Dilapidation

“ Extravascular pigment.——In the early stages of malarial disease, except in the case of the spleen and the bone marrow, pigment is entirely confined to the lumen of the vessels and to their endothelium. But if we examine tissues from a case which has died at a late period of the disease, the pigment may then be found, not only in the endothelium, but also in the walls of the vessels, and even in the perivascular lymph spaces, whence, it may be inferred, it is subsequently carried to the lymphatic glands to be finally dealt with and broken up. ”

“ While dark-haired people show pigmentation in a very marked manner, those with red hair show it slightly or not at all. In some peculiar manner red-­haired people appear to possess a comparative immunity to the effects of intestinal stasis. Except for the face, the areas that show pigmentation most conspicuously are those exposed to friction, such as the inner aspects of the upper parts of the thighs, with the adjacent opposing surfaces of the buttock, the spines and abdomen where the corset or dress presses, the axillary folds, the bend of the elbow, and the neck. ”

“ What do you understand by Paget's disease of the nipple?
Paget's disease is a rare, inflammatory-looking, malignant disease of the nipple and areola in women, usually of advancing years, eventually terminating in cancerous involvement of the entire gland. ”

“ Lipoma.#--A lipoma is composed of fat resembling that normally present in the body. The commonest variety is the _subcutaneous lipoma_, which grows from the subcutaneous fat, and forms a soft, irregularly lobulated tumour (Fig. 45) . The fat is arranged in lobules separated by connective-tissue septa, which are continuous with the capsule surrounding the tumour and with the overlying skin, which becomes dimpled or puckered when an attempt is made to pinch it up. As the fat is almost fluid at the body temperature, fluctuation can usually be detected. ”

“ The extraordinary plumpness, or rather swelling of the body, observed in the beginning of this disease, does, in a few months, disappear, and they turn very lean and weak, only their face always, and sometimes also their legs, continue swelled. A great many little lumps like small hard seeds are then to be felt everywhere under their skin, which gradually increase till they break out externally, throwing out a fœtid thin ichor, which ceases to run in a little time, and a hard scab covers the part, which sometimes dries, and falling off, leaves the skin entire ”

“ In fact, the active cells are passing their daughters into the middle of the process, and these pass through similar stages as those derived from the ensheathing epidermis. In other words, the daughter cells of the constituents of the rete Malpighii which have grown into the corium pass through a degeneration precisely similar to that undergone by cells shed at desquamation, or those which eventually give rise by their agglutination to a hair. ”

“ A blue or bluish-black discoloration occurs in patches, varying in size and depth with the degree of force which produced the injury, and in shape with the instrument employed. It is most intense in regions where the skin is naturally thin and pigmented. In parts where the extravasated blood is only separated from the oxygen of the air by a thin layer of epidermis or by a mucous membrane, it retains its bright arterial colour. These points are often well illustrated in cases of black eye, where the blood effused under the conjunctiva is bright red, while that in the eyelids is almost black. ”

“ Larger bodies, such as needles or bullets, which are not capable of being destroyed by the phagocytes, become encapsulated. In the granulation tissue by which they are surrounded large multinuclear giant-cells appear (“foreign-body giant-cells”) and attach themselves to the foreign body, the fibroblasts proliferate and a capsule of scar tissue is eventually formed around the body. The tissues of the capsule may show evidence of iron pigmentation. Sometimes fluid accumulates around a foreign body within its capsule, constituting a cyst. ”

“ A subsynovial lipoma grows from the fat surrounding the synovial membrane of a joint, and projects into its interior, giving rise to the symptoms of loose body. Lipomas are also met with growing from the adipose connective tissue between or in the substance of muscles, and, when situated beneath the deep fascia, such as the fascia lata of the thigh, the characteristic signs are obscured and a differential diagnosis is difficult. It may be differentiated from a cold abscess by puncture with an exploring needle. ”

“ It may be less evident to the eye than to the fingers, and is best appreciated by gently stroking the bone from the middle of its shaft towards the end. The maximum thickening and tenderness usually correspond to the junction of the diaphysis with the epiphysis, and the swelling tails off gradually along the shaft. As time goes on there is redness of the skin, especially over a superficial bone, such as the tibia, the swelling becomes softer, and gives evidence of fluctuation. ”

“ The abdomen is composed of three joints; the first passes from the side lobes completely over the body, and on its upper surface, near the middle of the back, there is often a minute elevated pimple. The other two, pass obliquely from the lateral lobes, and are interrupted in their course over the body. The tail, or posterior portion, is expanded, something like that of the Isotelus or Dipleura, and has a deep puncture on each side, about half the distance between its terminal border and the last articulation of the abdomen. The lateral lobes are unlike those of any other genus. ”

“ These lesions are even less common in them than in the bones. We do not see in them those schirri, swellings, changes of texture in a word, which are so commonly met with in the other organs. Among the great number of subjects that I have had occasion to dissect or to have dissected, I do not recollect to have seen in the muscles of animal life other alterations than those of their cohesion, their density and their colour. It is a phenomenon that approximates them to those of organic life, in which we rarely meet with changes of texture, as the heart, the stomach, &c. ”

“ In addition to its constant formation of cells to replace those cast off from the surface, the active proliferation of the elements of the Malpighian layer is responsible for the development of the various appendages of the skin, the hairs with their sebaceous glands, the sweat glands, horny growths and the hoof, and, in the human subject, the nail. These occur as thickenings and down-growths of the epithelium into the corium.
The epidermis is devoid of bloodvessels, but is provided with fine nerve fibrils which ramify between the cells of the rete mucosum. ”

“ Herbert Spencer [12] maintains that when muscles are much used, or when intermittent pressure is applied to the epidermis, an excess of nutritive matter exudes from the vessels, and that this gives additional development to the adjoining parts. That an increased flow of blood towards an organ leads to its greater development is probable, if not certain. Mr. Paget [13] thus accounts for the long, thick, and dark-coloured hair which occasionally grows, even in young children, near old-standing inflamed surfaces or fractured bones. ”

“ The hair becomes white and woolly, and at length falls off; hard gelatinous swellings are formed in the cellular tissue; the skin gets hard, rough, and seamy, lymph exudes from it, and forms large scabs, which fall off from time to time, and under these there are often offensive running sores. ”

“ The amount of pigment varies: when small in amount the growth is brown, when abundant it is a deep black. The most remarkable feature is the rapidity with which the disease becomes disseminated along the lymphatics, the first evidence of which is an enlargement of the lymph glands. As the primary growth is often situated on the sole of the foot or in the matrix of the nail of the great toe, the femoral and inguinal glands become enlarged in succession, forming tumours much larger than the primary growth. ”

“ The lymph passes on to the deep inguinal and external iliac glands. The superficial glands through their relations to the genitals are frequently the subject of venereal infection, and also of epithelioma when this disease affects the genitals or anus; they are rarely the seat of tuberculosis. The deep inguinal glands lie on the medial side of the femoral vein, and sometimes within the femoral canal. They receive lymph from the deep lymphatics of the lower limb, and some of the efferent vessels from the femoral and superficial inguinal glands. ”

“ The congenital growth rarely increases in extent, except as the body grows larger, but often the pigmentation becomes more pronounced and the hair begins to grow coarser in adult life. The development of small hairy moles upon the face of elderly
Fig. 29.
women, especially those suffering from hypertrichosis, is very frequently noted.
In the treatment of the pigmentary mole, acids or the electrolytic needle may be employed. For small, round, dark spots on the skin a minute drop of nitric acid, applied with a wooden toothpick, will often suffice to remove the blemish. ”

“ The chief seat of this disease is from the bending of the knee downwards to the ancle; the leg is swelled to a great degree, becoming one size from bottom to top, and gathered into circular wrinkles, like small hoops or plaits; between every one of which there is an opening that separates it all round from the one above, and which is all raw flesh, or perfectly excoriated. From between these circular divisions a great quantity of lymph constantly oozes. The swelling of the leg reaches over the foot, so as to leave about an inch or little more of it seen. ”

“ All these conditions cannot remain after death. Hence, if we desire to form positive opinions concerning much which is unfolded by dissection, we must supply the defect by analogy. Thus, whenever, in any part of the heart or arteries, the cohesion between the internal membrane and the subjacent structure is manifestly lessened, and the membrane is unusually red at that part, we may regard these appearances as the vestiges of inflammation, without thinking that we go too far in so regarding them. ”

“ Infection takes place through an abrasion of the skin, and the disease usually occurs on the feet of adult males who work barefooted in the fields.
Clinical Features.—The disease begins on the foot as an indurated patch, which becomes discoloured and permeated by black or yellow nodules containing the organism. These nodules break down by suppuration, and numerous minute abscesses lined by granulation tissues are thus formed. In the pus are found yellow particles likened to fish-roe, or black pigmented granules like gunpowder. ”

“ Alarmed or taught by such occurrences, the common people often went about all their lives with the plica gradually dropping off. Formerly there was much theorizing and discussion regarding the etiology and pathology of plica, but since this mysterious affection has been proved to be nothing more than the product of neglect, and the matting due to the inflammatory exudation, excited by innumerable pediculi, agglutinating the hair together, the term is now scarcely mentioned in dermatologic works. ”

“ There is an increased vascularity of the medullary membrane, and the cancellated texture contains thin brownish-looking fluid instead of marrow. In cases of disease which has commenced in the cancellated texture, there is hardly any pain at first, and the progress of the disease is remarkably insidious. When the lower extremity is affected, the child is observed to limp; the limb wastes; it appears to be longer, partly from atrophy of the muscles, partly from relaxation of the ligaments and effusion into the joint. ”

“ Deep-seated collections may originate in glandular disease, or commence in the cellular tissue; they occasionally follow transverse wounds of the neck. Great infiltration of the cellular tissue supervenes over the trachea and sternum, and also under the fasciæ; purulent matter is secreted in the cells, and the parts are extensively separated; sloughing is prevented only by free and early incision. The nature and extent of the coverings of an abscess seated deeply in the neck are to be kept in view—the platysma myoides, the superficial and deep cervical fasciæ. ”

“ In consequence of the interference with nutrition occasioned by these changes atrophy and fatty degeneration of the cartilage-cells occur, and they form between the epiphysis and diaphysis a necrosed mass which irritates the living bone. This causes osteo-myelitis, which frequently results in a separation of the epiphyses. Occasionally pus is produced in such quantity as to perforate the periosteum, escape into the surrounding tissues, and become superficial. ”

“ Even the fluid from a blister, in virtue of the isolated cells of the rete Malpighii which it contains, is capable of starting epithelial growth on a granulating surface. Hairs and nails may be completely regenerated if a sufficient amount of the hair follicles or of the nail matrix has escaped destruction. The epithelium of a mucous membrane is regenerated in the same way as that on a cutaneous surface. ”

“ On the other hand, if it is not directly involved but is merely influenced by the proximity of an infective focus, its bone-forming functions may be stimulated by the diluted toxins and the growth of the bone in length exaggerated. In paralysed limbs the growth from the epiphyses is usually little short of the normal. The result of interference with growth is more injurious in the lower than in the upper limb, because, from the functional point of view, it is essential that the lower extremities should be approximately of equal length. ”