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THE USE OF CHRYSOPHANIC ACID IN THE TREAT
MENT OF DISEASES OF THE SKIN.
By R. W. TAYLOR, A.M., M.D.,
It may be truly said of chrysophanic acid that, unlike the majority of new remedies, it has a greater range of usefulness than has yet been claimed for it. Indeed, it is in the treatment of certain skin diseases—what quinine is to malarial fevers— almost a specific. This acid, as is well known, is in the form of a yellowish-brown powder, and is derived from an Eastern remedy called Goa powder, in which it exists to the extent of 85 per cent. It is also said to be derived from rhubarb. Originally this Goa powder was used for ringworm in Eastern countries, and it is only within a few years that its use has been extended to the treatment of other cutaneous affections. To Dr. Balmano Squire, of London, certainly belongs the credit of our more extended knowledge of the usefulness of this valuable agent and its derivative acid. Having myself used it extensively in a number of skin affections, I desire now to present my views as to its general sphere of usefulness, and to consider certain drawbacks which we must admit there are in its application. I hope thus to draw out the experience of other physicians who have used the drug.
First, let us consider the form and strength of the ointment to be used, since this is the most convenient mode of application. Some of the observers who first used it recommended a strength of two drachms of the acid to the ounce of lard or cerate. But I am positive that in this country this strength is far too great, such an ointment is rarely necessary, and should always be used with the greatest caution, as I will point out later. I may here remark that I have found no necessity for the use of hot lard in the formation of the chrysophanic acid ointment, nor for the solution of the acid in benzol before mixing with the cerate or
lard. My preference is that the acid should be thoroughly triturated with a few drops of alcohol before mixing it with equal parts of vaseline and simple cerate or cold cream. This makes a smooth ointment, which readily permeates the skin. As to the strength of the ointment preferred by me, I would say
that I constantly use it in the proportion of ten grains to the ounce of cerate, and rarely higher than one drachm to the same quantity. In speaking of the various diseases, I will state the proportions usually found beneficial for each. In general, brisk inunction once or twice a day, leaving a coating of the ointment on the parts, is all that is necessary; but in some instances it is essential to apply the salve spread on lint as a plaster. Care should always be taken that only the morbid tissue is thus covered.
To state its general applicability briefly, I may say that chrysophanic acid ointment is useful for chronic subacute skin affections attended with superficial infiltration or with much epi. dermal proliferation. In cases of very deep infiltration it is not, I find, so beneficial as other agents are, for the reason that the strength of the ointment required is necessarily so great that it of itself causes inflammation around the part, and even then does not yield any very excellent results. Then, again, it is not to be used upon excoriated surfaces. But in cases such as psoriasis, lichen planus, in some of the early papular syphilitie eruptions, its action is marvellous. My general rule is to employ it only in cases in which the epidermis is intact or not shed, or again when this layer is much thickened. The disadvantages of the ointment are, its staining qualities, its tendency to produce erythema, severe cedema, and sometimes furuncles. While we cannot prevent the pigmentation of the skin, we can use measures for its removal, such as brisk friction with powdered pumice-stone or a pad of flannel. As regards the inflammatory sequelæ, I think that as the observer becomes more familiar and skilled in the use of the agent, he will be less liable to see them. When I first used the ointment in the proportion of two drachms of the acid to the ounce of fat, I several times in cases of psoriasis saw much ædema around the patches following the appli. cation, but still the disease yielded so quickly and the inflammatory symptoms were so speedily relieved by cold water dressing, that in some urgent cases I did not regret its occurrence. However, I would from further experience counsel caution, and advise
a moderately strong oir.tment, although the cure will not be quite as rapid. In some rare instances little boils, and large ones even, will appear after the application of a mild ointment, and sometimes it will be necessary to stop the remedy in consequence, but such instances are quite rare. One fact has struck me very forcibly in using this agent, namely, that it has not very pronounced antipruritic properties; consequently, in some affections attended with severe itching we are compelled to combine with it one of the tarry oils, or camphor, or carbolic acid.
Let us consider briefly the value of chrysophanic acid in various skin diseases, for, as I have said, its range of application is very wide, greater than is generally couceded, and is not by any means limited to the treatment of psoriasis and ringworm. In acne much good can be obtained from the use of a mild ointment, ten to twenty grains to the ounce. But here its staining properties are an almost insuperable objection to its use. Yet my experience in dispensary practice has convinced me that many cases of simple and of the indurated form of acne will be benefited by it more than by any other single remerly. I have directed patients to just bathe the face well with hot water and then to rub over each papule or tubercle a little of the ointment, leaving a film of it to be absorbed. The result is that the next day the whole face is stained to the copper color of an Indian, to remove which it is necessary to scour the parts well with powdered pumice-stone, which operation, however, is not always followed by complete success. Great as is this drawback, there are persons who will undergo the annoyance in hope of ridding themselves of their chronic disfigurement. In cases of acne complicated with rosacea, and in rosacea, I have seen excellent effects from a tolerably strong ointment, twenty, thirty, or forty grains to the ounce. I have seen the dilated superticial capillaries wither under its use several times in very severe cases. Let me here say, that great caution must be exercised in using a tolerably strong ointment on the face, since in this situation it is liable to cause severe inflammation, sometimes resembling erysipelas. The best mode of procedure is to use at first a mild ointment and simply rub a little in, carefully watching the result. Then we may go a little further and apply it spread on linen lint constantly. Should at any time inflammatory symptoms show themselves, the application must be suspended and
water dressing applied. But care and observation will make the prescriber skilful in avoiding such accidents.
In eczema, the use of chrysophanic acid is limited, I think, to chronic localized spots, not attended with great inflammation. To these it can be applied in moderate strength continuously; but in general it will be necessary to combine with the ointment a sufficient quantity of the oil of cade, birch oil, or tar to relieve pruritus. In chronic eczema of the palms of the hands, I have used, with great benefit, an ointment made of the acid fifteen grains, diachylon ointment one ounce. The same oint. ment I have used, with equally good results, in chronic cases of scaling eczema of the scrotum, in which was considerable thickening. When used upon the hands or scrotum, the ointment should be spread on the limb, and kept continuously applied. It may be necessary, of course, to envelop the former in India-rubber gloves,and perhaps to envelop the scrotum, over thedressing, with gutta-percha tissue. In any case in which itching is severe, I think a sufficient quantity of any oil should be added. In two instances of sycosiform eczema of the beard in the chronic, and somewhat infiltrated stage, I produced a cure by using ten grains of the acid to the ounce of diachylon ointment, the dressing being kept on continuously. This, indeed, was after the usual remedies bad failed.
In ringworm of the scalp, chrysophanic acid is often very useful, but it is necessary to use it with considerable care, as it here may produce severe inflammation. Ten grains to the ounce of cerate and vaseline is generally sufficiently strong. Of course, it is necessary to use epilation in bad cases. One drawback to its use, however, is the staining of the parts to a pure flesh-brown color. I think it well to mention the fact to parents, when stating to them the advantage of rapid cure, which we are warranted in promising from use of the acid. Ringworm of the body is readily cured by an ointment of moderate strength, rubbed in several times daily. When used upon the trunk or extremities, chrysophanic acid will inevitably stain the underclothes. To get over this trouble as well as we can, I state the fact to patients, and advise them to wear such articles as are well worn, and to continue their use while under treatment, since the necessary time is usually not long.
In lichen planus I have seen some of the most rapid cures produced by this agent, but the itching which usually accom