-NOTES OF A- 
CASE OF ERYTHEMATOUS LUPUS, 
COMPLICATED BY THE 
Tubercular Syphiloderm. 
By 1. EDMONDSON D., 
Professor of Pathology, and Clinical Professor of Dermatology in the University of Maryland. 
The following case presented such unusual features, and, during 
its course, threw such difficulties in the way of correct diagnostica- 
tion, that I have ventured to report a somewhat detailed account of 
its characteristics; of the therapeutic measures adopted to combat it, 
and the reasons that have induced me to classify the malady as I 
have. The patient was referred to me by.my friend Dr. Samuel John- 
ston, Marcffiijth, 1879. 
He was a strongly built negro, about 43 years of age, married, but 
childless, engaged in business in a neighboring town. He was of 
temperate habits. He had suffered much from malarial fever, and felt 
at the time quite debilitated. Fifteen years previously he had had a 
sore upon his penis, but had no recodlection of any symptoms that 
would indicate constitutional syphilis. He had been remarkably free 
from cutaneous eruptions until recently. About two years previously 
he began to have some trouble with his nose, and consulted Dr. John- 
ston about it, who discovered ulceration of the nasal mucous mem- 
brane, with involvement and partial destruction of the cartilaginous 
septum. At the same time there was a small ulcer upon the left side 
of the neck. Under a treatment of combined potassium iodide and 
mercury, the lesions healed speedily, without any mechanical inter- 
ference. During November, 1877, a small spot of eruption made its 
appearance over the right side of the nose. This spread gradually and 
steadily, in spite of anti-syphilitic treatment rigorously carried out 
under Dr. Johnston's direction. Indeed, not the slightest influence 
seemed to be exerted upon its course, which had been steadily progres- 
sive until the patient came under my observation. 2 
At this time (March 13th, 1879) the skin was involved over the right 
nasal bone, not as far 'as 'the ala nasi, the canthus or eyelid. The 
eruption crossed over to the left side of the nose, involving its whole 
surface as far as the tip and nostril. It extended over the left cheek, 
sparing the eyelid, as far as the malar prominence, thence downward 
and slightly outward to a point level with the angle of the mouth, 
thence inwardly, including the upper lip nearly to the median line. 
The entire surface within these bounds was uniformly covered with a 
continuous, elevated, but somewhat rugous crust, rising abruptly from 
the healthy border. This crust was of a grayish slate color, and where 
thinnest, of a dirty opaline hue. The margins were irregularly con- 
vex. It was in a softened condition from citrine ointment, diluted with 
vaseline, that he had been using. When portions of it were raised 
with the finger, as could be done with ease, they were found to cover 
an infiltrated surface of uneven appearance, of dusky hue, but entirely 
free from ulceration. In some places the crust was moderately adhe- 
rent, and upon lifting it, tiny prolongations could be seen stretching 
downward as if they had filled the sebaceous ducts, the orifices of 
which, though visible, were of small size. There was not the slightest 
sign of fluid exudation, although the under surface of the crust was 
soft and sticky. The entire surface was prominent and more or less 
irregular, the crust attaining in places a thickness of from 2 to 3 mm. 
It was thickest upon the nose, which presented a strikingly bulbous 
appearance and a size disproportionately large. The crust suggested 
a resemblance to the rough bark of a tree and in its distribution and 
characters, the peculiar accumulations of lupus erythematosus, with 
excessive sebaceous products. There was no lymph-glandular enlarge- 
ment whatever. Except a slight stinging of the affected part, there 
were no subjective symptoms. Occasional malarial attacks were the 
only manifestations of constitutional disorder, nor were there any 
evidences of cutaneous disease except those described. 
Though hesitating to form at once an opinion as to the syphilitic or 
nonsyphilitic nature of the affection under consideration, the patient 
was given a prescription for potassium iodide and the syrup of the 
iodide of iron, and was directed to continue the ointment. He re- 
turned March 23d, feeling better and with the crust partially removed 
from his face in consequence of the softening influence of the ointment. 
He complained that I had given him the same medicine he had been 
taking for a long time and that it made him sick. I now gave him T'r 3 
of a grain of corrosive sublimate with tincture of the chloride of iron 
thrice daily, and directed him to use, in addition to the ointment, the 
spiritus saponatus alkalinus, which was to be rubbed with vigor into 
the part daily. 
This treatment was followed out until April 17th, when the crust 
had become removed in great part, so that it was now possible to 
gain a pretty good idea of the condition of the skin. Upon the cheek 
and upper part of the nose, this was of a dusky red color, clearly dis- 
cernible through the natural darkness of the complexion. The 
orifices of the sebaceous glands were noticeable, but not notably 
enlarged. The finger passed over this surface, encountered a slight 
feeling of roughness. There was no sign of scarring \ anywhere. 
Upon the nose and upper lip, there were now a few soft, tubercular 
prominences, varying in size from that of a small shot to that of a 
small pea. These gave a more or less knobbed appearance, but were 
more adherent than elsewhere. These nodules were situated upon 
the right side of the nose over the nasal bone and upon the left ala nasi 
and nostril; one or two were visible upon the upper lip close to the 
nostril. They were quite soft and indeed the whole surface offered 
but little resistance to the touch. Toward the tip of the nose, project- 
ing slightly beyond the medium line was a discoid, elevated, slate-color- 
ed scab about 2mm. thick and of the diameter of a five-cent piecefnick- 
el.) The left ala was thickened to twice its normal size and the nostril 
was correspondingly narrowed. A tiny ulcer of pinhead size and soft, 
was seen just above the nostril, upon the ala. A new discoid crust 
similar to the one just noted in size and appearance had developed upon 
the left cheek toward the ear. It covered a surface, the epidermis of 
which was whole and showed moderately dilated sebaceous orifices. 
There was nowhere fluid discharge. Citrine ointment was continued 
as an application and grain of arsenious acid was given thrice daily 
in pill. Upon June 7th, no improvement could be observed ; on 
the contrary, there had been slight extension to the right ala nasi, 
where several small tubercles of soft, fleshy feel appeared along with 
an extension of the crusts. He was ordered to use the emplastrum 
hydrargyri at night and to continue the daily application of the 
spiritus saponatus alkalinus. By July 9th, there was much improve- 
ment in the condition of the crust, which had been entirely removed, 
except three discoid ones, 1 cm. in diameter, upon the nose. The skin 
was still congested, and thickened, and if closely examined was seen 4 
to be covered with thin adherent scales. No sign of cicatricial forma- 
tion anywhere. The use of mercury was abandoned, it having now 
been given since March 23rd, with brief intervals to avoid the danger 
of ptyalism. 
Cod liver oil in liberal doses was administered, and spt. saponat. 
alk. cum pice was directed to be used twice daily. By Sept. 16th, 
his condition, so far as his cheek wasconcerned, was very satisfactory. 
There seemed to be but little disposition to renew the crust, though 
the skin remained reddened and thickened. The nose and upper lip 
were improved as regards the general surface, but the tubercles now 
extended over both alae, soft to the touch and equalling in size small 
peas. They also involved the nares, which were thickened and swol- 
len, and the lips to the vermilion border. J , was (Sept. 16) placed 
under the influence of ether, and with Volkmann's curette, I spooned 
out the infiltrated material which broke down with great ease and was 
removed in masses. In this manner much tissue was torn from iso- 
lated points upon the upper surface of the nose, while all of the integu- 
ment of thatportionborderingthe nares and extending to the lower third 
of the right ala was removed. The nitrate of silver point was next 
driven through all yielding portions of the diseased surfaces, after 
which dry lint was applied. 
He was directed to return in a month, and in the meantime, after 
the removal of the slough, to rub vigorously the spts. saponat. alk. c. 
pice into the parts not operated upon. Upon his return, Oct. 25th, 
most satisfactory improvement was observed. The nose was much 
reduced in size, cicatrization was perfect, except where here and there 
points of the new-growth had escaped destruction. These points 
were again scraped out, and the curette applied thoroughly to the left 
ala and upper lip, points not touched at the first operation. The lu- 
nar caustic was again thoroughly applied. Dry lint was again used 
as a dressing. Iodide of potassium was now ordered in doses of 10 
grs. thrice daily, and its good effects were seen in the steady 
progress toward recovery that now was observed. 
The patient was last seen March 22nd, 1880. Cicatrization was 
perfect everywhere. The nose, though showing the scars of the 
operations, was free from disease; was in excellent shape and showed 
no asymmetry from loss of substance. This was only observed in 
the alae, which were retracted so as to expose the septum to an 
extent equal to about 5mm. There was no evidence of returning 5 
tubercles here nor upon the lip. Recovery of these parts seemed 
perfect. The erythematous condition of the upper part of the nose 
and cheeks had almost disappeared under the use of spirits of green 
soap and tar, but their surface remained unctious, and the sebaceous 
glands could be seen to project their contents somewhat above 
their orifices. There was no longer any tendency towards the pro- 
duction of crusts, and the patient considered himself about well. As 
communicated by letter some months later, improvement continued 
to be most satisfactory. 
The difficulty in forming a correct diagnosis in the preceding case 
is apparent. That the malady was not lupus, pure and simple, must 
be conceded, since, though the characteristics of lupus erythematosus 
were undoubtedly present, the occurrence of the tuberculations in 
the affected area certainly cannot be ascribed to this affection, to which 
such lesions do not belong, nor yet can we admit that they could result 
from a combination of lupus vulgaris with lupus erythematosus, a 
condition though not impossible, certainly of great rarity. For, while 
the latter may perfectly well develop at an age corresponding to that 
of my patient, the former affection always appears for the first time 
before adolescence, though once developed, it may persist indefinitely ; 
moreover the tubercles were larger than those of lupus vulgaris, and 
invaded the parts with much greater rapidity. On the other hand, 
the vigorous anti-syphilitic treatment instituted by Dr. Johnston, and 
persisted in by myself for months, should have shown some 
therapeutic influence, had the morbid process been purely syphilitic, 
although it must be confessed that the enormous doses of potassium 
iodide that it is sometimes necessary to employ in old syphilitic 
cases were not given by us. However, in other lesions that appeared 
to have been undoubtedly of syphilitic origin, anti-syphilitic treat- 
ment directed by Dr. Johnston was followed by promptly favorable 
results ; while the lesions we are considering, developed and increased 
in spite of the remedies usually employed to control syphilitic mani- 
festations. Finally, the prompt and complete relief afforded by me- 
chanical interference, would seem to negative the idea of a syphilitic 
origin. 
It has occurred to me that a solution to the difficulty is afforded, if 
we ascribe the lesions to the engrafting of a tertiary syphilitic process 
upon lupus erythematosus. It cannot be denied that the symptoms 
of the latter affection were exhibited in the distribution of the earlier 6 
eruption, the erythematous condition of the skin, the peculiar impli- 
cation of the sebaceous glands, the special physical features of the 
ctust. Indeed, I do not think we can avoid the conclusion that lupus 
erythematosus was present. The tuberculations that developed after 
the establishment of the lupus must be regarded as the expressions of 
a very late syphilitic vice, developing in a point of least resistance, 
already the seat of a special granulation-tissue exudation, and itself 
prone to develop the results of late syphilis of extrordinary unamen- 
ability to treatment. It may be that a more energetic and powerful 
anti-syphilitic treatment would have accomplished the same ends, but 
it appears probable that the mechanical and chemical destruction of 
the neoplasm, incapable of higher organization and destined to ulti- 
mate disintegration, relieved the embarrassed nutritive functions of 
the tissues, and enable them to complete the reparative process un- 
der the influence of the specific remedies employed. This effected, 
the lupous infiltration, already exhibiting the favorable influence of 
the appropriate treatment employed, continued to give place to the 
process of health. .