« 이전계속 »
eight to ten years' standing, completely removed in a few weeks. But then the surface must be kept constantly moist, a circumstance requiring great care and determination on the part of the patient. When it becomes necessary to shave, flour and warm water, or paste, should be used, and not soap. Alkalies applied from time to time only, as in the form of wash or soap, always irritate, although, when employed continuously, they are soothing.
Ecthyma is not a common disease, and usually presents itself as the E. cacheticum, requiring in addition to the alkaline wash locally, a generous diet.
Acne is a disease always requiring constitutional rather than local remedies. Although not uncommon in private, it is rare in hospital practice. Careful regulation of the diet, abstinence from wine and stimulating articles of food, watering places, baths, etc., etc., constitute the appropriate treatment.
Rupia.--This disease I have never seen occur but in individuals who have been subjected to the influence of mercurial poisoning. Hydriodate of potassium and tonic remedies, with careful avoidance of mercury in all its forms, is the treatment I have found most successful.
Lichen and Prurigo.-In both these affections constant inuction with lard is as beneficial as constant moisture in the eczematous and impetiginous disorders. In the prurigo of aged persons, the Ung. Hyd. Precip. Alb. is a useful application, although the disease is not unfrequently so rebellious as only to admit of palliation. The chronic papular diseases often constitute the despair of the physician.
Psoriasis, and that modification of it known as lepra, are very common diseases, and are uniformly treated by me externally with pitch ointment. I have satisfied myself by careful trials that it is the pitch applied to the part that is the beneficial agent, as I have given pitch pills, and infusion of pitch, largely internally without benefit. With the hope of obtaining a less disagreeable remedy, I have frequently tried creosote, and naptha ointment and washes, but also without benefit. Lastly, I have caused simple lard to be rubbed in for a lengthened time, but without doing the slightest good. The oil of cade is also very useful, especially in psoriasis of the scalp. Internally, I give five drops each of Fowler's solution, and of the tr. cantharidis. It is rare that the internal treatment alone produces any effect on a case of psoriasis of any standing. If a case resists this conjoined external and internal treatment, I have always found it incurable. About a year ago I carefully treated a series of cases internally, with Donovan's solution, without producing the slightest benefit.
Lupus is a constitutional disease, and must be treated by cod liver oil, and all those remedies useful for scrofula, of which it is a local manifestation. The external treatment is surgical, consisting of the occasional application of caustics, red lotion, ointments, etc., according to the appearance of the sore.
Favus is a very common disease in Edinburgh, and is most readily removed, first, by poulticing the crusts till they fall off, and the skin presents a smooth, clean surface; secondly, by shaving the hair; and, thirdly, by keeping the scalp continually covered with oil, so as to exclude the atmosphere, and prevent the growth of the parasitic fungi, which constitutes the disease. For this purpose, a gutta percha or oil silk cap, must be constantly worn. A continuance of this treatment for six weeks produces a cure in young persons, if combined with cod liver oil, generous diet, and anti-scrofulus remedies internally. I have tried the lotion of sulphurous acid, recommended by Dr Jenner, and found it successful in a few cases, but the treatment by oil is so easy as to be far preferable to it. Very chronic cases are cured with difficulty, but so long as the oil is applied the disease never returns, and mere freedom from the disgusting crusts is a great gain.
Scalp diseases must be treated according as it depends on eczema, impetigo, psoriasis, or favus, in all cases first removing the crusts with poultices, then keeping the head shaved, and, lastly, applying alkaline washes, pitch ointment, or oil, according to the directions formerly given. Ringworm is a disease I have never seen in Edinburgh, and of what it consists I am ignorant. Some writers apparently consider it to be favus, and others a form of herpes. On two or three occasions I have seen a scaly disease of the scalp, in the form of a ring—that is lepra, which I have cured by pitch ointment, or oil of cade. My friend, Dr Andrew Wood, informed me some time ago, that he banished it from the Heriot's Hospital school by condensing on the eruption the fumes of coarse brown paper, and thus causing an empyreumatic oil, or kind of tar, to fall upon the part. This has led me to suppose that it is a scaly disease, and a form of lepra or psoriasis.
So-called syphilitic diseases of the skin, are, in my opinion, the various disorders already alluded to, modified by occurring in individuals who have suffered for periods more or less long, from the poisonous action of mercury. A longer time will be required for their cure, but the same remedies locally, conjoined with hydriodate of potassium, in smaller doses, with bitter infusions, tonics, and a regulated diet, offer the best chance of success.
The great difficulty in the treatment of skin diseases, generally consists in their having been mismanaged in the early stages--a circumstance I attribute to their not having, until a recent period, been much studied by clinical students. Many chronic cases of eczema are continually coming under my notice, which, in their acute forms, have been treated by citrine ointment, or other irritating applications, which almost invariably exasperate the disorder. I shall not easily forget the case of one gentleman, covered all over with acute eczema, who had suffered excessive torture from its have ing been mistaken for psoriasis, and rubbed for some time with pitch ointment. In the same way I have seen a simple herpes, which would have readily got well if left to itself, converted into an ulcerative sore, by the use of mercurial ointment. Nothing is more common than to confound chronic eczemas of the scalp with favus, although the microscope furnishes us with the most exact means of diagnosis. I need scarcely say that the correct application of the remedies I have spoken of can only be secured by an accurate discrimination, in the first instance, of the diseases to which they are applicable.
The general constitutional treatment in all these cases seldom demands aperient or lowering remedies except in young and robust individuals with febrile symptoms. In the great majority of cases, cod liver oil, good diet, and tonics are required. In a few instances, sedatives, both locally and internally, are necessary to overcome excessive itching or irritation. These the judicious practitioner will readily understand how to apply according to circumstances.
ARTICLE IV.- Remarks on the Treatment of Disease. By W. 0.
MARKHAM, M.D., Assistant Physician to St Mary's Hospital,
London. The study of modern Pathology has advanced in a most surprising manner our knowledge of the diseased conditions of internal organs. It has corrected many erroneous views once held as to the nature of diseases; it has given us surer bases for the establishing a better road to the comprehension of their nature; and, in addition, it has been the means of giving an unhoped for degree of certainty and extension to our powers of diagnosis.
In an especial manner do these remarks apply to the diseases of the organs contained within the thorax; and if any one should desire to measure the true and real advantages which the physician has reaped in diagnosis from the study of pathology, let him place himself" for a moment in the position of those who practised the healing art, before the days of Avenbruger and Laennec-bring himself face to face with diseases of the lungs and heart, and then try his hand at the treatment of those diseases, guided solely by the general symptoms which they offer, and unaided by the lights of physical diagnosis. Thus insecurely guided, he will soon find how poor his powers of analysing disease are; and in the case of diseases of the lungs, for instance, he will have to admit, with Cullen, that he knows not how to distinguish between them. Pleurisy, bronchitis, and pneumonia were, by that acute observer, all classed under the head of inflammation of the lungs. It is, indeed, most true that any man, at the present day, moderately versed in the use of
the diagnostic aids which medical science places at his disposal, can : exercise his judgment upon the nature of internal diseases, as they : exist during life, with a hundred times greater probability of suc
cess, than could by any possibility have rewarded the desires of th:
most skilled and practised physicians of old days; and, as we have already said, for this our thanks are due to modern pathologica researches.
Never was pathology more carefully cultivated than at this present time, and certainly never was the study of the signs of diseas of internal organs, derivable through their physical diagnosis, more curiously and minutely investigated. It may, perhaps, be ever suggested that, beyond a correction and development of facts and principles already laid down and established, neither the one ne the other of these studies, as hitherto pursued, have much more information to give us. The knife and the eye of the pathologs have left but little of the tale of disease untold, as far as by the that tale can be told. And, in the physical diagnosis of internal diseases, all we can expect to pick up in this cultivated field art, perchance, some small gleanings of the great things established by those master minds who gave us percussion and auscultation Avenbruger and Laennec have left us little either to take from er add to the facts and principles severally taught by them ; both brought their respective methods of diagnosis to a high degree of perfection.
Such being the position of the pathology and diagnosis of internal ! diseases, one cannot help thinking that the time has arrived when we may venture to consider dispassionately what effect has been exerted on our practical application of medicine to the treatment of disease, through the advances made in these studies; what new aids or guidance have been given by their light to the therapeutic of the physician ; whether they have furnished him with fresh weapons whereby to combat disease, or have instructed him how more effectually to use those he already possessed; whether, in short, he has turned to their true account the lessons they have taught him. For, after all, we must remember that this pathology and diagnosis of which we boast so much, are but two of those many handmaids whose duties are wholly subservient to the one great object which is the end and purport of the physician's life, viz., the cure w disease.
Scientific therapeutics must of necessity be based upon diagnosis: the nature of the disease and its seat must be ascertained, or how are we to hope, amidst the many agencies which are at work in the various organs of the human body, to reach by our remedial act the one which is at fault? In the case of these particular diseases to which we have specially referred, what has this extraordinary inprovement in diagnosis done for us? This is the question which we would ask, and which we would gladly see fairly and conscientiously answered. It is impossible not to admit, amongst the con
most valued and esteemed practitioners of our art exhibit in their treatment of acute disease, and I will here take, for special exemplification of my position, the acute diseases of the heart and its
membranes—that a true ratio medendi is still to be discovered; that the problem of their treatment has yet to be worked out.
As this assertion may seem strange to some readers, I must state on what grounds I feel justified in making it; and I will take inflammation of the pericardium as my illustration. Now, this disease in its acuter forms may, in an especial manner, be written down as the representative of so-called inflammatory disorders; here we have the thing, whatever it be, denominated inflammation, in its typical form; here is a malady which, if it kill not in the violence of its first onset, will yet leave behind it, what we must ever dread, a disorganized condition of one of the tripods of life, the great central, and ever-active organ of the circulation—a condition which in its turn will give rise to, and be succeeded by other disorders in different organs of the body; the end of which, as sad experience but too truly demonstrates, has, for the most part, but one issue-a fatal, though it may be a late, one. I know not if any disease in its present and remote consequences, is more to be dreaded than this.
What now has medical science, resting upon the accumulated facts, which experience has placed at her disposal, what antidote to such a bane has she to offer ? Our pathology and a skilful diag. nosis enable us to trace most anxiously, from day to day, and with surprising accuracy, the progress of the malady; we even anticipate its insidious attacks, and scarcely sooner can pathology demonstrate the existence of the inflammation to the eye, than does our diagnosis reveal it to the ear. If ever disease demands the physician's earnest thought, this one surely does ; its progress is rapid, and it may kill at once.
And what, now, has medicine to oppose to this vigorous and destructive malady? What are the results of treatment which may be fairly deduced from the accumulated experience of scientific
practitioners? Well, we find, that to the violence and energy of - this inflammation the most vigorous antiphlogistic treatment has
been opposed; the lancet has been plied with a most unsparing hand; but does M. Bouillaud find believers in, or imitators of his treatment now? On the contrary, his heroic and certain method of arresting the destroying agent-of “extinguishing” the disease, has been convicted of error, and condemned as “ uncertain and very dangerous.” The men of authority, also, amongst us, I mean those to whom experience and authority rightly give that title, will be found rather to warn the inexperienced against the lancet, and to arrest his hand, than to tell him of the benefits of blood-letting; we find them expressing regrets at the disappointed expectations of their former hopes and faith in this remedy, and bidding others beware of the dangers even which their experience had seen resulting from it; they pretend not to giving a true estimate of its value.
And mercury too, that other prime arrester of inflammationshas the voice of observation still to echo the praises which were once
NEW SERIES.-NO. 1. JANUARY 1855.