LUPUS The characteristic sign of lupus is the screened lupus nodule which is made up of a small circumscribed group of miliary tuberculous nodules and generally has its seat in the capillary layer of the skin and at times going deeper, into the corium.
Clinically, it presents a flat, brown infiltration. The brown color may be more distinctly brought out by the pressure of a cover-glass.
Pressure occurs, followed by infiltrations, by the confluence of neigh boring primary lupus macules which are mostly round and disk-like; these cause frequent interruptions of the nutrition of the epithelium and of the exfoliations. On the edges of these disks, new eruptions of nodules often occur, frequently as lupus serpigineous.
When both the capillary layer of the skin and the epithelium par ticipate in the whole process in a marked degree, we have resulting those papillary tumors called lupus verrucosus papillomalosus.
Besides the above-mentioned retrogressive epidermal metamor phoses, it sometimes happens that deeper changes take place and we have a softening and decay of the nodules and the formation of the characteristic lupus ulcers.* The surfaces of these ulcers are generally covered with a thick yellow scab. If much discolored by blood the scab is of a darker hue. After the removal of the scab, the uneven floor of the ulcer is seen, which generally bleeds easily. The border of the ulcer is hemmed in by the miliary lupus nodules.
The mucous membranes may be the seat of the primary areas. In this location it generally- forms diffuse infiltrations. The mucous membrane appears gray, uneven and granulated and ulcerations or deep fissures develop. Extensive destruction and mutilation of the tissues may occur during the advaneetnent of the lupus processes in the mucous membranes as well as in the skin.
Location.—Cenerally in childhood, the lupus appears in isolated areas which show according to their location a eorresponding favorite form. For instance, the millary and maculous forms have a predilection for the face; the lupus verrucosa for the tissues about the joints, etc.
Again, very frequently in childhood, the disease is found scattered here and there over the entire body. This is particularly frequent after the unite exanthemata such as .scarlet fever or measles or chicken-pox. This has been named lupus vulgaris post exanthcmalicus.
While most authors accept the theory of the endogenous hminatog enous infection for all these forms of disease, L'Ima and his followers remain true to the old accepted theory of inoculation tuberculosis, even for disseminated lupus.
Cases have been reported from various sources, which like the rest of the tuberculous skin diseases, when seen in connection with the acute exanthemata or occurring afterwards, have to be studied under children's diseases. Lately Tobler has compiled all of these cases which are mentioned in the literature.
I also have had occasion to observe two cases of disseminated lupus following attacks of measles. The first ease showed more than fifty lupus nodules (foci); which were spread here and there over the whole body. A periproctitic abscess was also present. In the second ease the foci were less in number but the child showed several maculous areas on the face, and isolated areas on the back of the hands, which Were somewhat different in appearance from the ordinary form of lupus and which corresponded more closely to tuberculosis cutis verrucosa.
Tuberculosis cutis rerrucosa is observed in patches, which are partly covered with papillary dirty brown or gray colored excrescences and partly with small pustules or scabs. Anatomically a circumscribed or diffused infiltration is observed, preponderating in the capillary layer of the skin. Epithelial cells, giant cells and 60111C caseation are also ob served. In this condition, tubercle bacilli are ordinarily found with ease and in large quantities; quite in contrast to lupus.
The differential diagnosis between the serpiginous form of syphilis and this condition presents some difficulties; the more so, as the serpiginous form of syphilitic lesions may be present for months or even years and healing may have occurred. leaving only fine epidermal scars as a result. A careful examination of the generally somewhat deep sears, sometimes discloses typical lupus nodules, and the finding of these make the diagnosis sure.
Sometimes the use of the tuberculin injection, as recommended by Neisser, followed by good diagnostic results. With the disseminated forms, one often observes at the first moment, a more or less remote similarity to acute universal psoriasis of the capillary layer of the skin, which is so often seen in childhood. The absence of the small scales, after the removal of which, in psoriasis the capillary layer of the skin easily bleeds; and the color of the single efflorescence, often also the various typical patches of psoriasis observed here and there over the surface of the body, are quickly decisive for purposes of diagnosis when carefully considered.