A Contribution to the Study of 
Lupus of the Throat. 
BT 
RAMON DE LA S0TA Y LA3TRA, M. D., 
SEVILLB, SPAIN. 
REPRINTED FROM 
Cbe Neto York JBeBfcal journal 
for July 10, 1886. Reprinted from the New York Medical Journal 
for July 10, 1886. 
A CONTRIBUTION TO THE STUDY OF 
LUPUS OF THE THROAT* 
By RAMON J)E LA SOTA Y LASTRA, M. D., 
SEVILLE, SPAIN. 
Gentlemen : I beg leave to submit to your considera- 
tion the result of my observations upon a disease the diag- 
nosis of which is not always easy. Although I have studied 
manifestations of lupus in the throat with the greatest care, 
I have sometimes failed to recognize the lesion. The latest 
instance of this kind occurred to me in the summer of 1884, 
when my friend M. Pizarro, M. D., professor of hygiene at 
the medical college in Seville, came, accompanied by his 
own physician, to consult me about an affection of his 
throat. I had vaguely heard before some of my fellow-pro- 
fessors say that Dr. Pizarro was seriously ill, and, therefore, 
I was not in the least astonished to find him very much 
emaciated, reduced in strength, extremely gloomy, and with 
a clayey complexion. 
He informed me that he had commenced to suffer with his 
throat about one year before, and that during that period he had 
been unable to feed himself except with milk and broth, as the 
swallowing of any solid food gave him a good deal of pain. 
On examining his mouth, I found his tongue covered with 
* Communicated to the American Laryngological Association, of 
which the author is an honorary member. 2 
LUPUS OF THE THROAT. 
psoriasic scales ; the palatal mucous membrane tumefied, lumpy, 
and of a wine-red color; the right arch, tonsil, and pillars being 
ulcerated, the ulcer extending inferiorly to the pyriform fossa and 
superiorly to the middle of the uvula, and involving one half of 
the structure, anteriorly to within half an inch of the palatal 
border, and penetrating into the submucous tissue. Its borders 
were red and swollen ; its surface was nodular, irregular, and of 
a hard, elastic consistence. There was some pain upon palpation, 
but bleeding was not occasioned. The patient felt no trouble 
whatever, either in talking, or while coughing, or swallowing 
any liquid. 
The pharyngeal mucous membrane wTas injected, bluish, and 
covered by granulations, the larynx being in its normal state 
with the exception of the right aryteno-epiglottic fold and the 
corresponding part of the inferior border of the epiglottis, which 
were somewhat tumefied and reddened. 
The patient's voice had its normal sound and ring, and breath- 
ing took place with perfect freedom. The submaxillary glands 
were somewhat swollen. In his morbid history nothing of a 
syphilitic character could be found, nor any other malady worth 
mentioning, save slight manifestations of the rheumatic dia- 
thesis. 
Taking into consideration these antecedents, the lingual pso- 
riasis, the peculiar features of the affection of the throat, and 
that my fellow-professor was in the sixtieth year of his age, I 
believed that I had to deal with an ulcerated epithelioma. I ex- 
pressed this belief to the physician in charge, who agreed with 
me both in the prognosis and as to the treatment. Neverthe- 
less, mistrusting the information supplied by our friend, and 
wishing to find something to modify our judgment as to the na- 
ture of the disease, in which we could not thoroughly discover 
some of the symptoms of epithelioma, we resolved to apply an 
anti-syphilitic medication, watching its effects most carefully. 
Immediately after, on consultation, Dr. Pizarro commenced to 
take Gibert's " syrupus deuto-iodureti hydrargyri," at the same 
time gargling frequently with a solution of potassium chlorate. 
This medication produced such very prompt and bad results that 
it became necessary to suspend it immediately and to substitute LUPUS OF THE THROAT. 
3 
compounds of iron, bitter tonics, and such restorative diet as the 
want of digestive strength and the difficulty in swallowing solid 
food would allow. When the organism became somewhat re- 
stored the specific treatment for syphilis was resumed ; but the 
lesion at the palate extended so very much and took on so bad 
an aspect in a few days that we were compelled to give up the 
specific treatment, and thus we became more positive than at 
first in the idea we had formed of the disease. 
The physician in immediate attendance upon Dr. Pizarro had 
to leave the city at this time, and I was then compelled to take 
entire charge of the patient. As it astonished me to find that 
this great ulcer did not produce lancinating pain, that it never 
bled, and that it never acquired a greater hardness now and then, 
I had some doubts on the subject, although I remained under the 
impression of having to deal with an epithelioma. From the 
moment I took charge of the patient I prescribed a potion con- 
taining sodium arseniate, to be taken in gradually progressive 
doses; gargles with a solution of resorcin; and powdered iodo- 
form, to be applied to the ulcer after having it washed with a 
solution of borax. For a month the ulcer continued to extend 
in periphery and in depth until it had destroyed more than one 
half of the uvula, a great part of the soft palate, and the amyg- 
dalae, as well as a portion of the pharynx. 
When I had lost all hope, the ulcer suddenly stopped its 
progress, and became covered by healthy-looking granulations of 
good consistence; cicatrization commenced to take place, and 
was finally completed in three months, some irregular scars re- 
maining, depressed in some places, prominent in others, partly 
discolored at intervals, red at others, soft here and hard there, 
the posterior being adherent to the pharyngeal wall. The lin- 
gual psoriasis still kept on. Deglutition became normal again, 
and my patient's restoration to health took place in a short 
period. It is now more than a year and a half since the oc- 
currences narrated, and Dr. Pizarro's cure still holds good. 
Reflecting upon all these facts, I became aware that my 
friend's disease had been a lupus, whose evolution I had 
witnessed without suspecting it even a single moment. But, 4 
LUPUS OF THE THROAT. 
as there is nothing to occupy the mind of a practitioner 
more important than an error of diagnosis, I have availed 
myself ever since of all the opportunities presenting to de- 
termine with the greatest possible accuracy those characters 
which made me doubt about the epitheliomatous nature of 
Dr. Pizarro's illness. I am now going to state, in the short- 
est possible way, what my observations and experience have 
taught me about lupus of the throat. 
This disease makes its appearance at any period of life; 
as I have seen it in adults oftener than in children, I can 
not agree with Hebra in its being a disease peculiar to 
childhood. I have observed it oftener in men than in 
women, and, although it is to be met with in every constitu- 
tion, the greatest number of those attacked who have come 
under my care were of a lymphatic temperament. A good 
many of them had suffered from scrofula, others from 
syphilis, a few from herpes, and some of them, like Dr. 
Pizarro, had been and were still subject to rheumatic mani- 
festations. Exception made of the diathetic states just 
mentioned, I have been unable to ascertain anything with 
regard to its inheritance. If the men whom I have treated 
were smokers, I do not dare to attribute to tobacco any 
part in the causation of the disease, as there are but very 
few men in Spain who do not smoke. Neither have I 
found that hard drinkers were more liable to suffer from 
lupus, as I have seen very many cases in persons who would 
not even drink a small quantity of wine at table. I have 
never been able to discover that great efforts of voice, ha- 
bitual exposure to an atmosphere overloaded with irritating 
substances, cauterization of the mucous membrane of the 
throat, the influence of heat or cold, or any local agencies 
whatever, are to be considered as especially prone to pro- 
duce this disease. 
I have never had the opportunity of observing the ini- LUPUS OF THE THROAT. 
5 
tial manifestations of lupus in the throat, but I have been 
able to detect the first steps in the invasion of the sound 
places attacked by the lupus later in the disease. 
Sometimes the mucous membrane assumes a purplish 
color, swells up, and becomes granular, and one or two of the 
granulations develop so much as to reach the size of a pea, 
or even that of a hazel-nut. Occasionally the tubercles be- 
come prominent in the throat previous to alteration in the 
mucous membrane, and without differing from its normal 
color. They may either remain superficial, as if they were 
hypertrophic papillae, or they may attack all the mucous 
tissues, and even penetrate down to the submucous connec- 
tive tissue. Their form is rounded, the tubercle being either 
hemispherical, oval, flat, or conical. Their surface is smooth 
and brilliant, but, if several of them become intimately 
united, they appear as a single mass, rounded, cloven, and 
anfractuous. The lupous tubercle can be distinguished by 
its very red color from the leprous tubercle, which is 
opaque and of a turbid white. It is very seldom that a 
single tumor is observed in lupus, as is the case in car- 
cinoma. 
Generally there are several of them, either scattered or 
grouped, but always quite distinct. I have seen them si- 
multaneously in the wall and in the wing of the nose, in 
the tongue, in the palate, and in the ventricular bands. On 
pressing them they present a sort of elastic resistance, 
which can be better felt than explained. This hardness is 
greater than that of inflammatory infiltrations, but it never 
reaches the consistence of the epitheliomatous tumor. 
Those parts on which the tubercles develop become rigid, 
for which reason their natural movements are sluggish, re- 
strained, or entirely lost. Therefore the tongue can not 
conduct the food for its convenient mastication ; the palate 
does not succeed in dosing the naso-pharyngeal space dur- 6 
LUPUS OF THE THROAT. 
ing deglutition, nor does it assume a proper position for 
articulation; the epiglottis allows the food to get into the 
larynx, and the vocal cords do not vibrate sufficiently. 
When the tubercles develop exuberantly in the larynx, 
breathing becomes embarrassed and may become stridulous. 
Even apnoea may result. Contrary to what happens in car- 
cinoma and in leprosy, which almost always produce, the 
one lancinating pains, the other a more or less complete 
anaesthesia, there is no alteration whatever in the sensitive- 
ness of the parts affected with lupus. After a shorter or 
longer period the tubercles soften and become ulcerated. 
This melting down does not take place in a complete man- 
ner. In some cases only the surface of the tumor becomes 
fissured or excavated as a margin to simple excoriations. 
In others the destructive process attacks a greater or smaller 
portion of the tubercle in its entire depth, producing ulcers 
which dip out of sight in the midst of the tissues. In the 
former cases the affected mucous membrane appears de- 
nuded, red, smooth, purple, and granular. It is painful 
upon palpation. It does not bleed either upon pressure or 
spontaneously. 
The cure is difficult and is always followed by indeli- 
ble scars. In the latter instances the ulcers appear either 
under the aspect of deep crevices, with raised, rounded, red, 
hard, and perpendicularly cut borders with a narrow and 
smooth bed; or as heavy losses of substance which affect 
all the thickness of the tissues, and whose ravages neither 
aponeurosis, cartilage, nor bone can check; their borders 
are prominent, congested, and elastic, and their bed is 
granular, uneven, bright red, sensible to pressure, never 
haemorrhagic, and always covered with a sanious and puru- 
lent secretion. This indolence and want of haemorrhage are 
never found in carcinoma, nor are they observed in tuber- 
culosis. LUPUS OF THE THROAT. 
7 
In some cases the ulcers are developed in a slow but 
fatal manner, in others they spread with astonishing rapid- 
ity, while in some others they stop in the beginning, but 
how far their ravages may reach it is impossible to predict. 
I have found them superficial and of the size of a lentil 
after having existed for a long time. I have seen them de- 
velop in a few days, occasioning horrible mutilations. I 
have observed them remain apparently perfectly quiescent 
during months and even years, and then suddenly and with- 
out any perceptible cause take on such destructive activity 
that their ravages have been quite frightful. I have watched 
them progressing continuously, in spite of the greatest care, 
to stop short at the most unexpected moment. When the 
healing of an ulcer is complete there remains an irregular 
scar, raised in some places, depressed in others; red in the 
former and white in the latter instance ; a very retractible 
scar, which produces great deformities. Lupous scars differ 
from those originating from syphilitic ulcers in that these 
latter are white, radiated, and depressed. Sometimes there 
are preternatural adhesions of the arches to the posterior 
pharyngeal wall, of the uvula to the arches, of the pillars to 
the back of the tongue, of the cheeks to the gums. The 
aryteno-epiglottic folds, the ventricular bands, and the vocal 
cords may unite together in a greater or less extent, pro- 
ducing alteration of voice or aphonia, difficulty of respira- 
tion, or its complete obstruction. Cicatrization always takes 
place slowly, stops without any apparent reason, or is easily 
destroyed. 
Besides the scars there remain infiltrations which deter- 
mine the enlargement of the part, the corresponding mu- 
cous membrane keeps purple, bright, granular, and dry, 
generally with more or less desquamation of epithelial scales 
without any resulting excoriations. 
Nevertheless, the submucosa appears uncovered occasion- 8 
LUPUS OF THE THROAT. 
ally, and some patients have come to me quite frightened 
at feeling the pain produced by the contact of the papillae 
with some exciting substance, believing in consequence of it 
that there was about to be a repetition of their former suf- 
ferings. But, fortunately, up to the present moment I have 
never seen such an unpleasant result. All practitioners 
agree in one thing-viz., that lupus in the mucous mem- 
branes is by far more difficult to heal than the same process 
in the skin. This I am quite ready to acknowledge, but, 
without boasting about originality, I must state that in 
many cases I have found quite efficacious the treatment that 
I apply to that terrible disease, no matter whether the lupus 
resides on the external or on the internal integuments. 
I do not despise nor condemn, as do German writers, 
internal medication. I prescribe iron and cod-liver oil to 
scrofulous patients, mercurials and iodine compounds to 
syphilitic ones, arsenical preparations to the herpetic, alka- 
line solutions to the rheumatic, and bitter tonics and invig- 
orating medicines to those whose constitution has been im- 
paired by any previous disease, by overwork, or by insuffi- 
ciency of nourishment. 
It seems to me that this general treatment has an active 
influence on the success of topical medication, from which 
we can not part, as through it we obtain undeniable success. 
"When the lupus is not ulcerated I apply a caustic substance. 
Until a few months ago I have used the tinctura iodi, but, 
having obtained wonderful and rapid cures with lactic acid 
in the cutaneous lupus, exedens et non exedens, I have not 
hesitated to apply it to the mucous membrane of the nose, 
of the lips, of the cheeks, of the tongue, of the gullet, and 
even that of the larynx; and I can assert that I have met 
with no other inconvenience but the natural pain, the inten- 
sity of which has been as varied as the number of patients 
I have observed. LUPUS OF THE THROAT. 
9 
In ulcerated lupus also I sometimes make applications 
of the lactic acid, but more frequently I wash the affected 
region with a solution of borax, covering it afterward with 
powdered iodoform. I always prescribe gargles with a so- 
lution of resorcin (one per centum), and my patients are 
submitted to the strictest hygienic regime. 
All patients who have submitted themselves to this 
treatment have recovered in a longer or shorter period; but 
I must confess my belief that, in some instances, the cure 
has been realized rather in the natural evolution of the dis- 
ease than by virtue of therapeutic measures. REASONS WHY 
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