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On the Arrangement and Treatment of Cutaneous DiseasesAuthor(s): Thomas HuntSource: Provincial Medical and Surgical Journal (1844-1852), Vol. 10, No. 13 (Apr. 1, 1846), pp.145-147Published by: BMJStable URL: http://www.jstor.org/stable/25499156 .

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ON CUTANEOUS DISEASES. 14S

pale tongue was associated with a painful abdomen, I have not seen verified in our experience.

Dr. Dielt noted the acute tuberculization of the

lungs preceding or following the epidemic; but he does not state whether such disease yielded more

readily to treatment than in ordinary, a fact which

some believe, and already quoted in this paper. Both

the fever and the tuberculatioz appear to have had

their more ordinary symptoms merged, so as to mask the

presence of each. He considers that the fever gave an

activity to latent tubercle, and there is no doubt that

rapid phthisis is not infrequently associated with fever,

suddenly presenting the latter stages of this disease, when the stage of deposition of tubercle must often

be traced back through the fever to an antecedent

period. Another point dwelt upon by Dr. Dielt is, "that

those enfeebled by anxiety, or deficient food, were very seldom affected." This strikingly agrees with our

observations here, and which was so general a truth, that I do not suppose there is a single practitioner who

will not bear testimony to the fact. Before parting with Dr. Dielt, let me trespass on the reader by a final

quotation from him, as referred to by Dr. Cowan, because it may find some corroboration in the statistics I have so very imperfectly tabulated. He states that " a decided exacerbation of the epidemic was observed

every third week, but in proportion as the cases were severe was their number diminished, as if the quantity of the poison remaining the same, its diffusion was

subject to periodical contraction and expansion." A paper, recording some of the effects of the mala

rious poison, can have little to do with its origin, although from my own scanty observations, I feel

inclined most to accuse vegetable decomposition. There is an opportunity about to occur in this district,

which, if well observed, might perhaps tend to throw

some additional light upon the development, march, and modifying agency of miasmata. The locality at

present healthy, and having the types, &c., of its

present diseases marked carefully, will be shortly ob noxious to the influence of marsh miasm, which may be accurately watched in its effects upon the sanitary constitution of the district, and the hilly character of the neighbouring ground will furnish currents and foci where its effects may be tracked out. This district

will again become, some two or three years hence,

changed in respect of originating malaria, and probably also become densely populated in the course of time by busy hives of beings dependent on the commercial

activity which large dock-space creates. The mala rious area will be partly covered by the water of the

docks, and partly by the surrounding warehouses and tenements.

In referring to the map, the reader will remark, on the Cheshire side of the River Mersey, a large body of water, called "Wallasey Pool," up which, for a considerable distance, the tidal waters of the river at present flow. New docks are in the course of construction upon this site, and as the tidal flow will

be cut off by a sea-wall run across the mouth of the

pool, a large space will not only be left divested of its

periodic salt-water covering, but the depth of mud, accumulated for centuries, must be removed. It is

genuine mud, not river silt, but a noxious deposit from

half stagnant water, the amount of which, along with

the subjacent rock and sand, has been estimated, at a rough guess, and from inspection of the plans and the works, which appear to be already completed, at from 1,500,000 to 2,000,000 cubic yards of excava

tion. Here may be presumed to be a fountain of

intermittent fever, which will be unsealed for the first time in our neighbourhood, and then, if I may retain the figure, resealed, but not till it has told upon the excavators and surrounding population. If along with

meteorological observations the medical practitioners of the districts of Birkenhead and Wallasey would note

carefully the advance and progress of the endemic

threatening their quarter, valuable data might be ob tained bearing upon the etiology of ague, the exoteric

periods of Dr. Laycock, and other important subjects of research.

In reference to malarious agency, I have at present a patient, a lady, who whilst on a visit to i fen district,

caught ague in one of its most severe forins, insomuch that her life was apprehended to be in great danger for a tong time. After removal, she gradually recovered; but though now enjoying ordinary health, yet at every catamenial period she gets a regularly formed quoti dian fit, and then she has no more of it until the next

period comes on. It is an interesting illustration of MD. Laycock's esoteric periodicity, or internal series of chronal changes. The ague influence also ilu

presses itself upon any catarrhal or other disorder. The antagonism of typhus and ague is partly borne

out by the topography of our epidemic, which the map will exhibit; the usual fever district, where the typhus always " has a home" in Liverpool, was not touched

by the epidemic, which visited the best sanitary quarter of the township.

(To be continued.)

ON THE ARRANGEMENT AND TREATMENT OF CUTANEOUS DISEASES.

TO THE EDITOR OF TH' PROVINCIAL MEDICAL AND SURGICAL JOURNAL.

SIR, A series of papers which have recently appeared in

the Provincial Journal, from the pen of your corres

pondent, " S.A.R.," on cutaneous diseases, must hare attracted the attention, and to a greater or less extent won the approbation of all your readers, who take any interest in the subject. The classification is natural, the definitions concise and pointed, and the whole may be studied with advantage by those who are in search of a bird's-eye view of the various diseases of the skin which they are liable to be called upon to treat.

Nosology, however, whether general or cutaneous, is a

very unsatisfactory science, utterly useless except for

purposes of description, very liable to mislead and ass the learner, and pretty generally repudiated

who are practically familiar with the ever

pg phases, and complications of disease.

ilIan's arrangement, which is convenient enough for all the useful purposes of classification, is never theless open to many objections; among the least of

which it may be mentioned that it is full of contradic

tions, and overladen with a needless multiplicity of subdivisions. The degrees of severity and stages of some diseases are honored with distinctive names

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146 ON CUTANEOUS DISEASES,

and the definitions of others are at direct variance with

the generic character of the divisions under which they are placed. No writer on cutaneous diseases since

Willan's time, not even Bateman, his friend and pupil, has adopted the arrangement of that ingenious man,. without some attempt at improvement. The light'lV modern anatomy, as reflected from microscopic exami

nations, has more recently shed her beams upon this

department; but it may be affirmed, that every attempt to improve upon Willan has failed in some weak point

or other; and every author has probably met with

difficulties which he did not anticipate. Your correspondent has at the outset fallen into anm

error, which is liable to lead to mistakes in practice. Under the class of inflammations, he includes several

diseases which are not always nor generally inflam

matory, and when he comes to speak of the treatment, he says, that all inflammatory diseases of the skin

must be treated on antiphlogistic principles. This

last position is unquestionably true and important; but does the author remember that under the head of

inflammatory diseases, he has included sudamin4,

miliaria, pemphigus, impetigo, ecthyma, rupia, porrigo, and furunculus ? And does he propose to treat these

diseases generally by low diet, bleeding, purging, and

antimonials? There is no mode of escaping the horlm of some such dilemma as this, and it is therefore

earnestly to be wished, that the talent and ingenuity which has been actually thrown away in attempting to

reform the classification, had been devoted to the

improvement of the treatment of these diseases, a

department of therapeutics which numbers but few,

labourers, and has consequently been inadequately cultivated.

The chronic and non-specific diseases of the skin, are often found intractable and unmanageable under the most approved rules of treatment; and the

dermnato-pathologists who have succeeded Willan,

appear to have been satisfied with arranging, and

grouping, and delineating diseases, without proposing any suggestions which might even open a prospect of

permanent improvement in their treatment. I trust

that the following observations, which are not the crude fancies of an hour, but the results of many years' rigid and close enquiry, will meet the eye, not only of

your respected correspondent, but of many readers,: who from hospital or other public appointment, may have an opportunity of putting my suggestions to the test of practical experiment on a large scale. I will endeavour to condense my views as much as possible.

The chronic, non-specific, non-contagions diseases of the skin, by which I nean lichen agrius, certain varieties of prurigo, psoriasis, lepra, chronic eczema, impetigo, acne, sycosis, and lupus, are disorders of constitutional origin, and compose the group of diseases of which I propose to discourse. My remarks apply to all of them without exception, and to few other diseases.

1. They are all curable (when uncomplicated, every stage and in every degree of inveteracy, wtli the patient's strength is not irrecoverably exhausted, by intemperance or other cause.

2. It is not necessary to distinguish them from each other in order to treat them successfully. Psoriasis, lepra, lichen, and eczyma imnpetiginodes, in their

more aggravated forms, present a mass of dark-coloured

thickened incrustation, full of fissures, which bleed and

discharge serum or purulent matter. This obscures the primitive eruption, but the indication for treat

ment remains the same.

3. It is necessary to ascertain whether these diseases be of syphilitic origin or not; many of them are to be met with of this character.

4. It is also necessary to determine whether the disease be attended by a febrile condition of the system or otherwise.

The indications of treatment are very simple. Febrile action must first be reduced by bleeding, general and local, purgatives, antimonials, colchicum, low diet, &c. Then, if the disease be syphilitic, and

especially if also of squamous character, mercury, liberally administered will be all that is required. If the disease be not syphilitic, the pulse being natural, the general surface cool, and if there be nothing wrong about the general health which other means will

rectify,, we may confidently rely upon arsenic, rightly administered, to restore the patient. No external

applications are ever necessary to the cure. Tepid baths are, however, admissible and desirable.

Arsenic, however, is seldom rightly administered, and therefore often fails. The following rules for its safe and effectual exhibition will be found exceedingly valuable in practice --

1. The use of arsenic is contra-indicated where there is a feverish state of the general system, a quick pulse,

hot skin, &c.

2. It should never be given on an empty stomach. 3. It should never be given in increasing doses. This

is a fatal and almost universal mistake. 4. The largest dose ever required is five minims of

Fowler's solution three times a day. 5. This dose, if mixed with the food, will not irritate

the stomach or bowels, but will, in the course of a few

days or weeks, produce an itching or smarting in the

conjunctiva. This membrane will appear slightly in

flamed, and the lower eyelid will soon become a little

puffed or swollen. The cutaneous disease will now

begin to decline, and the dose must be reduced to four minims.

6. If the conjunctiva continues much inflamed, the dose must be further reduced, but the conjunctiva should be kept tender throughout the whole course.

7. If the skin becomes more inflamed, the course

Inust not be interrupted, but a few leeches must be

applied to the margin of the diseased portions, or an occasional aperient exhibited.

8. The arsenical course must be continued for as

many months after the final disappearance of the erup tion as it had existed years before. This will prove a

security against a relapse. 9. The medicine should be procured from Apothe

caries' Hall. It is very commonly adulterated by druggists.

10. Cutaneous disorders treated in this way seldom

turn, and never severely; nor is there any danger of metastasis.

This plan, when fairy carried out, has never failed in my hands, in any of the diseases above enumerated.

But where the disease depends upon local causes, these must be previously removed; and attention should also be directed to the state of the digestive organs, and any deviation from healthy function should

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OPERATION OF THE POOR LAW. 147

first of all be rectified by treatment on established

principles. Incidental Variations.-1. Cutaneous diseases are

sometimes complicated with diarrhea and general irritability of the intestinal canal. If this cannot be

readily relieved by common measures, arsenic will be found to soothe the bowels, (the pulse being quiet,) in the same degree in which it allays the irritability of

the skin. Both surfaces suffer from the same consti

tutional derangement which the arsenic rectifies. 2. Some individuals are, from idiosyncrasy, un

usually susceptible of the effects of arsenic. In these

cas, doses of- from one minim to two, will be borne

with impunity, and will prove as effectual as a larger dose in common cases. The curative powers of arsenic will always be found to reside in doses too small to be

mischievous.il

I shall feel greatly obliged to any member of the

Association who may feel disposed to give my plan a fair trial, to communicate the result through the

medium of the Journal. It will ultimately be found

that arsenic is a specific for these diseases, for the cure

of which it has never yet had a fair trial.

I remain, Sir, Your obedient servant,

THOMAS HUNT. Herne Bay, March, 1846.

PROVINCIAL

4ttebfcal & urgicaal journal. WEDNESDAY, APRIL 1, 1846.

The sickening details which the working of the Poor-Law Act, under its present system of ma.

nagement; is continually bringing before the public notice, are, we fear, likely to produce a very mis. chievous effect upon the moral feelings of the

country. No maxim is better founded, no truth more apparent, than that familiarity with evil

begets a disregard of it. The progress of cruelty, from its first initiatory steps in the unchecked

thoughtlessness of childhood, through a long course of crime, and ultiMxtely to murder itself, by the band of the hardened adept, has been forcibly pour trayed by Hogartb; and no one can look upon his vivid sketches witlot acknowledging their strict

conformity to the ruWh of nature and experience. It is tile same with every species of iniquity; the innate consciousness of moral wrong is soon dead.

ened, and repeated contemplation of evil of any

description, rapidly accustoms, and even reconciles the mind to its existence.

We say, then, that it is greatly to be feared that the inflictions so frequently perpetrated on the dis tressed poor by the harsh operation of the Poor

Law, will tend much to lower the moral feeling of the country, 4nd to break up those sympathies

which should exist between man and his fellow. man. The poor are becoming accustomed to dis.

regard the social ties of family affection, for they see them habituallyand recklessly severed under the sanc tion of legal authority. The relievingofficers, guar dians, and commissioners, as the instruments through wiich such authority is exercised,aredaily witnesses of the lessons which they are called upon to enforce, and cannot but carry the poison into their own homes. They severally, in their respective sta tions, become accustomed to disregard the cry of

suffering, for the duty appointed them by law is to withhold the relief required until the necessity for it is extreme, and then to yield it with unwilling hand, and with restrictions which replace bodily want by distress of mind and outraged affection.

The inquiry into abuses existing in one union, is

quickly followed, therefore, by a call for a like in

vestigation into similar practices in another; and, though the cases may differ according as the system

works on different points, yet they all bear the

impress of undue harshness, and testify to the same

unhappy consequences. The Halstead Union has, within the last few days,

afforded cause for inquiry into the working of the system, and in this instance the charges are against the relieving officer. These charges were-ist.

That he refused to give an order for medical relief, the case being one that required it. 2nd. That he refused to give assistance, notwithstanding the case

was urged upon his notice by a respectable and

competent person, as being one in which delay in

giving the required aid would prove fatal, without

himself visiting the patient, or taking steps to

judge of the propriety of the application. 3rd. That he has frequently authorized and paid for tlhe attendance of a midwife.

With regard to the third charge, it may be briefly observed, that in addition to this female func

tionary, being not even recognized by the law, it was stated in evidence, that tile person employed as such by the relieving officer, was, from habits of intoxication and negligence, otherwise incompetent.

The second charge was fully made out by the evi dence of Mr. Rodick, surgeon, of Halstead, who Irad been asked to see one of the sufferers as he

was passing the house, and himself went to the

relieving officer, pointing out the necessity which then existed of immediate attention being paid to the case.

We cannot, however, enter into details; it is the system to which objection applies, rather than to any individual infringement of it. Ac

cordingly, the defence pleaded by the relieving officer, backed, we may observe, by a previous decision of the Board of Guardians on the point, was to this effect; and in addressing the Assistant

Poor-Law Commissioner, who presided at the

investigation, we find him saying, " That this inves

tigation did not apply to himself, but to the system;

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