THE HISTORY AND THERAPEUTICAL VALUE OF

ARSENIC IN SKIN DISEASES.

BY MALCOLM MORRIS, M.R.C.S.

Joint Lecturer on Dermatology at St. Mary's Hospital Medical School.

(Continued from page 440, Vol. xxiii.).

SPECIAL HISTORY IN SKIN DISEASES.

THE foregoing history of the use of arsenic in general diseases, especially in intermittent fevers, shows clearly the alternate periods of belief in, and fear of it as a medicine, and must be understood to comprehend the history of its use in skin diseases. It will have been noticed that up to the time when its action was first physiologically examined, each period of excessive popularity was followed by a period of equally excessive distrust. But after the commencement of the eighteenth century, the re-actions seem, with two notable exceptions, at different times in Germany and France, to have become less and less marked, and by this time its value in general medicine, especially in fever, appears to have been justly estimated. The history of its use, and of the process by which the modern estimate of its general value has been gradually arrived at, will be of assistance to us in trying to steer between the equally excessive use and disuse of it in skin diseases, and in trying to arrive at a fair estimate of its value in this special department.

I now intend to give, first, a brief history of the use of arsenic in skin diseases, in order that we may see and avoid the extremes to which partisans on either side have been drawn; secondly, a description of the physiological action of

it as at present accepted; and thirdly, the results of personal experience. In conclusion, I hope to be able to draw some reasonable inference as to the particular class of skin diseases in which it may be prescribed.

In the history of the general use of arsenic, it was noticed that it was in common use among quacks as a remedy against ague and fever, even at the time when it was in greatest disfavour among medical men, and this was also the case as regards skin diseases. Two remarkable instances of this may be mentioned, one in Germany and one in England. Ackermann gives the prescription kept as a secret by a family of surgeons for many years, which they declared to have been most successful in the treatment of herpes. An Edinburgh Pharmacopoeia of about 1775 gives a prescription under the name of solutio mineralis arsenici which was used among the people to cure leprous diseases.

Besides this popular use I have only been able to discover three distinct references to its early use by medical men. In 1784 Dr. Adair, who had practised in the West Indies, states in a communication to the Medical Commentaries of London that he had used it internally with opium in the form of pills in cancer, elephantiasis, and yaws. According to Desgranges, who speaks on the authority of Dr. Valentin, Rush of Philadelphia used to prescribe it for dartrous and other serious affections of the skin, seemingly without success, but also without any ill-effect. Oberreich who wrote on arsenic in the year 1803, speaks in exaggerated terms of it as being the most efficacious remedy in a large variety of different diseases, including herpes and cancerous ulcers.

1

These individual experiences had no widespread effect, and until Dr. Thomas Girdlestone of Yarmouth contributed his wellknown letter to the Medical and Physical Journal of London, in April, 1806, no actual case of cure by means of it had been recorded. He says, that "although I had frequently used with success the arseniate of potash in mesenteric, and many other scrofulous affections, yet your old acquaintance Mr. B. was the first patient on whom I tried the effects of this medicine in lepra. You remember that he had laboured for fourteen years under

1 Harles, p. 114.

that disease, tried repeated salivations, many physicians and every quack medicine, without any effect, and was at last cured by small and repeated doses of arseniate of potash. It is now several years since his cure was completed, and my experiments and success have extended to some hundreds of cures of lepra, lichen, prurigo, psoriasis, tinea capitis," &c.

Another early case is reported in the Medical and Physical Journal of 1807, by T. Y., who gives the notes of his own case. He says: "I had had severe psoriasis diffusa since 1800, had tried every known remedy without avail, local and constitutional, when I began arsenic as recommended by Girdlestone. Began three drops twice a day, increased to seven, in six weeks I was quite well." Its use in skin diseases seems to have become known immediately, for in 1807 Dr. Bardesley of Manchester gave his experience of Fowler's solution, and in 1812, an American physician, Dr. Redman Coxe, narrated a cure of lepra of fourteen years date cured by arsenic.

Nevertheless Willan in the first edition of his great work on cutaneous diseases makes no mention of it, but it must soon have been recognised in English practice, for Biett, who was the first to use it at the celebrated Skin Hospital at St. Louis, is said by Cazenave to have introduced it from the London hospitals. Bateman in his edition of Willan, published in 1819, speaks of Fowler's solution being extremely beneficial in inert cases of lepra, owing to its tendency to support the strength, and to stimulate the cutaneous vessels.1

In a monograph on arsenic by Mr. John Marshall, 1817, he says that Dr. Browne, senior physician to the Sea Bathing Infirmary at Margate, gives arsenic in skin diseases, but always limits the dose to 5 m. of Fowler's solution, twice a day, beginning with 3 m., and his reason for not giving more than 5 m. is because of the deleterious effects he has witnessed when the drug has been pushed.

In France Fodéré used it with success in some dartrous affections, as well as in intermittent fevers, but it was not a recognised remedy in skin diseases till Biett, as has been already stated, introduced it at the Hospital of St. Louis in 1817. By the year 1820, he had invented the arseniate of ammonia, which

1 Page 33.

he

gave

in addition or in alternation with the solutions of Fowler and Pearson. He seems, according to Cazenave's article on arsenic in the year 1833, to have used it not only in lepra and psoriasis, but also in eczema, impetigo, and urticaria tuberosa with success, and to have tried it, but without avail, in porrigo, acne, sycosis, and lupus. Rayer, whose first work was published in 1826, mentions arsenical preparations for chronic cases of almost every disease, but in his introduction he says that " for his own part he ardently hopes that experiments of another description, put to the same test, may cause these violent remedies to be superseded by external medicines, more rational, more immediate in their effects, and less dangerous." In his later edition, translated by Dr. Willis in 1835, he says that arsenical medicines are most frequently and most successfully employed in certain chronic and obstinate forms of eczema of the scrotum, margin of the anus and labia; they ought never to be used in exanthematous, and but rarely in chronic bullous inflammations, occasionally in lichen, and sometimes in spite of much abuse, with success in prurigo, pityriasis, psoriasis, and lepra.2 Cazenave in his article in 1833 said that marvellous effects resulted from the administration of arsenical preparations, not only in lepra and psoriasis, but also in eczema and impetigo, though they failed in porrigo, acne, and sycosis. In his Manual on diseases of the skin published in 1853, he repeats even more emphatically his former opinion. Devergie, Hardy, and Bazin all largely recommended arsenic, the two latter chiefly in dartrous affections.

In Germany the use of arsenic has not been so extensive as in France and England, for Hebra, the distinguished dermatologist of Vienna, has, since 1840, taught rather the value of external instead of internal remedies, and the necessity of placing the latter on some scientific basis. He says: "I set not the slightest value on any remedies except those which (after repeated trials, and when I am accurately acquainted with the complaint) I find to produce a favourable change in its course, or, in other words, to cure the patient. I never attribute therapeutical powers to a medicine, unless I observe its employment to be invariably and constantly followed by some change in the 1 Traite de Maladies de la Peau, Paris, 1826. 2 Page 85.

morbid products, and by the termination of a disease in a shorter time than when it is allowed to undergo spontaneous involution." Yet he gives it in psoriasis, remarking that arsenic has a decided curative action, and can make this affection undergo involution for a time, if not permanently, and also in lichen ruber with good results. On the contrary, he denies its value in eczema, and says, in strong language: "I cannot concede to arsenic the undefined blood purifying and eczema curing powers, which are attributed to it by English and French physicians." Neumann and the other German writers adopt pretty nearly Hebra's views.

2

Though the science of dermatology had taken deep root in France in the early part of the century, chiefly, or I might say entirely, due to the labours of the St. Louis physicians, yet it had not done so in this country; for, after the death of Bateman, who carried on Willan's great work, nothing of any importance was published on the subject till 1842, when Mr. Erasmus Wilson's work on diseases of the skin appeared. In this early edition, not very much mention is made of arsenic; under the head of eczema, it is included among several other remedies as a suitable one for the chronic and obstinate forms. Its action is described in a footnote in the following words: "Arsenic, when it acts on the nervous system, performs the part of an alterative, but when its effects are directed upon the digestive system, it appears to act like cantharides upon the mucous membrane of the kidney, viz., by counter irritation, by exciting inflammatory action in the interior, and thus determining from the surface." 3 In lepra also Mr. Wilson had used it, but he does not strongly urge its adoption, as its action is only incidentally mentioned in a footnote. In his lectures delivered before the Royal College of Surgeons in 1871-2-3, Mr. Wilson points out that in eczema there is no medicine more harmless, more certain in its effect, and more successful than arsenic. The good qualities as well as the dangerous effects are again referred to when dealing with lepra, but it will be sufficient for me to say that Mr. Wilson strongly advocates its use in this disease.

No Englishman, and probably no man who ever lived, used

1 Hebra on Diseases of the Skin. New Sydenham Society Trans. Vol ii. p. 89. 2 Ibid. Vol. ii. page 143. 3 Page 172.