Lupus may arise in several ways, and it is only the constitu tional cachexia which, modifying its subsequent course, gives it a specific character. Its seat is most frequently about the alai of the nose, the lips, and the cheeks. Its commencement may be referred to three principal varieties of cutaneous eruption, the vesicular, the pustular, and the tubercular : occasionally resem bling herpes, it more usually begins like a spot of impetigo ; and when it attacks the cheek, it sometimes presents the form of tubercles. In the early stage it differs from the two former by its insidious commencement and slower progress, by the firm adhesion of the crust and the surrounding tumefaction of the skin, and its dusky color. When such characters mark any form of eruption about the nose or the cheek, it is not improbably lupus, especially if scrofula can be traced in the family : if it be lupus, the crust covers an ulcerated surface, which very soon begins to spread. From tubercle of the skin it is chiefly distin guished by the absence of the bronze tint, and by its forming a defined group or patch on one check. In the majority of cases of lupus, scales or crusts soon form on the surface, which gradually thicken into scabs, and leave ulcers behind when removed; but in one variety the disease proceeds without any ulceration at all, the destruction of the skin in its progress being marked by seams and scars, which are not seen in tubercle: such cases are naturally less distinct than those in which ulceration has occurred.
Scrofulous ulceration is very commonly seen in the side the neck, and the formation of an abscess there must always be re garded with great suspicion. Indolent abscesses in other parts of the body, without assignable cause, are also very probably due to scrofula. They are not uncommon on the back of the hand, and in the neighborhood of the elbow. The characters by which scrofula is recognized have already been discussed (Chap. IX. Div. 1, § 1); and we may here call to mind the fact that, in scro fulous children the cutaneous eruptions are usually of the suppu rative kind, and are remarkably indolent and intractable: impetigo larvalis is one of this class; they often excite inflammation and enlargement of the cervical glands, which may be the first begin ning of scrofulous ulcer.
Although the one disease be most common in ohildhood, while the other occurs at adolescent*, or after maturity, yet occasionally scrofulous ulcers are seen in adults, and lupus at a very early age.
The ravages of syphilis on the face are sometimes closely allied to lupus, and there is every probability that in such cases the scrofulous diathesis is present as well as the syphilitic taint : it is recognised by its coppery tint, and the coexistence of other symptoms, such as sore throat, eruption on other parts of the body, ace. Syphilitic lupus is quite distinct from caries of the bones of the nose, which is to be regarded as a specific action of the venereal poison : it usually results in extensive ulceration and great disfigurement We have to distinguish lupus from epithelial cancer of the lip, which usually commences by a single nodule, and gradually increases in size without ulcer ating, until it has acquired considerable dimensions. The distinction is less easily made between it and another form of cancer of the skin in the early stage, when there is no appearance of morbid growth, and only a spot of ulceration, which subsequently spreads in every direction, and commits fright ful ravages. Subsequently the distinction is less difficult, because lures in
its progress leaves scars behind when the disease has subsided, while in cancer there is no trace of the healing process at alL Cancrues oris in childhood again has not the indolent, sluggish characters which mark all the preceding conditions : it begins with ulceration in the inte rior of the cheek, which spreads with great rapidity, producing sloughing and destruction of all the tissues adjoining. The fetid smell and rapid progress of the disease prevent its being confounded with any other of analogous character.
§ 11.--Endernial Diseases of the &in.
Systematic authors refer to a variety of diseases as inherent in various locaities, to which particular names have been assigned in the clistricts where they occur. Exainination of the statements given seems to prove pretty clearly that many of them are referable to syphilis and scrofula; others again are probably varieties of tubercle of the skin, which is much more liable to be developed in warm climates than our own ; the worst cases seen in this country generally occur in persons who have returned from India. The Arabian Ele phantiasis consists rather in hypertrophy and induration of the cellular tissue than in any true disease of the skin. Such disorders need not occupy a place in these pages, beciinse they are so rarely met with, and are not likely to throw any difficulties in the way of the student.
§ 12. Cellular Inflammation.--7-Praatioally, it is very inoonve nient that we are obliged to separate this disease from erysipelas, when studyingeiatis. diagnosis : and to make the distinctions clear we ought to in mind, at the same time, the characters of phlebitis, secondary suppurations, and even erythema. All are, more or less, allied to eaoh other, but yet their true history and their pathology present them to our notice as distinct disease& The history of cellular inflammation classes it at once as an acute febrile disease ; from the first rigor till its distinct localiza tion there is nothing to indicate what or where the inflammation is to be. Deep-seated pain flrst calls attention to the part affected, and is very likely to be referred to some internal organ, because it has not the burning or stinging character which in erysipelas draws the attention of the patient or the attendant to the skin ; cases of this kind have been treated as some curious or anomalous example of internal disease, until accident has revealed the mis take. This lesson should not be forgotten. The akin presents a lurid redness, and is tense, but not hard to the touch; pain is aggravated by pressure, but there is not much superficial tender ness; the border of the redness is not defined, but gradually dies away in the surrounding skin. These characters are quite suffi cient to mark the disease; to erysipelas it is allied by the fever and the redness, but the color and the sense of touch at once dis tinguish it; the condition of the skin is more like erythema, but there is no fever or tension in that disease. From the swelling accompanying phlebitis it is completely removed by the redness of the one affection, and the white oedematous condition of the other.