Treatment of Anasarca.-Blood-letting is better adapted for anasarca than for any other variety of dropsy. Where it occurs suddenly from exposure to cold, or excess in the use of spirits, venesection is often not only useful, but actually indispensable. The blood drawn is sometimes cupped and buffy, but more commonly it will have the appearance (hardly, however, less satisfactory) of great firmness of coagulum. The effects of blood-letting will be materially aided by the employment of purgatives, saline and antimonial medicines, and the relaxant diuretics, especially digitalis, nitre, and the acetate of potash. The student will of course understand, that neither these nor any other diuretic medicines are likely to be of service without very copious dilution, and nothing answers this end so effectually as lukewarm barley water. There cannot be a greater error than to imagine that dropsical accumulations may be lessened by withholding liquids.

It is unnecessary to say that this plan of treatment is adapted only to one variety of anasarca. In all cases, the practitioner, by tracing the origin of the disease, and weighing accurately the accompanying symptoms, must form for himself some idea of its proximate cause. He will thus occasionally find the necessity of supporting the system, instead of lowering it; and to effect this, he will have recourse to the use of tonics (bark, camphor, bitters, and aromatics) in combination with diuretics.

Considerable diversity of opinion has prevailed regarding the propriety of scarifications in anasarca. By some they are utterly condemned, as leading to erysipelatous inflammation and gangrene, while in the hands of others they have proved eminently serviceable. This may partly be attributed to differences in the mode of operating. It cannot, however, be denied, that in languid habits of body, scarifications are occasionally dangerous. The relief which they afford, however, is often surprisingly great, and compensates the degree of risk which they bring with them.

Blisters and issues have been recommended in the cure of anasarca, but they are not advisable. Frictions, oil-skin stockings, and bandages, are useful where the effusion of serum arises from local obstructions; but they are unimportant in that more numerous class of cases, in which dropsy of the cellular membrane is associated with a disposition to effusion in the great serous membranes of the thorax or abdomen.

CLASS X.

CHRONIC CUTANEOUS DISEASES.

CHAP. I.

PATHOLOGY OF CUTANEOUS DISEASES.

Outline of their Pathology. Causes operating generally in the production of Chronic Cutaneous Diseases. Causes operating locally. General System of Treatment. Division of Affections of the Skin into constitutional and local. General Character of the Remedies employed.

A GREAT variety of affections are comprehended under the head of chronic cutaneous diseases. Expanded as they have been by some authors into a nosological system, and each made the subject of distinct investigation, it may appear impossible, consistently with the design of this work, to enter upon a discussion of them with any prospect of advantage to the student. I am indeed fully sensible, that in acquiring a knowledge of these affections, attention to detail is requisite. Still it behoves the student to be aware, that there are certain general principles which connect all the chronic diseases of the skin together, and link them in with the great chain of constitutional disorders. To point out these, although in a very summary manner, may possibly be useful. I shall attempt further to direct the attention of the reader to the leading natural divisions of chronic cutaneous disease, hoping thus to lay before him the elements of a study which the detailed descriptions of authors may hereafter assist him in pursuing, but a complete knowledge of which can alone be attained by constant attention, and extensive opportunities of observation.*

We have two works in our own language expressly dedicated to cutaneous affections, viz.-Bateman's Practical Synopsis of Cutaneous Diseases, and Plumbe's Practical Treatise on Diseases of the Skin. The student will also consult with great advantage Rayer's Treatise on Diseases of the Skin, translated by Mr. Dickinson. London, 1833.

Causes. Considering the diversity in the aspects of chronic cutaneous disease, there is less variety than might have been expected in their exciting causes. They may be distinguished into such as operate generally, and such as act through the medium of the skin itself.

1. In the first class may be ranked the presence of a poison in the system. This is very often the poison of lues, which, in common with other secondary effects, produces every possible variety of cutaneous disease. At other times, the poison is that of mercury. Hence it is that cutaneous eruptions constitute so important a part of that complaint to which modern pathologists have given the title of pseudo-syphilis. Sometimes the poison is of a more familiar kind, such as shell-fish, bitter almonds, and other indigestible articles of diet, the influence of which, however, is only partial and transitory.

2. The next source of cutaneous disease is simple debility. To this we attribute the cutaneous eruptions bearing the character of ecthyma and rupia, which are observed in persons convalescent from tedious diseases, very remarkably in those of a naturally scrophulous habit, who are recovering from confluent small-pox. Closely allied to it is the state of cachexia, the consequence of bad food, want of air and exercise, and irregular modes of living. It has been conjectured, that in these cases the blood becomes altered in its qualities, and probably loaded with saline particles, which, irritating the cutaneous capillaries, produce different varieties of eruption. This doctrine of the old pathologists, although but little talked of in modern times, still preserves its influence on practice, as will be apparent by considering the extensive use now made of the alterative vegetable decoctions, the principal effect of which is to improve or sweeten the condition of the blood.

3. A weakened or cachectic state of the system is not, however, the only one in which chronic cutaneous disease occurs. In some instances a degree of plethora is present. In the language of the humoral pathologists, the blood is too rich, and stimulates too strongly the vessels through which it passes. This is particularly observable in the pustular eruptions to which young persons are subject about the period of puberty, constituting the acne simplex and punctata of Willan.

4. A disordered state of the stomach and bowels is one of the most common causes of chronic cutaneous disease. Some

times this consists merely in the lodgment of crudities in the alimentary canal. At other times, the presence of acid in the stomach appears to be the direct occasion of the cutaneous affection. Hence the use of purgatives and of absorbents in the chronic diseases of the skin.

5. Chronic cutaneous disease is sometimes observed in combination with symptoms denoting disorder of the thoracic viscera. I have already had occasion to illustrate this pathological principle when treating of the hæmorrhoea petechialis, or purpura. Lichenous eruptions sometimes accompany an

hepatized state of the lungs.

6. Cutaneous disease appears to depend in some instances. upon the mere circumstance of advanced age. Many old people suffer severely from pruriginous affections, depending probably upon some change which the texture of the skin undergoes as life advances.

Besides these general sources of cutaneous affections, there are others whose influence is very extensive, which may be referred more immediately to the skin itself.

1. The first I shall notice is a peculiar irritability, or delicacy, of the skin. This is the probable cause of those numerous cases of strophulus which occur in infants, whose skin is as yet unaccustomed to the stimulus of air and soap. This irritable state of the skin often exists through life; and hence it is that leeches and blisters produce in such habits very unpleasant effects. The principle appears to be one of very general application in the pathology of cutaneous complaints. In some instances it would appear that such a peculiarity of the surface descends from parents to their offspring. Lepra and Icthyosis afford the most remarkable examples of the hereditary transmission of cutaneous disorder.

2. The next cause of chronic cutaneous disease which requires attention, is want of cleanliness. It is doubtless on this account that obstinate cutaneous affections are so much more common among the lower than the higher classes of society. Hence, too, the great value of warm ablution in their

treatment.

3. The third is local irritation. Its influence in the production of cutaneous disease is generally acknowledged, and is indeed very extensive. The principle is fully shown in the common effects of blisters, plaisters, and antimonial lotions;

but it is chiefly exemplified in those eruptions which follow the long-continued stimulus of the sun's rays, of flour, sugar, lime, or soap, constituting some of the species of eczema and psoriasis.

4. The last source of chronic cutaneous disease which I shall notice is contagion. There are not many cases, however, to which it applies. Psora and tinea capitis are perhaps the only unequivocal proofs of it which can be adduced.

Treatment. In laying down a few general principles applicable to the treatment of these affections, I must first advert to the necessity of distinguishing them according as they are constitutional or local. Chronic cutaneous diseases may, in fact, be divided into two classes, such as implicate the constitution to a greater or less degree,―and such as are decidedly local, arising from local causes, remediable by local means, and in the ordinary course of events not influencing the system at any period of their progress. There is a foundation in nature for this distinction; but in other respects these two classes of diseases are too intimately connected to make it possible to discuss them separately. In practice, however, it must be remembered, that where the disease is essentially local, topical remedies are required. On the other hand, where the constitution is in fault, local measures are of little or no avail. It is true, that in the treatment of the latter kinds of cutaneous disease we are often glad to have recourse to local means (even though their influence be but insignificant), for a large proportion of such affections are unaccountably obstinate.

Of those kinds of cutaneous disease which are connected with constitutional disturbance, many are set up by nature as a relief to internal disorder, and their cure would often be followed by some serious mischief. Thus the crusta lactea of infants suddenly suppressed has been succeeded by hydrocephalus; the psoriasis of elderly persons, by apoplexy; the drying up of an old ulcer, by a paroxysm of asthma. In connection with this subject, we may mention also the curious but well-ascertained fact, that very obstinate cutaneous diseases have sometimes been removed in the course of a fever. Warts and scaly diseases of the skin, which had resisted all remedies, have, especially, yielded in this manner.

In the treatment of cutaneous affections, the condition of the general system is first to be looked to; and according as a