DERMATOLOGICAL NOTES BY J. CLARK M’GUIRE, M.D., l)t riimlnliK/ixt, Lou inn'll) ('it;/ Honjntal. Ahsknic. Syphilis. Acne. Treatment of Warts. Ichthyol and Resorcin. Resorcin. Ointment Basis. Lanolin. Iodide Potash Eruptions DERMATOLOGICAL NOTES. By J. CLARK McGUIRE, M. D., Dermatologist, Louisville City Hospital. ARSENIC. A paper on the value of arsenic in skin diseases, by Dr. G. H. Fox, read before the New York Dermatological Society, April 27, 1886, has called forth a very extensive controversy in regard to the value of the drug in this class of diseases. He con- demns the practice of giving arsenic in nearly every form of cutaneous disease, as irrational and harmful. Following this paper, Dr. Prince A. Morrow, editor Jour- nal Cutaneous and Venereal Diseases, re- quested the readers of his journal to an- swer the following questions : 1st—Are you in the habit of using arsenic generally in the treatment of diseases of the skin ? 2d—In what form of skin disease is it of superior value to other remedies ? 3d—What ill effects, if any, have you observed from its use ? 4th—What preparations do you pre- fer, and in what doses do you employ it? He has received some forty replies from physicians in various parts of the country. To the first question twelve answered yes; nine, no. The other nineteen made indi- rect replies, such as “ rarely,” “ generally,” “ scaly diseases.” Answers to the second question included about every disease to which the flesh is heir. One enthusiast answered, “ not only generally, but invari- ably in every case.” To the third question, fifteen had met with no ill effect from its use. 'I he others mentioned a variety of symptoms. In answer to the last request, twenty-five used Fowler’s solution, exclu- sively, in from one to fifteen minim doses; six, either Fowler’s or Donovan’s solutions. Three pinned their faith on arsenious acid alone. One gentleman gives us a goodly list to pick from. He mentions arsenite potash, arsenite soda, arsenite ammonia, arsenite quinine, DeValgan’s, Fowler’s, or Donovan’s solution, and arsenious acid. I believe this is about all the preparations of arsenic we have. From my individual ex- perience, I can indorse all that has been said by Dr. Fox in regard to the indiscrimi- nate use of the drug. In regard to arsenic, at least, I can almost agree with Dr. Oliver Wendell Holmes, who has said, “ If all the medicines in the world were thrown into the sea, it would be better for the men and worse for the fishes.” I believe more harm than good has been done from its use. I seldom prescribe it, except in such cases in which we wish to stimulate the skin, es- pecially the mucous layer, as in psoriasis, pemphigus, and chronic scaly eczema; have never seen the slightest benefit from its administration in any form of acne or alopecia. SYPHILIS. Excision of the Chancre as a means of aborting Syphilis.—Dr. Andronico, Medical Record, September 18th, 1886, reports four cases of excision of the initial lesion, with the result of preventing secondary symp- toms in all the cases. In the Journal of Cutaneous and Venereal Diseases, December, 1886, we find Dr. Zarewicz reports fourteen cases—in one case, in fourteen hours after the appearance of the lesion; in four cases, in six to ten hours ; in two, after twelve hours; in one, after fourteen hours; and two, in from twenty-one to twenty-two days. In every case constitutional symptoms made their appearance, but he still advocates the procedure, because in this way the initial lesion is done away with quicker than by any other means, and because it will modify the secondary symptoms. Professor Morrow has said : “It does not modify the intensity of the general symp- toms, since benignity or malignancy of syphi- lis is a matter of individual constitution. Out of one hundred and twenty-six cases 2 DERMATOLOGICAL NOTES. of excision of the infecting chancre, as practiced by Diday, Langenbach, Zeissl, Mauriac, Berkeley, Hill, and some fifteen others, there were one hundred and twenty- three failures, and three reported successes.” (Journal Cutaneous a fid Genitourinary Dis- eases, February, 1887.) Though the procedure is still advocated by Auspitz, Unna, and other German au- thorities, the great majority of syphilo- graphers have concluded it is useless as an abortive measure. In this country it has been condemned by Taylor, Bumstead, Keyes, Morrow, and others. Taylor has said: “It never could have been entertained, had it not been for con- founding the chancre and syphilis. The journals have lately reported several cases of tion-venereal syphilis. In one case, a man was inoculated by means of a tatooing needle, which the operator had several times placed in his mouth to wet. Another case, that of a young lady who had con- tracted a chancre of the lower lip from kissing her sweetheart. Physicians will frequently declare a patient free from syphi- lis, simply from the negative history of the case; or if the patient bears unmistakable signs of the disease, in their opinion, he has necessarily lied in his statement. Never- theless, it is true, he may be entirely un- aware, it is possible for him to have con- tracted the disease through non-venereal sources. I have had intelligent patients express their surprise, when they were in- formed of the danger of a mucous patch in their mouths. When we consider the many sources through which the disease may be conveyed, it is only surprising we do not meet with more cases of this kind.” Dr. Kline, in the British Medical Journal, January 20th, 1883, reports that thirty mar- ried women, nine husbands, and two infants contracted syphilis directly or indirectly from a diseased midwife. In a paper read before the Medico-chirurgical Society of this city, September 24th, 1886, and pub- lished in the American Practitioner and News, October 16th, 1886, I reported four cases of syphilis without history of infec- tion, referred to me by Drs. D. W. Yandell, E. R. Palmer, Wm. Cheatham, and Ap Morgan Vance. I quoted a statement of Dr. G. H. Fox, showing we can entirely ignore the history of these cases, depending on the appearance of the eruption alone. For our diagnosis, he says: “ When the diagnosis is based on the clinical features of the eruption, and the diagnostician does not outrun his experience, the diagnosis is al- most as certain as a mathematical demon- stration.” I will now add additional cases to those already reported : Case V.—Mrs. —, forty-five years of age, seen in consultation with Drs. Hayes and Vance. Patient apparently in good general health; three ulcers, about the size of a ten- cent piece, situated in the left cheek, just above the lips; a deeper oblong ulcer in the side of the nose, presenting an elevated indu- rated margin, with a gray base ; there was but little suppuration; complaint of severe pain about the parts; no eruption or scars elsewhere on the body. Patient denied all knowledge of any way by which she could have been infected. When first seen, she was seven months pregnant. She is now perfectly relieved of her trouble, and has been delivered of an infant at term. No eruption on the body of the child. She makes the statement that she aborted at seven months, during her last pregnancy, before this one. A child, who is now seven years of age, when born “was covered with a severe eruption of fearful looking sores.” The child’s teeth are now worn off nearly even with the gums. Syphilis had never been suspected by the mother. Case VI.—A gentleman sixty-five years of age, referred to me by a prominent phy- sician of this city, exhibited a papular eruption about the back, chest, and scalp, several scaly patches on the wrist and palms. The rash had been pronounced eczema, and treated as such without benefit, by several physicians. Though there was no history of infection, there could not be any doubt of the diagnosis from the ap- pearance of the eruption alone. The pa- tient immediately recognized the disease depicted in Dr. Fox’s collection of photo- graphs of “Skin Disease Syphilitic,” as identical with his own. There were two indurated sores on the end of the first and second fingers of the right hand. There is good reason to suppose he was inoculated at these points. The eruption has now nearly all faded away under anti-syphilitic treatment. Case VII.—Mrs. C—, referred to me by Dr. Cheatham, presented herself at my office, complaining of a painful tubercular erup- tion, situated on the cheeks, forehead, and chin, a small ulcer on the side of the nose, and an irregular shaped scar, of pink color, on the cheek, in front of the lobe of the ear, several scaly patches on the wrists and hands. The patient and wife DERMATOLOGICAL NOTES. 3 denied the possibility of syphilis as a cause. She had been treated for eczema for some time, without benefit. Within six weeks, under specific treatment, the eruption had entirely disappeared. In regard to the treatment, inunctures of mercury in the form of lanolin ointment were used directly upon the lesions, as well as elsewhere on the body. As soon as the symptoms began to fade, protiodide mercury (Keyes’ tonic treatment) was substituted. I have reported these cases, not only to show the possibility of recognizing syphilis from the clinical features alone, but to show the importance of appropriate treatment, for in nearly every case the patient had been under treatment for some other dis- ease, such as hydroa, eczema, lupus, etc. It is needless to call attention to the harm that might have resulted to the patient if such treatment had been continued. Professor Kaposi has lately stated that he regarded syphilis a curable disease: “Out of the different infectious constitutional diseases it is the easiest eradicated from the system.” He advises mercurial inunctions as the most reliable method of treatment. ACNE. Many cases of this disease have recently been reported as cured by means of the urethral sound. Dr. Hutchinson, of Chi- cago, Medical Record, May 29, 1886, re- ported six cases out of seven of the disease in females cured by means of the hot vagi- nal douche. The treatment is said to be founded on the belief that acne in the female is due to hyperaemia and irritability of the uterus. I have had no experience in this method of treating the disease, but have succeeded in curing five out of the last six cases I have had, almost exclusively by means of local treatment. TREATMENT OF WARTS. Several observers have reported the cure of warts by the internal administration of sulphate magnesia. In one case, a child was promptly cured with three grain doses twice a day. Another, in which a woman was relieved within a month, by a drachm and a half taken daily. Several French physicians report cures within fourteen days, by the internal administration of arbor vitae. The best local application in my experi- ence is the mono-chloro acetic acid. After applying it to the lesion it will immediately turn white, to change to a black color within twenty-four hours. ICHTHYOL AND RESORCIN. These drugs have recently been highly recommended in the treatment of several diseases of the skin. Ichthyol is obtained from a bituminous sulphurous mineral from the deposit of fossil fish. Dr. Stelwagon, Journal Cutaneous and Venereal Diseases, November, 1886, reports thirty-nine cases of acne, acne rosacea, ec- zema, lupus, and favus, which he had treated with this substance. He found it of benefit in about half the cases of acne and acne rosacea ; observed little or no improve- ment from its use in the other diseases. Prof. Unna has highly recommended it in the treatment of urticaria, herpes, and her- pes zoster. He uses it in the form of a ten per cent, ointment, and gives daily five or ten drops internally to children. He also used it in the form of “ plaster mulls.” These plasters consist of very thin sheets of gutta-percha, coated on one side with an adhesive substance containing one or more medical substances, and backed on the other side with undressed muslin. Besides icthyol, they may contain salicylic acid, oxide zinc ointment, iodoform, boric acid, etc. Any of these preparations may now be obtained in this city. I have never seen a more perfect plaster, and believe they will come into more general use in this country when they are better known. I have used ichthyol in cases of acne and acne rosacea, but so far have seen no ap- preciable benefit from its employment. RESORCIN. Dr. I hie, of Leipsic, Journal Cutaneous and Venereal Diseases, August, 1886, con- siders resorcin a sure cure for eczema marginatum and tinea versicola. Com- mences with a ten per cent, ointment, gradually increased to fifty or eighty per cent. If no irritation is caused, patient may use a three per cent, ointment daily. In alopecia areata, and seborrhoea, he ad- vises the following prescription : Resorcin, 5.10; olei ricini, 45.; alcohol, 150.; Balsam Peru, .05. Dr. Sherwell has,found it of use in the same class of cases. Dr. Jackson, of New York, reports a number of cases of epithelioma that have been benefited by the employment of a ten. per cent, oint- ment. 4 DERMATOLOGICAL NOTES. OINTMENT BASES. Since the introduction of lanolin, several new ointment bases have been recom- mended. The latest is the agnine. It is similar to lanolin, but has not such an ob- jectional odor. Professor Morrow regards their therapeutical effects as essentially the same. Mollin is still another ointment base recently recommended. It is a soft soap, containing 17 per cent, excess of fat. It makes a good ointment, especially when combined with mercury. It can easily be rubbed in the skin, and will not become rancid, even when exposed to the atmos- phere. LANOLIN. Lanolin was first introduced to the pro- fession by Prof. Leibreich, of Berlin. It is said to consist of cholesterine and fat acids, and is obtained from the wool of sheep, horns, hoofs, and hairs of certain animals. It should contain thirty per cent, of water, but it is not always possible to obtain a per- fectly reliable preparation. Dr. Piffard has said: “It is protected by letters patent, which specifies it as a perfectly white, neutral ointment. This description cer- tainly does not apply to the article supplied for sale.” As obtained here, it is straw color, and has an offensive odor. It takes up more water than any other fatty sub- stance, therefore it is more rapidly ab- sorbed by the skin than any other fat, for, according to Professor Unna, of Vienna, the more a fatty substance absorbs water, the more rapidly it is itself absorbed by the skin. Compared with vasaline, he found 100 parts of vasaline absorbed 4 parts of water, while 100 parts of lanolin absorbed 105 parts. Dr. Aubert, of Lyons, declares that lanolin not only retards cutaneous ab- sorption, but even completely prevents it, yet Dr. Lassar found iodine in the urine ten minutes after inunctions of iodide potash in lanolin ointment. A marked fall of the temperature in intermittent fever has been observed after inunctions of quinine in this ointment. It is to be recommended only in those cases in which we wish to obtain thor- ough and quick absorption, as in chronic eczema, syphilis, psoriasis, the parasitic diseases. I have used it with the most fa- vorable results, with chrysarobin io per cent., in the treatment of tinea tonsurans and tinea sycosis. With equal parts of the official mercurial ointment, it makes a good preparation for the inunctive plan of treat- ing syphilis. I have used ten per cent, chry- sarobin lanolin ointment on the plaques of psoriasis on one side of the body, and the same strength of chrysarobin in liq. gutta percha on the other side. The lesions treated with the former preparations seemed to clear off quicker than those treated by means of the latter. IODIDE POTASH ERUPTIONS. Among the valuable papers of drug eruptions written by Professor Prince A. Morrow, are several on the bullus form of iodic eruptions. The last case reported by this author (Journal Cuta?ieous and Vene- real Diseases, 1886) is accompanied by an excellent colored plate. I can testify to the correctness of the likeness, as I saw this patient at Charity Hospital, New York, through the courtesy of Dr. Morrow. Of the last nine of these cases reported, four have proven fatal. At the last meeting of the Medico-chirurgical Society of this city, I reported a case of iodide potash eruption in a woman about thirty years of age, who was being treated for syphilis. When I first saw her, there was a profuse vesicular rash about the lower part of the abdomen, the right groin, and extending down the thighs to the knee. On the outside of the thigh the vesicles had broken, exposing the corium, so the part looked like a piece of raw beef. A few isolated vesicles were situated about the cheek and arms. She had been taking ten grains of the iodide potash three times a day for eleven days. The diagnosis was made from the fact that syphilis seldom produces a vesicular eruption. It was un- like any other form of simple eruption, and because the rash began a few days after be- ginning the use of the drug, to completely disappear ten days after discontinuing its administration. It is a well known fact these eruptions do not depend upon the amount of the drug that may be taken ; five grains may cause it as well as five hundred. It is, without doubt, due to an idiosyncracy of the individual.