A few practical points in the application of solidified carbon dioxide may not be amiss. Crusts, scales and horny surfaces should be removed to allow a more rapid effect. The snow may be molded or cut with a knife so as to correspond to the shape and size of the lesion. Thin sheet-lead may be cut to exactly fit lesions of very irregular outline. This lead is then placed on the lesion and the snow placed on it. It is wise to protect the surrounding tissues by applying chamois or asbestos with an opening just long enough to expose the spot to be treated. Superficial lesions of great extent, such as may be seen in some cases of lupus erythematosus, and lesions in the mouth or interior of the nostrils may be conveniently treated by dissolving solidified carbon dioxide in ether. This semigelatinous liquid is then painted on the surface with a camel’s hair brush and the frozen condition easily maintained by continuous applications of the mixture. Areas that have been exposed to the X-rays or radium are particularly sensitive to refrigeration. Hence it may be advantageous in individual cases to give a preliminary treatment with the X-rays or radium because thereby shorter and more superficial freezing is possible and less scaring probable. The effect produced on the skin by freezing varies with the amount of pressure exerted and the duration of the application. The depth to which the skin is frozen naturally depends directly upon the amount of pressure. If the pressure is light the freezing is superficial; if moderate, a little deeper; or if firm, the tissue may be frozen to a depth of 1/8 inch or more. The degree of pressure must be regulated somewhat by the location of the lesion. Thus a soft part can easily stand deep pressure while skin over a bone must receive a much lighter treatment. The duration of the application depends upon the effect desired and should always be timed with a watch. The reaction varies with the part frozen and is more marked where the blood supply is poorest such as the toes and the rims of the ears. Young children show a more intense reaction after applications than adults do for treatments of the same length. Horny lesions and new-growths of great depth naturally demand longer applications. The approximate duration of refrigeration will be mentioned in the text under the various diseases.
Counter irritation may be produced by the action of blisters, sinapisms or caustics over the vasomotor centers, as suggested by Crocker. Occasionally this method assists in relieving obstinate skin lesions.
Hyperemic treatment. The production of active or passive hyperemia is useful in such diseases as eczema, psoriasis, keloid, scars, alopecia areata, tuberculosis cutis, syphilis and the various staphylococcus infections. Hyperemia signifies an improved metabolism of the tissues due to an increased blood supply in the part, followed by the active removal of deleterious substances by the dilated veins. Active or arterial hyperemia is produced by local hot air. The hot air systems may be divided into two classes, dry hot air represented by the Turkish bath and moist hot air as found in the vapor or Russian bath. Passive or venous hyperemia is produced by elastic bands or bandages which alter the circulation of the part or by suction glasses or exhaustion apparatus. In dermal practice our interest is confined to two methods: the first is radiant heat which necessitates Bier’s non-luminous apparatus, or Dowsing’s luminous form; the second method is by suction or exhaustion cups introduced a few years ago by Bier who worked out scientifically the relation existing between the rubber ball and the glass cup which, in various sizes and shapes, comprises his apparatus. For the details of these processes, the student is referred to any book on hyperemic treatment. Hyperemia of the skin may be produced by friction or massage. This branch of local treatment has been developed along scientific lines in recent years and often proves useful in cases of dermatitis resulting from stasis or faulty circulation with a tendency to local edema. While hand manipulations are usually preferable, vibration and mechanical vibratory massage are occasionally employed.
Mechanical and operative measures are often needed in the practice of dermatology. The former includes bandages, suspensories, elastic and inelastic stockings, caps, masks, gloves and mittens of various fabrics and many less important items. Operations are mostly of a minor nature and include excision, skin-grafting, curetting, incision or puncturing, epilation, linear, punctate and multiple scarifications, extraction of comedones and cutaneous trephining. Besides instruments (many of which are illustrated in the text) needed for these measures, it is necessary for the physician to have the ordinary surgical outfit.
Electricity plays an important part in present-day therapeutics, relatively more important in cutaneous treatment than in many other branches of medicine. The galvanocautery and the thermocautery (Paquelin cautery and a small modification, the microcautery of Unna) are used for their caustic and destructive effect, especially in lupus vulgaris involving the mucous membranes. Galvanism has been used generally as a sedative and locally for pruritus and Raynaud’s disease and for the relief of the pain in herpes zoster. Faradic and static electricity are not used for specific purposes in dermatology, but on the same indications that would call for their use in general medicine.
Cataphoresis (ionisation or ionic medication) consists of the introduction into the skin of drugs dissolved by the constant or galvanic current. By this means certain substances; alone incapable of penetrating the tissues, are able to do so with the assistance of the electric current and at the same time they preserve their chemical and therapeutic properties. Mention will be made in the text of the cataphoretic use of such remedies as sodium chlorid, potassium iodide, iodine, chlorine, mercury, copper, zinc and cocaine as they relate to alopecia, chloasma, keloid, morphea and other diseases.
Electrolysis represents the application of a galvanic current as a cauterizing or destructive agent and is useful in the treatment of hypertrichosis, nevi, warts and other new-growths. Under the discussion of the treatment of the first named disease will be found a detailed description of the technic.
High-frequency currents (also known as high-tension currents) were first practically employed in general therapeutics by D’Arsonval but it was Oudin who gave us the initial knowledge of their use for diseases of the skin. There are a number of types known as high-frequency currents of which the autocondensation, the autoconduction and the heliocoidal shunt of D’Arsonval, the resonator of Oudin and the hyperstatic of Piffard are the most important. The last two are chiefly used for skin lesions. My personal experience has been largely with the Oudin resonator and as an adjunct to other measures in the treatment of seborrhea, alopecia areata and prematura, acne, rosacea, urticaria, eczema, pruritus and other paresthesias, lichen planus, lupus erythematosus, lupus vulgaris, varicose ulcers, etc., it is most valuable. These currents have a general and local tonic effect, reducing high arterial tension in many cases and improving metabolism by increasing the hemoglobin in the blood. They are applied by means of different electrodes of which the hammer-shaped glass vacuum is the most used. Glass-pointed, carbon, brush metallic (producing an effluve), solid metal and pointed metallic (known as fulguration or high-frequency sparking, for decided limited action) electrodes may be employed as needed. They may be held just far enough from the skin to prevent sparking, in actual contact with area treated, or at a distance to insure sparking. If general administration is desired, the patient lies on a condenser and holds an electrode. The so-called unipolar X-ray tube, connected with the Oudin resonator gives off X-rays when coming in contact with the surface, and has a limited sphere of usefulness.
Radiotherapy (Roentgen-ray Treatment; X-ray Treatment) is well established as a therapeutic agent and nearly all dermatoses have been treated, at least experimentally, by this means. Freund and Schiff were mainly responsible for the introduction of the X-rays in dermatology, but since that period many investigators have added much to the exact knowledge and application of radiotherapy. Such diseases as epithelioma, tuberculosis cutis, acne, rosacea, sycosis ringworm, favus, eczema, psoriasis, hypertrichosis, lupus erythematosus, keloid, sarcoma cutis and mycosis fungoides are amenable to the X-rays. They are indirectly germicidal through tissue reaction, as in shown by the cessation of purulent discharges in eczema and cancer after their applications. Cells of embryonic type become degenerated without the surrounding healthy stroma being affected, and hence it is possible for hair-follicles and sebaceous glands to become atrophied when subjected to the X-rays. For the clinical behavior and pathological action of the Roentgen-rays, the reader is referred to the article on X-ray dermatitis.
American homeopath, he directed several hospitals in New York.
Professor of dermatology.
Served as Lieut. Colonel during the 1st World War.
See his book online: American homeopathy in the world war