The Treatment of Sycosis. by t A. H. OHMANN-DUMESNIL, PROFESSOR OF DERMATOLOGY, ST, LOUIS COLLEGE OF PHYSICIANS AND SURGEONS. REPRINTED I ROM The St. Louis Medical and Surgical Journal. March, i8go. I THE TREATMENT OE SYCOSIS.* A. H.Ohmann-Dumesnil, of St. Louis. Professor of Dermatology, St. Louis College of Physicians and Surgeons. Hyde1, in his excellent treatise, defines sycosis as “ an acute or chronic non-contagious inflammatory affection of the surfaces provided with relatively long hairs, in which the fol- licles and peri-follicular tissues are involved in an exudative process, producing pustules, tubercles, infiltrated patches and crusts perforated by hairs.” It will be found that, in the majority of cases, it is the beard which is the favorite site of the disease, the upper lip being the first part involved. The appearance presented is quite characteristic, the pustules having a distinct yellow color, being very slightly or not at all elevated and each one being pierced by a hair. The lesions are painful to the touch, manipulation of hairs that are involved eliciting a certain amount of pain. Tubercles and elevated pustules are the result of the inflammatory pro- cess, which will also produce tubercular infiltration and red- ness, and thickening of the integument. The affected hairs are easily extracted and this process is accompanied by the exudation of a small drop of pus. I will not dwell upon the clinical characteristics of this disease, which a careful exami- nation will easily differentiate from those similar to it. ’••Read Before the St. Louis Medical Society, February 15,1890. 1 J. N. Hyde. A Practical Treatise on Diseases of the Skin, 1888. 2 A point, in connection with this affection, which is of inter- est to the physician is the fact that it rapidly lapses from an acute to a chronic state. It assumes chronicity with a faithful- ness that cannot but excite an intense interest, especially when it is coupled with the fact that it has a tendency to spread in a symmetrical manner, until it has invaded all the hair follicles appertaining to hairs of a like »construction. This spread varies in rapidity in different individuals and is steady and progressive to such a degree as to make the patient solicitous in regard to his appearance. Moreover, complications will present themselves in the form of a diffused inflammatory process manifesting itself by a redness and thickening of the skin, infiltrated patches and pustules of various sizes and of a conical shape. These com- plications, of course, intensify the discomfort of the patient, as far as subjective symptoms are concerned; and, object- ively, tend to do the reverse of improving the personal ap- pearance. When we have added to this the fact that treatment is unsatisfactory, the patient is very apt to have his confidence in physicans shaken. The efficacy of treatment, as generally practiced, is various. In certain cases reasonably rapid and good results are obtained, whereas in others the most persist- ent attention to therapeutic measures seems to be equalled only by the general absence of anything like satisfactory re- sults. The majority of authors of works, devoted to a consid- eration of skin diseases, state that some cases of sycosis yield rapidly to treatment and that others do not. Writers of spe- cial articles on this affection give accounts of their treatment, which tend to show that the disease is stubborn to treatment and prone to relapse. I will not particularize the authors, as every one who has had any opportunities to undertake the treatment of sycosis will readily assent to their general state- ment of a common experience. In considering the fact that the results of treatment are, in general, so unsatisfactory, we naturally reason that there must be some cause for this and it then becomes a question to determine the cause or causes, which operate in such an obstructive manner. To determine all of them would be a difficult task, but some of them are so evident and afford such a plausible explanation, that it may not be amiss to 3 enumerate them. In the first place, a certain proportion of the cases seen have the deeper portions of the root-sheath in- volved. Even if we pull out the hair we have a difficult con- dition to contend with, viz: making a remedy penetrate down into the follicle. But this is possible, by the adoption of proper measures. In the next place, we have an irritated condition of the integument and if we attempt to use certain irritants to combat the chronic peri-folliculitis, we only in- crease the general inflammation. Again, the difficulty of preventing the spread of the disease is constantly adding fresh foci of an acute inflammatory nature, so that we have a con- dition presenting acute and chronic ph ases of the same trouble. Let us now look into the cause of such a state of affairs; and ascertain why it is that some cases are easily amenable to treatment and others so stubborn. Why it is that the disease has a tendency to spread and why relapses are so frequent, is also of some interest in connection with treat- ment- Also, what should be the rational mode of applying therapeutic measures, based upon an investigation of these circumstances. Modern investigation has shown that sycosis, ordinarily termed non-parasitic, is a parasitic diseases and one which is anto-inoculable and infectious. Tommasolk, Unna3 and Bockhardt have investigated the subject in a manner both scientific and thorough. They have found that two varieties of sycosis exist—the bacillogenic and the coccogenic, not to mention the hyphogenic, known as tricophytosis, and an en- tirely different affection. As bacilli and cocci are incapable of invading the horny layer the effects are produced by way of the hair-bulb. Bacillogenic sycosis is much less frequent than coccogenic. It attacks chiefly the upper portion of the bulb and suppurates but sparingly in the follicle. The inter- follicular coat shows a strong erythema, but less swelling and infiltration than the coccogenic form. The clinical features are those of the milder form of the disease. The bacillus has been named the bacillus sycosifems fcetidus. The bacilli are short rods, somewhat thick, with rounded ends, and elliptical 2 P. Tommasoli. Monatshefte fuer Praktische Dermatologie, 1889. 3 P. G. Unna St. Louis Medical and Surgical Journal, August, 1889, 4 Bockhardt. Monatshefte fuer Praktische Dermatologie, December, 1887, p. 450. 4 in form. They do not liquefy gelatin; but upon inoculating it with a needle, yellowish-white nail cultures, with a smooth head, are formed. Upon potatoes they form rapidly as a thick, yellow mucoid growth, having an unpleasant odor, the potatoe assuming a dark green color around the growth. Coccogenic sycosis is seen everywhere. There is total suppuration of the follicles, followed by scars. However, the upper half of the hair-bulb only may be affected for a long time without such results. As in the bacillogenic form, the horny tissues are not invaded by the cocci. The primary point of departure is the lymph space, the fibrous coat next and finally the structural portion of the follicle. The ordinary pus cocci (the staphylococci) are the cause of cocco- genic sycosis, which is the severer form of the disease. A third variety is produced by the invasion of a bacillo- genic sycosis by cocci, and still other mixed forms in which existing diseases of the skin are complicated by the microbic process. That both forms of sycosis are infectious there is no reason to doubt. Small epidemics have been observed in Leipzig, Berlin, Paris, Hamburg, etc., and in each one the cause was traced to one barber shop. Auto-infection is easily accom- plished by the use of a dull razor, rubbing with a towel, spreading an infected ointment, etc. Irritation of the bearded skin may produce a favorable ground for cocci to live and multiply; and, as these organisms are in the air in large numbers, in many localities, infection can be easily explained. One more word, before I come to a consideration of the treatment of sycosis. It may be supposed that the fashion of detecting micro-organisms in every disease has taken posses- sion of the investigators I have mentioned. To make their position more strong and support their arguments by facts, which tend to prove its truth they have made experimental inoculations upon themselves. These inoculations were made with pure cultures and they succeeded, in every instance, in producing a typical form of the disease, having the character- istics of one or of the other variety. I do not intend reviewing the treatment which is recom- mended by different authors and writers upon the subject, but will outline the therapeutical measures which have proven most successful in my hands and which have given me satis- 5 factory results. For purposes of convenience I will divide the treatment into two stages, viz: the curative, and the pro- phylactic. When the curative portion of the treatment is undertaken it has been my practice, lately, to epilate as thoroughly as possible. Where a large area is involved this cannot be done at once but will have to be performed at successive daily sit- tings. Care must be taken to epilate thoroughly and the vibrissse, in the nostrils, should not be overlooked. Not only is this epilation to be faithfully carried out, but such pustules or small abscesses as exist should be opened and their con- tents evacuated. When hairs are extracted the pus contained in the follicle should be evacuated, as much as is possible. In regard to the tubercular infiltrations, when such exist, I pay no attention to their treatment as they disappear in a short time under the effects of the medication employed. As soon as the last hair of that sitting has been extracted apply cam- pho-phenique pure and order the patient to make a similar application at night. This simple treatment constitutes the curative portion. After a variable length of time it will be observed that pustules are a very unusual lesion and it is then the proper time to institute the prophylactic portion of the treatment. This is absolutely essential for two reasons. In the first place, a few micro-organisms may be deeply lodged in some crypt; and, if the patient is permitted to neglect all treatment, they will constitute a focus from which a general infection will spread and a consequent relapse of the disease will occur. In the second place, the omission of any treatment exposes the patient to the dangers of a fresh infection from without. Having had sycosis once shows a susceptibility to the disease which is increased by the fact of having contracted it. For these reasons a patient, who is apparently cured, should be subjected to a further course of treatment. The pro- phylactic course which I pursue is very simple. I or- der the patient to shave every morning. He is directed to make his lather with a bichloride of mercury soap using a 1 in 1000 bichloride solution in water. He is also cautioned to render aseptic his razor, shaving brush, etc., by some simple means. After having shaved, a bichloride solu- tion is ordered to be applied, the strength varying from 1 in 6 500 to 1 in 1000 according to the tenderness of the skin. At night the same application is made or sometimes varied by ordering lanolin to be rubbed in. I have had a happy experience by the use of this method. The curative treatment has accomplished its purpose in from two weeks to three months. The duration of the disease when I saw it varied from three weeks to seven years in different individuals. In long standing cases the tubercular masses disappeared under the influence of the campho-phenique which, besides being antiseptic, has marked reducing powers. While it is true that, at the termination of the curative treat- ment the skin is red and more or less inflamed, the slight dermatitis which exists disappears spontaneously under the prophylactic treatment. The duration of this latter treatment is indefinite. 1 have some patients who have pursued it for about two years. They have never experienced any relapses and are so well pleased with the results that they prefer continuing it to run- ning the risk of contracting the disease once more. I have not detailed any cases in order not to transgress upon the limits of space, which should be allotted to the sub- ject. That the method of treatment, which I have outlined above, is infallible and specific can not be claimed. There is no doubt, in my mind, that cases will present themselves which will not yield to it. Besides this, the application of the remedies and the therapeutic measures advocated will be wrongly applied by some and they will, in consequence, ob- tain bad results or none at all and will feel disposed to con- demn the methods. But, despite this, the therapeusis which I have given was based solely upon the supposed parasitism of the disease and the results obtained have tended to prove that the position taken, tnat sycosis is parasitic, is a strong one. In conclusion, the only wish that I can express in this con- nection is that others may be induced to make an honest trial of the method given above and see if the results I have ob- tained are the same in their hands or if, by a fortuitous coin- cidence or series of coincidences, my patients have had such happy results in their cases. 5 South Broadway.