502 DISEASES OF THE SKIN. 



out advancing for a long time, even for several years. It is only in 

 rare instances that lupus takes on a subacute course, so as to produce 

 extensive destruction in a few weeks. As the malady advances, its 

 appearance changes. In some instances the nodules multiply and 

 grow larger ; their surface becomes tense and shining, and is covered 

 with detached scales of epidermis (lupus exfoliativus). As the disease 

 goes on, the hardness of the spots and nodules is resolved, and the 

 affected portion of the skin, which formerly rose above the surround- 

 ing level, or which at least was even with it, now sinks gradually, and 

 attaches itself firmly to the part beneath it ; and, as the recovery pro- 

 gresses, shrinks and is converted into a white, hard, shining cicatrix. 

 When the course of a lupus is as above described, large portions of 

 the skin becoming transformed into a tissue resembling that of a scar, 

 without any ulcerations having occurred, it is called lupus non exedens. 

 Apart from the unsightliness of the scars themselves, the face may 

 suffer great deformity, in this form of lupus, from contraction or dilata- 

 tion of the nostrils, and from ectropion caused by retraction of the 

 cicatrices. In other instances the outset of the disease is quite similar 

 to the above ; brownish-red spots and nodules form, which continually 

 shed scales of dry epithelium. This condition, however, having con- 

 tinued for a variable period of time, the nodules begin to grow, the 

 maculae become papules ; new nodules form, and while the surround- 

 ing skin becomes more hypersemic, red, and shining ; a superficial ero- 

 sion occurs upon the summit of one of the nodules, the product from 

 which rapidly dries into a scab. These scabs gradually grow thicker 

 and broader by accretion of fresh matter at their base. If forcibly 

 detached, a slight bleeding ensues, and we can perceive that there is a 

 loss of substance of the skin, in which the middle of the scab is embed- 

 ded more or less profoundly. This is the characteristic course of that 

 form of the malady known as lupus exedens or exulcerans, and also as 

 1. rodens, as well as herpes rodens s. exedens, s. esthiomenos. Some- 

 times the disease begins from a pustule, without the previous develop- 

 ment of a reddish-brown spot or nodule. In such instances, lupus at 

 its outset might easily be mistaken for a simple impetigo, and the 

 error would only become apparent upon the discovery that there is a 

 loss of substance in the cutis, beneath the scab. According to Itiett, it 

 is convenient to distinguish two forms of ulcerative lupus, a superfi- 

 cially destructive and a profoundly destructive form. The former often 

 involves a large extent of surface, and occurs not only upon the fact 

 but upon the shoulders, and other parts of the body enumerated above. 

 Sometimes the process subsides at the point first attacked, leaving a 

 scar, which, by its ribbed and reticulate aspect, closely resembles the 

 scar of a burn ; meanwhile it continues to extend at the edges of the 



