A guide to the treatment of diseases of the skin : with suggestions for their prevention for the use of the student and general practitioner

Front matter

A

GUIDE TO THE TREATMENT

DISEASES OF THE SKIN:

CHAPTER I. Introductory Observations

i. On tbe various morbific influences which excite disease in the skin, and determine its character . . . . 1

n. Diagnosis . . . .5

ill. Prognosis . . . .9

rv. General observations on treatment . , 11

Alterative treatment . . 13

Arsenic . . .15

Iodine . . .27

Urtica . . .28

Galium . . .28

Cod-liver oil . . . 29

Willan's arrangement of skin diseases . . 30

CHAPTER XI. On the Vegetable Parasites of the Human Skin . 212

CHAPTEE XII.

On Metastasis in its Practical Bearings . .218

CHAPTEE XIII.

On the Prevention of Diseases of the Skin Management of the skin General health Bathing

Air and exercise

Diet

CHAPTER XIV.

On the Turkish Bath

. 233

. 234

. 237

. 239

. 241

Chapter I

GENERAL OBSERVATIONS ON THE ORIGIN, DIAGNOSIS, PROGNOSIS, AND TREATMENT OE DISEASES OF THE SKIN.

I. ON THE VARIOUS MORBIFIC INFLUENCES WHICH EXCITE DISEASE IN THE SKIN, AND DETERMINE ITS CHARACTER.

Diseases of the Skin have been divided by Willan into eight orders; and to this division, and to its nomenclature, we propose to adhere. But, first, it will be well to look at the skin as subject to certain morbific influences, which, whether from within or without, not only give a character to the disease, but must be specially studied with a view to enlightened and successful treatment. For instance, the smallpox reveals the existence of an abnormal influence of a specific kind, producing an eruption of pustules. But pustules may arise also from morbific influences of a widely different nature ; therefore, in treating pustular diseases, we have not to treat ptistnles as such, but we have to contend with the exciting cause which has thrown out the pustules, whether it be variolous, as in small-pox ; cachectic, as in ecthyma ;

2 MORBIFIC INFLUENCES WHICH EXCITE parasitic, as in scabies ; syphilitic, as in lues ; or antimonial, as in the eruption produced by the potassiotartrate of antimony. The pustules thrown out from these and other sources of disease, are sometimes so similar to each other in appearance as to deceive the most practised eye. Many cases are annually sent to the Small-Pox Hospital, diagnosed as small-pox, which turn out to be some other eruptive disease.*

It is therefore necessary to be familiar with the various morbific influences which are productive of eruptive diseases, and with the manner by which these influences are manifested in the system, independently of their appearance in the skin. In fact, the eruption is but the mode in which the blood-poison within is indicated, and by which it is sometimes eliminated from the system ; and, so long as the eruption is allowed to run its own course without check or stimulus, so long it remains an important sign of the nature and severity of the abnormal influence which throws it out, regulates its force, and determines its character and history.

Some of these influences are necessarily felt but for a limited time, as in the eruptive fevers, in which the poison exhausts itself in a few days or weeks, and the patient either sinks under its fatal spell, or recovers spontaneously. Other influences, less actively destructive, operate with little or no intermission, from the period of their first attack to the end of the patient's life, unless they are countervailed by therapeutical agency ; as in the diseases in the squamous group.

* Mr. Marson assures me that, during the last twenty years, several hundreds of patients have been sent to the Small-Pox Hospital with eruptive diseases not small-pox, hut which were believed to be small-pox.

DISEASE IN THE SKIN.

Here, then, we have a natural division of universally acknowledged importance, namely, the ephemeral and the persistent. Some of the persistent diseases are ephemeral and recurrent in their commencement, and gradually become persistent. But there is a third class, depending upon the influence of certain natural changes, epochs, or critical periods, in the life of the patient. Thus we have the crusta Inctea of infancy (porrigo larvalis), the ring-worm of childhood (porrigo scutulata), the acne of puberty (acne simplex), the sycosis and acne rosacea of manhood, and the prurigo senilis of old age. To these might be added the ncevus of foetal life, and the ephelis of pregnant women.

Therefore, in searching for those morbific influences which are developed in the skin, the student will do well to regard all skin diseases as either ephemeral, persistent, or climacteric.

The next important point to be noticed, is that some of these diseases are contagious, or communicable from one patient to another, others are not so. And it is remarkable that this wide distinction (not less pathologically palpable than all-important in practice) exists in all the above divisions. Not only are some of the ephemeral class contagious, as smallpox, and others not contagious, as heipes zoster; not only are some of the persistent communicable, as scabies, others not so, as lepra ; but, strange to say, the climacteric class contains contagious diseases, as ringworm* (contagious only in childhood), and a form of pityriasis (contagious only in adult age), as well as

* Ring worm is more properly endemic and infectious, than Btric tngious.

MORBIFIC INFLUENCES.

non-contagious diseases, such as strophulus, acne, and prurigo, none of them communicable at any age.

Diseases of parasitic origin (if such there be) maybe included under the contagiosa, in one or other of these classes. But it must not be forgotten that the minute animal or vegetable forms which the improved microscope has detected subsisting on the human skin, are not necessarily the cause, but more probably the effect of the morbid condition. Nor are we yet certain that any genera of animalculse are destined to subsist on the human integument in its healthy and vigorous condition.*

Injuries of the skin, from burns, scalds, the sun's rays, cold, dirt, the stings and bites of insects, or the handling of powdery substances, as also ulcers depending on mechanical causes, and ready to heal when these are removed, are not properly speaking diseases ; but some of them are easily mistaken for disease, particularly stings, bites, and excoriations.

Leaving these, then, out of the question, we have before us a simple view of the causes or morbific influences operating on the skin, in almost every form of eruption to which it is subject.

The following table will exhibit this in an intelligible form, and will be found useful in diagnosis. The only diseases mentioned by Willan which are not included in this synopsis, are pomphohjx, ephclis, spilus, and aphtha ; but pompholyx is only another name for pemphigus, and ephelis for a form of pityriasis. Spilus is a kind of neevus ; and aphtha is a disease not of the skin, but of the mucous membrane.

* See the chapter on the parasites of the human

DIAGNOSIS.

Tabular View of the Morbific Influences originating Cutaneous Diseases.

Ephemeral Influences produce

Persistent Influences produce

Contagious.

Non-contagious

Contagious.

Non-contagious.

Variola

Vaccinea

Erythema

Pityriasis ver-

Varicella

Ecthyma

sicolor

Scarlatina

Furunculus

Rubeola

Anthrax

Ichthyosis

Roseola

Erysipelas

Sudamina

Rupia

Erambcesia

Miliaria

Urticaria

Molluscum

Pemphigus

Vitiligo

Cancer

Elephantiasis

Climacteric Influences produce

,t Fatal. ' Nobvus

Infantile. Adolescent. Adult. Senile.

Acne simplex Acne rosacea Prurigo

Acneindurata senilis Sycosis

Contagious. Non-contagious.

Ring worm Strophulus Scald-head Crusta lactea

II. DIAGNOSIS.

It is an extraordinary fact, that to the modern medical student, well versed in the use of the stethoscope, diseases of the internal organs, concealed from view, present fewer diagnostic difficulties than diseases of the skin, which are visible. It is not, however, that the ear is more to be trusted than the eye, but simply that the ear is instructed in the sounds of the chest, the

DIAGNOSIS.

student is tutored to observe and discriminate them, and to confirm their indications by post mortem inquiries; whereas but few students have been instructed in the diagnosis of diseases of the skin, common as they are. Until of late, but few even of our hospital physicians or surgeons were able to distinguish one cutaneous disease from another ; and some of them are even now frank enough to avow it, and think it of little importance. Hence it is that the study of cutaneous diseases has necessarily become a special branch of medical practice ; and truly the great variety of these diseases, the number and frequency of their complications, the many difficulties presented both by their diagnosis and treatment, and the pain and misery often attending their development, render them worthy, not only of special attention, but of the study of a whole life.

The difficulties of diagnosis have been further increased by the popular nosology of cutaneous diseases. They are classed and distinguished by their primary forms, rather than by their matured and well developed' appearances ; so that such a disease as lupus exedens, which, as the student generally sees it, presents the features deformed and deficient — the nose or lips, or both, partly eaten away — is seldom recognised in its primary form, a harmless looking tubercle or scab occupying the tip or ala of the nose. Again, the scalylooking crusts of eczema, in their advanced and dried condition, never suggest to the tyro the minute vesicle of transparent fluid which is described as the diagnostic character of the disease. To remove these difficulties and discouragements, it will be our object to describe the secondary as well as the primary characters of each disease.

DIAGNOSIS.

But it is not enough to have discovered the name and nosological status of the disease. This will seldom of itself determine the treatment.

In the diagnosis of these disorders, the most important, and sometimes the most difficult point, to be determined, is whether they be of syphilitic origin ; many of them, especially the squamosae, being occasionally of this nature, and requiring the same treatment as other forms of lues. The reddish-brown, or copper-coloured, appearance of the eruption, taken in connexion with the history of the case, will generally lead the experienced and observant practitioner to a correct judgment ; and it is infinitely more important to determine this question rightly, than to assign the case to its proper order and genus.*

The next point requiring attention is whether the eruption be complicated with any other deviation from health, local or constitutional; functional or organic; whether there be a febrile condition of the system, a quick pulse, a hot surface, deficient secretions, local pain, or other marks of increased vascular action ; or whether the patient be anaemic, gouty, strumous, or dyspeptic.

Having determined that the disease is not any one of the specific eruptive fevers, nor the result of general dyscrasia, the next question is, what is its natural history ? Is it ephemeral and temporary, recurrent and periodical ; or is it naturally persistent, and liable to become inveterate and tormenting for the whole life ? The diagnosis will thus determine the prognosis. The next question is, whether the disease be contagious ?

* The author has given full account of theso important diagnostic symptoms in a separate work, On Eruptions requiring the Use of Mercury.

DIAGNOSIS.

And lastly, is the disease one of infancy, or dentition? one of childhood, of puberty, or of adolescence ? Is it connected with the uterine functions ? Is it peculiar to mid age, or is it a sign of natural decay ?

A confident and decisive determination of these questions, given at the outset, will go far towards the successful treatment of the disease, not only by suggesting the right course to be pursued, but by inspiring the patient with confidence and hope, and thus securing his concurrence and perseverance in adopting and carrying out our prescribed management. And it is positively essential that this diagnostic dictum should be given at once. In many internal diseases we cannot do this ; we must wait and watch, and test the secretions, — and sometimes test the disease by cautious treatment, too, — before we can assure either ourselves or our patient what it is we have to deal with. Not so in diseases of the skin. The man who is practically familiar with the various forms, phases, complications, and tendencies of cutaneous disease, ought to be able, with a good light, to pronounce on it at first sight. The student, therefore, should carefully trace the relation of the disease before him to one of the morbific influences described in the foregoing synopsis. The age and sex of the patient will at once limit the inquiry to a small class of diseases. The history of the disease, its origin, date, advance, or decline, its relation to the general health, and especially to certain organic functions, must all be taken into account; and last, not first, the character of the eruption, its present appearance, and its primitive form, must be carefully observed.

PROGNOSIS.

III. PROGNOSIS.

The prospect of recovery, a point on which patients naturally expect a definite opinion, is nevertheless a question which involves so many contingencies that it should be entertained with caution. For while it is certain that there are very few cases of chronic cutaneous disease which are utterly incurable, there are yet many causes which may conspire to render the cure remote and uncertain. For, not to mention the sometimes excusable want of faith and patience and perseverance on the part of the patient, (which indeed the author has always found by far the gravest difficulty with which he has had to contend), there are so many events, such, for instance, as the accidental invasion of other diseases, which may interrupt the treatment, that the most unwise course of all is that of naming a period at which the patient may expect to get well. For he will not fail to remember the time ; and he will certainly lose heart and hope on the arrival of that period, if he does not find himself entirely liberated from his annoying disease, even though it may be his own fault that he is not cured. It may be observed, however, that when the skin has been affected for many years, the curative process mast be extended through many months. Recent attacks, on the other hand, are generally found to yield in a shorter time, but they by no means invariably run a short course. It is always well for a patient to understand that, if from weariness of taking medicine, or from economical reasons, or any other motive, he attempts to evade the necessary conditions of success, either by taking larger doses than those prescribed, or by " waiting awhile to

PROGNOSIS.

see what nature will do," or by shunning the necessary examination at the time appointed by tbe medical attendant, he himself will certainly be disadvantaged. All these expedients, instead of expediting, will invariably and indefinitely protract his recovery. Nor must the prescriber himself show any signs of doubt or hesitation in the advice he gives, much less of weariness in well doing. It may seem childish to put these very obvious remarks in print : but the truth is that the difficulties of cutaneous therapeutics are not so much physicial as moral difficulties. If we cannot act on the mind of the patient, in vain will our prescriptions avail for his relief. Without hope, confidence, and determined resolve, on the part of the patient, we can do little with his disease. We must supply him with assurance from time to time, or he will soon lose faith. Above all things we must be truthful: the difficulties of the case must neither be ignored, nor exaggerated, and the conditions on which we must hope for full and final success must be stated at once, and as definitely as possible. Many a patient has thrown his chance of cure away by tripping off to the sea side, or to the continent to try some famous baths, j ust in that stage of the treatment when constancy and stedfastness are all- important. The object of the physician must be, of course, for his own sake, to cure his patient as quickly as possible. Delays and slow progress are painful to both parties, and the credit of the one as well as the comfort of the other, should both secure the earnest co-operation of each. The author is induced to insert these remarks from painful recollections, of many interesting but very manageable cases, from which the patients will probably never recover, because they lack one moral quality — stability.

TREATMENT.

I 1

The prospect of speedy relief may generally be held out in those most painful cases where we find inflammatory symptoms : but the final cure may nevertheless be far distant. Some few forms of cutaneous disease very rarely recover entirely, as will be noticed in the body of the work. This should be clearly stated at once, even at the risk of losing the patient, who will often rather fly to quackery, or to any one who will inspire him with false hopes, than believe the truth. On the other hand, attacks of herpes zoster, and other acute forms of skin disease, which often alarm the patient, we can assure them will subside in a few days. Lupus, lepra, and others of the chronic class, may require months, or even years, of steady perseverance, hoping against hope, and striving through all difficulties, before the disposition to disease will entirely cease. There is a physiological necessity for this, which no boasted novelties in medicine can ever set aside.

IV. TREATMENT.

The diagnosis being accurately determined, the treatment must in the first instance be regulated by established principles. Every obvious local or constitutional disorder which may happen to complicate the eruption, and which, in some cases originates and sustains it, must first be rectified if possible. Disordered secretions require particular attention ; the digestive and excretory organs must be watched and regulated, and the general health restored (if it be deranged) by appropriate remedies. All this must be done, and done effectually, before especial attention is directed to the cutaneous disease, except in those cases

TREATMENT.

in which the health suffers as a result, and not as a cause of the eruption. This may generally be determined by careful inquiry. We must also watch for the symptoms of any increased vascular action or febrile excitement which so frequently accompanies certain chronic affections of the skin. It is to be feared that this latter indication, though clearly pointed out by modern writers, is too much overlooked in practice. In adapting to the case in hand our depleting measures and cooling regimen, we must bear in mind that we may have to deal with an inflammatory disease, extending over a large portion of the surface of the body ; and that the skin is plentifully supplied with blood-vessels, exhaling normally a considerable quantity of fluid, which exhalation is often permanently suppressed, giving rise to congestion of the cutaneous vessels. The tender skin is likewise exposed to an atmosphere capable of becoming an irritant in disease. The most tormenting cases of skin disease sometimes consist of extensive inflammatory action of an acute type, but of long duration, thus combining the acute and chronic character. We may find a full, hard, frequent pulse, a skin universally warmer than natural, and, in the diseased portions, the patient suffers extremely from sensations of burning, smarting, itching, pricking, and stinging. If these symptoms occur in a plethoric subject, bleeding may, in extreme cases, be required, and leeches must be applied occasionally to the red margins of the more recently affected portions of the skin. In addition to this, it may be absolutely necessary to forbid stimulants, and to administer active aperients, salines, or antimonials, in doses which will not severely rack the stomach, an organ which it is impor-

TREATMENT.

tant to keep in tone during the treatment of these diseases. This system must be pursued for days, weeks, and even months, if necessary, until the smarting and tingling have in a great degree subsided, and the cool skin, quiet pulse, and tranquil nights suggest that the period is arrived for the commencement of the alterative treatment. A premature exhibition of alteratives is a great error, and often fatal to success ; and even after the alterative course has been properly determined upon, the pulse must be watched, the bowels regulated, and all inflammatory tendencies checked at their onset, and ultimately subdued if necessary by a few doses of Plummer's pill or other mercurial adjuvant. These are, however, extreme cases. They occur chiefly in the scaly class of diseases and in country practice, and they are of much less frequent occurrence than formerly. In the milder cases of inflammation, where the general febrile action is not so obvious, but there is much smarting or pruritus, topical bleeding or a slightly reduced diet may suffice. Occasional purgatives are useful, if not essential, in nearly all cases, and are of more service at intervals than when administered too f requently. There is no sort of reliance to be placed upon external applications, and they should be used with great caution. Warm or tepid baths of fresh water often prove a source of much comfort to a patient in the febrile stage of chronic cutaneous disease. The same may be said of fomentations ; they are seldom or never curative, scarcely auxiliary to the cure, but they soothe and amuse the patient, who likes to be doing something, and often speaks gratefully of their effects. Sea-water, sulphur-fume and hot-air baths, are all inj urious to the inflamed surface, and generally

TREATMENT.

unnecessary when the inflammation has been subdued.* Equally needless, and not seldom hurtful, are most of the ointments, lotions, and other applications which have been recommended in these diseases. When the skin is very harsh and disposed to crack or bleed, much comfort may be derived from glycerine diluted with five times its volume of orange flower water.

Much judgment is sometimes required to fix the proper limits of the antiphlogistic treatment. Ecthyma, a disease of debility and poverty, has been known to take the place of lepra, and eczema has often degenerated into impetigo when the low-diet system has been carried too far, — a condition which must be rectified by tonics. Indeed the degree of success attending the alterative treatment will much depend upon the nicety with which we have previously adapted our depleting measures to the actual necessities of the case. If the patient be much reduced, powerful tonics may be necessary to his recovery, and there are cases in which they are found requisite from the very commencement of the treatment. Both plethora and anaemia are conditions highly unfavourable to the recovery of lost health, and must be removed before the skin can become permanently sound. Among the poor, and especially poor infants and children, cutaneous disease often presents a type of debility from the first. And this may be ascertained not so much from the character of the eruption as from the general condition of the child. Squalor and emaciation, the sunken eye, the piteous sigh, the pale upper lip, together with a tendency to

* The Turkish or Roman bath, when properly administered, has Rvalue peculiar to itself, which will he noticed in a future chapter.

TREATMENT.

pustulation in the eruption, are but too obvious signs of imperfect nutrition, and a general anaemic condition of the system. In these cases mild purgatives are very useful, but they should be combined with iron, quinine, the mineral acids, or other tonics ; and cod-liver oil often supplies the great want— a nourishing diet.

Thus, by rectifying what is obviously wrong in the general system, we put the patient into a condition in which the local disease has a chance of getting well. And sometimes this is all we have to do : the vis me~ dicatrix nature will accomplish the rest. It more frequently happens, however, that the eruption continues in a milder form for some time, then begins to spread, and finally relapses into its original condition. To prevent this, many alterative remedies have been tried with various degrees of success.

Of these, arsenic has for a long period enjoyed the highest reputation. But, unfortunately, owing to a very general misapprehension of the conditions requisite for its successful operation, it frequently fails to eradicate the disease for which it is prescribed. It is likewise believed by many practitioners to be a dangerous medicine ; and, on that account, it is altogether proscribed and repudiated, by more than one member of the profession, and, by many, administered with a timidity which counteracts its efficiency. I venture to assert, that the right administration of arsenic is attended with far less danger than that of mercury, antimony, strychnine, opium, or any other poison now used medicinally : and in this opinion, I am not singular.

Arsenic is known to be a virulent poison in a laro-e dose ; and it is said to have the power of wasting and

TREATMENT.

destroying the vital principle with equal certainty, ■when small but deleterious doses are incautiously repeated too long together. A belief in the truth of this allegation has probably deterred many discreet practitioners from its due administration. But I can most confidently assert that the reputation of arsenic as a slow poison in medicinal doses, rests upon no evidence whatever. Still it behoves every practitioner who prescribes so virulent a poison, to acquire all the knowledge he can of the phenomena to be expected under its use, not only as regards the suspension of diseased action, but more especially with reference to its influence on the general economy. This knowledge is but scantily supplied by authors ; and it was one chief object of the publication of the first edition of this little work, to make known the results of the author's own experience, after closely watching the effect of the medicine for many years. The reader may rest assured, that the dangers attending the medicinal use of the mineral have been enormously exaggerated, and that its destructive properties have never been manifested, even in the hands of practitioners who knew not how to regulate its use. I have now administered arsenic to patients, in small but efficient doses, for months or years together, in many thousands of cases, and have watched in vain for the alarming effects attributed to its use. During more than thirty years' observations, I have rarely known it produce any unpleasant effects on the system in a degree incompatible with perseverance in its use ; and I have taken the pains to make extensive inquiries among more than a hundred of my professional brethren most familiar with its use ; and their testi-

TREATMENT.

raony to the safety of the mineral, when discreetly administered, is, without a single exception, in perfect harmony with my own experience.""'

Indeed, there are few medicines less likely to do harm than arsenic, when administered in the manner about to be described. In the hands of practitioners experienced in its use, I consider it absolutely safe. It is a medicine which never requires to be pushed. It is a remarkable fact, that doses large enough to disturb the system generally, often aggravate cutaneous diseases, which nevertheless will yield to smaller doses; so that its curative powers appear to reside alone in doses too small to he mischievous. It is impossible to hurry its operation: every attempt of this kind, not only fails, but retards the wished-for result. But a patient and persevering administration of small doses, under favourable circumstances, for weeks, months, or years together, will be found to exercise an almost omnipotent influence over the cutaneous diseases to which it is adapted.

The numerous failures of arsenic, as an internal remedy for skin diseases, may be traced to one or more of the following sources: 1. The syphilitic character of cutaneous disease is often overlooked ; arsenic is prescribed where mercury is wanted, and the former medicine has no influence whatever in most of these cases. 2. Some practitioners administer arsenic during the inflammatory or febrile stage of cutaneous disease, under which circumstances it rarely fails to increase the inflammation, and never does any good. 3. Other writers direct it to be given on an empty

• See" Memoir of the Medicinal Action of Arsenic." Transactions of the. Provincial Med. and Surg. Association, vol. xvi, port 2.

C

TREATMENT.

stomach, and are often obliged to abandon it on account of the gastric irritation it is said to excite.* 4. Many practitioners prescribe it in doses too large, and at intervals too distant, to obtain the full benefit of the medicine ; and lastly, all the writers I have as yet had an opportunity of consulting, both British and foreign, direct it to be given in gradually increasing doses. This, as it is the most common, often proves to be the most serious error, particularly if it is increased by daily or weekly increments. But if after a fortnight or three weeks it produces no sensible effect whatever, it is fair to assume that the dose is too small, and it may be increased say to one-fifth, once or twice a month, until it begins to assert itself; then the full dose may be considered to have been arrived at, and we must persevere in this without further increase.

Arsenic was long thought to be one of the cumulative poisons ; but that it does not accumulate in substance has been now abundantly proved. No mineral exhibited in small doses is so rapidly eliminated as arsenic. f Neither do its effects accumulate or increase in intensity after the first fortnight. The sudden energy with which its toxical properties were manifested in former days, arose from the habit of daily adding to the dose until a really poisonous dose was given. Such effects never occur if only moderation be used in its administration. Five minims of Fowler's solution three times a day is sufficient to begin with, and this dose must be reduced as occasion may re-