GENERAL REMARKS ON TREATMENT

The guiding principles in the treatment of diseases of the skin differ
in no respect from those which govern in the management of maladies
of other organs. A correct diagnosis is essential except in diseases
running an acute course, which get well in spite of the bungling often
consequent upon error; but such affections are not very common in
dermatologic practice, and usually a sine qua non to success is first to
know what the disease is.

The proper diagnosis in its relation to therapeutics does not con­
sist, however, in merely, naming the disease correctly, but also includes
an appreciation, so far as possible, of the etiologic and pathologic factors
in the case. Thus founded, treatment will be most promising as to
results, especially as to permanency. It is true, in most instances, that
it is not always possible to discover the true etiologic influences, and to
a great extent, therefore, the therapeutic management is often that which
practical experience has proved of service.

A cure, if possible, should be brought about as quickly as practicable.
The belief of the laity that impurities are trying to get out, and that it is,
therefore, dangerous to the general health to cure or to cure too rapidly,
and which formerly found honest believers among physicians, is wholly
without foundation. This view has been strongly supported pur­
posely by advertising nostrums, and has likewise been a convenient
cloak for medical advisers helplessly at sea in cutaneous therapeutics.
On the contrary, the putting of the skin, an important organ and emunc-
tory of the body, into a healthy state, will not only relieve the patient
of an annoyance and worry, but conduce to his general well-being.¹
The main difficulty, unfortunately, in many diseases is our inability to
cure quickly enough.

In most diseases both local and constitutional measures are required.
There is some diversity as regards the value of internal medication,
which in times remote held the prominent place in treatment, but which
was gradually displaced by those holding the opinion that skin diseases
are purely local maladies, with no relationship to the general organism,
and therefore manageable by purely external measures—a view which
reached its greatest prevalence under the late Professor Hebra, and is
still held to a greater or less extent by most of the German writers, the
French, English, and Americans taking a conservative middle ground.
The strongest support of this latter view is found in the fact that many
American specialists, as well as many in England, spent a few years under
the distinguished tutelage of Hebra, Neumann, and Kaposi, whose

This is also referred to under Eczema.

105

106                  GENERAL REMARKS ON TREATMENT

views as to local treatment practically coincided, and returned home
thoroughly imbued with this idea, but which, under the test of in­
creasing personal experience, has gradually given place to the opinion
that while external remedies are essential in almost all cases, the proper
constitutional management in many diseases is likewise important, and
that the maintenance of good health keeps up the tissue-resisting power,
and therefore is of potent influence in the permanency of cure in cuta­
neous as well as other diseases.¹ It is true that many affections are
purely local, often parasitic, and that, therefore, systemic measures
are scarcely called for, but in some of these, doubtless, cutaneous tissue
weakness, induced by general ill health due to constitutional or organic
disease, favors successful parasitic invasion, and therefore systemic in­
vigorating measures are sometimes of service. This is often demon­
strated also in pulmonary tuberculosis. The various therapeutic meas­
ures and special remedies, both local and constitutional, will be referred
to, more at length, in connection with the individual diseases. A brief
preliminary review of the underlying principles and of some of the chief
remedies, may, however, be of some service.

CONSTITUTIONAL TREATMENT

For the most part, in the general constitutional management of
those diseases of the skin in which this seems advisable, it is not so
much to be based upon the malady present as it is upon the patient
—in short, the individual is to be studied rather than the skin disease
with which he is afflicted, and in the general run of cases much more
is to be expected than if remedies with alleged direct specific action
upon the malady or the cutaneous tissues are depended upon. Such
remedies, though relatively few in number, are not, however, com­
pletely to be ignored, for they sometimes have a decidedly useful in­
fluence. As remarked in discussing the physiology of the skin, it is to
be considered as one of the four emunctories of the body, and when this
is diseased or its full usefulness compromised, the functional deficiency
is partly, sometimes completely, made up by compensatory activity of
the other three, more especially, however, the kidneys and intestinal
tract; and, conversely, impairment of one of the latter may indirectly,
or possibly directly, be influential in provoking cutaneous disorders, as
referred to under general etiology, either by the superinduced increased
activity, or, and more probably, by the action of certain excretory
products which ordinarily should find their outlet through the kidneys
or intestinal tract. This possibility is to be borne in mind in the treat­
ment. Very often in the management, increased activity of the kidneys
and intestinal tract, by remedies which increase the flow of urine, and
promote free movement of the bowels, has a material influence in lessen­
ing and modifying cutaneous disturbances, particularly those of an in-

¹ Duhring, “Treatment of Certain Chronic Inflammatory Skin Diseases,” Jour.
Cutan. Dis., 1909, p. 379, has been throughout a strong exponent of this view, and his
long and large experience (as indicated in this paper) has served to confirm him in this
belief.

CONSTITUTIONAL TREATMENT

107

flammatory character. The general treatment, therefore, is to keep in
view the maintenance of a proper condition of the general health of the
patient, and if that be defective, be corrected or modified, if possible, by
suitable measures and remedies. A clue is sometimes given by the
amount or character of the urine. In fact, all etiologic possibilities
are to be considered. In the absence of any special indications, and
yet where the character and extent of the malady, especially in inflam­
matory affections, are strongly suggestive of some systemic factor, the
family history will often throw light upon the possible underlying dis­
ease tendency—diathesis, or constitutional weakness.

Hygienic living, proper food, well-ventilated rooms, plenty of sun­
light, outdoor life, unless contra-indicated by the weather; and, espe­
cially in those of sedentary habits, exercise in moderation; rest in some
diseases and cases; and sometimes, when feasible, temporary change
of scene and climate—are all to be considered of therapeutic importance.
As already indicated in discussing general etiology, in the large majority
of cases commonly met with, digestive disorders, such as dyspepsia,
gastric catarrh, constipation, etc, are the factors which most frequently
call for correction, and the various known remedies for these conditions
accordingly play an important rôle.

The dietary, therefore, is often of importance, and sometimes requires
supervising directions. In some affections, it is true,—as, for instance,
taking the extreme examples of verruca and xanthoma palpebrarum
and the parasitic affection, scabies, etc,—the consideration of the
question of food would be an absurdity. On the other hand, however,
the cases of extensively distributed eczema, of xanthoma diabeticorum,
many instances of pruritus, psoriasis, acne, dermatitis herpetiformis,
and others, improper feeding is often an important factor, or at least
an aggravating influence, and its proper regulation requires attention.
The patient is not, however, to be wholly ignored in this considera­
tion: his tastes, wants, and idiosyncrasies are to be consulted, for some­
times articles of food usually readily digested by others may, in individual
instances, be not only distasteful, but disturbing and fermentative.
As a rule, the well-to-do class consumes too much nitrogenous food,
and this is not infrequently a more or less damaging factor in some of the
inflammatory diseases. Even with this, however, an extreme position
is generally unwarrantable, for there are cases encountered in which
gastric weakness is a cause, and in which starches are badly borne, the
stomachic condition being overcome or palliated by chiefly a meat diet,
the eruption often undergoing perceptible improvement as the digestion
is thus improved. In other cases a purely milk diet can be employed for
a time with benefit; or, more frequently, conjointly with meat once daily.
The use of alcohol is, in the inflammatory affections, particularly eczema,
prejudicial and directly damaging, and should be interdicted or at least
limited, depending upon the habits and needs of the patient—as, for
instance, in the old and feeble. The excessive, and sometimes moderate,
use of tea, coffee, and tobacco is likewise to be prohibited. As to par­
ticular foods, those of difficult digestion, and others concerning which
there may be a possibility of unfavorable influence, are best avoided; and

108

GENERAL REMARKS ON TREATMENT

among such may be named pork in all forms, especially sausage and
scrapple, lobsters, crabs, clams, oysters (except in cold winter season),
and other “shell­fish,'’ veal, fish, pastries of all kinds, fresh breads,
“hot cakes,” waffles, cheese, dressed salads, acid fruits, seeded and acid
berries, pickles, usually condiments, except in moderation, nuts, and
sweets; potatoes in excess, cauliflower, cabbage, and onions are likewise,
especially in some individuals, often detrimental. The cereal foods may
ordinarily be taken in moderation, with milk or cream and salt, if desired,
but ordinarily with no sugar.

General tonics, both simple and nutritive, as readily to be
inferred from etiologic considerations, are often useful in certain skin
diseases in which debility or loss of general tone is an influence, as
often in eczema, pompholyx, seborrhea, acne, and other affections.
Anemic conditions are met with—iron, manganese, sometimes small
doses of arsenic and the hypopbosphites; quinin and strychnin are
also indirectly not infrequently of service. The most valuable general
nutritive tonic, however, in some cases, is cod-liver oil in small or moder­
ate dosage. The digestives and ordinary bitter digestive tonics, some­
times with an acid, sometimes with an alkali, by their influence on diges­
tion are often of service in promoting general invigoration; frequently
such, with a laxative, as required to keep the bowels free, will be all that
seems necessary or indicated.

Aperients find more than occasional use in cutaneous disease,
and the maintenance of a free action of the bowels, especially in the
inflammatory affections, cannot be overestimated, as aiding in getting
rid of toxic products, and usually improving digestion as well. Ex­
cept in anemic individuals, the salines are usually to be preferred; they
are given in dosage sufficient to produce free action, but not, except
rarely, active purgation. As a frequent or daily saline, magnesium
sulphate is probably the best, often usefully given with iron, as in the
“mistura ferri acida,” but sodium sulphate, sodium phosphate, and the
various natural aperient mineral waters are likewise valuable. Calomel,
usually in quickly following small doses, administered at intervals of
several days or more, can sometimes be employed with advantage,
especially if there is suspected torpidity of the liver. One of the most
valuable laxatives, as an occasional one, is the antacid magnesia, particu­
larly valuable when gastro­intestinal toxin development is probable.
Among the vegetable laxatives cascara, as the extract or fluid extract, is,
in my judgment, the most useful, although the other well-known drugs
are often used. For infants and young children castor oil, cascara, and
gray powder are the most serviceable. Plain enemata, often used, both
in infants and adults, as a rule are not to be commended except as a
temporary measure, although in some instances in adults an occasional
full flushing out of the lower bowel may prove beneficial.

Gastro­intestinal antiseptics are of considerable value in
some instances of eruptions seemingly due to auto­intoxication, as
urticaria, erythema multiforme, some cases of eczema, etc Among
those that may often be used with advantage are the laxative antacid
magnesia, minute doses of calomel administered at half-hour intervals

CONSTITUTIONAL TREATMENT

109

every several days, charcoal, salol, sodium salicylate, minute doses of
carbolic acid, and some others.

Diuretics.—These are often useful, and the free action of the
urinary flow thus promoted, together with occasional laxatives, often
proves very serviceable in some of the inflammatory and hyperemic
affections. They can often be employed with advantage especially
in eczema, psoriasis, markedly inflammatory acne, and acne rosacea,
dermatitis exfoliativa, dermatitis herpetiformis, and like inflammatory
disorders. The saline diuretics are, upon the whole, the best, and
in this class potassium acetate and potassium bicarbonate. These
are also valuable antilithemic remedies, and it is, as a rule, especially
in cases with this etiologic basis, that they are found most useful. In
such cases, too, sodium salicylate, ammonium salicylate, salophen, etc.,
often find an important place. In pruritus and other neurotic affections
small doses of belladonna can be conveniently used conjointly, as this
also has diuretic action, as well as other influence. Other vegetable
diuretics are also sometimes given. In all instances water should be
taken freely, as this in itself is a good diuretic. Possibly the influence
of oil of turpentine, oil of copaiba, etc, noted occasionally in a few dis­
eases, may be due, in a measure at least, to diuretic action.

General Alteratives.—All remedies, whether simple tonics, di­
gestives, etc, which improve nutrition are naturally to be classed as
general alteratives, but the drugs referred to here are those which possess
this property independently of such influence. The chief alteratives
of this class are the mercurials, iodin preparations, and the animal ex­
tracts. It is not unlikely that the alleged alterative effect of some of
these drugs may in fact be attributable to their germicidal influence, as
referred to further on. There can be no question of the value of mer­
cury in both the early and late stages of syphilis, and of the iodids in the
late syphilitic manifestations, for the evidence of eruptions quickly melt­
ing away under their influence is overwhelming. As will also be seen in
the course of the text, the iodin preparations are not without effect in
some cases of strumous affections. The favorable action of the iodid salts
in actinomycosis and blastomycetic dermatitis is also attested; its in­
fluence in large doses in some cases of psoriasis is undoubted, but whether
from alterative action or its effect as an alkaline salt is not definitely
known. The potassium iodid is the salt most commonly prescribed, but
in my own experience sodium iodid is just as effectual in syphilis, and less
apt to be disturbing.¹ Arsenic is also a valuable alterative.

The preparation of the mercurial to prescribe is greatly a matter
of prejudice or personal custom. The protiodid for active administra­
tion in the early eruptions of syphilis, and the biniodid in association
with potassium or sodium iodid salt in the late syphilodermata, are prob­
ably in most general use, and are those which I usually prefer. In
the later stages, however, corrosive sublimate is likewise a favorite
remedy with many. Mouth administration is usually satisfactory,
but cases are encountered which do not seem to yield to this plan,
and in such, inunctions with blue ointment are generally curative.
¹ See Dermatitis medicamentosa.

110

GENERAL REMARKS ON TREATMENT

The hypodermic method is a favorite plan with some. This remedy is
likewise found useful in some cases of lichen planus and a few other
affections.

Tar and carbolic acid are also remedies which occasionally appear
to possess alterative properties, and are sometimes prescribed for this
purpose, especially in psoriasis and eczema. The same may be said
of phosphorus, which, in ¹/₁₀₀ to ¹/₂₀ grain (0.0007 to 0.0035 gm.) dose
thrice daily, in pill or oily solution, is sometimes prescribed for lupus
erythematosus, lupus vulgaris, and other diseases. It presumably
acts through the nervous system, but there is no uniformity of opinion
as to its value; it has practically no place in treatment with the large
majority of dermatologists. In one or two instances of erythema indura-
tum it seemed to me of value; and in zoster, zinc phosphid, from ¹/₁₀ to ¹/₅
grain (0.007 to 0.014 gm.) four or five times daily, is sometimes of dis­
tinct service. Antimony, warmly supported by Malcolm Morris for
acute and subacute inflammatory diseases in robust individuals, notably
in eczema and psoriasis, is prescribed in dosage of from 3 to 10 minims
or more of the wine three or four times daily. Although this remedy
is also somewhat favorably referred to by Crocker, Duhring, and a few
others, it is not in very general use, probably owing to the care required
in its continued administration, lest depressing or other untoward action
should result. Turpentine has been advised in the same affections by
Crocker, to be given conjointly with free diluent drinks. Copaiba,
according to my observations, occasionally acts favorably in the same
class of cases. It is probable that the last two, in addition to some
general alterative action, benefit by their diuretic effect as well and pos­
sibly also have some special alterative influence directly upon the cuta­
neous structures. Quinin, which is sometimes apparently useful in ery­
thema multiforme, erythema nodosum, herpes zoster, eczema, and other
diseases, especially if there is an underlying malarial element, might
also be included in this class.

Animal extracts have lately been playing an important experi­
mental rôle in cutaneous therapeutics, as well as in other branches
of general medicine, and that some have a general alterative influence,
as well, possibly, as a special alterative action, cannot be denied; the
action is not, however, a regular one, but, on the contrary, exceptional.
Thyroid extract has proved valuable in myxedema, and occasionally has
some influence in cases of psoriasis, and has also been employed with
alleged benefit in lupus vulgaris and other chronic diseases, but its
possible untoward effects have limited its use. The dose of the desic­
cated extract, as furnished in tablet form, varies from ½ to 10 grains
(0.035 to 0.65 gm.) or more three times daily, always beginning with
moderate doses, and, if necessary, increasing, but cautiously. A glycerin
extract is also made. Suprarenal gland extract has recently been ex­
tolled for vitiligo.

Special Alteratives—The influence of the various remedies men­
tioned under Germicides, as well as some of those under General Altera­
tives and other heads, might also possibly be due to special alterative
or direct action upon the skin, but the chief exponent of this class, which

CONSTITUTIONAL TREATMENT

III

might likewise be termed “special cutaneous stimulants,'’ is arsenic,¹
when administered in dosage to get its special effects, and which is
entirely distinct from its use in small doses as a general tonic This drug
probably acts both directly and through the nervous system, and par­
ticularly, as shown in the experiments by Ringer, Murrell, Nunn, and
others, upon the epithelial layers. Clinical observation, both as to its
therapeutic action and toxic effects, is corroborative of these observations.²
It is likewise to be considered a potent nerve stimulant, and therefore also
of possible value in some diseases of neurotic origin. It is a remedy which
is more especially indicated in the superficial dermatoses. Like most
remedies which possess some certain value, it was formerly given almost
the standing of a panacea, Hunt being one of its most extreme ad­
vocates; and following this comes the rebound, and in comparatively
recent years there has been a tendency with some dermatologists to
belittle its value and set it aside, but this is, in my judgment, just as
unwarranted as the other extreme. It is, it is true, still much overrated
by the general profession, who often prescribe it indiscriminately, fre­
quently upon the basis of a “skin disease,” and much harm thus results.
Its chief value, upon the whole, is in sluggish and sluggishly inflam­
matory cases of cutaneous disease, those which originate in the epithelial
layers or in which these are prominently involved, as psoriasis, lichen
planus, and a limited number of persistent dry eczemas; and also in those
diseases of neurotic character, as pemphigus, dermatitis herpetiformis,
and some others.

Jaborandi, or its active ingredient, pilocarpin, is sometimes of value
in cases in which benefit is to be derived from stimulation of the sweat
function, as in the dry, scaly diseases, ichthyosis, psoriasis, etc. Cal­
cium sulphid, sulphur, elsewhere referred to, and some other remedies
have also been accredited with special alterative action in certain dis­
eases, the sulphur preparations especially in the diseases of the glandular
structures.

Germicides.—While probably no remedy administered internally
is distinctly germicidal, there are, doubtless, some which, in a few dis­
eases, in some manner, make the body and its tissues an unfavorable
habitat for micro-organisms, or which are antidotal to their products.
We know that the value of quinin in malaria is based upon this fact,
and it is scarcely to be doubted that mercury and arsenic (salvarsan)

¹ Sodium cacodylate and, more recently, atoxyl—arsenical preparations—have been
variously extolled as valuable substitutes for the ordinary preparations; their alleged
lessened possibility of producing toxic action being lauded. They have some, probably
an equal, value, but observations do not support the early published statements of
marked superiority. Salvarsan has recently largely supplanted these preparations.

² In a recent elaborate and exhaustive paper on “The Action of Arsenic on the Skin
as Observed in the Recent Epidemic of Arsenic Beer-poisoning,” Brit. Jour. Derm.,
1901, p. 121 (with many case and histologic illustrations, review of the subject, and
references), Brooke and Leslie Roberts conclude as follows: “In the face of the facts
which we have endeavored to place before the reader, we have no hesitation in saying
that arsenic, and the other members of the nitrogen group, must be distinguished from
all other medicaments by the fact that their action, whether therapeutic, pharmaco-
logic, or toxicologic, is entirely dynamic, and consists essentially in altering the ratio to
the tissues of one of the most active normal ingredients of the body—namely, oxygen.”
See also Dermatitis medicamentosa for toxic effects upon the skin and for other litera­
ture references.

112                  GENERAL REMARKS ON TREATMENT

act the same way in syphilis. It is not improbable that other remedies
strikingly useful in other diseases may owe part of their success to this
action. Cod-liver oil often seems to have this property, independently of
its nutritive influence. Sulphur, owing to its exhalation through the skin,
internally, may also possibly have a slight influence in lessening the hold
of cutaneous micro-organisms, as in the alleged favorable action of
calcium sulphid in boils, seborrhea, acne, etc. It has appeared to me
that those whose skin has naturally more or less of a sulphurous exhala­
tion, as shown by the rapidity with which silver or silver-containing
jewelry is tarnished, are less liable to exhibit such parasitic diseases as
tinea versicolor, ringworm, etc, and on this supposition its administra­
tion in such affections may be an advantage conjointly with the proper
local treatment.

Tuberculin and other prepared toxins or vaccines are remedies or
agents whose anticipated effects were presumably based upon some
germicidal or antidotal properties. It is well known that in recent
years the hypodermic injections of “tuberculin” for lupus vulgaris
and the other forms of cutaneous tuberculosis have been employed,
and sometimes with a decided effect upon the disease, which is more
fully referred to in connection with these maladies. The uncertain
and variable effect, however, of this and other prepared toxins, or vac­
cines, gradually led to their practical abandonment; but in the past
few years, chiefly through the enthusiastic work of Wright and others,¹
who have endeavored to place their employment upon a scientifically
exact bases, various “vaccines” are again being cautiously and tentatively
tried in several dermatoses. Wright found by experimental investiga­
tion in certain diseases, as, for instance, sycosis, furunculosis, acne,
tuberculosis, and a few others, that the phagocytic power of the blood
was reduced, and that this was neither due to the serum nor to the
leukocytes, but to the diminution of some unknown constituents, which

¹ Literature, Wright and Douglass, “An Experimental Investigation of the Rôle
of the Blood Fluids in Phagocytosis,” Proceedings of the Royal Society of London, 1903,
vol. lxxii, p. 357 and 1904, vol. lxxiii, p. 128; Potter, Ditman, and Bradley, “The
Opsonic Index in Medicine,” Jour. Amer. Med. Assoc, 1906, pp. 1722 and 1793 (with
review of important papers and complete bibliography); Houghton, “A Review of the
Opsonins and Bacterial Vaccines,” Therapeutic Gazette, January 15, 1907 (with com­
plete bibliography); Pernet and Bunch, “The Opsonic Treatment of Certain Diseases
of the Skin,” Brit. Jour. Derm., 1906, pp. 339, 397, and 427; and Houston and Rankin,
“The Blood in Relation to Skin Diseases,” Brit. Med. Jour., October 6, 1906; Gilder-
sleeve (Monthly Encyclopedia of Practice of Medicine, September, 1907) gives a clear
account of the technique; A. E. Wright, “Principles of Vaccine Therapy,” Jour. Amer.
Med. Assoc, 1907, vol. xlix, p. 479; Potter, “Further Observations on Opsonins in
Normal and Pathologic Sera,” ibid., p. 1815; Varney, “Opsonic Therapy in Skin
Diseases,” ibid., pp. 316, 487, and 567; “Inoculation of Polyvalent Staphylococcic
Suspensions in Staphylococcic Infections of the Skin,” ibid., vol. liii, 1909, p. 680;
Whitfield, “The Opsonic Method in Skin Diseases,” Jour. Cutan. Dis., 1907, p. 529;
Von Eberts, “Bacterial Inoculation in the Treatment of Suppurative and Tuberculous
Diseases of the Skin after the Method of Wright,” ibid., p. 538; and Schamberg,
Gildersleeve, and Harlan Shoemaker, “Bacterial Injections in the Treatment of Dis­
eases of the Skin,” ibid., p. 544; Engman, “Bacteriotherapy in Certain Diseases of the
Skin,” ibid., 1910, p. 553; Gilchrist, “Vaccine Therapy as Applied to Skin Diseases,”
ibid., p. 568; Towle and Lingenfelter, “Vaccine Therapy in the Treatment of Diseases
of the Skin at the Massachusetts General Hospital,” ibid., 1910, p. 583; King Smith,
“The Relationship of Vaccine Therapy to the Treatment of Certain Diseases of the
Skin,” Jour. Cutan. Dis., 1911, p. 432 (see under Acne for other references).

CONSTITUTIONAL TREATMENT                         113

he called “opsonins,” and further, that the hypodermic injection of an
appropriate “vaccine’’ would influence the quantity or activity of the
“opsonins,” and have an effect upon phagocytosis, and indirectly upon
the disease. If the dosage of the vaccine was correct, the “opsonic”
power of the blood, and consequently phagocytosis, was increased, and
by a series of proper dosages could be brought up to normal and exert
a favorable curative action; but on the other hand too large a dosage
would still further decrease the “opsonins” and thus lessen the phago-
cytic power and probably have an intensifying effect upon the disease.
This opsonic action was believed to be due to some alteration in the mi­
crobes which permits their being ingested by the leukocytes; but the effect
is now attributed to an increase and stimulation of the “antibodies.”
He devised a method (a modification of Leishman’s method) of measuring
the opsonic power of the blood which need not be detailed here, and by
doing this from time to time he was enabled by this “opsonic index” to
reach an approximately correct dosage, and also to regulate its frequency;
and in the various diseases named, as stated by him and a few other
observers, the curative influence was striking. As is readily inferred,
therefore, if “vaccine” treatment of any disease is determined upon, the
first doses should be the smaller, and subsequent doses, as well as fre­
quency, regulated by a study of the “opsonic index.” ¹

Vasomotor Constringents.—Several drugs are credited with
this action upon the cutaneous vessels, leading to their contraction and
the reduction of hyperemia. They are more especially employed in
acne rosacea, and less frequently in purpura, pruritus, and a few other
affections. Ergot is sometimes prescribed for this purpose, principally
in acne rosacea and purpura, usually in moderate dosage. It has also
been used in ordinary acne, where lack of tone in the muscular fibers of
the skin is suspected. Inasmuch, however, as there is in these cases often
gastric irritability or digestive weakness, which the drug frequently seems
to increase, its field of usefulness is somewhat restricted. Ichthyol has
been highly extolled, especially by Unna, for promoting vasomotor con­
traction, and as especially useful in acne rosacea, and also in such affec­
tions as lupus erythematosus and other hyperemic diseases. It is usually
administered in capsules, 3 to 15 minims or more three times daily, but
opinion as regards its value as a constitutional remedy is by no means
unanimous. My own observations do not give it very high rank.
Thiol has also been suggested as possessing the same properties as
ichthyol.

Analgesics.—Antipruritics—It may be stated, as a rule, that
in the inflammatory dermatoses most drugs known as analgesics are
often of aggravating influence in their after-effects; less frequently
they are directly damaging. This scarcely holds true, however, in such
diseases as herpes zoster, which sometimes, on account of the neuralgic
pain, requires the administration of such remedies. In this malady
opium or morphin can be used if deemed advisable, but in others, espe-

¹ More recently, most observers have dispensed with the opsonic test, owing to
its difficulties and tediousness, and to the belief that the effect of one or two trial
doses gives sufficient indication as to frequency of administration and quantity.

8

114                  GENERAL REMARKS ON TREATMENT

daily those of itchy character, it is apt in its later influence to increase
this symptom. The safest drugs to employ for the pruritus, when neces­
sary, as it sometimes is, to procure a night’s rest, are the bromids and
chloral; belladonna, gelsemium, phenacetin, and antipyrin may also be
used for this purpose, and in some cases lupulin in full doses may be
tried. Upon the whole, however, they are best avoided if possible;
relief from the itching can usually be obtained by certain local applica­
tions, to be referred to.

Natural Mineral Waters.—The use of the stronger natural
aperient waters has already been incidentally referred to; their good
effects are due to their laxative action. The milder aperient waters,
usually taken at the various springs, have the same influence, but, in
addition, the large quantities taken serve to keep the kidneys in free
action as well, and thus act in two ways. The value of the alkaline waters
taken freely is undoubted, but whether of any more service than the ad­
ministration of ordinary alkalies with plenty of drinking-water is some­
what problematic. The iron waters and arsenic waters are also well
known, and as substitutes for the ordinary drugs have a value, and the
same may be said of the sulphur waters, in which laxative influence and
alterative and probably antilithemic action are combined; but these
waters are not useful in gastric catarrh or dyspeptic cases. Inasmuch
as the underlying factor in many cases is a gastro­intestinal catarrhal
or digestive disturbance, usually with constipation, the most useful
spring waters, on the whole, are those of alkaline and slightly laxative
character. These are also beneficial in underlying rheumatic conditions.
The moderately active laxative waters of an alkaline character are more
especially to be preferred with bons vivants—those who have been storing
up the effects of overfeeding and overdrinking.

No one can doubt the favorable influence of the natural spring waters
if taken liberally, for the reasons given, but taken at home, their effect
is relatively nil compared to the influence gained at the resorts them­
selves, where, in addition to the free drinking of a mildly therapeutic
water, are conjoined usually a rigorous dietary supervision and the un­
questioned effect of change of scene, climate, release from care, etc.
These last are the influential factors at drinking springs; the medicinal
ingredients of the water are the least potent in the final effect gained.

Simon¹ has made favorable reports of the value of injections of sea-
water in skin diseases, but others, among whom C. J. White,² have not
been able to corroborate this alleged favorable action.

Electricity.—The general tonic and alterative action of general
faradism, galvanism, or static insulation or shock can sometimes be
made use of with advantage in cutaneous diseases associated with lack
of nervous tone, especially galvanism and static electricity. Shoemaker,
Brocq, and one or two others are the only ones who have given much
attention to the advantages of electrization, an adjuvant in the manage­
ment of some cases which, from my own experience with its use, I can

¹ Robert Simon, “Applications therapeutiques de l’eau de mer,” Paris.

² C. J. White, “Injections of Sea-water in Skin Diseases,” Boston Med. Surg. Jour.,
July 29, 1909.

LOCAL TREATMENT

115

indorse. In some cases of eczema, urticaria, pruritus, and other mala­
dies or cases showing neurotic relationship its influence is sometimes con­
siderable.

LOCAL TREATMENT

As a rule, in cutaneous diseases external applications are necessary
both for the favorable or curative action exerted upon the malady itself,
as well as for the relief of the accompanying itching or other troublesome
subjective symptoms. External treatment is, therefore, of great im­
portance, and generally much more essential for immediate relief than
systemic remedies, although in many affections, as already stated, a
judicious blending of the two will give far more satisfactory permanent
results in the aggregate than local measures alone. It is true some of
those running an acute short course, and some of the chronic disturb­
ances,—relatively few in number, however,—are not influenced by
external treatment, and unless demanded by annoying itching, burning,
or pain, local applications are unnecessary.

The measures employed in the external management of skin diseases
are varied, and are mentioned with more or less detail, and their special
manner of employment described in connection with the diseases in
which they are employed, each more particularly in that disease wherein
the method or drug finds its most prominent employment. To avoid
unnecessary repetition, but brief reference in a general way will, therefore,
be made here, and only to those most commonly resorted to. The essen­
tial underlying principles of external treatment should be mild, soothing,
and protective applications for acutely inflamed surfaces; similar prepara­
tions in the early part of the treatment of subacute inflammatory types,
moderately stimulating for those of sluggishly subacute or with slight
infiltration, and actively stimulating for thickened, infiltrated, sluggish
areas. Various modifications are often required to suit the individual
case. Fortunately, most of the remedies thus employed are antiseptic,
and this is a very important factor in cutaneous therapeutics.

Water.—Baths.—Water is employed for two purposes—cleanli­
ness and to remove the products of disease. As a general rule, in acute
inflammatory disease, notably in many cases of eczema, it is prejudicial,
and its use, therefore, restricted as much as is consistent with the require­
ments just stated; in some instances of acute irritability its place must
be taken by some cleansing oil or grease, such as olive oil, almond oil,
cold cream, or vaselin. A thorough soaking with one of these, especially
the oils, will usually soften crusts or scales rapidly and facilitate their
removal; sometimes the parts must be kept bathed with it by means of
compresses, and renewed from time to time. In such instances water can
almost be dispensed with or used only at intervals. Rain water or boiled
water is less irritating than ordinary water.

In some of the hyperemic and more acute diseases, and in chronic
diseases of a somewhat acute or subacute type, such as dermatitis
exfoliativa and some cases of eczema, baths made mucilaginous with
gelatin (about ½ to 1½ ounces to the gallon), starch (about ½ to 1 ounce
to the gallon), bran (about 1 or 2 ounces to the gallon), are usually

116                  GENERAL REMARKS ON TREATMENT

soothing in character, and sometimes permissible and palliative in their
effect. On the other hand, in some cases and some diseases of a sluggish,
chronic, scaly character, such as, for instance, ichthyosis and most cases
of psoriasis, the free use of water for washing and cleansing, or in the form
of baths, plain or medicated, is not only not damaging, but is often a very
important factor in the treatment. The warm to hot bath is frequently
sufficient in the less aggravated cases, or it can be made alkaline, as is
frequently necessary, by the addition of a varying quantity of an alkaline
salt, depending upon the character and tenacity of the scales and the
irritability of the skin. Those commonly used for this purpose are
sodium bicarbonate (averaging 1½ drams to the gallon), sodium borate,
potassium carbonate, or ammonium muriate (averaging a dram to the
gallon). The sulphur bath is occasionally used in the chronic sluggish
dermatoses, and is best made with potassium sulphid or Vleminckx’s
solution (averaging a dram to the gallon). The salt bath (averaging 3
ounces to the gallon), as commended by Piffard, is also useful in some of
these cases. Tar baths are, at present, not much used. Corrosive
sublimate baths will be referred to in the course of the text. An ordinary
tub-bath takes about 30 gallons. The bath should always be taken warm
enough to permit of immersion for from three to twenty minutes without
chilling.

Steam and hot-air baths are only occasionally advisable in derma-
tologic practice, and in the same diseases in which alkaline baths are
prescribed. The cold shower or plunge may also be of service in ex­
ceptional instances, but in cutaneous therapeutics has an extremely lim­
ited usefulness. The same may be said of the wet-pack. The natural
spring-water baths are also sometimes resorted to, and the effects, owing
to the methodic manner in which they are carried out, and supplemented
by the advantages of change of environment, diet, etc, are sometimes
striking.

Soaps are frequently demanded in connection with the use of water
for cleansing purposes, but should be even more rigorously excluded in
acute eczematous diseases and similar conditions. But the same reasons
why water must sometimes be used also hold with soap, but great care
should be taken to remove such washings with clean water. There are
two classes of soaps, the mild and the strong—the soda soaps, of which
Castile soap is a representative, and the potash soaps, of which sapo
viridis is the one commonly employed. The soda soap should be as
nearly neutral as possible. Its use for toilet purposes has an influence in
keeping the skin in healthy condition, but in those of thin epidermis and
sensitive skin must be employed in moderation, and exceptionally
individuals are met with whose exposed skin, especially the face, does
not bear well even its occasional use; in some instances, however, this
signifies that the soap contains too much free alkali. As a rule, the
washing of the face when using soap, especially on skin at all sensitive,
should be done at bedtime; if done during the day, the exposure to wind
and weather is irritating. An attempt to overcome this has led to the
manufacture of a “superfatty soap,” which is less irritating to some skins,
but it is sometimes uncertain in this respect with others. Soda soap,

LOCAL TREATMENT

117

more freely used than for ordinary toilet purposes, is of advantage in the
treatment of acne and some other affections, and it may also be used in
some cases in connection with the warm bath in place of the alkaline
salt. Sapo viridis may also be so used, but it represents a stronger
alkaline bath.

This latter, known also as sapo mollis, or green soap, is a strong soap,
and should not be employed in diseases of an acute or, as a rule, subacute
type. For removing adherent scales and crusts in sluggish conditions,
however, it is sometimes valuable; also in some cases of acne, seborrhea,
and psoriasis of the scalp, etc. It may often in these cases be used with
greater advantage in the form of the tincture of sapo viridis, corresponding
to the spiritus saponatus kalinus of Hebra. The best sapo viridis is that
imported from Germany; the extemporaneously made soap having, espe­
cially in tincture form, proved, in my experience, often unsatisfac­
tory.

Medicated soaps, made by the addition of various drugs to the
soda soap basis, are now prepared by various manufacturers, and while
their action is often questionable and their field of usefulness small,
occasionally they may be prescribed advantageously—as, for instance,
the sulphur-naphthol soap, for body toilet use after an apparent cure
of tinea versicolor. Medications have also been made to the super­
fatted basic soda soap. The tincture of green soap can often be ad­
vantageously medicated with resorcin and other drugs for use in the
shampoo for seborrhea, etc.

Dusting-powders have a somewhat limited field in cutaneous
medicine. They are prescribed in the erythemata, especially ery­
thema intertrigo, in erythematous eczema, hyperidrosis, bromidrosis,
and some other affections. Those in more common use are zinc oxid,
starch, lycopodium, rice, talcum, magnesium carbonate, boric acid,
zinc oleate, zinc stearate, and others, those most valuable being referred
to under eczema and other diseases in which they are employed. They
are variously used for their protective, antiseptic, astringent, and drying
properties. They are not applicable where there is free gummy or puru­
lent discharge. The first requisite of a good dusting-powder is that it
should be absolutely free from grittiness, which can be readily ascer­
tained by rubbing some between the two finger-ends.¹

Lotions are much more agreeable applications than ointments,
and are useful in many diseases, in some of which they may be used
alone. In others they are found too drying to employ continuously,

¹ Kapp (“Ueber Toilette­ and Schmink-puder,” Derm. Wochenschr., 1912, liv, p.
458) has studied the various vegetable and mineral powders, especially from the
point of their mechanical action on the skin, and also made examinations for germ
contamination. The material was (67 specimens—powders, powder-boxes, powder-
puffs, etc) obtained from private patients of the better class. Only 5 specimens were
free from organisms. In 53 were found non-pathogenic organisms; 2 showed mucor
mucedo; 1, a hyphomycete; 3, staphylococcus pyogenes aureus; 1, Unna’s morococcus;
1, streptococcus; 1, tubercle bacilli. The vegetable powders have the disadvantage of
the swelling of the granules from moisture, and when within the follicular openings
possibly provoking enlarged pores; in this respect, rice powder is the least harmful.
Mineral powders may produce mechanical irritation by the sharp edges and spiculæ
of the grains; the least harmful mineral powders being zinc oxid, precipitated magne­
sium carbonate, and magnesium silicate.

1l8                GENERAL REMARKS ON TREATMENT

but can be satisfactorily used intermittently or conjointly with oint­
ments. They are probably most frequently applicable in acne, urti­
caria, pruritus, erythema intertrigo, some cases of eczema, etc. In
some cases the drying effect can be lessened or abolished by the addition
of from 1 to 5 or 10 minims (0.065 to 0.33 or 0.65 gm.) of glycerin to the
ounce (32 gm.), but this ingredient should rarely exceed this amount
in most instances, as it may prove irritating, whereas in minute quantity
it is often a valuable addition. From 5 to 10 minims (0.33 to 0.65 gm.)
of alcohol to the ounce (32 gm.) may also frequently be added with
advantage for the pleasant, cooling sensation it produces—when not
contra-indicated, as it would be in exceedingly acute conditions, more
especially, however, when the rete or corium is exposed.

According to the effect desired, lotions are of various characters, as
indicated by the following qualifying names—soothing lotions, anti­
septic lotions, astringent lotions, stimulating lotions, antipruritic lotions,
etc. They will be found specifically referred to in connection with the
various diseases in which they find application.

As an example of an extremely mild, soothing lotion may be men­
tioned that usually designated calamin liniment, calamin-zinc-oxid
liniment, consisting of 1 to 2 drams (4-8 gm.) of zinc oxid and calamin,
4 to 10 minims (0.26-0.65 gm.) of carbolic acid, and 2 ounces (64 gm.)
each of lime-water and oil of sweet almonds. These pulverulent ingre­
dients make it of a slightly astringent and protective character. In
some instances olive oil instead of the almond oil seems more accept­
able. It is to be applied frequently by tapping it on, or the parts can be
kept enveloped with cloths or lint wet with it. Closely similar, but dis­
tinctly drying in its character, is the plain or aqueous well-known cal-
amin-and-zinc-oxid lotion, consisting, in the average formula, of about
1 or 2 drams (4-8 gm.) each of calamin and zinc oxid to the 4 ounces
(128 gm.) of water, or of 2 ounces (64 gm.) each of lime-water and plain
water; to this is sometimes added, in minute quantity, as stated above,
carbolic acid and glycerin. This is especially valuable in some cases of
erythematous and vesicular eczema of the acute type, in erythema
intertrigo, and some other affections. Both these powders seems also
to be slightly antiseptic, but this property of the lotion can be further
emphasized by the addition of from 5 to 15 grains (0.35-1 gm.) of boric
acid to the ounce (32 gm.), and which does not compromise its soothing
character. Lotio nigra, with an equal quantity of water or lime-water,
is another example of a soothing antiseptic lotion. As a plain antiseptic,
soothing lotion, free from sediment, may be mentioned one of boric acid
of the strength just indicated, and which can often be used alone, but
also more frequently with great advantage conjointly with a soothing
salve. It is one of the most valuable mild antiseptic lotions we possess,
and in my practice is indispensable. Astringent lotions in the strictest
sense are those containing tannin, alum, zinc sulphate, and the like, used
most commonly in hyperidrosis. The stimulating lotions are well illus­
trated by the sulphur washes and tarry lotions, prescribed respectively
in acne and chronic eczema. Antipruritic lotions will be referred to
under the head of Antipruritics.

LOCAL TREATMENT                                   119

Ointments are the most frequently employed preparations in
cutaneous therapeutics, and, upon the whole, in many cases, are by
far the most valuable; they probably find their greatest usefulness as
applications in eczema, to which the reader is referred for many points
concerning the various formulas and other matters not here touched
upon. The best ointment bases are: (1) Prepared lard, which is the
best all-round base, possessing penetrating powers scarcely exceeded by
any other fat, but which has the disadvantage of tending, after a time,
to rancidity, and should therefore always be fresh; (2) petrolatum, or
its equivalent, vaselin or cosmolin, is also valuable, having but little
tendency to change, constituting a good protective, but lacking some­
what in its power of penetration, although Luff's experiments point
to the contrary; occasionally, either from imperfect purification or for
other cause, it is found to disagree; (3) cold cream (unguentum aquæ
rosæ) is soothing and cooling, and is to be considered an admirable base,
when properly made, and may often be used when other fatty applications
disagree. These three, used sometimes separately, sometimes in mixture
of two or all, are those which will be found most satisfactory. To these,
other fatty substances, such as spermaceti, wax, suet, and the like are
sometimes added for special purposes, and of which simple cerate (cera-
tum simplex), simple ointment (unguentum simplex), are some pharma-
ceutic examples. The stiffer substances are necessary when a good deal
of liquid medication is to be added, such as lead-water, oil of cade, etc.;
if an aqueous substance, and in much quantity, enough lanolin with
which it can first be rubbed up, together with variable amounts of
simple cerate and lard, or petrolatum, can be satisfactorily employed
as the base. Lanolin, introduced by Liebreich, and since more or less
generally advised, is said to surpass in its power of penetration all other
bases, but this is not borne out by experience; and it is an unsatisfactory
and even impracticable base when used alone, but in the proportion of
from 10 to 20 per cent, to other bases, it is sometimes a valuable addition
in seborrhœa and ringworm of the scalp, and some other maladies.
Water readily mixes with it, but this ingredient with this fat does not
seem to have the cooling influence that it does in cold cream. Adeps
lanæ is a closely similar preparation to lanolin. Glycerite of starch is
another base occasionally employed, but is not in general use, and
sometimes produces irritation. Upon exposed surfaces it is some­
times an advantage, purely cosmetic, to add a small quantity of
calamin, umber, etc., to give the ointment selected a skin color (see
under Eczema).

Ointments are of various characters as regards the incorporated
medicament—soothing, stimulating, etc. Soothing or mild ointments
find their use in irritable and acutely inflamed cutaneous maladies, as in
eczema of such type, and not only protect the skin from irritation, moist­
ure, air, or other injurious influences, but are directly comforting and
healing to the diseases surface. The best exponents of this class are the
zinc-oxid ointment, cold cream, simple ointment, cucumber ointment, and
a few others. Zinc oxid, as well as calamin, bismuth subnitrate, and
some other substances, in the proportion of from 5 to 15 per cent, or

120                  GENERAL REMARKS ON TREATMENT

more, add slightly astringent and mildly antiseptic properties to such
ointments, and are rarely detrimental. The addition of from 2 to 5
grains (0.135-0.33 gm.) of salicylic acid or from 5 to 10 grains (0.33-0.65
gm.) of boric acid, adds still further to the antiseptic character, and, as a
rule, is not in this quantity disturbing, even in acute conditions, but all
such additions in these cases must be made with caution. Cocoa-butter
can also sometimes be added with advantage in the quantity of from
5 to 10 per cent.; it has a stiffening influence on the ointment consistence.
Diachylon ointment is much used in Vienna, and if well made and fresh,
is in many cases grateful, but it does not seem possible to be sure of a
good preparation, and one improperly compounded or old or rancid is
sure to irritate. Mild ointments are applied either by anointing or by
spreading on patent lint or other suitable material; if lint is used, the
ointment should be spread on the woven side, as, being free from fuzzy
particles which are apt to stick to the skin, as well as being less likely for
the fibers to break apart when the salve is spread on. It may also be
applied on paraffined or waxed paper, being thinly spread; this is more
especially applicable on parts where there is but little motion.

A good example of an antiseptic, and yet mild salve, in addition to
those named, is the boric acid ointment (unguentum acidi borici).
Stimulating ointments are constituted of one or more of the several bases
named, with the addition of a drug having stimulating properties, such
as sulphur, tar, white precipitate, calomel, or other mercurial, resorcin,
salicylic acid, chrysarobin, etc., and, according to the proportion present,
they vary from one scarcely stronger than a soothing salve to that actually
caustic. Stimulating salves are usually to be well rubbed in.

Pastes are a form of ointment suggested by Lassar and elaborated
by Unna and others, which are largely made up of pulverulent sub­
stances, most commonly starch and zinc oxid, with usually a petroleum
fat as the fatty constituent. Lassar’s formula—Lassar’s paste—
consists of 1 part each of zinc oxid and starch and 2 parts of vaselin, to
which is commonly added 1 or 2 per cent, of salicylic acid—salicylic
acid or salicylated paste. Duhring commends highly a somewhat
softer paste, and more cleanly, consisting of 1 part boric acid, 3 parts
each of zinc oxid and starch, and 12 parts vaselin. Others will be found
referred to under Eczema. These preparations are often of greater
value than ordinary ointments in some cases of eczematous disorders of a
subacute or not too acute type, owing to their stiffer consistence and to
their greater adhesiveness, and also to their porosity; they make a thin,
usually rapidly drying, protective coating.

Attempts have been made from time to time to find cleaner, ready-
made and spread ointment applications to take the place of the ordinary
salves but so far the preparations known as salve-mulls or salve-muslins,
devised by Unna and manufactured in Germany, and now obtainable
in most of our large cities, are the only satisfactory substitutes; these
often act very satisfactorily, the zinc oxid salve-mull being especially
valuable. Their costliness is a disadvantage, and considerably limits
their employment. Plaster-mulls, or plaster muslins, also devised
by Unna, are adhesive, plaster-like applications, variously medicated

LOCAL TREATMENT

121

with mild to stimulating or caustic ingredients which have a more
limited field; a tolerably fair substitute is now found in the “rubber
plasters” of our own plaster manufacturers.¹

Oils are sometimes used in place of salves, both for the removal
of crusts and scales and for the purpose of medication, especially upon
the scalp; they may be variously medicated. Olive oil, almond oil,
liquid petrolatum, and oil of cade are among those most frequently
employed. These and others will be. referred to in connection with the
diseases in which they are used. Oily preparations, as well as lotions
without sediment, are best applied to the scalp by means of an “eye-
dropper,” putting a drop here and there and then spreading or rubbing
in with a piece of woolen rag.

Fixed Dressings—But little reference need be made to such in
this place, inasmuch as those commonly used are sufficiently fully con­
sidered under Eczema and Psoriasis. In a way the salve-mulls, plaster-
mulls, and rubber plasters already referred to are to be considered in this
class, especially the latter two, which are adhesive and can sometimes be
kept applied several days without change. Their use is, however,
limited, and principally to some sluggish, chronic, thickened, dry types
of eczema, patches of lichen planus, keratosis palmaris, and other epider­
mic thickenings, as clavus, and in some cases of lupus and tubercular
syphiloderm.

Tragacanth, bassorin, and acacia mucilaginous applications, as well
as gelatin dressings (glycogelatin), have been employed in recent years,
and will be referred to specifically under Eczema.

Collodion and liquor gutta-perchæ also furnish rapidly drying coat­
ings, and may likewise be variously medicated. Collodion is more valu­
able than the gutta-percha solution, as it dries more quickly, is a thicker,
firmer film, and exerts a more positive compressing action, which is of
advantage. It has its chief field in psoriasis, in lupus erythematosus, in
ringworm, small thickened patches of sclerous eczema and of lichen
planus, callositas, and other keratoses. In psoriasis and ringworm,
chrysarobin, formerly known as chrysophanic acid, is usually the medic­
inal ingredient, in from 10 to 15 per cent, proportion, sometimes with
from 2 to 5 per cent, salicylic acid; and frequently this last alone, as in
occasional cases of ringworm, callosities, clavus, etc. Oil of cade, pyro-
gallol, known formerly as pyrogallic acid, and other drugs are also thus
used. Collodion paintings, especially of pyrogallol and resorcin, some­
times act with unexpected energy, so that some caution is at first neces­
sary. As a rule, unless the added ingredient is an oily one, a mixture
of equal parts of plain collodion and flexible collodion is a more satis­
factory vehicle, the former alone tending to crack too easily, the latter
drying somewhat less rapidly and not possessing the same compressing
power. In those instances where this last property is especially desired,
as usually in lupus erythematosus, the plain collodion is the best. Other
details will be found in connection with the various diseases in which this
vehicle is employed, especially psoriasis. The gutta-percha solution,

¹ Stelwagon, “Notes on the Use of Medicated Rubber Plasters in Certain Cuta­
neous Diseases,” Med. News, October 8, 1887.

122

GENERAL REMARKS ON TREATMENT

or traumaticin, is used chiefly as a vehicle for chrysarobin or salicylic
acid, in the treatment of psoriasis and some keratoses.

Salve-pencils and paste-pencils, the former composed of wax, oil,
sometimes with a gummy or resinous substance added, and the latter
usually of a variable mixture or compound of tragacanth, acacia, starch,
and other ingredients, haVe been brought forward, with different medica­
ments incorporated, for application to small spots or areas, but their
field of usefulness is so extremely small that special comment is not
necessary.

Antipruritics.—Carbolic acid is the most valuable antipruritic,
and is often added for this purpose to ointments or lotions—in the
former from 3 to 30 grains (0.2 to 2 gm.), and in the latter from 2 to about
10 grains (0.135-0.65 gm.) to the ounce (32 gm.), the proportion depend­
ent upon the condition of the skin and the obstinacy of the pruritus,
markedly inflammatory cases, and especially in children, requiring the
smallest quantity. It is most agreeably prescribed in lotion form.
Occasionally it is not well borne. Liquor carbonis detergens (formula
under Eczema), a solution of coal-tar in an alcoholic solution of soap-bark,
is somewhat similar, and an exceedingly valuable remedy, used in lotions
chiefly from 1 to 3 drams (4-12 gm.) or more to the half-pint (256 gm.);
or in ointments, 5 to 30 minims (0.35-2 gm.) to the ounce (32 gm.).
Resorcin, from ½ to 5 or 10 grains (0.035-0.65 gm.) to the ounce, accord­
ing to the condition or disease, frequently exercises an antipruritic and
quieting action. Boric acid in solution, usually saturated, also seems at
times to exert, probably indirectly, a mild, quieting, soothing, or anes­
thetic action, and can often with advantage be made the basis for the
other more active remedies just mentioned. Weak alkaline lotions, 2
to 16 grains (0.135-1 gm.) of borax or sodium bicarbonate to the half-
pint (256 gm.), are also sometimes of service in certain itching diseases,
but are usually not to be employed in eczema. Menthol, hydrocyanic
acid, liquor picis alkalinus, other tarry preparations, and other drugs, are
sometimes employed for antipruritic effect, and will be referred to else­
where, especially under Eczema and Pruritus.

Parasiticides are those remedies which are destructive more espe­
cially to the grosser animal and vegetable parasites. Among the most
valuable are sulphur and its compounds; among the latter, especially
sulphurous acid, the sulphite and hyposulphite of sodium, the sulphid of
calcium, especially as the compound known as Vleminckx’s solution,
and potassium sulphid. These, as others, such as naphthol, the mer­
curials, and carbolic acid, are destructive to both animal and vegetable
parasites, and find their employment chiefly in ringworm, favus, tinea
versicolor, and scabies. Chrysarobin and iodin are also valuable vege­
table parasiticides, and both Shoemaker and Crocker speak well of
copper oleate in ringworm, and the former commends its action also
in other vegetable parasitic diseases. In scabies precipitated or sub­
limed sulphur and naphthol, of those named, are most commonly em­
ployed; frequently also styrax and balsam of Peru. The mercurials,
especially corrosive sublimate solution, white precipitate, sulphur,
stavesacre, and naphthol ointments, are commonly used against pediculi.

LOCAL TREATMENT

123

In fact, the so-called parasiticides are numerous, as will be found in the
text devoted to the parasitic diseases. They are in reality the same as
antiseptics and bactericides, these latter usually meaning those which are,
as a rule, somewhat weaker, and employed against the lower organisms,
such as the pus-cocci, etc In this class are boric acid, carbolic acid,
resorcin, weak corrosive sublimate solutions, weak solutions of formal-
dehyd, washings with tincture of green soap and water, and many others,
the most valuable in dermatologic practice being boric acid and resorcin.
The value of ichthyol as an external application, the first knowledge of
which we owe to Unna, is, in part at least, due to its bactericidal property,
as attested by its favorable action in sycosis, furuncles, acne, etc There
are two varieties on the market, sodium ichthyol and ammonium ichthyol,
the former usually going under the name of ichthyol. Aristol, acetanilid,
iodoform, and others are also occasionally resorted to, but the last named,
owing to its offensive odor and its venereal suggestiveness, should find
rare application among respectable ambulatory patients.

Caustics are substances or agents which are more or less active
destroyers of tissue. Among the strongest more commonly employed
in dermatologic practice, and which are destructive alike to normal
and morbid tissue, are caustic potash, chromic acid, zinc chlorid, and
the galvanocautery and actual cautery, including the Paquelin cautery.
They are used in malignant growths; chromic acid and caustic potash
are sometimes used on warts. Caustic potash is an active caustic, and
sometimes misleading at the time of its application as to the actual
amount of destruction taking place; unless, therefore, care is exercised, it
may destroy too much. When sufficient action has been effected, vine­
gar or dilute acetic acid should be applied to the part to neutralize it and
prevent further destruction. The pain is considerable at the time, but
rapidly subsides. Zinc chlorid, usually applied in paste (see Lupus and
Epithelioma), is slow and increasingly painful, but valuable, producing
a hard, leathery slough. Another caustic frequently resorted to, and
which is in a sense elective, sparing, as a rule, normal tissue unless ap­
plied for too long a time, is arsenic. It is used in limited growths, such
as small epitheliomata, as a paste with usually 1 or 2 parts of acacia; or to
more extensive areas, as in lupus, as a 5 to 10 per cent, ointment. It
requires from one to several days, according to the strength used; some­
times a repetition is necessary. It is painful, and produces marked in­
flammatory edematous swelling, but if used with proper precautions
it can scarcely be said to be dangerous. Pyrogallol has the same elective
action, but not so constantly. Its method of application, as well as that
of the other caustics, will be referred to under Lupus vulgaris and Epi-
thelioma. Pyrogallol in collodion sometimes acts unusually sharply,
and when so prescribed, must be done, at first at least, with caution.
Nitric acid and the acid nitrate of mercury, are comparatively super­
ficial caustics, and are sometimes employed in warts, nævi, and other
cases in which slight or surface destruction is sought. Trichloracetic
acid (the deliquesced crystals, or saturated solution) is also an extremely
useful, somewhat superficial discutient and caustic which has recently
been much extolled (C. N. Davis, D. W. Montgomery and Culver,

124

GENERAL REMARKS ON TREATMENT

Heidingsfeld,¹ and others) for seborrhœic and senile keratoses, warts,
simple moles, xanthoma, and similar lesions. Lactic acid, if used freely
and continuously, also has caustic action, but if applied scantily its effect
is superficial, or more that of a discutient. Among other discutients or
keratolytics is salicylic acid, used as a 10 to 25 per cent, rubber plaster
or plaster-mull, or as a 10 to 25 per cent, solution in collodion, or a 10 to
25 per cent, ointment (applied as a plaster); in epidermic thickenings it is
often of great service. Other caustics are occasionally used, and will
be found referred to in the course of the text.

Liquid Air and Carbon-dioxid Snow.—While treatment of
certain cutaneous diseases by intense refrigeration, mildly or actively
destructive according to degree and application, has been from time to
time recorded and liquid air had several times been publicly and pre­
viously lauded by A. C. White and others, it remained for Dade’s brilliant
demonstration of the use of liquid air² at the meeting of the American
Dermatological Association in New York, 1905, to give this method an
established and accepted standing; especially valuable in pigmented and
vascular nævi, lupus erythematosus, keratoses, superficial epithelioma,
and the like.

Liquid air as an efficient, and probably the best, destructive refrig­
erant or freezing cauterant, has since had the endorsement of Jackson,
Saalfeld, Beckett, Trimble, Zeisler, Whitehouse, and others, but the
almost insuperable difficulty in obtaining and preserving it has almost
led to its entire abandonment, the more readily owing to Pusey’s valu­
able discovery (1905) of a practical substitute for it in the easily and
always procurable carbon-dioxid snow. Its degree of cold is not so
low as that of liquid air, but it is low enough, and the action is about
the same. Since then its value has been repeatedly attested by Pusey,
Heidingsfeld, Zeisler, Bowen and Towle, Sutton, Jackson and Hub-
bard, Hutchins, Gottheil and Schalek, and others.³ My own expe­
rience has been equally favorable. Liquid air is applied with a cotton

¹ Heidingsfeld, “Trichloracetic Acid in Dermatology,” Archiv, cx, 1911, Heft 1 and
2; D. W. Montgomery and Culver, “Trichloracetic Acid as a Keratolytic Agent in
Seborrhœic Keratoses,” Jour. Cutan. Dis., 1912, p. 523.

² Literature concerning therapeutic uses of liquid air: A. C. White, Medical Record,
New York, vol. lvi, 1899, p. 109; Jour. Amer. Med. Assoc, vol. xxxvi, 1901, p. 426;
Interstate Med. Jour., vol. ix, 1902, p. 657; and Gaillard’s Med. Jour., vol. lxxix, p.
410; Saalfeld, Dermatolog. Zeitschr., 1900, p. 997; Beckett, Australasian Med. Gaz.,
vol. xxiv, 1905, p. 313; Trimble, Med. Rec, New York, vol. 1xviii, 1905, p. 58, and
Jour. Cutan. Dis., vol. xxv, 1907, p. 409; Dade, Trans. VI. International Dermat.
Congress, 1907, vol. ii, p. 672; Whitehouse, Jour. Amer. Med. Assoc, vol. xlix, 1907,

P. 371.

³ Literature concerning therapeutic uses of carbon-dioxid snow: Pusey, Jour. Amer.
Med. Assoc, vol. xliv, 1907, p. 1354, and Berlin klin. Wochenschr., June 15, 1908; Zeis-
ler, Dermatolog. Zeitschr., 1908, p. 409, and Jour. Cutan. Dis., 1909, p. 32; Bowen and
Towle, Boston Med. and Surg. Jour., vol. lviii, p. 868; Heidingsfeld, Ohio State Med.
Jour., August, 1908; Heidingsfeld and Ihle, Cincinnati Lancet Clinic, January 30, 1909;
Hubbard, Jour. Cutan. Dis., 1908, p. 134; Jackson and Hubbard, Med. Rec, New York,
April 17,1909; Sutton, Dublin Jour. Med. Sci., July, 1909, and Jour. Amer. Med. Assoc,
vol. lii, 1909, p. 464; Gottheil, Internat. Jour. Surg., vol. xxii, 1909, p. 7; Schalek,
Dietetic and Hygienic Gazette, November, 1909; Stelwagon, Therapeutic Gazette, Aug.,
1910; Pusey, Jour. Cutan. Dis., 1910, p. 352 (review of therapeutic uses, and bibliog­
raphy); Bunch, “Treatment of Nævi, Based on More Than 200 Cases,” Brit. Med.
Jour., August 10, 1912; R. Cranston Low, “Carbonic-acid Snow as a Therapeutic
Agent in the Treatment of Diseases of the Skin,” Wm. Wood & Co., New York, 1911.

LOCAL TREATMENT

125

swab, made by wrapping a piece of cotton around the terminal part of
a flat piece of wood, which can be made of suitable size and shape for
the case in hand. It is applied with moderately firm pressure, and for
from ten to thirty seconds or more in deep-seated formations. The
degree of action depends upon the amount of pressure and the duration
of the application. The after-effect is almost the same as that following
the application of carbon-dioxid snow, as described below.

Carbon-dioxid snow is generally obtained from the large steel cylinder
of liquid carbon dioxid, supplied by soda-water fountain supply com­
panies; it can be kept in the office or cellar and drawn from as the snow
is needed. It is a clumsy apparatus and, for the office, unsightly. A
much more elegant and convenient source is the small cylinder (12 inches
long, 1¼ inches in diameter) of liquid carbon dioxid sold by certain auto­
mobile supply-houses for the easy inflation of the tire; one cylinder
furnishes ample snow for a single treatment. With several of these
cylinders and the necessary valve-cock at hand one is sufficiently well
supplied. When necessary an angioma in an infant can be treated at its
home, as a cylinder and the valve-cock can be easily slipped into one’s
pocket. The method of procuring the snow is simple. A somewhat
thick chamois skin (or a thin one doubled) is tied over the gas-nozzle in
such a manner as to leave a small pocket opposite the gas outlet; the out­
let end of the cylinder, if the large one is used, should be dipped down
about 6 inches lower than the other end; if the small cylinder, the outlet
end is held about perpendicularly down. The gas is then turned on (by
puncture of the seal in the small cylinder) and the snow collects in
the chamois pocket, which, when ready, is detached from the nozzle.
It is either then manipulated through the chamois to form a ball, which
may be cut to the required shape and size, or it may be packed or rammed
into a hard-rubber mold, such as an ear or nose speculum or a small
section of a larger tube. It is then ready for the application.¹ The
snow pencil or mass is to be handled by the operator with a small piece
of chamois so as to avoid personal damage to the skin; it is then applied
to the diseased patch with a moderate pressure, and held there from ten
to sixty seconds; even longer in deep-seated disease. The duration de­
pends upon the object desired; as a stimulant and discutient, as, for ex­
ample, in thickened patches of lichen planus or eczema, a few seconds
may be sufficient; in small superficial angiomata, in thin pigmented nævi,
superficial lupus erythematosus, etc., ten to thirty seconds; in lupus,
epitheliomata, etc., from thirty to sixty seconds or longer. In with­
drawing the snow pencil or mass the area is seen depressed and frozen
white and hard, with a slight, narrow surrounding zone of erythema. It
thaws out in a few minutes, becomes red, and possibly slightly swollen;
later, trifling vesiculation or a distinct bleb or blister forms. This can
be punctured. Later, slight exfoliation or thin crusting usually takes
place, and after a time drops off, leaving a scarcely noticeable scar; in
cases where the action has been superficial, scarcely more than a whitish
mark, sometimes no permanent trace. When the action has been long

¹ Several observers have claimed an advantage from mixing the snow with ether,
or dipping the snow pencil or molded mass in ether before applying.

126                  GENERAL REMARKS ON TREATMENT

continued and with considerable pressure there may follow thin sloughing,
usually of a dry character. There is not much (rarely objectionable)
pain, as a rule, in the application, but while thawing and for a short time
subsequently there may be in some instances considerable discomfort,
rarely troublesome. In most instances no after-treatment or dressing is
necessary, unless on covered parts where the clothing may rub. Later,
the superficial abrasion or ulcer may need a simple protective application.
If later observation shows that the action has not been sufficient, the
snow application is to be repeated. A large area of disease, as, for
instance, in lupus erythematosus or in nævi, should not be treated at the
one time, but in sections, and in such instances it is advisable to apply
the snow in square-block form, so that the surface may be treated
evenly.

Mechanical or Operative Measures.—Excision is practised
in epithelioma, lupus, and other malignant formations. The cases of
lupus and epithelioma, the two principal affections sometimes thus
treated by dermatologists, in which permanent success is most promising,
are those in which the disease exists as a small, sharply defined, circum­
scribed patch, the knife going well beyond the apparent limiting border.
In more extensive cases of lupus this method has also been recently
employed, following it up with skin-grafting by the Reverdin or Thiersch
plan; with proper technic and under antiseptic precautions, good results
have been secured by those skilled in this method.

Curetting, with the ordinary cutaneous curets, is a much more
common recourse in dermatologic practice, and is extremely valuable
in certain diseases, more especially in lupus vulgaris and epithelioma,
but it should rarely be relied upon alone, a supplementary light cau­
terization, especially with pyrogallol salve or caustic potash solution,
as described under these diseases, always being practised. Under this
conjoint plan recurrences are much less likely to present than if curetting
alone is depended upon. This instrument, with sharp or blunted
edges, is also employed for other minor purposes, and such will be re­
ferred to in the discussion of the individual diseases in which it finds
use.

The galvanocautery and Paquelin cautery, and Unna’s small modifi­
cation of the latter, the microcautery (Microbrenner), already men­
tioned under caustics, are often used to destroy tissue, in lupus espe­
cially. Besnier was a strong advocate for the galvanocautery in this
disease, used with sharp and pointed instruments.

Linear and punctate scarifications with the single blade or sharp
point, or with the variously devised multiple scarifiers, are found useful
chiefly in lupus vulgaris. They are sometimes employed also in lupus
erythematosus, and occasionally in small thickened sclerous eczematous
areas. Punctate scarification is also resorted to in acne rosacea. The
puncturing and incising knife or acne lance can often be employed with
advantage in sluggish and suppurating acne lesions.

The cutaneous punch or trephine, brought into prominence by
Keyes, and made in various sizes from that with scarcely more than a
pin-sized opening to one \ to \ of an inch or greater in diameter, is occa-

LOCAL TREATMENT

127

sionally resorted to for minor operations, as in the removal of gun­
powder grains, small-sized tattoo-marks, moles, epitheliomata, and
other growths. Probably its most common use is in the removal of
diseased tissue for pathologic investigation.

Comedo extractors are variously shaped small instruments with a
central hole, varying from that of the ordinary watch-key-like instru­
ment to that somewhat similar to a long double curet, but with the
shank curved toward the ends.

Electrolysis, sometimes termed the electric or electrolytic needle
operation, which we owe principally to Hardaway, is an extremely
valuable procedure in certain diseases or conditions, as in the smaller
nævi, telangiectasis, acne rosacea, warts, for the removal of superfluous
hair, etc, and its method of employment will be found described in
connection with these maladies. Electrolytic destructive action can
also be effected by means of small metallic discs, and is sometimes em­
ployed for this purpose in lupus vulgaris (q. v.), as originally recom­
mended by Gärtner, Lustgarten, and Jackson.

Electricity can also be used in other ways, the faradic current being
valuable in some cases of acne, in alopecia, alopecia areata, and a few
other diseases; in the first, applying it by means of an ordinary electrode
or roller electrode, and in alopecia by a special metallic comb or brush, and
in alopecia areata by means of a tinsel brush. The galvanic current is
also a decided cutaneous stimulant, and is useful in sluggish conditions,
in alopecia areata used cautiously, in acne rosacea, acne vulgaris, in
herpes zoster, and in some other affections. It is not improbable that
there may be much more value in the treatment of superficially circum­
scribed dermatoses by drugs introduced by means of electric cataphoresis
than the past few experiments in this direction would seem to indicate.
The static current is likewise of adjuvant service, especially in diseases
of a neurotic character, the roller applied over the clothing sometimes
starting the absorption of infiltration; and the spark applied with the
pointed electrode, carefully used, a decided stimulant to the patches
of alopecia areata.

Radiotherapy¹ (Röntgen-ray Treatment.—x-Ray Treatment).—
Ever since the experimental therapeutic use of this agent was stimulated
by the recognition of its occasional accidental action on the cutaneous
structures, observed by various skiagraphers, the literature of the day
has furnished varying statements of its value in many of the dermatoses.
Led mainly by Freund and Schiff in Vienna, Pusey and Williams in this
country, Walsh, Morris, and Sequeira in England, and Oudin, Barthé-
lemy, and Darier in France, its employment has been gradually adopted
by all, or almost all, those engaged in dermatologic practice. For the
past several years it has outranked everything else in its wide applica­
tion, and the cutaneous disease was rare indeed that has escaped its
trial. Continued observation and experience, including my own,
though showing that some of the claims were extravagant, nevertheless

¹ Those desiring to pursue the subject further are referred to the book publications
on Radiotherapy, by Freund, Williams, Pusey and Caldwell, Allen, and Beot, in which
references to the extensive journal literature will also be found.

128                  GENERAL REMARKS ON TREATMENT

very properly accord it a most important position in the treatment of
certain diseases of the skin; while it should not be allowed to supplant
other means and methods, it is to be recognized as a potent and helpful
addition to our resources, especially in epithelioma, lupus vulgaris, and
other cutaneous tuberculoses, in lupus erythematosus, sycosis, extreme
and obstinate types of acne, in limited rebellious cases of eczema, ring­
worm of the scalp, and some other diseases to be referred to in the course
of the text. Its possibilities for evil, both for the patient and operator,
should rightly limit its use within reasonable bounds and under sufficient
precautions. Its reckless and indiscriminate application to any derma-
tosis, otherwise easily treated and handled, is to be deplored. It is
true that the dangers, with improved technic, and the exercise of care,
have been almost reduced to insignificance. There are, however, in­
dividual idiosyncrasies to be considered. Caution, therefore, should
be the invariable rule in the use of this powerful agent, and the first
several exposures should be tentative, not closer than 10 inches to the
tube, and not more than 3 to 5 minutes’ duration. A certain amount
of bold hazard, when one is experienced, is occasionally permissible
in such cases as the more malignant epitheliomata and extreme cases
of cutaneous tuberculosis, for frequently improvement is not brought
about till the first, and sometimes the second, degree of x-ray dermatitis
is provoked; but in such diseases as acne, sycosis, eczema, and the like
no such risk would be warranted, and action beyond the production
of the mildest erythema should be carefully guarded against. While
the general hints given here and in connection with the diseases in which
it is used will probably suffice for the intelligent, cautious worker, it
would be a great advantage for those desiring to employ this treatment
largely and thoroughly, if opportunity were first sought to gain at least
a moderate practical knowledge with the apparatus and technic from
one already familiar with the method.

While it would be exceptional to use more than one tube at the
one-treatment exposure, Lawrence,¹ in the treatment of granuloma
fungoides, generalized eczema, and psoriasis, has employed with benefit
as many as six tubes at a time.

The x-ray tube can be excited by either a coil or a static machine,
and either will prove satisfactory in cutaneous cases. As to the size
of the coil or static machine, the larger (within reasonable limit), prob­
ably the better, but the coil capable of a good 6-inch spark, or a static
machine capable of an 8-inch spark, will be capable of doing good work;
the small apparatus requires a somewhat longer exposure, and the rays
from a static machine are weaker than those from a coil, but such can
be readily compensated for by longer exposure or shorter distance, or
both. A coil capable of a 12-inch spark is that in most common use,
and this, as well as the larger and heavier static machines, are to be
preferred, especially if they are also to be used, with the additional
requisite apparatus, for the production of high-frequency currents.
The static machine can be operated by hand, water, or electric power;
the coil with currents from storage batteries or the street current. The
¹Lawrence, “ X-ray Baths,” Jour. Cutan. Dis., 1908, p. 247.

LOCAL TREATMENT

12g

coil has, as is well known, the greater advantage of reliability. Of the
various forms of interrupters—mechanical or vibratory, mercury dip,
or mercury jet or turbine, and electrolytic—the so-called mechanical
interrupter is, upon the whole, the simplest and least troublesome,
although they are all efficient, and each has advocates. It is not pos­
sible to give a fast rule as to the necessary amperage of current for the
coil in the treatment, as this varies, depending upon voltage, and size
and construction of the coil. Now that such instruments of precision
as special ammeters to measure amperage and voltage of the energizing
current, and the number of milliamperes actually going through the tube,
supplemented by the Wehnelt or Benoist’s penetrometer, Sabouraud-
Noiré pastilles, etc, are on the market, greater accuracy and standardiza­
tion of current may soon be realized; such are very essential if the so-
called “single dose” method is practised;¹ but one learns a great deal
from experience and observation, and safe and successful treatment of
most cutaneous diseases is possible in cautious hands without these
various additional appliances.

The x-ray tube should be, preferably, the kind that admits of regu­
lation of the vacuum, as the vacuum of a tube is an important factor
in the treatment of cutaneous diseases. As is well known, the rays from a
tube of low vacuum exert their action chiefly superficially, and those from
one of high vacuum, mainly in the deeper parts. As a rule, in skin dis­
eases, with some exceptions, a deep action is not required; it should not
be more than equal to a 2-inch spark-gap—in other words, a so-called
low vacuum or “soft” tube. This has seemed to me the most efficient.
Some, however, favor a higher or “medium” or “medium soft” vacuum,
and others, again, a higher vacuum, or “hard” tube. If the dermatosis is
exceedingly superficially seated, the vacuum can be set low—¼ to ½­inch
spark-gap—and then allowed to rise. Should the desire be, in some in­
stances or at times, to have the extreme outer surface of the skin rela­
tively spared, as obtains in some stages of the treatment of epithelioma
and lupus, where surface action is to be avoided or has already been
sufficient or troublesome, then a thin sheet of aluminum can be inter­
posed (Thompson) between the tube and the part treated, thus shutting
off or limiting the short or superficially acting rays; instead of the alu­
minum sheet old tubes that have become considerably darkened and
coated with metal can be used.

Great care should be exercised that the wires connecting the tube
with the coil or static machine are firmly attached and so placed that
there is no possibility of their getting loose or in any other way coming
in contact or even in close proximity to the patient, in order that un­
pleasant shock and unnecessary alarm may be prevented.

An important desideratum in x-ray treatment is the protection of
the other parts not being treated. Various plans are in vogue, and are
well known. The most common is the covering over of the surrounding
and nearby parts with thin sheet-lead or several layers of tin­foil, an
opening being made sufficiently large for the diseased area. If the dis-

¹ MacKee and Remer (“The Single-Dose X-ray Method,” Jour. Cutan. Dis., 1912,
p. 528) briefly review this method, and advocate it.

9

130

GENERAL REMARKS ON TREATMENT

ease is on the face, a mask can be made (pasteboard or gauze) and covered
with four or five layers of tin­foil, except at the part immediately over the
disease, which can be cut out. These devices, however, consume time.
In my own work, which is largely for disease seated upon the face or some
parts of it, I usually employ the Friedländer shield over the tube; the
size of the opening used can be readily regulated. With this or similar
shield¹ one could do away with the necessity of attaching any protect­
ing foil to the patient; but it is probably better to place a narrow band
of foil around about the diseased area, to protect the surrounding skin
from stray rays; this can be fastened with adhesive plaster. Particular
attention should be given that the scalp, hair, eyebrows, and eyelashes
are protected, for exceptionally a single exposure, especially if at all pro­
longed, will be followed by complete hair-loss of the part exposed; a
regrowth, however, finally takes place. In long exposure the lips should
also be protected.

In ordinary therapeutic work the protection, by the above measure,
thus given the operator will usually be sufficient to prevent any damaging
action. In addition to this an arrangement can readily be rigged so
that the current is stopped before the operator approaches the tube.
An additional screen can also be placed between the tube and the part
of the room where the physician or attendant is seated while the exposure
is going on.

Further data as to the action of the rays, both therapeutically and
pathologically, as well as the distance of the tube and duration of ex­
posure, will be found under x-ray Dermatitis and in connection with the
diseases in which the method is employed.

In place of the x-ray, radium and other radio-active substances have
been variously extolled. Radium has apparently about similar radio-
active properties, and probably some properties peculiar to itself. While
not so generally applied, radium, in the hands of those skilled in its use
(Wickham, Abbey, and others²), produces brilliant results in some con­
ditions. For use in cavities, such as the mouth, nose, etc, and for easy
application to small cutaneous lesions, it has some advantages, more espe­
cially of convenience. It can be used either in a properly arranged
applicator, or, on surface lesions, the glass receptacle or aluminum capsule
containing the radium can be fastened with adhesive plaster. The dura­
tion of the first application should not be, if the preparation is a strong
one, more than ten to twenty minutes; after several days it is again re­
peated, and later, if necessary, and if there are no reactive symptoms,
the time of exposure can be gradually lengthened. Duration and fre­
quency depend upon the activity of the preparation—it should have
the highest possible radio-activity; with the weaker preparations the les­
sened power must be made up by increased quantity and much longer
or more frequent application. The weaker, being comparatively inex­
pensive and safer, can be entrusted to the patients with instructions
for exposure at short intervals.

Actinotherapy.—To Finsen, chiefly, we owe the established usage

¹  Several similar protecting shields are now on the market, the lead-glass shield
being an especially convenient one.

² Wickham and Degrais, Radiumthérapie, Paris, 1909.

LOCAL TREATMENT

131

of the application of concentrated light deprived of its heat rays to the
treatment of cutaneous disorders. His experimental studies with the
concentrated light, demonstrating its destructive action upon bacterial
life, led him to apply it to the treatment of lupus vulgaris. Since then
he and others have broadened its therapeutic field, and it is now, in some
of its forms of application, also used in lupus erythematosus, epithe-
lioma, alopecia areata, and some other diseases. While Finsen at first
resorted to sunlight, applying it through a properly shaped water-con­
taining lens, owing to the uncertainty of this source, he and his asso­
ciates Forchhammer, Bang, and others, subsequently discarded this
for the carbon arc-light of high power, this being richer in the acting rays,
and always available. The main forms of apparatus are: First of all, the
Finsen (so-called large Finsen), and the smaller, similar (Finsen-Reyn)
lamps; in these the principle of several condensing lenses, arranged for
concentration in a telescope-
like tube, is the essential part.
This, it is maintained, and
doubtless rightly, is necessary
for the deep penetration of the
rays, and in order to get suffi­
ciently deep curative action.
It naturally necessitates some
distance between the actual
light and the part being treated,
and requires more prolonged ex­
posure to obtain reaction; the
light, therefore, is focused upon
the required point. One of the
sections between the lenses is
filled with distilled water, and
around this section there is a
thin hollow jacket, through
which ordinary water is kept
circulating; the heat rays are
thus filtered and overheating
of the apparatus prevented.

In addition, on the part treated there is firmly pressed a hollow com­
pressing lens, consisting of two quartz lenses set in a metal band,
through which water is also kept circulating; besides still further
straining out the heat rays, this compression lens also serves to press
out the blood from the tissues, the blood being a hindrance to the
deep penetration of the rays. The pressure is maintained by fastening
this hollow lens with straps or elastic bands, aided by the attendant.
The large Finsen lamp requires with medium commercial voltage a
current of 80 amperes; the Finsen-Reyn lamp 20 amperes. Lortet and
Genoud, and, later, others, in order to lessen the time of application,
as well as to reduce the cost of the apparatus and the amount of current
required, discarded the principle of the telescopically arranged condens­
ing lenses, and constructed an apparatus so as to bring the light close to

Fig. 23.—Finsen hollow compressing lens
referred to in the text; the two tubes are for
ingress and egress of water. Cut is about
two-thirds its actual size.

132

GENERAL REMARKS ON TREATMENT

the part treated. This consists of a basin- or bowl-shaped, thin, hollow
metallic shield, at the projecting center of which is set a lens, on each side
of the shield; the arc light, of carbon points, is brought up close to the
inner lens, and against the outer lens the patient presses the part to be
treated; the apparatus is kept cooled and the heat rays strained out by
keeping water continually circulating through the thin cavity of the
shield and lenses. While at first this form of apparatus, known as the
French, or Lortet and Genoud, lamp, and as the London Hospital
lamp, was lauded as an improvement, further experience has shown it
to be much less penetrating, and much less effective in the treatment of
lupus. It usually brings about a much more rapid surface-action, but

Fig. 24.—The Finsen hospital lamp (showing the method of employment): The
projecting tubes can be shortened and lengthened so as to permit the focusing of the
light upon the diseased area being treated; the light is directed through the hollow lens
(through which water is circulating), which is kept pressed down upon the part under
treatment. It will be noted that both attendants and patients are provided with dark
glasses to protect the eyes from the brilliant dazzling light.

fails in depth, even when the time of exposure is continued as long as
with the Finsen lamps.

It has, however, a field of usefulness in superficial dermatoses, such
as superficial lupus vulgaris, alopecia areata, and some others. It
requires from 5 to 15 amperes. Bang and others, in efforts to save time
in application, constructed a somewhat similarly arranged pressure lamp,
having, instead of carbon, hollow-iron electrodes at the arc, which were
kept cooled by water running into their cavities. The arc of iron elec­
trodes is rich in the erythema-producing short rays, and a decided surface
reaction can be brought about in a few minutes, but it is still less pene­
trating than the Lortet and Genoud lamp. It is, however, useful where

LOCAL TREATMENT

133

a quick superficial action is desired. Moreover, it requires but a few
amperes of current. Somewhat similar, but still less active, lamps are
those devised by Görl, Leduc, Piffard, and others, in which the light
comes from the electric spark between several, or more closely contiguous,
metal electrodes; this light is rich in the ultraviolet rays, but its action is
exceedingly superficial. Another lamp which Kromayer¹ has brought
forward as a substitute for the Finsen lamp is that known as the “quartz
lamp.” This is a mercury-vacuum lamp, made of melted quartz glass,
imbedded in a running water-bath, whose casing, the size of a fist, permits
of the exit of the light through a quartz window, which, like Finsen’s
compression lens, may be used as a compressorium. There seems to be
no question that in lupus vulgaris the most efficient lamps are those
known as the large Finsen, and the later smaller one known as the
Finsen-Reyn lamp,² and probably next in value the Kromayer quartz

Fig. 25.—The Finsen-Reyn lamp in operation (Allen).

mercury­vacuum lamp. The Finsen method will be further considered
in the section on Treatment of Tuberculosis of the Skin.

In addition to these several lamps intended for the close or con­
centrated treatment of a limited area, there are others now employed
with carbon, carbon-iron, and iron electrodes by which the actinic
light is projected by means of a parabolic reflector upon large surfaces;

¹ Kromayer. Jour. Cutan. Dis., 1908, p. 257 (with review and references).

² Finsen, La semaine mêdicale, Dec 22, 1897; Finsen and Forchhammer, Mit-
theilungen aus. Finsen’s med. Lyseninstitut, Nos. 5 and 6, Jena, 1904. (This covers
all work done at the Finsen Institute to date.) Bang, Monatshefte, July 1, 1898;
Valdemar Bie, Brit. Med. Jour., Sept. 30, 1899; Macleod, Brit. Jour. Derm., Sept.,
1899; Stelwagon, University Med. Mag., Phila., Dec, 1900; Discussion, Section Der-
matol., Trans. Internat. Cong., Paris, 1900; Discussion, Brit. Med. Assoc, Brit. Jour.
Derm., 1901, p. 381; Leredde and Pautrier, Annales, 1902, pp. 327, etc; Hyde, F.
H. Montgomery, and Ormsby, Jour. Amer. Med. Assoc., 1903, xl, p. 1; F. H. Mont­
gomery, Jour. Cutan. Dis., 1903, p. 529; Morris and Dore, Practitioner, April, 1903.
Also the book publications by Freund, Williams, Leredde and Pautrier, Allen, and
Others.

134                  GENERAL REMARKS ON TREATMENT

the heat effects in some of these latter are also of therapeutic value in
some cases. These larger reflecting lamps are found useful in those dis­
eases usually benefited by sun exposure, as psoriasis, some cases of
eczema, etc.

The high-frequency current (known both as high-frequency
and high-tension currents) probably had its first introduction in medi­
cine by W. J. Morton, of New York, but the experiments by Tesla, with
modern apparatus, and the enthusiasm of D’Arsonval led to its present
position in medical therapeutics; it was Oudin, however, who gave it this
impetus in the treatment of diseases of the skin, and whose enthusiasm
stamped it with almost alluring powers. Many of the claims made for
it have failed of corroboration by other writers, but that it has value in
some dermatoses, no one who has conscientiously tried it can deny. It
is still, however, in the experimental stage, and needs much more ex­
perimentation before its proper status can be known. The subject
has excited sufficient interest to lead to the publication of some mono­
graphs and to giving it an important place in works on allied subjects.¹
Variously shaped electrodes have been designed for its application, but
those of greatest value and most generally useful in dermatology are the
hammer-shaped vacuum electrode and the carbon, and glass-point,
electrodes; and where a more prompt and decided limited circumscribed
action is required, a pointed metallic electrode.²

Sundry other measures and instruments sometimes have
a use in dermatologic therapeutics, such as poultices for removing
crusts; roller bandages for supporting dressings and otherwise aiding
in the treatment, as in eczema of the legs associated with varicose veins;
rubber or elastic bandages and elastic stockings for similar purpose,
but these must be used with caution, owing to possible irritation. Coun-
terirritation over the vasomotor centers controlling the affected region—
a local measure with, however, a constitutional influence—has been
highly commended by Crocker in obstinately recurring eczema and
similar inflammatory diseases; it may be effected by sinapisms, blisters,
or with the galvanic electrode, or with the point or roller electrode of the
static current. Massage or rubbing with oils or ointments is some-
times of service in starting up the absorption of inflammatory exudates
or induration, and is also valuable in elephantiasis, scleroderma, in
alopecia, and some other affections. It has long been known that
“stirring up the skin”—i. e., increasing and promoting temporarily
active hyperemia—is of benefit in certain cases, and especially in slug­
gish and chronic areas, and we know now that it does so by accentuating
and imitating nature’s method. Some of the measures already men­
tioned doubtless owe part of their value to this action. Bier’s hyperemic
treatment—the production of active and passive hyperemia by means

¹ Denoyés, Les Courants de Haute Frequence, Paris, 1902; Chisolm Williams, High-
frequency Currents in the Treatment of Some Diseases, London, 1903; Freund’s Radio-
therapy, and Allen’s recent work.

² MacKee, Jour. Cutan. Dis., 1909, p. 245, gives a favorable experience with this
last method (fulguration, or high-frequency caustic spark), and briefly reviews the work
of others, with references.

LOCAL TREATMENT

135

of hot air, cupping, and bandaging—is another method lately utilized
for this same purpose.¹

In addition to the various instruments already indicated may be
mentioned the dental burr and hook used in the destruction of iso­
lated tubercles in lupus vulgaris; the depilating forceps, with easy spring,
for extracting hairs; a hypodermic syringe, and a slightly larger but
similar syringe for washing out acne-abscess cavities; an atomizer for
spraying and cleansing purposes; and a small massage cup for local
massage of the face, and for favoring bleeding and discharge in the open­
ing of acne lesions, etc In some cases a glass pleximeter to observe the
lesional appearance under pressure, a magnifying glass for more accurate
inspection in occasional instances, small grappling forceps, and some
other instruments usually contained in an ordinary pocket case, to­
gether with other special instruments and apparatus mentioned for
particular purposes in the course of the text will be found of service in
dermatologic practice.

¹ Sibley (Lancet, Feb. 4, 1911, and Archives of the Röntgen Ray, April, 1911) records
favorable influences in various chronic dermatoses from Bier’s hyperemic treatment
(the suction cup method), especially when used immediately or shortly before other
therapeutic applications.

But first, if you want to come back to this web site again, just add it to your bookmarks or favorites now! Then you'll find it easy!

Also, please consider sharing our helpful website with your online friends.