The diagnosis of lupus is in general easy. When we consider the location of the disease, the color of the lesions, their slow development, the absence of subjective symptoms, the presence of cicatrices in cases of long standing and the repeated relapses after even vigorous attempts at treatment, we ought not to be often led astray. A question may sometimes arise as to whether certain tubercles or ulcerations are lupous or syphilitic. The length of time they have existed will usually settle this, when we remember that syphilitic lesions may reach a degree of development in a few weeks that might hardly be accomplished by lupus in years. The single tubercle of lupus exedens is to be distinguished from sarcoma and epithelioma. In sarcoma the development of the lesion is much more rapid, while in epithelioma, the tubercle is hard, but in lupus exedens it is soft.
In no disease of the skin is the prognosis more dependent on the character of the treatment. In early cases it is absolutely good if sufficiently vigorous treatment be instituted, while lack of appreciation or lack of vigor on the part of the physician is responsible for most of the extensive and long-standing cases that we meet with.
Treatment.- Lupus erythematosus may sometimes be cured by the induction of an artificial eruption produced by the action of irritants. This method however, is not to be commended. It is much better to destroy it with an active caustic, provided the extent of the eruption does not contra-indicate this method. When the lesion is quite small, excision may be practiced; or thorough scraping with the dermal curette, followed by nitric acid, or the actual cautery. Lupus vulgaris demands the same treatment as the other form. In lupus exedens thorough removal with the knife of the diseased portions, including a portion of the surrounding apparently healthy tissue is the better plan.
Dr. Mackay reports two cases of lupus healed after a few weeks of treatment by twenty per cent. Ointment of resorcin, applied after scarification. The application of resorcin was attended with but comparatively little pain.
Sulphurous acid, in the form of a lotion or an oil, or in the gaseous state has been employed as remedial agent in lupus. The gaseous form may readily be obtained by burning in a jar, and allowing the fumes free contact with the surface to be treated. This can only be used upon parts removed from the respiratory organs. As a rule two applications daily, each for about twenty minutes, will be found best. The lotion is best obtained by the use of the pharmacopoeical preparation of the acid diluted in strengths of one in two, or one in three. This can be applied to any part of the face without producing disagreeable effects. The oil is preferred by some and is prepared by dissolving the anhydrous acid in castor or olive oil. Satisfactory results frequently follow this method of treatment.
Alveloz has lately been recommended as a local application for lupus and cancer. Cases have been reported where brilliant cures were effected by the use of the drug. I have had no opportunity of testing its virtues.
The application of ice will frequently relieve the severe pain that is sometimes the accompaniment of lupus; some authors claim curative effects from the use of ice.
Arsenicum alb. and Hydrocotyle, are the main internal remedies.
Others may be indicated as follows.
Aurum mur.- When starting from the nasal mucous membrane; a discharge from the nares very offensive; absorption of the bones of the nose melancholia.
Cistus.- Lupus on the face worse from cold air.
Graphites.- Lupus on the nose; obstruction of the mares dry, cracked skin; every injury tends to ulceration.
Guarana.- Lupus of an ochre-red color, yellow spots on the temples.
Hepar.- Lupus on the elbows; ulcers with burning or stinging edges; nodosities on the head sore to the touch; swelling of the upper lip.
Hydrastis.-Ulcers on the legs exfoliation of the skin; purulent discharge from the nostrils; faint, sinking feeling at the stomach.
Kali bichrom.- Ulcers painful to the touch; worse in cold whether; ulceration of the nasal septum; loss of appetite; all the secretions are tenacious and stringy.
Lycopod.- In recent cases; hunger with constant feeling of satiety; arms and fingers go to sleep easily; purulent discharge from the ears; weakness of memory; melancholia.
Nitric ac.- Lupus on the nodules of the ears; offensive purulent discharge form the ears; dry scaly skin; affections of the bones and glands; in dark complexions.
Oleum jec. ass.- A valuable remedy.
Staphysagria.- Ulcers on the alae of the nose; weary pains in the limbs as if bruised; teeth turn black and decay; in scrofulous subjects.
Epithelioma
Epithelioma, or epithelial cancer of the skin, is characterized by the appearance of a hard tubercle or nodule, slowly increasing in size until ulceration sets in, which ulceration may extend both laterally and deeply and destroy all tissues with which it comes in contact. As its name implies, it is an outgrowth from the epithelial tissues, in which a more or less extensive and exuberant proliferation of epithelial cells occurs. The typical epithelioma may be said to take its origin in the Malpighian layer, the cells of which increase in number and seek accommodation in the deeper layers of the skin. As they increase however, some of them, from the pressure of the neighboring connective tissue are forced to occupy a smaller space than they would if permitted of this to multiply compression, small rounded bodies are formed in which the cells assume a stratified arrangement, constituting the epithelial cell-nests well-knows to every microscopical observer. Coincident with this extension of the disease inward there is a greater or less projection outward, forming a distinct sessile tubercle, or a more flattened growth.
Primary cancer of the skin is a rare condition while epithelioma, involving both cutaneous and mucous surfaces- as ordinary cancer of the lip – is sufficiently common. Cancer of the skin however, which has developed secondarily to some pre- existing morbid growth is the variety most frequently found in practice.
Epithelioma is distinctly the product of irritation not an acute and transient irritation, even if frequently repeated, but rather one that is hardly if at all, appreciable to the senses, and which is persistent and active through a lengthened period. Thus we may find that a purely innocent and benign growth like a simple wart, may after a lapse of years become the seat of an epithelioma, which would not otherwise have appeared. A localized seborrhoeic condition, which of itself implies an irritation of the epithelial lining of the glands, may, and not infrequently does, become the starting point of cancer. Lupus offers an inviting field for the development of the disease; and in general it may be said that an ulcerating lupus, if left to itself, will almost invariably in time become supplanted by epithelioma. Sarcoma. Sarcoma more rarely is followed by epithelioma, and this rarity may be explained by the fact that sarcoma usually runs its course and has destroyed the patient before the cancerous affection has had time to develop the irritation produced by the sarcoma being more active than that which ordinarily leads to the occurrence of the other disease.
Epithelioma is met with clinically in two distinct forms, in one of which the cutaneous involvement is more superficial than in the other. In the superficial variety, which is less frequently met with than the other the patient attention is first attracted to a little crust-usually on some part of the face. This he picks off, and gives little further attention to the matter. A new crust forms and this is in turn picked off and reveals perhaps, an slightly excoriated surface. He consults a physician, who, failing to recognize the gravity of the condition, prescribes some salve or other or lightly touches the part with caustic. The lesion extends, and perhaps rarely reaches the hands of a surgeon until it has advanced to the stage of frank ulceration. We now find a sharp-cut ulcer extending through the entire thickness of the skin but not involving the subcutaneous tissues. This ulceration advances at its borders, or sometimes in one direction only, while reparative changes may some times occur in the other, much after the manner of some cases of lupus. The progress of the ulceration is exceedingly tardy, and years may elapse before the ulcer has attained any considerable size and when it does, we will sometimes find that cicatricial tissue now occupies a portion of the territory that had been the early seat of the cancerous lesion.
The other or tuberous form of epithelioma, will be recognized at the beginning as a hard tubercle occupying the seat of what may have been previously the situation of a wart, mole etc. This tubercle increases in size, and the tissues beneath it are palpably involved in the morbid process. The skin surrounding the tubercle is also involved to a certain, or, rather, uncertain extent, as is evident to sight and touch. later ulceration appears, and the margins of the ulcer are everted and hard. As the ulcer spreads laterally so also does it become deeper and the process continuing unchecked leads in time to a fatal termination.
