9. BULLOUS DISEASES AND ANOMALOUS FORMS OF BULLOUS ERUPTION


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….


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.

Herpes.

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 Labialis.

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.

Herpes Progenitalis.

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.

Melford Eugene Douglass
M.E.Douglass, MD, was a Lecturer of Dermatology in the Southern Homeopathic Medical College of Baltimore. He was the author of - Skin Diseases: Their Description, Etiology, Diagnosis and Treatment; Repertory of Tongue Symptoms; Characteristics of the Homoeopathic Materia Medica.