I. On Some disregarded phenomena of Lupus

by Balmanno Squire, M. B., Lond.

Surgeon to the British Hospital for Diseases of the Skin.

I desire here to call attention, 'to some points in the pathology of Lupus which are worthy of attention, but which so far as I know are not referred to in any of the numerous text books which hâve recently been published.

In using the word Lupus I mean the disease which is often designated under the title of Lupus vulgaris ; I do not include the disease which of late years has been styled Lupus erythematosus, for that is for me a disease quite distinct name. I hâve proposed the name Vespertilio ( Vespertilio , a bat) for the last form Lupus, and as I think ought to be called by quite a distinct named disease.

In this paper then, I am referring only to Lupus and not to Vespertilio.

I. One of the phenomena of Lupus which, so far as I know, has hitherto remained unnoticed is this ; namely that in some cases the disease comports itself in a manner quite unlike its usual habit. Ordinarily the disease has certain régions of prédilection. As a rule it altacks first the face, preferring a particular part of the face namely the lower half of the face, and exhibiting a decided proclivily for one particular spot namely the lower half of the nose. Now in some cases this preference is conspicuously lost ; the disease exhibits apparently no prédilection whatever for its accustomed haunts. It is présent in many places, but in none of its usual situations ; not anywhere on the face, not on the gums, or on any part of the buccal mucous membrane, not on the neck, or on the hands or feet, or the forearms or legs. But this aberration of position would not alone be sufficient to idenlify . the phenomenon in question. Lupus is occasionally met with in unwonted situations without however exhibiting any further peculiarity. Thus I hâve seen it affecting one of the buttocks only, and although it was of many years duration and exteri-

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sively developed in that situation, it was nevertheless absent from every other part of the body.

Now in the condition I ara referring to, there is a further peculiarity in addition to the misplacement of the disease namely, that each patch of lupus is placed side by side with another pathological condition. That condition is a pre-existent scar ; not however a scar caused by previous lupus, but a scar resulting from other causes. I first saw such a phenomenon, many years ago, in the case of a child nine years of âge in whom numerous scars were présent al different parts of the body. A clear history ofthese scars could not be obtained either from the girl or from her parents, but they were probably the relies of scrofulous ulcers, they.certainly were not the relies of previous lupus. Now, at the time the child came under my care, every one of these old scars had become afïected with a small patch of Lupus at some part of the edge of each scar. These scars were situated at various parts of the trunk, the thighs and the upper arms. The patient had no trace of lupus in any of the usual situations of lupus. Since then I hâve seen several, but not many similar cases.

Now in these instances the impression produced on my mind, although I cannot prove its correctness, is that the individuals thus affected would hâve remained freefrom Lupus if they had not had scars. I believe that they had Lupus because of their scars. Here I may recall the fact that cancer will not uncommonly develop itself on the edge of an old scar. It is well known that scars are predisposing causes of cancer. But that scars are predisposing causes of lupus is a fact which I believe has remained hitherto unknown. If then, as I allégé, scars of any kind, are in lhemselves a cause of lupus, some light is thereby thrown on the ordinary progress of the disease. The well -known obstinate tendency of lupus to recur on the edge of an old lupus-scar is thus in some measure accounted for.

But scars are not the only potent causers of Lupus. I say « potent » because, in cases of the kind I hâve referred to, scars are apparently capable of giving rise to the development of lupus in individuals who, otherwise, would never hâve beeD attacked by the disease. Such a presumption is justifiable . by the circumstance that, in such cases as I am quoting, the disease had not developed itself in any other situations than on the edges of scars. It is not merely a question of lupus appearing in a situation jwhich would hâve been exempt if an old scar had not been there. It is a question of individuals becoming attacked by lupus who would hâve remained altogether free from lupus if they had been exempt from old scars.

There is another potent cause of lupus. This cause is well exemplified in a case which came under my care, some years ago, at the British Hospital for Diseases of the Skin. The patient, a woman thirty years of âge, was affected with necrosis of the cartilage of one of the .floating ribs. This produced a sinus on one side of the loins. From this sinus a thin purulent discharge constantly trickled down the patient’s side. The edges of the sinus became affected with lupus, and the disease spread, but not uniformly in ail directions. It spread only downwards, being limited to that portion of the skîn which was constantly moistened by the purulent discharge.

I am of course well aware that a similar phenomenon is often to be met with when, in the case of lupus invading the face of a scrofulous person, a

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submaxillary gland undergoes chronic suppuration and, bursting gives rise to a sinus. In such cases the edge of the sinus generally becomes affected with. lupus. It is the habit of most pathologists to ascribe such invasion of the edge of the sinus to the auto-inoculability of Lupus, and to assume that the lymphatic vessels hâve conveyed the disease from the skin of the face to the lympathic glands. Without disputing that assumption in the last named condition, I nevertheless claim that it cannot account for the primary development of lupus on the edge of a sinus, leading from a carious rib-cartilage. It seems clear therefore that the edge of a sinus, whether produced by a carious rib or a suppurating lymphatic gland, is itself a potent cause of lupus, quite independently of any auto-inoculation of lupus that may co-incidently be taking place. Now if an old ulcer, such as the mouth of a sinus, is capable of proving a starting point for lupus in an individual otherwise quite exempt from lupus, it would follow that the chronic ulcers, which are so often produced by lupus itself, must of themselves be most potent perpetuators of the disease.

I therefore submit that the two distinct kinds of fact that I hâve brought forward are, each of them of some scientific interest : namely as tending to elucidate, in some tangible degree, the marvellous chronicity of one of the most chronic of the diseases that we hâve to deal with.

II. Now let me pass to another of the hitherto unrecognized phenomena of Lupus. I refer to a very astonishing, but yet a very constant, phenomenon of lupus which however has nevertheless quite escaped, as I believe, the attention of dermatologists. It is well known that one of the favourite situations of lupus is the hand : that here lupus commits ravages which (considering its behaviour in other régions), are astonishing. Although lupus destroys completely the cartilaginous part of the nose, nevertheless the portion of the nose whose framework is constructed of bone always escapes destruction. So also comparatively thick although soft structures, such as, the lips, resist the ravages of lupus, even when attacked by it on both surfaces, at least in so far that they always escape absolute destruction. Now the Angers are comparatively thick. They are as thick at least as the lips. They are provided also with a strong bony framework. But yet the Angers when attacked by lupus are always completely deslroyed by the disease. Tendons, bones, every structure of the Anger vanîshes completely. So that one may meet with hand s which look as if ail of the Angers and the thumb had been amputated at the heads of the metacarpal bones. This I say is a sufûciently astonishing phenomenon of Lupus, having in view its behaviour in other situations. Now here is the place for mentioning another phenomenon of an extremely quaint kind. It is to this phenomenon that I desire to draw attention, hecause I do not And it mentioned in any of the text books that I hâve consulted. In a hand thus mutilated there will be found, neatly perched over the heads of each metacarpal bone, the nail of the corresponding Anger : a nail perfectly well. formed, and growing most luxuriantly and prosperously in its new and somewhat strange situation. There it is! Axed on to the end of the long metacarpal bone : just as in olden times the head of a criminal, whose body had beencâst away, used to be Axed onto a pôle. Ûftentimes, whenl hâve examined Angers that had not yet been completely destroyed but only shortened by lupus, I hâve seen the faithful Anger nail clinging bravely to the end of the mutilated Anger. I hâve found the nail always at the end of the Anger :

naraely whether the fmger has been only slightly shortened, or on the contrary very rauch shortened. So that evidently, as the finger gradually melts away under the influence of lupus, so the finger-nail gradually sinks downwards on the apex of the shortening finger, until the nail finally cornes to rest on the head of the metacarpal bone.

But I do notbringforward these disregarded phenomena of Lupus, inerely, because they are quaint and odd. I draw attention to them because it seems to me that, in the future such phenomena may not improbably throw some useful light on the natural history, and even on the betler treatment of ordinary cases of lupus. I myself can only regret that I am unable to draw conclusions, of the kind I suggest, from these most interesting data. We are of course aware that the matrix of the nail is a highly vitalized structure, but a great deal more than this is involved in the weird journey of the nail down the whole lenglh of the moribund fmger.