SOME BASIC REMEDIES IN THE 'TREATMENT OF DISEASES OF …

60 BASIC REMEDIES IN THE TREATMENT OF DISEASES OF THE SKIN

nucosa closing the passage. This attemptmnust not be persisted in too long, for thesepatients do not bear starvation well, and thecaecum may be in a worse conditiotn thanone tlhinks, If operation is decided uponwhat shall we do ?

Everyone is agreed now that primaryresection of the growth with immediaterestoration of the itntestinal canal is badsurgery, so we need not consider that. Butthere has been a good deal of discussion asto whether one shouild explore the abdomenso as to know exactly where the growth is,and theni to do what seems best, or whetherone should contenit oneself with opening theabdomen in the right iliac fossa, and drainingthe cecum. To this operation has beengiven the name of "blind caecostomy."Those in favour of "blind czecostomy"argue that the patient is saved the shock ofthe lhandling of the intestines (there may bediffictulty, if distension is marked, in return-ing the gut to the abclomeni), and thatt, asthe cxecutn will probably have to be drainedin any case, it had better be done first aslast. Those in favour of exploration maintaim that it is not alw.ays easy to differentiatesmall from large initestinie obstructioni in itslater stages, thiat it is better to know exactlywhat onie has to deal with, that if the growthis low down a sigrnoidostomy is much moresatisfactory, anid does its work better than aczecostomy, and that sometimes in left colongrowth the jejunum, which normally liesin front of it, is implicated in the growth,and is the main cause of the ob.structioni.(I had a case of this sort three monthsago.) My own feeling is agaitnst ' blindcaecostomy," among other reasons, becauseI do not thinik a caecostomy drainis thecolon well if the growth is in the sigmoid,and if the growvth is inoperable a permanienitcacostomy leaves the patient in a miserableconditioni, and once made it is niot easy toclose and replace by a more convenientar-tificial anus.As we are discussing obstruction, I will

not go into the question of the treatment

of the growth, but just ask the question,"When the enterostomy has been safely per-formed, 1Fow are we to decide whetn to pro-ceed to the radical operationi in operablegrowtlhs ?" While one mi-ust, of course, beinflueniced to some extent by the state of thegrowth, I am inclined to advise yotu not tohurry. At least three weeks will be requliredto allow thie intestine to recover. Fortuniatelyonie does not ofteni have to combat any gravedegree of toxaemia, but the condition of thetongue will generally show that there hasbeeni some, and the tongue is the best guidein deciding on the patient's general condi-tioin. The appetite, too, often improvesamazingly after the enterostomy, and thepatient's condition will improve rapidly onthe more genierous diet he is willing to take.

SOMEBASIC REMEDIES IN THE'TREATMENT OF DISEASES

OF THE SKIN.By HENRY C. SEMON.

M.D., M.R.C.P.

Lecture delivered for the Fellowship of MedicineNovember 12, 1928.

CREDULITY is common to mankind, and itwas a wise physician who advised hisaudience to " huLrry to pirescribe a newremedy while it is still effective." Thatepigram, as I read it, does not encout-age anabsolLlte coniservatism, although the impli-cation is cyniical. No man can afford tosit still, and the doctor who steadily refusesto avail himself of weaponis which the ad-vance of allied sciences have placed in hishanids runs the risk of suiperaninuationbefor-e his time. Ill considering a subjectfor this lectut-e, I set myself the task of givingyou somliethinlg practical. It occurred tome that an approach to a dermatologicalthesis throtugh the fair avenues of phatma-

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BASIC REMEDIES IN THE TREATMENT OF DISEASES OF THE SKIN 61

cology had the merit of niovelty, and mighteven prove interesting, anid whatever yourcriticisms I have at any rate enjoyed thecompilation and satisfied my conscienice.I have, as you will hear, devoted the greaterpart of my theme to a stuidy of the drugswhich, in somne cases, for centuries haveenjoyed a universal conIfidence and esteem,'but I have not scorned to mention suchmodern derivationis anid substitutes which,on the score of cleanliness or convenience,my experience has taught me to value, andwiich therefore do not fall under theimplied stigmna of the opening quotation.

Th.e fun-damental principles of therapeuticscience apply as much in dermatology as inthe other and better known branches ofmedicine. It is not so mulch what is usedas the mnethod of application that countstowards success. 1 know very little ofhomnceopathy, but if its basic principle is theadmninistration of drugs in very gr-eat dilution,the precepts would in no wise conflict withthose of der-mato-therapy.

Tlhere is no derinAtosis in which the pre-scription of powerful r-emedies or strongsolutioins is necessary, with the single excep-tion of those in which a caustic effect isdesirec, and even in these the field is be-coming increasinigly Jimited by the intro-duction of elec-trical anid other methods oflocal destr-Lction.The principle is well illustrated in the

treatment of acute eczema. The number ofremedies recommnended is commensuratewith the absence of anly specific, and Iwould go so far as to say that there isprobably no pharmacological substancewhich, provided that it is dissolved in thecorrect proportions anid applied in arationail and regular inaniner, will fail togive relief. It may surprise somne of you tokniow, for instance, that evenl chrysarobin,one of the most active irritants in dermatto-logical use, can be applied wit li effect, ifsuitably diluted, in the violent stages ofweepinig eczema, and that resorcin in a

J per cent. aqueous solution is the equivalenit

on the Conitiinent of our favoutrite lotioplumbi, B.P., and in anal arid perinealdermatitij frequently mo-e effective.

In the inore chlonic infl m-nations thesamne principles hold good, anid if the appli-catioin conltainis too large a percentage ofthe active constituent, a chronic or subacutedermatitis can be suddenly converted intoan acute stage. This contretemps occursin about 50 per cenit. of all hospital out-patients, who have only to read an adver-tisement to believe and act upon it.FuLrtlher, to a consideration of dosage wehaveto discuss the technique of application,and the importance of properly preparingthe skin lesions for the reception of aselected remedy. It is surprising.how fre-quiently the affected limb or other part isswaitlhed in lint, over which somnetimes astrip of oiled silk and a more or less thicklayer of cotton-wool is firmly bandaged.Apart from the discomfort whiclh stuch aprocedulre inflicts, it is sometimes forgottenthat heat and moisture are the most iinpor-tanit aids to the growth of bacteria, and thata dressing such as has been detailed aboveis really notlhing better than aii incuibator-hot, moist fromii perspiration, and dark, withthe added factor of fr-iction to ensure thespread of bacteria over as wide an area aspossible. I have seen more than once asingle discharging boil with a constellationof small satellites exactly demarcated by theoutline of a square piece of boracic lint leftin situ for twenty-four hours ! The bestway to avoid the tragedy of such mishapsis to discard linlt and oiled silk and cotton-wool altogether, and to substitute a singlelayer of old linen, or plain white gauze orbutter-muslin, and as few turns of an openweb bandlage as possible. When lotionsare being used it is essenitial to instruct thepatienit or hiis nurse that they mu11st be con-stantly reu,ewed, so that the dressillg does notget the clhance of adhering to the oozingsurface. Oily liniments and ointments andpastes are not so liable to stick, and requirereplacement only twice or three times daily.


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If scabs and crusts are present, or if there ismuch offensive discharge I would refer youto Norman Walker's not infrequently for-gotten recommnendationi of the starch poul-tice. I would only add to that excellentdissertation the reminder that a starch poul-tice has an inevitable tendency to " set,"atnd that it should be renewed every hourand not left on for twenty-fouir, or its greatvalLe will niot be appreciated. Remember,too, that almost any di-ug can be incor-porated in a starch poultice, atnd that boricacid adds greatly to its soothing properties,and black-walsh to its antiseptic.

But wve munust not occupy too much of ourtime with these aspects of the general therapyof skin diseases. Our object to-day is a con-sideration of the plharmacology of a few ofthe simple and best known drugs in almostdaily use among dermatologists, which con-tinue to uphold their long-lived r-eputationsand to withstand the regular onslaughts oftime anid the advertisements of chemicalcombines.

I would remind you that the mode orvehicle of application of any given drug ismore impor-tant in der-matology than it is ingeneral medicinie, and that the same sub-stance may act more or less violently on theskin accordinig to whether it is incorpor-atedin a lotion, a cream, a paste or a plaster.One of the oldest and most valuable

suLbstances in skin pharmacy is sulphur, andit will afford an admirable starting point forour' discussioni. It was in use at the time ofHippocrates (400 B.C.), and was frequentlyprescribed in the Middle Ages for every sortof skin disease. It is used freely in dermato-logical practice at the present day, and is ofthe greatest valtue in seborrhcea and scabies.The mode of action is highly complex inthe former condition, but the uniderlyingfeature always is the production of H2S,whether applied locally or given by themnouth. Other products of protein inter-action with suLlphur are the alkaline sulphides,and both these and H2S are keratolytic if atall concentr-ated, that is to say, they tend to

dissolve the keratin of the corneous layer,and you will remember that calcium andbarium sulphide in the strength of aboutI part to 2 or 3 of a paste of starch andzinc oxide, are in daily use as depilatories,the keratolytic action of which is directlyresponsible for the dermatitis which occa-sionallv results.

This keratolysis is doubtless the mode ofits action as an antiscabetic remedy. It must,in order to deal with successive broods ofacari, be applied to the skin on tlh-ee follow-ing days, and it is further worthy of notethat the ung. sulphuris of the B.P. is ratheron the strong side (i part in 9 of benzoatedlard), and that an ointment of half thisstrength is equally effective and not so proneto cause keratolysis, i.e., sulplhur dermatitis-a very common complication during thewar. The well-known firm of Bayer havesolved the problem of complications by theintroduction of mitigal, an organic sulphurcompound in oil which is higlhly efficient,and has never caused dermatitis in my prac-tice in two years' trial (dimethylendiphenyl-disulphide).According to Unna, sulphur in weak

concentration is keratoplastic and acts asa reducitng agent. Under such a headingits most frequent indication is seborrhoeaof the scalp, and here we generally pre-scribe it in ointment form, in combinationWith salicylic acid, aa. I to 2 per cent.For acne of the face it is best applied incalami ne lotion and in the same strength,with or without glycerine or spirit. In theextreme indurated types of acne, in whichaIn exfoliating action is required, Lassardevised the followinig paste, which is thicklyapplied night and morning, and obviouislyimplies patient treatment-; ,8-Naphthol ... .... ... 5-o

Sulph. ppt . ......... 25-0LanolinSoft soap I100

M. ft. pasta.In ordinary Lassar-'s paste sulphur can be

used in I to 3 per cent. concentrations for


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BASIC REMEDIES IN THE TREATMENr OF DISEASES OF THE SKIN 63

the treatment of seborrhoeic dermatitis, afterthe acute manifestations of this proteandisease have been allayed by lotions. Sul-phur baths, which are erroneously prescribedfor scabies (because the acarine ova areobviously ignored by this procedure alone)are useful in furunculosis, and also inpruritus of the milder types. Sulphuratedpotash is used for this purpose in a strengthof about i' dr. to the gallon, and them-ineral waters of Harrogate, Aix la Chapelle,Loeche, Schinznach, Helouan, Aix les Bains,and a host of otlher spas, contain the elementmostly in a form appropriate to a prolongedand repeated contact with the skin. Abeneficent action is also claimed for the oraladministration of sulplhur, especially by thepr-omoters of spa treatment. I have neverconvinced myself that it acts in any otherway than as a mild laxative, than which thereare mnany less irritating and more pleasantvarieties, both natural atnd manufactured.

SIDE EFFECTS AND CONTRA-INDICATIONS.Sulphur dermatitis has alreadv been

i-eferred to. The unpleasant odour of H2Scan be generated in the skin of persons towhom the dr-ug has been given in largedoses by the imiouth. Precipitated stulphuiris more active in this respect than S. depur-lztumn, or the flowers of sulphur. Rememberthat sulphur- and lead are incompatible, andthat with potassium permanganate andichlorate explosive mixtures may result.Tar has been used at least as long as

sulphur in the treatment of skin diseases.Celsus valued it for eczema at the beginningof the Christian era,and Galen recommendedit for loss of hair and diseases of the nailsas early as A.D. 200. It appears to have beenneglected in the Middle Ages, and wve oweits re-initroduction to Hebra.There are two main sources of supply:

coal and wood. The former variety, prob-ably owing to the natural and artificialprocesses it has undergone, is less active,i.e., less irritating to the skin, and it isalways advisable, when the application of tar

is contemplated, to begin with one or otherof the numilerous coal-tar derivatives ratherthan to risk the application of oil of cade(juniper) or pine.Now crude coal tar, among the host of

complex compounds that can be distilledfrom it at various temperatures, containscarbolic acid, cresol, naphthol, xylol, certainpyredin bases, pyrogallol, and other lessknown irritating substances. It is fortunatethat the majority of them alre soluble inwater, so that washed coal tar, the pixcarbonis prep. (B.P.) is, from the standpointof pharmacology, a relatively standard pro-duct. As such alone, or mixed with anequal qtiantity of collodion flexile (B.P.), itmiakes an excellent paint for certain typesof ir-ritable weeping or dry dermatitis. Thegreat contra-indication to its application isthe presence of sepsis, and ever-y trace of thismust be eliminated before success can behoped for. It is also useful in psoriasis, andmost author-ities recommend that tar in someform or other should alwavs follow treatmentby other methods such as chrysarobin, theeradicating effects of which ar-e therebyprolonged.

Long-conitinued application- of tar oI itsderivatives, or the inunction in an ointmenitbase to wide areas, may be injurious by pro-ducinig " tar dermatitis," or by absorptioni ofphenol or cresol impurities affecting thekidneys. An occasional examination of theurine for albumin and casts should not beneglected in such cases.There is scarcely a dermatosis in which in

correct dosage and at the proper stage theexhibition of tar is not helpful. Its anti-pruritic properties in a I to 2 per cent.solution of liquor carbonis detergens, with orwithout lead, in the acute stages of eczemaare well kinown, and coal-tar soaps are justlypraised for their mild antiseptic and stimu-lating effects. It would be possible to givea course of lectures on coal-tar derivativesin medical use. From the point of view ofour thesis it must suffice to mention thealcoholic extract known as liquor carbonis


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detergens (Wright), and the L. picis car-bonis (B.P.), which resembles it, anthrasoland liantral, any of which can be dissolvedand applied in lotioIn, liniment, or ointmnentbases, from I to 5 per cent., accordinig to thetolerance of the individual case. If there isany doubt of that tolerance it is a wise planto begin treattnent witlh ichthyol, derived bydistillation from a bituminous shale depositfound in the Tyrol. This substance may, forour purposes, be classed with the tar pro-ducts. The original ichthyol is far superiorto the substitUtes introduced dulring thewvar, arid can be used even when sepsis ispresent. lt is a good dressing for boils, andis frequently applied in strong concentrationfor erysipelas. In Lassar's paste, 2 to 5 percent., I have found it useful for varicosedermatitis of the legs, and also in tradeeczemas in which, as a rule, tar applicatioiisare not well tolerated.The wood tars comprise those derived

from beech, juniper arid pine. Their con-stituents iniclude the guaiacols, creosoles arldtheir homnologues, and acetic acid. Oleumcadi (juniper) is the one chiefly pirescribedin Englanid, but the uise of wood tars islimited and need not detain us here. Beforeleaving the subject of tar I should like toadd a word about pyrogallol, which is a by-product of its distillation. Its strong re-ducing powers render it a valuable caustic,and in the treatment of lupus vulgaris (i dr.ad i oz. vaseline) it still numbers adherents.The mono-acetate known as eugallol is usefulin psoriasis (up to io per cent. in a paste oiointment), while the tri-acetate lenigallol, hasdone good service in my hands in E to 2 percent. cream or paste base in intractable casesof eczema, especially when a mycotic cause,as in eczematoid r-inigwormii of the extremities,was undei-lyiing. The incluisioni of resorcinin this series is justified by its derivationfrom benzole, a complex synthetic process.I have found it occasionally of the greatestvalue in intractable cases of weepinig derma-titis of the perineum and anal regions, whenthe usual reinedies have failed to give relief.

For this putrpose it is dissolved in water,i to i per cent., and frequently renewed. Instroniger concen-trations, in an oinitment base,the drug is occasionally used as an exfoliat-ing agenit in rosacea, and even as a causticfor veniereal warts, 50 to 8o per cenit. invaseline. As a hair tonic it is best prescribedas eur-esol, the mono-acetate, which is statednot to discolour fair h}air, as resorcin is aptto do.

All these tar- derivatives, and for thatmatter tar itself, are absorbed by the skinand may produce toxic manifestations refer-able to blood destruction and damiiage to therenal tubules. Fatal issues fr-om urxmiahave been reported, and pyrogallol, which isthe most toxic of the series, should never beapplied to large areas, as has been done forpsoriasis in the early days of its introduction.The dangers of carbolic acid absorptioni arewell recogniized, and it shouL'd be remem-bered that these derivatives are obtaiinedfrom the same source anid, although lesspoisonouis, can exlibit toxic manifestationswhiclh bear a close resemblance to thoseproduced by phenol. A close watch shouldbe kept on the urine of all cases in wlich,as in psoriasis, large areas hiave to be treatedsimlultanieously, and it should not be for-gotten that pyrogallol used in excess, or inpatients with an idiosyncrasy to the targroups, may produce exfoliative dermatitisas severe as that seen after chrysarobin.

CHRYS AROBIN.

Under the name of Goa powder, chry-sarobin was first intr-oduced to medicinefromn that PortuguLese coloniy in i864. Theimpure substanices are found in the cavitiesof a tree called Andira araroba, wlich hassinice beeni tr-ansplanited and grows freelyin Brazil, from wlhichi, since the war, mostof our stocks are derived. The yellowpowder rapidly absorbs oxygen from theatmosplhere and turns brown. It is xvashedwith benzol or- chloroform, and is said tocontain go per cent. chrysarobin after thistreatment. It is insoluble in water, but


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BASIC REMEDIES IN THE TREATMENT OF DISEASES OF THE SKIN 65

dissolves in chloroform, benzol, carbonbisulphide, and to some extetnt in ether.The main indication for the use of chiry-

sarobin is psoriasis, and in this disease itcomes nearer to beinig a specific than anyother remnedy as yet recommended. Thedrng must niever be used in acute or spread-intg cases. Its application requires verycareful control. It mu-st never be appliedto the face, for fear of producing a con-junctivitis, and even damage to the iris.The patient whose hands are affected mustbe warned against rubbing his eyes. Glovesshould be worn at night in such cases.A considerable experience of the use of

this drug in psoriasis has convinced me thatthe patient who selects to be so treatedshould be puLt to bed and inuncted oncedaily uintil the whole body (head and neckexcepted) has asslmed the characteristicreddish-violet inflammnatory reaction. ThisusuLally takes from ten to fifteen days, andis accomipaniied by variable degrees of dis-comfort, owing to itchlinlg and soreness.Both these sytmptoms are reduced by de-cubitus and abstention fromn baths duringthat per-iod. The patches of psoriasis in.volute completely at this stage, and theirformer areas are ou-tlined in white, and arein marked contrast to the reddish-violetpigmenitation of the normal skin. Thetreatment should not be regarded as com-plete until the white patches are just begin-ning to assume an erythematous reaction.The inutnctions should then be remitted. anda tar derivative, e.g., ol. cadi, in i to 5 percent. conicentrationi in Lassar's paste, wellrubbed in for a few days.- It is believed thatthis procedure lenigthenis the ensuing periodof imunLlity wlhich, in several bad cases Iwas called upotn to treat in I927, stillpel-sists.The concenitration of chr-ysar-obin, in the

simple vaseline base we use as our velhicle,should be weak for the first three days, oruntil we have ascertained the patient's toler-ance. I usually begin with a 3 per cent.and gradually work up to 5 or 6 per cent.

dose, but I know of a man who inuncts him-self annually and from the start with anointment containing a drachm to the ounce,i.e., about [2 per cent., without any demon-strable damage to his skin or renal function.This procedure implies risks which are notjustified by anv circumstances, and I shouldnot be surprised to learn one day that this-hero had overstimulated his case into one ofacute exfoliative dermatitis, or had suc-cumnbed to acute nephritis of chemicalorigin. As usually employed in generalpractice, chrysarobin is not of much value.The occasional and irregular anointing ofisolated patches with a chrysarobin paint,or its occlusion under one of the Beiersdorfchrysarobin or anthrarobin plasters, haslittle to recommend it, and its reputation asan anti-psoriatic would not be very high ifthese were the only means of atilizing it.

In very weak conicentrationi, chrysarobinand its derivatives will sometimes be foundeffective in clearing up the chronic forms ofseborrhoeic dermatitis. I use a i to ! percenit. combination with Lassar's paste for thepurpose. The drug can also be applied inintractable cases of tinea of the extremities.Care must be taken to exclude the acutevarieties, especially when in the vesicularstage, from such an indication. In myhands a I to 3 per cent. paint in tinct.benzoin has proved the most effective meansof employing it. Quite recently chrysarobinhas been given by the mouth and even intra-venously for psoriasis, with benefit. I havehad no opportunity so far of testing itsefficacy thus administered. I have usedthree der-ivatives of chrysarobin, for which itis claimed that they are as effective as theoriginal without beinig at the satne time sodirty or destructive to clothing, &c. Theyare anthratrobin, neorobin and cignolini. Idid not find that the claims put forward forthe substitutes were proved, and I considerthat clhrysarobin, properly used and con-trolled, is one of the most valuable drugsever introduced inito the dermatologicalpharmacopceia.


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66 BASIC REMEDIES IN THE TREATMENT' OF DISEASES OF THE SKIN

SALICYLIC AcID.The chief dermatological function of this

drug is keratolytic. It has a relativelysimple formula, a benzine ring with OH andCOOH radicles attached, and it was firstpresented to medicine by Kolbe as a puresubstance in I874, although it had lonig beenknown and valued by herbalists in the crudejulices of the sweet birch, and as oil ofwintergreen.The macerating, keratolytic action of local

applications indicates its use in any cuta-neous condition in which hyperkeratosis is afeature. Thus, warts and corns may besoftened, anid the former even eradicated, byplasters or paints containing it. It is oftenof great value, before excochleation with asharp spoon, as a preparatory and macerat-ing application in lupus and lupus verruco-sus. In my experience most of the plastersand applications compounded for thesepurposes are much too weak, and 1 havenever seen any harm from 40 per cent. andeven 50 per cent. concentrationis, whethercombined with other druigs such as creosoteor not.

It is often compounded with tar anidchrysarobin in the treatmenit of psoriasis,and with sulphur is a favour-ite remnedy foracne, either in aqueous or ointment base.1t is sparingly soluble in water (only abouti in 500), so that unless the watery solutionlscontain calamine or zinc it should be dis-solved in spirit, as e.g., in hair lotions, inwhich it helps to control atnd diminiish theformation of dandruff. Unless I require akeratolytic action I do not use salicylic acidin greater concentration thall 3 per cent. asan antiseptic and adjuvant to other drugs inthe prescription.

This is not the place to discuss the in-dicationis and action of salicylic acid by themouth, but there is one very definite andvery frequentlv successful indication, viz.,in all cases of erythema inuiltiforme, andpreferably as salicini, up to 40 or 50 gr. a day.In my experience there is no other medicine,taken by the mouth, which so consistently

relieves a dermatological condition, pro-vided the diagnosis is correct. The phenyl,-ester of salicylic acid, salol, used to be muchin vogue as an intestinal antiseptic, but isnowadays replaced by such remedies askaolin, which aim at absorption of toxins, orby attempts to alter the bacterial flora byadministrations of lactodextrin or theemnulsions of B. acidophilius and the lacticacid bacilli.

It is worth remembering that idiosyncrasyto salicylic acid and also to its derivative,the univer-sally uised aspirin (acetyl-salicylicacid) is occasionally met with, and may giverise to alarming symptoms such as sweat-inig, vomiting, diarrhoea, cardiac weakness,niephritis, and erythematous rashes associatedwith oedema, especially of the eyelids.Bicarbonate of soda in large doses pei- os isrecommended as an antidote. Dermatitisat the mouth angles is sometimes attribut-able to tooth anid inouth preparationscontaining the drug.

CALCIUM.

Since Almroth Wriight published hisexperimental investigations in I896, calciumpreparationis have been used for most con-ditions in which a diminished coagulationvalue of the blood was suspected. Urticariaand chilblains were regarded as the chiefdermatological indications, and the admini-.stration of the various calcium salts has beensomewhat overdone, and has given rise to acertain amount of therapeutic disappoint-ment in consequence.The only local preparationi in general use

is the liquor calcis, which is derived fromCaO by the addition of water (CaOH,).The action is soothing and astringent, andwhen mixed with olive oil is still a favouriteapplication in burns (Carron).Modern therapy gives it an important

place. It is claimed that it reduces inflam-mation, and can even prevent or diminishthe normal inflammatory response in animalspreviously treated with it. This action isthought to be due to a reduction of the


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BASIC REMEDIES IN THE TREATMENT OF DISEASES OF THE SKIN' 67

endothelial permeability for blood serum.Additionally, there is a pronouLnced narcoticor soothing action on the whole sympatheticor vegetative nervous system. This has notreceived the attention it deserves in thiscountry, but in Germany the treatment byintravenious injections of calcium salts haslong been practised, and has been found ofvery real utility in urticarial conditions ofall kinds, notably angioneurotic oedema(u. gigans), strophulus, and even purpura.The additioni of bromide to such injectionshas been found to intensify and prolongtheir action, which lasts only about twenty-four hours as a rule.

In this way the physician can make cer-tain that the calcium really reaches thecirculation, a desideratum which is by niomeans assured when the salt, either thechloride or lactate, is given by the mouth.The firm of Knoll has put up a dissolvedmixtur-e of calcium chloride and urea inIO c.c. (Afenil) ampoules, and this dose canbe safely injected every day or every otherday if required, for two or three weeks at atime. In my experience there is no bettertreatment for chronic urticaria of obscurecausation. Great care must be taken notto inject into the subcutaneous tissues, andalso to use a ver-y fine needle, which obviatesthe unpleasant feelings of heat engenderedby rapid transition of the solution.

I have to confess to considerable scepti-tism of the value of the calcium salts whenorally administered, and I have seen nothingto compare with the dramatic effects thatoccasionally follow the intravenous injec-tions. The favourite salt in this country isthe relatively soluble lactate (i in io). Othercombiniations such as the phosphate arehardly soluble at all in cold water.As calcium sulphide, the metal is used

frequently as a chemical depilatory.There are three heavy metals which are in

constant use in dermato-therapy, lead, mer-cury and bismuth, and it is unlikely that, inspite of changing fashions, any one of themwill be entirely abandoned. Lead is themost poisonous of the three, and its use

should, in my opinion, be confined to localapplications only. Apaart from its well-known indications as the lotio plumbi (B.P.),it is sometimes forgotten that the liquorplumbi sub., when mixed with milk (i in 9), isone of the most soothing and astringentremedies we possess. The ung. plumbi sub.(B.P.) (i in 8) is useful in ally type of painfulcrack or fissuLre, atnd this action is usuallyaccelerated by the addition of tar, if thelocalization is on the feet or hands.The indications for mercur-y are too well

known to nieed specification here, but Iwould recommend you never to order theold blue ointment (ung. hydrarg.) for pedi-clulosis, as the cure is often worse than thedisease, owing to the severe dermatitis thatis apt to follow a 30 peer cent. applicationto hairy regions. As an anti-luetic remedymercury is fast losing its ancient prestigeto bismuth, and I believe it is the experienceof most authorities that the latter is morerapid and less toxic in its action. Of themany preparations I have tried during thelast five years in the V.D. Department at theRoyal Northern Hospital,includingthe metalitself in suspension, and chemical combina-tions with iodine and quinine (quinby), anidarsenic (bistovol), I have recently employedone which seems to me to fulfil at leastsomiie of the most important claims putforward by the makers. This substance isbismogenol, and is an oily suspension of asalt of bismuth and salicylic acid. it isgiven intramuscularly inl I c.c. dosage inacute cases up to thrice weekly, anid is reallypainless, does not give r-ise to infiltrationis orto stomatitis of any severity, while so far- asiiiy experiellce goes it relieves the pains oftabes and the headache of meningeal irrita-tion more effectively than anv arsenicalpreparations, and even (in two cases) afterthese had failed.My impression is that the persistent and

intractable W.R. yields more readily tobismogenol than to any other of the bismuthsalts, but I have not yet worked long enoughwith it to test the claims put forward on thisscore by Continental clinicians.


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