, and fourteen days ago very small papules presented themselves on the 

 inner surface of the left thigh, about the region of Scarpa's triangle. 



In addition, growths, the date of appearance of which is uncertain, are pieseiit over 

 the insertion of the left deltoid, and nearly in tlie centre of the back sliglitly to the left 

 of the spinal column. 



The growths are said by the paticiit to appear first as small pink circular points 

 raised above the surface of the skin and of about the size of a pin's head. Tlu^y grow 

 until they reach the size of a pea, when secondary points appear to develop at the 

 periphery of the primary growths, and as a rule separated from these latter by narrow 

 tracts of healthy skin. These secondary tumours develop and become absorbed into the 

 parent growths. As a result, the main tumours increase in size and the whole mass 

 takes on an irregular shape. 



The patient complains that the growths itch intensely when exposed to the sun's 

 rays, and that they pain him when pressed or when they come violently into contact 

 with anything hard. 



The people of his village pronounced him " Waash," /.«■. unclean, and refused to eat 

 with him. 



Clinical examination. — General appearance healthy, expression dull and apathetic, no 

 wasting, no sign of any systemic disease, no glandular enlargement. Heart, lungs, liver 

 and spleen normal. Urine: no sugar, no albumen. 



The growths in the situations indicated resemble nothing so much as the mountains 

 on a relief map (Fig. 39) looked on from above. There is the main elevation with spurs 

 and ridges projecting from it, these latter representing the secondary growths which have 

 united with the parent lesions. The tumours are of a definite pink colour, contrasting 

 well with the brown pigmented skin, have a shiny aspect, are neither scaly nor ulcerated, 

 and show no signs of breaking down. To the touch they feel smooth, firm, yet soft in 

 consistency, are easily moveable and are not adherent to the deeper tissues (Fig. 38). 



