Chapter 4

The eruption, erythematous in character and consisting of isolated pea or bean-sized elevations or of linear streaks or irregular patches, limited or more or less general, and usually intensely itchy, makes its appearance suddenly, with or without symptoms of preceding gastric derangement. The lesions are soft or firm, reddish or pinkish-white, with the peripheral portion of a bright red color, and are fugacious in character, disappearing and reappearing in the most capricious manner. In many cases simply drawing the finger over the skin will bring out irregular and linear wheals. In exceptional cases this peculiar property is so pronounced and constant that at any time letters and other symbols may be produced at will, even when such subjects are free from the ordinary urticarial lesions (_urticaria factitia_, _dermatographism_, _autographism_).

The mucous membrane of the mouth and throat may also be the seat of wheals and urticarial swellings.

#What is the ordinary course of urticaria?#

Acute. The disease is usually at an end in several hours or days.

#Does urticaria always pursue an acute course?#

No. In exceptional instances the disease is chronic, in the sense that new lesions continue to appear and disappear irregularly from time to time for months or several years, the skin rarely being entirely free (_chronic urticaria_).

#Are subjective symptoms always present in urticaria?#

Yes. Itching is commonly a conspicuous symptom, although at times pricking, stinging or a feeling of burning constitutes the chief sensation.

#In what way may the eruption be atypical?#

Exceptionally the wheals, or lesions, are peculiar as to formation, or another condition or disease may be associated, hence the varieties known as urticaria papulosa, urticaria hæmorrhagica, urticaria tuberosa, and urticaria bullosa.

#Describe urticaria papulosa.#

Urticaria papulosa (formerly called _lichen urticatus_) is a variety in which the lesions are small and papular, developing usually out of the ordinary wheals. They appear as a rule suddenly, rarely in great numbers, are scattered, and after a few hours or, more commonly, days gradually disappear. The itching is intense, and in consequence their apices are excoriated. Sometimes the papules are capped with a small vesicle (vesicular urticaria). It is seen more particularly in ill-cared for and badly-nourished young children.

#Describe urticaria hæmorrhagica.#

Urticaria hæmorrhagica is characterized by lesions similar to ordinary wheals, except that they are somewhat hemorrhagic, partaking, in fact, of the nature of both urticaria and purpura.

#Describe urticaria tuberosa.#

In urticaria tuberosa the lesions, instead of being pea- or bean-sized, as in typical urticaria, are large and node-like (also called _giant urticaria_).

#What is acute-circumscribed [oe]dema?#

In rare instances there occurs, along with the ordinary lesions of the disease or as its sole manifestation, sudden and evanescent swelling of the eyelids, ears, lips, tongue, hands, fingers, or feet (_urticaria [oe]dematosa_, _acute_ _circumscribed [oe]dema_, _angioneurotic [oe]dema_). One or several of these parts only may be affected at the one attack; in recurrences, so usual in this variety, the same or other parts may exhibit the manifestation.

(These [oe]dematous swellings occurring alone might be looked upon, as they are by most observers, as an independent affection, but its close relationship to ordinary urticaria is often evident.)

#Describe urticaria bullosa.#

Urticaria bullosa is a variety in which the inflammatory action has been sufficiently great to give rise to fluid exudation, the wheals resulting in the formation of blebs.

#What is the etiology of urticaria?#

Any irritation from disease, functional or organic, of any internal organ, may give rise to the eruption in those predisposed. Gastric derangement from indigestible or peculiar articles of food, intestinal toxins, and the ingestion of certain drugs are often provocative. The so-called "shell-fish" group of foods play an important etiological part in some cases. Idiosyncrasy to certain articles of food is also responsible in occasional instances. Various rheumatic and nervous disorders are not infrequently associated with it, and are doubtless of etiological significance. External irritants, also, in predisposed subjects, are at times responsible.

#What is the pathology of urticaria?#

Anatomically a wheal is seen to be a more or less firm elevation consisting of a circumscribed or somewhat diffused collection of semi-fluid material in the upper layers of the skin. The vasomotor nervous system is probably the main factor in its production; dilatation following spasm of the vessels results in effusion, and in consequence, the overfilled vessels of the central portion are emptied by pressure of the exudation and the central paleness results, while the pressed-back blood gives rise to the bright red periphery.

#From what diseases is urticaria to be differentiated?#

From erythema simplex, erythema multiforme, erythema nodosum, and erysipelas.

#Mention the diagnostic points of urticaria.#

The acuteness, character of the lesions, their evanescent nature, the irregular or general distribution, and the intense itching.

#What is the prognosis in urticaria?#

The acute disease is usually of short duration, disappearing spontaneously or as the result of treatment, in several hours or days; it may recur upon exposure to the exciting cause. The prognosis of chronic urticaria is to be guarded, and will depend upon the ability to discover and remove or modify the predisposing condition.

#What systemic measures are to be prescribed in acute urticaria?#

Removal of the etiological factor is of first importance. This will be found in most cases to be gastric disturbance from the ingestion of improper or indigestible food, and in such cases a saline purgative is to be given, probably the best for this purpose being the laxative antacid, magnesia; or if the case is severe and food is still in the stomach, an emetic, such as mustard or ipecac, will act more promptly. Alkalies, especially sodium salicylate, and intestinal antiseptics are useful. Calcium chloride in doses of five to twenty grains should be tried in obstinate cases. The diet should be, for the time, of a simple character.

#What systemic measures are to be prescribed in chronic and recurrent urticaria?#

The cause must be sought for and treatment directed toward its removal or modification. Treatment will, therefore, depend upon indications. In obscure cases, quinine, sodium salicylate, arsenic, pilocarpine, _atropia_, potassium bromide, calcium chloride, and ichthyol are to be variously tried; general galvanization is at times useful, as is also a change of scene and climate. A proper dietary and the maintenance of free action of the bowels, preferably, as a rule, with a saline laxative, is of great importance in these chronic cases.

In acute circumscribed [oe]dema treatment is essentially that of urticaria, the diet being given special attention.

#What external applications would you advise for the relief of the subjective symptoms?#

Cooling lotions of alcohol and water or vinegar and water; lotions of carbolic acid, one to three drachms to the pint; of thymol, one-fourth to one drachm to the pint of alcohol and water; of liquor carbonis detergens, one to three ounces to the pint of water, or the following:--

[Rx] Acidi carbolici, ..................... [dram]j-[dram]iij Acidi borici, ........................ [dram]iv Glycerinæ, ........................... f[dram]j Alcoholis, ........................... f[Oz]ij Aquæ, ................................ f[Oz]xiv. M.

Alkaline baths are also useful, and may advantageously be followed by dusting-powders of starch and zinc oxide.

#Urticaria Pigmentosa.# (_Synonym:_ Xanthelasmoidea.)

#Describe urticaria pigmentosa.#

Urticaria pigmentosa is a rare disease, variously viewed as an unusual form of urticaria and as an urticaria-like eruption in which there is an element of new growth in the lesions. It begins usually in infancy or early childhood and continues for months or years, and is characterized by slightly, moderately, or intensely itchy, wheal-like elevations, which are more or less persistent and leave yellowish, orange-colored, greenish or brownish stains. Exceptionally subjective symptoms are almost entirely absent. Anatomical studies show that the lesion has in some respects the structure of an ordinary wheal, with [oe]dema and pigment deposit in the epidermal portion, and cellular infiltration made up principally of mast-cells.

The nature of the disease is obscure and treatment unsatisfactory. Ordinarily as early youth or adult life is reached it spontaneously disappears. The treatment advised is usually on the same lines as that of chronic urticaria.

#Dermatitis.#

#What is implied by the term dermatitis?#

Dermatitis, or inflammation of the skin, is a term employed to designate those cases of cutaneous disturbance, usually acute in character, which are due to the action of irritants.

#Mention some examples of cutaneous disturbance to which this term is applied.#

The dermatic inflammation due to the action of excessive heat or cold, to caustics and other chemical irritants, and to the ingestion of certain drugs.

#What several varieties are commonly described?#

Dermatitis traumatica, dermatitis calorica, dermatitis venenata, and dermatitis medicamentosa.

#Describe dermatitis traumatica.#

Under this head are included all forms of cutaneous inflammation due to traumatism. To the dermatologist the most common met with is that produced by the various animal parasites and from continued scratching; in such, if the cause has been long-continued and persistent, a variable degree of inflammatory thickening of the skin and pigmentation result, the latter not infrequently being more or less permanent. The inflammation due to tight-fitting garments, bandages, to constant pressure (as bed-sores), etc., also illustrates this class.

#What is the treatment of dermatitis traumatica?#

Removal of the cause, and, if necessary, the application of soothing ointments or lotions; in bed-sores, soap plaster, plain or with one to five per cent. of ichthyol.

#What is dermatitis calorica?#

Cutaneous inflammation, varying from a slight erythematous to a gangrenous character, produced by excessive heat (_dermatitis ambustionis_, _burns_) or cold (_dermatitis congelationis_, _frostbite_).

#Give the treatment of dermatitis calorica.#

In burns, if of a mild degree, the application of sodium bicarbonate, as a powder or saturated solution, is useful; in the more severe grade, a two- to five-per-cent. solution will probably be found of greater advantage. Other soothing applications may also be employed. In recent years a one-per-cent. solution of picric acid has been commended for the slighter burns of limited extent. Upon the whole, there is nothing yet so generally useful and soothing in these cases as the so-called Carron oil; in some cases more valuable with 1/2 to 1 minim of carbolic acid added to each ounce.

In frostbite, seen immediately after exposure, the parts are to be brought gradually back to a normal temperature, at first by rubbing with snow or applying cold water. Subsequently, in ordinary chilblains, stimulating applications, such as oil of turpentine, balsam of Peru, tincture of iodine, ichthyol, and strongly carbolized ointments are of most benefit. If the frostbite is of a vesicular, pustular, bullous, or escharotic character, the treatment consists in the application of soothing remedies, such as are employed in other like inflammatory conditions.

#What do you understand by dermatitis venenata?#

All inflammatory conditions of the skin due to contact with deleterious substances such as caustic, chemical irritants, iodoform, etc., are included under this head, but the most common causes are the rhus plants--_poison ivy_ (or _poison oak_) and _poison sumach_ (_poison dogwood_). Mere proximity to these plants will, in some individuals, provoke cutaneous disturbance (_rhus poisoning_, _ivy poisoning_), although they may be handled by others with impunity.

Many other plants are also known to produce cutaneous irritation in certain subjects; among these may be mentioned the nettle, primrose, cowhage, smartweed, balm of Gilead, oleander, and rue.

The local action of iodoform (_iodoform dermatitis_) in some individuals is that of a decided irritant, bringing about a dermatitis, which often spreads much beyond the parts of application, and which in those eczematously inclined may result in a veritable and persistent eczema.

#Describe the symptoms of rhus poisoning.#

The symptoms appear usually soon after exposure, and consist of an inflammatory condition of the skin of an eczematous nature, varying in degree from an erythematous to a bullous character, and with or without [oe]dema and swelling. As a rule, marked itching and burning are present. The face, hands, forearms and genitalia are favorite parts, although it may in many instances involve a greater portion of the whole surface.

#What is the course of rhus poisoning?#

It runs an acute course, terminating in recovery in one to six weeks. In those eczematously inclined, however, it may result in a veritable and persistent form of that disease.

#How would you treat rhus poisoning?#

By soothing and astringent applications, such as are employed in acute eczema (_q. v._), which are to be used freely. Among the most valuable are: a lotion of fluid extract of grindelia robusta, one to two drachms to four ounces of water; lotio nigra, either alone or followed by the oxide-of-zinc ointment; a saturated solution of boric acid, with a half to two drachms of carbolic acid to the pint; a lotion of zinc sulphate, a half to four grains to the ounce; weak alkaline lotions; cold cream, petrolatum, and oxide-of-zinc ointments.

#How would you treat the dermatitis due to other deleterious substances of this class?#

By applications of a soothing and protective character, similar to those used in eczema and burns.

#Dermatitis Medicamentosa.#

#What do you understand by dermatitis medicamentosa?#

Under this head are included all eruptions due to the ingestion or absorption of certain drugs.

In rare instances one dose will have such effect; commonly, however, it results only after several days' or weeks' continued administration. With some drugs such effect is the rule, with others it is exceptional, nor are all individuals equally susceptible.

#How is the eruption produced in dermatitis medicamentosa?#

In some instances it is probably due to the elimination of the drug through the cutaneous structures; in others, to the action of the drug upon the nervous system. The view that the drug acts as a toxin or generates some toxin or irritant material in the blood, to which the eruptive phenomena may be due, has also been advanced.

#What is the character of the eruption in dermatitis medicamentosa?#

It may be erythematous, papular, urticarial, vesicular, pustular or bullous, and, if the administration of the drug is continued, even gangrenous.

#Name the more common drugs having such action.#

Antipyrin, arsenic, atropia (or belladonna), bromides, chloral, copaiba, cubebs, digitalis, iodides, mercury, opium (or morphia), quinine, salicylic acid, stramonium, acetanilid, sulphonal, phenacetin, turpentine, many of the new coal-tar derivatives, etc.

#State frequency and types of eruption due to the ingestion of antipyrin.#

Not uncommon. _Erythematous_, morbilliform and erythemato-papular; itching is usually present and moderate desquamation may follow. Acetanilid, sulphonal, phenacetin, and other drugs of this class may provoke like eruptions.

#Mention frequency and types of eruption due to the ingestion of arsenic.#

Rare. Erythematous, erythemato-papular; exceptionally, herpetic, and pigmentary. Herpes zoster has been thought to follow its use. Keratosis of the palms and soles has also been occasionally observed, which, in rare instances, has developed into epithelioma.

#Mention frequency and types of eruption due to the ingestion of atropia (or belladonna).#

Not uncommon. _Erythematous_ and _scarlatinoid_; usually no febrile disturbance, and desquamation seldom follows.

#Give frequency and types of cutaneous disturbance following the administration of the bromides (bromine).#

Common. _Pustular_, sometimes furuncular and carbuncular and superficially ulcerative. In exceptional instances papillomatous or vegetating lesions have been observed. Co-administration of arsenic or potassium bitartrate is thought to have a preventive influence in some cases.

#State frequency and types of cutaneous disturbance due to the administration of chloral.#

Occasional. Scarlatinoid and urticarial, and exceptionally purpuric; in rare instances, if drug is continued, eruption becomes vesicular, hemorrhagic, ulcerative and even gangrenous.

#State frequency and types of eruption following the administration of copaiba.#

Not uncommon. _Urticarial_, erythemato-papular and _scarlatinoid_.

#Mention frequency and types of eruption resulting from the ingestion of cubebs.#

Uncommon. Erythematous and small papular.

#Mention frequency and types of eruption resulting from the administration of digitalis.#

Exceptional. Scarlatinoid and papular.

#State frequency and types of eruption resulting from the iodides (iodine).#

Common. _Pustular_, but may be erythematous, papular, vesicular, bullous, tuberous, purpuric and hemorrhagic. Co-administration of arsenic or potassium bitartrate is thought to have a preventive influence in some cases.

#Give the frequency and types of eruption observed to follow the administration of mercury.#

Exceptional. Erythematous and erysipelatous.

#Give the frequency and types of the cutaneous disturbance following the ingestion of opium (or morphia).#

Not uncommon. Erythematous and _scarlatinoid_, and sometimes urticarial.

#Mention the frequency and the types of eruption following the administration of quinine.#

Not infrequent. Usually _erythematous_, but may be urticarial, erythemato-papular, and even purpuric. There is, in some instances, preceding or accompanying systemic disturbance. Furfuraceous or lamellar desquamation often follows.

#State frequency and types of eruption resulting from the ingestion of salicylic acid.#

Not common. Erythematous and urticarial; exceptionally, vesicular, pustular, bullous, and ecchymotic.

#Give frequency and type of cutaneous disturbance due to the administration of stramonium.#

Not common. Erythematous.

#State frequency and types of eruption resulting from the administration of turpentine.#

Not uncommon. _Erythematous_, and small-papular; exceptionally vesicular.

#X-Ray Dermatitis.#

#What several grades of x-ray dermatitis (x-ray burns, Rontgen-ray burns) are observed?#

Three grades are usually described: erythema, superficial vesication, and necrosis. The first and second may come on shortly--a few hours to several days--after exposure; occasionally later. The third grade may present also in the first several days, but in many cases one to several weeks may elapse before it appears; it is quite commonly preceded by erythema and vesication. The necrosis may be superficial or deep, and quite usually results in a persistent ulcer covered by a leathery coating; it is usually painful.

#Give the prognosis and treatment of x-ray dermatitis.#

The first grade--the erythematous--usually disappears in one to ten days; the second grade requires one to several weeks, and may be quite sore and tender; the severe or necrotic burns are persistent, sometimes lasting for months and several years, with little tendency to spontaneous disappearance, and rebellious to treatment.

Treatment of the milder types is that of erythema (_q. v._); the necrotic type occasionally demands thorough curetting and skin-grafting before it will heal.

#Dermatitis Factitia.# (_Synonym:_ Feigned Eruptions.)

#What do you understand by feigned eruptions?#

Feigned, or artificial, eruptions, occasionally met with in hysterical females and in others, are produced, for the purpose of exciting sympathy or of deception, by the action of friction, cantharides, acids or strong alkalies; the cutaneous disturbance may, therefore, be erythematous, vesicular, bullous, or gangrenous. It is usually limited in extent, and, as a rule, seen only on parts easily reached by the hands.

#Dermatitis Gangrænosa.#

#What do you understand by dermatitis gangrænosa?#

Dermatitis gangrænosa (_erythema gangrænosum_, _Raynaud's disease_, _spontaneous gangrene_) is an exceedingly rare affection, characterized by the formation of gangrenous spots and patches. It may be idiopathic or symptomatic. Some of these cases, especially in hysterical subjects, belong under the "feigned eruptions," being self-produced.

As an idiopathic disease, it begins as erythematous, dark-red spots--usually preceded and accompanied by mild or grave systemic disturbance--which gradually pass into gangrene and sloughing; the eventual termination may be fatal, or recovery may take place. As a symptomatic disease, it is occasionally met with in diabetes and in grave cerebral and spinal affections.

In Raynaud's disease (symmetric gangrene) the parts affected are the extremities, such as fingers and toes, the ears and nose, only occasionally other parts. The first symptoms observed are coldness and paleness of the part; followed sooner or later by congestion of a dark red, livid, or bluish color, with sometimes swelling, and tenderness and shooting pains. The termination is usually in gangrene of a dry character, with, in some instances, vesicles and blebs along the edges; in other cases the parts become atrophied, withered, and indurated.

Treatment is based upon general principles.

#Erysipelas.#

#What is erysipelas?#

Erysipelas is an acute specific inflammation of the skin and subcutaneous tissue, commonly of the face, characterized by shining redness, swelling, [oe]dema, heat, and a tendency in some cases to vesicle- and bleb-formation, and accompanied by more or less febrile disturbance.

#Describe the symptoms and course of erysipelas.#

A decided rigor or a feeling of chilliness followed by febrile action usually ushers in the cutaneous disturbance. The skin at a certain point or part, commonly where there is a lesion of continuity, becomes bright red and swollen; this spreads by peripheral extension, and in the course of several hours involves a portion or the whole region. The parts are shining red, swollen, of an elevated temperature, and sharply defined against the sound skin. After several days or a week, during which time there is usually continued mild or severe febrile action, the process begins to subside, and is followed by epidermic desquamation.

In some cases vesicles and blebs may be present; in other cases the disease seriously involves the deeper parts, and is accompanied by grave constitutional symptoms. In exceptional instances sloughing takes place.