The general question of the treatment of diseases of the skin involves the consideration of the different and several indications, and of the means at our command for the fulfilment of these indications. Before, however, we can properly appreciate the special features appertaining to any one given morbid condition, it is better to devote a little time to the discussion of the general factors which lead to the development of cutaneous disease; in other words, to consider the question of etiology.
Primarily it may be stated that cutaneous lesions are due to influences of forces from without, or from those which exist or arise within the body. To the former class may be assigned such as depend on temperature and climate, such as are due to traumatisms of various kinds, such as result from various parasitic invasions, etc. This is in reality but a limited class; on the other hand, the etiological factors which arise within the body itself are very numerous. We will, however, first consider the external causes.
Excessive heat or direct exposure too the sun may excite undue activity of the sudoriferous glands, and result in the production of sudamina, or the extremely annoying papular affection known as lichen tropicus; or to an erythematous or even vesicular inflammation, commonly known as sunburn; or to the more trivial affection called ephelis, or freckles. Excessive cold may result absolute congelation of exposed portions of the integument, followed by death and sloughing off thee parts; or a less degree of cold may excite the condition known as pernio, or chilblains, or in some persons produce chapping or fissuring of the skin; or, by depressing the general vitality, promote an outbreak that otherwise would not have occurred. Of the animal parasites that may infest the body, the different varieties of pediculi, or lice; the acarus, or itch insect; the leptus, etc., produce affections more or less annoying, but usually readily removable. On the other hand, the infinitely minute and to the naked eye invisible parasites of vegetable origin, as the achorion and the trichophyton, give rise to affections which are exceedingly tenacious, and sometimes well-nigh incurable.
The internal causes of cutaneous diseases, however, are far more frequently in operation, and are far more important than those of external origin. In this class we may place those affections of the skin which are due to pre-existing lesions of some part of the nervous system, as, for instance, zoster, which results from an anterior lesion of the ganglion attached to the posterior root of a spinal nerve; or some of the lesions of leprosy, which succeed certain degenerations of the spinal cord. The nervous system, however, may be in a perfectly sound condition, and yet act as the medium for the transmission of some internal irritation to the surface; thus, the gastric irritation resulting from the ingestion of shell-fish may manifest itself chiefly on the skin in the form of urticaria, or a chronic irritation of the pelvic viscera may be the active cause of rosacea. Again, cutaneous lesions may be the active cause of rosacea. Again. cutaneous lesions may be due to internal changes which have in turn arisen from external causes as, for example, the cutaneous manifestations of syphilis, which are due to an internal dyscrasia produced by the entrance into the body of a certain form of morbific matter from without. Leprosy may be placed in the same category.
Still another internal cause of cutaneous lesions will be found in that condition of ill nutrition or imperfect as similation known as scrofula or struma.
Finally, we may have external lesions resulting from the accumulation in the blood of certain materies morbi. Most of the so-called medicinal rashes are due to this. Or, again, we may see the materies morbi generated within the body itself through imperfections in the digestive, assimilative, or excretory functions. As a matter of fact, I believe that fully one-third of the cases of cutaneous disease which come under the physician’s eye are due to this last-named cause. If this be true, a somewhat brief consideration of this topic will not be out of place at this point.
In order that nutrition may be healthily carried on in any part, there must be – (1) a proper state of the blood; (2) a proper condition and behaviour of the tissue to be nourished; and (3) a right exercise of the controlling influence exerted by the nerves. And these three must work harmoniously together. Deviations from health may originate consequently from a flaw in any one of the three conditions above named. The theoretical origin, therefore, of diseased changes in the skin may be specially in the blood, as we see in zymotic affections, and here the skin affection is only symptomatic or a part of a more general disease; in the tissues themselves, as seen in the case of warts, cancer, keloid, psoriasis; or in the nerves, as in pruritus, and, it is thought and now generally taught, herpes, pemphigus, and urticaria.
If the exact origin of disease be not as stated, the parts of the system chiefly concerned in the production of diseased conditions may be emphatically in one case the blood, in a second the tissues, and in a third the nerves. But of course, inasmuch as the ordinary action of these three agencies is bound up and related in the closest manner in health, the misbehavior in disease of one affects, secondarily, the proper action of others of the three agencies concerned in healthy nutrition. So that all are more or less involved in disease when fully developed, but primarily one or the other is mainly concerned in it.
Now there is much readiness to ascribe disease to changes in the blood, but not to sufficiently recognize the influence of perversions in the inherent cell-life of the skin structures, nor the controlling supervision of the nerves in the generation of cutaneous disease. Cancer is an example of disordered tissue- life.
It is more than probable that the origin of some diseases of the skin may really be in the central nervous system, and the cutaneous trouble is the effect of a general disturbance of the nervous system; or in the nerves themselves that run to the affected part; at any rate the nerves are mainly concerned, or they may constitute the agency by which the morbid changes in the skin are produced.
Some of the causes that produce altered states of the blood -current, are:
1. Poisons of acute specific diseases- for example, those of small-pox, etc.
2.The circulation of special poisons, be they animal- syphilitic; medical substances-arsenic, etc.; or dietetic, such as shell-fish, giving rise to urticaria, roseola, erythema.
3.Dietetic errors, as in wine-drinkers, high-livers, non- vegetarians, etc., leading to the increase of urea and uric acid in the blood.
4.The tuberculous, scrofulous, and lymphatic dyscrasiae, giving rise to non-specific eruption-impetigo, acne.
5. The gouty and rheumatic diatheses, as in lichen agrius.
6. Altered and lowered nutrition from such causes as bad living, poverty, misery.
7. The accumulation of excreta in the blood from non- excretion, suppression of natural discharge, kidney disease, etc.
8. Convalescence from severe and lowering disease by which the body is rendered much less able to resist disease.
9. Climacteric, or endemic influences, often malarial in nature, which act by deteriorating the system generally.
10 Disorders of the liver and spleen leading to pigmentary deposits in various parts, jaundice, and pruritus, etc.
Local irritants frequently lead to alternations of tissue, and rank here with burns, scalds, parasites, the occupations of bricklayers, masons, and washerwomen, etc., as causes of local mischief.
Dyers, and those who handle cheap clothing frequently suffer from erythema due to the irritant action of dyes.
Certain tissue peculiarities may be inherited. The father may transmit dispositions in tissues to behave in particular ways directly to the child, as a local peculiarity, independent of any blood state, and in this sense psoriasis, cancer, ichthyosis, may be hereditary
There are two sources of local irritation that deserve special notice. I refer to the use of flannel worn next the skin, and scratching. Some skins are so irritable in health as to be excited to an unbearable degree by the use of flannel. In a very large number of cases of skin disease pruritus is in this way intensified and the disease even protracted, and in proportion to the degree of uncleanliness. Flannel acts, as a mechanical irritant, by augmenting the local heat, and intensifying reflex action.
Scratching plays an important part in the modification of skin diseases, most of which are accompanied by itching. To relieve itching scratching is the most natural thing to do. What does it do? 1. When there is no eruption it may produce one.2. It augments and modifies existing eruptions. 3. When the disease is non-contagious, secretion, in scratching, may be transferred from place to place; and if acrid, set up local inflammation; and when contagious, scratching is the surest method or inoculation, as in the case of contagious impetigo. Children is this way transplant the disease from the head to various parts of the body. Mothers, beyond a doubt, get the disease about their hands from contact with children.
Upon the nature of the cause depends the contagious or non- contagious quality of any disease. It is generally conceded that parasitic and the acute specific diseases are contagious.
Sex has some influence as a cause of disease; males suffer by preference from sycosis, pemphigus, psoriasis, eczema, and epithelioma; and females from acne, kelis, and lupus especially.
In our own clime race would seem too exert an influence upon lesions of the skin. Dr. Morrison, of this city, has preserved histories of five hundred cases of skin diseases in Negroes, and forms the following conclusions:
“Acne and lesions due to pediculi and insect-bites are uncommon. Mosquitoes, the cimex lectularius, and insects in general, do not produce the same ill effects” (My own observation, which has been quite extensive, would lead me to disagree with the doctor in regard to the pediculi. They are very apt to have lesions from this cause). ” Ainhum is peculiar to the race, two cases having been seen; one man had lost one little tow, and that of the opposite foot was affected.”
Chancre is more indurated, and more frequently complicated with phimosis.
Chloasma appeared to show a lessening of pigment, instead of an increase. (Dr. Heitzmann takes issue with Dr. Morrison on this subject, and asks how can a diminution of the normal pigment be termed chloasma, an increased pigmentation being usually understood by that name.)
Chilblain is common.
Elephantiasis Arabum mostly follows syphilis.
Erythema multiforme is difficult to diagnose, as are all erythematous conditions.
Eczema appears to be more amenable to treatment; 129 cases are recorded.
Favus and pediculi capitis are rare. (The latter is common. D.)
Keloid appears common, especially false keloid after injuries. It is seen following variola and zoster, and after piercing the ears.
Lupus is seldom encountered.
Lymphadenitis is quite common.
Pruritus is much complained of, and it is said that syphilitic lesions itch in this race.
Scabies was rarely seen. (I have seen several cases.)
Syphilis is abundant.
Scaly and pustular lesions are often seen.
Urticaria wheals do not seem to be so elevated, but very itchy.
Dr. Atkinson reported a pustular folliculitis very frequent in young, closely-shaven negroes. The pustules penetrate into the follicles of the beard without producing that degree of irritation which is to be called sycosis. He thinks that fifty per cent. of the young negroes who shave very close have it.
He has noticed that it is common to find deep and permanent pigmentation after the application of a mustard plaster. (I have often noticed the same condition.)
Involution occurs after a time in keloidal tumors; they become flaccid, and, after some years, soft.
Pediculosis appeared to him to be as frequent in colored as in white children.
Acute exanthemata produce, upon desquamating, a peppered appearance, looking as though the skin were dusty or sprinkled with fine powder. In scarlatina it is due to the slight elevation of the papules, which is not evident in Caucasians.
Whatever be the causes of the various cutaneous affections, we are chiefly concerned with the means that the physician has at his command with which to treat them successfully. First of this is hygiene. It goes without saying that recovery is facilitated by the substituting of good hygienic surroundings for bad ones; and under this head we may include fresh air, wholesome food, cleanliness, exercise, and seasonable clothing. It is hardly necessary to go into details on these points, if the fact is recognized and remembered; and in all chronic affections of the skin, and in some of the acute ones, these matters should be inquired into, and corrected when possible. Our resources further include mechanical, chemical, and pharmaceutical remedies, and also electricity. An elastic bandage applied to an old, infiltrated eczema of the leg is an illustration of the first; an active caustic applied to an obstinate ulcer may be considered as an example of the second; but by far the largest proportion of remedial agents will be found in the pharmaceutical division. This class embraces remedies used both internally and externally.
The homoeopathic materia medica is rich in remedies having a direct and specific action upon the skin. And the fact that we always prescribed for the totality of symptoms manifested in our patient, laying stress upon the affection as shown in the skin only as a symptom of the diseased condition, often leads us to prescribe, with the happiest results, a remedy not ordinarily classed among the skin remedies. Great improvements have been made by both schools, in the last few years, in the external applications. Formerly lotions and ointments were almost the only means of making external applications, but within recent years we have learned the value of collodion, of solutions of gutta-percha (traumaticin), mixtures of gelatin with glycerin, starch, etc., plasters and other bland compounds and mixtures, as excipients for the drugs that we desire to bring into direct contact with the diseased parts.
Electricity, also, as a destructive agent (electrolysis), or as a modifier of local nutrition, or as an excitant of reflex action, plays a by no means humble part in the treatment of these diseases.
If physicians would give as much thought and care to the study of these affections as they do to others, not only would our armamentarium be enriched and purified, but our successes would be greater and failure less. They should not be content with the mere diagnosis and naming of the disease, but should study the peculiarities of each case, and the influence exerted by the general health or condition of the patient on the special lesions in question.
When treating of the several lesions, therapeutically, it shall be my endeavor to give the best that is recommended by both schools of medicine. We must bear in mind that “The physician’s highest and only calling is to restore health to the sick.” “The highest aim of healing is the speedy, gentle, and permanent restitution of health, or alleviation and obliteration of disease in its entire extent, in the shortest, most reliable, and safest manner, according to clearly intelligible reasons.”
Keeping these aphorisms of our illustrious master ever before us, we will proceed in the next chapter to take up the different lesions of the skin, and study them with the best light we have at our command.