MODERN THEORIES and TREATMENTOF ECZEMA

BY

JOHN T. BOWEN, M.D.Assistant Physician for Diseases of the Skin, Massachusetts General

Hospital, Boston

Reprintedfrom the Boston Medical and SurgicalJournalof October 10, iSgj;

BOSTONDAMRELL & UPHAM, PUBLISHERS

283 Washington Street1895

S. J. PARKHIL.L & CO., PRINTERSBOSTON

MODERN THEORIES AND TREATMENT OPECZEMA. 1

JOHN T. BOWEN, M.8.,Assistant Physician for Diseases of the Skin, Massachusetts General

Hospital, Boston.

A great diversity of opinion has prevailed amongdifferent schools and different authors from the earliestdays of dermatology as to the proper conception of theterm eczema, an affection that is so varied in its clinicalmanifestations, and so greatly influenced by manyfactors of both external and internal nature that to-dayit is improbable that a definition satisfactory to thelarger number of students of this disease could beformulated. Many writers have indeed abandoned allattempt at a strict definition, and have contented them-selves with a discussion of the various clinical appear-ances and pathological features that are met with. Oflate years much interest has been aroused by thedoctrine of a parasitic causation for some of its forms,and certain authors have gone so far as to declare thatevery case, that is properly speaking an eczema, is ofparasitic origin. My object is not an attempt to coverthe whole field of the pathology of eczema, but todescribe some of the later theories that have beenadvanced, and to point out their strength or weakness,as they appear to me.

The chief writers in their conception of eczema maybe dividedbroadly into three classes : (1) those who con-sider the clinical and anatomical features as of chiefimportance, (2) those who lay most stress upon thecourse of the disease, (3) those who base their concep-—

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tion upon the etiology.1 Read before the 'Warren Club, May 7,1895.

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In the first class, those who make the form of thedisease their criterion, belong notably Hebra and theVienna School. Hebra’s definition of eczema is, “Anaffection of the skin, of mostly chronic course, char-acterized by the formation of grouped papules andvesicles, or by more or less deeply red patches coveredwith scales, or weeping; or in which, in addition tothese features, yellowish or green or brown crusts areformed. This affection is continually accompanied bysevere itching and therefore by excoriations, and is notcontagious.” Hebra, therefore, regarding the anatomi-cal features as of chief importance in the conceptionof eczema, cleared the air by proving that many con-ditions that had been regarded as independent diseaseswere in reality but different stages or forms of aninflammatory process that had hitherto been recognizedin a much more restricted way.

To this view the Vienna School has held fast, andNeisser declares his loyalty to the old definition ofHebra, which he would enlarge only by laying greaterstress on the changes in the epithelium, changes whichhe regards as specific, and as essential to the formationof the clinical picture of eczema.

These epithelial changes have been especially studiedby Leloir, and consist in (a) the immigration of puscorpuscles into the spaces between the prickle cells j(b) an edema of the epidermis, and particularly anedema of the basal horny layer; (c) a tendency todekeratinization, shown by the disappearance or lessen-ing of the eleidine, and of the granular layer; (d) thepersistence of the nuclei of the horny layer, which inconsequence of the dekeratinizing process are no longercoherent, having lost their normal adhesive attribute,and tend to exfoliate in the form of scales. At a laterstage, begins the process of vesiculation, of the forma-tion of the elementary lesion of eczema, which has its

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place usually in the middle or upper layers of the reteMalpighii. This process of vesiculation consists es-sentially in the formation of a clear space or cavitybetween the nucleus and protoplasm of the cell, and isdue to a sort of dropsy of the epithelial cell. This“alteration cavitaire ” goes on increasing until areticulum is formed of various sized meshes containingthe nuclei. This is the vesicle or primary lesion ofeczema.

Before the appearance of these epithelial alterations,however, Leloir was able, in cases of erythematouseczema, to detect a dilatation of the vessels in thepapillary layer of the corium. These vessels were alldilated and filled with blood, and there was alsoobserved a migration of the white corpuscles into thepapillae, which are filled with round cells, and also intothe epidermis, where they appear as migratory cells.Besides this the papillae were seen to be filled with anabundant serous exudation, one of the chief character-istics of eczema. This serous exudation it is, accordingto Leloir, that determines the epithelial alterations.Neisser, on the contrary, thinks that this is very im-probable in cases of eczema not produced by externalagencies. In cases of so-called artificial eczema, wherethe affection is obviously due to the action of an irritantacting from without, he considers that the epitheliumis directly and in the first instance affected, while theinflammation may be due partly to the epithelialalteration, partly to the direct action of the irritant onthe vessels. If it could be proved histologically thatan artificial eczema differs from the acute stage of thechronic process in the epithelial cells being affectedbefore there are signs of exudation, an importantargument in favor of separating artificial eczemas fromthe chronic process wouldbe obtained. Unfortunately,we know very little of the way in which the irritant or

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agent that produces an eczema acts, and such questionsmay be regarded as offering a legitimate field for study,and their solution the certainty of a great advance inour knowledge. One thing, however, seems clear,that there is an epithelial alteration in eczema (thathas only of late years received due recognition), aprominent feature of which is the “ alteration cavitaire ”

of the individual cells, together with a dekeratinizationin the upper layers, edema of the epithelium, and theimmigration of exuded cells.

That the nervous system plays an important r6le ineczema there can be little doubt. The intense itching,which causes the patient to rub and scratch the affectedpart, thus increasing the inflammation, is one of themost important factors in determining the course ofthe affection, but we are here also in the dark as to itsetiology. It may be conjectured that the inflammatoryinfiltration in the upper layers of the corium, actsdirectly upon the nerve filaments, or it may be thatthere are definite structural alterations of the nervesthemselves. Anatomical reasons for the latter vieware advanced only by Colomiatti and Leloir, who havedescribed changes in the nerve fibres in cases of chroniceczema. Leloir declares that there are certain varietiesof eczema where there are undeniable lesions of theperipheral nerves, and to these he gives the namoeczematous dermato-neuroses. Relying upon theseanatomical changes in the nerves (which have not asyet received confirmation from other sources) Leloirand Colomiatti argue for the nervous origin of manyforms of eczema, and in this they are more or less fol-lowed by Schwimmer and Bulkley. These authorslooking upon eczema as (in great part) a constitutionalaffection, consider that it has its origin in tropho-neurotic influences proceeding from various nervousconditions, and cite in support of their view the

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frequency with which these nervous affections arefollowed by or associated with an eczema. Besidesthese writers few if any have been willing to ascribeto tropho-neurotic influences more than a very specula-tive value, the subject of tropho-neuroses generallybeing so little susceptible of proof. Following Hebraand of late Neisser, it seems most rational to lookupon the undeniable relationship that often existsbetween nervous disorders and eczema as of a vaso-motor character.

An able and instructive paper on the pathology ofeczema was read by Neisser before the GermanDermatological Society in 1892. He holds fast in theessence to the doctrines of Hebra, and as his paper isin accord, to a certain extent with my own views, Iquote the resume that he offers of the present state ofour knowledge of the etiology of this disease. Neisserdistinguishes (1) the primary, actual cause of eczema,(2) the predisposing agencies that pave the way forthat cause, (3) the conditions which determine thechronicity of an eczema.

(1) As primary actual causes we now recognize theaction of mechanical agencies : chemical substancesthat exert their effect from without; chemical toxicsubstances that exert their effect from within theeconomy ; and micro-organisms bacteria, fungi, andperhaps animal parasites,

(2) Predisposing agencies which increase the sus-ceptibility of the skin for eczematous irritation. Inthis class are included (a) general conditions, asanemia, cachexias, the lymphatic diathesis, gout, diabe-tes, etc.; (b) local conditions of the skin, as seborrhea,prurigo, psoriasis, tinea tricophytina, various forms ofdermatitis, etc, also abnormal conditions of thevessel’s tone, as in the dentition of infants, or vaso-motor neuroses.

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(3) The conditions which determine the chronicityof an eczema. This is the chief question upon whichopinions and schools differ, What causes an eczema tobecome chronic ?

In his answer to this question he separates theprimary causes that directly determine the chronicityfrom the secondary causes that affect simply its course.

(1) A primary chemical or mechanical agency is notalways of temporary or limited duration, but may bein continuous or frequently recurring activity.

(2) The effects of the action of chemical or me-chanical agencies, perhaps of a short duration, maypersist at the place of irritation in the form of tissuelesions, not perhaps apparent, but ready to show them-selves if new favoring influences present themselves.

(3) There may be lesions of the cells and vesselsover a greater territory than the outbreak of eczemawhich was confined to the part most intensely affected,would indicate.

(4) In case micro-organisms are the exciting causeboth the recurrence and the dissemination are easilyunderstood.

Secondarily, the course may be affected by variouscircumstances, such as the implantation of micro-organ-isms, contact with water, soap and irritating substances.The partial loss of the epithelial covering favorsnervous phenomena such as itching, and the vesselwalls may be badly damaged. Also irritation ofcontiguous parts, or from nasal and anal secretions,may affect the course. Causes that lie in the organismitself may favor the course of an eczema; not onlythose of external character, as defects of the circula-tion, varicose veins, etc., imperfections in the skinitself, as seborrhea, hyperidrosis, etc., but also internalconditions, as dentition, alimentary disturbances, uterineaffections, which act in a reflex manner through the

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vaso-motor system, diabetes, arthritis, kidney affectionsand many others.

With regard to most of these views I record myselfas in agreement. As to the question of separating theacute cutaneous inflammations of eczematous typecaused by the direct action of external irritants fromthe eczemas, I am inclined to believe with Besnier,Leloir, Brocq, White, Crocker and most authors notdirectly connected with the Vienna School, that thisseparation should be made, at least for the present. Itis true, as Neisser states, that many cases of dermatitisvenenata are precisely similar in their clinical aspectto the acute stage of a chronic relapsing eczema, but itis equally true that there are certain points of distinc-tion that often make it possible for the expert todetermine the etiology of the affection (as has beenpointed out by White), without the aid of a history, orof the significance of the locality affected.

The artificial dermatitis has usually an acute courseand yet this too may be followed by recurrent attacksof eczema without exposure to the primary cause, eitherin Loco or at a distance from the first eruption. Inthese cases the artificial dermatitis is to be regarded asthe starting-point or essential cause of the eczema, towhich are added, in determining the relapses, thepredisposing causes mentioned and the conditions thatfavor chronicity. Among the latter conditions itseems to me that much stress should properly be laidon the assumption, mentioned above by Neisser, thatthe primary dermatitis, whether caused by externalchemical and bacteriological irritants, or by influences atpresent not understood, leaves, after the skin hasreturned to its natural color and consistency, “damagedcells ” or “ irritable vessels,” so that causes that wouldbe innocuous to a healthy skin are sufficient to giverise to an attack of eczema. Otherwise, it is difficult

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to explain the predisposition that exists in apparentlyhealthy subjects to recurrent attacks of eczema whenonce an acute dermatitis has been experienced.

The artificial dermatitises form a well-defined group,both from their etiology and from the clinical appear-ances in some instances, although no evidence of theirhistological divergence from the type of acute eczemahas yet been presented. For the present at least theyshould be grouped by themselves, although consideredas belonging to the class of eczematous affections.For I agree with Torok and Brocq that in the presentstate of our knowledge we should look upon theeczemas as a group or class, although 1 am in no senseprepared to accept Brocq’s subdivisions. But, in fact,is Neisser so far away from the views of those whowould separate artificial dermatitis from eczema, whenhe divides the eczema class as follows : (1) eczemaacutum circumscriptum, produced by various externalcauses, to which are to be added the acute eczemasthat may be of parasitic origin ; (2) eczematosis, inorder to give a name to the eruptions that recur con-tinually in an acute or subacute form ; (3) the localizedchronic eczema ?

It is only, it seems to me, by viewing the process ina broad way that we are likely to obtain further truthas to the etiology. Attempts have therefore beenmade to separate from the group of eczemas, individualprocesses ; and it is along these lines that we may lookfor the advances of the future. Naturally, much dif-ference of opinion exists as to the right of variousforms to be excluded from the eczema group. Eczemamarginatum, the form found chiefly upon the thighand scrotum, and distinguished by circinate patcheswith bright red advancing borders and scaling centres,is certainly to be distinguished from the eczemas.

I agree with Neisser and Besnier that what has been

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described by the name eczema marginatum comprisesa variety of processes etiologically distinct, in someinstances being caused by the tricophyton tonsurans, inothers by the microsporon minutissimum, the affectioncalled erythrasma, while in others it is in all probabilitydue to a variety of micro-organisms. It may often bedetermined by the microscope which of these causes isactive. As Neisser points out, it may be difficult tosay in a given case whether the eczematous inflamma-tion be primary or secondary, whether the parasitesare engrafted upon a pre-existing eczematous inflam-mation, or are themselves the cause of it; but in eitherevent, as it has been proved that this class as formerlyconstituted comprises several entirely distinct cutaneousaffections, the name of eczema should only be retainedfor the convenience of mutual understanding, untilfurther study, for which there is a fruitful field, hassucceeded in dividing the group into its individualelements.

A word as to the different forms, classed by theVienna School under eczema, which the French con-sider as independent affections under the name oflichen. The lichen simplex chronique of Vidal is theonly one of these affections that seems to possess anydistinct claims to a separate position. The pathogno-monic features of lichen simplex chronique as givenby Brocq are the nervous state or temperament of thesubjects affected, the fact that pruritus antedates theeruption, the circumscribed character of the eruptionin plaques, its absolute dryness and its chronic rebel-lious course with tendency to recurrences. It is truethat in many cases this form bears a closer resem-blance to lichen planus in clinical features, course,and reaction to treatment than it does to eczema. I amnot willing, however, to consider its claims to inde-pendence as satisfactory, but still it seems to me that

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this class of cases should be carefully grouped togetherfor further study. The form described by MalcolmMorris under the name of eczema follicularis, whichconsists of sharply bounded plaques, made up ofsmall red, firm papules situated exclusively about thefollicles, often covered with a small scale penetratingthe follicle, is regarded by Neisser and Jadassohn asentitled to a place apart from the eczemas, and thisview is borne out by the microscopical studies ofJadassohn. Whether their interpretation will be con-firmed and accepted, it is as yet too early to predict.

Under impetigo we now understand a vesicular,bullous and pustular eruption, in which the final stageof crusting is most apparent, caused by the action ofmicro-organisms of various kinds, chiefly those of pus,upon the skin, and often associated with an eczema-tous inflammation. The so-called impetiginous ecze-mas are complications of eczema with impetigo ; itmay be impossible in a given case to say whether thepus micro-organisms were implanted upon a previ-ously inflamed territory, or whether the eczema was asecondary process. Impetigo is therefore contagious,and produced by local inoculation. Impetigo con-tagiosa is the name that was used before its etiologywas known, and under which it is now placed bymany writers.

ECZEMA SEBORRHOICUM (UNNA).Unna has emancipated himself fully from the pre-

existent theories, which regard eczema from ananatomical and clinical standpoint, and bases his con-ception of the disease upon purely etiological princi-ples. He defines eczema as a chronic parasiticcatarrh of the skin, accompanied by desquamation,itching, and a tendency to respond to irritation withexudation and pronounced inflammation. His posi-

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tion was first defined in 1887, and it may be of inter-est to examine briefly his theories and to note in howfar they have been accepted by other dermatologists.His conception of seborrhea had been previously madeknown. He regards the oily seborrhea (seborrhea-oleosa) as caused by a hypersecretion of fat pouredout from *he sweat-glands. The dry seborrheas hewould drop entirely from this class, regarding them aschronic inflammatory processes of the skin accom-panied by an abnormal amount of fatty matter, whichis produced by a hypersecretion of the sweat-glands,and not of the sebaceous glands. This fatty matterhe declares is not situated in the scales alone butpenetrates the epidermis and corium as in no otherknown disease. The dry seborrheas are, therefore,according to Unna, examples of seborrheal eczema.The starting-point of almost all seborrheal eczemas isthe scalp, where it may exist for years without caus-ing especial notice. The pityriasis capitis which leadsto alopecia, and which is identical with seborrheacapitis, comes under this heading, and is Unna’s firstform of eczema seborrhoicum.

In his second class of cases the scaliness increasesand fatty crusts are formed between the hairs, and acorona seborrhoica is formed at the margin of theforehead. Later it may extend to the temples andneck, to the region of the nose and cheeks, etc.This is the so-called crusty form.

The third form is classed as the moist variety, andin this weeping occurs and the rete may be laid bare.In the sternal region the crusty form is the one usu-ally seen, rarely the scaly and moist. It takes onhere a circinate and marginate appearance, with a redborder and yellow, greasy centre. From the shoul-ders the affection spreads downward on the arms, usu-ally in the crusty form, seldom in the moist, and has

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a marked predilection for the flexor surfaces and forsurfaces in contact with one another.

The three forms are often found existing at thesame time on different localities. In 1889 Unna,after studying the histology of this form, declaredthat the pathognomonic feature was an alteration ofthe epithelial layers, beginning in the lowest pricklecells and continued upward to the horny cells, of apurely edematous nature. In 1892 he made knownhis discovery of the morococcus, a form of diplococ-cus that is distinguished by its formation into clustersof a mulberry shape, which will produce characteristiclesions when inoculated in pure culture upon a healthyskin, and which he considers the cause of eczemaseborrhoicum.

To what extent have Unna’s views of eczema se-borrhoicum been accepted ?

Besnier considers that there is a complication ofeczema with seborrhea, an affection which he hadbefore noted but never properly formulated; that itis impossible to say as does Unna that the inflamma-tion is primary and the seborrhea secondary. Hedoes not further agree with him that the sebaceousglands take no part in the process, believing that bothsebaceous and sweat glands are active. He thinks aparasite is probably the causative agent, and that thesteatorrhea is probably one of the essential causes inthe production of the eczema.

Leloir and Vidal, while apparently accepting Unna’sviews in great part, declare that the individuals withwhom seborrhea is constitutional, often even heredi-tary, are the ones who are most apt to be affectedwith seborrheic eczema. In these subjects, psoriasis,pityriasis rosea, etc., may take on a seborrheic appear-ance. Their microscopical studies confirm in the mainthe researches of Unna. They add, however, that

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further investigations both clinical, bacteriological andhistological, are necessary to clear up the true na-ture of the affection or affections, classed by him asseborrheic eczema.

Crocker thinks that it is proper to retain the oldname and conception of seborrhea, inasmuch asthis affection, though often accompanied by inflam-mation, may be entirely wanting in all inflammatoryappearances. He thinks it probable that seborrhea isan affection caused by micro organisms. To the caseswhere clinical signs of inflammation are present hewould give the name seborrheic dermatitis; and thishe divides into seborrhea eczemaformis, seborrheapsoriasiformis and seborrhea papulosa seu lichenoides,which latter is identical with seborrhea corporis,lichen circinatus, etc.

Elliot thinks that the process is so different clini-cally from what has hitherto been called eczema thatthe name should be discarded, and that Crocker’sname of seborrheic dermatitis, given to one phase ofthe disease, is suitable for the whole affection, whichhe considers a parasitic dermatitis. His histologicalexaminations varied from those of Unna in not show-ing fat present in the coils or ducts of the sweat-glands, nor a fatty infiltration in the corium and rete,nor does he think that the fatty hypersecretion is de-rived from the sweat-glands.

Torok cannot admit a relationship of the scaling tothe crusty and moist forms, nor to eczema-generally.The crusty form he would separate entirely from theeczemas and class as a mycosis, while the third ormoist form is in his eyes a mixed affection. He isunable to accept the morococcus as the cause of sebor-rheic eczema, as Unna’s inoculation experiments donot prove that the morococcus is not simply a producerof an impetiginous complication.

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Neisser’s resume, of eczema seborrhoicum is thatUnna’s first or scaling form is not an eczema, but re-mains a primary affection of the fat-secreting glands,with minimal secondary inflammatory manifestations.His second or crusting form is also not an eczema butan affection allied to psoriasis (from which it mayoften be almost impossible to differentiate it), almostalways dry, with a slight inflammatory infiltration.It is probably of parasitic origin and is connected withseborrheal alteration of the skin. His third or moistform is eczematous and parasitic without doubt. It isusually connected with seborrheal alterations of theskin, so that it is impossible at present to decide whichfactor is most important and should determine thename. It is possible that the second and third formsare forms of the same mycosis.

Taking the opinions that have been cited, and in-cluding besides the views of those who have writtenor spoken at lesser length on the subject, it may besaid that Unna’s theory has by no means met withgeneral acceptance among experts. Much confusionhas, in my opinion, been introducedby the name sebor-rheic eczema, and much prejudice has in that waybeen excited against Unna’s whole position. If weexamine carefully the evidence that he has adduced insupport of his theory that there is no such thing as ahypersecretion of the products of the sebaceous glandswhich causes an accumulation of fatty masses uponthe skin, we find that he has by no means proved hiscase. The histological studies of Unna, Leloir andElliot fail to confirm the view that the sweat-glandsalone are concerned in the hypersecretion of fat, nor dothey show any specific changes in the case of sebor-rheic eczema, as is pointed out by Neisser. I believethat undue weight has been laid upon the pathologicalsignificance of the association of eczema and sebor-

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rhea. Unna’s first or scaly form certainly belongs,with our present knowledge, among the seborrheas,even if it is possible to detect some evidences of in-flammation histologically. As Besnier and Neissersay, it is impossible to assert, as does Unna, that theinflammation is primary and the hypersecretion second-ary. Until further evidence can be brought we mustbelieve that the sebaceous glands have a part in thehypersecretion of the fatty products.

The second or crusting form should also be sepa-rated from the eczemas, as it has been hitherto, underthe name of lichen circinatus, seborrhea corporis, etc.Its association with seborrheic affections of the scalp,and the fatty hypersecretion that is unquestionablypresent, warrant its retention provisionally among theseborrheas, until its etiology has been explained. Itmay be associated or complicated with various degreesof eczematous inflammation. Its parasitic natureseems highly probable, but is as yet unproved. Itssimilarity to psoriasis has been pointed out, and thedifficulty that often confronts one in differentiatingthe two affections. Whether in these cases there is apsoriasis modified by its implantation on seborrhealsoil, or whether, as Brocq believes, there is a group ofaffections, intermediate between eczema and psoriasis,which are developed especially on seborrheal subjectsand which deserve a separate name these are ques-tions that may fairly occupy the attention of future in-vestigators.

Unna’s third or moist form I would regard as a der-matitis combined usually with seborrheal alterations.It is very difficult to determine the relative importanceof the inflammation and hypersecretion. Its parasiticnature seems probable, but as the morococcus has notyet been accepted as the causative agent, nothingdefinite is known. It deserves a separate place among

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the class of eczemas, on account of its serpiginous andcircinate form, its association with seborrhea, its pro-gress from above downward and its probable parasiticnature. Uuna has rendered a service chiefly in call-ing attention to the combination of clinical appear-ances that characterizes the third form and its possibleetiological relationship to the second form.

A tuberculous eczema, such as Unna calls theeczema localized about the eyes, nose, mouth and earsin children and attended with rhinitis, phlyctenularkeratitis and otorrhea, is not accepted in this sense byany’ of the authorities, so far as lam aware. Noproof exists that tubercle bacilli can cause an eczemasimply, and if the characteristic new formation ispresent, we have a tuberculosis, and an eczema only asa complication.

TREATMENT.

Turning now to-the treatment of eczema, it is mypurpose to pass in review the chief methods that havebeen introduced or advocated during later years. Atthe outset it may be said that most of these methodsdepend for their efficacy upon the consistency of thepreparations recommended, their power of adhesion tothe skin or their mode of application. No specific hasbeen discovered and few new drugs have been addedto our store of internal remedies.

Arsenic is never used as a routine treatment, andnever in the acute stages. It is reserved for thechronic, unyielding varieties, and even here its use hasbeen much curtailed. A variety of drugs are used inter-nally, according to the general indications of the in-dividual case, but no new remedies of much valuehave been introduced. Ergot, phosphorus and anti-mony have their advocates, but their specific influenceon the disease is far from proved.

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In the treatment of the acute forms our attentionshould be directed to the use of remedies to protectthe inflamed surface from the outer air, to absorb thesecretions and to limit their formation, and to lessenthe itching which in many cases is intolerable.

One of the most useful principles that has been in-troduced during the last fifteen years is that of sub-stituting, especially in the more or less acute forms,variously compounded pastes for the ointments thathad previously been relied on. Hebra’s method wasto spread the ointment or liniment upon lint or cottonand have it worn continually. The good results ofthis procedure were due in the main to the absolutesealing up of the inflamed surface from the outer airand to the removal of the products of the inflamma-tion. But as fats are an important constituent of allliniments and ointments, it is found that irritation isfrequently caused by the splitting up of these fats intofat acids and glycerine, under the influence of thesecretions with which they are brought in contact.This irritative property varies apparently much in dif-ferent cases, owing both to the individual susceptibilityand to the grade of the inflammation. It is to beascribed both to the action of the fat acids and to theglycerine probably, as both of these substances areoften of an irritating nature. These drawbacks areobviated by the use of preparations composed of in-different or astringent powders mixed with vaseline insuch proportions that a smooth, thick paste is formed,admirably suited for the absorption of the products ofinflammation and for protection from the outer air.Chief among these is the well-known Lassar’s paste,composed of equal parts of oxide of zinc and starch indouble the quantity of vaseline. Its advantages asclaimed have been substantiated by experience. Someof these are that it does not liquefy at the ordinary

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temperature of the skin, but dries on quickly and canbe retained even in very hot weather by sprinkling ona little powder. It can be applied to very smallpatches, and adapts itself to all parts of the body.Hairy portions of the body are the only ones to whichit is not suited, as the hairs become matted togetherfrom the solid constituents. It is found in practicethat patients who are unable to endure the applicationof any ointment without violent reaction, bear thispreparation with ease, and even where vaseline aloneis not borne, the mixture with zinc and starch maysuit well.

At the time this paste was first spoken of Lassar be-lieved that salicylic acid was almost a specific foreczema, and he therefore combined it with his pastein the following formula:

Acid, salicyl 2.0Yaselin 50.0Zincoxid.)

« 25.0 M.Amyl. J

This paste should be spread over the inflamed andoozing region in a thick layer, and may afterward becovered with a thin layer of absorbent cotton. Thedressing is changed once or twice daily if the secre-tion is considerable; if not, it may be left in positionfor several days oftentimes. By means of this pastealone many cases may be completely healed withouthaving recourse to more stimulating remedies in thelater stages. The salicylic acid is of no practical usein acute forms, and although a small percentage israrely irritating, it is best left out. The chief actionof salicylic acid cutaneously is of a keratolytic char-acter— that is, it has the property more than anydrug known of softening and dissolving the hornylayer, without at the same time causing a dermatitis.In the later stages of eczema, where there is infiltra-

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tion in the cerium and hypertrophy of the horny layer,the addition of the salicylic acid to the paste is in-dicated, even in much greater proportions than in theabove formula.

Salicylic ointments in the treatment of infantileeczema have been much praised. Taking this paste asa base, various medicaments, such as sulphur, ichthyol,boracic acid, etc., may be incorporated with it, and insome instances a more favorable effect obtained thanwhen the drug is mixed with animal fats or withvaseline simply.

Many attempts have been made to produce prepara-tions that when dried upon the skin will form firm butflexible thin coatings, exerting a certain amount ofpressure, protecting equally from the irritation of theouter air and from the entrance of micro-organisms,to which various medicaments of known value ineczema may be added. Pick introduced gelatinedressings, which he at first used in combination withchrysarobin in the treatment of psoriasis, and to theseUnna and Beiersdorf proposed to add a percentage ofglycerine. Later Pick brought forward a sublimategelatine dressing which he recommends both for theearlier erythematous and papular stages, and for thethickened, scaling varieties. Thirty grams of glycer-ine are mixed with sufficient water, macerated forseveral hours, then liquefied on the water bath andevaporated to 75 grams. To this are added 25 gramsof glycerine and 0.05 grams of corrosive sublimate.This gelatine dressing is liquefied by heat when used,and a thin coating is painted over the affected part.In chronic eczemas of the lower leg especially, thispreparation has often proved itself of value.

Acting upon the principles of the gelatine dressing,and in the endeavor to obtain a preparation that wouldoffer all its advantages without its disadvantages,

20

notably that of being obliged to heat the preparationeach time before applying it, Pick introduced trag-acanth, and Elliot proposed bassoriu as a base for in-corporating medicaments, preparations which, likegelatine, are useful in certain forms of eczema as wellas in a variety of cutaneous affections. Unna, work-ing upon the same lines, introduced ichthyol varnish,a mixture of ichthyol in various proportions withstarch, solutions of albumin, etc. An almost endlessvariety of substances may be obtained in this waywhich form protective coatings upon the skin. Theiruse is limited, however, as it has not been shown thatthey are superior to other methods, and in many in-stances their inferiority is distinctly apparent. In cer-tain cases, however, they are a useful addition to ourresources.

Much greater practical value must be accorded tothe salicylic soap-plaster recommended by Pick for thevesicular and moist as well as the thickened forms ofeczema. Its advantages in my experience are fargreater in the latter class of cases. Its composition isas follows:

Emplastr, saponat. liquefact. ....80.0Olei olivar. 20.0Acid, salicyl 2.5 M.

The plaster is spread, and cut into strips which arefirmly adapted to the affected parts and left in posi-tion for several days. Its great advantage is that it isnot necessary to change it frequently.

A real value must be admitted for ichthyol andresorcin, which belong, according to Unna, to thegroup of reducing agents, and owe their therapeuticaction to this property. Ichthyol as used is really asulphoichthyolate of ammonium which is obtainedfrom a bituminous substance found in the Tyrol. Its

21

efficacy is probably due in part to the large percent-age of sulphur it contains, and in part to its consistency, as it readily forms a sort of protecting andadhesive varnish when applied to the skin. Unnaconsiders it of special efficacy in the so-called nervouseczemas and in intertriginous affections. It may beused in solution with water in various proportions, ina thick varnish, mixed with albumin or starch or inointment form. On moist patches an emulsion withwater of the strength of one to ten, or one to twenty,is often of service, especially when followed by asoothing ointment or paste. It may also be incorpo-rated with the various pastes, varnishes and gelatinepreparations that have been described. The objec-tions to its use are its color and disagreeable odor.Thiol has the advantage of being odorless, and hasseemed to me in many cases an efficient substitute forichthyol.

Resorcin, which is of much value in many cutaneousaffections, has but a small place in the treatment ofeczema. In certain scaling forms it may be used withadvantage, but its irritating properties, especially incertain individuals, limit its range of usefulness inthis affection.

Much prominence has also been given by Unna tohis treatment by ointment and plaster muslins, asystem that has no doubt its advantages, but whichshould not be looked upon as superseding otherequally good, and in certain cases superior methods.The ointment muslins are made by impregnatingmuslins on one or both sides with the ointment wishedfor. The muslins thus prepared are cut into strips,applied to the skin and bound down by muslin band-ages. It is often of advantage to spread the ointmentor pastes that we wish to use on muslin, and ready-made applications of the sort are often convenient,

22

but it is difficult to see how the method, so minutely-elaborated, contains any new principle or offers anyespecial therapeutic advance.

The plaster muslins are made by spreading the drugto be used upon a thin layer of gutta-percha backedwith muslin. The advantage claimed for this kind ofplaster is that a larger percentage of the medicamentis brought into contact with the skin, the amount ofadhesive substance needed being so much smaller. Ineczemas these plasters have been recommended for thetreatment ©f the chronic infiltrated patches, and areoften of much service when combined with whiteprecipitate, salicylic acid, etc. Their usefulness isfar greater in tuberculosis and in chronic processeswith hypertrophy of the horny layer than in eczema.

Lassar’s method of treating eczema, even in theacute stage, by means of baths may be mentioned,active remedies such as tar, chrysarobin, etc., beingborne while in the bath without irritation. Thismethod was supplemented by the use of ointments,pastes, etc., in the intervals when the patients werenot in the bath.

In conclusion, it may be repeated that the writer’sintention was merely to touch upon some of themethods of treatment that have been suggested of lateyears. The older, and in many cases more reliable,methods have not been mentioned. It is to be re-membered that there is as yet no specific for eczema.That the regulation of the diet, attention to hygiene,and the removal of any conditions unfavorable to thegeneral health, are of very great importance. Internalremedies are often of great aid, especially in the so-callednervous forms ; and success depends in this class ofcases more upon the general management of the pa-tient’s life, and upon moral influence and support,than upon topical applications.

THEBOSTON

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