ents is What ingredients in this nostrum caused the dermatitis I am unable to say. One of the stated ingredicommon salt, but the quantity is small. Common salt in saturated or strong solutions may cause a hyperemia and desquamation. I have seen a number of cases of extreme irritation from its use by hair dressers, who applied it with friction in order to get a stimulant effect. In the form of strong brine baths it may produce a general papular eruption of the skin. about the eyes, and some scaling and crust formation. effects from handling hides, also taxidermists and furOn being questioned, he stated that he had rubbed riers, who employ it constantly. Chromium, or bithe above-named preparation into his scalp on two chromate of potash, is used perhaps more extensively consecutive nights. On the morning after the first than arsenic in dyeing, calico printing, and to produce application there was a slight redness of the scalp, pigments. It may be found in various articles of and some burning and itching, but as he thought that wearing apparel, and may produce a dermatitis on was a sign of activity in the application he tried it persons wearing such articles. Mercury is responsiagain the following night. The next morning the ble for a certain number of cases of inflammation of eruption showed on his face, and he could hardly open the skin from occupations. It is used in the form of his eyes. the acid nitrate by makers of felt hats, also by furriers, taxidermists and those making thermometers and barometers. The surgeon and nurse, as you well know, come in for their share of its irritant action. It is also employed in many of the cosmetic nostrums and may cause much trouble thereby. The pathologist may suffer from an eruption of eczematous type from having his hands in tissue soaked with solutions of formalin or various fixation fluids, as Zenker's fluid, for example, which contains corrosive sublimate, bichromate of potash, sodium sulphate and glacial acetic There are always a certain number of cases appear-acid. I have seen 2 cases of dermatitis in girls who ing at the hospital with dermatitis following the appli- worked in a chocolate factory. Both were on the cation of liniments. In some cases the applications arm and hand, took the form of a papulopustular derhave been made by means of cloths wet with the matitis, disappeared under treatment when they preparation, in others they have been rubbed in with changed their work, and reappeared when they reconsiderable friction. The eruptions in these cases turned to it. One occurred in a girl who stirred the are nearly always of the same character, being erythe-hot chocolate, the other in the one who made it into matous or papular, occasionally accompanied by edema, moulds. I am not prepared to state positively, from and sometimes showing vesicles and bullæ; the inten- the observance of these 2 cases, that the chocolate sity depending somewhat on the part to which the only was responsible for the dermatitis, as these are application had been applied. These preparations, the first cases of the kind that I have seen mentioned. for the most part proprietary, are largely made up of The appearances favor such an opinion, however. A the essential oils, especially oil of thyme and turpen-mild papular dermatitis may be seen at times among tine, and some contain caustic soda. They may show those working in candy factories, but I have never their irritative action on the face, or some sensitive seen among them anything of the type shown in the part, by accidental contact with the hands which have above cases. A dermatitis termed "impetigo glycobeen moistened with the application. Certain plas-sique" has been described by Nivet, as occurring in ters, particularly belladonna plaster, applied as coun- sugar refineries. In using certain drugs externally terirritants may cause a scarlatiniform eruption, not with therapeutic intent, one must be on the lookout only in the neighborhood of the application but over for signs of irritation, which may at times arise even the general surface. There are quite a large number from a weak application. Many times the trouble of cases of dermatitis, many of the eczema type, arises from too free use of the drug, or a too vigorous which are due to irritating substances brought in con- application on the part of the patient; but more often tact with persons on account of their occupation. from a too strong preparation being used on an unThe most common among these are seen in domestics known skin. The condition of the skin must also be who have been using strong alkalies, strong soaps or considered, for an ointment which could be applied soap powders, such as pearline and soapine, for house- without any irritation to a sound skin might cause hold purposes. The various brass and metal polishes, much irritation if the skin were broken. The quality and shoe polish, particularly that used in cleaning tan or age of the drug may make much difference in its leather shoes, may cause dermatitis of varying grades. irritant qualities. For example, an ointment of chrysPrinters are liable to a dermatitis of the hands from arobin from one druggist may have no injurious effect handling type wet with caustic potash solution, that on a skin, while a neighboring shop with the same substance being used to clean the type. Painters prescription will produce an ointment which causes may get an inflammatory condition of the skin from much irritation. The ointment base may be a source the use of turpentine, and they may also have a der- of irritation, either from the fact of individual suscepmatitis from some of the pigments which they use. tibility to a certain base, or because it has become Arsenic is largely used in the arts, more so formerly more or less rancid. Glycerin, for example, seems than at present. It is employed in making such arti- to act as a decided irritant to some skins even when cles as wall paper, playing cards and artificial flowers, much diluted, and occasionally one meets with a case also in curing hides. It is a favorite ingredient in when any form of fat seems to be contraindicated. cosmetics, proprietary face lotions and powders, and Almond oil appears most frequently to have an irridepilatory pastes. It may produce erythematous, tant effect, possibly because it becomes so easily ranpapular, vesicular and pustular eruptions, and the cid. It is used pretty generally by the so-called facial grinders of the arsenious acid coming in direct contact massagists to make what they term skin food. I have with it may get ulcers. Its effects are more commonly had two of these people come to my office with an seen on the hands, about the nails, in the alæ nosæ, on the lips, behind the ears, or anywhere where folds of skin come together. Longshoremen may show its active eczematous inflammation produced by their own applications. This may have been, as I have said, due to a slight rancidity of the oil, or there may have been some cheap grade of oil used, and such due to the iodine which it contains. A few years ago grades are very apt to be adulterated. Preparations I tested several persons in whom I had seen iodoform containing mercury, either in the form of an ointment or dermatitis with iodide of potash given internally and lotion, are among the most active of therapeutic agents found them all extremely sensitive to that drug. Carin producing dermatitis. The degree and extent of irri- bolic acid may cause varying degrees of inflammation, tation depend on the strength of the application, and from erythema to destruction of tissue. As with the length of time which it is applied, also largely on other substances used as antiseptics, individual suscepthe susceptibility of the individual. I have frequently tibility often shows itself to a marked degree. I have seen under a surgical dressing of corrosive sublimate known a physician who was obliged to give up sura mild papular eruption limited to the site of the ap- gery entirely owing to such a susceptibility. It is an plication; but occasionally one sees a general erythema extremely valuable drug in dermatotherapy, espefrom such an application, and in some cases the erup- cially as an antipruritic, but it must be used carefully tion beneath the dressing is papulovesicular and the and its action watched, as it may in an unsuitable case part edematous. The most frequent application cause much irritation. It is a favorite ingredient of against pediculi pubis is probably unguentum hydrar- proprietary ointments, in some of which it is introgyrum; so much so in fact that it has become a popu- duced in considerable quantities. I have seen a decilar remedy for that trouble. Personally I never ded vesicating effect produced by the application of prescribe it for that purpose, for I believe that the some such nostrums. The much advertised Cuticura average person will use it much more extensively ointment is said to contain nothing outside of coloring than ordered, and that in consequence disagreeable matter and perfume but 2% of carbolic acid and a results may follow. vaseline base. Salicylic acid is a drug much used in The most exaggerated case of local inflammation treating skin diseases. It has also been used in surfrom this preparation that I have ever seen was in a gery as a substitute for carbolic acid, and its use in man who came to the City Hospital clinic some time this connection has given rise to frequent cases of ago after using it. His penis and scrotum were enor- dermatitis. It may be used in treating some skin dismously enlarged, hyperemic and edematous, the for- eases as strong as 12% in ointment form, but I have mer being nearly as large as a quart bottle. There seen much irritation from the application of an ointwas also an extensive papulo-erythematous dermatitis ment which contained only 1% of the drug. Apover the pubic region and abdomen. He stated that plied to the scalp in an alcoholic solution, or a 6-perhe had been given for relief from pediculi pubis an cent. ointment, I have seen it produce a diffuse, fine, ounce of "blue ointment," and told to rub it in the papular eruption over the forehead, ears and neck. affected parts for three consecutive nights. In order Quinine is used in so-called hair tonics, particularly to save time he rubbed it all in the first night, and not those of a proprietary character, to a considerable exonly over the pubic region but up on to the abdomen tent. It is also recommended in alcoholic solution as as well. The result was the condition which I have a local application in hyperidrosis and for the relief of described. night sweats. Any of these applications may produce irritation, particularly on the scalp, varying in character from a pruritus to a scarlatiniform eruption. Persons who are sensitive to the local action of this drug are generally susceptible to its internal action as well. So before using it locally it is well to inquire if the person has ever had an eruption after taking it internally. Sulphur is a drug which is constantly used by the laity for skin eruptions and advised by druggists, their choice lying between that and oxide of zinc. It is certainly a valuable drug in many cases if properly used, but it must be used carefully and its action watched, for it is capable of causing much irritation in some cases. It may cause a dermatitis of varying grades - erythematous, vesicular, or papular, whether applied as an ointment or lotion, in powder form, in a bath, or by fumigation. The following case, which was a surprise to me, illustrates well its action in a susceptible individual. Another case was that of a woman who had been given unguentum hydrargyrum for the same cause by the surgeon on one of the ocean steamers, and had applied it for four days and nights. When I saw her, about a week after the applications, she had a general eczematous dermatitis which included the face as well as the body. I have seen the same general eruption with symptoms of salivation produced in a person who used inunction of unguentum hydrargyrum for one application only, the abdomen being the site of the application, and 2 drachms of the ointment being used. This of course was a case of extreme susceptibility to the drug. Mild grades of localized dermatitis of the erythematous type after inunctions with unguentum hydrargyrum are, in my experience, not uncommon. In a hairy individual I have often noticed an inflamed condition about the hair follicles after inunction, and this was undoubtedly due largely to friction. I have also seen cases of papulovesicular eruptions in infants who had been swathed in flannel smeared with unguentum hydrargyrum. Dermatitis from the application of iodoform to ulcers and wounded surfaces is not at all uncommon, and many cases of varying intensity have been reported. The dermatitis may be caused by the drug in powder form, in ointments, in an ether solution, or in gauze. The eruption is usually erythematous, but may be papular, vesicular, or even bullous, and accompanied by edema. As a rule it is localized, but, as the report of cases shows, it may be general. Even the powder flying about the room is sufficient to affect some susceptible individuals. Its irritant action is undoubtedly A. B., a girl seventeen years of age, being troubled with dandruff, applied to her scalp on going to bed an ointment containing 10 grains of sulphur and 15 grains of zinc oxide to an ounce of vaseline, which had been prescribed for another member of the family. About four or five hours after, she was awakened by a sensation of burning on the scalp and about the face. This increased in intensity and she was finally obliged to get up and wash the head. In the morning, when I saw her, the face was covered with a patchy erythema, the skin about the eyes was much swollen, and the scalp very tender and much reddened. Such a case is of course remarkably unusual, but from a stronger ointment, and especially if there is an in flammatory condition of the skin, as an eczema, such NOTES ON THE TREATMENT OF ATAXIC PA results are not uncommon. TIENTS BY CO-ORDINATION EXERCISES, BY JAMES J. PUTNAM, M.D., BOSTON. THE power to see the hopeful aspects of hopeless diseases is one of the best gifts of modern medicine. The number of maladies whose very name makes the physician think only how he may gracefully bow the patient from his door grows daily less; yet it is at once a warrant of the blindness in which we tread our accustomed paths and also of the hopefulness of the future that now and then the pointing out of obvious principles can claim the merit of substantial discovery. Why should the idea of training the ataxic patient to control his disorderly movements have waited for its practical development and almost for its conception until 1890, when the progress of the ataxic baby and that of the relatively ataxic school boy had been forever before us? Obviously, the reason is that we saw only too clearly the final outcome of the disease and, like fatalists, let our energies be paralyzed by Tar in its several forms is extremely useful in some forms of skin disease, but, if injudiciously used, it is capable of producing much irritation. Like some other drugs it cannot be used on certain skins even in very dilute applications, and in acute inflammatory conditions it must be used with the greatest care. It may produce erythematous and papular eruptions, and at times those of an erysipelatous character. The dermatitis may extend some distance beyond the point of application. Another condition which may be produced by it is the so-called tar acne. This is composed of small, hard, red papules, in the centre of each of which is a dark point. This condition is most abundant in the hairy portions and is very rebellious to treatment. It persists for a long time after the applications have ceased, and may take several weeks to completely resolve. Chrysarobin is a drug much used in the treatment of psoriasis and some other chronic conditions of the skin. It probably causes local irritation more frequently than any other drug commonly used. It stains the sound skin a purplish-red color but not the diseased patches. It also stains the nails the prospect. and gives the hair a purple tinge. The dermatitis It is to Dr. Fraenkel, a Swiss physician, that the produced by it is usually erythematous, or finely pap-credit of bringing the true value of this method before ular, but it may be more intense. I had under my the profession is justly given, though Granville,2 and charge at the Carney Hospital a girl with a general perhaps others, had long before recognized the theoexfoliative dermatitis which was brought about by a retical possibility of success in this direction. Fraenfew applications of an ointment containing 6% of kel's first communication, in 1890, was followed in chrysarobin. Applied to the face or scalp it is very 1897 by a second, made before the Medical Congress apt to produce a violent dermatitis of erysipelatous of Moscow, at which the method was elaborated, type and maybe a conjunctivitis. I saw such a case various apparatus described and cases reported. Since at the City Hospital a few weeks ago. It may irri- then a host of physicians have brought their confirmatate the sebaceous glands and produce an acne like the tions and criticisms, and, as is usual, the methods and so-called tar acne, with a black point in the centre of the apparatus have been shown more and more to be each papule. In applying the drug a very weak susceptible of simplification, so that in fact the treatstrength should be tried at first. In susceptible indi- ment in its essentials is at the command of any physividuals and those with delicate skins, I have seen a cian or gymnast, or even of any intelligent person 1-per-cent. ointment cause much irritation. In using an who will master the principles at stake. In saying ointment, only a small amount should be applied at a this, I would not be understood as meaning that skill time, and that well rubbed in with a swab. Other- and labor are not required for the best results, and wise the ointment is apt to get rubbed on to the neigh-in fact one of the medical gymnasts who has trained boring sound skin, which being more sensitive than several of my patients has told me that the lesson is the diseased portions may become inflamed. Solutions peculiarly exhausting for the teacher. The following points should be strictly borne in mind: of the drug in collodion or traumaticin dry where they are applied, and so do not spread in this way; but they are not always suited to the condition of the (1) It is skill, not strength, that it is sought to deskin. Of the animal irritants, the mosquito, flea, bed-velop. It is indeed important that the muscles should bug, black fly, wasp, bee and hornet are apt to make be in a state of good vigor and healthy nutrition, and their presence appreciated, and as a rule the person special treatment, as by massage and exercises, may afflicted makes his own diagnosis. Sometimes, how-be directed if necessary to that end, but so far as the ever, especially in emigrants, the dermatitis produced inco-ordination is concerned the need is to teach the is so extensive that it makes one suspect one of the brain and through it the lower reflex centres, to feel, exanthemata. I have seen an emigrant so poisoned and gauge, and respond to the feeble and distorted imby mosquitoes that the eruption on the exposed parts pulses that come from skin and joint and muscle. closely resembled variola. Spiders may drop from the ceiling during the night and cause an inflammatory condition of the face which at first sight might be mistaken for erysipelas. Caterpillars may cause a line of erythema, wheals or vesicles where they have passed over the skin, or even deeper forms of inflam mation. The jelly fishes which are abundant in the salt water about here may cause much redness of the skin, and even large wheals. I have seen a boy who got into a school of these fishes and whose body was so covered with large wheals as to suggest a giant urticaria. (2) The movements, such as walking and stooping, or writing and simple piano exercises, etc., which one would freely prescribe to a healthy person, are often far too complex for the ataxic, and it is therefore necessary to begin with relatively elementary motions, such as drawing the leg up and down in bed, or moving the finger from one spot to another. On the other hand, however simple the movement, the patient should be called upon to perform it with promptness 1 Read before the Suffolk District Medical Society, Section for See Collins's Treatment of Nervous Diseases. Wm. Wood & Co., New York, 1900. Clinical Medicine, Pathology and Hygiene, April 18, 1900. and accuracy and at the word of command. To in- of a tendency to pretty severe pains in the legs, and culcate these habits from the outset, and to reduce the the second, whose improvement has been truly redifficulties at each step so that attention and effort will markable, is one in whom the ataxia developed with make success possible, and will ensure skill and con- great rapidity. fidence, are the prime requisites for a good result. (3) Dulness, monotony and fatigue, on the one hand, and superficiality on the other, are the rocks to be avoided, both by the introduction of sufficient variety into the exercises and by giving them something of the entertainment of games of skill. For these reasons the exercises of putting the finger on to spots on a card or into holes on a board, as suggested by Fraenkel, are well modified by using marbles of various sorts or colored pegs, for the same purpose (as also suggested), or by giving these tasks an amusing turn, taking care, however, that the amusement occupies a subsidiary place. Simple tunes, played on a glasichord, or on bells or glasses, by calling, at varying rates of speed, the numbers indicating the notes which the patient should strike, would be in this line. The first patient had been suffering from characteristic pains for many years and from disorder of co-ordination for about two years. This had increased during the six months before he presented himself at the Massachusetts General Hospital to such a degree that he was then almost confined to his chair, though able with the aid of the furniture to get about his room and shop a little. The treatment by training in co-ordination was begun in June, 1899, but was continued for only a few months, and in a somewhat desultory manner, owing to the necessities of the case. This year it has again been resumed. The aim was first to teach him to walk with crutches, then with canes, and this has been accomplished to such a degree that he now goes about with the aid of the former in the neighborhood of his house quite freely, and As regards the leg co-ordinations, the infinitely vari- in the way of exercises he can walk across the room able movements of walking, at the command of a alone. He is still improving. The treatment has prompt instructor, so many steps forward, backward, been carried out faithfully in the face of considerable to the right and to the left, with the eyes open, with difficulty by Mr. Harding, the superintendent of the the eyes closed (as should indeed be the eventual gymnasium of the Boston Young Men's Christian aim with most of the exercises); stepping over obsta-Union. cles, halting, balancing and the like, furnish ample op- The other patient is a much younger man, of excelportunity for the exercise of skill and for the training of persistence, attention and habit. lent general health. The rapidity with which the ataxic symptoms came on is well indicated by the fact that only two weeks before he came to me, supported by a friend on one side and with a cane in the other hand, he had been to several dances, and had walked, his home. He had, in fact, considered himself perfectly well up to that time, though in reality some unmistakable signs of tabes had been already present. Under the guidance of Mr. Wiberg, teacher of medical gymnastics, he devoted himself assiduously to the treatment here indicated, day by day and almost hour by hour, with the result that at the end of three months he was able to walk several miles alone or with the partial aid of a cane. His gate is still ataxic, but he has recently been able to resume his work, which without this method of treatment would have (5) Finally, there are certain classes of cases which been impossible. I may say, further, that the latter the experience of various physicians has shown to be patient and one other have thought that the paresill adapted for this sort of treatment. These are sum-thesias from which they had suffered diminished under marized as follows by Collins in his excellent book on the co-ordinatory improvement. the "Treatment of Diseases of the Nervous System," page 243. "The employment of this method of treatment is contraindicated in weak, anemic patients and in those who suffer more or less constantly with pains or crises; in cases of acute or subacute tabes, that is, in cases of sudden onset and in which the habitual (4) The temptation is often strong to let the patient try to get on without any instructor, by following a set of prescribed exercises, and in the first case I treated I attempted this, using a good set of move-in the night, during a snowstorm, four or five miles to ments which had already been suggested by a colleague in another city. The result was not encouraging, however, and I should not again waste time in the effort if it was possible to get even moderately skilled assistance. The necessity for obedience to the word of command, which calls for close attention and for movements which come to have something of the character of involuntary reflexes, is certainly a great help in stimulating both the conscious and the subconscious attention and the power of instinctive control. Clinical Department. manifestations of the pre-ataxic period succeed each TWO CASES OF ABNORMAL SEXUAL DEvel OPMENT.1 BY GEORGE G. SEARS, M.D., BOSTON. other rapidly; in patients with tabic optic atrophy, fragile bones and those who have had what is generally called spontaneous fracture or rupture of tendons. THE following cases are interesting illustrations of When any cardiopathy or aneurism exists the method a condition described by recent writers under the head must be tried very tentatively, if at all. It is not ap- of infantilism, in which more or less complete arrest plicable to very obese or arthritic patients, and, finally, of development of the genital organs is associated it is absolutely contraindicated when there are great with changes in the economy of a most diverse kind laxity of the ligaments and severe arthropathy." and manifested by gigantism, dwarfism, feminism, My experience is not sufficient to justify me in sup-muscular dystrophies, or affections of the special porting or in contradicting these statements, but, in senses, but about which our knowledge is still too infact, they are not borne out by the history of the two complete for definite classification. In the first, impatients whom I bring before the society tonight. The first of these has improved considerably in spite 1 Read before the Suffolk District Medical Society, Section for Clinical Medicine, Pathology and Hygiene, April 18, 1900. perfect development of the genital organs in a boy is nearly spherical in form and about half the normal accompanied by dwarfism and feminism, while in size. The pubic hair was thick, but grew like that of the second (a girl) the failure of the genitals to develop is associated with a tendency to gigantism and the assumption of male characteristics. The thyroid gland was not felt in either case. CASE I. A male, twenty-five years old, but who appeared no more than sixteen or eighteen, was admitted to my wards in the City Hospital a few weeks ago, after an altercation with the police, in which a difference of opinion arose as to whether he had had a fit or was simply drunk. Physical examination revealed an individual not more than five feet two inches in height, but of good muscular development. a woman, with a sharply defined horizontal upper limit. The most striking feature, however, was the breasts, which were of remarkable development, pendulous and of a size more than sufficient to perform the functions for which such organs are presumably adapted. The nipples and areola were also well developed and the latter were deeply pigmented. His sexual appetite, according to his statement, was normal. He claims that he should have been married some time ago were it not for his diminutive size. He says that he has a brother who has developed on the same lines as himself. In the photograph the deep shadows have given a harder appearance to his face than was really present. The curves of the hips, on the other hand, appear less pronounced, while the very redundant prepuce gives, in the picture, the appearance of greater size to the penis than is really possessed. Examination of the heart showed the presence of a well compensated mitral lesion. CASE II. A female, twenty-six years old, was admitted June 18, 1898. Her family history was negative. When twelve years old she began to grow mentally dull, and from that time until she was sixteen was troubled with frequent severe headaches often lasting a week. During the succeeding week she slept most of the time. When sixteen years old she states that there was a sudden swelling of the feet which lasted for a short time and then subsided, but the feet and hands then grew very rapidly. She has never menstruated, but has regular monthly attacks of vertigo and weakness. Physical examination showed an individual five feet eight and a half inches tall, weighing 145 pounds. Her face was distinctly Mongolian in type. The cheek bones were high and prominent, the lips rather large, the lower jaw heavy but not prognathous, the nose was normal, the hands and feet were much beyond the average size. The latter required a number nine shoe, while the former would probably need a number nine or nine and a half glove. The bones of the forearm and ankles seemed rather heavy, but the hands and feet themselves were not ill shaped. An x-ray photograph of the hands showed no abnormality except the size. The muscular development appeared normal, but she became easily tired. There was no axillary or pubic hair. The external genitals were those of a girl of ten. The vagina scarcely admitted the little finger, which reached with difficulty a very rudimentary cervix. The ovaries could not be felt. There was absolutely no development of the breasts, and her hips and general contour were those of a man rather than a woman. Her mental development had apparently been arrested with her sexual, for she was very childish and easily led. She was depressed, and frequently expressed a wish to die. The first glance failed to discover the sex. The hair on the scalp was luxuriant in its growth, but the cheeks and chin were devoid of beard. On the upper lip there was a little soft down, but no more than is A NEW JOURNAL FOR NURSES. The first issue often seen in women with dark skins. The deep-set of a new journal edited and owned by nurses will apeyes, surrounded by dark shadows, and the rather thick lips gave the impression of great sensuality. The voice was somewhat high pitched, but was more becoming to a man than a woman. The hips were broad, well padded with fat, and moulded with wellrounded curves. The penis was small, though not diminutive. It might be described as too large for a boy and too small for a man. The testicles were pear October 1st. It is to be the official organ of the Associated Alumnæ of Trained Nurses of the United States. The editorial staff contains the names of many women who have long been intimately associated with the development of nursing in this country. The general scope of the journal will be to disseminate knowledge of new methods which may be of interest to nurses and mothers. |