May 1940]

May 1940]
SEXTON: SKiN DisoRDmis
SEXTON: SKIN DISORDERS
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SOME FUNDAMENTAL PRINCIPLES IN THE TREATMENT

OF SKIN DISORDERS*
By GEORGE B. SEXTON
London, Ont.
V/E are living in a world in which change is pyogenic infections, which reach and disturb the
so rapid that very often old and funda- epidermal cell, the site of eczematous reaction.
mental principles are swept aside or forgotten Therefore it follows that treatment of a super-
in the confusion of newer ideas. Is it not pos- imposed dermatitis, apart from removing the
sible that in the field of dermatology one may exciting cause, consists in avoidance of soap and
be carried away by excessive enthusiasm for water, in oiling the skin frequently, in stimula-
newer concepts so far as to forget the simple tion of the skin metabolism by thyroid or pilo-
fundamentals of therapy? carpine as seems indicated, and in frequent mild
There is little doubt that with the modern exercise. X-ray should be avoided in this group.
trend in dermatology towards replacing a de- He remarks that the seborrhaeic habitus pre-
scriptive classification with one based on etiology disposes to a susceptibility to yeast and such
the rationale the results of treatment have pyogenic infection of the sebaceous glands as
been much improved. Allergy, for example, has acne and boils. It increases the tendency to
opened up an important field of investigation follicular irritations due to chemical agents and
and has visualized for us, theoretically at least, loss of hair. Treat this underlying factor by
the phenomena of reaction not previously under- a reduction in carbohydrate intake and the local
stood in cutaneous disease. The investigation of use of disinfectants and parasiticides, especially
the place of endocrines as a factor in etiology sulphur. X-ray aids materially in reducing the
and in therapy is receiving fresh impetus daily, activity of the oil glands. Focal infections, such
and the vitamins open up another avenue of as infected teeth and tonsils, may maintain an
approach to many indefinite dermatoses. The allergic state of the skin, for example, in re-
future must still hold much in store in the way current erythema multiforme or exfoliative
of the practical application of these and other dermatitis. Gall bladders have been held re-
principles to therapy. sponsible for urticaria, and gangrenous pyo-
dermia has been traced to an ulcerative colitis.
PRDISPOSITION PRINCILES Attention to any known focal infection is there-
It would seem to me, therefore, that re-em- fore of primary importance.
phasis of certain fundamentals of treatment is Stokes also emphasizes the neurogenic factor.
not inopportune at this time, and must precede He states that the origin and course of any form
the correlation of these new points of attack of dermatitis may be influenced by this. The
with our older knowledge. The first essential, influence of emotion may be seen in cases of
and one which, is frequently overlooked, is a rosacea and those eruptions which particularly
consideration of the contributing factors in pick out flexural areas, such as mycoses or
evaluating a treatment. Certain predisposing eczema. The pyogenic factor is illustrated by
elements may be responsible for preparing the the hereditary tendency to develop boils or
soil, as it were, and making the skin more carbuncles seen in certain families and, as pre-
susceptible to irritation or disease. Stokes' has viously stated, associated with a seborrhoeic pro-
discussed these factors in masterly style in his cess. The infectious eezematoid dermatitis of
treatise on eczema, and I wish briefly to review Engman and Fordyce he cites as a specific
some of his points and adapt these to the gen- example. The treatment of this group consists
eral field of this paper. of mildly antiseptic dressings such as potassium
The icthyotic or dry skin mechanism, accord- permanganate in a 1:5,000 solution and a reduc-
ing to Stokes,2 renders the skin more easily tion in carbohydrate metabolism, the use of
penetrated by irritants and less resistant to vaccines, ultra-violet therapy and the avoidance
* Read at the Seventieth Annual Meeting of the
of scratching. Among other predisposing factors
Canadian Medical Association, Section of Dermatology,
Montreal, June 21, 1939. is mentioned allergy, the importance of which
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THE CANADIAN MEDICAL AssocIATION
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has been previously indicated, the metabolic, application of radium is the method of choice
and the eczema asthma hay-fever complex. It in treatment. It is easily applied and gives
follows that a knowledge of predisposition in anexcellent cosmetic results. A few lesions are
individual may be of marked assistance in in- radio-resistant, and for these, Andrews3 prefers
stituting treatment prophylactic or otherwise. injection methods, using a solution of quinine
and ethyl carbamate. He believes this method
PROPHYLACTIC PRINCIPLES superior to radium therapy especially for
I do not believe that preventive medicine has haemangiomas of the more extensive sort and for
been given sufficient emphasis in the control of lesions about the eyes or on the lips.
skin disorders. The general practitioner, how- Acne vulgaris.-Much has been written in the
ever, has an opportunity of seeing and treating recent literature on endocrine imbalance in acne
these patients in the earliest stage of their con- vulgaris. I believe a small and selected group
ditions and when they are relatively simple to is amenable to glandular therapy. However,
handle. He is, therefore, in the best position the average child develops, at the early age of
to apply the principles of prevention. I will nine to thirteen years, an activity of the oil
refer briefly here, to a few of the commoner skin glands, which, though trivial at the time, may
conditions to which preventive measures are result later in a frank case of acne so embar-
particularly applicable. rassing to the sensitive individual. Early advice
Infantile eczema.-While many cases of in- should be given to both parent and child as to
fantile eczema are allergic and have an heredi- the frequent use of soap and water, diet (in-
tary background (atopic dermatitis), a goodly cluding the elimination of iodized salt), avoid-
number are apparently precipitated or have ance of picking and scratching, and the applica-
their primary origin in ignorance of infant care tion of an astringent lotion. This should check
on the part of the parent. A few instructions the condition outright or reduce its later severity.
to such mothers will do much to prevent the Dermatophytosis (ringworm).-The problem
later development of those advanced cases of of how to control ringworm assumes greater
infantile eczema which undermine the baby's importance nowadays with the increased conges-
health at the most critical stages of its develop- tion of public amusement places. Indeed, this
ment and try the patience of the whole family. condition is rapidly becoming one of the com-
The parents should be warned against clothing monest diseases for which the patient seeks re-
the baby too warnly, especially in the summer lief. Here again preventive measures will do
time, unnecessary handling, and exposure to much to cut down the incidence. The use of
extremes of temperature. The seborrhoea of the public foot baths containing 2 per cent sodium
scalp which is so common an early finding should hypochlorite solution as advocated by Osborne4
receive prompt attention. An oil shampoo fol- might well be used more generally. People
lowed by the application of a 21/2 per cent oint- should be educated to observe the first signs of
ment of ammoniated mercury is usually suffi- maceration and peeling between the toes, par-
cient to clear up such lesions. Any sign of ticularly the fourth and fifth, and to treat the
spread to a contiguous area is not to be taken condition as an ever present menace which may
lightly. Soap and water should be immediately assume, at any time, major proportions. They
discontinued and replaced by the cleansing of should be ordered to use their own towels, wash
the body with some of the better commercial cloths, and bath mat. The feet should be kept
creams or oils. Stimulating salves are to be dry and free from sweating by the use of white
avoided, and a mild Lassar's paste in equal cotton'socks in place of woollen and by frequent
parts of vaseline and eucerin or a 3 per cent dusting of the feet and socks with a drying
icthyol in zinc oxide ointment is sufficient to powder. The practice of applying a half
check the condition. strength Whitfield's ointment between the toes
Angiomata.-The deep-seated cavernous vari- once weekly for six months after all signs of
ety of hwmangioma might be limited if these the infection have disappeared is an added pre-
lesions were treated early, preferably at the sixth cautionary measure of merit.
month of life. While it is true that some of Malignant growths.-It is shocking in these
these early birth marks may involute spontane- enlightened days to have occasion to observe
ously, scarring occasionally results. The early the last stages of a devastating skin carcinoma.
May 1940]
Ma 190
SEXTON: SKIN DISORDERS
SETN SKI
Undoubtedly the department of cancer control
of the Canadian Medical Association has done
much already to educate both physician and
public in the early diagnosis and treatment of
malignant disease. Early change in the skin
is so apparent and accessible to treatment that
fatalities in primary malignant disease of the
skin should assuredly be a memory of the past.
The following conditions, outlined by Goldman,5
may be considered pre-cancerous in nature and
should be viewed constantly with suspicion or
early eradication advised: senile keratosis,
kraurosis vulvae, circumscribed melanosis, leuko-
plakia of the buccal cavity, penis and vulva;
erythroplasia, lupus vulgaris, late syphilis, scars
exposed to repeated traction and friction as from
burns, or leg ulcers; chemical reaction such as
to arsenic, aniline dyes or tar; physical agents
such as x-ray, radium, or sunlight, and, finally,
malignant degeneration of such benign tumours
as naevi and sebaceous cysts.
GENERAL DiSCUSSION
A proper diagnosis is of course of primary
importance in treatment, but the general prac-
titioner in particular and some dermatologists
lose sight of the fact that much can be accom-
plished even before a diagnosis is established.
The specialist has the advantage of experience,
of coufrse, in being able to recognize the most
significant stage of the condition and applying
treatment to the best advantage. The skin is a
highly important organ, performing numerous
functions, some of them vital to life. Unlike
other organs it is constantly being exposed to
multiple irritant factors such as heat, cold,
chemicals and infection. In the acute inflam-
matory stage of an eruption it has lost much of
its power of resistance. The injudicious use of
some proprietary salve, whose ingredients and
their strength are unknown, may be just the
last straw in making a localized eruption a
generalized and obstinate one.
Acute stages should be treated soothingly,
and I am thoroughly in accord with the views
of Bauchus and Siekman6 who state that "when
the skin is highly inflamed, oil or ointment
hold in the heat, increase vasomotor dilata-
tion, and prevent drainage. A cool continuous
wet dressing gives the quickest relief and has
the best curative effect".
The psychic side of therapy is important to
keep in mind. It should be remembered that the
DIODR
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patient who has a sudden onset of an acute
eruption is in a highly apprehensive mental
state, which is not conducive to recovery, under
even the best of local care. His mind should be
set at ease as to the cause, prognosis and infec-
tiousness of his condition. Rest is one of the
most important considerations in treatment,
especially of acute skin conditions, and its im-
portance is so mininiized by the average patient
that complete co-operation is rarely obtainable
unless one resorts to hospitalization. In fact,
the physician is constantly faced with the task
of attempting a cure while the patient continues
his usual occupation, which is more than likely
to be the primary exciting cause.
I think that placing a patient on a rigid diet
as a routine procedure in skin therapy often
does more harm than good. Obviously, in cer-
tain skin conditions proved to be associated with
a lack of vitamins or complicating such diseases
as diabetes, nephritis, or gastro-intestinal dis-
turbances, a specific form of diet is indicated.
In general, the patient with an inflammatory
condition should be told to avoid such articles
of diet as strong tea or coffee, sweets, pastries,
greasy foods, spices, sea foods, hot soups, and
alcohol. But to deprive a patient who is already
undernourished by placing him on a rigid
regimen of abstinence is probably to defeat our
purpose by lowering his ability to withstand the
disease.
There are certain drugs used as internal
medication which have a specific action. In-
organic arsenic directly stimulates the epithelial
layer of the skin and is useful in- thickened
psoriasis and lichen planus. I do n'ot believe
its use in eczema or in any acute condition of
the skin is advisable. Organic arsenic in the
form of arsphenamine or other derivatives is
universally used in syphilis and is a specific for
Vincent's angina. Mercurv, bismuth and the
iodides are also useful in syphilis. Mercury has
given beneficial results in juvenile flat warts
and some tuberculides; bismuth, in acute lupus
erythematosus and some resistant verruc,
iodides are a specificl in blastomycosis, actino-
mycosis and sporotrichosis. I have found intra-
venous sodium iodide, as advocated by Ruggles,7
very useful in allaying pain and shortening the
course of herpes zoster. Sulfanilamide is a
specific for streptococcal infections of the skin,
especially erysipelas and cellulitis. Its use in
such toxic states as pemphigus or Duhring's
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disease is of questionable value. Some evidence malignancy. X-ray, in my opinion, is definitely

is appearing that it may have a depressing in-
fluence on the general resistance of the patient.
Itching is relieved by very few drugs. Opium
and its der4vatives certainly should be avoided;
the bromides and barbiturates are probably the
drugs of choice. Any of the above drugs are
capable of producing a variety of reactions and
one should not hesitate to discontinue their use
at the slightest sign of sensitivity.
Time does not permit a discussion of the vari-
ous physical methods in use in the treatment of
skin disorders, although I might say a word as
to the part played by the roentgen ray. X-rays
are a useful adjuvant to therapy in skin dis-
orders, but it is a grievous mistake to suppose
that any physician can purchase x-ray equip-
ment and with little or no training expect to
get results. All too frequently even today
dermatologists are confronted with the tragic
results of x-ray over-dosage, mistaken diagnosis,
or lack of familiarity with skin reactivity. The
ocsiqna radiologist is not exempt from this
failure to recognize his limitations, and it is not
unusu-al to see such conditions as lupus vulgaris,
granuloma annulare or sarcoid irradiated as for
contraindicated in chronic psoriasis, hypertricho-
sis, lupus vulgaris, icthyosis and the acute in-
flammatory stage of tinea barbie.
SUMMARY
1. There must be due consideration of the pre-
disposing factors in evaluating a treatment for
a skin condition.
2. Under-treatment as against over-treatment,
especially of acute inflammatory processes,
should be urged.
3. The importance of preventive measures in
the treatment of skin disorders is frequently
overlooked.
REFERENCES
1. STOKES, J. H.: Complex of eczema: diagnostic and
etiologic analysis, J. Am. M. Ass., 1932, 98: 127.
2. IMem: Fundamentals of Medical Dermatology, Depart-
ment of Dermatology Book Fund, Phila., 1939, p. 16.
3. ANDREWS, G. C.: Treatment of angioma based on ten
years' experience at the Vanderbilt Clinic, Arch.
of Dermatol. & Syph., 1938, 37: 573.
4. OSBORNE, E. D., PUTMAN, E. D. AND RIcKLOFF, R] J.:
Prophylaxis and treatment of ringworm of hands
and feet, New York State J. of Med., 1933, 33: 1270.
5. GOLDMAN, IA.: Precancerous lesions of the skin, Jr.
Med., 1936, 17: 278.
6. BAUCHUS, HL H. AND SIEKMAN, C. F.: Practical man-
agement of a dermatitis with an allergic etiology,
New York State J. of Med., 1936, 36: 159.
7. RUGGLES, E. W.: Apparent specific effects of sodium
iodide in herpes zoster, Arch. Dermat. d Syph.,
1931, 23: 472.

RECURRENT PNIUMOCOCCIC MENINGITIS COMPLICATING

$1SKULL FRACTURE*
By ARTHUR R. ELVIDGE AND EPHRAIM ROSEMAN
Montred
THE mortality rate of pneumococcic meningitis gitis because it was secondary to a major head
is high, and until the advent of specific anti- trauma, had two recurrences, and, neverthless,
sera and, later, the sulfanilamide derivatives, had a favourable outcome. It afforded an un-
death occurred in nearly every instance. The usual opportunity to study the relative merits
Goldsteins1 have collected 150 cases of recovery of various therapeutic approaches and, inci-
from so-called pneumococcic meningitis up to the dentally, to observe diverse interpsting complica-
year 1927. Hewell and Mitchell2 note 30 cures tions and certain known dangers of such treat-
in the literature from 1927-1937, and, in addi- ment. The patient received a total of 3,593
tion, list 30 recoveries "in which the treatment grains of sulfapyridine (both by the oral and
consisted in part of the administration of sul- intravenous routes), 400,000 units of Type 23
fanilamide or related compounds". These anti-pneumococcic rabbit serum and had 118
authors also report 6 cases personally treated lumbar punctures. In all, this patient had three
with sulfanilamide and other measures with a attacks of meningitis, in two of which, the first
favourable outcome in three. Petersen3 states and third, Type 23 pneumococcus was isolated
that "the prognosis is bad under the best of from the
circumstances, as the mortality is practically 100 spinal fluid. He had had several com-
per cent, although some 160 cases of recovery plications secondary to sulfapyridine therapy,
have been reported". including oliguria with renal colic and haema-
We present this case of pneumococcic menin- turia, and an anwemia with a tendency to
agranulocytosis. He had alternately been in
*
From the Department of Neurosurgery, Montreal acidosis and alkalosis with carpopedal spasm.
General Hospital.