REMARKS ON AND TREATMENT OF PATIENTS IN THE SKIN CLINIC OF THE JEFFERSON MEDICAL COLLEGE HOSPITAL. BY J. ABBOTT CANTRELL, M.D., Chief of the Skin Clinic. REPRINTED FROM THE THERAPEUTIC GAZETTE, APRIL 13, 18Q2. DETROIT, MICH. : \ GEORGE S. DAVIS, PUBLISHER 1892. REMARKS ON AND TREATMENT OF PATIENTS IN THE SKIN CLINIC OF THE JEFFERSON MED- ICAL COLLEGE HOS- PITAL. GENTLEMEN While the general per- centage of the disease eczema is placed at thirty-three, it is probable that these figures would be increased were all cases recorded ; and, as this large percentage is based upon the experience of men well qualified to judge of cutaneous trouble correctly, it is proper that you, as general practitioners, should know something of the treatment of a disease forming so great a proportion as one-third of all cutaneous diseases. It will be greatly to your advantage that most of our patients to-day are sufferers from that disease. Jacob S., aged 15 years, presents himself for the first time, having an eruption covering the entire face and surrounding the neck, which has lasted full three months. Noticing the condition closely, we find scattered here and there a typical vesicle, while the re- mainder of the face is covered with a crust. The neck is inflamed, although not acutely, the whole surface being decidedly itchy. We have here a -typical vesicular eczema, and it might be advisable to state that, pre- vious to the present eruption, the boy says he had ivy-poisoning in the same locality, although we can safely exclude that disease from the diagnosis to-day because this disease has lasted three months, a length of time unlikely in dermatitis venenata. If you notice the borders of the present disease, you see that we have a decisive point in favor of eczema, for, besides having the oozing, we have the disease fading into the surrounding healthy skin. We often notice that eczema is a follower of poisoning by ivy. In the treatment of a disease of this kind, we must first remove the crust, so that we will not have any barrier to the desired effect of the treatment. To remove the crust, we will apply a starch poultice, or an olive-oil dress- ing, either of which will remove it, if prop- erly attended to, in a few hours, leaving the skin entirely clear of crust. While we have a decidedly moist eruption, with a crust form- ing rapidly, we have also an inflammatory trouble before us, and we wish to remove these conditions at one and the same time. For this we have recourse to several applica- tions, using either a saturated solution of boric acid in water, or black wash, from five to ten grains to the ounce, and applying either of these continuously for a period of half an hour, twice daily, then drying the parts, and incasing them in an ointment dressing, either a calamine, ora mild calomel ointment, or the ordinary zinc ointment, add- ing, as we have a decided tendency to itch- ing, about ten grains of carbolic acid. Fol- 3 lowing these instructions implicitly, we will find that this boy’s face will be almost well in about two weeks. This woman, the second patient, who is 60 years of age and a domestic servant, states that the present condition has lasted for the past four months, although she has had re- peated attacks for the last four or five years. The palms of both, hands are so stiff in the mornings that, without using an olive-oil dressing, she would be unable to do her daily work. The hands you notice are greatly swollen, while the skin in each palm is thickened, and at each joint you see a crack with slight bleeding, the edges of the fissure being heavy and rough. On the dor- sal surfaces you see that all the linear mark- ings of the skin are clearly perceptible at a distance, the knuckles being very much thickened and prominent. Around the nails the tissues much resemble the condition found in paronychia. We have here the disease generally re- ferred to as chapped hands, although it is very much aggravated. The cause of this trouble is, of course, the almost continuous immersion of the hands in water, and that they are not properly dried. In treating this affection, you must first re- move, as far as possible, the cause ; but in this patient’s case, as she must work for a living, she is obliged to do some of the things which would otherwise be interdicted. After softening the edges of the fissures with a starch poultice, which should be ap- plied for at least two hours, we then should use a permanent impermeable dressing, as 4 long as possible at each time. After the con- dition is made more favorable for curative measures, we will then apply a salicylic acid or resorcin ointment, ten or fifteen grains to an ounce of ointment base, preferring the most soothing,—namely, zinc oxide. Apply this twice a day, and cover with paraffin- paper and a bandage ; and, after a week, fol- low it with a sulphur sublimate and pix liquida application, using from one-half to one drachm of each to an ounce of oint- ment. This condition will take at least some months to relieve entirely, and the patient should be under strict discipline, with fre- quent observation of the disease. This man is 40 years of age, and presents a disease similar in character to our first pa- tient, although it is in a different locality, it being confined to the arms below the elbows, distributed entirely on the extensor surfaces of both forearms and the dorsal aspect of the hands and fingers, the disease not having at- tacked any of the remaining portion of the body. He states that it is recurrent, re- appearing generally every winter for the past five or six years, although not having been so severe as the present attack. We notice that the disease is of a decidedly moist character, being here and there crusted, and presenting at the upper border several full-formed vesi- cles, while the remainder of the disease has coalesced, forming one large patch. We also see that it bears a resemblance to the former cases,—that of fading into the surrounding healthy skin. He states that the arms are so stiff that he is almost unable to. per- form flexion, at least without causing much pain, and that on account of the irritation he is unable to go to sleep until far into the night. We turn our attention, first, to the crust re- moving it by the same process mentioned in the preceding case, then apply a soothing as well as a curative ointment. I know of none better than a calomel or resorcin ointment, with zinc oxide as a base, using twenty grains of either of these ingredients to the ounce, with about fifteen grains of carbolic acid to relieve the itching. Another admirable form of treat- ment would be a salicylic acid paste, which may be made as follows : Salicylic acid and carbolic acid, of each ten grains, using mu- cilage of acacia as a base with a slight quan- tity of powdered starch to thicken it. This may be applied directly on the parts two or three times a day, and covered with paraffin- paper, and then bandaged securely. This man, the fourth case, also presents the lesions seen on the former patient, but not so extensively. The disease is con- fined entirely to the wrists and back of the hands and fingers, being both vesicular and moist. He states that the condition gets al- most well during the summer, only to break out again almost at the first sign of cold weather. It has lasted in all five years, never having been entirely well. He is a black- smith by trade, being obliged to have his hands near the fire continuously, but previous to working at this he was employed in oil- works, and this evidently has been the first exciting cause. The disease presents the same characters as those previously seen, and as generally found in cases of eczema, 5 6 and will be found to be a decidedly aggra- vating case to treat, inasmuch as he is obliged to work as a blacksmith. After re- moving all bad effects, as far as possible, we may apply a twenty-five per cent, solution of glycerole of subacetate of lead, one or two drachms to an ounce of ointment base, or the diachylon ointment of Hebra, made as fol- lows : R Olei olivge opt., ; Pulv. lithargyri, ; Aquae, q.s. Mix by aid of heat. The next patient you see is an elderly man, presenting an eruption over the extensor sur- face of the right leg and dorsum of foot, this condition being more of a subdued inflamma- tion than any of the preceding cases, although we still have a form of eczema,—eczema rubrum. On inquiry as to the duration of this trouble, we find that he has had it for at least fifteen years, he being now 75 years of age. We find also that the whole leg, from hip to foot, is one mass of varicose veins, and near the inner malleolus he had an ulcer five years ago, which had existed between four and five years. Owing to the varicose con- dition, we have a diminished as well as a poorly-nourishing blood-supply to the parts, and also an entirely different condition to treat from that previously shown you. As the itching is of an intense variety, and as we are not hampered with a moist eruption, we apply simply a carbolic-acid lotion, three drachms to the pint of water, to relieve the itching, and have the leg encased in a silk- elastic stocking to protect the blood-vessels, preventing a possible rupture. If these con- ditions are complied with, we will give this man decided relief; if not, we may look for the breaking of a vein, followed by an ulcer, which will, of course, take some time to cure, the man being in a decidedly worse condition than at present. Willie H., aged 2 years, has had the present eruption almost from the day of his birth. He has a silver-dollar-sized crusted patch on the centre of each cheek, with several vesicles scattered here and there over the forehead, cheeks, and chin. Around the anus we notice also several small crusted lesions, with a few papules on the buttocks. The father and mother, as you see, are both hearty, as is the child itself, neither his parents or grand- parents having suffered from a similar dis- ease. One of the best treatments to be ap- plied to a child of this age, presenting a dis- ease so chronic in character, would be, a drachm of pix liquida in an ounce of collo- dion, painting this on the face three times a day, being exceedingly careful to keep it away from the eyes, on account of the sting- ing effect of the collodion. On the remaining portion, a calomel, resorcin, salicylic acid, sulphur sublimate, or pix liquida ointment, using ten or fifteen grains of either to the ounce of the ointment of zinc oxide, in- creasing this proportion as necessary, may be applied twice or three times daily, keeping the parts well covered. We must also look to the general condition of these patients, correcting any derangement that may exist in the digestive tract, looking also to the general tone of the patient, and 7 8 removing any rheumatic or gouty diathesis as far as possible either by the use of medi- cine or the restriction of diet, or both, as the case may be, seeing also that the intestinal canal is always free. A favorite formula of dermatologists, combining aperient properties, is as follows : “MISTURA FERRI ACIDA.” R Magnesii sulphat, gi; Ferri sulphat, £ss; Acidi sulphurici dil., fsp; Sodii chloridi, gr. x; Infusio quassiae, q.s. F|iv. M. Sig.—Give a tablespoonful of this mixture in a goblet of water, preferably warm, one-half hour before break- fast, and repeating before the evening meal, if neces- sary. The prognosis will depend upon the gravity of the case, its duration, and the tendency to recurrences. One more interesting case presents itself for the first time, showing an eruption, which appeared on Sunday afternoon, now two days ago. Noticing the condition closely, we find a group of vesicles, each lesion discrete, and surrounded by a reddish-pink areola, the whole patch in turn having the same areola. A few of the more central lesions have broken and discharged serum, forming a crust,—a condition rarely found in the dis- ease before us. The man states that before the appearance of the eruption he com- plained of a burning sensation of the af- fected parts, and that on the appearance of the eruption it changed to more of a neural- gic character, and that since the lesions in the centre have broken the pain is more intense. 9 We have here an acute vesicular eruption being preceded by a burning sensation and followed by pains of a more intense charac- ter. We exclude eczema, because it is never so acute, and though the lesions may be dis- crete, they have a tendency to coalesce, with a history of discharging serum, with crusting the rule, and being more of an itching sen- sation than that of neuralgia ; while in the herpetic eruption before us we have a dis- crete eruption, which does not coalesce, and one in which the lesions do not tend to rup- ture spontaneously, which is the rule in the former disease. The lesions here break down only by being bruised, and then we have an aggravation of the pain. As I have ex- plained that the pains get worse if the le- sions are ruptured, we must, if possible, prevent this. If the pain is not intense, sim- ple remedies will do. If the pain is severe, the stronger sedatives must be used. A drachm of bismuth subnitrate to a half ounce of ointment may be used, this gener- ally sufficing, or, with a view of preventing the rupture of the vesicles, we may use col- lodion, painting it on two or three times a day, and when the pain is very severe adding one or two grains of morphine. Generally, in addition to these remedies, we also have a nervous individual to treat as well, and we wish to advise sedatives in connection with the external treatment, using possibly the bromide of sodium or lithium as frequently as necessary. This disease does not tend to form scars, although that acci- dent has been noticed. 1010 South Third Street.