liquor potassii arsenitis, and liquor sodii arsenitis. A dose of
arsenious acid varies from one-fortieth to one-fifteenth of a grain
thrice daily, administered in pill form. The dose of the liquor
potassii arsenitis--or Fowler's solution of arsenic, as it is generally
termed--varies from one to five minims three times a day, the average
dose being two or three minims. It is best to begin with a small dose
and gradually to increase the quantity until the maximum dose is
ascertained; {618} after which the regular dose may be instituted.
Patients, it will be found, vary as to the amount they can safely and
beneficially take: in most cases two or three minims continued for a
length of time will prove a full dose, while in others four or five
minims will be tolerated. It may be given with water, elixir of
calisaya, or wine of iron. The practice of prescribing it pure,
directing a certain number of drops to be taken at each dose, is
objectionable; it does not ensure an accurate quantity or proper
dilution, and, moreover, gives the patient unnecessary trouble. A
prescription such as the following possesses practical advantages:
Rx. Liq. potassii arsenitis, fluidrachm iss;
Elix. calisayæ, fluidounce iv.
M.--Sig. One teaspoonful with a wineglassful of water thrice daily,
after meals. The dose here is three minims; should it prove too strong,
a half teaspoonful of the mixture may be ordered. The toxic effects of
arsenic should be borne in mind. Some persons are very susceptible to
the remedy, half-minim or one-minim doses sometimes causing unpleasant
symptoms. The usual ill effects consist of erythema of the fauces,
oedema of the eyelids, injection of the conjunctivæ, watering of the
eyes, pains in the head, nausea, sharp pains in the bowels, and
diarrhoea, coming on within a few days or a fortnight after beginning
treatment. As a rule, they pass away in a few days after ceasing the
use of the remedy.
The length of time that arsenic should be given will depend upon its
effects upon the general system and upon the disease. In most cases
improvement is noticeable within a fortnight, though its use from one
to three months is generally necessary to bring about complete
recovery; and it is best to continue the medicine in small doses for a
month or two longer. Arsenic is a nervine tonic. It acts as a stimulant
to the skin, exerting a decided impression upon the cells of the rete
mucosum; doing this, without doubt, directly through the nerves, which,
as is well known, are abundantly supplied to this structure.
Phosphorus has been used by several dermatologists, but with varying
results. It is liable to produce gastric disturbance, and is a
disagreeable remedy. Tar, in capsule or pill form, will sometimes prove
of value where arsenic and other remedies have failed. From one to
three capsules, containing from three to five grains each, may be given
for a dose. Carbolic acid has also been extolled by some, especially in
chronic cases with slight infiltration. Anderson speaks well of it, and
gives the following formula for its administration:
Rx. Acidi carbolici, drachm iij;
Glycerinæ, fluidounce j;
Aquæ, fluidounce v.
M.--Sig. One teaspoonful in a large wineglassful of water before meals.
In some cases, more particularly in strong, hearty, plethoric persons,
and in those having a rheumatic or gouty habit, the free use of
alkalies proves of great value. In these cases arsenic often aggravates
rather than improves the condition, whereas the alkali acts most
happily. It may be recommended in acute stages of the disease when the
lesions are red, heated, and growing. Liquor potassæ, in from ten to
twenty drop doses, diluted with a large wineglassful of water, thrice
daily, is the form generally prescribed. Improvement is sometimes noted
within a few days. Anderson calls attention also to the value of
carbonate of ammonium, in {619} from ten to thirty grain doses, in like
cases. The acetate of potassium, in thirty-grain doses, may also be
referred to as being sometimes useful.
Local treatment may now be considered. This is of great value, and
should be instituted in all cases, either alone or in conjunction with
internal remedies, according to the case. Sometimes it may be directed
alone with good results, more particularly in chronic, sluggish cases
where the lesions undergo but little change from time to time and are
unaccompanied by subjective symptoms. Before prescribing certain points
should be ascertained. The duration of the disease; the extent of the
eruption, including the number and size of the lesions, and their
acuteness or chronicity; the locality involved; the circumstances and
the age of the patient; and the time that can be given to the
treatment,--should all be taken into consideration. In this connection
it should be remembered that whatever plan of treatment is adopted, the
remedies should be applied thoroughly. The disease at best yields
stubbornly, and to secure satisfactory results the importance of
employing the agents properly should be insisted upon. This requires in
most instances considerable time once, and, in some cases, twice a day.
The scales are to be removed first. Where they are thick and adherent,
inunction with some simple oil, as olive oil, followed by the use of
soap and water, may be employed. Ordinarily, soft soap alone, well
rubbed into the lesions with a piece of wet flannel and rinsed off with
water, will be found sufficient. A 5 or 8 per cent. alcoholic solution
of salicylic acid may be employed for the same purpose. The bath,
simple or alkaline--the latter containing, for example, borax--is also
frequently of service.
In acute, highly inflammatory cases, where the skin is red, hot,
scaling profusely, and the lesions spreading from day to day, soothing
applications, as of olive oil, will generally prove most valuable.
Instances are sometimes encountered where the use of the simple bath,
followed by inunctions of olive oil or one of the petroleum ointments,
will prove to be the only treatment tolerated. The majority of cases,
however, seeking advice show the disease already well developed and in
the chronic stage, and here stimulating remedies are demanded.
One of the most valuable and generally useful remedies is tar, employed
in the form of ointment or tincture or in combination with other
substances, as, for example, the mercurials or sulphur. The tarry
products in common use are pix liquida, or common tar, oil of tar, oil
of cade, and oleum rusci (oil of white birch). The chief objection to
their employment is the penetrating odor, which is almost impossible to
banish. The oil of birch is probably the least objectionable in the
list. Officinal tar ointment, full strength or weakened, will be found
serviceable. It should be applied with a piece of cloth or stiff brush,
well rubbed into the skin, and should be used twice daily, the scales
having been previously removed by one or another of the methods
indicated. Similar ointments, one or two drachms to the ounce, may in
like manner be prepared from any of the other preparations of tar, as,
for instance, the oil of white birch. Where an ointment is not desired,
the oil of tar, oil of cade, or oil of white birch may be employed, the
remedy being thoroughly rubbed or worked into the skin. Attention to
the mode of application should always be insisted upon.
Other tarry preparations, such as liq. picis alkalinus, liq. carbonis
{620} detergens (the formulæ for which have been given in speaking of
the treatment of eczema), diluted, may also be prescribed in some cases
with benefit. Hebra's modification of Wilkinson's ointment may be
referred to as an energetic and useful compound:
Rx. Sulphuris sublimati,
Ol. cadini, aa. drachm iv;
Saponis viridis,
Adipis, aa. ounce j;
Cretæ præparatæ, drachm ijss.
M. Ft. ugt.
Another method of using tar consists in the so-called tar bath: the
patches are deprived of scales by means of soft soap, after which tar
ointment or one of the tarry oils is rubbed in, and the patient then
placed in a warm bath for several hours. A stimulating tarry mixture,
especially useful in circumscribed, infiltrated, obstinate patches, is
composed of equal parts of tar, soft soap, and alcohol. Tar should not
be applied over extensive surfaces without cautioning the patient that
systemic disturbance, produced by absorption, may possibly occur. In
ordinary cases, however, such an accident is very rarely noted.
Creasote, turpentine, and acetic acid, remedies similar to tar in their
action on the skin, may also be mentioned. The first-named may be used
in the form of an ointment, from one to four drachms to the ounce.
Turpentine may be applied pure or with oil, one to two or three parts.
In some cases thymol in the form of an ointment, from five to thirty
grains to the ounce, proves of service. The mercurials may also be
referred to, but it may be stated that they are not as valuable in this
disease as they are in eczema. The most useful is white precipitate in
the form of ointment, from forty to eighty grains to the ounce, which
is especially valuable in psoriasis of the scalp and of the face.
Lotions of corrosive sublimate will also sometimes be found of service.
The treatment of psoriasis by chrysarobin--or chrysophanic acid, as it
was originally termed--may now be referred to. It is a very valuable
method of treatment. Care should be exercised in the selection of a
reliable preparation, there being considerable difference in the
strength, and therefore in the results obtained, of the remedy as found
in the shops. Its disadvantages must be mentioned: It is liable to
irritate and inflame the skin, causing sometimes an acute dermatitis or
a follicular or furuncular inflammation and a variegated purplish or
mahogany-colored staining of the skin. The hair, nails, and the linen
of the patient also become stained. It may be prescribed in the form of
an ointment, from ten grains to one drachm to the ounce of lard or
petroleum ointment. The most desirable mode of application, that which
is least objectionable, is in the form of a pigment, with flexible
collodion or liquor gutta-perchæ, in the same strength as the ointment
mentioned. It should be applied with a brush daily or every other day.
The following formula, suggested by G. H. Fox, may be given:
Chrysarobin and salicylic acid, each ten parts; ether, fifteen parts;
collodion, enough to make one hundred parts. Another valuable remedy,
having a similar action, to be used in the same manner as chrysarobin,
is pyrogallic acid. Like chrysarobin, it stains the skin (a brownish
hue), but it possesses the advantage over that substance in not being
so irritating. Neither of these remedies, {621} especially the
pyrogallic acid, should be applied over extensive surfaces, on account
of liability to absorption and systemic poisoning.
Where the patches are not numerous a solution of sulphide of lime may
sometimes be used with excellent results, as according to the following
formula, known as Vleminckx's solution:
Rx. Calcis, ounce ss;
Sulphuris sublimati, ounce j;
Aquæ, fluidounce x.
Coque ad fluidounce vj, deinde filtra.
This may be perfumed with oil of anise, five or ten drops to the ounce.
It may be applied diluted with two or four parts of water or full
strength, and is to be rubbed into the skin with a flannel rag, after
which the parts are to be bathed with water and some emollient oil or
ointment applied.
Treatment is usually effective in removing the lesions, but,
unfortunately, in the majority of cases, relapses sooner or later
occur. It may be said relapses are the rule. The prognosis will depend
upon the case.
Pityriasis Rosea.
Pityriasis rosea, known also as pityriasis maculata et circinata, is an
inflammatory disease, occupying chiefly the trunk, characterized by
discrete or confluent pinkish or reddish macular or slightly raised
lesions varying in size from a small to a large coin. They are rounded
in form, but by coalescence may assume irregular shapes and
considerable size, as in the case of psoriasis. They are circumscribed,
usually clearly defined, superficially seated, of a bright rosy,
pinkish, or reddish hue, which sooner or later fades and is followed by
yellowish, salmon-colored, or rusty tints. The surface of the lesions
is from the beginning dry, and as the process advances furfuraceous or
flaky scaling sets in, similar to that observed in tinea versicolor and
in tinea circinata. This feature is more marked about the border, the
process inclining to recover in the centre and to spread on the
periphery, after the manner of tinea circinata. The skin is only
slightly, if at all, thickened. At times there is slight burning or
itching, but more frequently subjective symptoms are altogether
wanting.
The course of the affection is variable, in many instances lasting from
one to several months, while in exceptional cases it is more acute. It
tends to spontaneous recovery, and is to be viewed as a mild disease,
notwithstanding that the lesions at times, by their redness and size,
indicate considerable cutaneous disturbance. It is met with in all
ages, in our own experience more frequently in adults than in children,
and occurs in both sexes and in those possessing average general
health. It is one of the rarer cutaneous diseases, and is not
contagious.
It is to be distinguished from ringworm of the body, from tinea
versicolor, and from the macular syphiloderm, all three of which
diseases it at times closely resembles. It possesses some of the
peculiar features which characterize the vegetable parasitic diseases,
but in some respects it differs from them in its behavior. The
microscope fails to reveal fungus. Concerning treatment there is but
little to be said, as the process inclines in most cases to spontaneous
disappearance. Mildly stimulating ointments or {622} baths, as in
eczema, may be prescribed. When involution sets in recovery usually
takes place rapidly.
Pityriasis Rubra.
Pityriasis rubra is an inflammatory disease, usually pursuing a chronic
course, characterized by redness and abundant and continuous epidermic
exfoliation. It usually develops rapidly, beginning as small, red,
scaly patches. It may make its appearance on one or more regions, the
spots increasing in size rapidly, and coalescing to form large patches.
In a variable time the whole or a large portion of the entire surface
is involved, the skin being of a pale or violaceous red color and
covered with thin whitish or grayish lamellar scales. These are
abundant, and are rapidly formed, cast off and replaced by new, the
exfoliation being, as a rule, in the form of flakes. Thickening of the
skin seldom occurs. The surface when deprived of the scales is
hyperæmic and shining in appearance. The disease usually involves the
whole surface. Oedema, especially of the limbs, and stiffness of the
joints are sometimes observed. The disease is superficial in character,
rarely involving more than the upper cutaneous layers, and is always
dry. Fissuring is only exceptionally seen.
As a rule, the subjective symptoms are slight, burning and itching, if
present, seldom being violent. Symptoms of constitutional disturbance
may or may not be present, but chilliness is often complained of. The
disease generally occurs in adults, is acute or chronic, usually the
latter, with a tendency to relapses. Being a rare affection, the
etiology is obscure. Anatomically, there is found more or less marked
cell-infiltration of the cutaneous tissues, especially noticeable in
the rete and upper layer of the corium. In severe cases the papillæ are
not distinguishable; the same may be said of the sweat and sebaceous
glands.
Erythematous and squamous eczema and psoriasis bear resemblance to the
disease. Its superficial nature, wide or universal distribution,
absence of infiltration, character and rapid formation of the scales,
and the slight itching or burning will serve to differentiate it from
eczema. In psoriasis the whole surface is rarely if ever involved,
while there is more or less thickening of the corium, and the scales
are thicker and imbricated. It can scarcely be confounded with lichen
ruber or with pemphigus foliaceus.
The disease pursues a variable course. It may last for years, with
exacerbations, or outbreaks may occur from time to time. Treatment is,
as a rule, unsatisfactory. For external treatment applications of a
bland or soothing character afford the most relief. Vaseline, cold
cream, and oily substances are generally of most service. Stimulating
applications seldom prove useful--in fact, will in most cases give rise
to discomfort and positive aggravation. In regard to constitutional
remedies general indications are to be followed. There is no drug that
seems to exert a specific influence.
{623} Dermatitis Exfoliativa.
This term is employed to designate certain cases in which more or less
exfoliation is the prominent characteristic, and which cannot be
classified under the head of any of the other diseases in which this
symptom is noted. These cases have been variously described under the
names of general exfoliative dermatitis, recurring exfoliative
dermatitis, desquamative scarlatiniform erythema, recurrent acute
eczema, acute general dermatitis, and recurrent exfoliative erythema.
The affection is characterized by an erythematous inflammation, rarely
vesicular or bullous, acute in type, with desquamation or exfoliation
of the epidermis accompanying or following its development. There is
also usually more or less marked constitutional disturbance, in some
instances of a serious nature, and a tendency to relapse and
recurrence. It is possible that in some instances the disease could be
properly classified under the head of eczema, psoriasis, pityriasis
rubra or pemphigus foliaceus.
Lichen Ruber.
Lichen ruber is an inflammatory disease, characterized by small flat
and angular or acuminated, smooth and shining or scaly, discrete or
confluent red papules, having a distinctly papular or papulo-squamous
course, attended with a variable degree of itching. Two varieties are
met with--the plane (lichen ruber planus) and the acuminate (lichen
ruber acuminatus), the first of which occurs much the more frequently
in this country. The acuminate variety is met with chiefly in Austria,
where it was first described by Hebra: it is very rare in the United
States, only a few authentic cases being on record. In lichen ruber
planus the papules vary in size from a pinhead to a pea, and are
peculiar in that they are not rounded, but are quadrangular or
polygonal in shape. In their early stage they have a smooth, glazed
surface, and are free of scales, but later they become papulo-squamous.
They are more or less flattened on their summits, and show slight
umbilication with whitish puncta. They are of a dull pinkish, reddish
or violaceous color, the hue varying with the individual, age, and
locality. As a rule, they are numerous, and occur in variously-sized
aggregations, the distribution scarcely amounting to grouping. They
tend to coalesce and form patches, which are slightly elevated,
flattened, and uneven, the lesions when crowded together having a
mosaic pattern. In lichen ruber acuminatus the papules are smaller,
pointed, scaly, and disseminated, showing no disposition to group. This
variety of the disease spreads rapidly, pursues a chronic course, and
is a more serious affection, sometimes terminating fatally.
Lichen ruber planus usually presents itself upon the extremities,
especially upon the flexor surfaces, the forearms and wrists and backs
of the feet being favorite localities. Not infrequently it appears in
the form of short or long narrow bands, following the natural lines of
the skin, and sometimes nerve-tracts. The course of the disease is
generally slow, extending over months. Occasionally, however,
especially where the lesions are acute and very numerous, it is
comparatively rapid. New {624} papules continue to show themselves from
to time, the older ones disappearing by absorption, leaving persistent
marked reddish or brownish pigmentation, which is to be regarded as a
characteristic symptom.
The etiology of the disease is at times obscure, although, according to
our experience, patients usually show signs of impaired nutrition or
nervous depression, arising from varied causes, as, for example,
overwork or shock. It occurs at all periods of life, but is usually met
with at middle age, and is more common in women than in men.
Pathologically, the process is considered an inflammation of a chronic
character, accompanied by more or less alterative changes in the
structure of the skin, involving the several layers as well as the
follicles. The lesion is always of a papular type. Later investigations
(Robinson) into the anatomy of the lesions of lichen ruber acuminatus
and lichen ruber planus are apparently indicative of the distinct
nature of the two varieties, the former being considered a paratypical
keratosis, leading to retrograde changes and atrophy, and the latter an
inflammatory process occurring in and about the papillæ and upper part
of the corium.
In the diagnosis of lichen ruber the papular syphiloderm, lichen
scrofulosus, psoriasis, and papular eczema are to be excluded. The
irregular and angular outlines of the lesions of the plane variety,
taken with their flattened, slightly umbilicated, smooth, or scaly
summits and the dull-red or violaceous hue, are sufficiently
characteristic. The evolution of a patch of psoriasis is entirely
different from that of this disease, the former appearing as small
spots and enlarging by peripheral growth, the patches of the latter
resulting from aggregations of lesions. In papular eczema the papules
are rounded, bright-red in color, intensely itchy, and have a different
history and course. The prognosis of lichen ruber planus is generally
favorable, although some cases are exceedingly rebellious. According to
Hebra, in the severe forms of lichen ruber acuminatus, if neglected or
improperly treated, a fatal result may ensue.
A general tonic plan of treatment is almost always indicated, such
remedies as iron, quinia, strychnia, and the mineral acids proving of
benefit. Arsenic exercises in many cases a specific influence. When the
general health is much reduced arsenic fails, as a rule, to benefit
until the patient's condition is brought back to its normal tone. The
remedy should be given in tolerably large doses, and continued until
the lesions have entirely disappeared. On account of the itching and
discomfort experienced, external applications are demanded. The various
antipruritic remedies mentioned in the treatment of eczema may be
employed. Alkaline baths are useful. Unna has reported a few instances
of cure of well-developed cases of the disease by the use of an
ointment composed of two ounces of oxide-of-zinc ointment, forty grains
of carbolic acid, and from one to two grains of corrosive sublimate.
Tarry applications, especially in the form of lotions, often prove of
service, the liquor picis alkalinus and the liquor carbonis detergens
being the preparations commonly employed.
Lichen Scrofulosus.
Lichen scrofulosus is a chronic disease characterized by
milletseed-sized, flat, reddish or yellowish, more or less grouped,
desquamating papules, {625} unaccompanied by itching and occurring in
those of a scrofulous disposition. The lesions, of a pale red or
yellowish color, are usually numerous, are seated about the
hair-follicles, and show a decided tendency to group, giving rise to
patches of variable size and of a rounded or crescentic shape, which
sooner or later become covered with minute scales. They are always
small; are seen usually about the abdomen and chest, and exceptionally
about the limbs; are chronic in character; and as a rule, are
unaccompanied by itching. Pit-like, atrophic depressions may or may not
follow the disappearance of the lesions.