« PreviousContinue »
ORIGINAL LECTURES. *
LUPUS ERYTHEMATOSUS. By JONATHAN HUTCHINSON, F.E.C.S., Senior Snnreon to the London Hospital and to the Hospital for Diseases of the Skin, and Surgeon to the Moorflelds Ophthalmic Hospital.
Definition of the term Lupus—Nature o f the Disease and its Alliances—Peculiar Features of the Erythematous Form— Its Varieties—Less connected with Scrofula than the Common Form—Early Description by Hebra, Catenave, etc.—Published Portraits—Cases of Extreme Capillary Dilatation resembling Navus—These Cases most Common in Early Life—Mr. Macarthy's Two Cases—Case of LupusNavus in an Infant (Mr. Higgens' Case)—The New Sydenham Society Portrait—Details of the Case, with Important Facts as to Influence of Temperature and State of Circulation.
Gentlemen,—The name Lupus is applied to a chronic form of inflammation of the skin which has certain peculiarities, and which occurs in persons of certain proclivities. It is ■allied, on the one hand to scrofula, on the other to psoriasis, -and it partakes also, in some degree and especially in some cases, of the nature of the inflammation which produces chilblains. In different persons who are the subjects of lupus we recognise differing degrees of tendency to one or the other of these three types of morbid process, and hence it results that lupus is not always exactly the same. Some forms are so strongly strumous that it is difficult to separate them from scrofulous ulceration of the skin; others are very close to psoriasis; while a third group, in their local position, in their susceptibility to the influence of weather, and also in the nature of the local disease, show an essential resemblance to what we know aa chilblains. With such a wide range of liability to difference it is essential to state clearly what the peculiar features are which we regard as essential to lupus. First, let me say on this point that some of the forms of serpiginous syphilis so closely resemble the Lupus process that, excepting in that they are produced by a different cause, and curable by a different treatment, it is quite impossible to separate them. Unless you allow me to introduce into my definition a reference to cause, I should be quite baffled in an attempt to define lupus in any way which should exclude them. It is difficult enough with the patient before us to say which is which, but quite impossible in a mere verbal description. Beginning, then, by excluding everything which is due to syphilis, I will say that the name lupus is applicable to a chronic inflammation of the skin, attended by a cell-growth in the deeper layers, which spreads slowly at its edge, and thus involves adjacent parts, which inevitably disorganises the parts attacked, and always, after cure, leaves a scar. It is by this tendency to leave a scar that we separate lupus from psoriasis, for after the cure of the latter the skin is left quite sound. Now, the lupus-proces3 is in part one of new growth, and in part one of inflammation, and it varies, no doubt not alone in reference to the temperament of the patient, but also in respect to the precise tissue in which it originates. The alveoli of the corium are its usual site, but in different cases the sebaceous glands, the papillte, and the vascular system may be disproportionately involved. There are forms of common inflammation in which paralytic dilatation of capillaries is the chief feature, and others in which cell-multiplication is greatly in excess of the increase in supply of blood, and we recognise precisely the same modifications of the lupus-process.(a)
Now, I propose, in to-day's lecture, to ask your attention to a form of lupus in which the tendency to vascular dilatation is so conspicuously in excess of the other factors in the inflammatory process, that a special name has been given to it. Under the name Lupus erythematosus, observers have denoted a malady closely allied to lupus, indeed, in many
(a) There is also a rare form of cancer of the side, usually secondary to '*fi -r of the breast, in which the capillary dilatation is a very conspicuous
cases, absolutely identical with it, but of which the chief feature is an erythematous patch. This patch proves its nature by its long persistence, the slow spreading at its edge, and by its always leaving a scar when the morbid process ceases. There is exceedingly little evidence of cell-growth, at any rate in many cases, but I must ask you to believe that there is always some; it is not that one part of the lupus-proce3s is wholly omitted, but rather that another takes the lead. In some instances the vascular dilatation is extreme, and a condition closely resembling narvus is produced, whilst in a few a tendency to rupture of vessels is observed, and a Lupus erythematosus htemorThagicus is constituted. These extreme forms are rarely seen excepting in young children. The more common forms of erythematous lupus are met with, however, not in children, but in young or middle-aged adults, and are attended by much less peculiar conditions. Usually the disease begins on the nose, and a red, slightly roughened patch is produced on the middle of that organ; next, two symmetrical red patches are seen on the cheeks (seldom continuous at first with that on the nose), and after a time patches occur in both ears. The tendency to symmetry is very remarkable, and I must beg your especial attention to the fact that the patches are independent, and not continuous. Although erythematous lupus spreads at its edge, and is serpiginous, just like other forms of lupus, yet it differs from all other forms in its marked tendency to symmetrical development. Next to the ears come the backs of the two hands, and it is very rare indeed to see one hand alone, or one ear alone, affected. Often the cheeks are affected before the nose, and not unfrequently the ears before either, but usually the order of production is what I have stated. When the patches on the cheeks have become joined to that on the nose, a form is produced like that of a body with wings, which has been compared to a bat's wings or a butterfly.
There are other minor features of peculiarity by which we recognise this disease: the patches are usually abruptly margined, more red at their edges than in the middle, rough, dry, slightly scaly, and seldom attended by any crust; often a great number of little patches occur in a cluster, and some of them become confluent, and when this is the case the little patches, which are more or less round, are depressed in the centre and slightly raised at their edges, being what is known as disc-shaped. These discs are reckoned by some authorities as the characteristic feature of the disease, but they are by no means always present, nor is it always easy to distinguish them from those of common lupus. On some parts, and in certain cases, the surface of the patch shows a great number of little pits, which are the orifices of sebaceous glands made conspicuous by the shrivelling up of the surrounding skin, and by the presence (often) of little dried plugs of sebaceous matter. These conditions are most often seen on the nose, but frequently on the cheeks also, and they probably occur to those whose skins are naturally somewhat coarse, and whose sebaceous glands are large and sluggish. In most cases these two conditions of roughness with pitting and erythema are present together, but in a few there i.< scarcely any erythema. To these latter the term Lupus sebaceus was formerly given by some. This term might, perhaps, be retained for convenience, but you must remember that the two are really parts of the same morbid process, which receives minor modifications in connexion with the age and temperament of the patient.
Such, then, are the general features of erythematous lupus. It is a disease usually easy to diagnose if you know it. Those not familiar with its appearance would probably mistake it for chronic eczema, for a slight form of psoriasis, or for common lupus. From eczema the history usually distinguishes it at once, for your patient will probably tell you that he has had the patch exactly in its present position and state, getting little either better or worse, for years. Eczema, on the contrary, is either cured or spreads quickly. The peculiar positions affected, the forms produced, are facts also of great value in diagnosis. But above all you must look for the scars. If you find that it is spreading at the edge and healing with a thin but definite scar in the centre, your diagnosis is complete, for neither eczema nor psoriasis(b) ever do this. I am not much concerned to establish the diagnosis from common lupus. In most cases it is easy enough; and when it is not, then my assertion would be that (b) Perhaps as exception should be made for certain very rare forms
Vol. L 1879. No. 1488.