It shows itself in general first on the cheeks and sides of the face, where the skin becomes red and rough, and slightly puffy. On looking very closely—more closely indeed than most persons are wont to do—this appearance will be seen to be produced by innumerable small pimples, smaller than pins' heads, and which itch violently. Now and then, even in the course of a few hours, these pimples disappear, leaving the skin rough, and peeling off in branny scales, while the surface beneath is red and irritable, a condition which also in a few days may subside. This, however, is less frequent than the opposite course of the affection, in which a drop of fluid forms at the top of each tiny pimple, and escaping forms a yellowish, thin, transparent, watery, irritating discharge, which reddens still more the raw and weeping surface of the skin. The fluid when abundant dries at length into yellowish flakes or crusts, which sometimes assume a brownish colour if the surface is made to bleed by irritating or scratching. If the crusts are not removed, the fluid which still continues to be poured out beneath them soon changes into matter or pus as it is called, and this, shut up beneath the hard crust above, increases the irritation, and thickens the deposit. After a time the inflammation lessens of its own accord, the secretion diminishes, the crusts dry up, and at length fall off, leaving the skin red, slightly swollen, and its surface scaling off in flakes, which gradually cease to form, and the skin by degrees becomes quite sound again, and so remains, until perhaps the irritation caused by the approach of a new tooth to the surface, rekindles the old trouble, to go once again through the same stages as before.
It is on the cheeks, the sides of the face, and the top of the head that these changes may be best studied, but there are other situations in which the same kind of process often goes on. It may be seen in the creases of the neck, or the folds of the thigh in fat children, only as two surfaces of skin are there in contact the fluid never dries to a crust, but the skin, red and sore and swollen, pours out an abundant secretion which, just as when it occurs behind the ears, gives out a strong and offensive smell. It occurs, too, at the bends of the joints, as under the knee, and at the inside of the elbow joint, as well as on the front of the chest, the back, and sometimes even over the whole body, and especially at any part where the pressure of the dress irritates the skin. When thus general, it seldom fails to pass into a chronic state such as to call for constant, skilled medical treatment.
The attack often comes on with general feverishness, a hot skin, fretfulness, and restlessness, which subside when the skin begins to discharge, though the discomfort produced by the local irritation still continues. At other times, and this perhaps more often when the eruption first appears on the head, its onset is more gradual, and slight scurfiness and redness at the top of the head are first noticed, and then a little crust forms there which is firmly adherent, and is, therefore, often not entirely removed as it should be, and thus bit by bit the mischief extends until its cure becomes tedious and troublesome. When either from neglect, or from the ailment having set in acutely, the affection of the scalp is severe, the child's state is one of much suffering. The whole of the scalp becomes hot and swollen, and covered over a large surface by a thick dirty crust, through cracks in which a thick ill-smelling greenish-yellow matter exudes on pressure. At different points around, pimples form with mattery heads,—pustules they are called—while the glands on each side of the neck become swollen and tender. When thus severe on the head it will be found also not merely on the face, but also on the body, and the poor suffering child is not only a miserable object to look upon, but, worn by constant restlessness, it loses flesh, and seems almost as though it could not long survive. Happily, however, the condition scarcely ever terminates fatally, though feeble health and stunted growth are not seldom the results of the early suffering. But besides, severe eczema in infancy always returns again and again in childhood and in after-life, and there is also a distinct connection between liability to eczema and to asthma; and this not simply nor mainly that the disappearance of an attack of eczema may be succeeded by an attack of asthma, but that the child who in infancy has had severe general eczema is more prone than another to develop a disposition to asthma as he attains the age of five or six, and this even though he should not have had any return of the skin affection in a severe form.
It is evident then, that one cannot take too much pains to guard against the occurrence of eczema if possible, and at any rate to prevent its becoming severe. The disposition to it is often controlled by very simple precautions, such as bathing the face, the moment the skin shows any redness or roughness, with thin gruel or barley water, then powdering it with starch powder, and when the infant goes out, smearing the spot very lightly with benzoated zinc ointment, and making the child wear a veil. It will be observed that the exclusion of the air is in all these cases the object of the application far more than any specific virtue which it is supposed to possess, and many of the worst cases of eczema in grown persons are treated, in the great hospital for skin diseases in Paris, by an india-rubber mask, or by india-rubber covering of the affected part, and benefit thereby without any medicated application whatever. The thin layer of scurf which often forms on an infant's head should not be allowed to remain there, since its presence is a source of irritation. If it is very adherent, the surface may be well greased overnight with a little clarified lard which will soften it, so that it can be readily washed off with weak soap and water in the morning. If, however, the skin is very irritable soap must not be used, but the head must be washed with yelk of egg and warm water, and instead of a sponge, which would be too harsh, it is better to employ a very large camel's hair brush or a soft shaving brush, which is more handy, and the surface after careful drying may be lightly smeared with zinc ointment. All ointments used must be washed off most scrupulously every day, otherwise they become rancid, irritate, and make matters worse.
When eczema sets in acutely, with general feverish disturbance, cooling medicines are required, and the help of the doctor becomes necessary. These are the cases in which the eruption is not confined to the head or the face, but extends over the body generally. The child must be dressed as loosely as possible; and when in its cot, should lie there with no other covering than its little shirt; and nothing gives so much relief to the irritation as the abundant use of powder, either simple starch powder, or ten parts of starch powder to one of oxide of zinc, or carbonate of bismuth. All powders must be absolutely free from grit, or, in other words, quite impalpable; otherwise they irritate the surface. On the face and other parts where it can be employed, the puff may be used to apply the powder; but between the creases of the skin—which it is important to keep apart—fine linen, lint, or charpie must be employed, covered freely with powder, so as to prevent the surfaces from coming into contact. If the irritation is very distressing, a weak spirit lotion with a little carbolic acid may sometimes be sponged over the surface, and the powder renewed immediately; or other forms of soothing lotions may be used to abate the irritation.
When the scalp is affected in the acute form of eczema crusts form very quickly; or in other cases they collect because people fear to disturb them when they see the raw surface beneath. It is, however, a grievous mistake to allow them to collect; they are in themselves a source of irritation, and they entirely prevent any application reaching the skin beneath. They must always be removed, and never be allowed to form again. They can be removed either by the employment of a poultice, half of bread, half of linseed meal, or by the application over-night of a handkerchief soaked in sweet oil, and covered over with a piece of oiled silk, which softens the crusts effectually, and allows of their easy removal by abundant washing with weak soap and water.
The best applications afterwards vary so much that it is impossible to lay down any positive rule. Sometimes the Carron oil, as it is termed: a liniment compound of equal parts of linseed oil and lime-water—a popular and most useful application in burns—gives most ease to the irritated skin; sometimes the mere exclusion of the air by means of the india-rubber cap; sometimes the abundant use of powder. In every case, at least once in every twenty-four hours the whole surface must be washed quite clean with barley water or thin gruel; and when the discharge lessens or ceases, as it will do in the course of time, then, but not till then, various ointments may be of service.
When the chronic stage arrives, in which the skin becomes dry and scaly, then is the time for tonics, for iron, sometimes for cod-liver oil, and for arsenic; of which latter remedy, however, the results are uncertain; while in the acute stage, its influence is simply mischievous. Nothing is more difficult, nor calls for more skill, or larger medical experience, than the proper management of the various forms of chronic eczema.
The question is sometimes asked whether it is safe to cure, or, as people call it, to dry up these eruptions in teething children. There can be no doubt but that it is very desirable to prevent their occurrence as far as may be by the use of the precautionary measures which I have explained. But when they have existed for some time, either attended with profuse discharge, or causing great irritation by their extent, there is no doubt but that care must be exercised in attempts at their cure, that soothing measures such as I have advocated should be chiefly employed, and that the sudden drying up of the discharge by a too abundant use of dusting powders must be avoided. If, too, the diminution of the rash were followed by a worsening of the child's condition, by feverishness, by heaviness of the head, or any sign of disturbance of the brain, the attempt to cure the rash must at once be abandoned. At the same time I must add that such occurrences are very rare, and that for one case where I have had to regret my success in curing the rash, I have seen fifty in which I have been mortified by the failure of my endeavour.