Under this head we include the diseases which are especially characterized by the occurrence of the bullae as primary and essential phenomena. A bulla is a large portion of the cuticle detached from the skin by the inter position of a transparent watery fluid. In fact, a bulla is a large vesicle. In the wide sense of the term several diseases are really bullous, such as erysipelas, herpes, pemphigus, rupia, eczema of the fingers, and impetigo contagiosa. But of these there are only two that really rank under the term bullous-i.e., herpes and pemphigus.
Erysipelas belongs to the class of zymotic diseases; rupia is always syphilitic, and of course it is grouped under that head; the bulla produced by the coalescence of vesicles in eczema is an accidental and secondary phenomenon; and in impetigo contagiosa, the primary stage is a vesicle and not a bulla, the secretion subsequently becoming sero-purulent, whilst the general behaviour and outward aspect of the disease are those of an impetigo. Besides, herpes and pemphigus are peculiar and like in regard to the influence of the nervous system in their production. Therefore, true bullous diseases, or those which are probably of neurotic origin, and in which the bullae are primary, with transparent contents, are herpes and pemphigus.
Herpes and pemphigus might have been placed under the head of neurotic diseases, but then many others must have been included, such as urticaria, pityriasis rubra, etc., with them, if we carried out the idea of collecting together under one head all those diseases which primarily originate in disturbance of the nervous system and arranged them upon a pathological basis. As we have classified diseases, however, clinically, we place herpes and pemphigus under the convenient but most unscientific term, “bullous inflammation,” because it is to changes implied by that term that the practitioner first directs his attention in the matter of diagnosis and treatment.
Some anomalous forms of eruption will be noticed at the latter part of this chapter.
The term herpes, used by itself, has little significance, but the expressions herpes zoster, herpes labialis, herpes progenitalis, etc., refer to definite and distinct affections. The first of these we will describe under the name of Zoster, but the other two will be considered here.
Herpes is an affection of the skin, characterized by the development of small clusters of vesicles, usually situated on a slightly reddened or inflamed surface, and in the immediate neighborhood of the mouth.
The vesicles appear unattended with any pain other than a slight burning or itching sensation, and last for a few hours or a day or two. They then rupture and give exit to a slight serous discharge, when they dry up and leave a surface which heals in a short time without scars.
Herpes labialis usually attacks children or women, but is not commonly met with in men. In frequently comes on as a sequel of a cold, or slight febrile attack, and on this account has received the names “cold sore,””fever sore,” etc.
There may be a single group of vesicles, or there may be several, each group containing four or five vesicles. The eruption may be confined to one side of the face, affecting either the upper or lower lip, or both, or just as frequently it may appear on both sides of the mouth. A true zoster may appear on the face and invade the same regions as herpes labialis, except that the eruption is almost invariably unilateral.
The local treatment of herpes labialis involves nothing more than a little absorbent powder, or a sedative lotion- a little camphor-water being a favorite application.
The internal treatment will be taken up in the next article.
The term herpes progenitalis includes the herpetic affections of the genital organs of both sexes, and, when occurring in the male, is called herpes preputialis, and in the female herpes preputialis, and in the female herpes vulvaris.
Herpes preputialis most frequently occurs in young men between the ages of 20 and 40, and is not often met with as a first attack after that age. The vesicles may form on both the cutaneous and mucous surfaces. Owing to the anatomical situation of these parts, and to the friction to which they are more or less subject, the vesicles last for but a few hours only, breaking and giving rise to superficial erosions, which from neglect or uncleanliness may run into slight ulceration.
In herpes vulvaris the lesions may be upon the labia majora or the labia minora, or upon the prepuce of the clitoris, running the same temporary course as the other varieties of the affection.
Herpes progenitalis is not usually accompanied with much pain, unless the parts are subjected to undue friction. As in the male, herpes of the female organs is most frequently met with between the ages of 20 and 40. A single attack lasts for a few days only, but with many patients herpes proves to be a relapsing affection, and causing on this account serious inconvenience to those who are subject to it. In men, relapses my occur after almost every act of sexual intercourse, but curiously is much less frequent in married men than in those who indulge promiscuously and at irregular intervals only. In women of the town the affection is by no means uncommon, but is very rarely met with in married women or virgins, except when the attacks coincide with menstrual periods.
In this connection I will quote from an article in the Journal, Cutaneous and Veneral Diseases, August, 1883, where Dr. Unna reports his experience. He has meet with 200 cases in the female. He says: “In France, where prostitution is under surveillance, and where excellent syphilographers abound, herpes progenitalis early attracted attention and was ascribed to an unnatural irritation of the sexual organs to which prostitutes are subject. Venereal diseases cannot be the cause, for in married women suffering from syphilis or gonorrhoea herpes is not found. In prostitutes, herpes occurs as often in those without as those with syphilis. Acute and chronic blennorrhoea often exist as factors in the development of herpes progenitalis, by the congestion of the parts which they induce. There are prostitutes who have an attack of herpes every time they menstruate.
Less frequently pregnancy and the puerperal state induce a disposition to herpes progenitalis. Bruneau must be given credit for having shown that in women suffering with chronic metritis, cervicitis, etc., every herpetic eruption is preceded by increased sensibility and signs of heightened congestion of the pelvic organs. While the vesicles are still intact, the diagnosis is easy. The vesicles are yellowish, translucent and arranged in clusters. When the epidermis has given way, the surface crusted over, erosion present, the surface must often be first carefully cleansed before we can say whether the disease be a superficial wound, a burn, eczema, chancre or herpes. Herpetic erosions are all well defined and of a bright reddish hue. They are discrete, coalescent or confluent. In any case, the sharply defined contour and crescentic arrangement make herpes easy of diagnosis. The parts most liable to this affection, in order, are the labia minora, prepuce of the clitoris, labia majora, introitus vagina, and caruncula myrtiformes. The disease may be unsymmetrical when such organs as the prepuce of the clitoris, perineum, etc., are attacked. Pain usually precedes the eruption by several days.”
The etiology of herpes progenitalis is obscure, and no adequate explanation has yet been given to account for the attacks.
Diagnosis-The diagnosis of herpes progenitalis presents little difficulty, but care should be taken to distinguish it from mechanical abrasions and from contagious venereal lesions.
The treatment of this affection is simple. As a rule, nothing more is required than a little dressing-powder, or a sedative lotion; and if the parts are left at rest the erosions will be covered with new epithelium in a few days. Should ulcerations have occurred, they may be lightly touched with the solid nitrate of silver, and small pieces of linen may be placed between folds of mucous membrane that are lying in contact. These should be frequently changed, and the parts kept clean with warm water and soap.
When the affection assumes the relapsing form, patients will go from one physician to another, seeking a permanent cure, which we regret to say they will rarely attain until they reach the age at which the trouble tends to disappear spontaneously.
The internal treatment and the indications for the remedies are as follows.
Aconite-In the earlier stages with catarrhal fever.
Agnus castus-Herpes on the cheeks with gnawing itching, worse from getting wet.
Alnus rubra-Chronic herpes.
Apis mel-Large confluent vesicles; burning stinging pains; vesicular eruption on the lips; cold sores.
Arsen. alb-Red herpetic skin around the mouth, with burning, worse from scratching and after midnight. Herpes iris.
Aurum mur-Herpes on the prepuce and vulva. Herpes accompanied by intolerable itching.
Bufo-Herpetic eruption after a cold.
Causticum-Burning vesicles under the prepuce, which become suppurating ulcers. Burning vesicles on the face which, when touched, exude a corrosive water, afterward they dry up to a scurf.
Cantharis-Large, burning painful blisters with erysipelatous inflammation of the parts. Burning, tearing ulcerative pains, worse on the right side. Urinary complications.
Clematis-Itching blisters on the lower lip. Gnawing itching not relieved by scratching. Worse during increasing, better during decreasing moon.
Graphites-Herpes in females with scanty menstruation; burning blisters on the lower side and tip of the tongue; dryness of the skin.
Hamamelis-Herpes on the nose. Profuse epistaxis.
Helleb. nig.-White vesicles on the lips; aphthae in the mouth; in scrofulous children.
Hepar-Herpes which tend to recur; herpes on the prepuce, exceedingly sensitive to the touch; small ulcers form around the large one; unhealthy suppurating skin, after mercurial poisoning.
Kali bich.-Herpes after taking cold; fluent coryza; all the secretions are a of stringy and ropy character.
Mercurius sol.-Herpes on the prepuce with a tendency to suppuration; ulcers on the glans; itching of the genitals.
Moschus-Herpes, with excessive burning, in hysterical subjects; menstruation too early and too profuse.
Natrum mur.-Herpes occurring during fevers; eruption on the lips and flexures of the joints; vesicles on the tongue; itching and pricking in the skin.
Petroleum.-Herpes on the perineum and genitals; itching worse in the open air.
Rhus tox.-Herpes upon the hairy parts with burning and stinging; itching worse after scratching; rheumatic pains with great weariness.
Sepia- Herpetic eruptions around the lips; herpes during pregnancy; circular form of epilepsy.
Sulphur-Herpes about the mouth and nose with itching and burning, aggravated by warmth. Hot palms and soles.
Sarsaparilla-Herpes on the prepuce; after abuse of mercury.
Upas-Herpetic eruption on the upper lip, on the left side.
Zoster is an acute affection characterized by the development of one or more groups of large-sized vesicles. When there are several of these groups, it will be noticed that they are arranged along the course of one of the larger nerve-trunks whose filaments are distributed to the skin.
The most frequent and perhaps the most typical seat of the eruption is on the chest, where it may form a semigirdle corresponding to the area supplied by one of the intercostal nerves. Zoster, however, is by no means confined to the thoracic region, but may appear on the abdomen, the face, in connection with the trigeminal nerve, on the shoulders and arms, and on the thighs and legs.
The eruption may or may not be preceded by prodromal symptoms, which may partake of a mild febrile attack of one or two days’ duration, or, instead, of a more or less severe neuralgia, without fever; or neither of these phenomena may be present, the eruption itself being the first indication of the affection.
Each group or patch of vesicles may consist of from four or five to a dozen separate, non-confluent lesions situated upon a reddened, raised, and inflamed base. Occasionally the vesicles themselves may be absent, and nothing is to be seen except the circumscribed reddened patch. The several groups of vesicles constituting the typical eruption do not usually appear at the same time, but the patches may appear in succession, so that several days may elapse before all the lesions have developed.
The eruption having appeared, is accompanied with more or less pain of a neuralgic character, together with some soreness of parts if the vesicles rupture. As a rule, the lesions remain intact until after a week or so, when the fluid contents become absorbed, and the uplifted epidermis desquamates, leaving a reddened macule, or in some cases a small cicatrix, to mark the site of the lesion.
A striking peculiarity of zoster is the fact that it is strictly unilateral (with exceedingly rare exceptions). Cases of double zoster, in which both sides of the body have been involved at the same time, have been reported. Another feature of this affection is the extreme rarity or second attack, resembling in this respect the eruptive fevers.
The neuralgia which precedes or accompanies zoster may exhibit any degree of severity, and may indeed persist for an indefinite period after all symptoms of cutaneous irritation have disappeared. Instead of neuralgia, a more or less intense pruritus may be present, confined to the affected region, and persist for a long time.
As a rule, zoster is an affection of little gravity-that is, in persons who when attacked are in ordinary health. In those, however, who are aged or feeble, the prognosis is not always so favorable, as the vesicles may be followed by more or less severe ulceration. When the eruption appears on the head, and especially in connection with the branches of the trigeminus that are distributed to the eye ulceration of the cornea, and even destruction of the sight, may ensue.
Etiology-It has been very clearly demonstrated that the majority, if not all cases, of zoster appear in connection with irritation or inflammation of the ganglia attached to the roots of the sensitive nerves; but what sets up this primary irritation is not always clear. Zoster has been known to appear, after exposure to cold, in connection with pleurisy, after traumatisms, and after the internal administration of arsenic. Quite recently bacilli are said to have been found in the inflamed ganglia, but how they got there does not appear very clearly.
M.Fere reports four cases of herpes zoster, which occurred nearly contemporaneously among his 150 epileptic patients at the Bicetre. The first was a young man of nineteen, who had had a few violent epileptic attacks without any unilateral symptoms. The herpes was confined to the left side of the thorax and the left side of the face, and along with it he had some spasms of the left side of the face, and along with it he had some spasms of the left corner of the mouth, illusory impressions of persons approaching him from the left side, and some contractions and sluggishness of the left pupil.
The left side of the tongue also was much more thickly furred than the right. The temperature ran up to 107 degree F. at first, but all the morbid symptoms gradually subsided in a week. In the three other cases, in middle-aged men, the most prominent symptom was severe pain, with tenderness on pressure, down the spinal column. M.Fere is led to conclude from these and similar observations that the most probable cause of the herpetic eruption is a slight epidemic cerebro-spinal meningitis, which may be widespread, but perhaps only of sufficient irritative power to cause th herpes at the root of one or two nerves. Such a pathological condition would not be surprising in infectious diseases, for in them some forms of meningitis are not rare.
Zoster may follow influenza; Dr.Finzi reports a case in a girl of fifteen, who after recovering from severe attack of influenza, was seized with neuralgic pain, accompanied with a pricking and burning sensation shooting from the back around the right side. On being seen five days after, a chain of herpetic vesicles was found extending along the seventh intercostal space, the lymphatic glands in the axilla being swollen and tender, and pressure along the course of the seventh intercostal nerve, making the patient scream with pain. In from eight to ten days the vesicles disappeared, the whole duration of the symptoms having been about a fortnight.
Another case is reported of a case of zoster corresponding to the eighth intercostal nerve of the right side in a girl of eighteen, in whom the disease appeared at the beginning of an attack of influenza and lasted a mouth.
The writer had a case occurring in a girl of twelve corresponding to the eighth intercostal nerve of the left side, in which the eruption made its appearance three days after the beginning of an attack of influenza of severe form, and the eruption lasted two weeks.
Treatment-The chief indications are to preserve the integrity of the vesicles until their contents are absorbed, and to give relief to the neuralgic pain. We may attempt to carry out the first by the application of several coats of flexible collodion, or traumaticin, or we may brush the lesions over with oil, and then cover them freely with some indifferent dusting- powder. The neuralgia is to be treated exactly in the same way as if it were not accompanied with the vesicular lesions.
Zoster of the mucous membranes is not an infrequent affection. Three cases are reported in which the region supplied by the trigeminus was affected. In one of the cases the vesicles were located upon the mucous membrane of the left cheek; in the second case upon the conjunctiva of the right eye; and in the third case on the left half of the tongue.
The galvanic current, from four to eight cells of a battery of ordinary strength, has been found very beneficial if the pain is sharp, when applied from fifteen to twenty minutes daily. The principal internal remedies and their indications are as follows.
Aconite.-In the earlier stages, when the the neuralgic pain is accompanied by febrile symptoms.
Apis.-Burning and stinging pains with swelling; large vesicles, sometimes confluent; better from cold applications.
Arsen. alb.-Confluent eruption with intense burning of the blisters; worse after midnight, and from cold applications; neuralgia; in debilitated constitutions.
Cantharis.-Large blisters, burning when touched; smarting and stinging; mostly on the right side; worse in the open air.
Cistus.-Zoster on the back;neuralgic symptoms; in scrofulous subjects.
Comocladia.-Zoster on the legs; rheumatic pains aggravated by rest; relieved by motion.
Dulcamara.-Zoster after taking cold from damp air, moist, suppurating eruption; glandular swellings in neighborhood of eruption; eruption precedes the menses.
Graphites.-Zoster on the left side; large blisters from the spine to the umbilicus, burning when touched; worse indoors; better in the open air; dry skin, tendency to ulceration; in blonde individuals inclined to obesity.
Iris vers. -Zoster, especially on the right side; following gastric derangement; pain in the liver; neuralgic pains.
Kali mur.-Zoster;vesicles encircling half of the body like a belt; white tongue
Kalmia lat.-Facial neuralgia remaining after zoster; worse at night; palpitation of the heart; rheumatic pains.
Lachesis.-Zoster during spring and fall; the vesicles turn dark and are very painful; all symptoms are worse after sleep.
Mercurius.-Zoster on the right side, extending across the abdomen;worse at night, from the warmth of the bed; tendency to suppuration; easy perspiration without relief.
Mezereum.-Zoster in old people; constant chilliness; neuralgic pains; worse at 9 p.m.; burning, changing location after scratching; in scrofulous persons.
Natrum mur.-Eruptions occurring through the course of any disease.
Peppermint Oil, when applied locally, rapidly allays the pain of zoster.
Prunus spinosa has succeeded in removing the very troublesome neuralgic pain which often remains when the eruption of shingles has disappeared, by means of Prunus spinosa 30x.
Ranunculus bulb-Zoster aggravated by change of temperature; neuralgic sequels; in rheumatic subjects.
Rhus tox.-Burning and stinging pains aggravated by scratching. Small burning vesicles with redness of the skin; confluent vesicles; worse in cold weather; rheumatic pains during rest; sleeplessness with restless tossing about; zoster brought on by getting wet, while over-heated.
Sempervivum tect-In obstinate cases; may be used internally and locally.
Thuja.-Zoster with eruption only on covered parts; better from gentle rubbing, in individuals of lymphatic temperament.
Zincum.-Neuralgia following zoster; pains relieved by touching the parts; worse after dinner and towards evening.
Zincum Phosphorus-When other remedies fail; following brain-fag in literary persons.
Under this name a number of widely varying diseases have been described and one of the earlier writers, mentions upward of a hundred varieties of the affection. We will confine the name to a single disease, embracing but two varieties-namely, pemphigus vulgaris and pemphigus foliacea.
In Childhood two forms are observed; pemphigus acutus neonatorum, appearing during the first two weeks. The whole body is covered with bullae, some of the size of a hazel nut, and its course usually benign. A second form stands in close relationship to acute exanthemata.
In general pemphigus is characterized as regards eruption by the appearance of little separate blebs, usually grouped in threes or fours, seated upon slightly inflamed bases, which are quickly covered over by the enlarged bullae. These blebs may attain a size varying between that of a pea and hen’s egg. They are distended with fluid, which is at first very transparent, but soon becomes milky. The fluid may be quickly re-absorbed, or the blebs or bullae simply shrivel, the distended globe becoming flaccid. Very often the blebs burst in a few days, and then the contained fluid dries into crusts of lamellar aspect, beneath which is very slight ulceration. The contents are sometimes sanguinolent.
The bullae generally occur in successive crops; they develop in the course of a few hours; their outline is generally round or oval; they may be confluent, but are usually distinct. Now and then a species of false membrane is contained in the bullae. The reaction of the fluid is generally alkaline, but with the turbidity comes acidity. The local symptoms are, slight itching and smarting at the outset, and more or less soreness. The healing, process in pemphigus is sometimes tardy, a thin ichor being secreted by the surface originally blebbed, and so a quasi-impetiginous crust is often produced. In rare cases, in cachectic subjects, sloughing may occur. The disease attacks all parts of the body-but rarely the hand, the palms of the hands, or the soles of the feet. Sometimes the mucous surfaces- for example, the intestines, vagina, etc., are the seat of bullae in pemphigus.