Lectures On Dermatology

Author(s): Erasmus Wilson

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 Feb. 18,1871.] THE BRITISH MEDICAL JOURNAL. 163
considerable extent, and in another the inflammation would seem to be
LECTURES centred in minute points. In the latter case, it is evident that the seat
of the inflammation is the cutaneous follicles ; in the former, follicles
ON DERMATOLOGY and interfollicular space are blended in one general disorder. There
is redness of the affected parts, although but little ; there is also slight
DELIVERED AT swelling. In the blotches the redness is seen along the margin of
the disease, where it is the forerunner of subsequent changes ; while in
The Royal College of Surgeons of England.
the follicles the redness appears in the semblance of puncta, and the
swelling is more conspicuous, elevating the mouth of the follicle, and
By ERASMUS WILSON, F.R.S., producing that form of pathological lesion which is denominated a
Professor of Dermatology in the College.
" papula." If any evidence were needed of the precise seat of the pa
thological changes present in eczema, it might be found in this model ;
Lecture I. the papulae are many of them perforated by the hair which issues from
the aperture of its follicle, and along the circumference of the blotches
[The course for the Session 1871 was commenced in the Theatre of implication of follicles and interfollicular surface is distinctly
the gradual
the College on the 30th of January ; and the lectures wereperceptible.
amply We are also taught by this model the process of extension
illustrated with models, preparations, and strikingly effectiveofdraw
the disease?its creeping or erpetic character ; for between the two
ings. The inaugural course of the previous year had been extremes
devoted of simply prominent papulae and the larger blotches may be
to a synoptical survey of the whole subject of the pathologyfoundof the
smaller blotches of intermediate size.
skin ; the present was confined to the examination and demonstration
The next observation that may be made in reference to this model is
of the objeats composing the dermatological collection of thethe College
presence of a thin scab or crust on several of the blotches. The
Museum, together with a consideration of the principles of crust therais the product of an exudation from the inflamed skin, and if it
peutical management of cutaneous diseases. The dermatological
were col
removed, we should discover beneath it a raw surface moistened
lection contains 513 objects, and these have been arrangedbyinanthe
ichorous secretion. The secretion of eczema is apt to range in
most convenient order to facilitate their study, and at the same time
appearance, from simple transparency through the various tints of white
to conform to the recognised divisions of physiology and pathology.]
and yellow opalescence to the deep yellow hue of pus ; and, where any
The subject taking precedence of all the rest is common inflamma haemorrhagic tendency exists, whether arising from external injury or
tion ; and then follow in succession diseases resulting from fromblood
the weakened condition of the tissues, there we may find super
poisons and diathesis; diseases of the functions of nutrition, added
innerva the colouring principle of the blood, producing shades of different
tion, and pigmentation ; diseases of the epidermis and nails, and, tint,
lastly,
ranging from reddish-brown to almost black. These are the con
diseases of the hair, the sebiparous system, and the sudoriparous ditionssyswhich influence the colour of the crust ; while the degree of in
tem. In this way, seven primary groups or classes are formed ; and of its secretion and the quantity of such secretion will deter
spissation
these admit of a subsequent division into nineteen sub-groups : thus,thickness.
mine its
diseases of common inflammation include eczematous, erythematous, A special character of common eczema is the number of lesions pre
phlyctenous, furunculous and traumatic affections; the diseases
sent in de
the skin, hence the terms eczema polymorphicum and multiforme;
pendent on blood-poisons are the exanthematous, syphilousbut
and ele are certain of its forms which are remarkable for a dimorphic
there
phantous affections ; diseases of diathesis are represented by the leprous,
character, comprising nothing more than redness, followed by exfolia
strumous, and carcinomatous affections ; the diseases of function tion ofare
the cuticle, and to such forms have been assigned the term eczema
the trophopathic, neuropathic and chromatopathic affections ;erythematosum.
the dis These forms are represented by an interesting series of
eases of the epithelium comprise the epidermic and onychopathic affecin the dermatological collection, in one of which the exfoliation
models
tions ; diseases of the hair-system, the trichopathic affections ;has andtaken
dis place in circular disks, in another in rings, while a third is
eases of the gland-system, the steatopathic and idrotopathic affections.
remarkable for a desquamation of the entire surface of the integument.
First in the classification, and first, also, among affections of theThe
skin,
latter affection has been variously named dermatitis and dermat
is the disease eczema. The word is less ancient than many itis
of exfoliativa,
our but in reality it has every claim to be considered as an
eczema exfoliativum. It presents the peculiar characters of an inflam
pathological terms, and bears in its meaning the impress of the humoral
doctrines of earlier times. It signifies a "boiling out", and, asmation
A?tius
of the skin of the entire body, accompanied with intense redness,
ingeniously explains, conveys the idea of an inward heat, which anddrives
with repeated exfoliations of the whole of the cuticle in shreds or
off" the humours of the body from its surface like the seething flakes.
of a boilThe shreds and flakes, when seen upon the skin, give it a
ing fluid ; and although we no longer recognise the humoral doctrines,
" fluffy" appearance ; some are upwards of two inches in length, while
nor the expulsion of the humours of the body through the skin theby
freeanedge is half or three-quarters of an inch in breadth. Nothing
inward heat, we are nevertheless forcibly struck with the cogency of singular than the appearance of the body marked by these
can be more
the expression when we see the minute vesicular bubbles which white lines of exfoliating cuticle ; the features look as if they were
some
times cover the surface of an eczema, the copious exudation somewith graceful and symmetrical undulated curves ; and on the
tattooed
trunk of
times welling forth from its surface, and hear the sharp complaints and limbs the curves follow the direction of the normal lines of
our patients against the burning and scalding pains by whichmotion
it is acof the skin. To the eye of a patient suffering under this curious
companied. More ancient observers seem to have been impressed with the long curved lines sweeping around his body and limbs
complaint
the intense itching which is common to eczema, and to have suggested
called the idea of "ribs," and he spoke of his body as being
it in consequence psora, from the Greek word signifying "to rub""ribbed,"
; so and the comparison was by no means exaggerated. When
that, in the mere nomenclature of the affection, we have delineated
these longa flakes or exuviae of exfoliating epidermis are broken off, they
fill burn
fair picture of the disease ; that is, of a disorder which is hot, the clothes and bedclothes of the patient, and when in their broken
ing, scalding, often exuding in vesicles, or by a copious oozing from
state they are collected together, they resemble the bracts of hops.
The abundance of the epidermic exuviae is so considerable at the
the inflamed surface, and for the most part pruritic or itchy to a greater
or less degree. height of the disease, that in one of the cases illustrated by the pre
If we set ourselves the task of defining eczema, we should call it an parations in the museum, the weight of the scales collected from the bed
inflammation of the skin, attended with a breach of its surface ; and a amounted to more than two ounces daily, and in bulk to upwards of a
knowledge of the common characters of inflammation will teach us the pint ; and as the period of active exfoliation was prolonged for upwards
appearances which the inflammation and the breach of surface are cap of two months, I calculated that during that period the quantity of cuti
able of presenting. It is obvious that there will be redness, there will cular exuviae thrown off by the skin could not be less than ten pounds
be more or less prominence, there will be displacement of the cuticle, in weight, and more than a bushel in bulk. Devergie, however, gives
either in the form of vesicles or desquamation, and there will be exuda sanction to a higher computation than this ; for, according to him, the
tion, and the consequences of exudation in various degrees. One of quantity of exfoliated cuticle amounted to between two and three litres
the most eminent of our modern authorities on dermatology has said or quarts in the day, and consequently to between two and three bushels
very truly?" If you rub a drop of crot?n oil upon the skin, you have a month. This quality of exfoliation especially attracted the attention
immediately developed a case of eczema." And in like manner, it may of Devergie, and, likening the broken exuviae to the fine scales which are
be stated, that any irritation of the skin, whether the irritation come produced in pityriasis, he called the affection pityriasis rubra, and Hebra
from without or from within, is capable of exciting an eczema. has adopted the same term. But if we search into the intrinsic nature of
If we turn to the Model No. 1, representing the thigh and leg, we the disease, and refuse to be content with one only of its symptoms, we
perceive evidences of inflammation dispersed in a peculiar manner over shall be nearer the scientific truth if we keep the affection in the family
the limb ; in one situation there are blotches manifesting a lesion of of the eczemata.

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 i64 _ THE BRITISH MEDICAL JOURNAL. [Feb. 18, 1871.
The Professor concluded his lecture by the narration of a very inter Guided by general principles and experience, we may well warn all
esting case of eczema exfoliativum which he had at present under treat consumptives born of one or both consumptive parents, or having
ment ; this case was accompanied with all the symptoms already detailed, several blood-relatives consumptive, that there will be great risk of
and, in addition, with loss of the nails and loss of the hair. The their own children proving consumptive also, and that the risk is fur
patient was a man of gouty diathesis, and was also the subject of ther increased when a consumptive marries into another consumptive
lepra vulgaris. family ; and on this consideration, as well as for their own sakes, we
cannot sanction the union of such consumptive persons.
On the other hand, consumptives whose malady originated in an in
"IS IT PROPER FOR CONSUMPTIVES TO flammatory attack, without any clear history of family taint, and whose
MARRY?" present condition is that of arrested disease, with good general health,
need have no unusual solicitude as to the healthiness of their progeny,
By CHARLES J. B. WILLIAMS, M.D., F.R.S. if due care be taken with their hygienic and dietetic management. In
this respect, as well as in the general treatment of consumptives, the
This question is too wide and vague to admit of a direct answer ;affluent but it might have a better chance than those in straitened circum
may be usefully debated by those who have had much study and expe for change of air, a salubrious residence, and a variety in the
stances;
rience in connexion with the subject. best kinds of food, are potent but expensive means for the restoration
Holding, as I do, that consumption in its widest sense?including andnot preservation of health. But the indocility and caprices of the
affluent often deprive them of their advantages; and, even when
only cases of distinct tuberculosis, but those also of caseous pneumonia
and chronic inflammation, which are only different forms and degrees theyof seek advice, they too commonly are guided by their own in
the same malady?is a disease of degeneration and decay, it can hardly be
clinations as to how far they will follow it. Whilst I was writing these
supposed that I should generally recommend consumptives, with the lines,
seedsa gentleman entered my consulting-room, saying that he wished
of decay in them, either to waste their remaining stamina by sexual for inmy advice about the propriety of his marrying. Eight years ago, he
dulgence, or to incur the risk of unhealthy propagation from their hadownbeen sent home from India, condemned as a consumptive, having
decaying stock ; and yet I have advised many a consumptive to marry, spit blood daily for several weeks, and lost much flesh. However, he
and in numerous instances the result has been happy and fruitful. so far recovered as to be able to return to his military duties in India,
For a patient in coitfirmed or active consumption to marry,from couldwhich he again returned invalided two months ago, with a renewal
never be advised by any rational physician, on either physical or of moral
pectoral symptoms. It is needless to enter into details ; but I found
grounds. Both reason and experience forbid such a step, as fraught signs of limited disease in one lung, which, as I told him, was probably
with perils and penalties, present and future. inflammatory, and might be removed with proper treatment and care,
It is different with many of the now numerous class of cases of he might entertain his marrying project. " O !" said he, "I
and then
arrested or limited disease, in whom the bodily functions are active
am and
going to be married the day after to-morrow."
vigorous, and in whom there is a probability of life for many years
under favourable circumstances. Among these favourable circumstances
may often be counted the increased social and domestic comforts and
the ^livening communion and sympathy of a well assorted and well ON MODERN TREATMENT BY
regul?t^mapried life. To those who have not the gift of continence,
and who^ affections have been already engaged with the hope of mar
DRUGS :
An Extract from the Annual Oration before the Hunterian
riage, ? singl? life is one of unnatural restraint and disappointment, in
jurious to health, and likely enough to accelerate disease and decay. Society, 1871.
To such, a judicious marriage and the moderate exercise of the sexual
functions become a source of bodily health, as well as of mental happi- j
By T. BOOR CROSBY, M.D., F.R.C.S.
ness, the beneficial influence of which can hardly be overestimated. !
To such, the new life seems to have a regenerating influence, with Let usinnow consider the modern method of treatment of disease by
creased vitality and energy, extending even to the organic functionsdrugs.ofAs a natural sequence of altered opinion respecting the utility
assimilation and nutrition. I believe that these remarks apply to of both
bleedings for the suppression of acute disease, the antiphlogistic class
sexes, including childbearing and lactation in the female. So long as
of therapeutical agents, especially such direct cardiac depressants as
all these processes go on normally, with good and regular feeding and
digestion, the maternal organism receives fresh vigour from theI antimony,
quick fell from common use, and are now only employed in special
instances. Not only did this change occur, but faith in the curative
ening influence of foetal and infantile life ; and processes of degenera
tion and decay are retarded or suspended. So far is correct the comof drugs was shaken to its foundation, and thoughtful minds
action
mon belief that pregnancy and lactation retard the progress of phthisis.
began to question the value of the universal physic-giving practice of
But such remarks do not apply to sickly pregnancies, to severe former and exdays, from "which scepticism" have arisen great improvements
hausting confinements, and to excessive or disordered lactation. Such
unfortunate contingencies, which cannot always be foreseen, pretty ?"a rational selection" and "an improved mode of administration."
surely impair the vital powers and hasten the progress of decay. Modern therapeutics owes much to the past for many valuable reme
dies handed down to it, with an authority of the best possible kind?
Further, there is a considerable number of consumptive individuals
for whom, although the disease be limited and not active, marriage " the test
is of experience"?more to the application of chemical laws and
not desirable. To say, in general terms, that these are weakly to results of. physiological experiments. Pathology teaches us the stern
indivi
duals, does not sufficiently characterise them. Weak they are, both fact that
in many morbid conditions are out of the pale of therapeutical
body and mind ; but there is also a nervousness which aggravates control.
the A careful watching of the efforts of nature herself under dis
weakness and adds to sensibilities and sufferings. The weakness ease, unaided
ex by medicines, has shown how powerful is the vis medi
tends to the sexual function ; and although, unfortunately, it does catrix
not; these two circumstances have contributed much that is valuable
extinguish desire, it renders the exercise of that function harassingto theand reason-why of modern medicine. I will now direct your atten
exhausting. To such persons, married life would prove a perpetual tion to the application of some part of the above reasoning.
snare and worry ; and their safest course is to cultivate the grace of Tocon
chemistry we owe much that is effective and easily explainable
tinence in single blessedness. in the employment of drugs, and for the simplification and multiplica
The apprehension of procreating unhealthy children is an objection tion of remedial agents. Gout and acute rheumatism are diseases at
more valid with physicians and friends than with the consumptive tended
him with, if not wholly caused by, an accumulation of acid in the
self when his affections are engaged ; and we are bound to consider system,
that of uric acid in the former, and lactic acid in the latter. Modern
its weight varies also with circumstances. In predicating anything medicine has brought chemistry to its assistance in both, and, by the
concerning a future generation, it must be borne in mind that we cantreatment, may fairly claim to have diminished the severity
alkaline
deal only in terms of probability ; and to give them numericaland duration of the acute forms of both diseases. Both diseases are
value
would require larger statistics than any yet available. Although accompanied
our by pain, generally of a severe character; for its relief we
experience abounds in examples of children born of consumptive have a remedy?colchicum for the one, and of the application of busters
parents being unhealthy, and sooner or later falling victims totosome the swollen and affected joints for the other. For this plan of treat
form of the disease, yet the exceptions are numerous also, and I ment
prove of rheumatic pain, which experience proves to be most valuable,
the power of young life to countervail any inherited proclivity towe are indebted to our able coadjutor Dr. Herbert Davies.
decay.
I could cite many cases, but it would take more time and space To thanthe empiric experience of the past we are wholly indebted for the
can be given here. j valuable specific colchicum?specific certainly it is, as it possesses no

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