Upon what is the const.i.tutional treatment based?

Upon indications. Diet and hygienic measures are important.

In dyspepsia and constipation, bitter tonics, alkalies, acids, pepsin, saline and vegetable laxatives, are variously prescribed. Special mention may be made of the following:--

[Rx] Ext. rhamni pursh. fl., .............. f[dram]ij-f[dram]iv Tinct. nucis vom., ................... f[dram]iij Tinct. cardamomi comp., .......q.s. ad [Oz]iij. M.

SIG.--f[dram]t.d.

Or Hunyadi Janos or Friedrichshall water may be employed for a laxative purpose.

In chlorotic and anaemic cases the ferruginous preparations are of advantage. Cod-liver oil is often a remedy of great value, and is especially useful in strumous and debilitated subjects. Calx sulphurata in pill form, one-tenth to one-fourth grain four or five times daily, is said, acts well in the pustular variety. In some instances, more particularly in sluggish papular acne, a.r.s.enic, especially the sulphide of a.r.s.enic, acts favorably. Upon the whole, the line of treatment that keeps in view proper and healthy action of the gastro-intestinal ca.n.a.l is the most successful.

[Ill.u.s.tration: Acne of back.]

In inflammatory cases occurring in robust individuals the following is often of service:--

[Rx] Pota.s.sii acetat., .................... [dram]iv Liq. pota.s.sae, ........................ f[dram]ij Liq. ammonii acetat., .... q.s. ad ... f[Oz]iij. M.

SIG.--f[dram]j-f[dram]ij t.d., largely diluted.

State the character of the local treatment in acne.

This must vary somewhat with the local conditions. Cases which are acute in character, in the sense that the lesions are markedly hyperaemic, tender and painful, require milder applications, and in exceptional instances soothing remedies are to be prescribed. As a rule, however, stimulating applications may be employed from the start.

The remedies are, for obvious reasons, most conveniently applied at bedtime.

What preliminary measures are to be advised in ordinary acne cases?

Washing the parts gently or vigorously, according to the irritability of the skin, with warm water and soap; subsequently rinsing, and sponging for several minutes with hot water, and rubbing dry with a soft towel; after which the remedial application is made. In sluggish and non-irritable cases sapo viridis or its tincture may often be advantageously used in place of the ordinary toilet soap.

The blackheads, so far as practicable, are to be removed by pressure with the fingers or with a suitable instrument (see Comedo), and the superficial pustules punctured and the contents pressed out. Sc.r.a.ping the affected parts with a blunt curette is a valuable measure, but is temporarily disfiguring. As a rule, however, cases do just as well without puncturing and sc.r.a.ping, and these methods sometimes leave behind scarring.

State the methods of external medication commonly employed.

By ointments and lotions. If an ointment is used, it is to be thoroughly rubbed in, in small quant.i.ty; if a lotion is employed, it is to be well shaken, the parts freely dabbed with it for several minutes and then allowed to dry on.

State the object in view in local medication.

To hasten the maturation and disappearance of the existing lesions, and to stimulate the skin and glands to healthy action.

If slight irritation or scaliness results, the application is to be intermitted one or two nights; in the meantime nothing except the hot-water sponging, with or without the application of a mild soothing ointment, is to be employed.

Is it usually necessary to change from one external remedy to another in the course of treatment?

Yes. After a certain time one remedy, as a rule, loses its effect, and a change from lotion to ointment or the reverse, and from one lotion or ointment to another, will often be found necessary in order to bring about continuous improvement.

Name the various important remedies and combinations employed in the external treatment of acne.

Sulphur is the most valuable. It may often be applied with benefit as a simple ointment:--

[Rx] Sulphur, praecip., .................... [dram]ss-[dram]j Adipis benz.

Lanolin, ............ [=a][=a] ....... [dram]ij.

Or it may be used as a lotion, as in the annexed formula:--

[Rx] Sulphur, praecip., .................... [dram]iss Pulv. tragacanthae, ................... gr. x1 Pulv. camphorae, ...................... gr. xx Liq. calcis, ........ q.s. ad ........ f[Oz]iv. M.

Another lotion, especially useful in those cases in which an oily condition of the skin is present, is the following:--

[Rx] Sulphur, praecip., .................... [dram]iss Etheris, ............................. f[dram]iv Alcoholis, ........................... f[Oz]iijss. M.

A compound lotion containing sulphur in one of its combinations is also valuable in many cases:--

[Rx] Zinci sulphatis, Pota.s.sii sulphureti, .... [=a][=a] ... [dram]ss-[dram]iv Aquae, ................................ [Oz]iv. M.

(The salts should be dissolved separately and then mixed; reaction takes place and the resulting lotion, when shaken, is milky in appearance, and free from odor; allowed to stand the particles settle, the sediment const.i.tuting about one-fourth to three-fourths of the whole bulk).

At times the addition to this formula of several drachms of alcohol and of five to ten minims of glycerin is of advantage.

An external remedy, often valuable, is ichthyol. It is thus prescribed:--

[Rx] Ichthyol, ............................ [dram]ss-[dram]j Cerat. simp., ........................ [dram]iv. M.

The various mercurial ointments, especially one of white precipitate, five to fifteen per cent. strength, are sometimes beneficial.

A compound lotion, containing mercury, which frequently proves serviceable, is:--

[Rx] Hydrarg. chlorid. corros., ........... gr. ii-viij Zinci sulphatis, ..................... gr. x-xx Tinct. benzoini, ..................... f[dram]ij Aquae, ............ q.s. ad ........... f[Oz]iv.

In extremely sluggish cases the following, used cautiously, is of value:--

[Rx] Ichthyol, Saponis viridis, Sulphur, praecip., Lanolin, ............. [=a][=a] ...... [dram]j.

In such instances the application of a strong alcoholic resorcin lotion, ten to twenty-five per cent. strength, repeated several times daily till marked irritation and exfoliation occur (a matter usually of one to three days), will sometimes be followed by marked improvement. Acne of the back is treated with the same applications, but usually stronger; in this region applications of Vleminckx's solution and formaldehyde solution, weakened considerably, at first at least, prove of value.

_Obstinate and indurated lesions_ may be incised, the contents pressed out, and the interior touched with carbolic acid by means of a pointed stick. The _x_-ray has proved a most valuable addition to our resources in the treatment of acne, and is especially serviceable in extensive and obstinate cases. An exposure should be made about twice weekly, at a distance of five to ten inches and for from three to ten minutes, and a tube of medium vacuum used. It must be used with great caution and never beyond the production of the mildest erythema. The hair, eyes, and lips should be protected. The _x_-ray treatment is best reserved for obstinate cases, and then used mildly, and rather as an adjuvant to the ordinary methods than as the sole measure.

What precaution is to be taken in advising a change from a sulphur to a mercurial preparation or the reverse?

Several days should be allowed to intervene, otherwise a disagreeable, although temporary, staining or darkening of the skin results--from the formation of the black sulphuret of mercury.