THE DENVER

MEDICAL TIMES.

A MONTHLY JOURNAL OF

MEDICAL SURGICAL AND OBSTETRICAL SCIENCE.

OCTOBER, 1884.

ACNE.

BY JOHN H. DUNCAN, M.D., KANSAS CITY, Mo.,

Professor of Dermatology and Physiology in the Medical Department of the University of Kansas City, etc.

The disease of the skin known by the above name, is extremely common. It is seen daily by the general practioner, and often when he is consulted for the relief of it, the patient is turned away with some simple application or indifferently informed that it amounts to nothing, will pass away after a while, and, in short, is perfectly natural at a certain period of life. This lesion appears most often upon the face, and the embarrassment which it produces, especially in women, cannot be estimated by us. Moreover, the laity are apt to look upon the "bumpy face" of the young man with suspicion, when in reality he is perfectly innocent. It is not in the slightest sense specific. I do not say that persons with a specific trouble may not have Acne, any more than I would attempt to prove that a person with Syphilis cannot and does not have parasitic diseases of the skin. But the two diseases are etiologically and pathologically perfectly distinct.

It cannot be doubted but that without proper, active and energetic treatment as well as a moderate amount of patience on the part of both

the physician and patient, it is stubborn and rebellious. But when we have seen the permanent cicatrices left upon the face after an attack, disfiguring it to no small extent, and which are in a great measure irremediable, we wonder that it is passed by so lightly, especially when the deformity could have been so easily prevented by treatment. This latter point is especially fresh to me at this time, as I have recently had come under my care a young man who had the trouble for four years, and the scars left as relics of the Acne, are as marked as the pittings of Smail Pox. Duhring says without treatment it may continue for years, involving the skin in a destructive manner. In some instances it is attended with extensive suppuration and obliteration of the glands and ducts. leaving cicatrices which are permanent and disfiguring". Can it be said then because it does not prove fatal, that it is a trivial affection and time alone should be allowed to eradicate it?

Acne is an inflammatory affection and the structures in the skin primarily involved are the Sebaceous glands and folliclers. This inflammatory action gives rise to papules, pustules and tubercles, producing the varieties know as Acne papulosa, pustulosa and indurata. The typical variety is the pustular, in fact the papules tend to the formation of pustules. The first step in the formation of the papule is the plugging up of the excretory ducts of the sebaceous glands, by a secretion known as comedones (black head). This obstruction produees an hyperaemia and this in turn results in inflammation. These steps in pathology are of great

importance as regards treatment.

In Acne indurata, which by the way, is the most obstinate of all the varieties, the peripheral inflammation about the base of the papules is very marked, and the subcutaneous tissue becomes involved, giving rise to hardened nodules, capped by a pustule. In any event, however, it is an inflammation of the sebaceous glands.

As in diseases of other organs of the body, so in those of the skin, the point of perhaps most importance therapeutically, is to ascertain the cause of the lesion. This is certainly a great desideratum in Acne. In the great majority of instances the cause can be discovered, but we must confess in a few cases, we find no derangement of any organ of the body, and in short the person is in a state of health.

We find however, ordinarily, that the exciting cause of simple Acne is to be found (1) in a functional derangement of the alimentary canal, as constipation and dyspepsia, and (2) in Uterine complications affecting especially the menstrual flow. These are frequent causes and their correction is necessary in preventing a relapse. It is well to remember also, that it may be produced artificially, for example, by the ingestion of the

Iodides and Bromides, and by the local application of the preparations of Tar etc. Again without mentioning the individual affections, we can say that any constitutional disease, which tends to retrograde metamorphosis may be a factor giving rise to Acne. With these various causes, it is patent, that the physician consulted by an Acne patient, must, if he wishes to give satisfaction to his charge, as well as to himself, study closely the individual case, and having done so, not only attack vigorously the lesions by surgical means, but also by medicinal measures. After these considerations we naturally come to the management of Acne and in speaking of this, I will divide the treatment into local and constitutional and further divide the local into (1) treatment of Acne papulosa et pustulosa, and (2) the treatment of Acne indurata.

In regard to constitutional measures, remedies directed to the cause, whatever that may be, are to be given. If constipation exists, the tonic laxative "Mistura Ferri Acida", will answer the indications better than anything at our command. That constipation does exist to a great degree in all classes of patients, and notably in women, is known. That one or even two evacuations from the bowels daily is not positive evidence that constipation does not exist, we also know. We are rather to judge by the character of the discharges, than by the number as to whether constipation exists or not. Therefore as this condition of the bowels is so common, and as it is such a potent factor in keeping up the disease in question, I consider the administration of the above laxative as particularly beneficial. Sulpher in the form of Calcium Sulphide in % grain doses three times a day, gradually increased, acts nicely in some cases, especially the papular variety. Arsenic and cocrosive Chloride of Mercury also are useful. In the weak and debilitated, Cod Liver Oil, and the syrup of the Hypophosphites are indicated. The hygienic management of the patient cannot be too strongly insisted upon. All stimulating articles of diet and especially stimulating drinks, should be severely interdicted. Success cannot be attained unless instructions as regards eating and habits in general be strictly followed. I have thus referred to a few remedies for internal use in the treatment of Acne, and must be excused from taking up the management of the other causes, as indigestion, uterine derangements etc. A consideration of them would extend this paper beyond its proper limits and I am satisfied be unnecessary. I simply wish to lay special stress upon the practitioner discovering the cause and removing it if possible.

While I believe in internal treatment as an adjuvant in acomplishing a cure, I regard local measures as more rapid and positively indispen

sable. This must be attended to by the physician and I consider this proceedure of so much importance, that I possibly may go into the minutiae to an extent that the readers of this article may think unnecessary. In the first place, as the typical lesion of Acne is preceded or caused by comedones, they should be removed; and this is easiest accomplished by the "Comedone Extractor," a "watch key" or "Gross Ear Spoon" the latter of which I prefer. This may seem a tedious operation, but after a few sittings they will have been extracted, and thus the mechanical origin of the lesions removed. Any existing papules or pustules should be opened by an ordinary scalpel, the contents squeezed out and the blood allowed to flow freely. There need be no fear of leaving scars by cutting; on the contrary pits are produced by not opening the lesions, but allowing the contents by pressure to produce atrophy and consequent cicatrices. In simple Acne both before the lesions have been opened and afterwards, the application of water for fifteen or twenty minutes, as hot as it can be comfortably borne is very curative. application should be made at least twice a day, preferably in the morning and then in the evening just before retiring. It is soothing and softens the parts, so that the glands can empty themselves, and thus prevent the first step of the disease. After the evening bathing, an ointment of Sulphur one drachm to one ounce of Cosmoline) should be thouroughly rubbed in and allowed to remain through the night. Taylor's Kummerfeld, or Bulkley's lotion, each of which contains some preparation of sulphur are useful. Applications of Corrosive Chloride of Mercury, Carbolized ointment and Protiodide of Mercury, are also of benefit. But of all substances, Sulphur in some form is best. I have thus attempted to give the most satisfactory treatment of Acne papulosa and pustulosa, at least in my hands, and will conclude this article with the theraphy of of Acne indurata; the management of which is somewhat more difficult than that of the other varieties.

In this form internal treatment alone, would probably avail nothing. Local measures are here called for preeminently. The indurations must be thouroughly stabbed and torn to pieces and stimulating applications used freely. Free bleeding must be encouraged. Green Soap (Sapo Virides) rubbed firmly into the lacerated lesions is advantageous. Scraping the tops off of the papules with the dermal curette and thus setting up a general ozing of blood, may be resorted to. After these surgical measures have been used, the applications of the hot water etc. referred to above is indicated. The face after the operation, presents a very ugly appearance for a few hours, bnt as reaction comes on, it looks

much improved. This fact would suggest that the best time for the operation is in the evening, so that the patient can remain in-doors and by morning the parts will appear clearer than previous to the operation. Should the disease not yield readily to this treatment, each lesion after its top has been removed, should be touched with the Acid Nitrate of Mercury, strong Carbolic acid, or a Corrosive Sublimate Solution. A remedy which we resort to at times, but which is not always at hand to the general practitioner, is Electrolysis or decomposing the nodules by electricity. This is a very simple, comparatively painless, rapid and safe method of treatment.

While we encounter cases which are very stubborn, yet I am happy to say that the affection is curable, Hyde says "Acne is, I believe, an entirely remediable disease, in every case properly managed from the first. Scars of ancient ravages of the affection are, it is true, indellible: but even these are smoothed down in process of time, so that they become yearly less conspicuous and disfiguring.

1044 MAIN ST. KANSAS CITY MO.

COCCYGODYNIA.

A Clinical Lecture,

BY WILLIAM GOODELL, M.D.

Professor of Gynecology, University of Pennsylvania.

(Class of 1854.)

Reported by WILLIAM H. MORRISON, M.D.

GENTLEMEN:-The bad weather of this morning has kept our patients from arriving promptly, and I shall therefore occupy the early part of this hour with a few remarks on coccygodynia. This affection has another name-cyccyodynia-and means pain in the coccyx. You will see a good many cases of this affection, and it is well to be posted in regard to it.

What are the symptoms of cyccygodynia? They are pain in defecation, and pain in sitting down or rising up. In sitting down, women suffering from this disease will take hold of the back of the chair and sit down on one buttock, so as to avoid placing any weight on the coccyx. In rising up they do not rise directly, for in so doing a strain is thrown