The great number of diseases peculiar to the skin which present themselves for treatment are well worthy of the most earnest and anxious consideration of the general practitioner as well as of the specialist. It is only of recent years that the varieties of skin diseases have been made a special subject of study by numerous physicians in this country and abroad, and we may point with pride to the rapid strides made as regards the pathology, diagnosis, prognosis and treatment of these formerly obscure and obstinate diseases.
Correct diagnosis of cutaneous affections is the foundation of successful therapeutics; but diagnosis, properly speaking, does not alone consist in giving the correct or approved name to the disease immediately under consideration, nor even in a careful differentiation of the special variety. It involves a broader knowledge, including a more or less complete acquaintance with the nature and relationships of the various affections. The mere naming of a disease is a comparatively easy matter, and of greatly inferior value to that more comprehensive knowledge that appreciates that the disease is not a distinct entity by itself, but is rather the result of a particular or peculiar pathological process in progress in a person with a given constitution or habit of body.
In these days patients want to know what disease they are affected with, and, in the great majority of cases, they will read up for themselves all that they can find upon the subject. The term eruption will not answer for the more intelligent. The intelligent physician must not be content with being able to simply give the systematic name that is applied to the particular lesion or group of lesions present, but should also be able to make a diagnosis of the patient as well.
Of late years, dermatology has divided the different eruptions into classes and sub-classes, and with this division a more thorough and extended study of the causes pathology and treatment of the same has been accomplished, and the dermatologist can intelligently study the various lesions of the skin and form a correct opinion as to the duration, progress and ultimate result in each and every case.
A man says he has an eruption upon the face, and wants to know what it is and when he will get over it. His remark that he has an eruption conveys to the mind about as much of an idea of the trouble as if he said he had a hole in his coat. We must know, before we can express an opinion, what kind of an eruption it is. Is it vesicular, papular, pustular or tubercular? When we find that it is vesicular, we then wish to know the size of the vesicles, whether they burst or not, whether they itch or not and a number of other points which help us to arrive at a correct understanding of his case. We are then able to tell what the affection is, and its probable duration and ultimate termination.
We are enabled, also, to give him the proper medicines, prescribe a suitable diet, and to take such measures as will protect others against the disease, if it is of a contagious nature. Errors in diet predispose to certain affections of the skin, and in very many cases aggravate existing disorders. Want of cleanliness is a frequent cause of cutaneous eruptions, as well as of many of the preventable diseases. So, also, is the abuse, or even use, of alcoholic stimulants, cosmetics, tobacco, etc. A man’s occupations is sometimes to blame for his unhealthy skin; especially is this true of the baker, the grocer, the mason, the bricklayer, the painter, the photographer, etc. Frequently the medicines taken for some internal diseases cause an eruption, the nature and cause of which is not always seen at a first glance and may be entirely overlooked. Belladonna, Carbolic acid, Iodide of Potash, Sulphur, Iodoform, Antipyrine and a great many other remedies produce eruptions. Mental shock and emotions also produce eruptions.
The following cases of Dermatoses following mental shock were reported in our journals in 1889:
A lady, after witnessing a violent assault upon her husband, was much prostrated by the fright, and three weeks later a bullous eruption, having the characteristics of foliaceous pemphigus and accompanied by incessant pruritus, made its appearance.
Another case was a little girl who was rescued from burning, and remained for some time in a condition of prostration from fright. A month, afterward a pemphigoid eruption made its appearance upon the body, disappeared under treatment, but reappeared several times.
A third case was that of a woman who became very much excited in a quarrel with her husband. A few days afterward an exudative erythema made its appearance on the arms, hands and feet; and vesicles on the lips. E. de Smet has recorded cases of purpura haemorrhagica from the same cause.
The dermatologist must be very observing and a good cross- examiner in order that he may see all that is upon the surface of the body, and by his critical examination draw out all that is below the skin in the shape of abnormal sensations and symptoms. The more complete and thorough the description he obtains from the patient, the more accurate is his diagnosis apt to be, and the more successful his treatment; for the same affection in two patients may require almost opposite treatment. Take shingles, for example. The eruption may be precisely the same in two children, but the accompanying pains in one are burning, jerking and itching, worse in the evening, and from the slightest touch; in the other, burning, neuralgic pains, worse about midnight, but ameliorated by warmth. The first case will be relieved by Zincum met., the second by Arsenicum. Or, we may illustrate by two cases of acne occurring in a brother and sister. The one patient addicted to sexual excesses and strong drink, with a tired feeling all the time; the other, suffering with scanty menses, gastric difficulties and frequent diarrhoea. The disease is the same in both persons, but the causes are different, and we should be obliged to give Rhus in the first case, and Pulsatilla in the other. Again, an eczema in one may be the expression of ill-nutrition from privation or scanty supply of proper food, while in another it may be the result of a plethora due to excessive indulgence in the pleasures of the table. We may, it is true, apply the name eczema in both instances, on account of the similarity of the lesions; yet the real condition of the two patients is almost diametrically opposite.
A positive diagnosis, it should be remembered, is not always possible upon a first examination, but it is desirable at all times that we may distinguish between a contagious and non- contagious affection. For example, how important it is to recognize herpes of the prepuce, and not mistake it for chancre. The one, a disease of but little importance, the other of the greatest significance; in fact, a terrible infliction, which, if wrongly diagnosed, may lead to the infection of perhaps dozens of others, and among the number many perfectly innocent persons. This statement may seem rather strong, but instances are on record where several persons have become infected from using the common water-closet. And yet, these two diseases, herpes of the prepuce and chancre, are frequently confounded, but, fortunately for the welfare of the community, it is usually the innocent one that is mistaken for the more serious.
The prognosis is not as important, perhaps, as the diagnosis, considering the fact that very few skin diseases are destructive to life, but it is a great comfort to the patient to learn that the disease is one of no danger; that it is not contagious, and that, in a short time, it will be cured. When the patient has good reasons to suspect that the eruption upon the skin is only a manifestation of some form of syphilis, no words can convey the feeling of relief experienced when he or she is told that the trouble is only a skin disease and in no way connected with that loathsome disorder.
The causation is always to be carefully investigated and studied, for by removing the special causes in each case a return to health may be expected, or at least the patient is put in the best possible condition for recovery. All violations of the general laws of health may produce diseases of the skin, hence it is very important to inquire into the habits, occupation, diet and dwelling-places of those seeking treatment.
The treatment of skin diseases varies, of course not only in different affections, but in the same disease as it occurs in persons of different diathetic tendencies. Each patient must be treated according to the special indications in his case. We must consider his age, his surroundings, his diet and mode of life, and all co-existing diseases which aggravate or are the cause of his trouble. In short, treat the totality of symptoms.
The majority of cases of diseases of the skin are not preceded or even accompanied by severe constitutional disturbances; if there happen to be much fever and malaise, especially when the patient takes to bed from a sheer feeling of illness, and an eruption rapidly develops itself, something grave, probably one of the acute specific diseases, is present. This is all the more likely to be the case if the patient falls, as it were, suddenly ill. The main guide in these cases is the temperature: if the thermometer be raised in the axilla to 101 or 102 degrees F., and emphatically so if to a higher point than this, there can be very little doubt on the point than this, there can be very little doubt on the point. However, amongst the occasional exceptions, acute lichen, erythema nodosum, secondary syphilis, acute eczema, pityriasis rubra, acute pemphigus, urticaria, zoster, may be named, but these are not accompanied by high temperature. Secondary syphilis has been mistaken for the mottling of typhus and measles, acute lichen for measles, and zoster for pleurisy, on account of the pain. Occasionally in eczema there may be marked pyrexia, but not a markedly high temperature. When symmetrical, the disease is usually due to a blood-poison; when unsymmetrical, to local causes or perhaps to affections of the nervous trunks.
Perhaps one of the greatest errors committed in diagnosing cutaneous diseases is the dealing with them in a piecemeal manner. It is the universal expectation of the student to be able to diagnose a disease of the skin from merely looking at it. Many a student, if asked with a patient before him, What is that disease? will look,- and, it may be, look closely- and then make his diagnosis and give the thing a name. In no other class of disease would he do that. He would obtain the objective, and the subjective symptoms; and use every means at his command for physical examination. It is of equal importance that he exhibit a like careful comparison in lesions of the skin.
One of the first cares of the dermatologist should be to distinguish in diagnosis between primary and secondary phenomena. The one set are of course essential points of the disease, and the secondary results may, if care be not taken, be elevated to the rank of important items. For instance: In the case of an erythema, in connection with long-continued congestion, more or less thickening may occur; if this be not clearly perceived to be an accidental occurrence, the diagnosis becomes difficult. Take the case of pityriasis rubra, a disease in which the whole skin becomes intensely hyperaemic with free shedding of scales. If this be properly treated it will disappear, and leave not a trace. It may be unaccompanied throughout its course by any thickening of the papillary layer; but if it continues a long while this layer may be thickened, and then there are present hyperaemia, papillary hypertrophy, and scaliness, as in psoriasis; and the diagnosis between pityriasis rubra and psoriasis could not be made from the mere surface appearances and alternations only. But the two things clinically are wholly different. This shows the importance of attending to the primary elementary lesion and the history and course of diseases.
Again, in searching for the earliest stage of disease when that occurs in patches, it is necessary to go to the edge of the disease since it there presents its most recent characters.
The typical course and characters of any disease may be masked by the co-existing development of a second disease, and here the interminglage of the features of the twain will be detected, as in urticaria and scabies or purpura; scabies and syphilis;eczema and scabies; eczema and psoriasis, and the like. The capriciousness as regards the appearance and disappearance of an eruption of an erythmatous type, is suspicious of urticaria. Multiformity means that a disease is complicated, unless it be scabies or syphilis.
As regards the temperament, the dermatologist is generally enabled to say at a glance whether a patient is of full habit and likely to have a loaded system-especially the case in women; whether there be organic disease, or if there be a dyspeptic habit, or an ill-fed system, that signifies debility. If lymphatic, the patient is prone to eczema, impetigo, intertrigo, the pustular aspect of scabies and ringworm; if gouty, the scaly disease, chronic eczema and lichen agrius; if rheumatic, erythema nodosum; if strumous, eczema, lupus; if florid, psoriasis especially. There is also the cancerous cachexia, and in nervous subjects various hyperesthesia engrafted upon ordinary eruptions. Red-haired subjects are declared to be very liable to pityriasis of the scalp.
Some eruptions are more or less periodic in their occurrence, as in the case of pemphigus, but the dermatologist should remember that in districts where malarious disease is common, a disease not usually possessing periodic features may sometimes be so influenced that its eruption occurs in a periodic manner, or the febrile disturbance by which it is accompanied may show itself in periodic outbursts.
Psoriasis, eczema, and syphilitic disease are essentially those which recur.
Occupation exerts considerable influence in some lesions of the skin. Cooks are particularly liable to eczema and erythema, and bakers, grocers and bricklayers to lichen about the backs of the hands; chimney-sweepers are liable to epithelioma of the scrotum; cotton-workers to urticaria; butchers and graziers to whitlow, boils and malignant pustule and ecthyma; cavalrymen and shoemakers to eczema marginatum in the fork of the thighs; young women who come from the country and have the full diet fare of the city servants and those who change their mode of life, so that it entails more exercise and better living, get an overloaded system that shows itself in erythema papulatum, erythema nodosum, or impetigo.
The age of the patient is very important. During the first six weeks of life congenital syphilis develops itself; intertrigo, eczema of the scalp, and seborrhoea capillitii also occur about the same time. Syphilitic pemphigus occurs, it is said, before the child is six months old, not afterwards; during the first few months and up to and through the period of dentition, strophulus and eczema are met with. Cancer (epithelioma) is a disease of late life-it does not occur before thirty, generally about sixty and beyond. Lupus is a disease which commences in early and young life, and the same may be said of syphilis. The parasitic diseases occur in the young, rarely after twenty-one years of age. Herpes circinatus is the form seen in adult life. In old people, phthiriasis, ecthyma cachecticum, pemphigus, and pruritus, with cancer and rodent ulcer, frequently occur.
We should have some rules as to the mode of studying skin diseases. The following are probably the best; they are taken from Fox:
1. The observer should always strip his patient so that the disease may be exposed to the fullest extent compatible with a due regard to the proper feelings and sensitiveness of the individual. To be satisfied with seeing a bit of a patch of disease in this spot, or just a spot or two there where the malady is most marked even, is often to run great risk of arriving at an erroneous diagnosis, if not to actually make one, certainly to miss the recognition of transitional stages, which are of the utmost importance in determining the general character and often the exact nature of a disease.
2. It is of much importance that mere stages of diseases should be regarded as stages and nothing else. Diseases must be dealt with in their entireties. Where the whole of a disease is made up in any particular instance of certain stages, in estimating the nature and characteristics of that disease one stage must not be regarded in particular-be thrust into undue prominence-at the expense of others. The several stages together constitute the disease.
3. A clear distinction should be drawn between essentials and accidentals. For instance, the essence of scabies is the acarus in its furrow. All else that follow-the follicular irritation, improperly called lichen, the ecthyma, the urticaria, which may occur in many different diseased states of the skin- is accidental, and due to the irritation and the scratching practiced.
4. It should be a point with the dermatological student to make as little as possible of mere superficial appearances and changes, because these are brought about as the result of, and are indeed often secondary to, more important and primary changes in the deeper parts.
5. It is important to pay special attention, as far as possible, to the primary anatomical seat of the disease. What the primary seats of individual diseases are, so far as regards cutis, cuticle, follicles, and the like, I shall discuss in another place in speaking of elementary lesions and the individual diseases themselves.
6. Special attention should be paid to the fact of the character of an eruption being permanent, or transient, or interchangeable. The case of lichen planus may be taken to illustrate this point. In it the characteristic lesion is a red flattened papule covered by the minutest scales. This is the sole lesion present. The papule never changes into a pustule or a vesicle; but not so it is with the papule of eczema or variola. The tendency of a syphilitic papule is to become oftentimes a pustule or tubercle, which gives place to an ulcer, and so on. The eruption as a whole may be again capricious, appearing and disappearing suddenly, often in the course of a few minutes. This feature in itself is almost diagnostic of urticaria.
7. Those who are studying skin diseases should observe whether an eruption be uniform or multiform in character. Multiformity implies (a) the co-existence of two or more diseases, in which case there will be present the features of the two or more diseases commingled; or it implies (b) the existence (I) if the lesions be inflammatory-that is, if pustules or vesicles be present, of scabies, or (2) if the lesions be degenerative, if ulcers and suppurating tubercles, for example, be present, of syphilitic disease. The difference between the two main classes of cases, the complicated disease on the one hand and scabies and syphilitic on the other, being that in the former there are no transitional stages observed, as in purpura urticans, pemphigus pruriginosus, impetigo and scabies; syphilis and scabies, etc.; whereas, in the latter class, they are present as between the papules, vesicles, and pustules of scabies, or the papules, tubercles, pustules and ulcers of syphiloderma. Multiformity as it exists in scabies and syphiloderma. Multiformity as it exists in scabies and syphilitic eruptions- relates in each case to such different kinds of eruption, and the multiformity moreover in complicated or co-existent diseases is seen to be due to the commingling of such distinct lesions without transitional forms that the character of multiformity becomes at once a very reliable guide in diagnosis; of course, other things help, as rest, development, etc., but multiformity is a good rough test of syphilis, scabies, or complicated diseases.
8. It is wise to note certain differences, not only as to the general nature and character of cutaneous diseases as they exist in the old and young, but also in reference to the same diseases as it occurs in the old and young. The cutaneous diseases of childhood are essentially distinguished from those of the adult, in that they are uncomplicated by organic diseases of the internal organs, and by those more complex and profound perversions of nutrition which arise from overworked or badly used organs, such as gout, dyspepsia, free retention of excreta in the blood, rheumatism, and so on. They contrast with those in the old by the absence of coincident degenerative changes in the body, which are to be the lot of the man who passes the meridian of life. The cutaneous diseases of children are uncomplicated in this respect, and speaking generally, they are the result of the misuse of pabulum supplied to the body, or the direct consequence of improper diet. The case of eczema infantile may be taken as an example. But there is a differences in constitutional conditions-the diathetic conditions in the child who suffers from skin diseases are different from those of the adult or aged. It does not take any long time to see how frequently the subjects of skin diseases in the young are strumous, and what an influence this diathesis has on the skin diseases of the young as contrasted with those of the middle aged and of an age beyond the latter period of life; that syphilitic affections other than those hereditarily transmitted are specially the privilege of the adult, and so on; that in the advanced in years there are not only complicating organic diseases of internal organs, blood alterations due to mal-assimilation, degenerative tissue changes such as cancer, but disease specially connected with decay of the nervous system, as in senile pruritus. But to put what I wish to enforce in a few words, I may say that, as regards kind, the diseases of children are the result of malnutrition from deficient or bad feeding; those of the adult the result of mal- assimilation; those of the aged the result of degenerative changes. As regards complications, diseases of the young are often closely connected with the strumous diathesis especially; those of the adult with functional derangements of internal organs and mal-assimilation, such as dyspepsia, hepatic and renal torpor- and with the diathetic conditions, phthisis, rheumatism, and the commencement of gout; those of the aged are linked with nerve pareses and degenerations of the skin, as evidenced by increased pigmentation, atrophy of the glands, and of the nerves in the papillae, and also with organic diseases of important internal organs. All this is important therapeutically.