TUBERCULOUS DISEASES OF THE SKIN Lupus, scrofuloderina and tuberculosis cutis verrucosa are the most important of these.
The characteristic histological picture of tbe miliary tubercle with giant cells and epithelial cells with a tendency towards caseation, the positive bacteriological findings, and the experiments on animals, have done away with all doubts as to the tuberculous origin of these diseases.
Besides those lesions which are genuinely' tuberculous in character there are still left many conditions which may bc observed clinically in individuals supposed to be tuberculous. The nomenclature of these has always caused the greatest difficulty'. They are partly grouped. however, under the heading acne scrofulosorum.
In 1S01, Barthelemy proposed the name folliculitis or acnitis for these particular cases., on account of their supposed origin in the follicles; but he did not strictly raise the question of their relation to tuberculosis. To Darier is due the credit of having called particular attention,to the tuberculous origin of these lesions. He combined these dermatoses under the name tubercalide.
Now commenced a period of zealous study of these diseases and their causes. Long treatises were written from this theme and these gave occasion for many sharp discussions and controversies at the Con gress. at Paris in 1900. At that time Bocci; proposed a division of these conditions into perifollicular, superficial, and nonperifollicular deep rooted tubereulide, and combined the whole group under the designation of the exanthemata of tuberculosis.
However, as a united action in regard to the nomenclature was not reached, I will add another name proposed by Pautrier, i.e. "Les tuberculoses cutanees atypiques." Thus it may be noted that the clinical conception of these derma toses after the basic labors of Darier, Boeck, Hallopeau and others, was generally accepted.
.513 To the above-mentioned conditions may be added the long well known picture of the papillary necrotic tteberettlide.
The chief characteristic of these form.s is comprehensively, expressed by Zollikofcr, as a tendency to gradually spread out over the territory of predilection; a chronic condition resulting; which may run along for weeks, showing apparently but slight inflammatory reaction all the time.
Another peculiarity exists, in that these lesions remain inoffensive. That is to say, they are without contageousness towards healthy tissue. They show- no disposition to invade neighboring healthy districts, either upon the surface or deeper.
While the combination of these clermatoses with tuberculous dis eased organs is acknowledged by almost all authors, chiefly on account of their clinical observations, and that these lesions occur only in those who are tuberculous; still the question of their origin forms the subject of a lively controversy to-clay.
In the beginning, when the disease was first recognized and the name tuberculide was just, being evolved, Hallopeau accepted the toxine hypothesis and tried to draw a. sharp contrast between these. forms and
the old bacillary skin tuberculosis, by coining the word toxituberculide. According to him, the infective material (analogous to bromine or iodine poisonings) coming from distant tuberculous foci lying upon the skin, would travel by the circulation in the epidermis, and being deposited would cause atypical changes which were called tuberculide.
The apparent symmetry with which these eruptions appear on both sides of the body, caused Boeck to form the theory of Angto-Neuroses. ffe did this by placing the attacking points of thc toxin, not directly in the blood vessels, but in the vasomotor nerve centres, an opinion, however, which Boeck himself dropped later on.
Jadassohn opposed the toxin theory, relying chiefly upon the findings of Philippson in cases of tubercalous thrombo-phlehitis. Inde pendently of him, Darier put himself on reeord for the bacillary origin of the tubereulide. Indeed he goes so far as to express a belief that it is the bacilli which are weakened in their virulence or even dead bacilli which when deposited in the skin will lead to t,he various forms of the tuberculide.
The ever increasing frequency of the finding of bacilli in lichen scrofulosorum and the other forms of tuberculosis, is the cause for the acceptance of a bacillary origin for these dermatoses; and in fact, this is now very generally believed (Jadassohn, Neisser, Conaby, Nobel).
On the principle of these hypotheses, partly formed by histological and bacteriological findings, and partly by positive inoculative experi ments; we cannot speak any more of a sharp contrast between the old skin tuberculosis and the so-called tuberculide, but must trace back, particularly the homogeneous forms, from the disseminated miliary exanthem with plentiful bacilli, to the lichen serofulosorum; from the multiple post-exanthematous lupus to the erythema induratum—all of these to a blood infection with bacilli in the most various grades of virulence and vitality.
The difficulty of making a very early diagnosis of tuberculosis of the apices of the lungs; or of the so frequently occurring tuberculosis of the bronchial glands in childhood, is well known. By a most minute examination of the skin we are at times rewarded by the finding of isolated or multiple foci of lichen serofulosorum, follicular effioresences or disseminated lupus. The finding of any one or more of these would show us the existence of a latent tuberculosis and thus put us on our guard and suggest the therapeutic remedies which used thus early, would save life by relieving the patient of the danger threatened by a new exacerbation or general spreading of the tubereulous process.
The most frequent forms of skin tuberculosis occurring in child hood, are lupus vulgaris., and serofuloderma.