Exudative Diathesis

EXUDATIVE DIATHESIS, an anomaly of constitution in which a child's organism is prone to inflammatory diseases of the skin and mucous membranes. The term E. d. was introduced into science in 1905 by Prof. Czerny. Much of this diathesis was known earlier and appeared in literature under the name of inflammatory diathesis (Th. White, 1782), but Czerny's great merit lies in the clear delineation of the clinical picture, its relation to nutrition, and its significance for the pathology of childhood. Gradually, this concept expanded, changed, acquired layers, and in connection with this, the name also changed. French authors included this diathesis in the concept of arthritism, the English in that of lithemia, Stoeltzner in the concept of oxypathy, Heubner, Sittler, and others in the concept of lymphatism. Much more correct, however, is isolating it into an independent form, and the most suitable name is exudative-catarrhal diathesis. Exudative-catarrhal diathesis is a congenital anomaly of constitution. Its manifestations are encountered in many family members and are transmitted to offspring. According to Maslov's data, in the parents of exudative children, the presence of the same diathesis in childhood is noted in 43.7% (homologous heredity); quite often there is generally unfavorable aggravating heredity (tuberculosis in 13–17%, alcoholism, neuropathies, etc.), and only in 12.7% can the parents be considered healthy. Transmission of the predisposition through the mother is more frequent, but transmission through the father is also undoubted. For the most part, exudative children are the first or second in their family. According to Pfaundler, boys have this diathesis twice as often as girls; however, according to Maslov and other authors, no such clear predominance of sex is noted. Age plays a large role. Exudative-catarrhal diathesis is most often revealed at the age of 3–6 months, and its stormy manifestations persist for the first two years. Then the child's organism is gradually desensitized, and the manifestations of the diathesis in subsequent years become softer and rarer and may even pass completely by the period of puberty. For revealing the diathesis, social-living conditions and feeding are of great importance. Unhygienic surroundings, overcrowding, gross errors in care, overfeeding, and improper composition of food contribute to an earlier revelation of the diathesis and a more severe course of its manifestations. But in general, the social-living factor does not play a decisive role. According to E. Granat, exudative children live in satisfactory housing conditions significantly more often than the entire mass of children and nevertheless show manifestations of the diathesis. In the majority, exudative children are children of white-collar workers (53%); children of workers constitute only 37%. Most often, E. d. is encountered in children born in the winter months. The first skin changes are usually revealed in the autumn and winter months; in the summer, E. d. does not appear for the first time but only gives flare-ups. This dependence between the season of the year and the manifestation of the diathesis is possibly connected with the sanitary-hygienic peculiarities of care. Acute febrile diseases often lead to a subsiding of the diathesis. Exudative-catarrhal diathesis is a very common anomaly of constitution. Cameron (America) believes that the majority of modern children have this diathesis in one form or another. According to Bartel, its frequency in Vienna is 44%; according to Zellweger, in Basel, it is 24%. According to Maslov's data, among Leningrad children, exudative-catarrhal diathesis is especially frequent in children of the first two years (31.7%), much rarer in children 2–6 years old (21.7%), and in children 6–15 years old, only 8%. The essence of E. d. is not yet fully clear to us. Some are inclined to see at the basis of this anomaly of constitution a weakness of the entire connective tissue and explain the whole picture by a disturbance of its biochemical and biological properties, poor resistance, and sluggishness of chemical regeneration (Bogomolets). The peculiarity of the enzymatic apparatus in E. d. and of intermediary metabolism has been proven (Maslov). Recently, many authors have put forward the position that E. d. is an allergic state, a manifestation of hypersensitization of the organism to various kinds of substances which produce no effect on a normal subject or produce only a pharmacological action. The results of skin tests with extracts of food substances and with proteins not included in the composition of food (epidermal scales, animal hair, etc.) speak in favor of this view. According to the research of a number of authors (Moro, Gyorgy, Witebsky, Woringer, and others), exudative children in the majority of cases react positively to egg white and less often to cow's milk. These so-called trophoallergens dominate during the first 12 months of life; pneumoallergens are encountered in the 2nd–3rd year, and other manifestations at a later age. American authors (Stuart, Shannon, Blackfan, O'Keefe, Rowe, and others) conducted numerous experiments with skin tests to establish the type of food substance to which there is increased sensitivity in exudative children and to exclude it from food and the environment. But upon strict scientific verification, it turned out that in the majority of cases, the tests do not possess strict specificity. They only allow one to judge the increased state of readiness for irritation of the epidermis or vessels, and their significance for substantiating dietotherapy is very small (Scholtz, Corper, Noeggerath, Reichle, and others). It is quite possible that the skin manifestations are not caused by proteins, and the matter concerns only a parallergic disease. Increased sensitivity of the skin in exudative patients has been revealed not only to proteins but also to non-protein substances, e.g., to fat (Gartier, Czerny, Monrad, and others), to flour (Lemaire et Lesne), to formol, turpentine (Tachau), mustard (Rakhmilevich), and to mechanical irritations. A number of attempts were made to approach the pathogenesis of E. d. by studying the peculiarities of metabolism. Thus, Scheer attributes the ability of cellular colloids to bind water in E. d. to a large accumulation of acid valencies, and due to their accumulation in the skin, alkalosis develops in the blood. According to Scheer, the average figure for reserve alkalinity in E. d. is 42 volume % CO₂ (with fluctuations from 23.6% to 56.6%). An increased content of organic acids and ammonia is determined in the feces. Verification data by Burtscher, Niederwieser, and Muravina showed that in the majority of cases of E. d., the figures for alkaline reserve are below normal, and sometimes very significantly; the figures for organic acids are slightly increased; consequently, there is more likely acidosis than alkalosis. No connection between shifts in acid-base balance and the severity of manifestations is noted. It has been established that in children with E. d., the total amount of serum proteins is reduced, especially the content of globulins (Tur, Levy). This hypoproteinemia is not caused by the loss of protein as a result of inflammatory exudation but is a constitutional feature of the blood, which causes a decrease in the oncotic pressure of plasma proteins, explaining both the hydrolability of exudative patients and the reduced resistance to infections. The amount of non-protein substances in the serum is usually within normal limits. Czerny, Monrad, and others speak of reduced tolerance to fats, of a reduction in the assimilation of fats. According to Steinitz and Weigert, a portion of the administered fat is not utilized by the organism. The study of the lipemic curve by Friedman and Shmerko showed that in exudative patients who react with an exacerbation of skin phenomena to the introduction of fatty food, curves are obtained with a very sharp rise, a short-term maximum, and a rapid fall. In the part of exudative patients who tolerate fat well, the blood fat curve gives a slow and gradual rise and fall. In E. d., there is also a reduction in tolerance to sugar; alimentary glycosuria is easily obtained with a small exceeding of the limits of the norm (Aschenheim and others). According to Lopatin, blood sugar is within normal limits in the latent period but decreases sharply in the period of skin manifestations. One can also note the tendency of E. d. to retain chlorine and sodium: the amount of NaCl in the blood and tissue fluids is increased (Freund, Opitz, Menshikov). The question of water metabolism is closely connected with salt metabolism. Czerny believes that E. d. depends on a congenital defect in the chemistry of the organism, mainly in the tissues, allowing fluctuations in water content (hydropathic constitution). A certain poverty of the blood in amylase and antitrypsin with a normal content of catalase and lipase is quite characteristic for E. d. (Maslov, Morev). Especially characteristic is the instability of the enzymatic apparatus and its rapid exhaustibility. In appearance and nutrition, exudative children most often belong to two types: pasty and thin. With a pasty habitus, the weight of the children is usually above normal, but the children are loose, the musculature is flaccid, the skin and mucous membranes are pale, and the children are sleepy and phlegmatic. Blue eyes are quite frequent in them. The weight curve of such children is distinguished by its unevenness: steep rises, frequent falls, and weight plateaus are observed, caused by the lability of water metabolism. With a thin, erethic habitus, we have a weight below normal, delicate, pale skin, shiny eyes, long eyelashes, insufficiency of the subcutaneous fat layer, and increased irritability.

According to Granat, 44% of all exudative patients can be classified as the first type, 42% as the second type, and only 14% have normal weight. The earliest manifestations of exudative diathesis include seborrhea of the newborn, or so-called 'gneiss,' i.e., the formation on the head around the large fontanelle and on the crown of brownish greasy scales with a hyperemic, and sometimes weeping, surface beneath them. Later, eczema of the entire scalp may form in these areas. Milk crust (crusta lactea) appears quite early, i.e., limited redness of the cheeks with thickening of the epidermis, which becomes covered with small white bran-like scales and subsequently develops into widespread weeping eczema of the face. A tendency toward intertrigo appears relatively early. Unlike ordinary intertrigo, in exudative patients it appears even with perfectly proper care and, moreover, not only in the groin and armpits, but also behind the ears, in the joint flexures, on the neck in skin folds, and on the limbs. Eczema develops on the basis of intertrigo as a secondary phenomenon. A very frequent manifestation is strophulus, i.e., a rash in the form of red spots, in the center of which rises a spherical, somewhat firm, dark-red nodule, accompanied by significant itching, with a predilection for localization in groups on the arms, legs, and around the joints. The presence of itching causes, both in strophulus and in facial eczema, the appearance of excoriations, secondary infection of the skin, and transition into impetiginous and crusty forms. Skin manifestations on the face and head are usually the most frequent. Regarding mucous membranes, the manifestations of exudative diathesis are primarily expressed by the so-called geographic tongue (lingua geographica), i.e., the appearance on the tongue of white, limited stripes and spots, which are inconstant and bizarre in shape, caused by swelling and desquamation of the epithelium. This phenomenon is not encountered particularly often. Much more frequent is a tendency toward recurrent catarrhs of the nasopharynx (coryza, pharyngitis, bronchitis). These catarrhs in children with exudative diathesis can proceed with prolonged high temperature, lead to bronchiolitis and asthmatic bronchitis, and sequential enlargement of the lymph nodes. When combined with lymphatism, we will have hyperplasia of the tonsils and the follicular apparatus of the nasopharynx. In some children, there is also instability of the gastrointestinal tract, easy onset of diarrhea, and mucous stools. In individual cases, manifestations of exudative diathesis can also include signs of irritation of the urogenital tract in the form of vulvovaginitis, cystitis, and pyelitis. A fairly constant and characteristic phenomenon is also irritable weakness of the nervous system. In many cases, nervousness is a secondary phenomenon resulting from constant skin itching and errors in the care and upbringing of children, but in a number of cases, signs of increased excitability in the form of pylorospasm, restless sleep, crying out, spastic constipation, enuresis, etc., precede or run parallel to it. One should also note the abnormal state of their autonomic nervous system tone. In most cases, there is a disturbed balance in the sense of a predominance of vagotonia and hypotonia of the sympathetic system. This state is linked to a disturbance of protein metabolism: protein causes the secretion of digestive juices rich in alkalis and alkaline salts, the organism becomes depleted of calcium, and hence the lowering of the tone of the sympathetic system. Regarding the blood, one can note as a characteristic phenomenon eosinophilia (up to 10-20%) in the presence of slight leukocytosis (especially during the period of skin manifestations). Regarding the cardiovascular apparatus, one can emphasize a certain lability, instability of cardiac activity, a slight degree of hypertension (an increase in blood pressure to 110-115 instead of 84-97 mm in normal, according to A. Sokolov) and a peculiarity in the structure of the capillaries with a disordered network of more tortuous and intertwined terminal capillary loops (according to Maslov). Enlargement of the liver and spleen is a frequent phenomenon. Regarding the endocrine apparatus, one sometimes finds an enlarged thymus gland and hypofunction of the thyroid. Such is the picture of exudative diathesis in early age. In older children, its manifestations become more and more rare and change in form. Usually, skin processes are limited to urticaria, strophulus, less often lichen urticatus, prurigo mitis, and idiosyncrasy. A tendency toward asthma and vagotonia remains. In the period of 4-12 years, the child becomes desensitized to trophoallergens and tolerates well what he previously tolerated with difficulty. The course of exudative diathesis largely depends on the lifestyle and environmental conditions of the child. Under good conditions, the diathesis can remain in a latent state for a long time and only occasionally produce flare-ups and exacerbations of the skin and mucous membranes. Under unfavorable conditions of environment, care, and feeding, skin manifestations in the form of seborrhea, intertrigo, weeping eczema, and prurigo persist stubbornly, lead to secondary infection, and bring the child to a very serious state. It is not uncommon in such severe forms with extensive skin manifestations for there to be a rapid drop in weight, the development of general intoxication, and sudden death. It is possible that this is a case of anaphylactic shock caused by the inhalation of various kinds of allergens (in particular, microbial dust). In isolated cases, at autopsy, extravascular hemorrhages and leukocyte thrombi of the vessels in the region of the nerve centers were found. The presence of exudative diathesis in a child predisposes the child to prolonged glandular fever, a prolonged course of bronchopneumonia, nasopharyngitis, pyelitis, and nephritis. Many diseases in exudative patients proceed with a number of functional disorders of the nervous system. In the first year of life, exudative patients in most cases give negative tuberculin tests. Subsequently, they can become infected with tuberculosis. The latter usually takes a peculiar course in them in the form of so-called scrofula. The symptom complex 'scrofula' represents a series of phenomena involving the skin, mucous membranes, and glands. Regarding the eyes, phlyctenular conjunctivitis and keratitis with phlyctenules, photophobia, and lacrimation are noted. Regarding the nose, there is persistent chronic coryza with sticky mucous secretion that irritates the skin and causes its infiltration. Regarding the ears, purulent otitis. The lymph nodes are always enlarged—cervical, parotid, fused into clusters, prone to caseation and suppuration, resulting in long-non-healing ulcers and scars. Sometimes in exudative patients, scrofuloderma is revealed—large, dense nodules embedded in the subcutaneous tissue, representing caseous foci, which can be resorbed or, by fusing with the skin, open outward, discharging liquid, flocculent pus. Such a picture of tuberculosis is usually favorable and subsequently does not lead to sharply pronounced forms of pulmonary tuberculosis. Nobel and Schonberg had the opportunity for a detailed examination of scrofulous children after 8-12 years and in no case found serious tuberculous changes in the lungs. The treatment of skin manifestations in exudative diathesis remains an unresolved problem to this day. Diet therapy should be the basis. Czerny's diet, which is based on limiting the intake of whole milk and butter and increased introduction of vegetables, fruits, and meat, does not always yield a favorable result. Experience shows that sometimes skin manifestations subside with the introduction of food rich in fat, in particular the Czerny-Kleinschmidt mixture. Scheer proposed for treatment milk acidified with hydrochloric acid (released for sale in concentrated form under the name Kitanmilch). Its rationale is shaky, and in practice, it does not yield the expected result. Variot recommends as a supplement to breastfeeding sterilized and homogenized milk with 10% sugar. In view of the fact that milk is generally a food that promotes the development of eczema, milk-free therapy was developed (Popova). It consists of almond milk (half and half with whey), Moll's pudding food (made from cake or rice), sugar, butter, egg yolk, and egg white. Hamburger composes his food from liver, olive oil, meat, brains, vitamins, and salts. All these modifications of diet, while yielding successful results in isolated cases, cannot be considered as indicated in all cases, and the indications for them themselves are still unclear and not developed. There are indications that sometimes an abundance of carbohydrates is harmful: limiting vegetables and bread and increasing proteins produces a therapeutic effect (Mathieu). Finkelstein proposed a special eczema soup for treatment: milk is curdled, the casein clot is separated from the whey, rubbed through a sieve, and 1/3-1/10 part of the whey and 4/5-9/10 of water or a mucilaginous decoction are added. Finkelstein proceeds from the harmful influence of whey salts; in some cases, his soup is beneficial, but it is dangerous due to its poverty in salts and is not suitable for long-term use. It is quite rational to exclude from the diet those substances to which the exudative patient has increased sensitivity, but the determination of these substances by means of skin tests yields little, and one has to proceed from experimentation on the child. Replacing mother's milk with another woman's milk or a milk-free regimen, cow's milk with goat's milk, replacing animal fats with vegetable fats, one vegetable with another, excluding eggs, cocoa, etc., produces a good therapeutic effect in suitable cases.

In general, in dietetics, one has to proceed by trial and error, individualizing each case. It is recommended to attempt desensitization of the organism by excluding milk from the diet and gradually accustoming the organism to it, starting with minimal doses. One can try giving it 1 hour before a meal in minimal quantities (e.g., a few drops of milk per os an hour before breastfeeding). Attempts at protein therapy with different types of milk (subcutaneous injections of milk at 0.2–0.5 every 2–4 days) should also be assigned to this group. For the same purpose, injections of peptone or its administration per os (0.1–0.2 an hour before a meal), hemotherapy, and autohemotherapy (1–2 cm³ every 2–3 days) are used. With the goal of desensitization, preparations containing sulfur have been proposed, in particular sodium thiosulfate per os, sulfur oil subcutaneously, and hyposulfite intravenously. To influence metabolism, many recommend the administration of thyroidin, pancreatin, and insulin with glucose. To influence the autonomic nervous system, some prescribe atropine, while others prescribe adrenaline. Undoubtedly, in a number of cases, a reduction in itching and skin manifestations is observed from them. For this same purpose, the administration of calcium chloride internally in large doses (up to 2–4 g per day) is widely practiced. Sometimes intravenous administration of CaCl₂ produces an effect. Recently, X-ray therapy of the thymus gland has found application in the treatment of constitutional dermatoses, but the theoretical premises for this are dubious. The use of ultraviolet rays (quartz lamp) is widely utilized. Huldschinsky recommends combining irradiation with a quartz lamp with smearing weeping surfaces with a 2–5% solution of silver nitrate until darkening and drying occur. Among other preventive measures, staying in the fresh air, light physical exercise, sponging with warm water, and good hygienic conditions are recommended. In many cases, climatotherapy has a good effect: staying on the seashore, both in the north (Baltic) and in the south (Black Sea, Mediterranean); mountain climate also usually results in the disappearance of the phenomena of exudative diathesis, but unfortunately, upon the child's return to the previous location, the phenomena of exudative diathesis recur. Local treatment of skin manifestations is carried out according to the rules generally accepted in dermatology (see Eczema, Prurigo, etc.).