On Lupus vulgaris, or "The wolf" / by Balmanno Squire.

  • Squire, Balmanno, -1908.
Date:
1888
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Licence: Public Domain Mark

Credit: On Lupus vulgaris, or "The wolf" / by Balmanno Squire. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    peculiar to Lupus leads at IcDgtli to local iuflaruination and ulcera- tion even in persons whose general health is excellent. It is only to be expected that in scrofulous persons the inflammation thus aroused should evince the scrofulous type, should lead to scrofulous infiltration and chronic suppuration of the corresponding lymphatic glands and should modify somewhat not onjy the character of the ulceration of the Lu]:)us-patches but also the appear- ance of the scars left by the Lupus-ulcers. It is easy to comprehend that the phenomena and consequences of inflammation, whether excited by Lupus or any other cause, are not the same in a scrofulous as in a healthy person. Some authors have refei’red Lupus to syphilis. It has been assumed that Lupus is an evidence of inherited syphilis namely that it is always so. Others have maintained the view that Lupus is in some cases a syphilitic disease while in many cases it is not so. It has been held that in some instances it is impossible to distinguish Lupus from .syphilis since some cases present an aspect which is neither solely that of Lupus nor solely that of syphilis but seems rather to be partly of the one kind and partly of the other. For my own part I have never seen a case which exhibited an appearance intermediate between that of Lupus and that of syphilis. Lupus it is tme has a superficial resemblance to some i^hases of syphilis, but the numerous characteristic differences that exi.st between these two diseases suffice in every case to distinguish clearly the one disease from the other. To confound Lupus either in part or absolutely with either inherited or acquired syphilis is to evince an imperfect acquaintance with the characteristics of these two most distinct diseases. The term “ syphilitic Lupus ” is therefore inapplicable to any known condition and should be discarded. Other observers have referred Lupus to tubercle and have regarded Lupus as a localized tuberculosis restricted to the skin and adjacent mucous membrane. The origin of this belief was the discovery of the giant-cell in tubercle. For a time the giant-cell was believed to be peculiar to tubercle. When therefore it was subsequently found that in Lupus-tissue also the giant-cell was of constant occurrence the identity of the two diseases was considered as placed beyond question. But inasmuch as giant-cells are now known to be met with also in the marrow of growing bone, in granulation-tissue, in syphilitic gummata, and in sarcomata; it is clear that the presence of these cells in Lupus has not the significance which was formerly imputed to it. Several observers however have sought nevertheless to demonstrate that the tulercle-baciUus (which is found in the cells of tubercle, especially the giant-cells of tubercle, and which is now believed to be the essential characteristic of tubercle,) is to be found also in Lupus. Some have found the tubercle-bacillus constantly present in Lupus, but other investigators of considerable rej^ute have, after examination of numerous cases of Lupus, failed to find the bacillus in even a single instance. Leloir’ has attempted to produce tuberculosis artificiaUy by inoculation of liupus-tissue, and although in many instances he failed yet in others he succeeded in producing a generalized tuberculosis in which the tubercles contained bacilli. Whatever may be the correct interpretation of these observations it is at the least very difficult to comprehend how Lupus, if it be identical with tubercle, should fail so constantly as it unquestionably does fail, to produce general tuber- culosis in individuals who have been for long affected with Lupus. On the other hand the family history of persons affected with Lupus and, what is more, the clinical characteristics of the disease itself arc altogether opposed to the theory of any near relationship existiu”’ between it and pulmonary consumption. ° Lupus is a well-defined disease the cause of which is at the present time unknown. It occurs with uniform regularity in a certain definite percentage of the individuals of each generation but its choice of the individuals whom it affects seems, for all that is as yet known, a matter of the merest caprice. It affects the same percentage of the rich as of the poor. It is not more common in one country of Europe than in another. No influence of any known kind: whether peculiarity of constitution, occupation, mode of life, diet or hygienic surroundings : seems capable of influencing the rigid impartiality which governs its selection of individuals. On an average two cases of Lupus present themselves amongst a hundred cases of skin-disease. D<aflrnosis.--The disease which is the most liable to be confounded with Lupus is the syphilitic eruption known as the tubercular syphi- lide: an eruption which is e.specially prone to attack the face. Any of the several varieties of the tubercular syphilide may be mistaken for Lupus, namely the clustered non-ulcerating variety, the scattered non-ulcerating variety, the perforating ulcerating variety and the serpiginous ulcerating variety. As regards cither of the non-ulcerating vaiieties. the greater firmness of their tuberculcs, the deep pigmenta- tion of the aflected skin which they leave behind them, the depressed flat abruptly limited cicatrices which they produce, the much less tardy course which they follow and the coincidence usually of other symptoms of constitutional syphilis will suffice to distinguish them from Lupus. As regards either of the ulcerating varieties: the unbroken perpendicular walls of their ulcers, as if cut out with a punch, their smooth grey lardaceous floor, their comparatively hard edges, their less tedious evolution and involution and the flat sunken sharply-defined scars which they leave behind them, which scars while recent are deeply pigmented, such characters are amply sufficient to diagnose them from the ulcers of Lupus. The perforating rodent ulcer, an ulcer which is apt to affect pre- ferentially the face, more particularly one of the aim of the nose, may, in its earlier stages, be readily distinguished from ulcerating Lupus by its peculiar margin. The skin which immediately surrounds the depressed scab-covered ulcer forms a raised narrow ring which IS whiter than the surrounding skin and is of cartilaginous hardness to the touch. In its later stages the great depth to which the ulcer penetrates, destroying every tissue, even bone in its progress, and the character of the surfiice of the ulcer, which presents a smooth glazed appearance, and is of a pale dull-yellow colour, will, in conjunction with the peculiar margin of the ulcer, suffice to identify it. The serpiginous rodent ulcer may be distinguished by the character of its margin and by the character of its floor, which are the same as in the perforating rodent ulcer. Although both kinds of rodent ulcer are, like Lupus, wont to persist indefinitely if unchecked; nevertheless rodent ulcer, whether of the one kind or the other, makes its first appearance always at a much later age than Lupu.s, namely at the earliest in middle life or more commonly in old age. Moreover rodent ulcer affects usually only one side of the face whereas Lujius in most instances affects both .sides of the face. From Impetigo larvalis, a scab-covered eruption which often occurs on the faces of children. Lupus may be .easily differentiated. Impetigo progresses far more rapidly than Lupus. The scabs of Impetigo are of a lighter colour and a softer consistence, and are less firmly adherent to the skin beneath them. The surface of skin covered by the scabs is not an ulcer. The eruption is usually more extensive and less defined than in Lupus. The disease known as bat’s-wing-disease, an eruption which is described by most modern writers under the name of “ Lupus erythematosus,” can scarcely be mis- taken for Lupus (vulgaris). Nor does any relationship exist between these two diseases such as their identity of name would seem to imply. On the contrary they are obviously distinct diseases the one from the other. I have consequently proposed * the Latin name vespertilio {vespertilio, a bat) as a more suitable designation for bafs-wing-disease and have suggested that the name Lupus should be restricted to Lupus properly so called. The qualification ' vulgaris ’ is thus rendered unnecessary as applied to Lupus. The histology of Lupus has been investigated by Wedb^ Auspitz,* Virchow,^ Kaposi,® Essig,® Friedlander,'^ Colomiatti,® Lang,® Neu- mann,’® and many others. In the earlier stages of the disease a vertical section of skin affected Heuka’s PUNCTUKING Lancet (full size). 1882-83 swnces et merfioires lus i la sodete de biologic, Paris, 2 On ‘Lupus erythematosus’ or Vespertilio, l^onAow, 1887. ^ Grundziige der pathologischeu Histologic, Vienna, 1854 bifch^T ’ Die krankhaften Geschwiilste, II. Band, Berlin, 18G4-65. Svnhir''« pupillUren Ncubildungen der Haul, Ardiiv fur Dermatologic und bvphihs III. Hett, Prague, 1869. ° Pathologisch-histologische Untersuchungen uber Lupus, Archiv der Heil- kunde, Leipzig, 1874. ' Untersuchungen fiber Lupus, Virchow’s Archiv, LX. Band, Berlin, 1874. bulla natura e struttura del Lupo volgare, Turin, 1875. « Vierteljahresschr’ift ffi'r Dermatologic und Syphilis I. Heft, Vienna, 1875. ** Lehrbuch der Hautkrankheiten, Vienna, 1880.