erythema multiforme, and by many observers is regarded as merely a
manifestation of that disease. It is generally encountered in the
spring and autumn months, and occurs most frequently in children and
young {597} persons. It is usually associated with rheumatic pains, and
not infrequently with digestive derangement. It is not a common
disease. It is regarded by Lewin as an angio-neurosis. According to
Hebra, in most cases it is essentially an inflammation of the
lymphatics. Bohn regards it as due to embolism of the cutaneous vessels
giving rise to inflammatory infarctions. The process is an inflammatory
oedema. There is considerable serous transudation, with some
blood-corpuscles, and not infrequently with more or less hemorrhage.
The lesions usually bear resemblance to bruises, abscesses, and
gummata. The rosy hue, the apparently violent character of the process,
the number, course, and situation of the lesions, will serve to
distinguish it. The prognosis is favorable, as the affection tends to
disappear in a few weeks, rarely lasting more than a month.
As spontaneous recovery results, treatment should be conservative.
Rest, the more complete the better, sedative applications, as of
lead-water and laudanum or of carbolic acid, with the use of saline
laxatives and full doses of quinia, are the measures indicated. The
diet should be regulated according to the case.
Urticaria.
Urticaria, hives, or nettlerash, is an erythematous affection
characterized by the development of wheals of a whitish, pinkish, or
reddish color, accompanied by stinging, pricking, and tingling
sensations. The advent of the efflorescence is usually sudden; not
infrequently symptoms of gastric derangement precede its appearance.
The wheals are of variable size, shape, and color. Ordinarily they are
of the size of a coffee-grain or bean, rounded or ovoidal in shape, and
whitish, pinkish, or reddish in color. They occur isolated or in the
form of patches caused by a coalescence of several lesions, and vary in
elevation from half a line to several lines. Instead of the ovoidal or
rounded form, the eruption may appear in streaks or irregularly-shaped
patches. To the touch the lesions may be soft or firm.
The efflorescence disappears, as a rule, without leaving a trace.
Pigment-stains are in some cases left which may be slow to disappear.
Burning, tingling, stinging, and itching are prominent subjective
symptoms. The individual lesions are fugacious, inclining to disappear
at one part and to show themselves at another. They are more apt to
appear on parts subjected to pressure by contact of clothes, although
no region is exempt. No age is spared, but the disease, especially in
its acute form, is more common in the young. Ordinarily, urticaria is
an acute disorder, lasting a few hours to several days, in which time
frequent exacerbations may take place. On the other hand, it may be
chronic in the sense that relapses occur successively, the skin, in
fact, rarely being entirely free of the lesions.
At times the wheals are peculiar as to formation or are complicated
with another condition, and hence arise the so-called varieties of the
disease. The most common of these is urticaria papulosa, which was
formerly known as lichen urticatus. The lesions have the form of a
papule with most of the characteristics of a wheal. They appear, as a
rule, suddenly, and after a few hours or days gradually disappear; they
rarely {598} occur in numbers, and are generally scattered over the
trunk and limbs, especially over the latter. They are intensely itchy,
and hence their apices are usually excoriated and covered with
blood-crusts. The itching usually becomes more marked toward night.
This form of the affection is observed particularly in badly-nourished
or in ill-cared-for young children. The occurrence of the disease in
association with purpura, or as a complication of the latter, has given
rise to the names urticaria hæmorrhagica and purpura urticans or
urticata. The lesion is of a mixed character--purpuric and urticarial.
Sometimes the wheal formation is of such a nature as to give rise to
fluid exudation, producing a bulla; hence the name urticaria bullosa.
In rare instances large walnut- or even egg-sized nodes or tumors are
formed, constituting urticaria tuberosa, or giant urticaria.
The causes of urticaria are numerous. Two that are well known may be
classed under the heads of external and internal irritants. Under the
former may be mentioned stinging nettle, jelly-fish, caterpillars,
fleas, bedbugs, and mosquitoes; among the latter, whatever produces
gastric and intestinal derangements. These latter are responsible for
most instances of acute urticaria. With some persons indulgence in
certain articles of food, as fish, oysters, clams, crabs, lobsters,
pork, strawberries, and similar articles, almost invariably calls forth
the efflorescence. A number of medicinal substances, such as copaiba,
cubebs, turpentine, valerian, chloral, salicylic acid, iodide of
potassium, quinine, and others, taken internally, may provoke an
attack. Malaria, functional and organic diseases of the uterus, a weak
or irritable state of the nervous system, and impaired digestion are
common causes of both the acute and chronic forms of the disease.
Various nervous, hemorrhagic, and rheumatic diseases are also sometimes
associated with urticaria. In fact, an irritation from disease of any
internal organ, functional or organic in character, may give rise to
the eruption.
Anatomically, a wheal is seen to be a more or less firm elevation,
consisting of a circumscribed collection of semi-fluid material exuded
into the upper layers of the skin. It has its seat for the most part in
the papillary layer. The vaso-motor nervous system is probably the main
factor in the production of the wheal. Dilatation following a spasm of
the vessels results in effusion; in consequence, the overfilled vessels
of the wheal are emptied by the pressure of the exudation, and the
central paleness produced, while the pressed-back blood gives rise to
the red border.
The features of the disease are so characteristic that there is, as a
rule, no difficulty in distinguishing it from other affections.
Erythema simplex, erythema multiforme, erythema nodosum, and erysipelas
are to be differentiated. Erythema simplex is a simple hyperæmia, while
urticaria is a peculiar inflammatory exudation--a point sufficient to
distinguish the two. The papular and tubercular forms of erythema
multiforme are to be differentiated by their more persistent character,
the locality affected, and the absence usually of marked itching and
burning. Erythema nodosum may resemble urticaria tuberosa, but the
nodes in the former are usually encountered upon the tibial surfaces,
are of much longer duration, and are free from itching. It is only when
several wheals coalesce, causing swelling and burning, and then only
when occurring about the face, that it may be mistaken for erysipelas;
but the evanescent {599} character of the eruption in urticaria, its
rapid formation, the itching, and the absence of constitutional
symptoms usual in erysipelas, are points of difference.
TREATMENT.--Most cases of acute urticaria may be speedily relieved.
Relapses may occur, however, upon repeated exposure to the exciting
cause. The prognosis of chronic urticaria, on the other hand, is not
always so favorable, and will depend in a great measure upon the
ability to remove or modify the predisposing condition. The first
essential in the management of a case, therefore, is an investigation
into its etiological cause.
In the acute disease, where, as in the majority of cases, gastric
disturbance is the exciting factor, a purgative--preferably a
saline--should be given. In severe cases, if food is still in the
stomach, an emetic will be of service, sulphate of zinc, ipecacuanha,
and mustard being the best. The diet should be of the simplest kind.
Aperients are generally indicated until recovery takes place. In
chronic urticaria, where faulty digestion is the exciting cause,
remedies appropriate to that condition are to be prescribed. In all
cases attention is to be directed to the state of the general health.
If there is a suspicion of malaria, quinine and arsenic may be
administered. Functional and organic affections should receive proper
management, as they may prove to be the active cause of the disorder.
If diuretics are called for, acetate of potassium will often best serve
the purpose. The alkaline and laxative natural mineral waters are
sometimes useful. In obstinate cases, especially in those in which no
assignable cause can be detected, pilocarpine, atropia, tincture of
belladonna, chloride of ammonium, bromide of potassium, and arsenic may
be tried. Change of climate is at times advisable.
On account of the great distress usually attending the affection, local
treatment is demanded in almost all cases. Baths and lotions are the
most serviceable methods of applying external remedies. Sponging the
surface with vinegar or alcohol, pure or diluted, may afford relief. A
lotion of carbolic acid, two to four drachms to the pint of water, will
frequently give prompt ease. The latter lotion may be improved by the
addition of two or three ounces of alcohol and a small quantity (one to
two drachms) of glycerin to the pint. A lotion of thymol, one grain to
the ounce of alcohol and water, is likewise of value. Benzoic acid and
borax, each five to ten grains to the ounce of water; chloral, ten to
twenty grains to the ounce; dilute hydrocyanic acid, one to three
drachms to the pint; and diluted ammonia-water,--may also be mentioned.
Alkaline baths made with carbonate of sodium or potassium, three or six
ounces to the bath, are sometimes serviceable. Starch, gelatin, and
bran baths may in like manner be used; and acid baths, half an ounce of
hydrochloric or nitric acid to the bath, have been recommended.
Dusting-powders, especially when applied after baths, will in some
cases prove acceptable.
* * * * *
URTICARIA PIGMENTOSA, called also zanthelasmoidea, is an unusual form
of the disease, cases of which during the past few years have been
reported. It begins usually in infancy, and may continue for a period
of months or years. The wheals are intensely itchy, are more or less
persistent, and leave yellowish, orange-colored, greenish, or brownish
{600} stains. Its nature is obscure: by some observers it is regarded
as an urticaria; by others it is claimed that there is a new-growth
element in the lesions. Most cases certainly show urticarial lesions
and run the course of this affection. It is more than probable that the
different cases reported are not examples of one disease. Treatment is,
as a rule, unsatisfactory.
Dermatitis.
Dermatitis, although in its general meaning signifying any inflammation
of the skin from whatever cause or character, is a term usually applied
to those forms which are directly traceable to the action of irritants.
Such irritants may act from without, as cold, heat, caustics, etc., or
through the medium of the blood, as in the eruptions following the
ingestion of certain drugs. The intensity of the inflammation varies
from a simple erythematous condition to actual gangrene. Redness, heat,
pain, swelling, and at times itching, the common clinical signs of
inflammation, are present, but are variable as to degree. The
inflammation may be confined to a small area or may be diffused,
depending usually upon the cause. The forms of dermatitis are
designated according to the causes which produce them.
DERMATITIS TRAUMATICA.--Under this head are included all those
inflammations of the skin which are due to traumatism. Contusions and
similar injuries, abrasions and inflammation from the pressure of
tight-fitting garments, bandages, etc., excoriations, and the like, are
common examples of this form. The excoriations from scratching in
pediculosis, scabies, pruritus, eczema, and other itchy diseases are to
the dermatologist the most frequent examples of traumatic dermatitis.
They subside on removal of the cause, leaving often, especially if the
scratching has been at all violent and the cause long continued,
thickening of the skin and pigmentation, both of which, notably the
latter, may be more or less permanent.
DERMATITIS VENENATA.--All inflammatory conditions of the skin due to
contact with deleterious substances are classified in this group. Apart
from chemical irritants, certain plants, notably those of the rhus
family, are capable in some individuals of producing inflammation of
the skin. The two well-known plants of this group are the poison ivy or
oak and the poison sumach or dogwood. The majority of persons are not
affected by these plants, but in many contact, or in some mere
proximity to the plant, will be followed by a dermatitis, variable as
to degree. The inflammation may simply be of an erythematous character
with slight swelling, or, on the other hand, it may be vesicular,
pustular, or bullous, with marked hyperæmia, oedema, and swelling. As a
rule, the inflammation appears soon after exposure or contact,
sometimes within a few hours; not infrequently, however, several days
will elapse before the symptoms present themselves. Itching is commonly
a prominent symptom, as also heat and burning.
The eruption usually begins as an erythema with heat, swelling, oedema,
and itching, remaining for several days, and then subsiding, or, as is
frequently the case, vesicles or even blebs are developed, and the
affection then is, as a rule, slower in disappearing. Oedema and
swelling may be {601} slight, or, as often occurs, so great as to cause
marked temporary disfigurement. The face, hands, and genitalia are the
parts generally involved, although the disease may extend to other
regions, at times involving large areas or even the greater portion of
the whole surface. The lesions, either spontaneously or through
violence, rupture, and dry to crusts, and subsequently fall off,
leaving erythematous spots, which in turn gradually fade. The affection
runs an acute course, lasting from one to six weeks. In some cases,
especially in those with a tendency to eczema, its duration may be
prolonged. The poisonous principle has been found to be toxicodendric
acid, and is exceedingly volatile in character.
The eruption is influenced by treatment. Bland astringent lotions or
ointments are most serviceable. The fluid extract of grindelia robusta,
two to four drachms to the pint of water, dabbed on frequently, or
cloths wet with it kept constantly applied, will usually have a
remarkably beneficial effect. Black wash, either alone or followed by
the oxide-of-zinc ointment, as in acute eczema, and lead-water, are
both serviceable. A saturated solution of sodium hyposulphite, a lotion
of sodium bicarbonate, one of carbolic acid, one or two drachms to the
pint of water, a weak ammonia lotion, and other applications of a
similar nature, may also be advised, frequently with good result.
Other substances which at times act on the skin somewhat similarly to
the rhus plants are the aniline dyes, mezereon, arnica, and certain
other drugs, as savin, croton oil, tartar emetic, mercurials, etc.
DERMATITIS CALORICA.--Both heat and cold are capable of producing
serious disturbances of the skin. The condition varies from a simple
erythematous inflammation to a state of actual gangrene, depending upon
the degree and duration of the cause, and to some extent upon the
recuperative power of the exposed parts. Whether due to heat
(dermatitis combustionis, combustio, burns) or to cold (dermatitis
congelationis, congelatio, frost-bite, chilblain), the clinical
symptoms are about the same. Treatment is generally of a soothing
character.
In cases of dermatitis due to cold which are seen immediately after
exposure, the parts should gradually be brought back to a normal
temperature, at first being rubbed with snow or cold water applied. In
ordinary chilblains stimulating applications are most serviceable, such
as tincture of iodine and frictions with oil of turpentine. Balsam of
Peru, camphor, lead plaster, carbolic acid, twenty to sixty grains to
the ounce of ointment, camphor, and similar remedies may also be
mentioned.
In burns where the inflammation is of a mild degree, sodium
bicarbonate, either as a powder or in saturated solution, is effective;
while in those of a more severe grade a solution of 2 to 5 per cent.
will be of greater advantage. In burns or frost-bites in which the
inflammation is vesicular, bullous, pustular, or escharotic the
measures advisable in ordinary inflammation are to be employed.
DERMATITIS MEDICAMENTOSA.--Medicinal eruptions are due to the ingestion
of certain drugs, some of which produce in a large proportion of
individuals, sooner or later, well-defined cutaneous manifestations; on
the other hand, many drugs are only exceptionally noted as giving rise
to cutaneous disturbance. Of the former, the iodides and the bromides
stand conspicuous; while of the latter class, arsenic and quinine may
be cited. The glandular structures of the skin are frequently involved,
{602} especially in the iodide and bromide eruptions, and apparently
the inflammation and resulting pustules are due to the effort at
elimination through these structures. In other instances, especially
the erythematous and urticarial eruptions, the effects of the drug seem
to be due to some action upon the nervous system.
Arsenic.--Exceptionally eruptions are seen to follow the continued
administration of arsenic. They are of an erythematous type, resembling
the macular syphiloderm and measles; or papular, somewhat similar to
the papular manifestation of erythema multiforme. Vesicles, herpetic in
character, and pustules have also been observed. An urticarial-like
eruption has occasionally been noted. In several instances arsenic has
seemed to hold a causative relationship to an attack of herpes zoster.
Arsenical dermatitis is most frequently seen about the face, neck, and
hands, and lasts usually from a few days to two weeks. Workmen in
arsenic-works are occasionally observed to have a pustular, ulcerative,
and even gangrenous eruption, due to the local action of the drug.
Atropia or Belladonna.--A scarlatinoid rash is a frequent result of
ingestion of belladonna, even a small dose at times sufficing to
provoke the eruption. It is seen most frequently in children, face,
neck, and chest being usually involved. Dryness of the throat and
general malaise may be present. Usually there is no febrile
disturbance, and desquamation seldom if ever follows, the rash usually
passing away within a few hours or days after the drug has been
discontinued.
Bromides.--The eruption from the bromides is usually pustular in type,
occasionally furuncular, and at times giving rise to purulent
accumulations of a carbuncular character. In some individuals a single
dose suffices to call out the eruption; usually, however, it is only
after a few weeks' administration that the cutaneous lesions are
observed. In rare instances even its prolonged use is unaccompanied by
any disturbance of the skin. The face, neck, shoulders, and back are
most prone to its effects. The pustules have their seat in and about
the sebaceous glands. A small dose of arsenic or bitartrate of
potassium with each dose of the bromide will sometimes prevent the
eruption caused by the latter.
Cannabis Indica.--An eruption of a vesico-papular type, the lesions
pinpoint- to pea-sized, scattered over the entire surface, accompanied
with considerable pruritus, has been recorded, following within twelve
hours after a full dose of the drug, and disappearing in a few days.
Chloral.--A scarlatinoid or urticarial eruption, dusky-red in color,
somewhat itchy, occurring especially about the face, neck, and
extremities, occasionally follows the administration of chloral. In
some instances, if the drug is long continued, glandular enlargement,
vesicles, petechiæ, ulceration, and sloughing, and rarely death with
symptoms of purpura hæmorrhagica, result. In a few cases the drug has
produced simple purpuric lesions.
Copaiba.--The copaiba eruption is well known. It may follow a single
dose, or, as is more often the case, after several days' or a few
weeks' use of the drug. It is maculo-papular or papular in type, itchy,
and resembles urticaria and erythema multiforme. The extremities are
usually invaded, although not infrequently the whole surface is
attacked. A {603} scarlatinoid rash has also been observed. The
disturbance usually disappears in a few days.
Cubebs.--A diffused erythematous eruption, with milletseed-sized
papules, coalescent here and there, occurring over the face and trunk,
and to a less extent the extremities, disappearing with furfuraceous
desquamation, is occasionally observed.
Digitalis.--A few cases of scarlatinoid and papular eruptions have been
recorded as following the administration of digitalis.
Iodides.--Eruptions from the ingestion of the preparations of iodine
are not uncommon. They may be erythematous, papular, vesicular,
pustular, bullous, or purpuric in character. The erythematous type is
not uncommon, appearing in patches chiefly about the forearms, face,
and neck. The papular and vesicular forms are rarer, the latter
occurring usually about the chest, limbs, scalp, and scrotum. A
markedly eczematous eruption, occupying the greater portion of the
entire surface, with copious secretion, has been occasionally noted. A
pustular eruption, acne-like in character, resembling that seen
following the bromides, is the most frequent. It is seen commonly about
the face, shoulders, back, and arms. Iodine has been found in the
contents of the lesions. A bullous eruption, occurring chiefly about
the head and neck, has also been noted. This form is rare. The lesions
usually begin as small vesicles or vesico-papules, and develop to
blebs, containing a serous, puriform, or sanguinolent fluid. In some
cases the eruption does not go beyond the vesicular or vesico-papular
formation. Purpura has also, although rarely, been observed, the
lesions being small, simple in character, and occurring mainly about
the legs; or exceptionally assuming a grave hemorrhagic type, which may
terminate fatally. All of the eruptions of the iodides disappear
rapidly after the drug has been discontinued.
Mercury.--An eruption of an erysipelatous character, beginning about
the face and extending to other parts, has been occasionally noted to
follow this drug. The skin is smooth, shining, red, dry, and itchy.
Opium, Morphia.--An erythematous eruption, scarlatinoid in type,
favoring the chest and flexor surfaces of the limbs, with or without
itching, is in some individuals caused by even the smallest dose of
opium or its alkaloid morphia. It may disappear in a few days or be
prolonged and followed by marked desquamation. In some persons one or
two doses will give rise to intense itching without any eruption, or if
the drug is continued the erythematous condition described is
developed. Opium has also rarely caused profuse sweating and sudamina.
Phosphoric Acid.--An instance of a bullous eruption has been recorded
as following the administration of this drug.
Quinine.--Quinine rashes are not infrequent, appearing usually first on
the face and neck, and then invading other parts. The eruption may be
patchy or confluent. The type is generally erythematous. Chill, nausea,
and other symptoms of malaise precede its development. There may be
oedema and injection of the conjunctivæ, and redness and dryness of the
naso-pharyngeal passages. Itching and burning are almost constant
symptoms. Desquamation, furfuraceous or lamellar, follows. Eruptions
resembling urticaria and erythema multiforme have been observed. A
purpuric type has also been noted.