A system of practical medicine. By American authors. Vol. 4

by Unknown

Vesicular eczema may show itself typically, the whole of the affected skin taking on vesicular formation, or, as frequently happens, it may be associated with other varieties of the disease, more particularly pustules and papules. Abortive vesicles and vesico-pustules and vesico-papules are common, occurring here and there mixed with the vesicles and about the circumference of the patch. The amount of surface invaded varies. The disease often manifests itself in different regions simultaneously, as, for example, upon the neck and flexor surfaces of the forearms or upon the trunk and the thighs. In infants the face is the locality usually attacked, constituting the so-called crusta lactea, or milk-crust, of former writers. While the disease tends to manifest itself upon the thin skin of the flexor surfaces of the extremities and upon the face, such is not always the case, for the hands and fingers are also often invaded.

Eczema Pustulosum.—This variety of the disease (designated by some writers eczema impetiginosum) is closely allied to the preceding variety. The lesions may develop as pustules or may become pustular from pre-existing vesicles; both lesions are not infrequently found together, although one of the two will usually predominate. In pustular eczema the swelling, heat, and itching are seldom so marked as in the vesicular variety, and the lesions are generally larger and firmer. As in the case of the vesicles, they rupture and dry, forming yellowish or greenish bulky crusts. This variety is most frequently encountered about the face and scalp, and in those—especially young people—who are strumous, ill-nourished, or in a depraved state of health.

Eczema Papulosum.—Eczema papulosum is characterized by small, rounded or acuminated papules about the size of a pinhead. Sometimes they are well defined and circumscribed, but more frequently they possess no sharply-marked outline or form. They are reddish in color, the tint varying with the individual and with other circumstances, and are usually discrete, although not infrequently they are so numerous and so crowded together as to coalesce and form patches or aggregations of disease, which often show considerable infiltration. They begin as papules, and usually preserve this character throughout their course. Vesicles or vesico-papules not infrequently coexist. Sooner or later the lesions disappear, but are usually replaced by others, the process in this manner continuing its course for weeks or months. The itching is in almost all cases severe and persistent, the patient generally scratching himself to the extent of producing excoriations and blood-crusts. Papular eczema shows a preference for certain regions, notably the extremities, especially the flexor surfaces. The face is seldom attacked. It is one of the most obstinate varieties of the disease.

In addition to the principal varieties of eczema, just described, there are other forms of the disease which on account of their peculiar features require mention. Of these eczema rubrum, or eczema madidans, may first be spoken of. It is to be viewed as a secondary condition resulting from one or another of the primary varieties. Thus it usually follows eczema vesiculosum or pustulosum. It is characterized by a reddish, moist or discharging surface, the serum, sometimes bloody, usually exuding freely and forming thick yellowish or brownish crusts, together with more or less thickening of the skin and other secondary changes. In other cases discharge is wanting. The condition varies with the stage of the process and with other circumstances: at one time the red, inflammatory dry or oozing skin is the most striking feature, while in other cases this is completely obscured by large, diffuse masses of crust. It may occur upon any region, but it is most frequently met with on the legs, especially in adults, and more particularly in elderly people. It is usually chronic in its course, and may continue for years, better and worse from time to time, but usually evincing no disposition to spontaneous recovery.

Another clinical form of the disease is known as eczema squamosum, which frequently has been preceded by the erythematous variety, and in many cases is to be viewed as a stage of that variety. It may also follow other varieties. It appears in the form of reddish, dry, more or less infiltrated, scaly patches, the amount of scaling being variable. The scales are usually small or fine, and as a rule are scanty. The condition is generally chronic, and is often met with on the scalp.

Fissures, superficial or deep, are not infrequently met with in eczema, usually in the chronic or recurrent forms of the disease, and may be so pronounced as to give rise to the so-called eczema fissum. This is often seen about the fingers and hands, especially the palms. In localized infiltrated patches of chronic eczema a peculiar warty condition is occasionally met with, which is known as eczema verrucosum; or if simply hard, rather than wart-like, eczema sclerosum.

Eczema is divided into acute and chronic, the several forms of the disease being so different in their clinical pictures as to demand such a division, which relates rather to the pathological changes than to time. Thus the disease may show acute symptoms throughout its course, or, on the other hand, may in the beginning take on a chronic action. As a rule, it tends to chronicity, secondary changes in the skin usually manifesting themselves early in the course of the process.

ETIOLOGY.—Eczema is the commonest of the cutaneous diseases, and seems to be of more frequent occurrence in this country than in Europe. It is met with among all classes of society and at all ages. Individuals with light hair and florid complexions are more often subjects of the disease than those of the opposite temperament. Not infrequently the disease is hereditary, although examples are very common in which no such history obtains. So-called eczematous subjects, in which at longer or shorter intervals throughout life and under variable conditions the disease manifests itself, are of frequent occurrence in practice. The state, though well known clinically, is difficult to define, consisting of a peculiar inherent condition of the system at large and of the skin itself which under favorable circumstances permits the disease to assert itself from time to time. The association in some cases of chronic bronchitis and allied affections of the respiratory tract with eczema, and the clinical observation that as one disease improves the other becomes worse, has led some dermatologists to regard eczema as being catarrhal in its nature.

The constitutional causes which may produce the disease are numerous, and are worthy of careful study as bearing directly upon the treatment. Disorders of the digestive tract, including dyspepsia in its many forms and constipation, are not infrequently found to be the exciting cause of an attack, while faulty excretion through the several emunctories, and the existence of a gouty or rheumatic disposition, may all prove potent factors. Deterioration in the tone of the system, arising from varied causes, with impaired nutrition—as seen, for example, during pregnancy and lactation—is sometimes accompanied with an outbreak of the disease, while nervous exhaustion and other neurotic states, as is now well established, are not infrequently active causes.