Lupus, its Extirpation. With Reports of Cases. BY v z B. MERRILL RICKETTS, M. D., CINCINNATI. REPRINTED FROM Oe Neto ¥orfc fHrtiical journal for September 23, 1893. Reprinted from the New York Medical Journal for September 23, 1893. LUPUS, ITS EXTIRPATION. WITH REPORTS OF CASES* By B. MERRILL RICKETTS, M. D., CINCINNATI. So much has been said about this disease during the last three years by men who have spent the greater part of their time not only in treating it, but in studying its pa- thology, that it might seem preposterous for one with limited advantages to offer anything new whatever concerning this much-dreaded disease. The ravages that it produces and its persistent character have made not only the sufferer but the surgeon desperate. Considered in the light of experi- ence, it is not strange that the treatment of to-day gives but little relief. Kooh has perhaps more nearly approached a panacea for lupus than any other investigator. Whether or not the future treatment and consequent good results are to be obtained by following up his principles is yet a question. That the disease is both local and constitutional there seems to be no doubt, and when a lesion is cured the preponderance of evidence is that it was a mistaken diag- * Read before the Dermatological Section of the First Pan-American Medical Congress, held in Washington, D. C., September 5, 6, 7, and 8, 1893. Copyright, 1893, by D. Appleton and Company. 2 LUPUS, ITS EXTIRPATION. nosis; that it was not lupus, but some other disease of less virulency. However this may be, we must necessarily de- pend, to a great degree, upon the clinical history and ap- pearance of the lesion. While we depend upon the micro- scopical investigation, we must not accept the picture as one to be recognized at all times. While I believe that the bacilli when found indicate a certain disease, I can not accept a statement that it is not that disease because the bacilli can not be found. In other words, I am not ready to accept the microscopical investigation as infallible. I would rather depend upon the clinical history and appear- ance in making a diagnosis of lupus than the statement of any microscopist. Neither do I believe in the infallibility of any diagnostician. Anything may be deceptive ; just so may a person be deceived. The rarity of the disease and the few cases which the average practitioner has the oppor- tunity of seeing, especially outside of the larger cities, is no doubt the occasion of mistaken diagnoses. It is not supposed that a man who sees a great many cases of dis- ease is as likely to be mistaken in his diagnosis as one who sees but few. Consequently we must rely mostly upon the statement of those with greatest experience, especially in distinguishing lupus from other diseases. My experience has been somewhat limited-I have seen in clinical and pri- vate practice about sixty-five cases-but I was early con- vinced that treatment of any kind availed but little. This naturally led me to resort to more desperate means than were usually employed by those with whom I was associated. Scarification, curetting, cauterization in the various ways, the application of caustics, such as nitrate of silver, car- bolic acid, etc., all convinced me that the disease, when pos- sible, should be excised or that constitutional treatment was necessary. Constitutional treatment having been found useless, left to my mind nothing but total extirpation. Un- LUPUS, ITS EXTIRPATION. 3 fortunately, the disease occurs mostly about the face, eve- lids, nose, ears, and lips-places where extirpation is made with the greatest difficulty, and where the greatest deform- ity is the result. I believe that the extirpation of lupus is about as certain, when done in its earliest stages, as some of the forms of epithelioma and sarcoma. The ques- tion arises, When does it become constitutional, and to what degree may it become constitutional when extirpation would be useless ? It is also important to determine that degree in any of the malignant growths. If lupus is found upon the finger, we would not hesitate to amputate it; if lupus were to appear upon the hand, we would naturally resort to all means of treatment to save the hand. Would it not be better to remove the hand early in the progress of the disease? We know that the removal of a finger affected with lupus has cut short the disease, and that the patient has lived for years without any recurrence. Now, if this is so, why is it not rational surgery to extirpate any diseased lesion that may appear upon any part of the body ? The means that we now have at our command in restoring parts with both single and double pedunculated grafts should encourage both the operator and the patient in re- sorting to early surgical interference, no difference upon what part of the face the disease may be found. The dread of suffering, taking an anaesthetic, and being de- formed, I might say, is the occasion of so much procrasti- nation, not only in the treatment of lupus, but all other dis- eases. Wrhat are we to do with these unfortunate creatures when they present themselves to us for treatment ? Are we to tell them that nothing can be done, that it is folly to attempt to relieve them ? Believing, as I do, that all dis- eased tissue should be removed when possible, I have been led to extirpate lupus on several occasions with most grati- fying results. So far I have not made any classification of 4 LUPUS, ITS EXTIRPATION. the disease. It is, however, necessary in order that we may talk more intelligibly and simplify matters. I have treated the two forms of lupus in the same manner. 1. Lupus vulgaris. 2. Lupus erythematosus. Of the former I have seen forty-two cases; of the lat- ter, twenty-three. Case I.-Female, aged sixty-seven years, single, white, Amer- ican, poorly nourished, posterior spinal curvature, most excel- lent habits. There had existed for about eighteen years a lesion upon the left cheek on a line with the lower edge of the ear. This was red and had gradually increased in size, with here and there a tubercular nodule, giving all the characteristics of lupus vulgaris. There were also cicatrices in the surrounding tissue, showing that some of them had at various times healed and given place to more recent ones. She consulted me to see if something could not be done. My diagnosis being that of lupus vulgaris, I offered no suggestions other than the total ex- tirpation of the diseased tissue. This she readily consented to, and under the influence of cocaine, subcutaneously, I removed what I believed to be the entire amount of tissue involved. Union was primary, and she was discharged at the end of five days. Within the course of six months it was evident that the disease had not been entirely removed, and I again excised it under the influence of cocaine, with the same good results, so far as healing was concerned. She was discharged at the end of six days, and we again felt that we had done all that was necessary to rid her of the annoyance. At the end of twelve months the disease again manifested itself, and I concluded to excise it as before under the influence of cocaine, curetting the surface thoroughly, and applying arsenious acid in combination with cinnabar. This was done, and an extensive sloughing was the result. It required several weeks for the wound to heal by granulation, her health in the mean time being somewhat im- paired. However, by judicious management and her ability to take the requisite amount of food, her recovery was uninter- rupted, and she was discharged at the end of eight weeks. LUPUS, ITS EXTIRPATION. 5 There was no family history of tuberculosis in this case. The spinal curvature was attributed to an injury. However, 1 am inclined to believe that the subject was a tubercular one with- out any special manifestations. She died three years after from an attack of acute gastritis, the lupus never having manifested itself again in the slightest degree. I report this case to show the importance of persistency in the treatment not only of epithelioma and other malig- nant growths, but that of lupus in any form. What the result would have been at the end of ten or fifteen years, had she lived, I am, of course, unable to say. Case II.-Female, aged seventy years, widow, white, Ger- man, in a most excellent state of health, consulted me in January, 1889, for a small lesion upon the margin of the right nasal ala, which had existed for eight years. The disease had been slow in progress, giving her no special discomfort or an- noyance. It had, however, made inroads upon the wing, involv- ing a surface about half an inch along the lower margin, extend- ing about three eighths of an inch upward along the side of the nose. My diagnosis was lupus vulgaris, and my suggestion was its total extirpation. This was consented to, and the operation made under the influence of cocaine, subcutaneously. A slid- ing flap was taken from the cheek and placed in the interven- ing space, allowing the lower margin of both remaining pieces of the ala to form the lower margin of the wing. Primary union was the result, and the patient is to-day entirely free from the disease. This has now been fifty-four months. Pos- sibly there may yet be a recurrence, but has not the result proved that the operation was justified ? There was no indi- cation of tuberculosis in this case, nor was there any history of its having existed in her family. Case III.-Male, aged forty eight years, white, Irish, excel- lent health, weighing about one hundred and sixty-five pounds, laborer, irregular and dissipated habits. He consulted me in July, 1887, for a lesion upon the left side of the nose, 6 LUPUS, ITS EXTIRPATION. about midway between the inner canthus and lower margin of the ala, which had existed for eleven years. The disease had been slow in its development, and there was no special discom- fort or pain. It gave all the characteristics of lupus vulgaris. I advised its total extirpation, and made the operation on the following day, under the influence of cocaine, subcutaneously. I removed a piece of integument about an inch wide and an inch and a half long, cutting through the cartilage into the nasal cavity. A sliding flap was made, filling the space per- fectly, and resulting in primary union. This has never re- curred, and I feel sure the man is as exempt from a recurrence of this disease as if it had been epithelioma. He did not give any history of tuberculosis, except on the father's side, in which case the patient's own uncle died from what was considered consumption following pneumonia. Case IV.-Female, aged sixty-three years, single, white, American, in good health, weighing one hundred and twenty pounds, consulted me in 1890 for a lesion upon the left cheek just in front of the ear, covering a surface about an inch and a half in diameter. This answered the description of erythema- tous lupus, and it was so classified. It had existed about twelve years, without giving any pain or discomfort except a burning sensation, itching, and extensive exfoliation of the cuti- cle. It had gradually become larger, and caused considerable anxiety on the part of the patient and her friends. Extirpation was suggested and readily consented to. This was done after thoroughly anaesthetizing the field of operation with subcutane- ous injections of cocaine. The edges of the wound were coap- tated with silk sutures, and primary union secured. I cut in this, as in all the other cases, far beyond the line of demarca- tion, and removed the entire integument and cellular tissue overlying the muscular structures. There has not in this case been any return. This is the only case of erythematous lupus in which I have been able to do the operation of extirpation, and I am quite sure that I would earnestly advise such a course, although my experience is limited to one case. True, LUPUS, ITS EXTIRPATION. 7 where the disease has been allowed to progress to an ex- tensive degree over the cheeks or about the eyelids and lips, or nose, or ears-in other words, where the disease has been allowed to extend to such a degree that extirpa- tion would cause great deformity, which could not be pre- vented or overcome by grafting-one must necessarily hesi- tate in resorting to such radical measures. In conclusion, I wish to say that I would not hesitate to extirpate lupous tissue in any case where the parts may be restored in any way whatever. Neither would I hesitate to amputate a finger or toe upon which either one or the two forms of lupus existed. There are cases, however, where it might be unwise to extirpate the lesion. Even in cases of multiple lupus I would advise their excision if the areas affected are small. Whether this plan of treatment should be limited is a question with the operator. So far, I have seen but three or four cases of multiple lupus. T am quite sure that in each case good would have resulted from the extirpation of the lesion which either one of them possessed. Would it not be well for us to draw a halt in saying that there is nothing to be done in cases of lupus ? I believe that the pendulum should be swung in the oppo- site direction, and that the preponderance of evidence at the present time fully justifies this statement. Even though the disease should recur, it is not until quite a length of time has elapsed. I believe that the end justifies the means, and that it is humane to subject these unfortu- nate patients to the operation of extirpation, even though the relief be but for a short time. This, of course, re- quires more judgment in cases of lupus upon the various parts of the face. I have presented the subject to see if it can not be brought more prominently before the surgeons- that is, the operation of extirpation. I think that the cases I have reported, and the subsequent good results 8 LUPUS, ITS EXTIRPATION. from extirpation, fully substantiate what I have said. Pos- sibly I am deceived in my diagnosis, but I am thoroughly convinced in my own mind that I am not. I do not mean to be understood as saying that the disease will not recur in either one or all of the cases; surely I could not be so foolish as to say that. I propose to extirpate lupus, if possible, wherever found. I believe if this is done that a great deal of suffering, disfiguration, and I might say loss of life, will be prevented. It would give me great pleasure if those who have been interested in this procedure would address me upon the subject. By doing this, I hope to tabulate the various cases in which the operation has been resorted to. "The Trinidad," 137 Broadway. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. 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