THE Treatment of Acne in Both Sexes BY RELIEF OF GENITAL IRRITATION. A GENERALIZATION OF SHERWELL'S METHOD. By J. M. WINFIELD, M.D., Attending Dermatologist to the Long Island Hospital Dispensary, Brooklyn, N. Y. [Reprinted from the Journal of Cutaneous and Genito-Urinary Diseases for March, 1891.] NEW YORK: D. APPLETON AND COMPANY, 1, 3 and 5 Bond Street. LONDON : CAXTON HOUSE, PATERNOSTER SQUARE. The treatment of ACNE IN BOTH SEXES BY RELIEF OF GENITAL IRRITATION. A GENERALIZATION OF SHERWELL'S METHOD. By J. M. WINFIELD, M.D., Attending Dermatologist to the Long Island Hospital Dispensary, Brooklyn, N. Y. ALTHOUGH acne is the commonest of skin diseases, yet it is the one disease that is most frequently passed over with little or no treatment, the physician trusting the cure to develop- mental changes. The acne pustule will cease forming after an indefi- nite period, but the disfiguring marks may remain for a lifetime. The object of this paper is to add the report of a number of suc- cessful cases to those already recorded in which treatment has been directed to the reflex origin of this disease. All authorities writing on Acne vulgaris and Acne rosacea refer to uterine and other sexual pathological conditions as having a causa- tive action in these affections, yet very little is said regarding treat- ment of these functional or organic irregularities. European authors, even the late works of Anderson and Crocker, ignore almost wholly any reference to general or local treatment of the sexual organs. The American writers have paid more attention to this etiological point. Prominently among them are Piffard and Robinson. Early in the last decade Drs. Denslow1 and Hyde recommended the use of ergot in the treatment of acne and its annex, rosacea. The theory was that ergot exerted a tonic action on the non-striated mus- cles surrounding the sebaceous glands, thereby enabling them to more readily expel their secretions. It has been proven that ergot does have a good effect in certain 1 Denslow: N. Y. Med. Journal, Feb., 1881. | 2 The Treatment of Acne in both Sexes. cases in females where the menstrual functions were irregular, but in those cases the result appears to come from its oxytocic power rather than its tonic effect on the involuntary cutaneous muscles. Dr. Piffard * places acne in the group of reflex affections, " in con- sequence of a firm belief that in the majority of instances it is not a primary condition, but one dependent on disease of other organs re- flected on the skin. The organs specially involved are those connected with the sexual or digestive systems." In describing treatment he recommends that strict search be made for sexual causes, and when found removed if possible. It is observed that acne is a disease of youth, and there are many conflicting opin- ions regarding sexual excess-be it from masturbation or excessive venery-acting as an aggravating cause. Neumann3 says it occurs in persons of abstemious habits as well as those who are addicted to over-indulgences. It would seem that masturbation has but very little to do with its causation, for we often see adolescents without acne who from their own confession have indulged in the common, if not universal, habit. Still, if this or any other mode of excess adds to the already existing passive congestion of the genital mucous membrane, undoubtedly there would be an outbreak of acne on the face and neck. There is at the period of puberty a hypersesthetic condition of the genital ap- paratus, and ninety per cent of young males will be found to have hypersensitive urethral canals. In girls at the beginning of menstrual life there are frequently a number of peculiar reflex nervous phenomena, which have more or less effect on the cutaneous circulation of the face, which is often enough to cause acne. Nearly the same thing produces acne rosacea at the climacteric period. In addition to these physiological causes, we constantly hear the gynecologist lament the fact that so many young women have some form of menstrual irregularity such as dys- menorrhoea, amenorrhoea, or menorrhagia, all of which can produce enough reflex trouble to cause acne. Reflexes appear to play an active part in producing other skin diseases: for instance, urticaria seems to be a disease reflected from a deranged alimentary canal to the trunk, and chronic urticaria has been cured after operations for the relief of oophoritis and salpingitis.4 The natural conclusion to be drawn is that acne is not a primary 2 Piffard: "Materia Medica and Therapeutics of the Skin," Win. Wood & Co., New York, 1881. 3 Pullar's translation of Neumann's text-book, "Skin Diseases," London, 1871. 4 Dr. E. Frank : Prag. med. Wochenschrift, No. 6, 1890. The Treatment of Acne in both Sexes. 3 disease, but one derived from some other deranged organs, and those organs are most frequently the sexual. In 1884 Dr. Sherwell,5 of Brooklyn, published a report of a num- ber of cases of acne in the male subject treated by the cold sound. His results were so uniformly good that his method was adopted by a number of dermatologists, among whom was Dr. Denslow,6 of St. Paul, who read a paper at the ninth annual meeting of the American Der- matological Association, entitled " Urethral Irritation in the Male the Cause of Certain Neurosis, and also of Acne." In all of Sherwell's cases there were hypersensitive urethras; while Denslow reports cures fol- lowing the relief of stricture as well as sensitiveness of the urethra. The following personally observed male and female cases have been selected from private and dispensary practice. In nearly all of them the treatment of the acne by relief of genital irritation was not begun until after most other well-known remedies had been faithfully tried and found to be ineffectual. The male cases were systematically sounded at frequent intervals, as recommended by Sherwell. Private Cases-Males. Case I.-Male, aged 19. Good general health. Denied all vene- real disease. Admitted having masturbated. Irregular in eating and drinking. Face and shoulder thickly studded with severe indu- rated acne, which has existed for about two years. Irregularities of eating and drinking corrected. External application of sulphur oint- ment and like measures. After continuing the general line of treat- ment for about three months without any effect on the disease, his urethra was searched, and a highly hypersensitive spot was found at the junction of the membranous and prostatic portions. After discontinuing all other treatment the sounds were passed every other day for about one month, when the acne had about dis- appeared. Then the patient was lost sight of for six months. When he again reported the acne was all gone and has continued so for over two years. Case II.-Male, aged 20. General health-excepting a slight gleet-perfectly good. Habits at present correct. Has had simple acne for about two years, following an attack of obstinate gonorrhoea. Search was made for stricture, which was found at two and one-half inches. It was dilated until No. 24 French would pass without diffi- culty. By the end of three months the stricture was practically cured, and the acne was well and has remained so for over two years. No other treatment, external or internal, was used. 5 Sherwell: Journal Cutaneous and Venereal Diseases, Wm. Wood & Co., N. Y., Vol. IL, No. 11, 1884. 6 Denslow : N. Y. Med. Record, Wm. Wood & Co., Nov. 7th, 1885, vol. xxviii., No. 19. 4 The Treatment of Acne in both Sexes. Case III.-Male, aged 20. For four years has suffered from a severe indurated acne of face and neck. General health good. Denied venereal disease or masturbation. No other treatment was given ex- cept the cold sound, which was used twice a week for about a month without any effect on the disease. Then they were used every other day; at once the acne began to yield. Pustules ceased forming and the induration became less. At the expiration of four months from the beginning of treatment the young man was discharged, without any relapse as far as is known. Case IV.-Male, aged 17. Good health. Masturbated, but not excessively. Simple acne covering face and shoulders. The cold sound was used at once, supplemented by an ointment composed of resorcin and sulphur. The acne, as well as the desire to masturbate, rapidly grew less under treatment. Patient is still under observation, although he apparently would have been well long before this had he not grown careless. Negligence is the cause of a great many cases of failure in the cure of acne. Especially is it so when the sound is in- dicated. The patient gets the idea that such a unique method is un- necessary, and consequently grows indifferent, and either stops all treat- ment or continues in such an irregular manner that little or no good can be accomplished. Dispensary Males. Cases V., VI., VII., VIII., IX.-All males from the Long Island Hospital Dispensary. Ages ranged from 17 to 25 years. As a rule their general health was poor. Acne of the variety found in poorly-nourished and strumous people. Local application of resorcin, ichthyol, and sulphur ointments. Internal treatment con- sisted of tonics, iron, quinine, and cod-liver oil. After a time their health began to improve, but the acne remained about the same. As a last resort the sounds were used, along with sulphuret. potassium lotion. In three of the cases the urethras were found to be exquisitely sensitive. The other two had slight stricture toward deeper portion of urethra. The sounds were used every other day on all of the cases. The first three improved, but were lost sight of before cured. The strictures in the other two were dilated until a No. 24 French sound would readily pass. The improvement of the acne kept pace with the dilatation of the stricture, and in three months they were dismissed cured. The following cases in females were treated on the same principle as the males. When there was found to be any uterine irritation or disorder, it was corrected if possible. In nearly every case of acne in the female there will be found some menstrual or genital trouble. Almost all women have a temporary outbreak of acne at the menstrual period, and if there is a chronic rosacea it is apt to be aggravated at that time. If it were not for the difficulty of searching for uterine The Treatment of Acne in both Sexes. 5 disease in young unmarried women we would have fewer cases of acne in the sex. Notwithstanding this, it is as much the duty of the dermatologist to search every organ as a possible cause for disease of the skin as it is for the gynecologist to search for disease in his special sphere. If we are unable to institute an examination to determine the exact nature of the urethral disorder, we can somewhat relieve the vaginal hyperaemia by hot douches, as recommended by Robinson,7 which were used in the following cases. Hospital and Private Cases-Females. Case I.-Female, single, aged 20. Acne and rosacea for two years. She was of a highly nervous organization. Menstruated when she was about 15 years old, and it was always painful and irregular. General health poor. Was given a pill composed of iron, arsenic, and ergotin. Local application of sulphur ointment and resorcin lotion. This treatment was continued for about six months without any per- manent effect. Then the hot vaginal douches were begun, and at once the acne as well as the painful menstruation subsided, and by the end of three months (i.e., nine months from beginning of treatment) she was dismissed cured, which lasted about eight months, when there was a slight relapse. The patient resorted to the douche without seeking advice. This time the cure has been permanent. In this case the douche was given daily for four days before the expected period, dis- continuing them when the flow was established. Case II.-Girl, aged 14 years. Health good. Menstruated at the age of 10|, which had always been without pain. Hesitating to use the vaginal douche on such a young girl, all other available means were tried, with no beneficial result. Her mother was finally persuaded to use the douche every morning during the inter-menstrual period. In less than a fortnight improvement could be observed, which contin- ued until complete recovery in about six weeks, with no relapse for over two years. Case III.-Female, aged 24. Has had acne simplex and dysmen- orrhoea since her sixteenth year. The acne is aggravated at each menstrual period. She received no local treatment except hot facial baths. Internally, fifteen drops of ergot, t. i.d. Hot douches every other day, discontinuing at the menstrual period. Immediate improve- ment began, and continued until the fifth month, when the acne was cured and the dysmenorrhoea greatly relieved. There has been no relapse for over two and a half years. Case IV.-Seen at the Long Island Hospital Dispensary. German- American girl, aged 17, of tbe type often called neurolymphatic. Has had simple acne since the establishment of the menses in her four- teenth year. Never had any pain or irregularity at the menstrual period, but the acne was always aggravated. 7 Robinson: "Manual of Dermatology," N. Y., 1885, p. 262, 6 The Treatment of Acne in both Sexes. She was directed to take plenty of out-door exercise and to attend to her diet. Was given tonic treatment and a five-per-cent (/?) naph- thol ointment locally. This met with partial success. After two months the hot douche was begun. The good result began immedi- ately and continued so for four months, when a relapse occurred, the patient having grown tired of treatment. She is still under observa- tion. Case V.-Married woman. Never been pregnant. Menstruation irregular and very painful. On vaginal examination the genital organs were found to be small and undeveloped, and there was stric- ture of the cervix uteri, causing an obstructive dysmenorrhcea. Treat- ment consisted of dilatation of the cervical stricture and hot vaginal douches. The acne pustules ceased forming as the abnormal genital condition improved. By the end of six months the face presented a greatly improved appearance. The enlarged capillaries which re- mained were scarified and a fifty-per-cent alcoholic resorcin wash applied. Internal treatment consisted of iron and ergot. A letter just received states that her face is well and that she is in good gen- eral condition. Now over two years. Case VI.-Female, married 12 years. Has had two children. Complained of leucorrhcea and general pelvic distress. Examination revealed an extensive bilateral laceration of cervix. There was a mild rosacea of the chin and nose. Her health was poor. General tonics were given and a local preparatory treatment for operation on cervix. Nothing was done for the acne, which disappeared after the operation and has remained a thing of the past for nearly two years. Cases VII., VIII., IX.-Were all married women, seen at the Long Island Hospital Dispensary. Ages ranged from 20 to 40 years. In all there was some form of genital irritation. Two had retro- flexions and were in a low anaemic state. Case IX. had a severe bilat- eral laceration. The acne was the simple form. They were referred to the Gynecological Department, where they received the proper treat- ment, and by the time they were dismissed their skin was well. In conclusion, it will be observed that the relief of genital irritation will not cure all cases of acne. The hot douche or cold sound is of no avail in strumous or anaemic subjects until after they have had tonic treatment and improved hygienic surroundings. Then these local measures may and do prove a valuable adjunct. On examining the above list of cases, it is noticed that the best results were obtained in private practice rather than in those from the dispensary. The explanation is that it is exceedingly difficult to persuade the average dispensary patients to use these methods in the proper manner or to continue them for a sufficient length of time. It is hard to convince them that treatment applied to the sexual organs can have any cura- tive effect on a disease of the skin located on the face. Another cause of failure is that they come from strumous ancestry, live in unhealthy The Treatment of Acne in both Sexes. 7 houses, and eat unwholesome food. Still another is that these people pay little or no attention to the healthy action of the skin. In un- married females the objections to a vaginal examination are so great that we are often deterred from insisting on the proper use of the hot douche. Therefore in these cases we have to work blindly, while in private practice we can prevail upon our patient to do as we wish. Still, if in all cases of acne that come under our notice we were to insist oftener on measures of relief directed to the genital apparatus, the results would be better in this common but annoying disease. 11 New York Avenue.