2. SOME GENERAL OBSERVATIONS


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 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.

Melford Eugene Douglass
M.E.Douglass, MD, was a Lecturer of Dermatology in the Southern Homeopathic Medical College of Baltimore. He was the author of - Skin Diseases: Their Description, Etiology, Diagnosis and Treatment; Repertory of Tongue Symptoms; Characteristics of the Homoeopathic Materia Medica.