MEDICAL INTRO |
BOOKS ON OLD MEDICAL TREATMENTS AND REMEDIES |
THE PRACTICAL
HOME PHYSICIAN AND ENCYCLOPEDIA OF MEDICINE The biggy of the late 1800's. Clearly shows the massive inroads in medical science and the treatment of disease.
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ALCOHOL AND THE HUMAN BODY In fact alcohol was known to be a poison, and considered quite dangerous. Something modern medicine now agrees with. This was known circa 1907. A very impressive scientific book on the subject. |
DISEASES OF THE SKIN is a massive book on skin diseases from 1914. Don't be feint hearted though, it's loaded with photos that I found disturbing. |
Part of SAVORY'S COMPENDIUM OF DOMESTIC MEDICINE:
19th CENTURY HEALTH MEDICINES AND DRUGS |
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and please share with your online friends.
GENERAL SYMPTOMATOLOGY
A disease of the skin is made known by integumentary structural lesions visible to the eye and usually appreciable to the touch, and by certain sensations emanating in its tissues, recognizable only by the patient, and having no outward sign. The former are known as objective symptoms, and are to be found with but few exceptions in all cutaneous affections; the latter, as subjective symptoms, which are usually associated with structural lesions, but which also, like the former, may exceptionally, as in pruritus, constitute the sole symptomatology of the disease.
Objective symptoms speak for themselves, and constitute, there fore, the foundation upon which our knowledge of diagnosis must be built—in some instances, conjointly with an examination into the his- tologic features, history of the disease, and other factors. Subjective symptoms, while sometimes of valuable aid, are often unreliable, owing to the fact that they are only under the cognizance of the patient, and therefore subject to exaggeration, undervaluation, and misinterpreta tion, according to the temperament, nervous susceptibility, intelligence, and honesty of the individual.
While these two classes of symptoms alone constitute the semei- ology in most dermatologic cases, in a small minority the symptoms are not limited to the integument itself; in some instances an affection of the liver, kidneys, stomach, or nervous system is present, but in the majority of such cases the eruption is merely an accidental consequence of such, and not an associated symptom of some general underlying pathologic process. Such diseases, it is true, may bear an etiologic relationship, al though it may not be a direct one.
The constitutional symptoms usually observed in connection with some cases do not possess any distinct characteristics, and even in those diseases in which they may occasionally be observed, as in ery thema multiforme, they are extremely variable as to degree. In other instances, as in the later stages of granuloma fungoides, leprosy, and the like, the ensuing systemic symptoms are not so much a part of the disease itself as a consequence of the resulting septic infection which commonly occurs.
Subjective Symptoms.—Subjective symptoms consist of a feel ing of heat or burning, tingling, prickling, stinging, formication, itch ing, and pain. Disturbed sensation, such as diminished and height ened sensibility, designated respectively anesthesia and hyperesthesia, also to be considered in this class, are occasionally noted. Pain is a rare, or at least an uncommon, symptom, but is met with in such affec tions as boils, carbuncles, in some ulcerations, especially of the deeper kind, and may be of a burning, aching, boring, or shooting character.
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The neuralgic pain frequently associated with the development of zoster is an example of the last named. Shooting and darting pains are also of common occurrence in some stages of leprosy. In many skin affections, however, subjective symptoms are wholly wanting.
Itching, or pruritus, is, however, the most frequent symptom com plained of, and is present in a variable degree in many diseases of the skin. It is a particularly troublesome one, as a rule, in eczema, and especially in the papular and vesicular types, although present in all varieties—sometimes slight, at other times severe, almost constant or paroxysmal. In urticaria, dermatitis herpetiformis, scabies, pediculo sis, and some cases of psoriasis it is also present usually to a disturbing degree. In occasional instances it exists independently of any visible lesional symptoms, constituting the malady known as “pruritus,” in which it is often intense. Itching varies in character, as well as in degree, sometimes being more of the nature of pricking sensations, tingling, and biting. In other cases it may consist of the sensation as if insects were crawling in the skin—formication. It is probably due to various causes acting upon the peripheral nerves, such as an irritant operating or gaining entrance from without, as in certain of the parasitic diseases, an irritation from some general toxic substance from within, as in jaundice and some instances of uric acid saturation, and also from the direct action of local inflammatory processes, either through pressure on the nerve filaments or through their irritant products.
Objective Symptoms.—The varied nature of the pathologic processes which take place in the skin, with the modifications influ enced by the peculiar character of its anatomic structure, gives rise, as might be supposed, to various and diverse structural alterations which produce the cutaneous symptoms known as the elementary or primary lesions. Each variety of lesion has characteristics that serve to distinguish it from the others, although there be much diversity as to size, shape, color, and other features, and some may show a transi tion stage verging into another form, as a papule into a vesicle, a vesicle into a pustule, and so on. These elementary or primary lesions, as the qualifying term signifies, are the objective lesions with which cutaneous diseases begin. Even if the eruption, as a whole, has undergone changes, the component individual lesions losing their elementary characters in the coalescence or massing that often ensues, still, here and there, as a rule, may be found some that throw light upon the initial features and materially aid in diagnosis.
The elementary lesions may continue as such, or may, as stated, undergo modification, either from accidental or natural change or from extraneous causes, and pass into what are known as the con secutive or secondary lesions. These are the two divisions into which the objective symptoms can be conveniently and naturally placed, and the various kinds of lesions of which these two clasess are composed must be clearly understood, as a knowledge of their appearance and nature is of essential importance for the intelligent study and compre hension of the various cutaneous diseases. A few lesions not readily classifiable under the subdivisions usually made, such as horns, some
ELEMENTARY OR PRIMARY LESIONS 57
warts, the “burrow,” or “cuniculus,” produced by the itch-mite, etc., will receive sufficient attention in considering the diseases which they represent or of which they may form a part.
ELEMENTARY OR PRIMARY LESIONS
Macules.—Synonyms.—Spots; Erythematous spots; Maculae; Fr., Taches; Ger., Flecke.
Macules are variously sized, shaped, and tinted spots and discolora- tions, or circumscribed alterations in the color of the skin, without, as a rule, appreciable elevation or depression.
They may constitute a part or the whole of the eruption, or may simply be an early stage or an associated symptom in mixed cases. They may also be congenital or acquired, evanescent or permanent, scanty or abundant, and may or may not disappear under pressure. Depending upon the character and origin of the lesions, there may or may not be associated itchiness. In size they vary from that of a pin point to that of the palm or larger, and while commonly, especially the small macules, more or less rounded or oval, they are not infre quently somewhat irregular in outline; they may have a sharp defini tion or be ill defined. The color may be of any tint or shade, depend ing upon the disease of which it may be a part or symptom. The lesion is the result of numerous pathologic processes. It may be produced by simple hyperemia or congestion, the most familiar example of which is the pinkish or reddish spots and patches of erythema, in erythema hyperæ- micum, and which may also, by coalescence and profusion, form an eruption more or less diffused over the surface. The pinkish or reddish macules of the various exanthemata, of typhoid fever (rose-spots), and of copaiba and other drug rashes, are also examples of the hyperemic type. The ring or zone of hyperemia sometimes found surrounding other lesions, known as the areola or halo, might also be considered as an annu lar erythematous spot or macule; it is usually, however, distinctly in flammatory. The hyperemic macule has sometimes a trifling degree of underlying accompanying inflammatory action, but rarely sufficient to give perceptible elevation. When there is a slight escape of the coloring- matter of the blood, the hyperemic color is soon mellowed by a yellowish or yellowish-white tinge. Sometimes, in such macules, there may be ex tremely slight, scarcely perceptible, branny scaliness; this is also observed in the spots or macules of tinea versicolor.
Occasionally the erythematous spots tend to merge or develop into slight elevations,—a midway lesion between macules and papules,— known as maculopapules or erythematopapules, and, when this charac teristic is predominant, the eruption is described by the qualifying term erythematopapular or maculopapular.
Other macules may be the direct consequence of hemorrhage into the skin, without preceding or accompanying hyperemia or inflamma tion, as the spots of purpura, which are usually first bright red, un affected by pressure, and change to a dull red, yellowish, and finally fade away. Long-continued inflammatory action with deposit of the
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GENERAL SYMPTOMATOLOGY
coloring-matter of the blood or the deposition of pigment, as in lichen planus, syphilis, and some other diseases, especially when on dependent parts, leaves behind dark-red or brownish colored macules or stains of more or less persistence. Other examples of pigmentary macules are freckles, chloasma spots and patches, and nævus pigmentosus, which are due to excessive pigment deposit, and may be of different degrees of shade from light yellow to almost black. When such deposit is diffused, involving large areas and of more or less uniform distribution, it is com monly designated a discoloration.
Small circumscribed discolored spots sometimes are of artificial origin, resulting from the forced introduction of pigment-matter in or beneath the skin, as in tattoo-marks and powder-stains. The skin may also be discolored temporarily by certain chemicals or dyes. In contradistinction to the dark macules are the white spots of vitiligo, and those associated with other atrophic changes of the skin, as in leprosy and other disorders. Casual mention may also be made of the reddish spots or macules due to capillary dilatation or new growths, as in the acquired blemish designated telangiectasis, and in the con genital formation known as vascular nevus.
Wheals.—Synonyms.—Pomphi; Urticæ; Fr., Plaques ortiées; Ger., Quaddeln.
Wheals are variously sized and shaped, whitish, pinkish, or red dish edematous elevations, of an evanescent character.
Their common and most typical expression is as the lesion of urti caria, although they can also be produced by the bite of a mosquito or by the sting of the common nettle. They are closely related to ery thema, and can almost be considered as erythematous spots or macules with underlying edema. The peripheral portion of a typical wheal is usually pinkish or reddish, the central and main portions whitish or pinkish white, and they not infrequently have a shining aspect. Some times they are, however, almost wholly white, and in others pink or red, with a mellowing toward a white color centrally. In shape they are most commonly rounded or ovoid, pea- to bean-sized, and considerably elevated; if numerous and close together, from enlargement and the arising of new efflorescences in the interspaces, solid plaques result, usually in their main aspect appearing to be white, edematous, elevated, flattened infiltrations, with or without pinkish shading here and there, and generally with a pink or red edge or areola. In other instances, mixed in with the ordinary rounded forms, there may be linear wheals, from a fractional part of an inch to several inches or more in length, and, if not arising spontaneously, such forms can commonly be brought out by rubbing or scratching. By a coalescence of ordinary wheals, linear forms, etc., gyrate or ring-like plaques of irregular configuration some times result. In some cases, and also in occasional individuals free from ordinary attacks of urticaria, signs, letters, and various characters can be produced by firmly drawing the finger or the blunt end of a pencil over the parts—a condition known as “dermatographism” (q. v.).
Exceptionally, wheals are much smaller than are commonly seen,
ELEMENTARY OR PRIMARY LESIONS 59
especially in young children, in whom some or all of them may be more of the nature of conic or acuminate papules, often capped with a minute vesicular point—the so-called urticaria papulosa. In some cases, too, in adults, as well as in those younger, the edematous exudation is so rapid and profuse that the epidermis is lifted up, and a bleb, or bulla, produced —urticaria bullosum.
Wheals are always attended with more or less burning, a feeling of heat, and itching, and these subjective symptoms, especially the itching, often exist to an intense and annoying degree; the scratching and rubbing thus induced lead to aggravation of the lesions present and the development of new ones. The lesion is of rapid formation, usually fully developed in a few seconds or a few minutes; it is evan escent and capricious, often coming and going quickly and in the most erratic manner, without any subsequent scaliness or exfoliation. It is angioneurotic in character, due to some irritation from within or without, and has its seat in the papillary layer or in the body of the corium. There is, first, a dilatation of the vessels, then a sudden exudation of serum takes place, followed by a contraction of the vessels, which prevents absorption; as soon as the spasm of the vessels abates, absorption gradu ally or quickly takes place, and the wheal disappears.
Papules.—Synonyms.—Pimples; Papulae; Fr., Papules; Ger., Knötchen.
Papules are small, usually superficially seated, pin-head to pea- sized, circumscribed solid elevations.
They show considerable variation in size, shape, and color, and are of diverse character and origin, and therefore are due to many different pathologic processes, and have their seat in different structures of the skin. They may be white or whitish, as in milium, which pro duces a papular elevation; yellow, as in xanthoma; bright red, as in eczema; dark or coppery, as in syphilis; violaceous, as in lichen planus; and almost black, as in some of the papular infiltrations of some varieties of sarcoma.
The papule, or beginning solid pimple of acne, and the red pin point to pin-head-sized papule of eczema are its most familiar exam ples. In both of these the lesion is usually rounded at the base, and conic or pointed in shape, whereas the papule in lichen planus is usually irregular at the base and flat or umbilicated in form. The papules of the papular type of erythema multiforme are also generally somewhat flattened, and sometimes, and exceptionally also in lichen planus, with a tendency to slight central depression or partial absorption and simul taneous peripheral extension, the papules then being faintly or distinctly circinate or annular. In other lesions, instead of being acuminate or flat, the top may be convex or bluntly rounded. In addition to the various examples of papules already referred to, may be mentioned those which are formed by epidermic collections about the hair-follicle outlets, as in keratosis pilaris, and which are harsh, rough, and grayish, with, sometimes, a reddish base. The same may be said of the follicular papules observed in pityriasis rubra pilaris and in ichthyosis. It will
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GENERAL SYMPTOMATOLOGY
thus be seen that this lesion may be inflammatory or plastic in origin, as in eczema; due to duct obstruction or obliteration, as in acne and milium; to cellular or new-growth infiltration, as in xanthoma and lupus; to hy pertrophy of the epidermic layer or scale accumulation, as in keratosis pilaris; or of the papillary layer—the papillae—as in ichthyosis and warts. They sometimes arise from erythematous spots, and may not become fully developed papules, being erythematopapular or maculo- papular. As a rule, inflammatory papules are itchy, sometimes markedly so, as in papular eczema and lichen planus; other papular formations are rarely attended with active subjective symptoms.
Papular lesions persist as such, or in some diseases at times change into vesicles, as in eczema, or into pustules, as in acne and some syphilitic papules. Some are, as already described, essentially squamous; others may become so, as with lichen planus and the papular syphiloderm, constituting the squamous papule; the eruption in which such feature is predominant is designated papulosquamous. Sometimes the transforma tion into a vesicle or pustule is incomplete or partial, the lesion remaining comparatively solid, and thus arise the lesions known as papulovesicles or vesicopapules and papulopustules; and when this is displayed in a greater number of the lesions the eruption is described as vesicopapular or papulovesicular and papulopustular. The duration of papular lesions is variable, depending upon their nature, origin, and management.
The term lichen is sometimes erroneously used to designate a papular eruption as a whole, and the word lichenoid, as synonymous with the term papular, but the former, especially, is a misleading and more or less obsolete term, unless used with a qualifying adjective—as, for example, lichen planus and lichen scrofulosus. Lichenification is a term that the French apply to a condition of the skin usually observed about the joints, characterized by some thickening, dryness, and often slight rough ness and sometimes trifling scaliness, with accentuation of the lines of the skin; and with, in most instances, closely crowded or coalescing, slight, flat, dull-reddish, papular elevations. They believe this condi tion results from chronic inflammatory processes, others are inclined to consider it as an expression of lichen planus or chronic eczema, the peculiar added lichenification features being due to the consequent rubbing, friction, scratching, and possibly to some extent to local medication.
Tubercles.—Synonyms.—Nodules; Small tumors; Tubercnla; Fr., Tubercules; Ger., Knoten.
Tubercles are solid, usually clearly circumscribed, rounded, pea- sized, somewhat deep-seated, elevations, generally of a persistent char acter.
Clinically, there is a close analogy between papules and tubercles, and the latter might almost be described as or named an exaggerated papule; it is not always an easy matter to classify them. It can be considered as an intermediate or merging lesion between a papule and a small tumor. The tubercle commonly consists of a cellular infiltration, is usually neoplastic, as in the tubercles of leprosy, lupus, syphilis, etc.,
ELEMENTARY OR PRIMARY LESIONS 6l
although it may also be hypertrophic and inflammatory. The deep- seated character, its more intimate association with the corium or sub cutaneous tissue, and its commonly convex or bluntly rounded pro jecting portion are the features that distinguish it from its near affinity, the larger-sized papules. These latter are more of the nature of surface lesions, with but slight tendency to downward growth; in short, a papule may be said to be a solid lesion extending upward; a tubercle, a solid lesion projecting both upward and downward.
Some confusion has been added to the term tubercle, so long used in dermatologic description to designate this primary lesion variety, by its more recent application to a product of tuberculosis. In dermatology it refers solely to the form and general characters of the lesion, and not to its nature.
While generally circumscribed and rounded, tubercles may also be conic and somewhat flat or irregular in outline. They are of gradual growth, and when close together, coalesce and form solid infiltrated areas, with sometimes an entire disappearance of their original nodular character. Usually, however, more or less distinct characteristic tuber cles are to be recognized at the peripheral portion, or outlying close to the border. In color a tubercle is usually dull reddish, but in xanthoma they are yellow, in fibroma normal or pinkish, in molluscum conta- giosum pinkish and waxy, and in some cases of sarcoma and carcinoma purplish red or blackish.
Tubercles are not only of slow formation, as a rule, but sluggishly persist, and are extremely slow in disappearing. Some persist indefinitely, with no tendency to involution, as in fibroma. In others, after some weeks, months, or at times even years, involutionary changes set in, and they disappear by absorption without trace, or with some remaining atrophy and discoloration; or they undergo degenerative and destruc tive changes and ulcerate, as often observed in the tubercles of syphilis, lupus, leprosy, etc, and are followed by scarformation.
Tumors.—Synonyms.—Tumores; Phymata; Fr., Tumeurs; Ger., Knollen; Geschwülste.
Tumors are soft or firm, usually more or less circumscribed, though variously sized and shaped, elevations, having their seat in the corium and subcutaneous tissue. They are generally large and prominent formations, the smallest size commonly accepted under the term—a somewhat vague one—being that of a large pea or a large tubercle, the dividing-line from the latter being more or less arbitrary, as tubercles are often spoken of as small tumors. More commonly, however, it im plies a growth of dimensions exceeding those of a cherry. They are fre quently walnut- to egg-sized or larger. Their color is usually that of the skin, but the latter is sometimes put upon the stretch, and may look thinned, glistening, and often pinkish or reddish.
They are generally semiglobular in shape, originate, as a rule, deeply, either in the subcutaneous tissue or conjointly in this and the corium, and gradually develop to their normal size or to indefinite proportions— to a slight extent spreading out into the deeper structure, to a greater
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GENERAL SYMPTOMATOLOGY
degree laterally, and in many instances probably most upward where there is less resistance, finally resulting in variously sized, shaped, and constituted firm or soft prominences, sharply or fairly well circumscribed, or intimately associated or blended with the adjacent tissues, or forming pendulous tumors. In those of markedly inflammatory or active origin, as in carbuncles, gummata, and similar growths, there is a good deal of lateral extension, the mass becomes suppurative and necrotic, the skin dark to purplish red, with its gradual destruction in totality or at points. The tumors of granuloma fungoides, sarcoma, carcinoma, leprosy, and like malignant affections also usually undergo final destructive changes, terminating in small or large ulcerating masses or open ulcers. On the other hand, the sebaceous cyst, ordinary fibroma, angioma, keloidal growths, lipoma, myoma, lymphangioma, etc., are benign, or relatively so, usually maintaining their integrity throughout. Tumors are, there fore, as is to be inferred from the various cited examples, of different constitution, character, growth, and termination, according to the seat of origin and the nature of the pathologic process, influenced probably by accidental or extraneous factors or conditions.
Vesicles.—Synonyms.—Little blisters; Vesiculæ; Fr., Vesicules; Ger., Bläschen.
Vesicles are pinpoint to small pea-sized, whitish, yellowish, or red dish, circumscribed epidermal elevations, containing clear or opaque fluid. They arise as vesicles or are formed from pre-existing papules. They may be acuminate, conic, or rounded, sometimes slightly flattened. Their color depends upon their contents and the degree of the accom panying inflammatory action. The contents may be, as usually always at first, perfectly clear and watery, consisting of pure serum, which may subsequently, and in some instances almost from the start, show a slight cloudiness; later some lesions become seropurulent, and in others there is a slight admixture of blood. Thickness of the epidermal covering is also an influencing factor in the coloring, as shown in the sago-grain-like vesicle of pompholyx. For the most part inflammatory vesicles are well distended and conic or acuminate. Those of eczema are usually minute, pinpoint to pin-head in size, or sometimes slightly larger, yellowish and glistening, aggregated or crowded together, superficially seated, with thin walls, and generally tending to spontaneous rupture. The lesions may be so close together as to coalesce, sometimes almost before completely formed, and undermine the horny layer of the epidermis. The tendency to the appearance in groups, aggregations, or closely packed masses seems to be more or less characteristic of the lesion, although in some diseases they may be scanty, isolated, or discrete, even if generally disseminated. The former is shown in eczema, herpes simplex, herpes zoster, and dermatitis herpetiformis; the latter in miliaria, sudamen, hydrocystoma, and varicella.
While ordinarily rounded, conic, or acuminate, they may be oblong or somewhat linear, as frequently seen in some lesions in scabies, or oblong, irregular, or angular, both at the base and in their body, as in dermatitis herpetiformis and some cases of herpes. In these latter
ELEMENTARY OR PRIMARY LESIONS 63
two diseases, as well as in others, sometimes instead of being distended and tense, they are only partly full and flaccid. Exceptionally in the larger vesicles a tendency to umbilication is exhibited. Some display but little, if any, tendency to spontaneous rupture, as in herpes simplex, herpes zoster, hydrocystoma, etc. This latter feature depends upon their point of origin, whether superficial or deep, and the thickness of the stratum corneum. Some simply have the upper corneous layers as the epidermal covering, others the entire horny stratum, while still others are still farther down, beneath the granular layer. In the palms and soles, owing to the thickness of the horny layers, their covering is com monly thick and tough; in this region, too, owing to this fact, under mining sometimes results. They are usually the result of exudation from the vessels of the papillæ; sometimes they are due to sweat retention, generally in some part of the gland-duct. They may be one-celled or simple, having but a single chamber or cavity, as in the vesicles of eczema and sudamen, or multilocular or compound, having two or more cavities or chambers, as in the vesicles of variola, herpes, and varicella.
Vesicles are rarely persistent as such, but break spontaneously and crust over, as in eczema; dry up and desiccate into a thin crust, as usually in herpes simplex and herpes zoster; the contents are in part or completely absorbed or evaporated, the covering wall exfoliating as a thin scale, as in sudamen; develop into blebs through either coales cence or enlargement, as sometimes in herpes zoster, and frequently in dermatitis herpetiformis; or they become pustules, as in variola, and sometimes in eczema. In this last, however, as in some other diseases, the lesions often do not become strictly purulent, but are of a sero- purulent character, forming vesicopustules, and when such a feature is a predominant one, the eruption is usually designated vesicopustular or pustulovesicular. In exceptional instances the vesicles undergo con siderable enlargement, approaching to or almost merging into blebs, or they may be originally of fairly large size, and in such the eruption is often temed vesicobullous, although this same designation is also some times applied to mixed vesicular and bullous eruptions. As a rule, vesicular eruptions are attended by a good deal of burning and itching, although in some instances, as in sudamen and hydrocystoma, sub jective symptoms are entirely absent.
Blebs.—Synonyms.—Blisters; Bullæ; Fr., Bulles; Ger., Blasen.
Blebs are rounded or irregularly shaped, tense or flaccid, pea- to egg-sized or larger, epidermic elevations with serous or seropurulent contents; they are, in brief, similar to vesicles except as to dimensions. While commonly rounded or oval, they may be, as with vesicles, some what irregular in shape. They sometimes arise from vesicles, either by direct extension or growth, or from the coalescence of several lesions. In their most typical, although probably not most common, expression, as in pemphigus, they frequently spring from a seemingly healthy or noninflammatory surface, so that they may or may not have a mildly inflammatory or hyperemic areola. They arise in dermatitis herpeti- formis either as blebs or by coalescence of vesicles from an apparently
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GENERAL SYMPTOMATOLOGY
normal or reddened skin, or develop upon pre-existing erythemato- papular lesions. As accidental lesions, they may develop upon urticarial efflorescences, as in urticaria; upon an erythematous or erythemato- papular base, as in erythema multiforme; or arise in erysipelas, leprosy, and some other diseases. They are not an uncommon feature of rhus- poisoning and other forms of dermatitis. In their earliest formation bullæ are, as a rule, clear or pale yellowish, their contents being serous and of a neutral or alkaline reaction; later they usually become some what clouded or turbid, and whitish or yellowish in color; if containing blood, uniformly mixed, the color is reddish or brownish; if this ad mixture is not evenly distributed through the bleb, the appearance is whitish or yellowish, with an intermingling of reddish or brownish streaks or flakes. Sometimes they are seropurulent from the beginning.
At first they are usually tense and distended, but unless sponta neously or accidentally ruptured the walls become flaccid; in some instances the latter character is noted throughout. They are unilocular or one-chambered, have, as a rule, somewhat tough walls, which do not readily burst. In some cases, however, their covering is thinner than ordinarily, ruptures early either spontaneously or as the result of trifling external accidental agencies, the broken walls remaining temporarily attached to the skin as thin, irregular shreds. In pemphigus foliaceus this is especially noticed, the thin walls breaking rapidly, scarcely before there is much observable exudation, and new exudation frequently taking place before the corneous layer has been fully replaced, and as soon as slightly lifted up breaks again, and so the process continues; frequently in these cases the lesions are so closely contiguous that they coalesce, the exudation producing essentially a more or less general undermining. The base of the broken blebs varies somewhat in appear ance and character, ordinarily being simply the red rete or corium, ap pearing as a red superficial abrasion, which soon heals over. At other times it is a decided erosion, dotted or streaked over with seropurulent or purulent matter or blood, and continuing to secrete actively for a variable time; occasionally the surface shows a vegetating or papillo- matous tendency.
The course of bullæ is essentially the same, therefore, as with vesi cles, and they terminate in the same way by suppuration, by partial absorption, desiccation, and crusting, and by rupture and thin crusting; those becoming purulent finally ending in like manner as those which remain serous or seropurulent—by rupture, desiccation, and crusting, the latter being thicker and sometimes quite bulky.
Blebs are, as remarked, usually unilocular or one-chambered, and, as with vesicles, have their seat in the epidermis, either in the superficial or deeper layers; in some instances the entire epidermis is lifted up. As a rule, they are rarely accompanied by active subjective symptoms, although often a sensation of tension and slight burning attend their development. Their presence is usually to be considered either an acci dental one, as in urticaria, erythema, etc, due to the intensity and rapidity of the inflammatory action and effusion; or an expression of some general nerve disturbance or depression, chronic autointoxication,
ELEMENTARY OR PRIMARY LESIONS
65
septicemia, a depraved or cachectic state of the health, and the like, as in dermatitis herpetiformis, pemphigus, and syphilis.
Pustules.—Synonyms.—Pustulæ; Fr., Pustules; Ger., Pusteln.
Pustules are pinpoint to finger-nail-sized circumscribed epidermic elevations containing pus. They are, in brief, similar to vesicles and to the smaller blebs having an inflammatory areola, except that the contents are purulent instead of serous or seropurulent, as in these lesions. They originate as pustules or arise from vesicles, and, if from the latter, sometimes may become only incompletely purulent, con stituting vesicopustules. They may also develop from a papule, and here likewise the transition in some lesions or cases may be incomplete, the papular basis being maintained, the suppurative change taking place at the central apex portion, resulting in the lesions known as papulo- pustules. In many instances, however, when arising from vesicles or papules, the pustular metamorphosis may be so rapid that the vesicular or papular origin can scarcely be recognized. As a rule, however, in such instances there is an intermingling of the primary formations, which have continued as such, or undergone only slight transformation; in fact, it is usual to find lesions in all stages of transition.
In color pustules are usually yellowish, unless they contain an admixture of blood, when they are reddish or brownish yellow. In shape they are acuminate, as often in eczema and sycosis; conic or rounded, as usually in acne, furuncle, and an occasional type of im petigo (Duhring’s impetigo simplex); or flat or flattened, as in most cases of impetigo, in ecthyma, flat pustular syphiloderm, etc; in some diseases with central depression or umbilication, as in variola and the varioliform syphiloderm; and occasionally oblong or somewhat linear, as some times in scabies. In size they vary from a pinpoint, as in the smallest pustules of eczema, to that of a finger-nail, as in the lesions of impetigo and ecthyma. They may be superficially seated, as in eczema and im petigo pustules; or moderately deep, as in some lesions of the latter disease and of sycosis; or deep seated, as in most pustules of the last- named affection, in acne, and in furuncle. They are, therefore, as regards the point of origin, somewhat variable, that of eczema, impetigo, and ecthyma usually or chiefly in the mucous layer, that of sycosis around the hair-follicle, that of acne in or about the sebaceous gland, and that of boils deep in the corium. The hair-follicle plays an important part in most pustular lesions, either as the sole or conjoint seat of the suppu- rative process or as the port of entrance for pyogenic cocci. As a rule, pustules form rapidly and are generally attended by a good deal of inflammatory action, sometimes with considerable burning, pain, and tenderness, but itching, except in those of eczema, is rarely complained of. Exceptionally their formation is slow, as occasionally in the pus tules of impetigo, ecthyma, and syphilis; this usually results in a flatten ing and a tendency to central depression, or in stratification of the crust, as particularly shown in the condition known as rupia. In this latter the covering and upper portion of the contents of the pustule or small purulent bleb dry to a crust that is lifted up by the gradually forming
5
66 GENERAL SYMPTOMATOLOGY
and extending purulent collection beneath; this in turn dries to a crust, while the base of the lesion is still enlarging and secreting, and in this manner it may continue for a variable period. When fully formed, the entire overlying crust is thick and stratified, with that of small diameter at the top and the largest at the under part, presenting an oyster-shell- like arrangement. In impetigo and ecthyma the central part some times dries and becomes firmly attached to the underlying part, while the purulent collection to a slight degree extends peripherally as a spreading purulent wall.
Upon the whole, pustules usually, like vesicles and blebs, tend to rapid development, course, and termination, varying somewhat accord ing to their cause, nature, and seat. As with vesicles, they may be unilocular or have but one cavity, or multilocular, with several or more chambers. They generally end by rupture and discharge, with subse quent slight crust-formation and repair; or they may break imperfectly, with but little escape of fluid, and gradually dry into a rather thick, firm crust that finally drops off; or they may dry up without rupture. The color of the crust varies from a yellowish or yellowish brown, as in eczema, to reddish or dark brown, in syphilis, and may be thin, thick, friable, or firm, depending upon the character of the morbid process and other circumstances. The processes involving the corium may be fol lowed by scar-formation, as in variola, syphilis, acne, ecthyma, and the like.
CONSECUTIVE OR SECONDARY LESIONS
Excoriations.—Synonyms.—Excoriationes; Abrasions; Erosions; Scratch-marks; Fr., Excoriations; Ger., Hautabschürfungen; Excoria- tionen.
Excoriations are variously sized and shaped, but usually small, irregular, or linear, solutions of continuity, generally of a superficial character, and the result of traumatic or mechanical causes.
The most familiar and chief examples are the red denuded points, small abrasions, jags, and lines or shallow furrows produced by the finger-nails in the act of scratching, in efforts to gain relief from the troublesome itching in certain diseases, notably eczema, pruritus, scabies, and pediculosis. Not infrequently they are, especially the points and small areas, more or less irregularly covered with thin crusts com posed of blood and the exuded serum. As a rule, they involve the epi dermis only, rarely extending more than superficially into the papillary layer of the corium. The epidermis being denuded, the rete or corium is laid bare, and the lesions thus resulting are slightly depressed, although scarcely perceptibly, and are usually bright or dark red in color, with sometimes a yellowish or mellowed tinge, due to a thin coating of desic cated exuded serum; or they may be of a brownish or almost blackish color, owing to the presence or admixture of dried blood. They may be bordered by a narrow band or areola, with sometimes slight inflamma tory elevation. At times the excoriations are somewhat elevated, due to the fact that the lesions scratched are papules, as in papular eczema, the summits alone getting the brunt of the injury. The extent and
CONSECUTIVE OR SECONDARY LESIONS
67
depth of the excoriations depend upon the force employed in scratching and the resisting power or susceptibility of the skin; the latter may be an inherent peculiarity of the individual or be due to the cutaneous disease, as is frequently observed in eczema. The great difference in the char acter, amount, and depth of the excoriations in cases in which the dis ease is apparently of similar extent, the itching as intense, and the scratching as vigorous, is not an uncommon clinical observation.
The nails are not the only agents by which excoriations are pro duced, although the usual and common one; they may be the result of slight traumatisms of other kinds. Pricks and scratches caused by pins, needles, and other familiar articles are often responsible for isolated lesions; “skinning the finger,” “barking the shin,” giving rise to an abraded or “raw” condition of the skin, can also be cited. The simple act of rubbing, and even the friction of the clothing itself, will, in vesicu lar lesions and vesicopapules, often remove the surface and give rise to superficial punctate tears or abrasions. Persistent and repeated scratch ing in eczematous and other inflammatory processes often leads to greater infiltration and inflammatory activity; and in diseases in which itching occurs independently of any exciting structural changes, as in pruritus and pediculosis, a mild or moderate degree of dermatitis or eczematous inflammation is sometimes thus provoked. Long-con- tinued scratching and rubbing of a part, as in a long-continued pediculo sis, pruritus, eczema, and other diseases, will also, in addition to the induced inflammatory infiltration and thickening, sometimes produce more or less pigmentation; this is especially observed in those who have for a long time been the subjects of pediculosis, producing a pigmenta tion so extensive and dark colored as even to suggest Addison’s disease.
As a rule, excoriations being of superficial character, are rarely followed by scarring, but in some instances, where they are deep, in volving the corium, slight atrophic whitish spots are to be seen, and these especially about the upper back in the chronic affection last mentioned. Excoriations are often accompanied by small and large pustules, the opened points and abrasions giving ready opportunity for local integumentary infection by pyogenic cocci; in such instances, as well as occasionally in others where distinct pustular lesions are not formed or conspicuously present, there is sometimes noted a swelling of the neighboring lymphatic glands.
These lesions are frequently an important feature in many skin affections, and their character and distribution often alone suffice to the formation of a correct diagnostic conclusion, as illustrated espe cially in pediculosis and scabies. Their presence, too, is always signif icant of itching, and in the differentiation this factor bars out a number of diseases that may have other symptoms in common.
Fissures.—Synonyms.—Cracks; Rents; Clefts; Rhagades; Rimæ; Fr., Fissures; Ger., Hautschrunden; Rhagaden; Einrisse; Fissuren.
Fissures are linear cracks or wounds involving the epidermis or epidermis and corium, and the result of disease or injury.
They are most commonly met with where the epidermis is thick-
68
GENERAL SYMPTOMATOLOGY
ened and infiltrated, when due to cutaneous disease, which impairs the local nutrition and renders the parts inelastic; and especially if upon regions where there is a great deal of natural active or frequent move ment. They are, therefore, most frequently observed about the palms, fingers, soles and toes, and joints, especially the flexures; also at the angles of the mouth and lips, and about the nares and the anus. They are also not infrequent back of the ear. More commonly, but by no means al ways, they occur in the natural lines and furrows. They are usually seen in eczema, not infrequently also in other chronic inflammatory in filtrated diseases, especially those of a dry character, as in ichthyosis, scleroderma, psoriasis, lichen planus, dermatitis, and similar affections. In such diseases their production is often induced, aggravated, or in creased by applications that cause dryness, especially the free use of soap. Indirectly the tendency is added to, moreover, as in eczema of the hands and fingers, by the frequent use of water and contact with irri tating substances, as with cooks, laundresses, polishers, pasters, etc., the underlying disease or tissue weakness being thus increased. In those of sensitive and especially naturally dry skin, exposure to cold and wind will suffice to bring about a variable fissuring of the lips and hands— so-called “chaps’' or “chapping.” Fissures are also frequently noted at the angles of the mouth and about the anus in congenital syphilis.
They may be of various lengths, widths, and depths, the margins usually being abrupt and sharply defined; although generally straight, they may be curved or crooked. They may be dry or moist, and reddish in color, more particularly toward the base, and if they are at all numer ous and deep, impair the free movement of the part through fear of the accompanying pain and the possible deeper opening of the cracks and the production of new breaks.
Scales.—Synonyms.—Exfoliating epidermis; Epidermal exfolia tions; Squamæ; Fr., Squames; Ger., Schuppen; Hornplättchen.
Scales may be defined as dry, usually laminated, epidermal exfolia tions or desquamations; or as collections, on the surface, of loose, dry epidermis, resulting from some underlying morbid process.
A mild degree of ordinarily invisible or scarcely perceptible exfolia tion in the form of minute, thin epidermic particles is physiologically taking place constantly, which, if its removal is not facilitated by baths and soap-and-water washings, may accumulate sufficiently to be, on close inspection, noticeable as a branny roughness, as not infrequently ob served in those of the dispensary class. It is more pronounced or more quickly noted after discontinuance of ablutions in those of a naturally dry skin. Pathologic scaliness, however, with which we are concerned, is due to the rapidity of epidermic cell-formation or to an interference with the process of normal horny transformation, and is the result of various morbid processes. It presents itself from that of scaliness of a scarcely greater degree than that of the physiologic exfoliation already mentioned, to that of thick, circumscribed, or more or less generalized, imbricated, horny, epidermal accumulations, produced slowly and in slight or moderate quantity, or rapidly and in great abundance. As
CONSECUTIVE OR SECONDARY LESIONS 69
illustrating the extremes and the intermediate degree may be men tioned the insignificant branny or flour-like scaliness, or, as commonly designated, furfuraceous scales, of tinea versicolor; the scarcely greater of so-called pityriasis capitis; the slightly more emphasized in some cases of erythematous eczema; moderate or fairly abundant in squa- mous eczema, seborrhea, the milder types of ichthyosis, lichen planus, etc; and the usually profuse in psoriasis, the severer grades of ichthy- osis, some types of dermatitis exfoliativa, and pityriasis rubra pilaris. Sometimes the exfoliation is of the nature of thin, variously sized flakes, or lamellæ, as frequently in eczema, the milder varieties of dermatitis exfoliativa, erythema scarlatinoides, scarlatina, etc; in the last two, usually taking place, especially about the extremities, as thin, parchment- like or sheet-like more or less extensive films; in others, in the form of thicker imbricated masses, as especially well shown in psoriasis in ad vanced stages of pityriasis rubra pilaris, and severe cases of ichthyosis— in the last named occurring usually as thick, plate-like masses. They are generally loosely attached to the underlying epidermis, but ex ceptionally, as in lupus erythematosus, they adhere somewhat firmly.
In character scales are dry, harsh, horny, brittle, with a disposi tion to break up into thin flakes or minute particles; occasionally, how ever, from the admixture of oily secretion, as in some seborrheic scales, or of dried serous or seropurulent exudation, as is observed in some scaly masses in eczema, the accumulations are seen to be more closely agglutinated, less brittle, and sometimes slightly oily or gummy, forming, in reality, a mixture of scale and crust—crustœ lamellosæ—which, when thin, can be well designated crusty scales, and when thick, scaly crusts, although these terms are commonly used interchangeably. These latter scaly masses are usually dull yellowish, dirty yellowish, some times with a brownish cast or deeper hue; whereas ordinarily scales are white or grayish, and either lusterless or, as in some instances, as often seen in psoriasis, in some cases of eczema, lichen planus, etc, with a glistening, micaceous aspect.
Crusts.—Synonyms.—Crustæ; Scabs; Fr., Croûtes; Ger., Krusten; Borken.
Crusts are dried effete masses of exudation, usually with an admix ture of more or less epithelial débris. They vary greatly in thickness, color, size, form, and in other features. They are thin, flattened, and yellowish, as in impetigo contagiosa and in some cases of eczema; flat and thick and dark yellow to reddish brown in ecthyma and in some of the pustules of syphilis and pustular eczema; and thick, irregular, and of a brownish, dark-red, or blackish color, in some ulcerations, especially those of syphilis. In the last-named disease some of the pustules, bullous lesions, or ulcerations become covered over with oyster-shell-shaped crusts,—rupia,—as referred to in describing pustules. The crusts of syphilis, and also less frequently those in other purulent processes, are sometimes of a greenish hue. Crusts are, at times, somewhat soft and friable, frequently but lightly attached, as commonly observed in those of eczema and impetigo contagiosa, those of the latter often looking as if
70 GENERAL SYMPTOMATOLOGY
“stuck on” or imperfectly pasted on. Others are firmer, tougher, and more adherent to the subjacent tissues, as in ecthyma and syphilis.
These several characters depend chiefly upon the nature of the secretion, the crusts being variously composed of serum, pus, blood, and extraneous matter; sometimes exclusively of serum, as the com mon yellowish or candied-looking crusts of vesicular eczema; often of serum and pus, as the dirty, dark yellow, or greenish yellow of sero- purulent eczema and impetigo; and frequently with a varying quantity of blood, giving the crust a reddish or blackish appearance. They usually contain also more or less epithelial debris. The thickness de pends upon the amount of the discharge, more especially when the latter is dense and tenacious; to their firmer adherence to the under lying part, together with the duration. The crusts or “scabs” covering ulcerations are usually thickest and the most bulky; if removed, and the subjacent ulcerations still remain, the part soon scabs or crusts over again. More or less surface destruction underlies those of ecthyma, lupus, epithelioma, syphilis, etc, and in the last two especially it may be quite deeply seated.
Crusts other than those named possess some peculiarities. Those of seborrhea and of mixed seborrheic and eczematous processes are usually more or less unctuous to the touch, light or dirty yellowish, at times darker, somewhat lamellated, and adherent, possessing features of both crusts and scales,—crusty scales, scaly crusts, crustæ lamellosæ,— as referred to in describing scales. The crusts of favus, when more or less isolated and circumscribed, consist of somewhat thick yellow concavo- convex discs, friable and granular, with the convex side pressed down on or in the skin; but if the disease has been long continued, these crusts may be so closely set and continuous as to lose this peculiar shape, and form thick, confluent, yellowish, mortar-like masses; it is made up chiefly of the vegetable fungus, to which the disease is due, together with epithelial cells and débris. The crusts observed in certain forms of eruption due to the ingestion of bromids are sometimes thick and brownish or brownish yellow; they cover the part and dip down between the papillomatous projections usually present, forming an interlocking that gives them a firm setting, these crusts being noted especially for their persistence and tenacious attachment. The same characters, but, as a rule, much less pronounced, are also seen in some forms of iodid eruption.
Ulcerations.—Synonyms.—Ulcers; Ulcera; Fr., Ulcères; Ger., Geschwüre.
Ulcerations are rounded or irregularly shaped and sized losses of cutaneous tissues, sometimes extending into the subcutaneous struc tures, resulting from disease.
Excluding those arising from traumatic influences, and the ordinary simple leg ulcers wdth which dermatologists are rarely concerned, these excavations are the result—of impaired nutrition of the part, as in the ulcers on the lower part of the legs associated wdth varicosities and eczema; of suppurative inflammations, as in boils and ecthyma; of cell-growth combined with suppuration, with subsequent cell and tissue
CONSECUTIVE OR SECONDARY LESIONS
71
destruction, as in gummata and erythema induratum; and of cell- growth or infiltration, with retrograde metamorphosis, as in neoplastic formations, such as lupus and other forms of cutaneous tuberculosis, tubercular syphiloderm, leprosy, sarcoma, carcinoma, etc By far the largest number of cases of ulcerations encountered are due to syphilis, and commonly to the tubercular and gummatous syphilodermata.
Ulcerations may be small or large; some are scarcely larger than a pin-head, and from this intermediate sizes up to those covering a good deal of surface occur. In shape, they vary considerably: they may be rounded, oval, or irregular, and often, as in syphilis, and less frequently in lupus, crescentic, kidney-shaped, or segmental; when several of the latter are close together, they form a more or less wavy, irregular, and serpiginous tract. As dermatologically met with, ulcerations are, as a rule, superficial and shallow, as in many cases of lupus and tubercular syphiloderm, but in occasional cases of lupus, in some cases of the tubercular syphiloderm, in syphilitic gummatous lesions, in erythema induratum, in many cases of epithelioma, and in other neoplastic affec tions they may extend considerably into the subcutaneous structures. The character of the edges, which are usually clearly defined, sometimes with bordering inflammation and infiltration, differs materially—abrupt, almost as if the ulcer were punched out, sloping, everted, or under mined. Their bases are smooth or uneven, sometimes clean, others covered with a slough, and occasionally exhibiting a papillomatous or vegetating tendency, and discharging a scanty or abundant, offensive or inoffensive, serous, seropurulent, or purulent secretion.
Syphilitic ulcers, which may be either shallow or deeply seated, in addition to showing, usually, crescentic or segmental shapes, generally have perpendicular, sometimes undermined, edges, uneven floor, with a free purulent discharge, and ordinarily but little surrounding infiltra tion; if there is crusting, it is generally thick and dark colored or green ish. Lupus ulcerations are, as a rule, shallow, small, rounded sloping excavations often close together, running into each other, usually with but little, if any, surrounding infiltration, and having generally but a scanty discharge of a serous or seropurulent character; the crust, if present, is usually thin and yellow or yellowish-brown. The ulceration of superficial epithelioma is shallow, usually single, with sloping walls and surrounding slight infiltration, often with an elevated, roll-like, pearly, or waxy-looking border, and having generally but a scanty serous or viscid discharge, occasionally with a trifling blood admixture, and with or without a thin to slightly thickened brownish or reddish- brown crust. The deeper type of epithelioma shows greater excavation, more infiltration, somewhat inflammatory borders, the discharge similar to that of the superficial type, or more abundant, and sometimes more purulent, frequently with blood streaks or flakes; and often with a tendency to thick brownish or reddish-brown crust-formation.
Ulcerations may occur upon any part, but are common upon the leg, here usually of a simple inflammatory character, frequently in asso ciation, as previously stated, with varicosities and eczema. Those of lupus are most frequent upon the face, especially about the nose. Those
72 GENERAL SYMPTOMATOLOGY
due to syphilis are also common in the facial region, although likewise seen frequently upon other parts. Ulcerations may or may not be pain ful and tender. They may be stationary, progressive, or, except in malignant forms, undergo healing, always with the formation of cicatri- cial tissue.
Scars.—Synonyms.—Cicatrices; Fr., Cicatrices; Ger., Narben.
A scar or cicatrix is a connective-tissue new formation replacing loss of substance which had involved the corium or the tissues more deeply.
Scars may, therefore, be small, large, rounded, oval, or irregularly shaped, depending upon the size and other characters of the preceding ulcer or ulceration or the morbid processes that have led to their forma tion. Scars are not always, however, evidence that active or necrotic destruction has preceded, as is instanced by those of lupus erythemato- sus, scleroderma, favus, atrophy of the skin, and some cases of lupus vulgaris and syphilis. In some of these diseases the cutaneous struc tures are the seat of cell infiltration, which, in undergoing absorption or retrogressive, but non-ulcerative, changes, lead to superficial scar-for- mation, as in both varieties of lupus and syphilis. In the several other affections named the tissues undergo direct atrophy from distention, as in linea albicantes and other forms of atrophia cutis, or from pressure, as that in favus; or they may result from neoplastic overgrowth of the fibrous elements, as in keloid. Generally speaking, however, the pres ence of a scar points to a previous ulcerative process or loss of tissue from traumatism, and their shape naturally is determined by the form of the previous ulceration or destruction. When,, in certain diseases, this has been at all peculiar or characteristic, as in the crescentic, kidney- shaped, and serpiginous ulcers of syphilis, the forms of the resulting scars have a diagnostic value in passing judgment as to the causative disease and also as to ulcerative processes that may still be present nearby or elsewhere on the surface. Soft thin scars, especially when showing on their surface somewhat deeper, small, pea-sized depressions; small, rounded, thin scars arranged in segmental groups or in a serpentine manner; and scars with scallop-like edges—are all also suggestive, and usually conclusive, of syphilis. Thin scars on the face, with a somewhat glistening and stretched appearance, studded with minute depressions, corresponding to the gland-duct outlets, are characteristic of lupus erythematosus. Thickish, tough, and fibrous scars, sometimes of a slightly corded character, are frequent in lupus vulgaris, and when about the face, where this disease is most common, are an almost inva riably conclusive factor in the diagnosis between this affection and the tubercular syphiloderm that it resembles. A fibrous, stringy, or cord or ribbon-like thickening, frequently with a general keloidal tendency, commonly suggests burns as its origin, and almost conclusively so if at all extensive. The significance of the numerous, scattered, small, pea- sized, white, depressed scars, especially marked and abundant on the face, as pointing to a previous attack of smallpox, is well known. Numerous minute, pin-head-sized scars, disseminated over the general
LESIONAL CONFIGURATION AND DISTRIBUTION 73
surface, with a tendency to groups or aggregations, but commonly scanty or with no special predominance on the face, usually is clearly indica tive of a pre-existing secondary miliary papulopustular or pustular syph- iloderm. If somewhat larger and irregularly disseminated, they are significant of the small or varioliform pustular syphiloderm; and if finger-nail to bean-sized, flat, slightly depressed, generally distributed, but not necessarily numerous, the large flat pustular syphiloderm has usually gone before. The scar, therefore, is not only valuable as indicating the disease that has caused it, but its presence, especially if indicative of syphilis, may often afford valuable aid in determining the nature of obscure associated skin-lesions as well as the nature of some obscure organic or general disease. Recent scars are pinkish or reddish; the color is gradually lost, and gives place to a glistening or dead white; exceptionally, however, they are pigmented to a variable degree, which is commonly most pronounced at the margin or limited to this portion. Occasionally the redness is more or less persistent, even acquiring a purplish tinge.
Scars are usually smooth, soft, and more or less pliable, but occa sionally, as just referred to, may be uneven, thick, tough, stringy, puckered, or distinctly keloidal or hypertrophic. They consist of new formations of connective tissue, containing blood-vessels, lymphatics, and nerves, but unless extremely superficial, no hairs or glandular struc tures. From their very nature they are persistent formations, some times, however, becoming, in the course of years, less conspicuous, and coming up almost to a level with the surface. On the other hand, ex ceptionally, they may undergo hypertrophic change, growing thicker and elevated, tough, stringy, corded, and uneven, but remaining limited to the original destroyed or ulcerated area, constituting the so-called hypertrophic scar; less frequently still the hypertrophic scar-tissue growth extends, projecting into the bordering healthy skin, more or less uni formly or in the form of irregularly disposed or claw-like processes, thus developing into keloid. As a rule, scars are painless formations, but in occasional instances they may be the seat of some itching or pain, rarely constantly, but usually intermittently or of a paroxysmal character.
LESIONAL CONFIGURATION, DISTRIBUTION, AND OTHER FEATURES
The varying size of the lesions of different kinds, as well as of those of the same variety, has already been considered, and some of the terms usually employed were named incidentally. Several others may be here briefly referred to.
A single group or aggregation of lesions or area of disease consti tutes a patch, and this, alone or with other lesions, groups, areas, or patches, considered as a whole, is known as an eruption. When the eruption is made up of the same type of lesion it is said to be uniform; if of several or mixed types, multiform, polymorphous. The lesions, patches, or areas of disease, which are also sometimes designated as efflorescences, may be distinctly separated—discrete; if the component
74
GENERAL SYMPTOMATOLOGY
lesions tend to form groups or bunches of several or more, as in herpes simplex, herpes zoster, etc., the eruption is said to be herpetiform; or they may be close together or crowded—aggregated; or they may be fused, forming solid patches or sheets—confluent; or they may be seated only in one or two regions—limited or localized; more or less uniformly distributed over most of the entire surface—diffused, general, or general ized; involving the whole surface—universal; irregularly scattered— disseminated.
When a patch or area of disease is sharply defined, it is said to be circumscribed; if rounded and of sharp contour—orbicular or discoid. The term circinate is applied to those of circular outline, but its most usual application is to circular patches with clearing center, as in tinea circinata, whereas an annular or ring-like patch is a round or circular patch made up of a free or clear center and an enclosing ring or band; to a rounded area composed of several concentric rings, usually of different duration and stage, and, therefore, somewhat variegated as to coloring, the term iris is added, as in erythema iris and herpes iris.
The term gyrate refers to an irregular or festoon-like configuration, usually resulting from the coalescence of several contiguous rings, the eruption disappearing at the points of contact, as in some cases of pso riasis; and serpiginous when the eruption spreads in a creeping-like manner at the border, clearing up at the older part, as in the tubercular syphiloderm. An area of disease is said to be marginate when it is ab ruptly defined against the healthy skin, as in eczema marginatum and erythema marginatum.
The regional localization is sometimes added to the name of the disease, or, as for example, herpes facialis, seborrhea capitis, etc.; and occasionally the lesional origin or anatomic involvement, as keratosis pilaris; and sometimes the age or life period is indicated, as pemphigus neonatorum, pruritus senilis.
Additional names and terms other than those already given will be found in the course of the text, and, as with the foregoing, are mostly those with which students of anatomy and medicine in general have already been made acquainted, and which are, moreover, as a rule, self- explanatory.
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