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316 CALIFORNIA AND WESTERN MEDICINE Vol. 41, No.

5
point, attempting to reconstruct a machine which will They are often quite rebellious to treatment, and
give the most perfect performance possible. when they yield they are prone to recur, the re-
This paper should be re-read and studied carefully, currence choosing the same or a near-by site.
for the meat of its contents is in very concentrated
form. A distinctive feature is that the plaques attain
their full development at once, not spreading con-
DOCTOR BEACH (Closing).-I am grateful to you, centrically as in ringworm.
gentlemen, for the indulgence and leniency shown me While commonly the lesion retains the same
in your discussion. Twelve years of priceless intima- appearance throughout the entire extent of the
cies and close psychic rapport with the urological nummular plaque, it happens at times that the
patient, drawn from every walk of life, has furnished
me, as well as most of my urological brethren, a center fades with a disappearance of all, or nearly
different perspective and a new horizon. The latter all of the vesicles, while the borders become ac-
is responsible for my extraordinary interest in the tively inflamed and vesicular. This variety more
subject of personality. Perhaps not all of these ideas closely resembles ringworm than the ordinary
are unequivocal, but they represent some thoughts
gleaned in the search of a deeper and better com- type, and is designated by Brocq 2 as the trico-
prehension, especially as to the "How?" "Why?" and phytoid form.
"For what reason?" of it all.
ETIOLOGIC CLASSIFICATION

NUMMULAR ECZEMA* Upon an etiologic basis French writers consider


subvarieties such as (1) traumatic, (2) alimen-
By ERNEST DWIGHT CHIPMAN, M. D. tary or toxic, (3) neuro-arthritic, and (4) reflex.
San Francisco The original description of arthritic eczema by
DIscussIoN by William H. Goeckerman, M. D., Los Bazin corresponds exactly with our present-day
Angeles; Kendal Frost, M. D., Los Angeles; Howard picture of nummular eczema. It is interesting to
Morrow, M. D., San Francisco. note the emphasis which is placed upon the nerv-
ous system by the French, who refer constantly
HE ordinary eczematous patch is indistinct in to arthritic or neuro-arthritic types of eczema.
outline. The insensible blending of the dis- The recognition of the reflex variety adds another
eased with the healthy area is, in fact, a cardinal reason for the confusion which seems to exist
diagnostic point. There is, however, at least one in some quarters as to the relationship between
-form of eczema which presents a border so sharply nummular and what is called neurotic eczema.
defined that it has been given such designations This subject will recur presently.
as orbicular, discoid, circumscribed, herpetoid, As to the mechanism whereby the lesions occur
nummular, and possibly still others. Of all these, in sharply defined plaques, Brocq offered the sug-
none seems more appropriate than nummular for, gestion that they choose areas of diminished re-
meaning coin-shaped, the name indicates a circular sistance comparable to the fixed drug eruptions.
configuration as well as a clearly defined margin.
SECONDARY NUMMULAR FORMS
American textbooks grant little space to num-
mular eczema, although it is given complete recog- Thus far our discussion has been limited to
nition by European writers. The importance original or primary forms; but by other means
which Brocq 1 attached to it is evidenced by his secondary nummular forms may be produced.
division of eczema into four types, viz., (1) true These may cause confusion. First, is the transi-
vesicular eczema (amorphous eczema of Dever- tion of a primary amorphous patch into a sharply
gie), (2) papulovesicular eczema, (3) nummular defined plaque by reason of invasion by bacteria
eczema, (4) erythematous eczema. or fungi. Next is the development of an eczema-
tization upon a preexisting, sharply defined der-
STRIKING CHARACTERS OF NUMMULAR matosis such as parapsoriasis, tricophytosis, even
ECZEMA certain syphilids, tuberculids, and dermatophytids.
The striking characters of nummular eczema This last item is of present-day importance, when
are the circular, or sometimes oval, form and the so much confusion exists concerning the concept
sharp outline. The lesions are circumscribed by of dermatophytids. Also to be remembered is the
a clearly defined circular border outside of which ease with which a neurodermite becomes eczema-
the appearance is perfectly normal, and inside of tized.
which the protean manifestations of ordinary The situation, already complicated by the neces-
eczema may be present. So sharp is the outline sity of distinguishing between primary and sec-
of these lesions that a ringworm infection is at ondary forms, is rendered more difficult by the
once suggested. description of like pictures under different names.
While plaques may appear on any portion of Especially confusing at times is the designation of
the body, the favored sites are the arms and hands, an eruption as neurotic eczema. A brief review
more particularly the dorsal surface of the hands of this topic will be worth while.
and fingers. NEUROTIC ECZEMA
The size of the plaques is variable. They may The idea of neurotic eczema first became promi-
be as small as a twenty-five-cent piece or as large nent in this country following the publication of
as the palm of the hand. The average size is per- a paper by Bulkley 8 in 1898, in which he dealt
haps slightly larger than that of a silver dollar. with various forms or phases of nerve disturb-
* Read before the Dermatology and Syphilology Section ances seen in connection with neurotic eczema.
of the California Medical Association at the sixty-third
annual session, Riverside, April 30 to May 3, 1934. These were considered under the following heads:
November, 1934 NUMMULAR ECZEMA-CHIPMAN 317

(1) neurasthenia, (2) nervous and mental shock, infection, though not the idea that circumscribed
(3) reflex phenomena of internal or peripheral eczemas may occur as the result of reflex action
origin, and (4) neuroses, either structural or from some disordered internal organ.
functional. Commonly, the diagnosis of neurotic
eczema was made on the basis of a phimosis or SUMMARY
the advent of a new tooth. Eruptions which oc- We may summarize briefly the questions of
curred on the arms or legs in a linear distribu- etiology, diagnosis, and treatment,
tion, or in anything approximating the course of Etiology.-Of course, if we knew the precise
a nerve, were called neurotic. cause we would be speaking of dermatitis and
In these cases there appears to be some basis not of eczema. We may seek, however, an ap-
for using the term "neurotic," as the supposition praisal of possible etiologic factors. Doing this
of definite nerve involvement seems tenable. In it seems to me that, granting its most frequent
many instances, however, the term "neurotic" has sites are the exposed surfaces of the hands, and
been applied simply because the subject was obvi- making due allowance for the effects of traumata,
ously a nervous individual, quite as the older our primary search should be for some internal
generation used the term "gouty eczema," to cover disorder. Whether it be the result of toxemia, of
any eczema which occurred in an arthritic subject. focal infection, or reflex action or of what not, the
We shall be upon much safer ground if we limit sudden appearance of a plaque in full develop-
the use of the term "neurotic" to those cases in ment renders the concept of internal causation
which there is definite nerve pathology, and for most plausible.
the rest accept the doctrine that the neurogenous Diagnosis.-The diagnosis of the ordinary pri-
background may be a participating factor in any mary form is simple. The tricophytoid form so
case of eczema, whether nummular or amorphous, completely mimics ringworm that we will make
and that possibly it may be the prime factor in microscopic examinations when the history tells us
some cases. that we shall find nothing. The composite forms
There are those who use the terms "nummular" often call for diagnostic acumen. They require
and "neurotic" interchangeably. It is readily complete history-taking, careful analysis of the
granted that nummular eczemas exist upon a neu- lesions and a determination of what the primary
rotic basis, but not all neurotic eczemas take on or essential elements may have been. Those sec-
the nummular configuration. It is quite possible ondary forms which were originally amorphous
that the distinction is not important, as long as had better be referred to as having undergone
we recognize the etiologic factors. And while it nummularization. This makes for clarity in our
may not be possible to designate any particular own minds, and serves as well our efforts at de-
reaction as neurotic because of its specific morph- scription.
ology, there is, nevertheless, a series of reactions, Treatment.-The subject of treatment requires
familiar to us all, which extends from the typical little discussion. The lesions are rebellious to local
circular marginate nummular all the way down to treatment, although at times they yield to frac-
the little amorphous patch in which the nervous tional doses of x-ray and the application of crude
system seems to give a clue to the dominant etio- coal tar. They are very prone to recur, however,
logic note. There are all degrees of sharp out- which suggests an undiscovered cause. What ap-
line, some only suggesting a circle, some linear pears most logical is to regard the lesion as a
in distribution suggesting nerve involvement, as in cutaneous reaction, the outward expression of
zoster and accounting for the old term "herpe- something wrong within. This calls for a com-
toid." Some, but not all, are rebellious to treat- plete survey of the patient from A to Z.
ment, and some but not all, have a tendency to Borderline Cases.-One more question arises,
recur. Most commonly, the subjects are women viz., are we dealing with an eczema, or something
of neurotic temperament, or those who have had which will one day be taken out of that mass of
emotional upsets or are depressed with worries. reactions from which already so many entities,
But if the lesions are not sharply defined circular have been abstracted?
plaques, they should not be called nummular; and The only reasons for calling it eczema are that
unless there is evidence of definite nerve pa- it oozes and itches, and that we do not know its
thology, they should not be called neurotic. cause. The same is true of dermatitis herpeti-
CIRCUMSCRIBED ECZEMA OF THE VIENNA formis and granuloma fungoides. My own feeling
SCHOOL is that the name has been handed down to us by
What French writers called nummular was a former generation in which 75 per cent of der-
termed "circumscribed eczema" by the Vienna matoses were given the label of eczema, but that
School. The latter considered eczema ani as in- some time in the future we may find a new name
cluded in this type, although today we sometimes on the basis of definite knowledge attained.
attribute the sharp outline of this affection either REPORT OF CASE
to primary or secondary mycotic or bacterial in- A case history is appended.
vasion. Ehrmann emphasized the statement that Mrs. S. complained of an eruption on the dorsal
circumscribed eczemas may be of internal origin. surface of the right hand of several weeks' duration.
As an example, he cited chronic appendicitis as The general history revealed a nervous state, with
an etiologic factor. This is of interest today, as chronic colitis. The eruption was recurrent and its ap-
pearance coincided with exacerbations of the intestinal
his observation antedated the doctrine of focal condition.
318 CALIFORNIA AND WESTERN MEDICINE Vol. 41, No.5

Upon inspection, an annular lesion the size of a fifty- HOWARD MORROW, M. D. (384 Post Street, San Fran-
cent piece was found. The sharply defined margin cisco).-The question of the classification of the ecze-
was composed of fine vesicles. The center was clear. mas is one which has evoked controversy for many
The patch was of the same size as at its inception, years. With increasing knowledge, a number of dis-
but the central portion had gradually become clear, ease entities have been separated from the category
leaving only the margin. Itching was moderate. Quite of eczema. Nevertheless, this term continues to be
close by were two small erythematous patches, the used to classify a group of eruptions which, clinically,
size of a large split pea. are not very closely related. The condition which the
In spite of the history of recurrence, in spite of the author designates as nummular eczema is recognized
evolution, the appearance of ringworm was so great by most dermatologists under various names, includ-
and the satellite lesions so suggestive of dermatophy- ing papulovesicular and neurotic eczema. The latter
tids, that scrapings were made. These were negative, term is objectionable, in that it causes confusion with
however, for fungi. After two fractional doses of neurodermite (lichen simplex chronicus of Vidal, etc.).
x-ray, plus local applications of crude coal tar, the Furthermore, a neurogenic etiology is rarely demon-
lesions disappeared. I believe that this patient pre- strable. For the present we must recognize the fact
sented lesions of the tricophytoid type described by that there is such an entity as nummular or papulo-
Brocq. vesicular eczema, and hope that eventually an etio-
2000 Van Ness Avenue. logic factor will be determined which will allow us to
give it a more satisfactory term.
REFERENCES
1. Brocq, L.: Traite Mlementaire de Dermatologie
Pratique, 11:64-75. MUSCLE AND TENDON INJURIES-IN
2. Brocq, L.: Vide supra. THE SHOULDER REGION*
3. Bulkley, L. D.: Neurotic Eczema, J. A. M. A.,
pp. 888-892 (April 16), 1898. By RALPH SOTO-HALL, M. D.
AND
DISCUSSION KEENE 0. HALDEMAN, M.D.
WILLIAM H. GOECKERMAN, M. D. (1680 North Vine San Francisco
Street, Los Angeles).-So-called nummular eczema
has interested me for many years because of its dis- DISCUSSION by Hugh T. Jones, M. D., Los Angeles;
tinctive clinical behavior and appearance. It can Edgar L. Gilcreest, M. D., San Francisco; J. Minton
easily be differentiated from the ordinary forms of Meherin, M. D., San Francisco.
eczema. When I first became familiar with this skin
picture, it was spoken of as impetigo circinata. The to the numerous complex structures in-
late Doctor Harris of Chicago was especially inter- D[UE
volved, the diagnosis of injuries to the shoul-
ested in it, and frequently called attention to its dis-
tinctive characteristics. Somewhat later I had a tend- der region has been inexact and often erroneous.
ency to place it under so-called infectious eczematoid A great interest has been awakened recently in
dermatitis. As our knowledge of the probable mecha- the diagnosis and treatment of these muscle and
nism of trichophytids increased, there was some tend- tendon injuries. Recent workers have emphasized
ency to explain its peculiar behavior and configuration
on this etiologic basis, although I, personally, never the fact that the actual pathology is often over-
could see much reason for this. However, in the light looked, and the diagnosis of sprain or arthritis
of still further studies on trichophytids, it seems to is made with the result that proper treatment is
me worth while to study such cases further from the not instituted early, and that disability is unduly
standpoint of trichophytosis. In a number of in- prolonged or made permanent. Many of the cases
stances in my experience where the skin lesions were
present in patients with early pernicious anemia and in our series exemplify this point.
diabetes, it was only after the systemic condition was We have studied eighty-eight consecutive cases
materially improved that the treatment of this form of of muscle and tendon injury, of which number
eczema proved satisfactory. I should not like to draw 40 per cent occurred in the region of the shoulder.
any definite deductions from this observation except
that I have learned to look carefully for some sys- The following represents the frequency of such
temic disturbances, even if the patient seems quite injuries in our series: Supraspinatus tear, 13;
well. I doubt if we can devise any fully satisfactory biceps (long head) rupture, 6; biceps (short
term for this skin picture other than a descriptive one, head) rupture, 2; biceps (slipping long head), 2;
until we know more about its causation. There is no triceps rupture, 2; rhomboideus major, 6; latis-
doubt in my mind that the eruption is distinctive in
its clinical behavior and appearance. simus dorsi, 2; trapezius, 1.
SUPRASPINATUS TEAR
KENDAL FROST, M. D. (1930 Wilshire Boulevard, Los A complete or incomplete tear of the supra-
Angeles).-This group of eczematous eruptions forms spinatus tendon, where it forms the roof of the
a relatively small percentage in the large group of shoulder joint, was first described by Codman'
eczemas, yet it is of considerable importance in this
differential diagnosis of circumscribed eczematoid in 1906. Since that time additional reports, to-
eruptions. The two major conditions to consider in gether with papers by Brickner2 and by Wilson,8
this regard are (1) eczematoid ringworm or dermato- have demonstrated that many cases of "painful
phytosis, and (2) infectious eczematoid dermatitis. shoulder" or "subdeltoid bursitis" are actually
These two conditions may resemble nummular eczema
very closely, yet the etiologic factors of each result due to a rupture of the supraspinatus tendon.
in a radical difference in therapeutic principle. The Ackerson and Codman4 have observed a complete
fungus of the eczematoid ringworm reacts to keto- or partial tear of the supraspinatus tendon in
lytic and antiparasitic agents which aggravate both 39 per cent of one hundred specimens of shoulders
the nummular and the eczematoid lesion. The latter
being a low-grade pus infection, reacts therapeutically which were dissected. This finding, we believe,
similarly to a pure eczema, as far as local treatment is does not concur with observations made by other
concerned. Its major importance lies in discovering *Read before the Industrial Medicine and Surgery Sec-
the source of infection, as against the more subtile tion of the California Medical Association at the sixty-third
metabolic etiology of the nummular eczemas. annual session, Riverside, April 30 to May 3, 1934.

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