December, 1936 RHINOPHYMA-CRABTREE 485 labor. May not the blow upon the abdomen have excited as the only adequate treatment is surgical, it be- violent contractions which, in turn, tore open the weak hooves the rhinologist to familiarize himself with area in the uterine wall? Spastic peristaltic waves have ripped apart an intestinal anastomosis before healing be- all the phases of this disease in order to be came firm. able properly to perform the prescribed surgical This comment merely represents another point of view. measures. At present the true explanation remains beyond us. Per- haps we would approach that objective more nearly if the It is at once apparent that the disfigurement and authors were willing to review cases of rupture of various humiliation caused by rhinophyma is of the utmost abdominal organs, attributable to trauma. Such study, concern to the person afflicted. In one instance, almost surely, would repay the time and energy involved. a case of a woman, the condition caused such The treatment responsible for this woman's recovery extreme personal embarrassment as to result in was that which should always be employed in the circum- stances, whether the complication be seen early or late. threatened suicide. Many of the sufferers are led Otherwise the issue will be fatal. to believe there is no cure for this ugly affliction. That is most unfortunate, because the administra- tion of proper treatment with satisfactory results LEON J. TIBER, M. D. (3875 Wilshire Boulevard, Los is rather simple. Angeles).-It is surprising that more cases of traumatic rupture of the uterus in advanced pregnancy are not re- With but few exceptions, rhinophyma occurs in ported, especially considering the tremendous number of the middle or later years of life, by far the greater automobile accidents. percentage coming between the ages of fifty and Is it not possible that in the case of a visible fall, as seventy years. It is far more common in the male on some steps, the attempt to break the fall so contorts the uterus that there is a compression area where the than in the female, the ratio being approximately uterus is flexed, and, on return to normal, this portion of twelve to one. the uterus presents itself as a weak spot? The authors To offer a lengthy discussion as to the etiology have pointed out the intra-uterine pressure spreads equally of rhinophyma does not fall within the scope of in all directions; therefore, if a rupture is to occur, it should happen at this point of weakness. a rhinologist. The condition frequently is con- It is interesting to note that, in the reported case, there sidered attributable to chronic alcoholism-at least was a demonstrable pathologic variation of the uterine in the minds of the laity. This common theory is muscular fibers. In the other cases cited it is assumed, and without foundation. It is per- from the case histories of previous infections and abor- entirely untrue tions, that the rupture of the uteri occurred at a patho- haps more logical to attribute the chronic alcohol- logic point. ism to rhinophyma than the reverse when the two My own experience in the treatment of ruptured preg- conditions coexist in the same individual. One nant uteri has been with three cases of previous classical author 1 suggests that in many instances there is cesarean section complicated by hard and neglected labors, none due to accidents. In properly selected cases, one may apparently a congenital predisposition to rhino- attempt to repair the tear. However, a subtotal hyster- phyma in the so-called wide-pored individuals. ectomy assures a more rapid and safe convalescence. Another states that the nose is the most constantly One must always remember that a uterus that ruptured fact once during pregnancy is certainly more liable to rup- exposed portion of the entire body, this ture in succeeding pregnancies, other conditions remaining possibly lending to the development and gradual the same. An early diagnosis with active treatment is progression of the condition. However, it is necessary. generally agreed that the type of tissue present Has there ever been any x-ray diagnosis in these cases- is the etiologic factor of primary importance. That a fluid level of the blood in the peritoneal cavity, an ex- truded fetus or otherwise irregularity of uterus? These rhinophyma is frequently a sequel or terminal might help to clear up a doubtful diagnosis. stage of acne rosacea, is an accepted fact borne out by the similarity of the pathologic pictures of the two diseases. RHINOPHYMA* ACNE ROSACEA By WINSTON C. CRABTREE, M.D. Acne rosacea is a subacute or chronic congestive San Diego disease of the nose and flush areas of the face. It begins as a passive hyperemia, which is followed DIscusSION by Philip K. Allen, M. D., San Diego; F. G. Novy, Jr., M. D., Oakland; K. C. Brandenburg, M. D., later by dilatation and proliferation of the super- Long Beach. ficial capillaries. Pustules are present. Accompany- ing the blood-vessel changes is an hypertrophy of HINOPHYMA is a condition perhaps best de- varying degree of the cutaneous and subcutaneous scribed by the single term "monstrous hyper- tissues. In some instances the hypertrophy may trophy of the end of the nose." A fairly accurate attain a sufficient degree to produce more or less clinical picture of the condition is presented by lobulated masses, thus deforming the normal struc- merely listing the descriptive terms often used in ture of the nose. Also, the pores become patu- naming the disease: whisky nose, nodular nose, lous and either sebum or pus, or both, may be copper nose, elephantiasis of the nose, growing expressed from them. This stage is known as nose, acne hyperplastica, fibroma molluscum and rhinophyma. Please bear in mind that this process cystadenofibroma of the nose. of development is very slow, the progression covering a period of several years, varying from RHINOPHYMA A DISEASE OF THE SKIN five to twenty. Rhinophyma being primarily a disease of the Histologically, early acne rosacea presents a skin, probably concerns the dermatologist more dilatation of the capillaries with newly formed directly than the rhinologist. However, inasmuch blood vessels, the increased blood supply resulting * Read before the Eye, Ear, Nose, and Throat Section in edema and overnourishment of the connective of the California Medical Association at the sixty-flfth annual session, Coronado, May 25-28, 1936. tissues. As the disease advances, deeper vessels 486 CALIFORNIA AND WESTERN MEDICINE Vol. 45, No. 6

Fig. 1 Fig. 2 Fig. 1.-An unusual case of rhinophyma with similar pathological changes affecting chin-gnathophyma. (Cour- tesy of Dr. Wiley M. V. Sams.) Fig. 2.-Rhinophyma which has undergone carcinoma- tous degeneration. (Courtesy of Dr. F. G. Novy, Jr.)

are involved, which may become surrounded in Fig. 3 Fig. 4 areas by thick mantles of infiltrate made up of Figs. 3 and 4.-One of author's cases of rhinophyma lymphocytes, epithelioid cells, and occasional giant showing "before and after" surgery stages. cells. The condition being chronic, and one which is prone to recurrences, leads, therefore, to con- ings may be omitted after seven to ten days as a siderable hypertrophy of the connective tissue and rule. The use of tincture of benzoin, 25 per cent sebaceous glands, which together comprise the first silver nitrate, trichloracetic acid, and scarlet-red signs of the later stage, known as rhinophyma. ointment, are all commendable for use postopera- Rhinophyma, histologically, consists of a marked tively in dealing with granulation and scar tissues. hyperplasia of sebaceous glands and connective One dermatologist4 recommends x-ray and some- tissue, plus many of the cellular elements found times carbon dioxid snow for postoperative treat- in acne rosacea. ment if granulations or scarring are in excess. SURGICAL TECHNIQUE OTHER PROCEDURES The surgical removal of the large nodular Treatment of rhinophyma by galvanocautery or masses is a simple procedure. Correct technique electrocoagulation should be rejected as unreli- in administering the proper local anesthetic, using able and dangerous, because of possible damage two per cent novocain, is accurately described by to underlying bone, cartilage, and nasal mucous Labot,2 the block infiltration being made chiefly membranes.5 The extent of the necrosis which along the borders of the nasal pyramid. Using a may follow use of the cautery cannot be accurately knife or razor, as preferred, the hypertrophic gauged at the time of operation. Also there may masses of tissue are readily pared off with exact result an extensive destruction to the epithelial precision, extreme care being taken to obtain tissue, which must be preserved to obtain a proper proper reshaping of the nose. Gordon New 8 sug- and prompt healing. Electrocoagulation has been gests placing the index finger of the left hand in suggested by some men as useful during e the each nostril as the paring is performed, thus per- operation for hemostasis. mitting greater accuracy. Rather profuse bleeding The literature of several years ago will reveal is readily controlled by pressure, plus the use of frequent descriptions of the use of skin flaps from hemostatic solutions, if such are desired. the forehead, or grafts from the arm, as neces- sary in procuring the proper cosmetic end-result Considerable emphasis should be placed on the in the treatment of rhinophyma. Such measures importance of not shaving too deeply, and for two have been almost entirely discarded. The use of reasons: first, to avoid injury to the nasal carti- the graft is now confined only to cases of rhino- lages, and, second, to preserve a thin layer of phyma with carcinomatous degeneration, or in in- subcutaneous tissue and many islets of epithelial stances where x-ray, radium, or cautery have been tissue, which are necessary for proper epitheliza- employed inadvertently, with a resultant destruc- tion. These small islets of epithelial tissue are tion of too much of the nasal tissues. from the sebaceous gland rests, and are plainly X-ray therapy is commonly employed by the visible as the surgery is performed if time is taken dermatologist in treating acne rosacea. Thus it to slow the bleeding. It is also important to pre- follows that the use of x-ray in treating rhino- serve a thin rim of epithelium around the nares in phyma may be of value particularly in diminish- order to prevent disfigurement from resultant con- ing the folliculitis, which may often be severe. tractions incident to cicatrization. Vaselin gauze, Such a procedure is frequently very useful as a hot compresses or xeroform gauze dressings are preoperative measure in better preparing the case to be used with tinfoil or a thin cast of dental for surgery, whereby sometimes 30 to 40 per cent wax, necessary for holding the dressings in snug involution of the tumor mass may be obtained.7 position over the nose. In mildly developed rhinophyma, the use of x-ray Healing with proper epithelization will gener- therapy in clearing the folliculitis may allay or ally occur with rather amazing rapidity. Dress- even entirely remove the necessity for surgical December, 1936 SCABICIDAL DRUGS-TEMPLETON-ALLINGTON 487 treatment. Radium, likewise, has its place in simi- tissue; but I would suggest, as an aid to prevent subse- lar therapy. This phase of the treatment of rhino- quent regrowth, the use of the x-ray as soon as epithelial phyma is, of course, to be placed in the hands of regeneration has taken place. the dermatologist. Thus, stress should be placed on the complete cooperation between dermatologist F. G. Novy, JR., M. D. (411 Thirtieth Street, Oakland). and rhinologist in procuring the best results. Doctor Crabtree should be commended on emphasizing the simplicity of the surgical treatment of rhinophyma. IN CONCLUSION The use of skin grafts and complicated surgical procedures are unnecessary, as epithelialization takes place rapidly In concluding, the following points demand from the remains of the sebaceous glands. emphasis: I do not agree with the author regarding the use of electrodesiccation. If this modality is used with a low 1. The actual causative etiology of rhinophyma current and care, good results may be obtained. Klauder is somewhat obscure, though the condition is (Arch. Dermat and Syph., 33:885, May, 1936), recently recognized as a benign sequel of acne rosacea. reported a satisfactory technique. He inserts the electro- 2. Adequate surgical treatment desiccating needle (unipolar method) into the mass, and of rhinophyma a low current is then turned on until a small area is is a relatively simple procedure. blanched. This is then curetted until bleeding occurs, 3. The use of skin grafts, cautery, and electro- when another area is treated or the same area is again coagulation have been, in the main, discarded. treated if further destruction is desirable. The advantages 4. X-ray is very valuable in of this method are that the operation is nearly bloodless both pre- and post- and the cosmetic result compares favorably with surgical operative treatment, and in some instances may excision. be sufficient treatment, to the point of excluding surgery. K. C. BRANDENBURG, M. D. (110 Pine Avenue, Long 5. Full co6peration between dermatologist and Beach).-We are indebted to Doctor Crabtree for pre- rhinologist is essential in all cases of rhinophyma. senting us with a simple but effective remedy for a most disfiguring condition which, though it does not endanger 1305 Medico-Dental Building. life, may render existence extremely unpleasant to the REFERENCES individual suffering from this hideous deformity of the nose. 1. Seelig, M. G.: Surgical Clinics of North America, It is surprising that the ingenious expedient of shaving 5:1385. off the redundancy has not been resorted to before; but, as 2. Labot, Gaston: Regional Anesthesia. W. B. Saun- with so many other simple procedures, we must be shown ders Company, 1930. by someone with Doctor Crabtree's courage and good 3. New, Gordon: Surgical Clinics of North America, sense. 1:1395. The importance of rehabilitating these individuals is 4. Allen, Philip K.: Personal communication. much greater than anyone who has not suffered from such 5. Maliniak, Jacques W.: Arch. Otolaryn., 31:273. a disfiguring condition can realize. As is also the case 6. Marin, Alberic: Canad. M. A. J., 25:589. with crossed eyes, these unfortunate individuals are fre- 7. Sams, Wiley M.: Arch. Dermat. and Syph., 26:836. quently highly sensitive about the matter and find it a marked social disability. DISCUSSION The knowledge that an effective treatment is available PHILIP K. ALLEN, M. D. (314 Medico-Dental Building, will be most welcome to wearers of "whisky noses." San Diego).-I am most interested in this paper from a standpoint of therapy, particularly the cosmetic end-result. Inasmuch as rhinophyma does not endanger life nor im- SCABICIDAL DRUGS: AN EXPERIMENTAL pair health, the appearance is of prime importance. The condition is by no means a new one. It was known to STUDY * Hippocrates and was described by the early Arabians. In By H. J. TEMPLETON, M.D. more than two thousand years innumerable types of treat- ment have been advocated, most of them without real AND therapeutic value. H. V. ALLINGTON, M.D. The nonsurgical treatment of rhinophyma has proved Oakland unsatisfactory. Local applications which are not caustic nor destructive may impede the progress of the disease, DIscusSION by George V. Kulchar, M. D., San Fran- but do not reduce the hypertrophy. X-ray and radium cisco; Hiram E. Miller, H. D., San Francisco; Samuel therapy have, on the whole, proved disappointing, although Ayres, Jr., M. D., Los Angeles. occasionally pleasing results have been reported. McKee states in his book, "X-Ray and Radium in the Treatment SCABIES is a disease whose treatment we gen- of Diseases of the Skin": "X-ray (and radium) seem to erally approach quite confidently, feeling that be of very little real service in rhinophyma." Acne-like we have in sulphur a near-specific which, in the lesions do disappear under x-ray treatment, and the seba- great majority of cases, is rapidly curative. How- ceous glands will become smaller and less active. In a markedly enlarged nose, however, the limited shrinkage ever, we have all had the experience of treating that can be effected by x-ray does not give satisfactory patients whose scabies was cured only with great end-result. Its usefulness is limited, therefore, to the early difficulty, even though not complicated by irrita- case in preventing further hypertrophy. Where consider- tion from the sulphur and though the balance of able enlargement has taken place other forms of treat- ment, mainly surgical, are indicated. the family were properly treated and the clothing Various types of surgical measures have been used. adequately sterilized. Such experiences have Acids, caustics, cautery, and scarification have all had modified, to a certain extent, our former cocksure advocates. It seems odd that the simple and most obvious attitude in regard to the ease of curability of this procedure of carving the nose down to the desired size disease. and shape should be left to comparatively recent times. KINGSTON S STUDIES The good results in such a simple sculptural operation are due to the anatomy of the condition. Removal of This attitude was intensified, and the present hypertrophic tissue leaves sufficient basal epidermal cells experimental work stimulated by an interesting to insure rapid and complete epithelialization. e Read before the Dermatology and Syphilology Section I agree with the essayist that the best cosmetic results of the California Medical Association at the sixty-fifth are to be obtained by surgical excision of the hypertrophic annual session, Coronado, May 25-28, 1936.