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ECZEMA*

BY J. M. KING, M. D., OF NASHVILLE, TENN.

In presenting this subject I shall consider, first, the pathological changes found in the diseased parts with their clinical aspect; second, the causes of these changes or of eczema; and third, the principles governing the treatment of the different stages.

Eczema is an inflammation of the upper part of the corium accompanied by the ordinary signs of inflammation. The increased blood flow to the part, and the different degrees of exudation following it are the immediate causes of the different clinical types of eczema, of which there are three primary and two secondary.

The erythematous type is one in which the exudation effects very slightly the cells of the epidermis; the cells are not bathed and softened by the serum, and separated from each other, as is the case in the more developed weeping types.

The surface is red, hot, and dry, and the epidermis is intact, and on account of increased nutrition there is a slight impetus given to the development of all the tissues, thus producing an increased mitosis of the rete cells, which is followed by a more abundant scale formation on the surface, and a slight hyperplasia of the structures of the corium. Swelling to some extent usually accompanies this type, and scratching and rubbing may produce weeping areas.

In the papular type the changes found are more exaggerated than those in the erythematous. The epidermis is more involved, inasmuch as papules are formed by increased exudation in certain areas, and usually a vesicle is found seated on the summit of the papule. Intense itching is nearly always met with in this type, and the scratching leads to rupture of the vesicles, and breaks off the summit of the papule; an outpouring of serum and blood takes place on the surface, and dries into a small blood cap, which covers the site of the vesicle. Papular eczema, as it is first seen, usually presents the papules studded with these small,

*Read at Meeting of Middle Tennessee Medical Association, Nov. 17, 1904.

dark blood caps. The papules may be discrete, or may coalesce to form an elevated, red, infiltrated patch several inches in diameter.

The vesicular type is the most typical form of true eczema, and it offers the best opportunity for studying the chain of pathological changes which take place in the lesion. Something unknown excites an inflammatory process, as in other types, resulting in an excessive edema, which affects the epidermis more extensively than in the other types. The cells of the rete are bathed and soaked in the serous exudate, and are wholly separated from each other, while serum collects in pools in the strata of the epidermis above, forming vesicles. These vesicles being ruptured, an outlet to the surface is made, through which flows, or weeps, a fluid made up chiefly of serum, and a fluid resulting from the dropsical degeneration of the rete cells, and this mixture of fluids stiffens cloth when moistened by it and dried. The cells placed in these surroundings cannot undergo the proper changes to form sound epidermis. Some undergo degeneration and others pass upward and reach the surface still edematous and still retaining their nuclei, instead of being converted into flat, horny cells without nuclei. Unna has named this process parakeratosis. A serous exudate from an abraded surface on a healthy skin will dry, and the place will heal within a short time; not so in eczema. The weeping continues for weeks and months, the fluid drying, forming yellow crusts, and the surface weeps again when the crusts are removed. So long as this condition lasts no healthy epidermis can be formed, and one object in local treatment is to remove the serum by absorption, and thus enable the cells to return to a normal development and the formation of a healthy epidermis.

Eczema rubrum, or eczema madidans, is a severe secondary type, resulting most frequently from vesicular eczema. The surface is raw and red, and there is so much weeping that crusts cannot form.

Eczema squamosum is a sluggish secondary form resulting from any of the above named types. It presents some scaling and decided thickening of the epidermis, with infiltration and thickening of the corium.

The favorite sites for eczema are the flexure surfaces, but no area of the body is exempt. Itching or burning is always present, and is most intense in the papular type. Eczema in this country is the most frequent of all skin diseases, being about onethird of all cases.

The causes of eczema are at the present time regarded as being constitutional and external. Hebra and the Vienna school believed at first that eczema was a local condition, but later in his life Hebra changed his views, and accepted the constitutional causes which were made so prominent by the French school. While this view is generally accepted, and while the pathological changes have been carefully examined with the microscope, still the specific constitutional disturbances which cause these pathological changes and an eczematous eruption are questions of speculation. However, in a brief statement, the constitutional causes may be given as any general conditions, temporary or persistent, which interfere with proper nutrition and excretion, and bring about impaired vitality. Experience has taught that gouty and rheumatic subjects are especially liable to eczema, and that in these cases excessively acid urine and defective kidney action are very important factors. Digestive debility and constipation should be given high places as conditions leading to specific causes of eczema in both adults and children.

The External Causes of Eczema: Heat rays, extreme cold, sharp winds, soap and water, dye stuffs, chemical irritants, drugs and trade articles, should be regarded, in my opinion, only as exciting causes acting conjointly with a favorable constitutional condition. For instance, two women may wash clothes with the same soap and water, and one would have eczema on the hands and the other would not. It is true that there is a difference in their skins, but it is more probable that the general conditions were more favorable to eczema in one than in the other, and that the irritating effect of soap and water was all that was needed to excite the skin to an eczematous action, just as a hot bath sometimes causes the macular eruption of syphilis to appear.

Unna and others have attempted to show that eczema is

caused by micro-organisms; that they pass down through the epidermis and cause the inflammation and edema observed, but this notion has not been accepted, and at present the authors themselves have modified their views.

The treatment depends upon the cause. Eczema developed by external causes is relieved usually by withdrawing the cause and applying a bland protective dressing. The constitutional disturbance is not so great as to cause the eczematous process to continue. The general treatment as to drugs, diet, etc., in cases of much constitutional disturbances, must depend upon the judgment of the physician. The local treatment in all cases should depend upon the subjective and objective signs.

Itching or burning usually demands attention in local treatment, and carbolic acid, menthol, thymol, resorcin, salicylic acid, are the remedies usually adopted.

The objective signs indicate the extent of the pathological changes with which we have to deal, and enable us to select the remedy, its strength and method of application.

Carbolic acid, one or two

In the acute stages of eczema there is inflammation, slight exudation, with burning or itching, and to meet these conditions soothing applications are demanded, and I would prefer a cooling lotion, never heat; and the calamin zinc oxide lotion would be, as a rule, my first choice, dabbed on alone, or applied on wet cloth, laid on, and kept wet with the lotion. grains to the ounce of liq. calcis, and parts, applied on a cloth, is also good. nigra, applied and allowed to dry, and followed with zinc oxide in ung. aquae rosae, will agree with many acute cases. The idea is not to stimulate, but to cool the surface and allay the itching, and reduce the slight inflammatory process.

sweet almond oil, equal Boric acid lotion, or lotio

It is not the nature of true eczema to be pustular and ulcerative, but these conditions occur through infection, so, in the majority of cases, it is essential to apply some mild antiseptic in conjunction with the other remedies. This point should always be kept in view.

A case moderately inflammatory, with distinct infiltration in the corium and thickening of the epidermis, will probably need

slightly stimulating applications, but it is always advisable to begin the treatment with the mild applications used in the acute stage until the nature of the skin is ascertained, and later cautiously add the stimulants. These stimulants promote absorption of the serum (which was described in the pathology as being in great excess, and bathing and soaking the cells), restores the cells and tissues to normal activity and the formation of a healthy epidermis. Tar, resorcin, salicylic acid, ichthyol, and hydrarg. ammoniat. in ointments or solutions, are the stimulants to use. I would recommend, in many cases, the conjoint use of a lotion and ointment, while other cases would respond more rapidly to an ointment alone; for instance, a mixture of one or two drams of liq. carbonis detergens to one pint of calamin zinc oxide lotion, is one of the most reliable lotions; or boric acid lotion applied and followed with ammoniated mercury or tar ointment; or the ointment may be used alone.

In sluggish, inflammatory cases, with pronounced infiltration and epidermic thickening, the same remedies will be demanded in stronger preparations.

Thickly indurated and verrucous patches are to be reduced and thinned by the application of sapo viridis, caustic potash, and salicylic acid, in conjunction with the plans above mentioned. Water and soap act like poison in many cases of eczema.

A few weeks ago a gentleman of 61 years of age came under my care suffering with eczema of four years' duration. It was located on both legs, surrounding the lower third, on the fore arms, and in patches on the hands. The type on the legs and forearms was chiefly papulo-vesicular, but was papulo-squamous on the hands.

The eruption appeared during the summer. He received treatment at that time in New Orleans, and since has been treated by physicians in California, Michigan, and other States, but his trouble remains with him.

He complained of constipation. His urine was excessively acid. Otherwise his general condition was normal. I directed him to take Kutnow's Powder, and to drink more water, and change his diet to some extent. This was not sufficient to pro

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