Under the head of local dermal inflammations we include those diseases which partake essentially of the nature of local diseases, and are characterized by inflammation, as the primary and the essential phenomenon. By inflammation we understand not merely hyperaemia, with engorgements of the affected parts by blood, so that the parts are swollen and red and hot, not only hyperaemia, with stasis in the vessels and serous effusion in addition; but also an increased activity in the tissues themselves outside the vessels, and the formation of new products, or “inflammatory exudation,” to use a commonly employed term.
The character and source of these new products are important items in this matter of inflammation. As regards the character of the new products, its typical features, and ultimate destination in marked cases are those of pus. Pus, in fact, is the highest grade of inflammatory products, but pus is not necessarily formed, and it is held that the new products may give rise to the production of a tissue-like connective tissue. Pus is derived from two sources-namely, from white blood cells, and also from connective-tissue corpuscle. There are three leading changes observed in inflammatory exudation-resolution, organization, and suppuration.
The local inflammations we are about to consider are generally characterized by hyperaemia and the presence of inflammatory infiltration. They are the erythemata; eczema, or catarrhal inflammation; that form which commences as serous catarrh of the papillary layer, and is followed by the outpouring of sero-purulent discharge, as in catarrh of the mucous membrane; plastic or papular inflammation, in which the inflammation is characterized as much by the absence of serous as by the deposit of fibrinous exudation: suppurative inflammation; and lastly, hyperaemia, accompanied by excessive formation of epithelial and certain cell growths in the papillary layer, conveniently termed squamous inflammation, as in psoriasis.
Two of these groups or classes might be separated from inflammation perhaps, and dealt with as hyperaemias solely, and these are the first and the last of the above named. In the former there is hyperaemia and serous exudation, as in erythema; but what is the important things to notice in relation to the point under discussion, there is no cell proliferation or cell infiltration in the tissues. If the hyperaemia is persistent then there follows in due course hypertrophy. To avoid, however, making another group in classification I have grouped the erythematous diseases under the head of local inflammations. With regard to “squamous inflammation,” there is here only hyperaemia and hyperplasia or hypertrophy, and no actual inflammatory infiltration. Psoriasis, the type of the class, is on the borderland only of inflammation; but we will group it under inflammations for the present at all events.
The reader will very naturally want to be told wherein lies the differences between hypertrophy and hyperplasia following hyperaemia, on the one hand; and the changes that occur in the skin in zymotic diseases, and those that are observed in lupus, syphilis, and leprosy on the other hand; and what are the differences that lead dermatologists to make the special class of disease to be dealt with in this chapter. In the first place, with regard to the local changes in the zymotic diseases- as small-pox and typhoid-these are only parts of general malady, and could not be regarded in group characterized essentially by peculiarities of local change. From an etiological point of view it would be impossible to do so.
Then, in regard to lupus, syphilis, etc., there are certain anatomical characters and behaviors about the growths, which, no less than peculiar concomitants of associated constitutional states and the like, that mark them as belonging to a special class of neoplasmata or heterologous new formations. In regard to the distinction to be drawn between hyperplasia consequent on inflammation, and hypertrophy, the latter is much slower, even if the etiology be left out of view; there is in the one the escaped blood cells developing into the new tissue, and in the other the increased supply of blood and transuded serosity.
But the two have certain analogies, and it is difficult if not impossible to draw line between hypertrophy and inflammation. But further, it may be said- and this applies to tumors and special neoplasms, and lupus and syphilis- whilst the inflammatory infiltration is caused by some irritant, the tumor of heteroplastic neoplasm arises spontaneously, or from a specific cause acting generally and modifying heat, redness, pain, and swelling, and these “signs” acutely developed; there is less tendency to spontaneous cure with tumors; and lastly, the inflammatory exudations directly tend to the formation of pus.
The diseases which rank under this head as having simply erythema as their primary and only feature are exceedingly simple and well defined. They are three; erythema, roseola, and urticaria. These erythemata re characterized mainly by the occurrence of active hyperaemia of the longitudinal plexus of the skin (erythema), and its immediate consequences- for example, serous effusion- nothing more. In erythematous disease the redness my be rosy roseola), or bright red (erythema urticaria); in urticaria “wheals” are present. The erythema in these diseases is removable by pressure. Unlike the more common eruptive diseases of the skin, the erythemata exhibit the closest connection between local and constitutional phenomena. Febrile symptoms antecede and are relieved by the development of the erythema in the exanthemata, showing that the local skin changes are secondary, and only parts of a general disturbance which is primary. I shall include under this head sections of follicular hyperaemia, pellagra, and certain medicinal rashes.
The term erythema, used by itself, is the name of a symptom, not of a disease, and may be applied to any reddened or congested surface not accompanied with elevation, and may be produced by a variety of causes. There are, however, two well-marked affections, erythema multiforme and erythema nodosum, which are distinct morbid entities, and deserve careful consideration.
The eruption of erythema multiforme is a diffused patch of redness over which circumscribed elevations, also red, are scattered. These elevations may be from an eighth to three- quarters of an inch in diameter. The small ones, according to size, may be called papules or tubercles, while the larger ones, which are always flattened, may assume the appearance of an elevated ring, around which a second or a third ring may develop. On the flattened tubercles, of medium size, vesicles are sometimes met with, and hemorrhagic effusions may also occur within them.
These lesions rarely persist for more than a few days, or at most a week or so, art the end of which time they gradually subside and disappear, leaving after them slight stains, which last a few days longer. After the disappearance of the first eruption, or even while it is still in full bloom, a second crop of lesions may come out, and after these a third, prolonging the trouble in this way for several weeks and even months. Two or more of the lesions mentioned may coexist, and the eruption may appear on any part of the surface, but as a rule it prefers the extremities. Slight febrile action may precede the development of the eruption, but it soon disappears, and there is rarely any accompaniment other than slight itching.
The causes of erythema multiforme are obscure; occasionally it appears due to errors of diet, and sometimes also to uterine disorder. The prognosis is favorable, so far as any trouble may result from the eruption; but when it is prolonged for weeks, as is sometimes the case, it proves very annoying. It attacks by preference the backs of the hands and feet, the arms, the legs, and the forehead. It is mostly an affection of children and young people. It attacks females more than males, and prevails in the spring and fall. Individuals who are troubled with it one year are apt to have it again at the same time in succeeding years. When occurring on the fingers it closely resembles chilblains. It may be commonly known by its superficial and protean character, and its symmetrical distribution.
This is a much more important but also rarer affection than the preceding one. The disease is characterized by the eruption of reddish tumors, from the size of bean to that of a small egg, and usually situated upon the lower extremities, between the knee and ankle. For a day or two the depth of color increases, then becomes somewhat purplish, and with the “black-and-blue” appearance which accompanies hemorrhagic effusions, and finally passes into the stage of green and yellow like an ordinary bruise. A week or ten days may be occupied by these processes; and, as the color changes, diminution of size takes place, and in about two weeks complete resolution is effected. Suppuration very rarely occurs. The number of the nodes is usually limited to three or four, but may reach nine or ten, and may appear on the thighs and upper extremities as well as the parts already named. The swellings are usually a little painful for the first day or two, but not afterward. Relapses may prolong the disease for several months. Occasionally the eruption is ushered in by febrile action, but not in all cases. It usually occurs in young females, and is not unfrequently accompanied by menstrual derangement. In many cases, however, the eruption is preceded by or complicated with arthritic pains. This has led many writers to believe the affection to be more or less closely connected with rheumatism.
The disease is self-limited, requiring no special treatment other than sedative applications to the affected parts.
In erythema multiforme the allopaths claim that “Unless the cause of the affection be discovered, little need or can be done in the way of treatment, and the affection may be left to run its course, which it will usually do in two or three weeks, and may not return until the following season, for in some persons this disease appears to affect a predilection for the spring and autumn months, returning annually at one or the other of these seasons.”
TREATMENT- When there is much itching and burning either a carbolic acid or veratrum viride lotion may be used. When the opposing surfaces are much inflamed they may be protected by dusting with buckwheat powder, or equal parts of starch and zinc oxide. Especial attention should be paid to cleanliness, and all irritants should be removed. Poultices are apt to do more harm than good, and better be avoided. Particular attention must be paid to the diet; such food as corn-flour, maizena, and the like must be forbidden, and proper nutritive substitutes be given to children in conjunction with suitable quantity of milk.
In the erythemata dependent upon general causes you must always remember the effect of ingesta; that a gouty or rheumatic habit, disordered menstrual function, dentition, delicacy of skin, or lymphatic temperament, are present in greater of less degree. It is important to allow the patient the use of an unstimulating diet only, to forbid him spirits, wine, and beer, to clear out the bowels, and in the early stage to adopt a soothing regime, with tepid sponging and emollient baths.
Bed-sores are best treated by attempting to “harden” the skin in the early stage by spirit applications, removing pressure as much as possible at later stages by pads, cushions, and water- beds, and by using charcoal poultices or soap plaster spread on soft leather to the sores. For chilblains, equal parts of turpentine and tincture of Aconite, and soap liniment, together with the indicated remedy, constitute the best treatment.
The internal remedies for erythema are;
Aconite-Erythema excited by the action of the sun’s rays.
Aethusa-Appearance and disappearance of reddish-blue spots on the trunk and left leg. General malaise.
Ailanthus-Irregular spots of capillary congestion. Dark almost livid eruption on the forehead.
Arsenicum iodide-Erythema, especially of the face.
Belladonna-Inflamed red patches. Irregularly-shaped scarlet spots over the body. More on face and upper part of body.
Berberis-Mottled spots as after bruise on the right shoulder, left humerus, back of the hand and wrist.
Bryonia-Red round hot spots on the malar bone, as large as peas.
Cadmium sulph-Red spots on the extremities.
Chelidonium maj-Round red spots, size of a half dollar, accompanied with burning pain, on anterior surface of the forearms and face, disappearing in a few hours.
Chloral hydrate-Bright red or bluish erythema over the whole body, permanent under pressure, mottled with livid patches and deep red spots. Pruritus of the whole skin.
Crocus sat-Circumscribed red spots on the face, which burn.
Condurango-Erythematous blotches on the face and arms.
Gelsemium-Papulous eruption on the face resembling measles.
Gossypium-Round little spots with pale red circles around the knee caps and over the shin bones, which itch very much.
Lactic acid-Several bright red blotches on the anterior surface of the leg, with slight burning and no itching. Relieved by cold. Eruption brightest at 8 A.M.
Laurocerasus-Erythematous patches, terminating in dark red purple spots.
Mercurius sol-Light red patches on the forearm and inner side of the thighs. Itching changed to burning by scratching.
Mezereum-Erythema on the legs in old people.
Nux vomica-Pimples on the face with itching, burning after drinking wine or alcoholic liquors.
Phytolacca-Painful erythematous blotches of a pale red color.
Pulsatilla nut-Erythema of the scalp. Dark blue or red eruption on the legs and ankles.
Rhus tox.-Ridges on the lower limbs.
Sabadilla-Red streaks on the arms. Worse from cold.
Ustilago-Fine eruption of a deep red colour, about the size of a pin’s head, appearing on any part of the body after scratching. On the neck it takes a circular form.
Mr. M., a very large and fleshy man of exceedingly good habits and with no history of specific trouble, presented himself for a long standing and obstinate erythema. The case had been prescribed for under nearly every conceivable diagnosis, the majority of physicians claiming it was due to syphilis. During a fishing expedition, some years ago, he thought he had been poisoned while in bathing, and since that time he has been exceedingly troubled with this persistent local inflammation. His unusual flesh had been a constant irritant, and being obliged too work for his living he had almost despaired of recovery.
In the folds of his right groin and extending back between the nates an immense phlegmonous surface was visible. So long had it existed that fissures and ulcerations, and excessive secretions of sweat and pus had complicated what might have been a short enduring, and simple sore. A rash, like measles, extended over the surrounding healthy skin. Extreme local itching and general aching pains made him exceedingly restless. These symptoms were always worse after midnight and during wet or cold weather.
With these indications he was given Rhus tox. 30 four times daily for a week. He was directed to use a local wash of warm water and lanoline soap, being careful to wipe the parts to perfect dryness. He was then to use a dusting powder to aristol and wear an abdominal supporter to relieve any chafing. In four weeks he was entirely well.
It is important to know this disease-not so much because it gives rise to any anxiety or trouble, as that it is likely to be confounded with measles and scarlet fever. Roseola is not generally considered to be a contagious disease, but rather occurs in an epidemic form. The eruption is preceded by some febrile symptoms; the rash is not much raised above the level of the surrounding part, and is of a rose color. It is in fact an erythema of a rosy hue. The eruption is patchy, and its color deepens somewhat as the disease advances. It is accompanied by slight itching and sensation of heat. Before the eruption makes its appearance and during the slight febrile symptoms, a slight redness of the mucous surfaces of the palate and fauces will be noticed on inspection of these parts. When not epidemic, roseola seems to depend chiefly upon derangements of the digestive apparatus as a producing cause, though it may likewise be due to sudden changes of temperature, violent exercise, taking cold drinks while the body is warm and perspiring, etc.
The eruption may appear suddenly during the night, and cover the entire body with its rose-colored patches, situated closely together, yet distinct.
Roseola is divided into two groups, Idiopathic and Symptomatic. In the latter group the roseola occurs as an accidental phenomenon in the course of acute diseases, and hence is called symptomatic; in the other group it exists as the sole and primary disease.
Idiopathic Group-Roseola infantilis is the name given to roseola when it is seen in infants. It roughly resembles measles minus the catarrh; it runs an irregular course as regards precursory symptoms, which vary in degree, and in the extent, degree, and seat of eruption. It may be quite general but patchy, or it may be limited to the arm, or the neck, or trunk; the rose blushes often come and go for several days capriciously, and are accompanied by local heat and itching, which are often marked at night. No catarrhal symptoms, as in measles, are present. The redness generally lasts a dozen or more hours.
When the disease assumes the form of rings (and this is generally observed about the buttocks, thighs, and abdomen), developed from little rose spots, and enclosing presently a healthy circle of skin an inch or so in diameter, the variety R. annulata is present. The concomitant symptoms are the same as those of the common form. It is not necessary to make all the varieties of roseola that are made by some authors.
The Symptomatic Group contains roseolas which are merely rosy erythmata developed in the course of acute diseases, generally appearing about the arms, breast, and face, thence spreading over the body. R. vaccinia coexists with the formation of the vaccine vesicle, and is accompanied by slight fever. It commences around and about the seat of the vaccination. In cases of fevers, about the tenth day or so, and indeed whenever the weather is very warm, the perspiration is apt to distend the sweat glands, which become more or less hyperaemic, so that little vesicles form, for example, miliaria and sudamina. Sometimes red blushes accompany this particular kind of vesicular eruption, and to these rosy blushes the name R. miliaris has been given.
After surgical operations a rash like scarlet fever very frequently occurs; its color varies somewhat; it is not contagious, and is without the general symptoms, the throat complication, hot skin, quick pulse, and tongue of scarlet fever. It is due, doubtless, to some volatile poison free in the blood. It has no gravity.
The Prognosis offers no point of gravity or interest.
The Diagnosis-Roseola is likely to be confounded with rubeola, scarlatina, urticaria, erythema. It is known from measles, in that it possesses no catarrhal symptoms; in that there is no relation between the febrile symptoms and the amount of eruption; in that there is no epidemic influence at work in its production; in that it is irregular in its distribution, non-crescentric, not uniform, not dark-colored; but irregular, rosy, and often commencing in other parts than the face. Rubeola has a regular course, and is not partial in regard to the distribution of its accompanying eruption.
It makes very little difference if roseolas be confounded with erythema, for the one is a red, the other is a rosy erythema.
In Scarlatina, the general aspect of the disease is grave; the fever is marked, the throat is bad, the tongue is peculiar; the skin harsh, dry; the rash general, punctiform, boiled-lobster like. The progress is more uniform, and the disease can be traced to contagious or epidemic influence.
In Urticaria, the diagnosis is at once settled by the discovery or production of a wheal, and the peculiar stinging character of the local irritation, with the capricious character of the eruption.
Treatment-The benign and self-limiting nature of the disease leaves but little need for work under this head. The old-school advise giving salines, aperients, laxatives, etc., and treating any special symptoms. Locally, in removing all causes of irritation-for example, irritated and tender gums, by lancing; acidity of stomach, by magnesia, soda or lime-water; intestinal irritation, by “alternatives,” such as rhubarb, and subsequently tonics, keeping up the warmth of the surface, and if possible, bringing on perspiration. The surface should not be chilled. The patient should be kept within doors for a few days, and have a warm bath at bed-time, followed by cutaneous frictions with oil; the diet should be light and non-stimulating.
Belladonna is the principal internal remedy. Ferrum phos, is highly recommended by some physicians. Large doses of antipyrine produce an erythematous eruption which is cinnabar-red in color, slightly elevated, and consists of rounded spots, disappearing under pressure. At the knees and elbows are found great red patches, chiefly on the extensor surface. The head, palmar and plantar surfaces are not affected.
Urticaria is an affection of the skin characterized by the development of white or reddish elevations termed wheals, which are accompanied with more less pruritus. These wheals may be few and localized, or, more frequently, they exist in considerable number, and are generalized.
Not infrequently a little heat and itching first appear; and, if the part be rubbed or scratched, the wheals become manifest. The elevations may last for a few minutes only or for a few hours, and disappear, leaving no trace behind. Later in the day, or perhaps the next day, a renewal of the eruption occurs, and these may be repeated for a few days or persist for months, constituting a chronic urticaria.