ON THE VALUE OF 
FREQUENTLY REPEATED DOSES OF ARSENIC 
IN THE TREATMENT OF 
BULLOUS DISEASES OF THE SKIN 
ESPECIALLY IN CHILDREN 
BY ' 
L. DUNOAN BULKLEY, A.M., M.D. 
NEW YORK. 
REPRINTED FROM 
THE NEW YORK MEDICAL JOURNAL 
FOR APRIL 13, 1889 
NEW YORK 
D. APPLETON AND COMPANY 
1889 . ON THE VALUE OF 
FREQUENTLY REPEATED DOSES OF ARSENIC 
IN THE TREATMENT OF 
BULLOUS | DISEASES OF THE SKIN 
ESPECIALLY IN CHILDREN 
BY 
L. DUNCAN BULKLEY, A.M., M.D. 
PHYSICIAN TO THE NEW YORK SKIN AND CANCER HOSPITAL, ETC. 
REPKIN TED FROM 
THE NEW YORK MEDICAL JOURNAL 
FOR APRIL 13, 1889 
NEW YORK 
D. APPLETON AND COMPANY 
1889 ON THE VALUE OF 
FREQUENTLY REPEATED DOSES OF ARSENIC 
IN THE TREATMENT OF 
BULLOUS DISEASES OF THE SKIN, 
ESPECIALLY IN CHILDREN* 
By L. DUNCAN BULKLEY, A. M., M. D., 
PHYSICIAN TO THE NEW YORK SKIN AND CANCER HOSPITAL, ETC. 
Arsenic is perhaps the most frequently used and the 
most commonly abused of all the remedies employed in the 
treatment of diseases of the skin, and it is safe to say that 
a large share of all patients with eruptions have this drug 
administered to them by some one at some time during 
their course; and yet the experience of every one will tes- 
tify that it is by no means the specific which could be 
wished for in these affections when they are taken as a 
whole. The cause of disappointment in the use of this 
therapeutic agent will be found unquestionably, as in the 
case of all therapeutic agents, in the failure to adjust the 
remedy to the particular diseased state for which it is valu- 
able, and to use it in proper and sufficient doses with, if 
necessary, such other adjuvants to treatment as may be re- 
quired. It is needless to add that in this lies the secret of 
the successful practice of medicine. 
* Read before the Section in Dermatology and Syphilography of the 
American Medical Association, May 10, 1888, 4 
ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
Arsenic is not an indifferent therapeutical agent, and 
there is no question in regard to its power to influence the 
skin ; but there is also no question but that it is useless, or 
even harmful, in many of the diseased states to which this 
organ is liable. 
It is not the purpose of the present paper to enter into 
the general subject of the use and value of arsenic in the 
treatment of diseases of the skin, nor to dwell on the neces- 
sity of an absolutely correct diagnosis and sound therapeu- 
tical indications in its administration ; this subject was fully 
discussed by the writer twelve years ago,* and the literature 
of the subject presented, with also clinical records and 
illustrations, and later experience has further confirmed the 
statements there made. The aim of the present communi- 
cation is to call especial attention to the undoubted and al- 
most specific action of arsenic in one certain form or variety 
of skin disease, and to place on record a few cases illustra- 
tive of the same; also further to show not only the harm- 
lessness but the value of frequently repeated and seemingly 
large doses of the drug in proper cases, especially in chil- 
dren. 
The most notable and striking of all bullous diseases, in 
which arsenic seems at times to exert almost a specific in- 
fluence, is pemphigus vulgaris. My attention was first 
called to the value of efficient doses of arsenic in this affec- 
tion by the writings of that brilliant, versatile, and inde- 
fatigable worker, Mr. Jonathan Hutchinson, who, in 1854, 
reported a number of cases of pemphigus, some of which 
had been treated successfully with arsenic; this report was 
followed by subsequent records of cases by himself and 
others ; and in 1877 the present writer f reviewed the litera- 
* "New York Medical Journal," August, 1876, p. 113. 
f "American Journal of the Medical Sciences," October, 1877, p. 
408. ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
5 
ture of the subject and reported on five cases of pemphigus 
treated successfully with arsenic in free doses, in one of 
which cases the drug had twice appeared to save life. As 
this latter case was a most important one, demonstrating the 
specific action of arsenic in pemphigus in an absolute man- 
ner, I shall take the liberty of again briefly alluding to it; 
the other cases here mentioned have been treated since: 
Case I.-Annie S., aged sixteen years, had had an eruption 
of bullae, especially on the limbs, coming and going for a year 
previous to the date of my first seeing her; it had nevei' given 
great trouble until a few weeks previously, when it increased 
with severity, the bases of the lesions taking on a diphtheroid 
character, and she rapidly sinking. When first seen there was 
every appearance of extreme exhaustion, with rapid and feeble 
pulse, and death was expected shortly by three physicians who 
had seen her. The eruption had affected the mouth, and the 
tongue and buccal cavity, as far as could be seen, were covered 
with ulcerating lesions, rendering speech and deglutition almost 
impossible; there were some large and distinct bulhe on the 
elbows and lower legs, but most of the lesions consisted of 
ulcerated surfaces, many of them covered with a pultaceous 
diphtheroid membrane, and some of them were horribly offen- 
sive. 
All other medicine was stopped, and Fowler's solution was 
given, well diluted, four times daily, in doses beginning with four 
drops and increasing by half a drop at a dose until eight drops 
were taken four times daily. The results surpassed anything I 
had seen in other cases; within twenty-four hours improvement 
was very visible, and after three or four days all the lesions as- 
sumed a decidedly healthier appearance; a load seemed lifted 
from the system, the patient was cheerful, could talk easily, and 
no new bullae had formed. Within a week or two most of the 
lesions had healed, no other remedy being used except a little 
carbolated zinc ointment to a few of the more offensive sores. 
Some two months and a half after the first visit she had a re- 
lapse, owing to a neglect of the medicine, and once more she was 6 
ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
in bed, prostrated and sinking. Again the eruption yielded to 
the arsenic alone in full doses, and she kept it at bay for some 
months, until she sank and finally died from tubercular disease 
of the lungs, which was aggravated if not induced by her most 
unsanitary surroundings in a room kept continually damp with 
laundry work. 
Case II.--Mrs. L., aged twenty-two, had been married five 
years, and had had several miscarriages before and after the 
birth of a child, two years and a half previous to the commence- 
ment of her eruption; this child was perfectly healthy, and 
lived four months and a half, dying of some lung difficulty. 
About three months previous to the date when she was first 
seen, March 8, 1881, she began to suffer from chills with fever, 
and an eruption on the forehead, which was followed in three 
or four days by lesions on the back. The disease increased in 
intensity until she was shortly confined to the bed, and was 
more or less helpless up to the time of her admission to Mount 
Sinai Hospital, on March 3d, where I saw her in consultation 
with Dr. W. H. Fluhrer. 
When seen she was in a pitiable condition ; the face was 
largely covered with crusts, and the arms and legs were also 
thickly sprinkled with the results of past lesions, in the form of 
crusted masses, with sharply cut, ulcerated surfaces beneath, 
scattered among bullae with more or less purulent contents; 
there were also a number of lesions on the chest and back. Her 
temperature on admission was 103° F. and her pulse 104 and 
weak, and she was emaciated and feeble. From the history 
and other reasons, syphilis had been suspected, and antisyphilitic 
treatment had been instituted, under which the eruption had 
grown worse; she complained of burning pain in all the lesions. 
All other treatment was discontinued, and she was given 
three drops of Fowler's solution, every two hours, well diluted, 
and a mild carbolic ointment applied to some of the worst sores. 
The hospital records of March 9th, the next day, show that the 
eruption had begun to improve at once under the arsenic; and 
three days later it was recorded that many of the lesions bad 
healed; the dose was then increased to four drops of Fowler's 
solution every two hours. For some reason, after the eruption ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
7 
bad almost disappeared, she began to get worse, failing in health 
and strength, and I was asked to see her again on April 8th, the 
temperature having again run up to 103° at times, with occa- 
sional drops to 99°. I found that there had been considerable 
return of the disease, but the diagnosis of pemphigus was again 
confirmed, and the arsenic continued in free doses, with atten- 
tion to the bowels and other details. To be brief, the patient 
again improved under the arsenic, and was discharged cured on 
June 17, 1881. 
Case III.-Mr. T., a large, strong man, forty-nine years of 
age, who had always enjoyed good health, was first seen in 
consultation with Dr. Klotz and Dr. Scheider, July 28, 1887. 
He had had pneumonia in January, which was followed very 
shortly by an eruption of bullae on the front of the chest; this 
increased rather slowly, and early in May bullae existed all over 
the chest, on the scalp, and within the mouth. After that time 
the disease developed more rapidly, and he had been confined 
to bed for three or four weeks previous to the first consultation, 
spending also part of each day in a water bath, as much relief 
was obtained thereby. 
When first seen much of the surface was covered with the 
eruption, which exhibited pemphigus lesions in various stages 
and conditions. The mouth was a mass of raw ulcerative lesions 
with ragged edges, and the lips were painful to use in any way. 
The arms, legs, feet, and hands, also the trunk, were the seat of 
bullous lesions, large and small, with raw surfaces caused by 
their rupture; the region of the sacrum was entirely bereft of 
epidermis, as also part of the feet and other portions, so that 
the suffering was intense. 
He was given the liquor sodii arseniatis in doses of two drops, 
to be increased slowly to ten drops every two hours, in Vichy 
water, a few drops of laudanum to be added if diarrhoea was 
produced ; a carbolized mouth-wash was prescribed, acalamine- 
and-zinc lotion applied to some of the inflamed portions, and 
the raw surfaces were dressed with cotton batting. The effect 
of the arsenic was seen shortly, and in a week it was recorded 
that the eruption had improved in every way; some of the sores 
had healed, and there was much less discomfort; but there had 8 
ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
also been some new development of vesicles, especially on the 
left upper thigh, where there were dozens of clear, distinct bullae 
of small size. The dose of the arsenic had then reached eight 
drops, but had not been taken as frequently in the twenty-four 
hours as was desired. One week later there was still improve- 
ment in the eruption, and there had been manifest gain in the 
general condition of the patient, who seemed reasonably com- 
fortable and cheerful. Shortly after this time lung symptoms 
set in, apparently due to an extension of the disease downward 
from the mouth, which, however, had greatly improved in con- 
dition. 
Soon after this the arsenic was discontinued for a day or two, 
and the change in the character of the eruption and the feelings 
of the patient was so apparent to every one that it was quickly 
resumed, and continued to the end. But it seemed finally un- 
able to cope with the disease, for, although it held the eruption 
in check to a very considerable measure, the patient sank from 
intestinal complications, with occasional recurrence of his cough, 
both seemingly from a development of the disease on the mucous 
surfaces, and finally died on September 10, 1887. 
Occasionally during the course of eczema, especially in 
elderly people, the nature of the process will appear to be 
changed, and lesions of a pemphigoid character will occur 
which may prove very distressing. These will continue to 
be formed in spite of the ordinary treatment employed for 
eczema, but will be found to yield promptly to the free use 
of arsenic alone, as in the following two cases: 
Case IV.-Mr. O., aged seventy-seven, was seen in consulta- 
tion with Dr. J. R. Conway, on February 12, 1884, on account 
of a very general eczema with which he had been confined to 
bed for a week. The attack had begun one month previously, 
and when he was first seen it covered the entire body and limbs, 
in the form of erythematous and papular eczema; there were 
no vesicular lesions, but some moist surfaces existed here and 
there from scratching. The eruption did very well under an 
acid, magnesia, and iron treatment, together with mild external 
measures, so that in three weeks he was very comfortable, and ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
9 
by the end of a month he had been out of doors, and seemed 
almost well again. 
He then became careless in eating, and possibly relaxed 
treatment too much, and on March 28th it was recorded that he 
had had severe very general itching, with the production of 
many large and small erythematous patches, upon which were 
many grouped vesicles, and three days later there developed on 
the left wrist a pemphigoid blister, large and tense, nearly an 
inch in diameter. He was placed on an alkali after eating, and 
given ten drops of the liquor sodii arseniatis between meals, 
well diluted. A few days later more of the bullous lesions ap- 
peared, one of them three quarters of an inch long, on the front 
of the right tibia, and other smaller ones elsewhere on the legs. 
The arsenic drops were increased to twelve, three times daily, 
and very shortly the production of bullae ceased. The arsenic 
was continued until May 10th, and, as he had had no bullae for 
some time, they were stopped ; but on May 15th they reappeared 
upon the legs, and he was given the arsenic alone, in ten-drop 
doses, four times daily, and the bullae again promptly disap- 
peared. The arsenic was continued for a month longer, and he 
went to the country apparently well. 
In December the eczema recurred, and shortly after the 
bullae reappeared, which, however, were again controlled by the 
arsenic; but his eczema remained more or less troublesome for 
some months later, although it finally yielded in the spring. 
Case V.-The next case resembled the preceding one very 
completely, except that the eczema element was less severe and 
less general; it need, therefore, be but briefly detailed. The 
patient, Mrs. C., aged seventy-one, was referred to me by Dr. 
Learning, February 5, 1877. The eruption had existed some 
months, and formed eczematous patches over the body and thighs, 
some of them erythematous and papular, some of them moist. 
During the course of the eruption pemphigoid blisters devel- 
oped, mainly on the abdomen, which yielded promptly to the 
free administration of arsenic. 
Arsenic is also found to be of very great service in con- 
trolling the bullous eruptions sometimes excited by the in- 10 
ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
ternal use of iodide and bromide salts, especially those of 
potassium. A single illustration of this will suffice: 
Case VI.-Miss E., aged thirty-five, had been under treat- 
ment for syphilis, which was contracted nearly four years pre- 
viously. As she lived some distance from the city, and neither 
she nor her family physician could be made to appreciate fully 
the requirements of the case, her treatment was carried out 
somewhat irregularly and with interruptions. One year before 
the occurrence of the eruption to be described, or early in the 
fourth year of her syphilis, she had a strange attack of partial 
paralysis, presumably syphilitic, from which she recovered under 
the treatment of her family physician, who understood her case; 
but after this date she had more frequent recurrences of epileptic 
seizures, to which she had been subject occasionally during the 
period of her syphilis, though unbeknown to me, and possibly 
once or twice during previous years. These epileptic seizures 
had increased during the year previous to my visit to be referred 
to, and she had been under the care of some irregular physician 
in another city for this trouble, and had also taken an advertised 
nostrum for epilepsy. By the latter part of April a bullous 
eruption appeared on the nose, and then on other portions of 
the face. This medicine was stopped on April 30th, but her 
own family physician, thinking the eruption to be syphilitic, 
had been giving her increasing doses of iodide of potassium, 
with the effect of daily increasing the eruption until seen by 
me, May 30, 1880. 
When first seen the whole face was covered with a thick, 
black crust, the results of former lesions, with also much crust- 
ing on the scalp. On the chest and back nearly a quarter of 
the surface was covered with new and old lesions, many being 
also on the extremities. Here and there could be seen bullae, 
rounded on top, up to half an inch in diameter, with apparently 
clear contents, giving exit to serum and blood when punctured. 
Some of these were recorded as seated on healthy skin, with 
almost no surrounding inflammation. Much of the eruption was 
composed of the crusted and ulcerated surfaces occupied by 
previous bullae, and, to render the diagnosis more obscure, they ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
11 
were largely arranged in circular and serpentine forms. She 
was extremely exhausted. Pulse, 120; temperature, 101'4° F. 
in the mouth. The bowels were acting twice daily. 
All other medication being discontinued, she was placed upon 
Fowler's solution, five drops every two hours, to be increased 
by a portion of a drop if necessary. She was also given a pill 
containing a third of a grain of opium, with two grains of 
quinine at bed-time, and locally carbolized oil (1 to 50) to be 
brushed over the lesions, some of which were very offensive. 
The results from the arsenic were even more than could 
have been expected. Almost immediately the patient began to 
improve, and three weeks later the eruption had almost entirely 
vanished. The crusts fell off very shortly after beginning the 
arsenic, no new bullse formed, and healing progressed very rap- 
idly. Several months later she was given mild mixed treat- 
ment, with a moderate quantity of iodide of potassium, but never 
again was she troubled with such an eruption. 
While arsenic proves of such signal advantage in the 
conditions already described in adults, its effects in some of 
the bullous eruptions in children are, if anything, even more 
marked in proper cases, and if given in efficient doses, as 
may be judged from the following cases: 
Case VII.-Rosalie B., aged ten years, was sent to me by 
Dr. J. Ackerman Coles, of Scotch Plains, N. J., May 25, 1887. 
The child presented a typical herpes iris, and her condition 
was then as follows: The eruption was confined to the hands 
and forearms, feet, and lower legs, with a few spots on the 
thighs and also about the mouth and on the lips, likewise within 
the buccal cavity. The feet and lower legs were pretty thickly 
covered with new and old lesions, and on the backs of the 
hands and wrists some were most typically characteristic, with 
a single bleb of some size and a circle of vesicles around, seated 
on a reddened base; in one or two instances there was a second 
circle outside of this. In some places the blebs were of very 
considerable size, and were recorded as about an inch in diame- 
ter ; in other places they had ruptured, and the surface was 12 
ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
either raw or covered with dried membrane or secretions. She 
suffered very considerably, more especially with the lesions on 
the lips and mouth, so that she could scarcely talk or take any 
nourishment. 
The history of the case was that in January, four months 
previous, she had a first attack, which lasted about a week. A. 
second attack came some few weeks later, and was even milder. 
The present attack had begun three weeks previous to her visit, 
and had increased steadily until the time she was seen. At the 
first visit she was given Fowler's solution, with an equal quantity 
of water, of which she was to take five drops every two hours, 
increasing the dose gradually to ten drops if necessary and if 
there were no unpleasant symptoms. 
The next day, May 26th, there was already some improve- 
ment noted; many of the lesions seemed less inflamed, and the 
child seemed more comfortable. A little castor-oil was then 
ordered, as there had been some constipation, and the drops 
were ordered to be increased. Five days later very marked im- 
provement was noted; the bullae and vesicles were flattened, 
and most of the lesions were gone from the mouth, she having 
used also a lotion of borax, carbolic acid, and honey. A week 
later the eruption had disappeared, leaving only stains. She 
was then taking seven drops of the mixture, or three drops and 
a half of Fowler's solution every two hours. 
On two subsequent occasions, when the arsenic was neg- 
lected, she had a recurrence of the eruption, which was promptly 
checked by a return to the frequent doses of the arsenic. The 
remedy was then taken at longer intervals until finally it was 
discontinued, and she remained free from eruption. 
Case VIII.-Edward D., aged four years and a half, was 
brought to me in his mother's arms, October 29, 1887, so se- 
verely affected with herpes iris that he could not walk. The 
eruption began on the foot, four weeks previously, apparently 
from injury, the toe having been stepped on. The eruption had 
spread rapidly, with the development of new lesions, until, when 
first seen, much of the body was the seat of the disease, it being 
especially severe upon the extremities. The hands and arms 
were almost covered with old or new lesions, and the feet and ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
13 
legs so badly affected that they were only wrapped up in band- 
ages, it being impossible to put on shoes or stockings. Much of 
the eruption consisted of abraded surfaces in various stages of 
inflammation, some covered with crusts, some raw, and between 
them, on healthy skin, were some characteristic bulhe of herpes 
iris, with clustered vesicles around; a new crop had appeared 
on the backs of the hands and feet the day before the visit, each 
fresh outburst being preceded by fever. There bad been con- 
siderable itching, and the child was much pulled down by the 
disease. 
He was given Fowler's solution, diluted one half with water, 
five drops to be taken every three hours, and a lotion of cala- 
mine to be applied freely to the diseased surfaces. 
Three days later it was recorded that there had been very 
great improvement; most of the inflamed surfaces had dried up, 
but a few new blisters had appeared here and there, with clear 
contents. The arsenic drops were increased to seven or eight, 
equaling three or four of Fowler's solution, every three hours, 
no other treatment being given. 
A week later he walked to the office, appearing almost well. 
There were, however, still a few new blisters developing from 
time to time, the largest one being on the left wrist, which 
measured half an inch by a quarter of an inch. It was found 
that bis diet, which had been purposely neglected in order to 
test the remedy, was very faulty, he taking tea three times daily. 
These matters were corrected, milk was freely given, and the 
arsenic continued at six drops, every three hours, as he had 
shown a little diarrhoea from the drug. The case then pro- 
gressed satisfactorily to the end, and the mother, seen a year 
after the last date, reports that all traces of the eruption van- 
ished very shortly, and that it has never reappeared. 
Case IX.-T., a previously healthy boy, aged two years, was 
seen in consultation with Dr. Packard, January 31,1885, on ac- 
count of what then appeared to be a dermatitis, beginning ten 
days previously on the left foot, from the irritation of rubber 
boots. It had increased and extended until much of the left 
foot and ankle were covered with a raw exuding surface, caus- 
ing much pain. It was learned later, however, that the erup- 14 
ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
tion had begun with blisters like those seen later in the disease. 
This first attack passed away very shortly under an ointment of 
oxide of zinc and a calamine lotion, with a little calomel and 
soda every other morning, and an iron-and-arsenic mixture. 
He remained well until the middle of July, when, after a 
bath in the ocean, an eruption of blisters appeared on the hands 
and feet and then over much of the body. This passed away in 
three or four weeks, but returned shortly after on the left leg 
and buttock ; the eruption kept recurring here until the patient 
was seen again on September 22d, when the hands and face were 
found to be swollen also, but with no eruption. He was given 
an alkaline and arsenic mixture with a laxative, and in ten or 
twelve days the eruption disappeared, and remained absent for 
a year or more. 
When nearly four years old, after bathing daily in the ocean 
for a month, he had an eruption on the left arm which remained 
confined there for a month, when it developed on the body and 
left leg the day before he was next seen, October 2,1886. There 
were then found three large bullae, sharply defined on the left 
knee, something over an inch in diameter, with perfectly clear 
contents, with smaller vesico-bullse on the body, and the remains 
of others on the left arm; all were seated on a more or less ery- 
thematous base, and there was considerable itching before the 
bull® developed. As there was evidence of very bad liver ac- 
tion, he was given a mixture of rhubarb and soda with arse- 
nic, and in a week the eruption had pretty much disappeared, 
but this was followed by a fresh outburst only a week or two 
later. 
These repeated developments of the disease recurred several 
times until, on November 11,1887, he was given Fowler's solu- 
tion, diluted one half, to take from four to eight drops every 
two or three hours. At this time the eruption was more pem- 
phigoid in character, the bullae rising quite suddenly from an 
almost healthy skin, with little or no inflammatory base; the 
bullae, some of which were at least half an inch in diameter, 
were seated on the buttocks, left thigh, and root of the neck. 
Six days later it was recorded that the lesions had all dried up 
and that no new ones had appeared, he then taking six drops of ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
15 
the mixture, or three of Fowler's solution, every three hours. 
Since that time he has remained free from eruption, and, al- 
though he has had disturbances of health requiring attention 
from time to time, he has never had any return of the bullous 
disease up to the date of writing. 
In looking at these cases, we see that arsenic has proved 
of signal advantage in several different forms or conditions 
of bullons eruption, occurring in patients of both sexes and 
of very diverse ages; the oldest patient was seventy-seven 
years and the youngest three years of age; four of the pa- 
tients here mentioned were males and five females. There 
is seen to be little in common in these cases except the fact 
that each of them presented bullae, and that they were most- 
ly of a chronic character, with repeated accessions of erup- 
tion until checked by the action of the arsenic. Of the 
three adults with true pemphigus, two died; but in these 
instances the drug was commenced very late in the disease, 
and one of them died, probably from tubercular lung trouble. 
From the manner in which the remedy controlled the erup- 
tion and benefited the patient's condition, from the results 
in the other cases of pemphigus previously referred to, and 
from what has been reported by others, there is little doubt 
but that in efficient doses, with proper adjuvants occasional- 
ly, arsenic may be counted on as a specific in pemphigus. 
It is especially, however, with regard to its free admin- 
istration in children, in proper cases, that particular atten- 
tion is drawn at the present time. Children bear arsenic re- 
markably well, and, although I have given it freely in a very 
considerable number of cases, both such as these and in 
eczema, I have never seen untoward results, or any which 
caused me uneasiness. As a rule, arsenic acts with them as 
a purgative before it manifests its other physiological effects, 
and it may generally be safely given in bullous eruptions in 
increasing doses; if the disease does not yield, it may 16 
ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
be increased until it purges, then the dose should be slack- 
ened to a point where it is perfectly borne. 
In many cases, of course, its effect will be more or less 
increased by the proper use of such other measures of diet 
and medication as circumstances may indicate; in the first 
case of a child here mentioned, castor-oil was given, and 
afterward the hypophosphites were added; and in the last 
child it was necessary to give occasional doses of calomel, 
and also an alkali and rhubarb and soda, and finally an iron- 
and-arsenic tonic; but in each instance it was the arsenic, 
used independently and in relatively large and frequent 
doses, which alone checked and controlled the eruption, 
while in the second case of a child only arsenic was used 
from first to last. 
In regard to the mode of action of the arsenic, it has to 
be acknowledged that we know little or nothing in refer- 
ence to the manner in which it operates in controlling the 
disease. To say that these lesions are neurotic in character 
and that the arsenic acts through the agency of the nerves, 
as it is beneficial in chorea and neuralgia, is only bringing 
the question one point nearer and not answering it com- 
pletely. Writing upon this subject some time ago, Mr. 
Hutchinson * uses the following language, which expresses 
briefly about all we now know of the matter: 
" Arsenic does not merely repress the eruption, but 
remedies the unknown constitutional causes on which that 
symptom depends, always very much benefiting the general 
health of the patient. Arsenic does not prevent the lia- 
bility to subsequent attacks, but such attacks are always 
much less severe than the original one, and tend, if treated 
by the same remedy, to diminish in intensity on each suc- 
cessive occasion." 
A single word may be added in regard to the mode of 
* Hutchinson. "Medical Tinies and Gazette," 1854, vol. i, p. 131, ARSENIC IN BULLOUS DISEASES OF THE SKIN. 
17 
administration of the arsenic. The preparation used in all 
these cases was either the arsenite of potassium or the arseni- 
ate of sodium in solution. These are undoubtedly the most 
appropriate preparations, and are those most commonly em- 
ployed. It is well to prescribe them diluted with a definite 
quantity of water, both in order that the increasing dose 
may be more gradually augmented, and that there may be 
a lessened chance of error in dropping out each dose. 
In giving the remedy every two hours it very often or 
generally comes apart from a meal; it is necessary, there- 
fore, to direct that the dose be administered in a considera- 
ble quantity of water-at least a third of a tumblerful. It 
is often better borne by the stomach when it is given in 
Vichy water, which is often also otherwise indicated in these 
bullous affections. 
4 East Thirty-seventh Street.