Cauterization--with nitrate of silver, with applications of pyrogallic acid in ointment or in liquor gutta-perchae, fifteen to thirty per cent.

strength, and with solutions (cautiously employed) of caustic potash, and exceptionally with the galvano-cautery.

[Ill.u.s.tration: Fig. 43. Single Scarifier.]

[Ill.u.s.tration: Fig. 44. Multiple Scarifier.

(_As modified by Van Harlingen._)]

Operative--scarification, either punctate or linear, and erosion with the curette. (See treatment of lupus vulgaris.)

Lupus Vulgaris.

(_Synonyms:_ Lupus; Lupus Exedens; Lupus Vorax; Tuberculosis of the Skin.)

What do you understand by lupus vulgaris?

Lupus vulgaris is a cellular new growth, characterized by variously-sized, soft, reddish-brown, papular, tubercular and infiltrated patches, usually terminating in ulceration and scarring.

Upon what region is lupus vulgaris usually observed?

The face, especially the nose, but any part may be invaded. The area involved may be small or quite extensive, usually the former.

At what age is the disease noted?

In many cases it begins in childhood or early adult life, but as it is persistent and tends to relapse, it may be met with at any age.

Describe the earlier symptoms of lupus vulgaris.

The disease begins by the development of several or more pin-head to small pea-sized, deep-seated, brownish-red or yellowish tubercles, having their seat in the deeper part of the corium, and which are somewhat softer and looser in texture than normal tissue. As the disease progresses, variously-sized and shaped aggregations or patches result, covered with thin and imperfectly-formed epidermis.

What changes do the lupus tubercles or infiltrations undergo?

The lesions, having attained a certain size or development, may remain so for a time, but sooner or later retrogressive changes occur: the matured papules or tubercles, or infiltrated patches, slowly disappear by absorption, fatty degeneration, and exfoliation, leaving a yellowish or brownish pigmentation, usually with more or less atrophy or cicatricial-tissue formation--_lupus exfoliativus_; or disintegration and destruction result, terminating in ulceration--_lupus exedens, lupus exulcerans_. This latter is the more usual course.

Describe the clinical appearances and behavior of the lupus ulcerations.

They are rounded, shallow excavations, with soft and reddish borders. In exceptional instances exuberant granulations appear--_lupus hypertrophicus_; or papillary outgrowths are noted--_lupus verrucosus_.

The ulcerations secrete a variable amount of pus, usually slight in quant.i.ty, which leads to more or less crust formation; later, however, cicatricial tissue, generally of a _firm and fibrous_ character, results.

[Ill.u.s.tration: Fig. 45. Lupus of Arm.]

In what manner does the disease spread?

The patches spread by the appearance of new tubercles, or infiltrations at the peripheral portion. New islets and areas of disease may continue to make their appearance from time to time, usually upon contiguous parts.

Are the mucous membranes of the mouth, throat and larynx ever involved?

In some instances, and either primarily or secondarily.

[Ill.u.s.tration: Lupus Vulgaris.]

[Ill.u.s.tration: Lupus Vulgaris.]

Is the bone tissue ever involved in lupus vulgaris?

No.

What course does lupus vulgaris pursue?

It is slowly but, as a rule, steadily progressive. Several years or more may elapse before the area of disease is conspicuous.

What is the cause of lupus vulgaris?

It is now known to be due to the invasion of the cutaneous structures by the tubercle bacillus; in short, a tuberculosis of the skin. It is not infrequently observed in the strumous and debilitated. It is entirely independent of syphilis.

What is the pathology of lupus vulgaris?

According to recent investigations, the infiltrations of lupus are due chiefly to cell-proliferation and outgrowth from the protoplasmic walls and advent.i.tia of the bloodvessels and lymphatics. The fibrous-tissue network, vessels and a portion of the cell infiltration are thus produced, the fixed and wandering connective-tissue cells of the inflamed stroma of the cutis being responsible for the other portion of the new growth (Robinson).

State the diagnostic features of lupus vulgaris.

In a typical, developed patch of lupus are to be seen:--cicatricial formation, usually of a fibrous and tough character; ulcerations; the yellowish-brown tubercles and infiltration; and the characteristic soft, small, yellowish or reddish-brown, cutaneous and subcutaneous points and tubercles.

How does the tubercular syphiloderm differ from lupus vulgaris?

The tubercular syphiloderm is much more rapid in its course, the ulceration is deeper and the discharge copious and often offensive; the scarring is soft, and, compared to the amount of ulceration, but slightly disfiguring; and it is, for obvious reasons, a disease of adult or late life. The history, together with other evidences of previous or concomitant symptoms of syphilis, will often aid in the differentiation.

How does epithelioma differ from lupus vulgaris?

The edges of the epitheliomatous ulcer are hard, elevated and waxy; the base is uneven, the secretion thin, scanty and apt to be streaked with blood; the ulceration usually starts from one point, and is often painful; the tissue destruction may be considerable; there is little, if any, tendency to the formation of cicatricial tissue; and, finally, it is usually a disease of advanced age.

In what respects does lupus erythematosus differ from lupus vulgaris?