TUBERCULOSIS CUTIS

In the class of tuberculoses of the skin must be placed all those
cutaneous lesions which are due to the presence of the bacillus of Koch.
Owing to the work of this latter observer, Baumgarten, and many others,
we now know that many of the cases formerly called papilloma, anatomic
wart, lupus vulgaris, tuberculosis cutis, scrofuloderma, etc, are examples
of the one and same process, probably modified by the condition of the
patient, the resistance of the tissues, and other factors.

The subject of tuberculosis, indeed, is becoming a broad one, and the
interest is ever increasing. The gravity of the disease, whether internal
or integumentary, is receiving the attention it deserves. Its danger to
the community is not yet, however, sufficiently recognized, and the indif­
ference of the individual, the public, and the press to the presence of
hundreds of cases of internal tuberculosis contrasts strikingly with the
hysteric clamor aroused by the discovery of a single leper in our midst.

There have certainly been many cases of cutaneous tuberculosis which
could be traced directly or indirectly to another in the family having the
constitutional disease, which, with other evidence, will be touched upon
again in considering etiology. While many clinical phases have been
reported in recent years, the cases of tuberculosis of the skin can prac­
tically be included under five heads: (1) Tuberculosis ulcerosa; (2) tuber­
culosis disseminata; (3) tuberculosis verrucosa; (4) scrofuloderma; (5)
lupus vulgaris. The first two are extremely rare, the third uncommon,
the fourth not unusual, and the last—lupus vulgaris—relatively quite
frequent. These various types deserve separate clinical description;
consideration of their etiology, pathology, and detailed methods of treat­
ment will follow the last.³

¹ Danziger and Pollitzer, Festschrift des Deutschen Hospitals, New York, 1911, and
Pollitzer, Jour. Cutan. Dis., 1910, p. 388, report a case cured by x-ray treatment;
and mention other recorded cases benefited, with references. A case (woman, Ameri­
can birth) under my care now being treated by x-ray by Dr. Manges at the Jefferson
Hospital has shown some improvement.

² Smith, Jour. Cutan. Dis. 1912, p. 100 (case demonstration); thinks he has had
slight favorable action in a few trials with autogenous vaccine.

³ In recent years there has been a gradual and growing belief that certain eruptions,
such as erythema induratum, lichen scrofulosorum, the various conditions I have re­
ferred to under acne varioloformis, lupus erythematosus, and a few others, are of tuber­
culous character, but not due directly to the tubercle bacillus, but to its toxins. These
diseases are frequently referred to as toxic tuberculides, toxic tuberculoses, paratubercu-
loses. Experimental inoculations and investigations, as well as clinical observations,
seem to bear out such possibility—a series in point being those experiments and
investigations recently made by Zieler (Münchener Med. Wochenschr., Aug., 11,
1908; abs. in Brit. Jour. Derm., 1909, p. 162), indicating that tuberculous changes
can be brought about by products derived from tubercle bacilli without the presence
of corpuscular or even ultramicroscopic portions of the bacilli. Zieler goes over the
subject still more exhaustively in “Experimentelle und klinische Untersuchungen zur
Frage der “toxischen Tuberkulosen der Haut”, Archiv, 1910, cii, 1 Heft, (with review
and references); and Much’s investigations (Unna’s “Studium,” xxi, p. 95, (vol. ii,
Unna’s “Festschrift”) showing that there are other elements of tubercle organisms beside
the ordinary bacillus, such as a granular form of bacillus, rows of granules and isolated

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