THE TREATMENT OF* ACUTE ECZEMA. By GEORGE H. ROHfi. M. D„ Professor of Hygiene and Clinical Dermatology, College of Physi- cians and Surgeons, Baltimore; Member of the American Dermatological Association; Active Member of the American Public Health Association, Etc. BALTIMORE : Office of the Medical Chronicle. 1883. THE- Treatment of Acute Eczema GEORGE H. ROH£, M. D., Professor of Hygiene and Clinical Dermatology, College of Physicians and Surgeons, Baltimore; Member of the American Dermatological Association; Active Member of the American Public Health Association, Etc. Willan and all other English dermatologists, until a very recent period, characterized eczema as a vesicular disease, accompanied by the discharge of a sticky, albuminous fluid. Other manifesta- tions of a pathological condition apparently similar to that under- lying the vesicular eruption were classed as separate and dis- tinct diseases. Thus, an itching papular eruption was termed lichen or prurigo; a pustular eruption was impetigo; and an erythematous or a scaly eruption was an intertrigo, psoriasis, or pityriasis. While these names still have a place in derma- tological nomenclature, they have at present, in most cases, a different signification to that possessed by them tw'enty-five years ago. Hebra, to whom belongs the credit of freeing dermatology from the clogs of artificial classifications and a meaningless terminology, recognized the close relation of these various manifestations, and gave to eczema a more comprehensive definition than was given to it by the English, French, or early German schools. According to this definition, eczema is an acute or chronic non-contagious inflammation 2 of the skin, manifesting itself either in reddened or scaly patches, papules, vesicles, pustules, or fissures, characterized in many cases by the exudation of a colorless or yellowish, sticky fluid, which dries into amber-colored or brownish crusts, and is accompanied by intense itching. If we accept this definition of eczema, our conception of the disease becomes at once much more clear and simple. We are led to pay attention to the pathological condition underlying the morbid process rather than to the manifestations of the disease in any particular case. It is probable that eczema is, in the majority of cases, due to external impressions upon the skin, i. e., it is the effect of some local irritant influence, either chemical or dynamic. There can be little doubt, however, that a peculiar predisposition of the skin to take on eczematous inflammation is necessary before the influences mentioned will produce an eczema. Thus, in some individuals, the most violent scratching or friction, chemical irritants, or changes of temperature or moisture, will fail to produce an eczema, while in others any of these influences, even in a mild degree, will produce an outbreak of the disease. It is not necessary to assume, however, that there exists a peculiar dyscrasia or diathesis, to which the term eczematous diathesis is applicable. The evidence which we have bearing upon this point seems to the writer to point to the opposite conclusion. Although the writer is firm in the conviction here expressed that eczema is mostly due to external physical impressions upon the skin, it is not intended thereby to exclude altogether affections of internal organs as predisposing, or even as exciting causes of out- breaks of the disease. Disorders of the digestive organs, the liver or kidneys, and disturbances of the nervous system, seem to have an etiological relation to outbreaks of eczema in some cases. Eczema is in all cases a curable disease. The predisposition of the skin cannot, however, be removed by any means at present known. Eczema is always liable to recur when the irritation is repeated. Hence, while the prognosis as to any individual attack is favorable, a permanent cure cannot be promised in any case. If it be true, as stated above, that eczema is, in by far the larger proportion of cases, due to a merely local impression of greater or less intensity, it follows, as a matter of course, that local measures should suffice for its cure; and we find this to be generally true. The acute variety of the disease is the only one considered in this 3 paper. In order to point out the proper therapeutic measures to be employed, it will be convenient to take up the various forms under which eczema manifests itself, and to present the treatment in con- nexion with each. Acute erythematous eczema most frequently occurs in consequence of friction of two opposing surfaces of the skin, the action of heat or chemical irritants, or the influence of moisture. Hence it is oftenest seen in the perineum, and on the inner surfaces of the thighs in chil- dren and adults, and in fact wherever the surfaces of the skin are habitually in contact, especially if the effect of the friction is heightened by heat and decomposing secretions. This condition, known in the vernacular as “ chafe,’’ is often the source of great annoyance both to physician and patient, from its obstinacy. In the writer’s experience, a simple drying powder of starch or precipitated chalk, often and thickly applied, has given the best results. Calomel is often a very excellent application if the inflamed surface is not too large; otherwise there is danger of producing the systemic effects of the mercurial. With the drying powder alone, combined with clean- liness, most cases of intertrigo, to borrow the old name, can be got well. In other cases, an alkaline lotion, half a dram of bicarbonate; of sodium to the ounce of water, or simply lime water, or a lotion containing one or two grains of carbolic acid to the ounce, may be used with benefit. It must be remembered that the cause of the disease must be removed in order to aid the cure. The parts should be kept clean, and the friction of opposing surfaces prevented as much as possible. The erythematous eczema due to the effects of heat, from exposure to the sun or to a fire—sometimes seen in cooks, blacksmiths or foundry men—is best treated by the application of rose-water oint- ment or simple bicarbonate of sodium lotion. Acute papular eczema is most frequently found on the forearms, hands and feet, and is often due to the influence of high temperature of the air (as in the so-called “prickly heat”) or to persistent scratching. The writer has seen it not unfrequently follow an out- break of the small papular urticaria, so often localized upon the back of the hand and fingers. The severe itching accompanying the urticaria causes the part to be rubbed and scratched until the tempo- rary disturbance of nutrition has become prolonged, and what was at first simply an evanescent affection has become one of more per- 4 manent character. The application which gives the best results in this form of eczema is either a lotion of carbolic acid in dilute alcohol, bay rum or cologne water, or an ointment containing one to two drams of ammoniated mercury in an ounce of vaseline. The drying powders above mentioned often answer all purposes exceedingly well. In many of these cases the digestive disturbance upon which the urticaria depended in the first instance remains, and should not be neglected. In fact, it may be stated here that the condition of the patient as regards his functions generally should always receive attention, as well as the local lesion for which the physician is consulted. Papular eczema frequently runs into a stage of further develop- ment of the lesion, and becomes vesicular. In other cases the vesicular form is the one first developed. This is the old typical form of eczema—closely aggregated, fragile vesicles, which, bursting, exude a sticky fluid that stiffens but does not stain linen. It is fre- quently seen upon the face, ears and genital organs. There is often much serous infiltration of the skin, giving the part the appearance of erysipelas. There is, however, no pain or febrile disturbance, so marked in the latter disease. In erysipelas the skin is dark-red and shiny, while in eczema the color is much less deep. In eczema there is also burning, and in most cases intense itching. Where the discharge is profuse, as it often is in these case*, a simple dusting powder of finely pulverized starch or precipitated chalk answers best. Calamine or calomel are also excellent local applications. In some cases, where the itching is very severe, car- bolic acid lotion, two grains to the ounce of water, or, what is still better, black wash kept constantly applied on clean muslin or lint, gives more relief than anything else the writer has tried. Lotions containing calamine and hydrocyanic acid are also highly recom- mended by authorities. As a general rule, ointments are not well borne in the most acute stage of vesicular eczema. Where it is desirable to employ them, one containing half a dram to two drams of calomel in an ounce of vaseline or cosmoline yields the best results, giving relief to the intense itching and checking the discharge. The local application of water as a cleansing agent, or water dressing, either hot or cold, is usually not well borne by the skin when in a state of acute eczematous inflammation, This is especially 5 true in the erythematous, squamous or vesicular forms of the disease. In these cases the use of water should be avoided until the most acute symptoms have subsided, when its use may be begun. Pustular eczema is most frequently seen as it effects the hairy scalp in children, or the hairy regions of the face in adults. The pustular character is very frequently the expression of a deprave- ment of the system. In these cases the ointment of calomel, half a dram to the ounce of vaseline, or of the officinal ammoniated mercury ointment, or oxide of zinc ointment made with freshly prepared benzoated lard, seem to give the best results. In addition, the use of iron internally, in the form of tincture of the chloride, is of importance in these cases. This remedy can be rendered very palatable by combining it with phosphoric acid, syrup and spirit of lemon, as in the following prescription recom- mended by Goodell: $ Tr. ferri chloridi 3 ii. Acidi phosphorici dil. . . . . 3 vi. Spiriti limonis . . . . . 3 ii. Syrupi . . . . . . ad vi. M. Sig. A dessertspoonful every four hours. Perhaps, in most cases of vesicular eczema, the vesicular character of the disease has disappeared when the physician is called. The vesicles have burst, and their contents have either dried into yellow- ish-brown crusts, or a red, weeping surface is exposed. This is the eczema rubrutn, vel madidans of authors, and should be con- sidered as a secondary form of the disease. When it occurs in parts where the skin is subject to much movement, as the flexures of joints, etc., fissures result, extending into the cutis,which are very painful some- times. This is what is termed in the books eczema fissum seu rimosuin. It yields most readily to the benzoated oxide of zinc ointment, or Hebra’s ointment, as modified by Piffard, made as follows: Lead plaster and vaseline, equal parts (or one part lead plaster to two, three or four of vaseline), to be melted together and stirred while cooling. The writer has found Hebra’s ointment, when made with the addition of oil of lavender and balsam of Peru, to be too irritating in the very acute stages of all forms of eczematous inflammation. Jq a small proportion of cases, eczema in all, or a number of its 6 various forms, will be found attacking the entire body or its larger surface. In such cases the vesicular and pustular forms will be found on the face, head, limbs and genitals ; the erythemato-squamous form will be found on the trunk; the flexures of the joints will be occupied by the fissured and weeping forms; while the papular variety will be almost exclusively localized upon the forearms and legs. The management of a case of acute general eczema is a difficult problem to solve in many cases. When the entire or the greater surface of the body is attacked, the patient should be confined to bed. He should be entirely undressed and placed between sheets. The remedies used will vary with the character of the lesion. Where the eruption is vesicular or moist, one of the drying powders before mentioned must be dusted on; where it is principally papular, an alkaline or spirituous lotion may be applied, and where the pustular character predominates, the calomel ointment will yield best results. A mercurial or saline laxative should be given at the same time. As the more acute symptoms subside, mild astringents should be applied; ol these, the modified Hebra’s ointment or oxide of zinc ointment will in general give satisfaction. Care is necessary to avoid the use of applications that are too irritating, as in this wav the disease is nearly always rendered worse. An additional caution may not be unnecessary, namely, to abstain from using mercurial applica- tions over large surfaces, as the constitutional effects of the drug follow rapidly from absorption. The writer used black wash pretty freely in a case of acute general eczema with the result of prompt relief of the symptoms, but, in addition, rather severe salivation ot the patient on the third day. Hence some other application should be chosen in cases where the extent of surface affected is large. Regarding restrictions of diet, upon which so much stress is laid by most authors, the writer can only say that he has observed little influence exerted by this over the disease. It is of far more import- ance to prevent local irritation, such as scratching, friction or irritant applications, than to supervise too curiously the patient’s bill of fare. Indigestible articles of food, spirituous liquors, coffee and tea, especially the last, should be abstained from. In treating acute eczemas, especially of children, it is important to prevent the patients from scratching, and thus intensifying the disease or causing it to spread oyer a larger surface, not in consequence of 7 contagion, be it remembered, but simply from the irritation of the skin. Dr. J. C- White, of Boston, makes a good suggestion in this connexion. It is to confine the little patient’s arms and hands in a straight jacket, which can be conveniently made by cutting a slit in one end of a pillow-case, then slipping it on over the head of the patient, and confining the hands and arms by stitching the front and back of the improvised jacket between the arms and the sides of the body. The face should be covered by a flannel or muslin mask, on which the ointment used is to be applied. It will usually be found very difficult to induce the parents or attendants to carry out these instructions. In many cases the mask or jacket is applied only a little while before the doctor’s expected visit, while during the rest of the time the child’s hands are unconfined, permitting unrestrained scratching or rubbing of the affected parts. In conclusion, it may be added that, in the management of acute eczemas, good judgment, common sense and the habit of correct observation are absolute pre-requisites to success. It is not merely necessary to know the various characters the disease may manifest, and a number of remedies or prescriptions applicable to these. What is of most importance is to recognize the stage and intensity of the disease, the general condition of the patient, and the local peculiarity of the skin. These acquirements cannot be learned from books or journal articles, but must be gained by experience and observation. What has been here written is only to render the acquisition of this knowledge easier, by summarizing some of the results of individual experience. THE MEDICAL CHRONICLE, Edited by GEORGE H. ROHB, M. D. The Medical Chronicle is a Monthly Medical Journal, pub- lished in the joint interest of the Medical Profession and of the editor. It will contain such original papers, lectures and clinical reports as appear to be of most interest and value to the Practitioner. The latest advances in the scientific and practical branches of Med- icine and Surgery will be presented in an intelligible shape and devoid of useless detail and verbiage. The editorial comments will be brief and plain. All measures affecting the interests of the profession will be discussed from an independent standpoint. Personalities will be rigidly excluded. 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