Obliteration of Congenital Pigmentations. Read in the Section on Dermatology and Syphilography at the Forty- fourth Annual Meeting of the American Medical Association. BY B. MERRILL RICKETTS, Ph.B.,M.D. CINCINNATI, OHIO. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION JANUARY 20, 1896. CHICAGO: PUBLISHED AT THE OFFICE OF TIIE ASSOCIATION. 1894. OBLITERATION OF CONGENITAL PIGMENT- ATIONS. Abnormal pigmentations of the human skin have always existed and are always more or less objection- able, especially where they occur upon the exposed parts of the body. I say always objectionable, meaning the congenital ones, and I might say the artificial ones sooner or later are objectionable. In order that we may be able to more thoroughly understand the character of the various pigmenta- tions, I have made the followingclassification, which I have found to be very convenient, and which I believe answers ordinary purposes. It is as follows : 1. Elevated pigmented surfaces. 2. Non-elevated pigmented surfaces. 3. Red, elevated or non-elevated, pigmented sur- faces. 4. Brown, elevated or non-elevated, pigmented sur- faces. In the elevated pigmentations, I have found ob- literation much easier than in any of the other three I have mentioned. Those that are non-elevated and have a brown color, are the hardest to obliterate, and require a greater length of time for treatment, and the results are not so good. On the other hand, the red ones, elevated or non- efevated, are removed with greater ease, especially if elevated. I believe that this classification answers every purpose in the treatment of congenital pig- mentations. As to the acquired ones, I do not care at present to have anything to say. When we con- sider how little progress has been made in the suc- cessful treatment of these lesions, and the great number of persons possessing them together with the demands which association brings, we can not help 4 but look with regret upon the present status of treat- ment. It is with horror that I look upon these deformities, and with great chagrin that we stand handicapped in giving relief to those who so often approach us with so many regrets. I believe it is the duty of every person to rid himself, so far as possible, of every characteristic that may be objec- tionable to his associates-warts, moles, cicatrices, tumors of various kinds, superfluous hairs, deformed nails, fingers, ears, lips, eye-lids and nose, are all of equal importance. The dentist prides himself in giving to his patient a set of teeth that is not only useful, but possessed of great beauty; the barber becomes noted in applying his artistic skill to the hair of both the head and face. With all these standing out in bold relief, we must admit our short- comings. Possibly the remedy lies in the extirpa- tion of these pigmentations, followed by skin-graft- ing, as suggested by Thiersch. It may be that it is something less severe, but who is to present it? I firmly believe that where the pigmentations are large and can not be excised, and the edges brought to- gether without deformity, that the Thiersch method offers the best results. Surely the grafts, together with the attending cicatrices, would be less objec- tionable than the discolored or elevated surfaces, and I am thoroughly convinced that I, myself, would resort to them, taking my chances, in preference to carrying one of these birth-marks. If the lesion is supplied with a great amount of blood, there is but little difficulty in destroying the vessels with electrolysis. This is the treatment which I offer as the best means, so far discovered, in destroying the elevated or non-elevated red pigmen- tations, also where the elevations are brown, unless it be by the Thiersch method. But, where the surface is brown, so far I have been unable to lessen the deformity to any great degree by electrolysis. Think- ing, perhaps, that I might be able to obliterate this discoloration, I selected a few upon myself and vari- 5 ous patients for experiment. I decided to use finely powdered feldspar and flint. These are ground for fifty hours and used extensively in the manufacture of fine pottery. I selected needles as fine as could be had, and with great care tattooed several lesions as carefully as I could, some with flint and some with feldspar. The result was an inflammatory process, which destroyed not only the color, but also the epithelium and part of the papillary layers. In each case there was a fine white cicatrix remaining, which was smooth and a little lighter than the surrounding skin. I am not sure that either the feldspar or flint was the least beneficial. I make the state- ment to show what could not be done with them. Where the lesions are small I have had better results with electrolysis and excision than by any other procedure. If excision is to be resorted to, it should be with the greatest care, the sharpest knife, and aseptically. I have not found it necessary to use but the lightest sutures, silk worm gut being the best; often these are not used unless there is great tension to be overcome, usually having found rubber adhesive straps sufficient to keep the walls of the wound together until primary union could take place. I have tattooed with all remedies so far suggested, and I am free to confess that notone of them is satis- factory in my hands. Possibly the fault lies within myself, more perhaps in the application than in the prolonged treatment, for I have been faithful in their application. There is one procedure that I value above all others in cases where any congenital pigmentation, whether elevated or non-elevated, red or brown, involves any great amount of surface. It is in the use of Thiersch's skin grafts. The great trouble is in overcoming the fear of both the operator and the patient that the grafts are not always certain. This is a very great desideratum, but one which must not be overlooked. If the operator is fearless, clean and 6 skilful, there is no reasonable doubt but that the skin will become adherent and that the surface will become smooth and lose the objectionable deformity. Even though the grafts should not become adherent, the resulting cicatrix is far less objectionable than the condition for which the operation was made. My own experience has taught me that these lesions when found upon the face or hands, can be removed and without any risk, unless it is in taking the anesthetic, especially where chloroform or ether is used. I do not believe that grafting is so successful when done upon surfaces which have been anesthe- tized by subcutaneous injections of cocain. It seems to me that the capillary supply upon which we must necessarily depend for nourishment to the graft is greatly lessened by the influence of cocain. It les- sens the congestions of mucous surfaces, and why not the normal capillary blood supply to the papillae? I would not, therefore, hesitate to use either chloro- form or ether where the lesion is extensive, in pref- erence to the subcutaneous injection of cocain. Then, too, the amount of cocain requisite to produce local anesthesia, would in all probability cause con- stitutional disturbance of an unpleasant character. I have now used cocain subcutaneously almost one thousand times, and with but two or three exceptions have never had any unpleasant results from it. So that, so far as the use of this remedy is concerned, I, myself, would not hesitate to use it even in the larger lesions. Then, so far as the administration of chloroform and ether are concerned, fortunately it is not necessary to prolong their administration, as the operation requires but a very short time if detail is looked after in thebeginning. In removing the objectionable tissue, hemorrhage is sometimes to be encountered, especially in the red ones where there is a great amount of blood supply. This, how- ever, can be overcome with the application of hot water containing chlorid of sodium in the propor- tion of one-half of 1 per cent. If this should not 7 control the hemorrhage, and if found impossible to apply the grafts with certainty, the surface may be allowed to granulate and grafted upon later on. The knife to be used should be the sharpest, and the tissue removed with one bold stroke. The skin to be substituted should be from the thigh or arm, which has previously been cleansed and made ready for the operation. The shavings should be as thin as it is possible to make them, there being but little capillary hemorrhage. If the surface is two, three or four inches square, the grafts should be as few in number as it is possible to cut them. If three or more inches square is required, it is best to remove the cuticle from the abdomen where the surface is Hat, and the knife allowed to make one broad cut. If it is found necessary to wait several days before applying the graft, the granulated surface may be mowed down with a curette, the hemorrhage checked and the grafts then applied; however, I have made it a rule to apply my grafts at the time of the primary operation, thus giving me two opportunities to secure their growth. Any surface upon which grafts should fail to become attached at the primary operation, can be covered at the second sitting. So far as the dressings are concerned, they should be simple but firm. I have found nothing better than as fine quality of cheese or tobacco cloth as I could procure, which enables the secretion to become absorbed, leaving the grafts as free as possible from other influences. So far as the use of these grafts goes, I have noth- ing in the way of improvement to offer on the Thiersch method. He has described in detail the conditions, operations and care of them, so I feel that it would be useless to speak further upon this, the most ingenious and useful plan of skin grafting. In conclusion, I will say that I believe this is the only available means we have of obliterating these birth-marks, unless it be electrolysis, on which I do not place so much value.