Is a const.i.tutional cause sufficient to provoke an attack?

Yes; but often the attack is brought about in those so predisposed by some local or external irritant.

Mention some of the external causes.

Heat and cold, sharp, biting winds, excessive use of water, strong soaps, vaccination, dyes and dyestuffs, chemical irritants, and the like. There is a growing belief that some cases presenting eczematous aspects are probably parasitic in origin. In fact, some observers hold to the microbic view of all cases of eczema.

Contact with the rhus plants, while producing a peculiar dermat.i.tis, usually running an acute course terminating in recovery, may, in those predisposed, provoke a veritable and persistent eczema. In fact, in our examination as to causes in a given case, especially of the hands and face, all possible exciting factors should be inquired into, such as the handling of plants, chemicals, dyes, etc.

[Ill.u.s.tration: Fig. 24. Eczema of Face.]

Is eczema contagious?

No. The acceptance of a parasitic cause for the disease, however, necessarily carries with it the possibility of contagiousness under favoring conditions. Such is not supported, however, by practical experience.

What is the pathology?

The process is an inflammatory one, characterized in all cases by hyperaemia and exudation, varying in degree according to the intensity and duration of the disease. The rete and papillary layer are especially involved, although in severe and chronic cases the lower part of the corium and even the subcutaneous tissue may share in the process.

Do the cutaneous manifestations of the eruptive fevers bear resemblance to the erythematous type of eczema?

Scarlatina and erysipelas may, to a slight extent, but the presence or absence of febrile and other const.i.tutional symptoms will usually serve to differentiate.

What common skin diseases resemble some phases of eczema?

Psoriasis, seborrh[oe]a, sycosis, scabies and ringworm.

How would you exclude psoriasis in a suspected case of eczema (squamous eczema)?

Psoriasis occurs in variously-sized, rounded, _sharply-defined_ patches, usually scattered irregularly over the general surface, with special predilection for the elbows and knees. They are covered more or less abundantly with whitish, silvery or mother-of-pearl colored imbricated scales. The patches are always dry, and itching is, as a rule, slight, or may be entirely absent. Eczema, on the contrary, is often localized, appearing as one or more large, irregularly diffused patches; it merges imperceptibly into the sound skin, and there is often a history of characteristic serous or gummy oozing; the scaling is usually slight and itching almost invariably a prominent symptom.

How would you exclude seborrh[oe]a (eczema seborrhoic.u.m) in a suspected case of eczema?

Seborrh[oe]a of the scalp is more commonly over the whole of that region and is relatively free from inflammatory symptoms; the scales are of a greasy character and the itching is usually slight or nil. On the other hand, in eczema of this region the parts are rarely invaded in their entirety; there may be at times the characteristic serous or gummy oozing; inflammatory symptoms are usually well-marked, the scales are dry and the itching is, as a rule, a prominent symptom. These same differences serve to differentiate the diseases in other regions.

How does scabies differ from eczema?

Scabies differs from eczema in its peculiar distribution, the presence of the burrows, the absence of any tendency to patch formation, and usually by a clear history of contagion.

How would you exclude ringworm in a suspected case of eczema?

Ringworm is to be distinguished by its circular form, its fading in the centre, and in doubtful cases by microscopic examination of the sc.r.a.pings.

How does eczema differ from sycosis?

Sycosis is limited to the hairy region of the face, is distinctly a follicular inflammation, and is rarely very itchy; eczema is diffused, usually involves other parts of the face, and itching is an annoying symptom.

State the general prognosis of eczema.

The disease is, under favorable circ.u.mstances, curable, some cases yielding more or less readily, others proving exceedingly rebellious.

The length of time to bring about a result is always uncertain, and an opinion on this point should be guarded.

Upon what would you base your prognosis in the individual case?

The extent of disease, its duration and previous behavior, the removability of the exciting and predisposing causes, and the attention the patient can give to the treatment.

In eczema involving the lips, face, s.c.r.o.t.u.m, and leg, and especially when this last-named exhibits a varicose condition of the veins, a cure is effected, as a rule, only through persistent and prolonged treatment.

Does eczema ever leave scars?

No. Upon the legs, in long-continued cases, more or less pigmentation usually remains.

How is eczema treated?

As a rule, eczema requires for its removal both const.i.tutional and external treatment.

Certain cases, however, seem to be entirely local in their nature, and in these cases external treatment alone will have satisfactory results.

What general measures as to hygiene and diet are commonly advisable?

Fresh air, exercise, moderate indulgence in calisthenics, regular habits, a plain, nutritious diet; abstention from such articles of food as pork, salted meat, acid fruits, pastry, gravies, sauces, cheese, pickles, condiments, excessive coffee or tea drinking, etc. As a rule, also, beer, wine, and other stimulants are to be interdicted.

Upon what grounds is the line or plan of const.i.tutional treatment to be based?

Upon indications in the individual case. A careful examination into the patient's general health will usually give the cue to the line of treatment to be adopted.

Mention the important remedies variously employed in the const.i.tutional treatment.

_Tonics_--such as cod-liver oil, quinine, nux vomica, the vegetable bitters, iron, a.r.s.enic, malt, etc.

_Alkalies_--sodium salicylate, pota.s.sium bicarbonate, liquor pota.s.sae, and lithium carbonate.