Physical diagnosis : a guide to methods of clinical investigation / by G.A. Gibson and William Russell.

  • Gibson, George Alexander, 1854-1913.
Date:
1890
    air vesicles or bronchioles into tlie connective tissues, by which means it reaches the root of the lung, and thence passes by the mediastinum to the neck. In this condition the skin does not pit on pressure, or does so very slightly, and the finger feels a distinct sensation of crackling when it is passed over it. Special Affections. In studying the appearance of any skin disease, as much of the surface of the body should be seen as may be possible or expedient, and in the course of the examination attention should be systematically directed to the locality of the disease, the outline of the affected regions, the type of the eruption, the nature of the lesion, and the structure invaded. Distribution.—The situation of the disease is a most use- ful guide in diagnosis. Certain affections are confined to particular spots—sycosis, for example, to the hairy parts of the face. Others have areas grouped anatomically, as in the case of eczema and psoriasis, the former of which exhibits a pre- ference for the palms, soles, and flexor surfaces of the extremi- ties, while the latter attacks the elbows, knees, and extensor aspects. Others, such as pityriasis rubra, are scattered in- differently over the body. Others again invade the whole surface, as may be seen in the cutaneous phenomena of the exanthemata. These remarks must not be accepted in the sense of absolute rules, for the points laid down are not of universal application. Diseases which are at first limited to definite regions have a tendency to spread from these areas ; scabies, to take a common example, although at the onset confined to the hands, and more especially to the webs of the fingers, invariably extends upwards along the arms, and frequently attacks those parts of the body which are most likely to come in contact with them. On the other hand, those diseases which have been mentioned as involving the entire surface of the
    body are commonly found to be more fully developed in certain regions; in measles, for instance, the rash, which is diffused over the whole body, is always much more distinct on the face, and more especially on the forehead. With such reservations the statements made regarding the dis- tribution of the disease are nevertheless of very general application. Conformation.—Where the disease is found in separate areas the outline of the affected spots may afford useful information, especially in cases of a parasitic or syphilitic nature. In ringworm, for example, the original shape of the patches is circular or oval, and dermato-syphilis has a tendency to assume circular and gyrate outlines. Type.—According to a time-honoured arrangement, the various disorders of the skin are grouped together in the two classes of primary and secondary diseases. To the former belong macnlce or stains, papulce or pimples, pomphi or wheals, vesiculce or blebs, hullce or blisters, pustulce or pocks, and tubercuke or growths. In the latter division are placed squamce or scales, exeoriationes or abrasions, ulcerationes or sores, rhagades or cracks, crustce or scabs, and cicatrices or scars. These terms are very useful when employed simply as defini- tions of certain appearances, but if used as a basis for classi- fication they are apt to lead to confusion, since very different pathological processes may be brought together by means of them. In every case it is necessary to note the type of the ele- mentary lesion, and to distinguish the essential from the accidental appearances; in pediculosis, for instance, the hsemorrhagic points, which constitute the primary or essential lesion, must not be confused with the excoriations and crusts, which are only secondary or accidental phenomena. Seat. In by far the larger number of the changes which it undergoes the skin is affected throughout all its layers. There are, nevertheless, a few diseases which are confined to one or other of its structural divisions, and although it may
    not be easy in the fully developed condition to determine the elements involved in any morbid process, there is no difficulty at the outset in assigning an affection to its true anatomical position. The epidermis is seldom the only seat of cutaneous diseases, but it necessarily suffers in the course of most of them. Its horny layer is specially affected in psoriasis and pityriasis, as well as in ichthyosis and xeroderma, while deposits of pigment and the formation of vesicles take place in the mucous layer. The corium is the starting-point of the great majority of skin diseases, the papillary layer being the primary seat of all diseases dependent on changes in the circulation of the skin, and the areolar layer becoming involved during their course. The appendages of the skin are the special seats of certain affections, and attention must be bestowed on the nails, the hair, the hair follicles, the sebaceous glands, and the sweat glands. As mentioned above, the different changes will be con- sidered in the light of their pathology, and in doing this their special anatomical seats will be pointed out. Nature.—The character of the morbid process must in every case be recognised. One or two skin affections are purely subjective, but these do not fall to be considered in a work on physical diagnosis. The processes giving rise to the appearances which have to be observed are hypersemias, exudations, oedemas, hfemorrhages, hypertrophies, atrophies, new formations, and parasitic invasions. In approaching these different disturbances it is better to consider the skin apart from its appendages, and to deal with the latter separately. Method of examination .—The patient should be examined in a good light, and as much of the surface of the body should be seen as is possible, either at once or in successive areas. Partial examination is apt to lead to error from the
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    Hypersemia of distinct papillse gives rise to the formation of 'pa'pules, whicti are small rounded elevations. Flesh- coloured papules arranged in groups are found in prurigo, and dull red papules, also aggregated together, are character- istic of lichen. Papules occur in the course of several acute general diseases. In typhus they are rosy and have a tendency to become petechial; in enteric fever they are pink and appear in successive crops; in scarlatina they are minute and scarlet, usually coalescing to form a uniformly distributed rash : in measles they are dull red and somewhat crescentic in outline ; and in rotheln dull red, but paler than in measles, grouped in clusters over the body, but uniformly distributed over the face. Papules form the initial stage of eczema and other skin diseases to be noticed presently, and they are also foiind in the early period of small-pox, cow-pox, and chicken-pox. Hyperemia of the vascular layer, along with exudation around the papillae, gives origin to pomphi, which are rounded elevations with a pale centre and a red halo, highly characteristic of urticaria or nettle-rash. Firm pressure causes the disappearance of the coloured zone. Accumulations of serum, consequent upon hyperasmia, and having their seat in the rete Malpighii, or between it and the horny layer, constitute vesicuhe and bullcv, which are only distinguished from each other by their difference in size. Vesicles, which should not, strictly speaking, exceed a pea in size, are found in hydroa, where each bleb is situated on a distinct red base, and herpes, in which they are at first separate and surrounded by red zones, but afterwards become closely grouped together, and frequently coalesce. It is to be noticed that in herpes zoster the vesicles are developed along the course of distribution of nerve trunks. Vesicles occasionally develop at the summit of the papules in lichen, and form the second stage of eczema ; they not infrequently attend erysipelas, and are highly suggestive of scabies when localised about the hands, and more especially the webs of