Practical observations on the pathology and treatment of certain diseases of the skin generally pronounced intractable : illustrated by upwards of forty cases

Front matter

an

THE BRITISH ASSOCIATION OF

DERMATOLOGY

Preface

Chronic diseases of the skin, though rarely fatal, are the source of a vast and unknown amount of human misery ; and many of them may he ranked among the most afflictive and dis¬ tressing with which our frail nature is visited. Many thousands of persons suffering from these disorders for the greater portion of their lives, are virtually abandoned by the profession, and have become the prey of mountebanks and murderers, or the victims of despair. It is, indeed, a deplorable fact, that our knowledge of the treatment of the more intractable forms of cutaneous disease, has not kept pace with the advancing pathology of the times. On this point the concurrent testimony of writers on the skin is in harmony with general experience. The skill and experience of Willan, the father of the British dermatology, not less than of Bateman his pupil and coadjutor, were confessedly unequal to the management of several of these disorders ; nor have their succes¬ sors, either English or foreign, made, as yet, any palpable advance in cutaneous therapeutics. A modern author* says, with reference to these maladies, “ It might even he made a question whether we have not absolutely retrograded in the views we entertain of their proper treatment.” It cannot be denied, however, that of late years a few very creditable attempts have been made towards the establishment of improved principles of treatment. Mr. Plumhe

* Dr. Jonathan Green.

Vlll

PREFACE.

has written well on the distinction between purely local affec¬ tions of the skin, and those of a constitutional origin. Dr. Green has shown how much may be done, (and by inference we may learn from his cases, how little,) by baths and fumi¬ gations ; and more recently, Mr. Erasmus Wilson published a valuable and elegant treatise on the diseases of the skin, in which he has attempted, without altering the Willanean nomen¬ clature, to arrange these disorders on a system more in ac¬ cordance with minute anatomy than that of Dr. Willan ; he has likewise contributed some useful hints towards simplifying their treatment. The splendid work of Bayer has been translated into English, and presents, with its beautiful illustrations, a valuable record of modern dermato-pathology. It is likewise full of his¬ toric references, and will be long esteemed as a text-book of this branch of medicine. A few other works of minor value have been published, and the periodicals have recently presented scanty demonstration that here and there a practitioner is attempting to contend with these “rebellious” diseases. Nevertheless, the humbling and appalling truth still forces itself upon our atten¬ tion, and is acknowledged by none with more candour than by the respectable authors above alluded to,— that if an unfortunate patient is suffering under confirmed Lepra, Psoriasis, Prurigo, Lupus, or any other severe chronic cutaneous disease, there ap¬ pears but little chance, under any treatment hitherto adopted, of his getting radically cured.

The day has dawned which will see this opprobrium medicorum consigned to the pages of history. The study of cutaneous pathology is awakening from its long and disgraceful torpor. Both surgeons and physicians, having become painfully conscious of their deficiency in a branch of the healing art, which belonging to the province of either, has been generally disowned, or at least neglected by both, are setting themselves to acquire a little rudi¬ mentary knowledge of the subject. Even public attention is awakened. Not only are treatises on the skin becoming less rare, but public lectures on the subject are advertised in the newspapers : and the Medical Society of London has recently allotted and

PREFACE.

]X awarded the Fothergillian medal for the best essay on Lepra and Psoriasis. There is reason therefore to hope, that the members of the profession generally, are disposed to listen to any sugges¬ tions which may tend to the advancement of this much-neglected branch. The author avails himself of this lucid appearance in. the medical horizon, to introduce to the notice of his brethren a few practical illustrations of a system of treatment which he has been accustomed to pursue with the most happy results for many years ; and with which, the more familiar he becomes, the more deeply he is convinced that it will he approved and ultimately adopted by the profession.

The cases related in illustration of the author’s views are chiefly taken from notes of his own private practice during the last twenty years. The examples are selected, not because they are peculiarly successful, hut because as a series they show the effects of a similar principle of treatment in all the various forms of eruption, as well as the various phases or types of disease to which this method is adapted. The mode of administering arsenic described in the following pages, is, in one or two particulars, so far as the author is aware, entirely new; and it certainly originated with himself. Upon the method of using this most potent mineral, will much depend the degree of success with which the cure of these diseases is attempted. Most of the cases detailed in this little work had been treated with arsenic, some of them “ heroically,” before they came under the author’s care. But as the fortress which is impregnable to artillery, will yield at length to the silent operation of the elements of nature, so certain diseases which are even aggravated by large doses of the poison, will ultimately yield to the gradual influence of its con¬ tinued use, in small and diminishing qualities.

Section II. Cases

Order I. — Papulae . . . .19

Strophulus . . „ . . .19

Order II.-— Squamae . . . .35

Lepra and Psoriasis . . . . .35

Psoriasis . . . . . .60

Pityriasis . . . . . .72

Icthyosis . . . . . .74

Order III. — Exanthemata . . .76

Urticaria . . . . .76

Order IV. — Bullae . . . .84

Order V. — Pustulae . . . .84

Impetigo . . . . . .84

Xll

CONTENTS.

Order VI. — Vesiculae . . . .90

Order VII. — Tubercula . . . .97

Sycosis, or Mentagra . . . . .105

Order VIII. — Maculae . . . .124

Section IV

Are local diseases ever salutary to the system at large, and are there any cases which cannot be cured without risking the general health ? . . . .137

. 153

Section I. Introductory Observations

Authors have described more than one hundred and fifty dis¬ tinct varieties of disease to which the human skin is subject. The cause, diagnosis, prognosis, and treatment, of every one of these, are discussed separately in some of the more elaborate works on the skin ; and no less than half a score different modes of classifying these diseases have been proposed. If science be properly de¬ fined “ knowledge reduced to a system,” the science of Dermato-pathology (a many-headed monster) appears hitherto, rather to have obscured and confused, than elucidated the materials of a study, at best sufficiently formidable. If something has been gained by nosological arrangement, perhaps more has been sacri¬ ficed ; and attempts to improve upon it, however ingenious and philosophical, have hitherto imposed upon the student more trouble than they have afforded him satisfaction. The nature of the subject forbids the hope of any absolutely faultless division. Concise and exclusive definitions, (the very materials of classifi¬ cation,) are scarcely applicable to the ever varying phases and

B

INTRODUCTORY OBSERVATIONS.

complicated phenomena of disease. The arrangement of Willan familiarized to the British practitioner for nearly half a century, is at once comprehensive and convenient, and his nomenclature must of necessity continue in use ; hut the system is full of con¬ tradictions, and beset with practical difficulties. It is often next to impossible in actual practice, to detect among the incrustations of skin disease, the primary and special forms of the eruption, (papula, vesicle, pustule, scale, &c.) which distinguish the orders of Willan ; and the recognition of his genera, must needs he a still more hopeless task, to say nothing of his species and varieties, which are grouped in almost endless subdivisions.

These difficulties, which more or less encompass every system, compel us to seek for distinctions at once more palpable and more consonant with the principles of general therapeutics. And hap¬ pily, there are connected with the most puzzling cases, certain circumstances which, in spite of the obscuration of the primary form, will furnish an observant practitioner with sufficiently clear indications of treatment. Nor ought these incidental features of the case to be lost sight of when the elementary form of eruption is distinctly visible, inasmuch, as the cases are few in which this latter distinction alone will suffice to indicate tho proper manage¬ ment. It is always desirable, and may be sometimes essential to ascertain the primitive character of the eruption, in order to de¬ termine its nature and origin, and the more conveniently to de¬ scribe it : yet it is far more important to observe previously, and mark, with close attention, those circumstances of the case which would guide our practice if the shin were sound. The neglect of this important principle is a fruitful source of half the ca¬ lumnies which the most respectable and popular writers on the skin have heaped, in unmeasured terms, upon a certain class of cutaneous disorders. They are described as refractory,” ob¬ stinate, notoriously rebellious to all modes of treatment,” “ unmanageable,” “ inveterate,” “ incurable.”

The diseases thus characterized by nearly all the modern writers on the skin, are by no author collected into a single class or order. Some of them will be found distributed among several of the

INTRODUCTORY OBSERVATIONS.

orders of Willan, and placed in close proximity with diseases from which it is very important to distinguish them. So that in grouping them for the purpose of simplifying their treatment, and rescuing them from the unfounded charge to which allusion has been made, I have found it necessary to pay very little respect to their elementary forms, and to direct attention chiefly to certain extraneous circumstances frequently connected with their history and development, which are liable to he overlooked, or too slightly regarded in practice. For all therapeutical purposes, therefore, the diagnosis will generally he found perfectly easy and simple, and will require no microscopic aid.

In order more plainly to detach these cutaneous affections from their respective nosological locale , and to isolate them in a dis* tinct group, without presuming to disarrange their orders and genera, I shall endeavour to present them to the notice of the reader in a negative aspect.

1. They are not of limited duration , but may, and often do, afflict the patient to the end of his life.

2. They are not necessarily complicated with or symptomatic of other disorders.

3. They neither originate in, nor is their duration protracted by, local causes .

4. They are not specially characteristic of debility or ex¬ haustion.

Under the first head are excluded from the group nearly the whole class of exanthematous and ephemeral diseases. Under the second, Strophulus, Aphtha, Phyma, and Syphilitic eruptions. Under the third. Scabies, Porrigo, (Tinea capitis contagiosa,) and certain local forms of Psoriasis, Pityriasis, Prurigo, Eczema, and Impetigo : and under the fourth. Pemphigus, Pompholix, Rupia? and some varieties of Ecthyma and Purpura.

There are a few other affections of the skin, which being rare or exotic, I shall pass over with little or no notice ; viz., Icthyosis, Molluscum, Vitiligo, Elephantiasis, and Eramboesia.

The remaining genera in Willan’s arrangement, viz., Lichen, Prurigo, Lepra, Psoriasis, Pityriasis, chronic Urticaria, Purpura,

b 2

INTRODUCTORY OBSERVATIONS.

[mpetigo, Ecthyma, Eczema, Acne, Sycosis, Lupus, and non-congenital Naevus, constitute the group selected for discussion. To these, my remarks will be chiefly confined ; and of them I do not hesitate to assert that in their uncomplicated forms, they are all as amenable to enlightened medical treatment, as any diseases which are generally considered curable by artificial means. I have described them negatively, because, although they are all, in a sense, chronic, idiopathic, and constitutional, yet neither these terms, nor any other positive cognomen would convey any distinct idea of the points of similarity, I had almost said identity, which attach in common to these singular diseases. Differing widely, one from another, in their eruptive forms, and scarcely presenting one positive, palpable, and distinctive point of resem¬ blance to each other respectively, they may yet he regarded as one disease , manifested in different individuals by different kinds and degrees of cutaneous inflammation or irritation sometimes producing no eruption at all, yet exciting an intolerable pruritus ; but more generally manifested by an eruption, papular, scaly, ex¬ anthematous, vesicular, pustular, or tubercular, as the case may be ; and in more rare instances, exhibiting simple enlargement of vessels without inflammation, or spots of extravasation only, the texture of the vessels giving way under the morbid influence. The inflammation sometimes assumes a subacute, or even an acute form, and is associated with a febrile condition of the system ; and this having been subdued by appropriate treatment, the chronic form of disease remains, becoming more or less “obsti¬ nate," according as its treatment is more or less judicious, and in this stage possessing the constitutional character of those other

* Since this sentence was penned, I have had the satisfaction of observing, that the intelligent and accomplished Dr. Billing takes precisely the same view of the subject. Considering that this author always uses the term “ morbid sensibility,” to express what surgeons usually call “ irritation,” there is a remarkable coincidence between the following sentence and my own phraseology. “ From analogy I infer, that the various cutaneous eruptions are but degrees of one state, — a morbid sensi¬ bility and loss of power in the capillaries of the rete mucosum, assuming various forms according to the age and constitution of the patient.”— First Principles of Medicine , 3rd Edit. p. 277.

DIAGNOSIS.

disorders in the group, which are never complicated with pyrexia. In these latter cases, the affection of the general system is inferred from the state of the skin ; the functions being often well per¬ formed, and the patient reporting himself in excellent health. That he really labours under some cachexy of the general system may be inferred from the following facts. There is no local cause for the disease, its origin must therefore be from within ; but as there is no organic disease of the internal organs, a general de¬ rangement must exist. The disease cannot he cured by local ap¬ plications ; and yet it is susceptible of cure from internal reme¬ dies ; and on the testimony of all writers on the skin, certain po¬ tent remedies administered internally, are found to have more or less control over the morbid condition of the skin. In what this constitutional lesion consists cannot perhaps be satisfactorily de¬ termined. Its seat may he in the nervous system, or it may pos¬ sibly consist of some unhealthy condition of the circulating fluids, which the yet imperfect discoveries of chemistry have hitherto failed to detect. The question is rather curious than practical, and the pathology of many other disorders easy of treatment, is in¬ volved in equal obscurity.

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 squamosse being occasionally of this nature, and requiring the same treatment as other forms of lues. The reddish-brown, or copper-coloured appearance of tbe eruption, taken in connexion with the history of the case, will generally lead the experienced and ob¬ servant practitioner to a correct j udgment ; and it is infinitely more important to determine this question rightly, than to assign the case to its proper order and genus. If there be reason to con¬ clude that the case is not syphilitic, the next point requiring at¬ tention, is whether the eruption be complicated with any other de¬ viation from health, local or constitutional ; and especially 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.

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 com¬ plicate the eruption, and which in some cases originate and sus¬ tain it, must first be rectified if possible. Disordered secretions require particular attention ; tlie digestive 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 effec¬ tually, before especial attention is directed to the cutaneous dis¬ ease, except in those cases in which the health suffers as a result, and not as a cause of the eruption. And under all circumstances we must watch for the symptoms of any increased vascular action or febrile (excitement which so frequently accompanies chronic affections of the skin. It is to be feared that this latter indication, though clearly pointed out by Dr. Elliotson and other modem 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 have to deal primarily with an inflam¬ matory disease, extending sometimes 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, and exposed to an atmosphere capable of becoming an irritant in disease. The most tormenting cases of skin disease often consist of extensive inflammatory action of an acute type, but of long duration, thus combining the acute and chronic character. We find a quick full hard pulse, a skin universally warmer than natu¬ ral, and in the diseased portions the patient suffers extremely from sensations of burning, smarting, itching, pricking, and stinging. The blood taken from the arm will occasionally, but not always, be found both cupped and buffy. If these symptoms occur in a plethoric subject, a second or third bleeding, each one ad deliquium will probably be required at intervals of a week or ten days ; 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 not only to restrict the patient to a low diet, but to administer active aperients, salines, and antimonials,

ANTIPHLOGISTIC TREATMENT.

in doses which will not severely rack the stomach ; an organ which it is important to keep in tone during the treatment of these dis¬ eases. This system must he pursued for days, weeks, and even months if necessary, until the smarting and tingling has 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 alte¬ rative 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 Plum¬ mer’s pill or other mercurial adjuvant. 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 reduced diet may suffice. Occasional purgatives are useful in all cases, and are of more service at intervals than when adminis¬ tered too frequently. 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 cuta¬ neous disease. The same may he said of fomentations ; they are seldom or never curative, scarcely auxiliary to the cure, hut 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 injurious to the inflamed surface, and un¬ necessary when the inflammation has been subdued. Equally need¬ less, and not seldom hurtful, are the thousand-and-one ointments, lotions, and other applications which have been recommended in these diseases. It is painful to contemplate the unnecessary tor¬ ments of a patient who has been tarred externally and internally, or tortured with caustic for weeks together, without the slightest re¬ lief, and whom the abstraction of a pint of blood and the exhibition of a smart purgative, would deliver from more than half his suffer ings. Much judgment, however, is sometimes required to fix the proper limits of the antiphlogistic treatment. Ecthyma, a disease of debility and poverty, has been known to take place of lepra,

ARSENICAL TREATMENT.

when the low diet system has been carried too far, — a condi¬ tion which is difficult to rectify. 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 he 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 he removed before the skin can become permanently sound. The pulse is generally a safe guide.

Thus, by rectifying what is obviously wrong in the general sys¬ tem, 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 medicatrix naturae 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 alte¬ rative remedies have been tried with various degrees of success. It is not necessary for me to enumerate them, my whole attention having been directed for many years to one antidote alone, which under proper regulations, acts with such uniform efficiency as to leave nothing to he desired. That remedy is arsenic .

Of the numerous alterative remedies which have been extolled for the cure of cutaneous affections, 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 practi¬ tioners to be a dangerous medicine, and on that account, it is pro¬ scribed and repudiated, perhaps by more than half the members of the profession. I venture to hazard the opinion, that arsenic will one day be universally esteemed as one of the most valuable of medicines, and that its administration will be attended with far less

ARSENICAL TREATMENT.

danger than that of mercury, antimony, opium, or any other poison now used medicinally.

Arsenic is known to he a virulent poison in a large dose, and it is said to have the power of wasting and destroying the vital prin¬ ciple with equal certainty when small, hut deleterious doses are incautiously repeated too long together. A belief in the truth of this allegation has prohahly deterred many discreet practitioners from its due administration. It must he admitted, that though the reputation of arsenic as a slow hut certain poison in medicinal doses, rests upon evidence which might fairly be challenged, yet it has such an extraordinary action over the human system, an action so unlike anything else, and in poisonous doses so rapidly and unaccountably destructive, that double and treble caution should ever he used in administering the mineral medicinally, even in very minute doses. It behoves every practitioner who prescribes so virulent a poison, to acquire all the knowledge he can obtain of the phenomena to he expected under its use, not only as regards the suspension of diseased action, hut more especially with refer¬ ence to its influence on the general economy. This knowledge is hut scantily supplied by authors, and it is one chief object of the publication of this little work, to make known the results of my own experience, after having watched 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 greatly ex¬ aggerated, and that its destructive properties have never been manifested, except in the hands of practitioners who knew not how to regulate its use. I have administered arsenic to patients in small hut efficient doses, for months and years together, in a great variety of cases, and have watched in vain for the alarming effects attributed to its use. During thirty years’ observation, I have never known it produce any unpleasant effects on the system in a degree incompatible with perseverance in its use ; and Dr. Duffin, of Edinburgh, asserted in the year 1826, that he had prescribed it in nearly four hundred cases, and had never seen it do any mis¬ chief. Indeed there are few medicines less likely to do harm than arsenic, when administered in the manner about to he

10 THERAPEUTICAL PROPERTIES OF ARSENIC.

described. 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, have no power over cutaneous diseases which will yield to smaller doses ; so that its curative powers appear to reside alone in doses too small to be mischievous. It is impossible to hurry its operation : every attempt of this kind, not only fails, but retards the wished-for result. But the patient, persevering administration of small doses, under favourable circumstances, for weeks, months, or years toge¬ ther, will be found to exercise an almost omnipotent influence over the cutaneous diseases under review.

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 only a limited and temporary influ¬ ence in most of these cases. 2. Some practitioners administer arsenic during the inflammatory or febrile stage of cutaneous dis¬ ease, under which circumstances, it rarely fails to increase the in¬ flammation, and never does any good. 3. Dr. Cormack, and one or two other writers, direct it to be given on an empty stomach, and are often obliged to abandon it on account of the gastric irrita¬ tions 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.

The general result is, that although in spite of all this misma¬ nagement, cutaneous diseases very often yield to the medicine, yet few practitioners can be found who prescribe it with confidence and perseverance, and perhaps still fewer with satisfaction and success. If mercury wrere generally exhibited in the same timid and unsystematic manner, the day of its reputation would soon be drawing to a close.

The proper mode of prescribing arsenic may be inferred from

THERAPEUTICAL PROPERTIES OF ARSENIC. ] I

N

its therapeutical properties ; and as these appear but indifferently understood, I will endeavour to place them in such a light as shall render obvious the practical inferences I have drawn from them.

1. There is especially one property in arsenic regarded as a medicine which must he duly appreciated in prescribing it before it can be administered with safety or general success ; I refer to its cumulative effects on the system. So long ago as 1807, Dr. Bardesley, of Manchester, pointed out this peculiarity. He says,

he has observed the arsenic to accumulate in the system after using it for a time, and to produce flying pains, flatulence, para¬ lytic affections of the limbs, and other unpleasant symptoms. He therefore objects to the too long continuance of the medicine. M. Bayer also observes, <f that the effects of arsenical medicines, slow and silent in the beginning, may suddenly acquire greater intensity, and prove the cause of lesions more or less severe in their nature.” He likewise adds, it would be culpable temerity to persist for too long a time in the use of remedies possessed of such energetic actions on the economy, that they are apt them¬ selves to become the cause of serious disorders.” # Hufeland speaks in similar terms of the “ disastrous effects of arsenic after a considerable time.”t Arsenic is not the only medicine which has a tendency so to accumulate in the system as to appear inert for a time, and then suddenly assert its influence in a degree more or less alarming. Digitalis and colchicum have also this property. On the other hand, opium and antimony act with more efficiency at first ; and as the system becomes habituated to their presence, the dose must be gradually increased. That the system should thus manifest increasing intolerance of repeateddoses of some medicines, and accommodate itself by degrees to constantly aug¬ mented quantities of others, is to my mind wholly inexplicable ; but the fact being well established, the practical inference is plain ; — as the latter medicines must of necessity be exhibited in increasing doses in order to ensure any long continued effect, — so if we would have the benefit of the cumulative poisons, on safe conditions, it is obvious that the dose must be gra- * Rayer on the Skin, p. 88. f Journal de Medicine, 1811.