On lupus erythematosus; or bat's-wing disease / by Balmanno Squire.

  • Squire, Balmanno (Alexander John Balmanno), -1908.
Date:
1887
Catalogue details

Licence: Public Domain Mark

Credit: On lupus erythematosus; or bat's-wing disease / by Balmanno Squire. Source: Wellcome Collection.

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    toes. Kaposi9 describes a form of Lupus erythematosus in which the eruption, instead of consisting of a limited number of patches which slowly increase in size, is constituted by very numerous minute spots of the size of a lentil or less. Each spot presents the characters which have been above described as proper to the “ elementary lesion ” of this disease. These spots are either diffusedly scattered or are aggregated into clusters. The eruption may be developed gradually or acutely, and, after first invading the face and other parts of the head, may, by successive acute outbreaks, invade the neck and portions of the trunk and limbs, or may at length become almost universal. This form of the disease is accompanied by various local and general symptoms such as:—Nodular doughy painful subcutaneous swellings situated especially over the larger and smaller joints. Boring rheumatic pains in the bones and joints. Numerous bean-sized sanious blebs. Inflammatory swelling of the lymphatic glands and of the parotid glands. Erysipelas affecting various portions of the skin but preferably the face, or another condition described by him as Erysipelas perstans faciei. As to general symptoms, he mentions fever of an irregularly remittent type. In connection with the Erysipelas perstans faciei, he enumerates fever of a typhoid character, great prostration with unconsciousness resulting in coma or com¬ plicated with pleuropneumonia and ending sometimes in death. This “ disseminated or aggregated ” form of the disease may coincide or not with the “ discoid ” form, that is to say, with the disease which has above been described as “ Vespertilio.” In the course of five years he had under care in all 22 cases of Lupus erythematosus, 7 of them being males and 15 being females; this disseminated form was confined to the females, but 10 out of the 15 were thus affected; of this 10 as many as 9 had repeated attacks of erysipelas, and 3 of the 9 died under the complications above named. For my own part, I have never seen this “disseminated” form which makes up nearly one half of the total number of Kaposi’s cases of Lupus erythematosus, and I have no reason for supposing that in this country the “ disseminated ” form ever occurs. The course followed by Vespertilio is in every case an extremely chronic one. Individual patches of the disease may last for several years: the disease usually persists for a very long series of years. In its tedious progress it undergoes here and there, as I have already mentioned, spontaneous cure, while continuing to spread at other parts. Whether it have disappeared spontaneously or under treat¬ ment, the disease always, or almost always, leaves behind it a scar. This scar if situated on the scalp constitutes a permanent bald patch, and if situated on the face, is in some few cases complicated with permanent and sometimes very disfiguring teleangiectases. As to the causes of Vespertilio we know but little. I have already adverted to the influence of sex and of age in its causation. Kaposi10 * has observed in some cases, as a local cause, the pre-existence of a pronounced local seborrhoea. In the diagnosis of Vespertilio it is necessary to bear in mind the comparative rarity of the disease, namely, the fact that on an average only one or at most two cases of it present themselves amongst a thousand cases of skin disease, so that, in the presence of doubt, probability is always strongly against Vespertilio, while in the case of a male the chances against Vespertilio are at the least quite the double of what they are in the case of a female. Next it is requisite to take into consideration not only the appearance of the eruption itself, but to a certain extent also its history as related by the patient, that is to say, its hitherto duration and the rate of progress of its individual patches, and furthermore to enquire what portions of the eruption appeared first and in what order of sequence, and at what intervals the remaining portions of it have followed. Then the age as well as the sex of the patient will afford material assistance in coming to a conclusion. So also will the presence or absence of local sub¬ jective symptoms, that is to say, itching or burning: and finally the map of the disease on the skin, or in other words, its situation on the face, the pattern formed by it on the face, and its presence at or absence from other portions of the skin. In judging by the map of the eruption it is however not to be taken for granted that the com¬ plete bat-like map will always present itself; thus, in some cases the bridge of the nose will alone be involved: in some the whole length of 9 ‘Neue Beitrage zur Kenntniss des Lupus erythematosus,’ Archiv fur Dermatologie und Syphilis, 1 Heft, Vienna, 1872. 10 ‘ Zum Wesen und zur Therapie des Lupus erythema tosus ’ in the Archiv fur Dermatologie und Syphilis, 1 Heft, Vienna, 1859. Fig. 3. scalp, will be the only regions involved: and so on. Nor will the scab always, or indeed often, present the characteristic appearance that it did in the case represented in the coloured illustration. It is gene¬ rally far too much frayed and rubbed off for that. The diagnosis of Vespertilio however stands within a comparatively narrow limit. It is in effect the diagnosis of an eruption of the face. It is never a very difficult matter. A patch with an ancient history and a scar in its centre can scarcely be taken for a patch of Herpes circinatus. It is equally obvious that a patch of the disease, such as I have described it, cannot readily be confounded with a patch of scaly eczema nor with a ringed papular syphilide. It would be difficult even to confuse it with an early rodent ulcer, whose elevated scabless border is whiter than the surrounding skin and whose depressed scab-covered centre presents a moist raw ulcer. Still more difficult is it to make a mistake between Vespertilio and Lupus (vulgaris). The name ‘ Lupus erythematosus ’ as applied to the disease under consideration is indeed an extremely misleading one. It has nevertheless been retained by most modern writers on the subject. In defer¬ ence to general custom I have felt con¬ strained to employ it here, but there are strong objections to it. One is that this disease is not Lupus, another is that it is not from any point of view an erythema¬ tous eruption, and another is that the name has already for long been commonly employed in an altogether different sense, namely, to designate one of the phases of Lupus (vulgaris). I have myself,11 amongst others, been accustomed to use it in that different sense. I therefore venture to propose the Latin name Vespertilio (yes- pertilio, a bat) for this disease. It has in fact long been known in this country under the name of Bat’s-wing-disease. The name has the advantage of being an arbitrary name just as Lupus is. It is perhaps for choice even a little more appropriate to its purpose than Lupus is for the condition that more properly comes under that name, for, as Devergie12 asks, “ Quelle analogie y a-t-il en effet entre la figure d’une per- sonne atteinte de lupus et celle d’un loup! ” It is difficult to conceive that any person familiar with Vespertilio on the one hand and with Lupus on the other can fail to perceive that these two diseases are clini¬ cally distinct from one another. In fact, in most of the more recent treatises on the diseases of the skin ‘ Lupus erythe¬ matosus’ is described under a distinct heading, just as Psoriasis is. It is com¬ monly recognised that in it we have a distinct genus, just as in Psoriasis we have a distinct genus. Out of this situation has arisen the awkward necessity of elon¬ gating the name of the disease Lupus (properly so called) and of terming it ‘ Lupus vulgaris.’ As to the differences between Lupus and Vespertilio I may mention some of them. First I may instance the respective maps of the two diseases, a subject to which I have adverted more fully in another place.13 The normal map of Vespertilio occupies the upper half of the nose and the upper part of the front of the cheeks, that of Lupus occupies the lower half of the nose and the lower part of the cheeks; Vespertilio commences almost always in adult life, Lupus commences almost always in childhood; Vespertilio hardens and toughens the affected skin, Lupus softens it and also renders it^much more friable; Vesper¬ tilio never produces ulceration of the skin, Lupus often produces ulceration; Vespertilio never leads to destruction of the cartilages of the nose or eyelids. Lupus, when it invades the nose or lids, often, nay generally, destroys the cartilages with eventually total loss of the 11 A Manual of the Diseases of the Skin, Fourth smaller Edition, London, 1887. 12 Traits pratique des Maladies de la Peau, 2ieme £d. Paris, 1857. 13 On the Topography of Skin Diseases as a means of determining their diagnosis. London, 1875. VOLKMANN’S SHARP SPOONS (full size).