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.

55

56

GENERAL SYMPTOMATOLOGY

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

58

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

6o

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

62

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

64

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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