CUTANEOUS

TUBERCULOSIS.

Its

Clinical

Aspects

and

Etiological

Relations.

\ By\j"ME"'c. WHITE* JjJD:

Its

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Papers

read

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Dirmatolcgical
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Association

Washington,
Boston November Medical

September

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UDRAKY.

CLINICAL

AND ASPECTS OF CUTANEOUS

BT JAMES 0.

ETIOLOGICAL TUBERCULOSIS.1
M.D.,

LATIONS RE-

WHITE,

Professor of Dermatology

in Harvard

University.

These

is

no

disease which
as

within
so

the

province of special
demands its earnest selected for been

this Association consideration formal of the

much has
not

this, which

discussion

to-day ;
one

for

only is
most

tuberculosis spread wide-

vital tissues

of

the

fatal and

of man, and in its cutaneous forms destroyers of frightful the source but great confusion disfigurement, mutual exists with and regard to the nature relations of some The of its manifestations. diversity of opinion which exists in the profession throughout this point,has been made the civilized world upon discussions prominently manifest in the innumerable and reports upon the action of Koch's remedy, which have been Such a published during the past year. universal and synchronous census of prevalent sional profesviews medical in pathologyis upon any subject in history. If this cyclonic un parallelled tation experimenin therapeutics, fanned into a popular craze by the

public

almost medical little of

and conducted to a lamentable press, and ridiculous of its end by the over-enthusiasm

supporters,
the external

who

in 'many instances phases of the disease the

knew

as

they were

as treating they did

shall creation of

result
a

in

proper

ing, employremedy they were immediate than the no more good interest in the study of the manifold
of
cutaneous

of

manifestations
not
1

it tuberculosis,

will

have
Read
at

vexed
the

the world
of the

in vain.
American

meeting

Dermatologieal
to

at

Washington, September
Cutaneous

23, 1891, introductory

the

Association dfeeuMion

upon

Tuberculosis.

It is my the

function,
to

as

Council,

place

the

interpret subject in
you Before in
as

the

instructions and form

of ological etias

its clinical
a

relations

before

possible
unnecessary

for

discussion.
more

simple this body

indicate

it will those have

or

be

than of

briefly to
the
or

wellbeen

recognized
hitherto

conditions

skin, which
individual

assigned a more position in cutaneous

and

less

dent indepen-

pathology
certain

which, with
it will
or

other
to

ogists, dermatolamong less clearly defined

are

conditions,

be

phases

my clinical

object
forms

show,
a

of

single

progressive affection.

only

I.

"

LUPUS

VULGARIS.

I may the

be

pardoned
of this of
vast

if I attempt term,
as

to

define

before

meaning
sketch

ordinarily used,
which number express involution of
to

by

you the its

briefest
course.

the and been

lesions

characterize of

The which

needless
invented
or

specific
ticular parevery festations. mani-

terms

have
of shows

each and these

phase
clinical form

development
the

great

diversity
of its

Several
are

distinct

types

primary stages

The formation of apparent macules recognized. point to a pea, or larger areas a varying in size from of which elevated of irregular outline, neither above are the tions infiltrageneral surface, but are felt to represent of the cutaneous tissues of varying depths Z. tnaculosus, planus. Papules, tubercles, nodules, or elevated above the surrounding skin much larger areas
"

to

the

extent

of
are

line found

to to

half-inch. extend the

more same

Like
or

the less

former

lesions into
the

these

skin, and
when These

exhibit

consistence
instrument.

pressed

upon constitute

with

deeply boggy, yielding blunt pointed any

A
more

Z.

tuberculosa*, nodows,
cluded inbe

elevatut, tumidus,
minute
under

non-exedens,
these

non-ulcerosus.

description of
the
common

ordinary early lesions,

term

lupoma,

would

wholly superfluous.

through progressive tissues. surrouuding cutaneous have Thus we an lymphangitis, accompanying may ening persistent oedema, teleangiectasis,great general thickwith pachydermia, papillary hypertrophy of or affected the regions, L. cedematosus, hypertrophic", papillosum,elephantiasicus, etc. Ail the various these cutaneous changes constitute manifestations in its periods of progressive development
occur

Some

modifications

of these

forms

changes

iu

the

or

evolution.

Lupus
interstitial

undergoes involution resorption, fibrous

The earliest in indication the
a

retrogression by ceration. uldegeneration, and

or

of

the

first

named of the

process

is

change
in

epidermal covering
form of scales in

varying follow exfoliativus,psoriasicus. Then a the depression of the elevations, and shrinking and slow formation of a smooth an atrophic process. scar, The of divided fibrous forms are metamorphosis by
amount, L, Vidal
never

primary

lesions

the

and

Leloir

into is

so-called

L.

sclereux, which

is

a as regarded by them slowly progressive which retrains virulent, development ulation, containing bacilli and yielding positive results on inocZ. and sclerogus, Jibrosus, a retrogressive change, no longer virulent, and not to be confounded

total, and
form

of

with forms.

the

scar

formation

which

follows

ulcerative

Ulceration
of

takes

place

in

lupus

tissue

in

variety
to

forms, L. exedens, ulcerosus, which, according

the

has received rapidity or penetration of the process, other designations superficialis, serpiginosus,profundus, The pkagadenicus. determining causes vorax, of this secondary understood. not are clearly process It is most probably not the result of the action of the tubercle introduction bacillus, but of the accidental into tissues already impressed by the former of suppuration-producing
"

cocci.

The

outcome

of of

this
true

destructive cicatricial

process

is the the

ual event-

formation

tissue, and

opment devel-

of a variety' of transitory during its course Z. crustosus, conditions rupoides ; : crusting stages are excessive exuberant or granulation is L. fungaides9 Finally, the cicatrix is established, capable vegetans. itself further of hypertrophy, L, keloides, and of presenting in its permanent possible appearance every etc. state, according to the seat, treatment, These constitute the cutaneous are changes which the the conditions under term ordinarily comprised elements of expression at command, lupus. With so many it is associated evident that of with its

chrouic
occurrence,

course

and titis, dermavery

dermatoses

occasional

erysipelas, etc., it is capable of exhibiting in individual cases. great variety of appearances

II.
"

TUBERCULOSIS VERRUCA NECROGENICA.

VERRUCOSA,

anatomical tubercle, had necrogenica, or like long been recognized as a chronic, inflammatory, warttubercle, affecting primarily the fingers of persons ward-tenders, working in dissecting and autopsy rooms,

Verruca

and

butchers.

In

the

last it
was

revision

of

our
"

system

of

classification, in
of the

1884,

epidermal
to

and

phies hypertroplaced under to papillary layers," next

and Vidal upon of of
were

ordinary
call

verruca.

Besnier its
occurrence

the

first to

attention of

persons

making
its
semblance re-

autopsies

subjects dying
to
some

forms

were

discovered in several been

in its tissues. instances in

consumption, and In 1884, lupus. In 1885 they were

the tubercles which

bacilli
also had

found

probably
and

their

inoculation, by tuberculous with. therein the inflamed axillary glands connected and Paltauf published Early in 1886, Riehl Verrucosa article "Tuberculosis Cutis," in on

produced

which

the

clinical

and

anatomical
were

features and

of its

this

now

well-recognized form the more identity with

established. the lesions of The all then familiar

described,
restricted of the

probable
tubercle in

anatomical tubercle
was

presence clinical its

bacillus also

varieties and

strated. demonfeatures

Since have its few become

occurrence

peculiar

multiform

fail

to

It form the

dermatologists everywhere, as is found and but to be by no means rare, losis. tubercuregard it as a phase of cutaneous nary fairly,I think, be accepted as the ordimay
to

of

manifestation of the
same

in

the

cutaneous

tissues

of

inoculation
derived
or

with cadaver

tuberculous of
man

matter, other from in the and mal, ani-

whether

from

the with

or

by contact subjects. There

of nodule of the
more or

infective

material variation

living
acter charsmall

is

considerable from the

lesions,
less

primary
type
with
to

inflammatory

quent its subsethe

more

wart-like extensive
areas

of

papillary hypertrophy, and deeper infiltration by

parts
well-marked of its

greater

inence, promformations trans-

characterized of
some or

verrucous

surface,

by

isolated

or

grouped,
central
an
or

dull

others, and inch,

by
other

nodules or purplish-red tubercles cicatricial depressed changes in thus affected portions. Areas may several combinations inches of in the

in the be may The

or

even

diameter,
above

and

present

various

lesions.

be wholly absent. When the papillomatous features may is by no plaques are multiple, and this coudition means the hands, have infrequent upon we opportunity of seeing how varied be the expression of the disease may
even

upon

the

same

individual. the

The

amount

of

mation inflam-

incident

to

also, manifesting itself

or

in the

formation
the

developmental stages is variable in zones of surrounding titis, dermaof superficial or deeper foci of
diseased I need

suppuration

within

tissues.
not
more

It

dergoes rarely un-

ulceration.

But

particularly

describe and

condition which

with

which

jou members

are

all familiar,
of this ation Associ-

concerning
have Dr.

several

recently published
Morrow's upon the
case

communications.

Among

them

is and

occurring
a

face

especially noteworthy, as presenting so exceptional

form

of

papillomatous
III.
"

lesion.

TUBERCULOSIS

CUTIS.

This

title

was

applied,
significance
be here

before had
to

its become certain

true
so

and

more

comprehensive
accepted
disease,
text-books those
most
a

generally
forms of all

by
which

dermatologists,
must

rare

mentioned.
on one

In

nearly
even same

and

general treatises recently published,

brief

skin

diseases,
the the

finds of

definition,
"

transcript
observed

in

fact

description Kaposi,
in

of and

certain

ulcers

by Jarisch,
the orifices upon
to
were

Chiari,
of the the

others, occurring about

stages
and membrane. had and of

patients

advanced the
mucous anus

consumption,
and These ulcers

vulva,
eroded,

extending

lips,about adjoining
and

discreet

shallow,

edges,
surface. their

presented Miliary tubercles

within the
true

slightly infiltrated, irregular reddish-yellow, a granulating

were

found

associated and in

with
one

extension within There

cases

the

buccal

cavity,
tissues
reason

instance the these of ulcer.

cutaneous

surrounding
for

is
as

no

apparent

regarding
forms

classic

otherwise

than

exceptional

local
state

auto-inoculation,
from the tissues. the

the them
on

patients'
to

tive assuming a rapidly ulceracondition of generally depraved There is certainly nothing in establishment

warrant
account.

pf

special

class

their

Under

the

title dermatitis

tuberculosa Heller there and

was

acuta, described
an over

or

eral genthe of

miliarv
case

tuberculosis,
child in which

has

of

outbreak the

macules,

papules, vesicles,

bullae

whole

surface,

subsequent
adherent in
to

to

the

development
innominate the of

of vein.

caseous

glands
were

the

right

Bacilli in
tions sec-

found of the

the

contents

vesicles, and

affected
term

tissues.

Under

the of

tuberculosa
at

pustulo-ulcereuse
the last

Dr. the

Gaucher,
International

Paris, described

meeting
an

of

Congress

of

Dermatology

affection

children, characterized by impetiginous occurring in young pustules, superficial in their early stage, but in shape, and terminating in deep ulcerations, circular
covered these with lesions
crusts.

Inoculation animals

of

the mild

pus

from

upon He

produced
it
as

peritoneal
some

tuberculosis. the The

cases

regarded
by
of older

identical
as

with

of

described
was

writers

impetigo

rodens.

process

benignant type.
SCROFULODERMA.

IV.

"

This

is

term

most

commonly
take

applied
in the

to

the

gressive pro-

changes
so-called
seat

which

place

skin

covering

in

The glands in the neck. primary of the is generally either in the subcutaneous process fibrous tissue, in the lymph glands themselves, or the periglandular structures. Briefly described is first the noticed
a

scrofulous

there beneath
more

firm, circumscribed

infiltration

skin,

which and

prominent,

slowly becomes finally is felt to

or

larger
soften.

and The

overlying skin is sooner hyperamic, thinner, and several points, allowing

beneath. vary Thus
in

later

implicated,
down the of ulcer. fluid These

becomes
at
one or

finally breaks
the escape
an

matters

is established appearance, months The

or

ulcers tion, dura-

greatly
and heal

size, numbers
years, in

and the

after

by
its

formation

of has

variable received

scars.

process

various

phases glands,
gommes Similar

scrofulous : following names scrofulous white swelling, cold abscess, sores, scrofuleuses, gommes scrofulo tuberculeuses. the

8
"

chronic

changes
the bones. too, of in

place in joints and

Here,
condition

resulting in skin overlying placed fingers and

children,
be

destruction
tuberculous

often disease

take of

must

tuberculous

dactylitis, a
the

the

toes,

principally
by
of in

former,

young

characterized

bottlethe
'

inflammation enlargement and chronic terminating often over-lying integument, and

shaped

structive deis of

ulceration much process,

more

of

the

same.

This than

affection the and The

common

occurrence
so

syphilitic
is, in my
ulceration

which

it

closely resembles,
for the latter.

opinion, often
resulting
from

mistaken all these

nected especiallythat conscrofulous with glands in the cervical region, extends far beyond the originalunderlying sometimes into the surrounding integument, and disease tinue conmay of to indefinitely, destroying large areas progress

forms, but

skin,
the

or

new

foci

of

ulceration of

in process

the

neighborhood
to
rare

may the

establish

selves themulcer

primary
doubt. of

by

of auto-inoculation allied is
a

without forms

Closely
tuberculosis and

these

ordinary

glandular

the small and

by Hallopeau Goupil under the title Lymphangiecta"ie suppurative of tuber culense. Swellings form along the course filbert to a a lymphatics, varying in size from
egg. The
issue

affection

described

gives by
Certain

overlying skin to a discharge

upon

softens of

and

ulcerates,

lymph

containing
is
panied accom-

bacilli.

The much

process

the

lower

legs

swelling.
have been
as

dermatoses of

regarded by
the of so-called the skin

writers
lichen
ring occur-

as

forms

scrofuloderma,

scrofulosum.
at

times

They are disorders in patients who are

are

affected

by

losis, tubercu-

but

they
some

Perhaps
Unna's

tuberculous way reference should here

no

in

processes. made be That

to*

"tuberculous

eczema,"

60-called.

the

skin active

immediately surrounding
state

tuberculous into
a

lesions

in

an

may

be

stimulated

sympathetic
and that

matitis deran

of eczematous
eczema

type

is well with

known,

in of be

tissue may
not

person sufficient

affected

tuberculosis

of any

gravity
modified

to

somewhat

impair general vitality an by such impression is

advanced no improbable, but I have seen reason for recognizing a Such specific tuberculous eczema. an appellation without proof is as objectionable to me the expression eczema." as syphilitic with such Finally, in connection pseudo-tuberculosis, I desire that in my to state cient opinion there is not suffievidence for regarding lupus erythematosus as
"

an

affection There
are

to

be

considered
other in forms

in

some

this paper. of disease of the

are

tuberculous
met

character, which
to
some

integument, occasionally
forms
are

with, closely allied above described, which,

of
reason

the

clinical
to

I have

believe,

ordinarily recognized as such, been in the habit of designating as With the simple statement mostly deep-seated,chronic processes
not

and'

which

I have culosis,. tuberare area

unclassified that

they

of restricted of them the

and

often

associated I will
not

with

evidences
to

tuberculosis
more

elsewhere,

attempt
is

define

now.

This

my all

opinion that we are possible manifestations

Such
then
are

equivalent to not yet thoroughly

of cutaneous

statement

particularly of with

familiar

tuberculosis.

the

tissue

changes by
cutaneous

which

losis tubercu-

manifests
mere are

itself in the of the

structures.

The

shows how varied processes the methods the skin expresses its resentment by which of the irritating find We of the virus. presence
we

enumeration

that

may

have

erythema,

followed

by deep

tions infiltra-

corresponding size and small ranging from papules to

of

hyperaemic elevations, tubercles of large size,

10

which

may

gradually undergo
and

absorption and

leave

remain in conditions of atrophied scars, or soften and ulceration discharge indefinitely, destroying open of integument, by serpiginous progress large extents and terminating in depressed or bypertrophied scare. Firm and densely sclerous infiltrations without marked

ondary tumidity and verrucous outgrowth, not tending to secForms of flattened Do -like ma changes. pertrop hypa pi of extremely slow development. Ulceration and destruction of the skin overlying glands primarily affected ; deep and nodular prominent, circumscribed infiltrations often of considerable size (gnmmata), leading destructive to softening and ulcers of indolent of the integument Tumidity and breaking down type. and covering phalanges, primary affections of the bones and In the surrounding larger joints as well. of skin not have areas immediately affected we may dermatitis of various grades and kinds, as well as the in the process, structures implicationof subcutaneous the glands, lymph vessels, fibrous tissues, cartilage

and

bones.

of the minute anatomical particular nature changes which give rise to these varied appearances, it is not my province to speak of ; this will be presented consideration to your by our more competent colleague. Dr. Bo
wen.

The

By
various

the

concurrence

of and

certain

of

these

lesions

in

arrangements

combinations,

differing some-

11

for

the

dicta

of

the

older
us

teachers,
from

antagonism
and anatomical

of

schools, have
clinical

prevented
the
common

recognizing
of the

interpreting
features We

identity
to

properly and

ail these

phases.

see

the

same

magnify
clinical

the forms

importance
in

and
two

pseudo-independent disposition to unduly individualityof distinct

kindred

the

great

diseases,
marked the of

syphilisand leprosy, dividing lines have

former the into well and student

until been

recently. Sharply
supposed
stages
to

to

separate
confusion

defined

the

and practitioner, the so-called has

the

equally
and

artificial cular tubernition recogtrue

division

between
of the

anaesthetic

forms of method of

latter

its esseutial

largelydelayed etiologicalnature.
the
we

the The of

determining
conditions of of the

mutual
are common
com

relations

the

rious va-

diseased observation their

discussing is by
to

close

features and

them

all, and
(to coin
our
a

points
in
to

approach
cases,

mergence
not

word)
efforts clinical what

individual

and far

by confining
certain
us

demonstrating

how

apart
Let

selected

types

apparently
we

stand.

consider, then,

evidence formed

possess
so

ously
I.
same

opinions,
concurrence

to-day, unbiased far as possible, of

clinical

by
their

previ
ical clin-

and The

unity. etiological
of various forms in the

individual.

attention my the last few years tuberculous character

Since

has
to

been the

in especiallydirected withquestion of the probable obscure and conditions of

of

various

the
as

skin, which
chronic ulcers

1 had

previously

inflammatory
of uncertain

processes, origin,scrofulous

hastily regarded phies, hypertrowarty

sores,

bone termined undetor

disease, questionable syphiliticlesions,

cutaueous

or

other

changes,
in

which

make of
cases

large

residuum

the

classification under the

that up in hosp*

clinics, often

bunched

title, " uncertain

12

agnosia," and
has
note

been the in

made

understanding of their my I have been clear to me,

of association of
same

real

nature to

surprised

frequency
the

various

clinical

forms

illustrate the
notes

better Perhaps I cannot than such concurrence by placing together have this point, which of cases bearing upon person. my observation
seventeen.

fallen

under

in the

past three
of

(1) Girl, aged

state

Enlarged glands
ulceration
upper

years. in neck

in

of
;

ulceration; extensive
of

surrounding

skin

in

serpiginous lupus on (2) Girl, aged eighteen. Chronic tubercles neck on leg in ; chronic patch
on

right thigh. ulceratingglands

of ulceration
;

state

ulcer

lupus of nose. (3) Man, aged thirty. Serpiginous lupus of face, of varied begun after a cut upon its type, said to have Fifteen site. Lately, a patch of deep years' duration.
palate ; lately, tubercular
tubercular
infiltration

(4) Girl, aged eight years. Lately,

broad belt from
ear

upon sixteen. active

ear.

arm.

Swollen

glands in neck ulceration extending glands

in

for in

to

(5) Girl, aged twenty.

some

Scrofulous
ulceration.

neck,
and

of them

in

state

of

Tubercular

ulcerative

Sclerous lupus of face. lupus on front neck. Solitary and large tubercle on back. of tuberculosis (6) Child, aged eight. Verrucous wrist. Lupus-like tubercles on knee and arm. old. Tuberculous (7) Child, eighteen months litis dactyof fingers. Chronic scattered tubercles same on

arm..

(8) Child, aged

hand.

nine

months. and

Dactylitis
on

of

one

Scattered

nodules

tubercles

arms

and

legs. glands in neck, surrounded (9) Child, aged six. Swollen of cutaneous ulceration berant by large areas ; exuulcerative lupus of nose. (10) Man, aged sixty-three. Multiple tuberculosis

13

verrucosa

of

fingers of

left and

baud. fibrous

On

same

forearm
a

tubercular,

ulcerative

lupus occupying

large
Some
well

area.

of the

tbese
concurrence or

cases

offer of

striking illustrations
cutaneous

as

of

sucb

forms I shall

witb ask will

cent re-

pulmonary
your

deep joint tuberculosis,

to

but

attention

such many

association similar

later.
cases

They
the

recall, I doubt
observation

not,
of

within

all. of
the in of fact the

enough
mixed

to

establish

and are numerous you, of the frequency of such

same

manifestations connection

frequent
scrofulous the

lupus
of

state, is well
statistics

proper known. I need Raudnitz former

cent,
a

The person. very with the so-called

familiar

and found

only refer to Pontoppidan,

evidence
cases

recently
scrofulosis and the

collected. in

The per

of

thirty

of

209

of in

lupus,
a

latter

determined

scrofulous

basis

still

larger percentage in lupus. Several objections would

the

be

raised, I
views of these

am

aware,

by
to

opponents
drawn the

of

these from

modern facts
as

unification

evidence

just presented.
occurrence

First, that
of such with cations of

simultaneous
is
mere

or

consecutive
or

forms

coincidence,
because

that thev

lupus
are

is

ciated asso-

scrofuloderma,
a

both

indi-

depraved
This

affections. the
so

is, of
the

vitality, although independent of simply a restatement course,

proofless assumption
Second,
cases,

old

dictum,
remained lesions

very

which the
taneous cu-

long

unquestioned.
exhibited
"

that the

in my

of the
as

"

scrofulous
were

above of

stated,

glandular merely the

But
to
an

exception disease, disposed of

with

protean
be

tions manifesta-

lupus

alone. of

this
extent
cutaneous

would
so

extending
or,

the
as

definition
to

lupus
form admit
to

comprehensive
tuberculosis,
are

include

every

of

in

other

words,

the

unity

we

contending
know that

for.

Third, it may

be asked, How

do

you

14

\
by
for

the

extraordinary lesions with lupus and your

in their

described

you
cases

as

ated associare

scrofuloderma

berculous tu-

nature,
are

admitting
so? this of fact their

the

moment

that

the

latter of all

changes
these

Because has

in been

examples

forms

many established and

by
bacterial conducted also

careful

examination and

anatomical

elements,

by

inoculation observers. does lesions

one

experiments
It know in may be that
an

by
forms

many

competent

legitimately replied, How

of
cutaneous
are

unusual

occurring

analogous
Does such
one

positively syphilodermata ? one challenge the syphilographer to establish ? No, diagnosis by microscope and inoculation
affection
trust

must

the

skilled

observation

of

the

plished accom-

of

dermatologist to changes many

of difference be in

recognize
in the

the nature
cutaneous
so

and tissues

tion posiby
that

shades

they
II.

cannot

appearances expressed in words. of the

minute

The

clinical The essential

numerous,

presence forms.
on

bac%Uu$

tuberculosa*

in all

data

which

this these

all-importantproof
conditions
so on

of
now

the
so

identityof
have been of the

rests

are

gathered by
are

reliable record

observers in
so

in all parts well-known for

as

world, and
present
the

many

publications,that
to

it will in
as

only

be

necessary
a

my

purpose

them

succinct

shape

possible. (1) Lupus.

every lesion bacilli

In

active

and

developmental stages
of

of

vulgaris
outside

recognized as occur. They

in the

characteristic
are

lupus
and the low in

found

inside

surrounding lesion, are always sparsely distributed, and are of with the activity they manifest vitalitycompared
other forms
are

of

cells, often

tissues

of

tuberculosis.
still less

In
or

the

retrogressive
with
our

phases they
present
tests

abundant,
at all.

cannot

be

discovered

16

That that is

this

bacillus

in with

all

these of

forms

is the

same,

and

it is identical the

that of

pulmonary

tuberculosis

proved by
III.

results

Inoculation
too, it
to

Here,
me

Experiments. would be wholly

waste

of

time

for

to
so

present
the

the details of the experimentation you in all parts of the world extensively conducted introduction the of this test

since It has

by

Professor

Koch.

following facts : tuberculosis when lated inocuThe bacilli of pulmonary Pure guinea-pigs produces tuberculosis. upon the and of same produce like prolonged cultures
results. The
cutaneous

established

tissues

of scrofuloderma,
verrucosa,

lupus,
and
more or

tomical ana-

tubercle, tuberculosis
tuberculosis
have all

miliary
less mal. anithis

repeatedly produced
when

general

tuberculosis

inoculated

upon

According
the the

to

Lingard
bacillus

jhe intensityor
varies

virulence

of with

effects of such

inoculation

in accordance in these with

activity of
Thus
matter

the

growth
inoculated
or

respective
the cular tuber-

forms.

guinea-pigs
found in sputa
on an

verrucous

tuberculosis,
80

die

of tuberculosis with material

from

average scrofulous

in

days,
in 206

lated inocu-

glands

days,

and

with

confirmed difference
so

to

be Now

one

These results are lupus tissue in 331 days. by Leloir's investigations. He regards the losis, between lupus and other forms of tubercuis concerned, far as their comparative virulence of quantity rather than of quality. the natural conclusion from from
one

these such and

experiments
various cal cliniform
same

is that

these of

materials, derived disease,

in
of

forms

produce
the
same

the
are

of tuberculosis

animals, because
know,
to

they
the

all

merely
of

varying expressions
has been

disease.

An

objection

raised,

as

you

soundness

17

such
should the

conclusions

on

the

ground
was

that

these forms that

inoculations
from which

reproduce
should of the

the

respective local
derived
;

material

employed
few
as

is, that
aside local

lupus
the lesions

inoculated

produce
cases

lupus.
in which thus

Setting
such

reports
have

interpreted as too exceptional such it seems to establish to me a possibility, explanation, that the cutaneous a perfectlysatisfactory of the animals tissues experimented are simply upon soil for the development of the bacillus unfavorable an

resulted

might

be

tuberculosa.
upon animals show tissues from

Is it not

as

difficult to inoculate does

not

leprosy
of certain of
terial ma-

and (or syphilis)

a

the

bacillus

leprosy
human

strong

selective The

for affinity

over

others?

inoculation
human

syphiliticlesions upon not reproduce the form of lesion or derived. which it was from Why expected of the lesion or stage of
called
which

tissues

does

stage of the disease

then should this be hitherto conditions such the tuberculosis the
to

lupus

We the

know

too

little of of bacilli

influence
to

biology by

permit
from

arguments

control

legitimate deduction
these

positive data
IV. from But effects
one

furnished

experiments.
of

Auto-inoculation. host
to

Transference

infection

another.
are

opportunities
of the upon conducted the

not

wanting

of

studying

the

inoculation

tuberculosis
not

all these forms of many of or human skin, although this has

or

been

by design
of the the
cutaneous
are

studied

in of
to

the the

initial disease
or

stages.
from from
one one

Instances

transference surface
so numerous

part of
host skin the
to

another,
that

another,
of of

this

origin
history
case

of of

tuberculosis sequence

cannot

be

denied.
many
from

The
a

of

multiple forms,
been need
not

of development which examples

warrant

clinic

have details

already cited,
be

my this conclusion.

The

repeated.

Orouier

reports

18

cases

in

which
of

openings
in

bones, and

developed after spontaneous of pus caseous lymph glands, collections Five of gland cases were deep fistulas. lupus
was

origin,three of osteomyelitis. Achard of lupus verrucosus cases occurring

former
can

cites
on

numerous

the

seats

of

subcutaneous

gummata.

Such

secondary

forms

evacuation of matter, the or immediately follow chronic after long periods, if the discharge become is how When consider we exceptionally restricted the seat of lupus generally, how extremely slow in its invade its peripheral tissues, to even ordinary course for twenty, confining itself to a small and single area

fiftyor

even

more

invasions from each

years, of new

it

seems

to

me

that

the

secutive con-

territory,often widely separated be most other, can plained reasonably excases on

in the

majority of
We
seats

the

theory
occur

of

re-

or

auto-inoculation.
view

find of

in

accordance forms the

with

this
most

that

multiple
in open
more

lupus

frequently
active
are no

children, in
than in

whom

disease
cutaneous

is

more

and

adults, whose

tissues than those

doubt

susceptible of
with whom

infection

of the

latter, and
from
one

transference surface
to

of infectious another from is

so

materials

part of the

of picking habits from likely to occur more frequent nudity of portions of and all from the of
more

sores,

the

the the

integument,
hands with

restless

contact

of

parts
seat

the

reported
the of
matter.

where of

body. lupus

CaseB has We

have

been

frequently
upon

developed primarily
shall
see

wounds.

below, other
of

dence evi-

successful

direct

inoculation

tuberculous

study
cutaneous

of

the

clinical

history of
be

cases

shows,

too,
from

that
one

tuberculosis
to

person form
oases

another,
which it

may without
was

transferred

the
are

from

necessarilyrepeating derived. The following

observed

by myself

19

Child, aged eight.

Scattered
Bister has tubercles similar
on

Verrucous
knee
on

tuberculosis
and
arm. arm

of wrist.

A of later

younger

tubercles

one

ment. developand open

Girl, aged

seventeen.

Verrucous
both feet. of

lesions

ulcerating forms upon lupus on one thigh.

Has lived in closest
areas

Serpiginous crusting

extensive skin I in my of many

three years. process intimacy with a sister who presents of the of multiform tuberculosis Duration

years' duration.
to

might

refer
one

other member these of

instances of
are
so

of
same

more

than

the under

lupus occurring family within

present
occurrence

experience,

but
not

tion. observaas

They
indicate transferred that

are

frequent
to

to

cutaneous
one

tuberculosis host

is

readily or

often
cordance ac-

from with
our

another, and
the

this is in

or

low

knowledge of and vitality, sparse

forms.

tivity comparative inacdevelopment of the

bacillus On
of skin

in these other

the

hand, there
which infected

is

an

extensive how in the

collection

observations,
become and

demonstrate

readily
more

the

may condition in the

by

bacilli

active
occur

greater
of of the

abundance

in which

they

sputa
a

pulmonary

tuberculosis.

Jadassohn the the his lected col-

reports
site of
a

case

tattoo

design. pigments
after

The with

development of lupus upon mark, coinciding with the lines of had phthisis,and mixed operator
his
own

saliva. of

Dubreuilh of

has

seventeen

cases

tuberculosis
the ritual of

the

penis
was

circumcision, in which
The
to

operator
this of these

in

consumption.
is well
were

peculiar
all.

nature

operation
bacilli

known found

gives an account of a patient with laryngeal and pulmonary phthisis, who bitten the finger, produced an was by a gnat on it wetted excoriation of the part by scratching,and

you in the lesions.

In

several

Behrend

20

repeatedly
which
cutaneous
woman

with

saliva.

This

terminated

in

sore,

did

not

heal, and
the

presented
In

tuberculosis. washed

every Dubreuilh's

appearance
case
a

of

young

handkerchiefs

containing

the

sputa

her phthisicalpatient. Nodules developed upon followed by swelling and suppuration of the fingers, few weeks small nodules axillaryglands. In the next of the which broke appeared along the course arm, down and discharged. The the original lesions upon of
a

hands the

became lesions in and

verrucous.

Bacilli

were

found

in

all

discharge from the axilla. guinea-pigs gave positiveresults.

the
cases

in the

oculatio In-

Here which the such

follow have

of

cutaneous
own

tuberculosis
within for

occurred years,

last three infection

my in which

under

observation

favorable
:

conditions

Woman,
on

thumb
to

through sputa existed aged thirty-two. Chronic of two years' duration.

its appearance she had

tubercular For been

a

mass

previous
husband

long time nursing her

tubercular

in

consumption.
months.

Child, aged eighteen

lesions
on

Scattered

Mother dactylitisof hand. died of consumption after nursing it six months. tered scatChild, aged nine months. Dactylitisand many Mother had limbs. tubercles on phthisis. infiltrated Woman, patch aged sixty-five. Diffused
arm,

with

on same.

back

of Was

hand,

and

verrucous

lesion in

on

finger
when

of it

nursing daughter aged sixty-six.

and forearm

consumption
lesions

appeared.
Woman,
of left hand

Multiform
six

on

back

It years' duration. appeared while nursing daughter in consumption. Child, aged twelve. Open ulcerative lupus of nose. ulcerative Sister has culosis tuberSclerous lupus on neck. of palate. of

Woman,

aged

fifty-eight

Verrucous

tuberculosis

21

of

ing finger. It appeared two years ago, just after nursdaughter, who died of consumption. culosis tuberWoman, aged forty-eight Open ulcerative of duration. left wrist of eighteen months' Husband within and daughter have died of consumption

the

last

two

Girl, aged

years. six.

The

latter

had

"

open

sores."

Swollen
for
nose

glands
three of six when

in

neck, surrounded
Exuberant duration. fourteen

by

extensive

ulceration

ulcerative Father months died old.

lupus
of

of

years. months' she

was

consumption

tubercular and aged sixty-three. Numerous ulcerative lesions the left covering large areas upon forearm. forms Several deeply infiltrated verrucous The disease on began on finger fingersof left hand.

Man,

seven

years

ago,

about

the

time

of

the

death

of

wife

from

of

consumption. Woman, aged twenty-four. Tuberculosis left forefingerof five years' duration.
consumption
two

verrucosa

Mother
was

died nursed

of chronic

years

ago,

and

by
of

her.

Woman,
two

tuberculosis aged forty-eight. Verrucous duration. Had fingers of nine months' viously prehad attended a patient in consumption, who for
cases

also

had

four of

months

an

These

probable
numbers

sore open inoculation

"

"

on

neck. be
roborated corcent re-

might
taken'

by great
reports.

of who

others has

from

Dubreuilh,
the
:

collected of the after usual

sixty of
course

them, presents
of in the
an

followingaccount
earliest lesions
a

process adult are livid in

The

inoculation
or an

generally
over sore

either

panaris
area.

ulcer
rucous ver-

with

erythematous

border, becoming
its whole

later In within

vicinityof
beneath
course

portions or the primary

cutaneous

the
or

nodules,

either

the of

tissues, often

the

lymphatics,

along the appear presenting at times the as-

22

pect
In and

of

scrofulous
tuberculous these in that

gummata,
local

and

followed
often have He

infants

meningitis has
manifestations

in adults

by adenitis. supervened, frequently

concludes

terminated

pulmonary
infective

tuberculosis.
matter

farther,

derived

from

surgical

in bacilli, produces a cutaneous is poor is tuberculosis of slow lupus forms, which progress, inoculation the of tuberculous also in bacilli,whereas poor ous cariand sputa gives rise to painful ulcerations

tubercle, which

le8ioo8 Now
no
means

rich

in bacilli. be claimed that all such

cases
as

it may prove
on

these

by
may has

the fact of inoculation, the such admit old

but

that

they

be

explained

theory
that and

of

diathesis, which
easy

hitherto

given
must

complete

and

satisfaction..

Everybody
an

diathesis, so-called, is only

rests
on no

inferential
basis
matter

condition,

scientific with

or

tangible
local and

whatever,
and is

whereas

inoculation tissue

fective inboth

consecutive
a

changes,

universal,

fact
we

demonstration. observed

If, then,
the undoubted

capable of the can explain a

clearest series
sive succes-

of

facts, which

closely resemble

in their

details
or

phenomena
inoculation,
occurrence

produced,
why
should
on
a

cially artifiwe

otherwise,
of

by

ever

think

interpreting their
basis of

purely
we

imaginative
to

causation
or

Why

should

sort re-

pure

assumption
methods

and

physical
are

first shown

supposition until natural of accounting for their rence occurto be of impossible application?

The their that

I believe, and are numbered, day 8 of diathesis will vanish when it is shown figment ary existence to explain the they are no longer necessary rence occurof diseases
to

which

closer of

observation

is demonstrating laws

be

capable
the

interpretation under
scientific

which and
ere

come

within

experimentation.

of scope A diathesis be
as

reasoning
opinion,
the
ex-

will, in my
for

long

be

shown

to

unnecessary

24

gers the

of
mucous

inoculation membranes Association

by
with the

surface

contact.

Would

that

V.

Another of
means

proof of
disease

immunity I possessed the same pulmonary tuberculosis. various of these forms identity
tuberculosis, is their
with the

cutaneous

with

by

no

infrequeut connection
the
same

pulmonary

form

in

known
:

person. statistics to has

need

establish

wellonly quote from this significant rence concurcent, states

Besnier

of that

his of

reported that twenty-one per of Leloir died phthisis; lupus patieuts

nineteen

lupus
that of

cases

ten
cases

were

Sachs per

reports
cent,

166

of
some

.consumption ; lupus thirty-four

form per before
cent,

in

had

tuberculosis and

in

the sequent sub-

cutaneous
to

manifestations,
the

sixty-two

Such ratios development of the latter. might be largely extended by quoting the figures of from other observers. The following three cases my clinic within the last will serve as year in America, of forms
an an

illustration

of such
which who

association would be

experience
of all

corroborated
I have
no

by
doubt. of of

the

observation

are

present,

Girl, aged
upper

sixteen.

Unmistakable

Lupus signs

nose

of six

years'
of

tion. dura-

tuberculosis

right
thumb,

lung. aged forty.

and back of Tuberculosis of left In

Woman,
and

palm

right

hand.

advanced

consumption. Man, aged thirty-five. Sclerous lupus of upper thorax. Apex of lung
The

chronic

and

ulcerative

affected. in

secondary

infectiou of

of

the

skin

pulmonary
sputa in
tact con-

tuberculosis
rich in active with
and

admits

bacilli must

ready explanation, for be constantly coming

the
use

the

fingers in
are
or

of

the the

handkerchief,
mouth

the

hands

often

used

to

wipe
the
of

after

expectoration
as

coughing
The

among

is well

known.

prevalence

poorer such

classes,

uncleanly

25

habit? and
skin The
to

the

infrequency

of

such
the

transfer*,strongly

illustrates, as
such

just mentioned,
of

immunity
tuberculosis forms upon by the

of

the

chances.

development
to

pulmonary
of cutaneous

quent subsean

the

existence

dividual in-

transfer

be explained, of may from of infective matter

to

course,

direct
the
to

surface

the

and air-passages, in any way of kindred is in

open such

lesions extension

upon with

ternal in-

organs clinical record of

accordance The

the

diseases.

tions manifesta-

siderable wholly, or for a consyphilismay be confined the to skin, whilst in period of its course, fore leprosy it may long be the only field of exhibition be-

other I should

tissues
not

are

affected.

mention to neglect in this connection the opinion which French gists, dermatoloprevails among that pulmonary is often tuberculosis developed used by of the operation of scarification, as a result as in the treatment of lupus, in consequence of thus them settingfree the bacilli to enter the general circulation. it In connection* with this question of self-infection, be of interest to note that at the meeting of the may to, M. LesCongris de la Tuberculose just referred

pinne
times
which

described in
cases

certain
of
a

manifestations

observed

at

indicated consisted

They
and
or a

of

lupus, chiefly in ulcerative forms, of the system. general intoxication tarrhal rapid elevation of temperature, caof the
mucous

tissues, typhoidal condition, simulatinga dothinenteritis,

symptoms
serous

and

acute

miliary granulation. As
infectious

soon

as

the

tion elimina-

products has been accomplished, these phenomena disappear, or they may be the precursor of a more He has tuberculosis. seen general them terminate in this disease of the peritoneum and lungs. In his opinion this state of general infection the agents of could be caused either by the bacilli or suppuration in the lupus tissue.
of these

26

With
upon

all this accumulation the

the
one

of varied
concurrence

evidence of
the

ing bearvarious stration demonthe and

question,
skin

the

forms

upon

of

the

same

person,

of
uniform the

bacillus
the

in all these inoculation

clinical
of such

forms,
tissues

results of

bacterium
reor

of

upon auto-inoculations
and of

itself

animals,
of their these

the

clinical upon
to

proofs
the

forms

original patient
the established the disease, with how
any
to

transference

others,
of
see gard re-

association
all this

with

pulmonary
entertained
form

forms

evidence, I say, I
can

do

not

reasonable
the essential

doubt

be

with

with
RELATIVE

which

we

identityof every are acquainted.

OF OUTANEOC8

losis of tubercu-

FREQUENCY been
common

FORMS.

It has far less

belief
this

amongst
is of the

us

that in

prevalentin
here

country
Of

than
more

whilst
occurrence

pulmonary opinion

tuberculosis than I there.

have

lupus is Europe,, frequent

of

correctness

the former
to

presented
nations in

statistical

proof
Such be
plained ex-

this Association

in former

communications.1
may well

unequal prevalence among by the differences

which of
our

habits
But
we

of

characterize
definition of

them.

liness personal cleanwith the enlargement been the

lupus

have

ering, consid-

these should With

various

figures need
all forms
to

revision, and
of cutaneous

inquiry
of
can

comprehend

tuberculosis.
these

regard

the forms

comparative prevalence
amongst
the

clinical

ourselves,
last two General

only
my
my

present the following brief statistics gathered from

own

observations
at

during

years

in

clinic this

the

Massachusetts

Hospital,

In

of cutaneous losis tubercucases period sixty-ninenew recorded, representing the following clinical were varieties: Scrofuloderma, thirty-four;lupus vulgaris,
1

Variations

in

Prevalence,

etc,

1876.

Immigrant

Dermatoses,

1SS0.

27

five

other

forms, thirty. This

to
cases,

subdivision

is Dot

tended, in-

of course, processes sufficient in all

represent
but it

sharply differentiated with loosely expresses

clinitheir

the relative prevalence of the accuracy, ical varieties ratio of here. The as they occur combined
at

number clinic

to

all

cases

of skin

disease is 69
to

observed

my

during

the

same

period

4,644.

AGE.

It

was

the

tenet

of

Professor after the

Hebra

that of twenty, in

lupus
and

rarely,if ever, usually showed

This
rule
was

developed
its often It the used

age

first manifestations
to

childhood.

doubtful

cases.

present

itself in of

diagnosis in that be typical lupus does may at this early majority of instances
so, it must

determine

period
greater
of

life,and, if

be accounted in
see

for
to

by

the

of susceptibility the specific germ.

the

skin We

youth

the

confirmation
the

reception of this

in the character

of the lesions

and

greater activityof

the process which lupus always exhibits at this age, and its not and complete extinction infrequent spontaneous after the history of middle life. So far, however, as the other it clinical is forms
we

have the

been
case

considering,
above
to

teaches,
within

apparent

from

cited the

observation, that no such limitation my exists, and that the skin dangers of inoculation
such

exhibits advanced

both susceptibility

in middle

life and

at

age.
HEREDITY.

important etiologicalquestion, I beg to reproduce here, the opinion I expressed in a paper on ternation Incommunicated the to "Hereditary Dermatoses" SyphiloCongress of Dermatology and Upon
this

graphy

held

at

Paris, in 1889, and

1 do

this with

less

28

hesitation

because

it has

not

been of

published
is

in

form

generally accessible to members That general or pulmonary

and

this Association.

transmissible

has

been

perfectly settled fact, as it plausibleground for its marked

It has
never

hereditary commonly accepted as a seemed the only to furnish

occurrence

tuberculosis

in families. that it

been

denied,

however,

might

velop de-

nature

independently of inheritance. was recognized, it furnished

of the
occurrence

When
a

its bacillus

planation satisfactoryex-

of the latter

class

of

cases.

But

it also

raises
cases

the

account

for

that

is, for
of

form the at all, and any from to capability of transference by person person direct contagion or inoculation, is the theory of hereditability

character

every tuberculosis

question, if it will not likewise hitherto regarded as hereditary, case. Admitting the infectious
in

the

longer necessary? A priori we of intra-uterine infection, possibility

between
nor or

cannot
even so

deny
if the little directly tion inocula-

connection

mother of the the

and

foetus

is

intimate,
of ovulum

preceding
male
germ.

bacillous

Such
The
to

cases

of

congenital infection are extremely rare. of proof in this question should, it seems said of leprosy, be transferred to the was the hypothesis of heredity. As to the
of
a

burden
me,
as

advocates transmission

of

predisposition
to

which after

shall

render

liable disease

the and

disease

birth, but
infection that I is

more person which is not the

a

requires a fresh available, peculiar fertility problem of heredity which

that the bacillus

to
a

make in

such the
sidering con-

nicety

cannot

appreciate,

of every

form

of tuberculosis

tissues readily received and developed in the normal of perfectly healthy animals. So, too, with regard to direct tissue some changes of childhood regarded as the inis result Mr. of

tuberculosis, and

not

tuberculosis

itself.

Francis

Galton,

in

his recent

interestingwork

29

on

"

Natural in which

Inheritance
one

"

of the

riages gives the history of 66 marconsumption.*' parents had

"

There
which

resulted number

from 107

these

unions
were

413

children,
to

of

had,

or

suspected

have,

consumption, equal to twenty-six per cent. its prevalence in the as general population
per may cent., be his inference is that
to

Inasmuch is sixteen in of
rate

this

increase chances

fairlyattributed
in such
was

the He

greater

fection in-

families. the

found,

too,

that the

when

the

mother of

consumptive
children
was

parent,

consumptive
was

larger
which the and he child

proportion than when

the father

the that

affected

parent,

explained
"lies for lies her ease disalso

by
much

the

fact

during infancy

hoars

daily in its mother's arms, her side, breathing the by

rooms." the milk If of the infant from tuberculous mother ?

afterwards air of

tainted may

sheltered

acquire the why not cows,

We

from then form

that that

of its diseased
case

any is inherited

of until

claim not may in any tuberculosis cutaneous of extrauterine possible source every eliminated.

infection

has

been

CONCLUSIONS.

In in
our

conclusion,

it

seems

to

me,

that

on

the

evidence

possession, collected within the last few years,' under a more judgment as enlightened and unbiassed its pathology, and to presented in a necessarily brief in this paper, and warranted we are incomplete form clinical various conditions of the skin to regard the have been we considering,as simply cutaneous phases of one its pulaffection, which, with comprehensive monary
and that much and and
most
a

other

tissue of all

manifestations,

constitute
as

important
unit
as

diseases, tuberculosis;

the

other

tissue In

leprosy.

lesions cutaneous equally multiform characterize syphilis changes which opinion it would greatly conduce my

so

to
tine

the

quicker
relatione
to

adoption
of all of and it* snch

of

this

consistent
if should
terms

view

of

the

forma,

we

entirely
as

eeaae

make

use

independent
hereafter

lupus
ical clinthan of

and

scrofuloderma,
or

designate
distinctive

such

local

varieties in the

by

no

more

titles

we

employ
or

description
The
sooner

of

the

manifestations clearer

leprosy
it

syphilis.
to

and
the

we

make
that all

apparent
of

the

public
are

and

profession
and

lesions and

tuberculosis

dangerous
the
more

contagious,
shall
we

mutually
control

convertible,
over

easily
of the

gain
scourge

the

future

course

greatest

of

mankind.

32

this truth has demonstrated so investigators, in the other belief that and no positively, brilliantly be regarded as more of pathology can domain securely the eaine Furthermore, established. investigatorshave cleared scrofula, surrounding the term up the mystery of by demonstrating that the larger part at all events, in reality the affections scrofulous, are formerly termed of other tuberculous In

troubles, caused

by

the

tubercle

bacillus. is

proof of this, tbey have shown constantly present and capable of

and that these cultures
a

that culture inoculated

this bacillus in

generations,
upon

when
true

other

organisms
of

produce
also that

tuberculosis. illuminated in the time

The

subject
the

lupus

has

been

vastly
For
a

by
wake

ological pathof for the in

studies discoveries

have

followed

of Koch.

long

searched

Doutrelepont and others, that the bacillus of tuberculosis, although very by a prosparingly represented, could be demonstrated longed further of and in sections search lupus tissue, in genthat it could be cultivated experiment showed erations, and by inoculation produce tuberculosis upon sole pathological proof that to the most The animals. be wanting, was the now production skeptical could of lupus itself by inoculation, and although the clinical sometimes least be caused that lupus may evidence at
vain, it
was

finally proved by Koch,

by
rich

direct in

inoculation

of

sputum
not

or

other
must

material be mitted adin

tuberculous
that

virus, is increasing,it
has in
as

experiment
this disease

yet
Jn

succeeded consideration
to

producing
of
the forms doubt

animals.
the
seems

insusceptibilityof
of human will have of the
can

lower

animals

disease, it
to

be

probable that dispelled by an overwhelming

facts. The anatomist
an

many the last

accumulation

clinical aid

fairly demand judgment

of

of the be

clinician, and
formed

may gent intelli-

only

by

consideration

all the

evidence.

33

bacillus, is product of the tubercle of so-called granulation tissue, composed tological hisnodule of small, round cells deeply stained ing by colortogether with larger cells possessing a agents, tubercle, nucleus,
that have elemeuts. beeu with centre, enclosed
are

The

the

clear and

called

large
and

cellular

nuclei cells.

homogeneous
cells
are

cells, epithelioid peripherally arranged the Langhans giant

the meshes of in distinction
or

These

between

connective from later becomes

a

tissue, and
modification

characterized,
their in the

normal

cells, by

instability. Sooner
nodule. Its
centre

begins
lose their

necrotic, that
the

is, the cell protoplasm is coagulated,

nuclei

staining agents, the results a coagulathere tion part in the degeneration, and in the Weigert sense, condition necrosis that a has been a cheesy degeneration. This usually termed fusion. concheesy degeneration, has given rise to much term, in Virchow long ago pointed out that it was
no

of responding to power also takes intercellular substance

sense

condition restricted of

peculiar
to

to

tuberculosis.

Its appearance

use

should and

be

the

macroscopical
products
the of

consistency
the

certain

degeneration,
of

dropping
It has of the

term

eutirelyfrom
at

nomenclature

microscopy.
been

claimed, giant

various the
were

tuberculosis, that

both cell

Langhans

periods in the history cheesy degeneration and pathognomonic of the

now
as

affection.
a

Neither

of them inasmuch

can

be

considered

as

specificattribute,
fouud,
and
an as as

cheesy
numerous

degeneration
other tions, condistill retaining

is

has the

been

said, in

Langhans

giant cell, while

with quently fretuberculosis, can especial association in its typical form in the tissue be seen about forms vessel of syphilis ligatures,and in several oid notably in gumm'ataand in the small papular or lichenvariety. Baumgarten's view that those cases
"

34

the Langhans syphilisin which giant cell is found, are a complication of syphiliswith tuberculosis, has not been supported by microscopical study nor by experiment. No of
one

has in
a

claimed gumma,

to
or

have in
a

found

the of

bacillus lichen

tuberculosis

papule

and animals have failed experiments upon syphiliticus, of these to by the inoculation produce tuberculosis the syphiliticproducts. Still, while Langhans giant cell has lost its claim to be a tain cerregarded as specific, be allowed of diagnostic value to amount must it, when record than
seen,
as

there

is

as

yet,
in and that

so

far

as

am

aware,

no

of those

its

discovery
be said

pathological processes
syphilis.
the its
some course

other

of tuberculosis it may

While of the in the sole

and

life
to

history

tubercle, together with

tendency
extent

adjacent
is of

tissue
we

are

to

progress specific,the

feature

that

have presence

practically to
of the tubercle every

regard
that

as

pathognomic,
The doctrine the every

the

bacillus.
tains con-

to-day reads,
of
the

neoplasm
is be

bacillus

tuberculosis
must

tubercle, and

in

tubercle

bacillus

present,
in

however,
the genesis histo-

sparingly.
Great progress
of tubercle of has of late been made

tuberculosis, by the aid offered bacillus, and by the discovery of new

methods

by
were

the

methods

hardening and staining. These by Flemming in his search

division, and
The the have been that of

augurate in-

for the evidences extended for

some

of nuclear and

constantly
had existed

improved.
under

belief

time,

influence

Cohnheim's

exudation

theory, that the epithelioid and giant cells of tubercle blood the cells, are produced from emigrated white shattered has been essentially by the experiments of
Baumgarten. Baumgarten
into
the

introduced chamber

bits

of

tuberculous eye of

tissue

anterior

of the

guinea-pigs,

35
#

and

allowed

the

infection the

to

progress
were

for

varying
the tion detec-

lengths of time, when tissue subjected to the of karyokinesis.

to

animals

killed, and
for the

modern

methods second of The

On

the

day
first

there

begins
spread
of the

be

an

increase

in the

number tissue.

bacilli,which

into
new

the

neighboring
are

signs

tubercle

be and

produced
not

from

from the

to epithelioid cells, which are seen the fixed tissue cells by karyokinesis, the cells. leucocytes or small, round

observed until a later not leucocytes are period in the development of the tubercle, and no in them at seen karyokinesis has been stage. any Hence Baumgarten regards the epithelioid cells as from derived of the fixed tissue cells, a proliferation had been the and not, as leucocytes. supposed, from doubted whether It has been we are yet justifiedin rived deregarding the epithelioid cells as in all instances

Indeed,

from

the

fixed its
us

cells
ever

alone,

and

the

history

of

tuberculosis, with
urge

changing
in
our

beliefs, may

upon the

caution

positive

properly assertions. have blood of

Nevertheless,

proved
cells the

experiments of Baumgarten conclusively that the emigrated white

a

bear

subordinate that
to

part in
the normal

the

development
the

tubercle, and
are

cells of

affected

part
causes
occurs

the them the may the

first
to

be

assume

infiltration be

by the virus, which the epithelioidshape. Next of the tissue with leucocytes,
impressed
in

which When
acme,

present

greater

or

lesser has

numbers. reached its

infiltration

with

leucocytes

begins to be a degeneration and death of the cells The forming the tubercle. leucocytes are probably the first to degenerate, they refuse to become
a are

there

stained, and
cells their

molecular the
next

detritus victims shrivel

A

results.
to

protoplasm
necrosis is

begins to produced.

epithelioid the degeneration, a tion coagulaup, and

step
in

The

further

the

86

degeue
the But

ration

is

softeuing of
a

the

necrotic

mass,

and

appearauces is no there No
pus

suppuration are falselyproduced. strictlyspeaking. suppuration in tubercle

cells
are

of

found
can

with

the

microscope

in

pure when

tubercle, atid there

the tuberculosis

is

only be a real suppuration a complicated with septic

process. The been

histogenesis of

the

Langhans

giant

cells

has

The best belief subject of much controversy. formed of to-day is that they are not by confluence of a single of several cells, but by nuclear proliferation ing Accordcell, with failure of the protoplasm to divide. to Weigert's view, the Laugbans cell represents a the tubercle
a

in miniature.

The

centre

of

the

cell
a

goes under-

partial coagulation necrosis,

nuclei
occurs us

while the
a a

of the

faster the

than of and of

cell

proliferation body can

with

divide, thus
nuclei
ceutre

giving

picture

single cell

arranged along
of
so

its

edge,

homogeneous

necrosis. fast
not
as

The do the

failure

divide the

nuclei, is

protoplasm to probably caused by

the that
case

the

irritant

of cell process of a division of the

being powerful euough to carry beyond its first stage, proliferation

nucleus. tubercle The irritant in
the

of tuberculosis
are

is the in

bacillus, aud
the

if the

bacilli cell is

so proliferationoccurs quickly sion. that the cell division keep space with the nuclear diviThis theory is strikinglysupported by the ease of lupus, where the bacilli are sparingly present, very

not

present fouud,

great numbers,
the cell

Langhans

as

and

where

for

this
"

reason

the

number iu

of
acute

Langhaus
miliary

cells is very

much large tuberculosis, for example,

larger than
where the

accelerated, Furthermore,
situated and
to

is process fouud iu great numbers. aud the bacilli are cells often coutain the Langhans bacilli, the

whole

aloug
which

periphery, the part that nourishment for they turn

still when

lives,
the

becouijiMMfitic.

37

The

theory
cells the with of

of of

Metschnikoff tubercle that its is that should it has

with be

regard

to

the
on

Langhaus
account

mentioned,

attentiou which

excited, and
has

of the
its
ganism or-

ingenuity
claims.

originator
the of

argued
of

His

theory

protection
bacteria
out

the in

white their

species against many blood corpuscles, which

nutriment. The he cells has

lies the

the
for

seek

bacilli and and

that called

thus

receive

feed
to

the upon this class

A

bacteria,
the

phagocytes,
of

Langhans
the

giant
is
cons'

cells

tubercle

belong.
tween bethe bacilli

struggle
the

for existence

autly taking place

and

cells and

micro-organisms,
their
bv

when
to
an

overwhelmed intra-cellular Able

by

antagonists,are
which
to

subjected
are

digestion
have

thev

auni8

hilated. aid

supporters

rallied
;

Metschnikoff

in his into

phagocyte
the the active

theory

but has

without

entering
must

further said cell the and this that

must

controversy

that

arisen, it
that the

be

characteristics
to
not

Langhaus
with

in order possess tubercle bacilli, have that the

carry been

on

its warfare

satisfactorily proved,
is
not

weight
to

of

authority
special

in

favor

of

theory. Turning now

the

features
to

presented by
consider is
:

cutaneous

tuberculosis, the first form

MILIARY

TUBERCULOSIS

OF

THE

SKIN,

as

this is the of

form internal
"

that

represents
It

almost has been

exactly
called
as

the

tubercle the French of

organs.
is

by
perty proneous cuta-

tuberculose
common

ulcereuse," but
better of many title is the almost
to

the of

ulceration

forms that
of

tuberculosis, the
tuberculosis,
of
on account

miliary

miliary nodules

Clinicallythis form at the juncture of the

at

sence prein process of rapid necrobiosis. situated consists of painful ulcers

mucous

constant

membrane
nose,
anus

with and

the skin vn^"ft

the

entrance

to

the

mouth,

38

and

also

is also

the ear, in patienU sufferingfrom upon nounced protuberculosis of internal This form organs. with the membrane met alone, and on mucous the skin

rarely attacks
from
mucous

except
The

by
of
a

extension of the

outward

surfaces. made
as

edges
up
out.

ulcer of small

are

characteristic, being

series

dentatio in-

looking
in the
can

if

punched
the
a

Miliary
The

cles tuber-

form

of

white yellowish-

transparent
ulcer.

nodules lesions of the

in parts of usually be seen are rapidly progressive, from the miliary tubercles, and from ulcers. To Chiari of
not

degeneration
of the first the due the when

confluence

small

and this

J arisen

are
a

accurate

descriptions
bacillus had prove found
in

form,

at

time

tubercle tions observawere

been

discovered. these of
a

Chiari's
for

the

rarity of
cases

ulcers total of of which

they

only
cent,

five

out

7,000 autopsies,
were

sixty

per

of the

subjects
not,
so

lous. tubercu-

These

lesions been

have

extends,
that their have

studied But

in

the

knowledge my logical histolightof the modern

as

far

methods. been
to

all the tend

made,
cutis with

structure

that of the

pathologicalexaminations the similarity of to prove of internal miliary tuberculosis

to

organs.

The

is found of

be

filled

to

siderable con-

depth
occasional the
centre

foci

small, round

cells, with
cells. In

epithelioidand
of that of The of these upon foci

Langhans
the necrosis

giant
has

progressed
the

rapidly, so
appearances

macroscopical
and often

examination

softening
tubercles and

apparent.
masses

cheesy degeneration are by their coalition form

tissue, in which
tissue
can

softened of unaltered

necrotic

the be

evidences found In there

granulation
parts.
found
a

only

in the the

outlying
am

number

of bacilli

in

this

is, I

convinced,
of the

further

miliary analogy with

In the

form the
cases

miliary

tubercle

internal

organs.

40

the

thinned

and the The

tense

layers of

the

epidermis above,
with soft under-

giving
miued

rise to

well-known

ulcer

degeneration is usually much ther faradvanced than in lupus, large areas of necrotic, softened tissue being usually visible under the scope. microExperiment by inoculatiou has, as has been said, proved beyoud a doubt that these scrofulous glands and ulcers are a tuberculosis of the subcutaneous tissues. The specifictubercle bacilli are always
present.
a

edges.

Their

detection

may,

in

some

instances,
others
are

be
are

matter

of considerable and is the in

difficulty ;
in

in

they
so

very
numerous
sown

abundant,
than
as

general they
lupus,
form

much
not

more

case

but

thickly

in the

miliary

just considered.

LUPC8.

In lupus

we

have

tuberculous

affection, having its

the of

starting point in the corium, affecting primarily lower portions, progressing upward by extension
the foci
of and

disease,

and

causing

in

most

instances

secondary
elements.

alterations non-specific
the

of

the

epithelial

discovery of the tubercle bacillus, had already pointed out with investigation histological
Before

much

clearness

the

resemblance
of
more

existingbetween
tuberculosis.
others
to
a

the Fried-

anatomical
lander
points
to

features

lupus
than

and all

contributed

correct

appreciation of
separate
then the

this

similarity, and
not

of difference
two

were

argued defined distinctly

A the advocates
on

that

the

enough
troversy con-

affections.
between
two

considerable
and

arose

r^nts of

the identitv of the

affections

oppoanatomical the

"rounds. Baumgarten

pointed out
in

that
was

cheesy
in

feneration, constant
Ss
lupus,
m0re
rise
"

so

tubercle,

wanting

that i""

less epithelioid and tissue presented lupus r

,

giant cells
to
a

greater

formation

"" ^

Wftg

more

va8CUiar, gaVe

rf

connective

tis8ue" did

41

not
was

present

so

capable
reasons

of he

distinctlyfrom
that the
are

miliary nodules, and For these anatomdirect suppuration. ical be separated considered that lupus should ence, tuberculosis. These points of differ-

sharply

defined

true

in the than

main,
the

are

now

cited

to

identity
attribute Neisser

rather

of the dissimilarity
cannot

prove tions. affecas

Suppuration,
an a*

however,

be of is
now

claimed

of has

lupus, any more pointed out, and

than
as

tuberculosis,

generally

accustomed What have been to call we acknowledged. and softening suppuration is in reality a breaking down A of the true suppuration often granulation tissue. but only when a septic process is engrafted on occurs, jections tissue. With the tuberculous regard to the other obof Baumgarten, they are precisely the points between of difference rapidly progressive and a more a and less virulent chronic Cheesy degeneration," process.
"

the
seen

synonym

for
account

an

advanced of its slow

necrobiosis, is
progress
their and Whether

not

in

lupus, on
soil

the
or
as

small
not

number the been

of bacilli is here

that

are

present.
to
are

unfavorable

existence,
in other much

has

often numbers

suggested, they
in
cutaneous

found

smaller

than
cutaneous

in most

forms offers
are

of tuberculosis. the sole

Miliary
to

tuberculosis here the

exception
the

this

rule,

as

bacilli
as

usually found be expected,

advanced The smaller
are

in great

numbers,

and

therefore,

would
a more

tissue

presents
of

anatomically giant
as

necrosis.

larger representation
number of

cells

and in

the

epithelioid cells
of
as

seen

lupus,

also of

characteristics

the has

more

forms

tuberculosis,

been

slowly developing showu by experimentation

with
uated atten-

animals, by feeding them upon bacilli. In these cultures of tubercle

a

experiments
bacilli takes

very

slow

and the

sparse

proliferationof
does
not

the

place, aud

neoplasm

progress

beyond

the

42

stage of the

primary epithelioidcell tubercle,

the

or

to

one

verging
same

upon

lymphoid
that
we

cell

tubercle with in

"

much

the

appearances The

meet

lupus.
has

been and

histogenesis of the Langhaus cell tuberculosis referred to in speaking of

increased in numbers of of the these belief cells that

already
was

generally,
in

the

lupus
are

evidenced when

support

they

duced pro-

specificirritant is not powerful enough of the cell protoplasm so fast as the to effect a division nuclei the specific irritant are divided, being the tubercle bacillus, and sparingly represented in lupus
"

the

tissue.

Thus,
anatomical

it should

tuberculosis.
seen,
was one

emphasized, that from a purely be separated from' standpoint, kipus cannot himself, who, as has been Baumgarten
be of the chief

opponents
reasons,

of the

tuberculous in
now

theory
its true From

from
not

anatomical the shadow

nature.

declares doubt
can

his

book text-

that

of

exist

of

tuberculous the

to as experiments that have been alluded proving that the epithelioid aud giant cells of tubercle derived from in the main a are proliferation of the

fixed blood

tissue

cells, and
we

corpuscles,
The

newly-formed
way.
to

cells

of

emigrated white that the confidently assume may lupus are produced in the same
not

from

the

be

an

of the lupus tissue is found first appearance accumulation of about the cells, situated

capillariesand lymph a growth of

But all connective

channels,
the cells

in

many
of
are

cases

adventitia that

these affected

senting reprevessels.

by the virus of tuberculosis are capable of this metamorphosis, and in view of Baumgarten's experiments, the possibility that the epithelialglaudular elements also take may
part
of the
in

tissue

the

process

cannot

be

excluded. cells of have

Few been

studies made of in the

the

histogenesisof lupus methods light of the newer

staiuiug aud

43

conclusions Unna his

in
a

derived
recent

from

paper investigationsin this of

experiments has published

direction. identical
as

upon
the

the results

iris. of the

He with

regards
the
*"

cells epithelioid zellen

"
"

lupus
These of

as

plasma
represent and are of the

of

Waldeyer,

and

distinct

from

Ehrlich's says,

mast

zellen." the

plasma
the
cutaneous

cells, he

first stage

tubercle,
endothelium connective

not

derived

exclusively
from finds of any nowhere

from of the

the

but capillaries, cells. He

fixed

tissue

wandering

evidence of the transformation any cells into epithelioid cells, as

;

has found

been

waudering cells in the vicinity of the process guished are sharply distinby their small size and by their deeply-stained
few the of

heretofore

assumed

the

nuclei, from
A

epithelioid or
that
at

plasma
in

cells. Uuna's of gations investi-

point
cells

considerable claim

interest the

is his round
are

agglomerations
of the
now

small,
nodule

found

the
as

periphery
even

lupus
but

not

leucooytes,
of of
seems

is

assumed,
as

derivatives methods events,

epithelioid cells, protoplasmic staining.

to

the

is

shown

early by
at

So

much,
of

all

be
as

settled well
as

"

that in other

the

role

the

cocytes leu-

in

lupus,

chronic

tory inflamma-

the

been has greatly exaggerated, and that processes, fixed cells are, the tissue least in main, the at of the
next

parents
The is the the the

epithelioid and giant cell formations. stage in the history of the lupus tubercle
of the The
to

degeneration

newlv-formed
cells be

cells in the

and

of of

tissue. fibrillary nodule

are

lying

centre

the first

affected,

their

protoplasm

becomes
extent

tain homogeneous, while the nuclei lose to a certheir susceptibility Following to staining.

Weigert,
are

the

cells in
as

lupus,
on

as

in internal
a

tuberculosis,

regarded
opposes of the

undergoing
view,
can

Unua

this

the be

coagulatiou necrosis. ground that no coagulation

determined,
and
that

protoplasm

44

there

is

no

death,
be

as

yet, of
the

the

cell.

However

this

question
of of the the

may

decided,
elements and

tuberculous

is a degeneration process influence under the toxic the the

a

bacteria,
that

represents
account

first small

stages
numbers
we

of

necrosis,
the
see

is, on

of
"

of
never

bacilli,of slow
in the
acute

progression
this

stage that

forms.

Together
The cells

with

degeneration taking place

is also of the

iu the

epithelioid cells, there

are

capable
virus
may
to

regenerative proliferation,when
a

process. fected afnot

by

the

extent

of

advanced

eration, degeninto
nective con-

and tissue.

finally become
In this
manner

converted is of

scar-tissue, that
the process
to,

takes

the

place
Uupa,

produced the lupoid the lupus nodule, in

his work

of

healing.

in

just

ferred re-

that that the

of spontain cases regards the scar-tissue neous healing of lupus infiltrations as different from following an ordinary loss of tissue, in the fact there is
never a

connective but is

tissue

reproduction of elastic fibres, that is never arranged in intersecting

to

bundles,
that in

placed horizontally
numerous

the

surface, and
rich
a

it contains

large
upon Hence he

ucell

spindles,"

protoplasm, which striped appearance.

tissue
as a

section

give
and
not

the this
an

skin

regards

cial cicatriferent indifments. ele-

true

lupoid tissue,
the absorbed

substitute

for

tuberculous

An
seen

advanced
in

stage
the

of

the that

regenerative
occurs

the

elephantiasis
to

in

is process Here lupus. tissue such

a

the
is
so

tendency
great,
that

forpoation
the

of

new

connective
to

and

dominates

degeneration

large portions of the body are converted of hvpertrophied fibrous into dense tissue, conmasses taining foci of degeneration to a greater lesser tent, exor aud presenting clinical appearances quite similar of advanced those of to elephantiasis. This formation

degree,

45

new

connective with

tissue the

in

greater is forms

or one

lesser of the

degree
causes

as

compared
the affection.

necrobiosis clinical

of the

multiplicity of
Another

exhibited

by

complication of lupus is the proliferation of epithelial elements that take place. So far as may of the process extends, must we regard our knowledge caused these phenomena as secondary and non-specific, formation, and by the irritation produced by the new analogous to the epithelialactivity in syphilis and other
chronic its

inflammatory

processes.

The

rete

iuna, cor interpapillary prolongations deep into with of and the that is so conthe papillae, outgrowth stantly allied to the epithelialproliferationin all papilof lupus papillaris,verrulomata, the clinical forms cosus A are produced. proliferation of the glandular elements also take emphasized long place, as was may since by the studies of Lang.

may the

extend

When reached
a

the

tuberculous

infiltration of

of

the the

corium

has

certain has from

grade

intensity and
and

overlying
by
a

epidermis
pressure of the

become

stretched there and

the

thinned results foci

the ture fraclaid

below,
rise

frequently
tuberculous of

epidermis,
to

are

bare,
these
a

giving
instances

the

forms

there with
a

complication

frequently, if septic process.

we

In lupus ulcers. not usually, exists To all the

true

presence tion suppuramicro-organisms

cutaneous

of the

pus that attends

are

micrococci
a

must

refer

very

lupus readily engrafted

and the
to liability

lesion.

The

pus

lesions shares

of with

nature, any the others

upon tuberculous

lesion

this

complication.
CUTIS.

TUBERCULOSIS

VERRUCOSA cutaneous to

The of which

last form
we

of

tuberculosis, the
is that and affection

anatomy

have

consider,
Riehl

first

curately ac-

described

by

Paltauf,

under

the

46

name
or

of

tuberculosis identical the hands with

verrucosa

cutis,
anatomical in

form
wart
so

nearly
often

quite
on

the

found and
at

of those table.

engaged
As

rooms dissecting

the

autopsy
and

described

by

Riehl of

and

Paltauf

the anatomical

characteristics

consist

greatly
a

elongated

covered enlarged papillae,

with

ened, thick-

also fills up the horny layer, which the papillae. Between the cornidepressions between fied epidermal layers are found dried of exudation, masses with nuclei that are partially stained, and heaps of granular detritus. The inter papillary prolongations are hypertrophied and extend deeply into the corium in places. The principal pathological changes many found in the upper are layers of the corium, in the foci* filled with papillaeand adjoining layers, which are of closely aggregated cells. These foci consist of a of round cells at the perigranulation tissue made phery, up cells toward large epithelioidand Langhans the
cases

lamellated

centre,

while of In
are

the
a a

centre

is formed its border.

necrotic

at

word,

the

majority of defined indistinctly mass, histological appearances

Besides these

itself

in

the

of tubercle foci of

well

defined.

tubercles,

suppuration are also found at the points where the epidermis has penetrated most deeply, which finally break form small through the overly iug tissue and filled with from the continued horny masses crypts The tubercle bacillus was growth of the epidermis. of granulation tissue. in the nodules constantly found On found the average, bacilli were in lupus, than more but less than form. cocci Microin the miliary cutaneous
were

found

in

all

the

parts where
and

there

was

an

acute

inflammation observations

and

suppuration.
of Riehl Paltauf have been

These verified

The observers. limits by the most competent of their been original description have enlarged, in that these wart-like to occur patches have been shown

48

knees,
Dr.

etc., in

the

form

described
under The

McCall

Anderson,
verrucosum.

many years ago the title of lupus

by
or

histological ances appearhere give as a of epithelioid and nests Langhans giant cells in the upper layers of the corium, with increase of a an papillary hypertrophy and cornified these were epithelium. Nor inflammatory picture of
appearances

scrofuloderma

present

in several bodies
or

cases

of

verrucous

berculosis tu-

lesions

lupus of other parts. They that most to occur seem frequently in the cases sent prefeatures of t he a necroclinically typicalverruca genica. With of bacilli found, I have regard to the numbers
not

the upon of scrofuloderma

of

people suffering from

been

so

fortunate of the

as

the

writers

quoted.
has

While been

the
a

detection

specific micro-organism
matter
a

comparatively easy others it has required equal to that demanded

and able
so

in and

some

long
for

instances, in laborious search,

in
not

their

detection go, I have

lupus
been

far

to

my demonstrate

as

own a

researches

striking divergence -from

characteristic distinction from of that

lupus

in this The
verrucosa

regard.
chief anatomical in tuberculosis affords of the the

papillary
tuberculous lie in

growths
the in lower

lupus,
While

is the the

situation

neoplasm.
ana

foci of

granulation tissue
of the corium in

middle

tuberculosis in the

found

lupus, they are quite constantly verrucosa, papillary layers, usually in the upper
portions
and in with this respect my experience that of Riehl Paltauf. and that in the form
occurs

themselves, papillae
accords It
must

quite exactly
also be the

admitted

under
at
a

sideration, con-

papillary outgrowth
at

early period, perhaps

affection, while
at
a

in

lupus
has

beginning very it is met with most frequently

tissues have become broken taken

the

very of the

later and

period, when
ulceration

the

down

place.

49

Anatomically, lupus
process. may often

therefore,

this in the

affection

differs
seat

from of and the it

papillaris Many
be

chiefly
transitional difficult which Riehl and of
to

superficial
forms from may
a

occur,

say, of the

microscopical
varieties
we

amination ex-

alone,
before
us.

two

have

Paltauf tuberculosis doubtful

must

have certain

undoubtedly
affections under

brought
that other distinct the be this from the
were

into

the

limits before and

to

regarded

as

or

classed

headings,
addition
at

their

work

be of the

regarded
disease. cutis the varieties distinctions have the classed in in the
to

as

our

knowledge
tuberculosis

For should of

present,
accorded disease.

least,
separate

verrucosa

place
that the often

among anatomical

Granting
lupus
these their lesions

verrucous

are

slight,
not,
until

we

still scope microwith

fact

that

were

taught
tuberculosis mind that for the

us

histology,
A them in

commonly
further

or

lupus.

argument

my fact their

separating
clinical evidence

from these

lupus,
cases

lies

points
"

being

produced
that
cannot

by

direct

inoculation, yet
be demonstrated

mode in

of

fection in-

as

large

number

of

lupus

cases.

* I
-

"

I " J

"

THE

THERAPEUTICS

OF

CUTANEOUS

CULOSIS.1 TUBER-

BT

OBOBGB

HENEY

FOX,
the New

A.M.,

M.D.,

Clinical

Professor

of

Diseases

of

Skin,
York.

College

of

Physicians

and

Surgeons,

In of the

discussing
skin,
measures

the

treatment

of

tuberculous
to

affections
first
then

it will

be

convenient
may

consider and of may from outset,

the the in

local

which remedies
cure.

be

employed,
may prove
we

constitutional

which In other

service

facilitating a
the

words,
and
at

regard
a

subject
point
of

first view.
to

from I
even

surgical
will
state

then the

ical medthat I

do and been

not

propose of

enumerate

the have confine the have

various from time

remedies
to to
a

plans

treatment

which but which which will have I

time

recommended,
of those and those

myself
sanction

cussion dis-

of found

high
to

authority,
be of
As

personally

value.

lupus
affections

vulgaris
of the
are

stands

foremost and
as

among
forms like this

lous tubercuof
neous cuta-

skin,

other
to
a

tuberculosis
we

amenable

treatment, disease.
are

will All
are

begin
in

with

the

local

therapy
that three of

of

agreed,
the removal of

I think,

objects
lupus.

to

be
are

aimed

at

local the

treatment

These with
as

(1)
pain

the
as

morbid the

tissue,
least of

(2)

little

possible,
A brief

(3)

with

resulting disfigurement.
various fulfil methods these tive respecin

consideration show how

vogue

will

perhaps

they

indications. The
one

oldest still

remedy

in

the
some

treatment

of

lupus

and

recommended
the in Annual

by
Meeting
of

surgeons,
tbe American

is the

knife.

Read

at

of

Association upon

Washington,
the
treatment

September,
Cutaneous

1891,

Dermatological to the cussion disintroductory

Tuberculosis.

52

This

will

certainly
with of

remove

the modern of

disease

when

limited in

in

extent,

and

the

improvements
almost

skinbe be
on

grafting,a patch
excised and the

lupus

wound

healed. much dread where result of may

size might any But this cannot and

a

accomplished
the
on

without

discomfort

part
from

of

the is
a

patient, and
involved, the

plastic operation
seldom The tory satisfac-

the face

is

cosmetic

point
knife

view. be

prevalent
but it
sults re-

fear

of the

surgeon's

irrational,
the favorable

exists, nevertheless,

and, in

spite of

reported by Hahn, Senger and others, in no case of lupus, large or small, is excision, in my opinion, methods of treatment at our preferable to other com-'
mand. The

cautery,
which I

as

commonly
and

employed,
diseased

is

another ing Actmust

agent,

would

unhesitatingly condemn.
tissue, it
or

equally upon either produce an

smooth,
studded

healthy

unuecessarily deep ulcer,

delusive isolated cicatrix nodules. used the

else
soon

the pear apa

superficialand
with

will

Whether

Paquelin or galvauo-cautery be generally painful and the result disfiguring.

Doubtless.
treatment
one

operation
uncertain

is
or

either

the

best

method

of I This

lupus
must

is that

employing heat in advocated by Besnier,

of I have
never

the and

which

frankly confess,
consists in

fairly
and

tested. linear

method

making
of

punctate

scarifications knives and

by

means

variously shaped
to

needles,
with the
a

buttons

of

galvano-caustic battery.
of

platinum, connected Being sceptical as

infection

resulting from as operations, such blood-letting scraping and scarification,I have failed to appreciate the advantages claimed for his method of treatment. by Besnier
The upu8
use

danger

general

tuberculous

of

the

fiat electrode

for

the T.

destruction

of the

tissue,as

endorsed

by

Dr.

G.

Jackson,

at

53

last There

meeting
is
no

of

our

Association,
as

T have result

tried that

repeatedly.
can

doubt

to

the but

good
the

be
to

tained ob-

by
the result

this
is
so

method, great
is
as

time the

required
method

effect
paratively com-

to

render

of

little value. The

curette
an

instrument

well in
to

deserving
treatment

the of

high reputation it When used lupus.

to

has alone

acquired
it is apt
removes

the

effect of

cure.

It

usually
tissue
on

the

diseased
even a

with

ease,

insufficient prove the greater tion porand when cocaine

cotton
to

is
new

injected or
surface,

applied large patch

to

pledgets of
be

the but

may
the

little tissue

pain

or

discomfort

scraped patient. The

a

with

healthy
a

remains

uninjured,
will

and

wound

is

left, which
smooth is Vol

properly dressed,
cicatrix.
a

heal

The of

size taste,

and but

speedily and leave shape of the curette

the form of the

largely
k
man n

matter
can

spoon nodules

For isolated recurrent hardly be improved. after a previous unsuccessful appearing in the cicatrix eased points of disoperation, and for the minute tissue noted after multiple scarification,even
curette

the

smallest Here
a

is apt burr
or

to
a

dental

prove dental

too

large.
can

excavator

be appears of

used

to

great
the size

advantage.
form will be of found
an

Indeed, whenever nodules,

lupus
burrs
to
a

in

disseminated

varying
curette.

greatly superior
instrument

small and which

With

such nodules the

deeply-seated
would Since years escape

of

lupus
of
use

can

many be bored

small
out

action the

recommending
ago in the I have used

scraping process. any of the dental burr six

Cutaneous
and

Journal

of

Venereal
the
ware una-

Diseases, greatest
that
a

satisfaction. Mr.

it many times and with Until quite recently I was of

Morris,
instrument
excavator

London,
for

had

vised previously de-

similar

double-screw

in

this purpose. This is a the which lacerating edges

54

of two in the form a cone lel paralarranged around the that as pitch of each spirals. It is claimed spiral considered separately is double that of the single
are

threaded

screw,

the
turns

cone

can

be

inserted

to

its full ing reduc-

depth
the

with

fewer

of

the

instrument, thus
the
to

the

duration

of

the

operation and
It
seems

suffering of
me

patient by fullyone-half. advantage is wholly theoretical

burr dealer As
too

that

this

and
or

that dental

the

ordinary

obtainable will

from

any

dentist

instrument

the purpose. fully answer regards scarification in the treatment I

of

lupus,
the

much,

think,
raised

has

been

said

in

its

favor, while
losis tubercu-

the

objection
is

against it,that
leads
to

it promotes

absorption
advocated

of bacilli and

pulmonary

scarification,as largely hypothetical. Linear provement imby Squire and Vidal, is certainly an the punctiform scarification employed upon
Volkmann
cure

by Dubini,
but
most

and

Veiel. in most

There
cases,

is and

no

doubt the

that

it will

lupus

leave of

satisfactory cicatrix, but involves usually an amount

this of
as a

method time and

ment treat-

patience

which

greatly lessens The only cases

treatment

plans of
nose.

Here
to
remove

the

ure. therapeutic measin which it is superior to other those of ulceratinglupus of the are and various curette applications which

its value

tend

the

diseased

tissue
cause or

are

liable

to

cause

considerable

through
destroys
the Vidal size

life

deformity, and with a misshapen

in such
a

the

patient
nose.

to

stumpy
while

go ification, Scar-

however,
the
to

cases,
new

it

gradually
of
tive connec-

lupus, permits
take form its of

growth
tends

tissue

place,
this

which

and

has cells the

shown

by

important microscopical observation,

alter their of connective may often

preserve As feature. the and

as

to

lupus
ssume

gradually
shape
claimed, the

configuration
be

of fibres
nose

tissue, and,

luire has
ilt.

actuallyre-

56

gins.
four
or

Mercurial five weeks

plaster
the with the
same

is

gallol, iodoform
order of
to

boric
return

applied, and after cyclus ot curetting,pyroacid dressing is repeated in

now

prevent

of

the

lupus
the

in

the
can

form be

miliary
For many from a any

infiltration. skin
I

Finally,
have had
more

wound

healed

rapidly by
years

transplantation.
sults satisfactoryre-

somewhat method used

similar which
a

plan
I

of

treatment

than I of cent.,
to

from

other

have

employed.
ointment

have,
which

however,

much

stronger
to

pyrogallol,varying

from

twenty-five
the duration The the
first

fiftyper
adds is
or

greatly shortens efficacy of the treatment. quite painful for

and

the

application twenty-four
considerable
use

times some-

fortymation inflamof the

eight hours,
of

and

may

give
But

rise the

to

the

part.
soon

continued
a

strong
in the

ointment

produces
it is is made

benumbing
and
no

sensation further is

locality to complaint of pain

and
a

which

applied,
the

until

ointment

continued dis-

This simple dressing is substituted. of the the application, coinciding with separation sloughing tissue, will often be regarded by the patient the dirty, more as painful than the pyrogallol. When left a brownish, pultaceous slough has separated and

clean,
beneath

raw

surface, mercurial
which the ulcer will cicatrix. extent, may be

plaster
become if the

be may converted
raw

applied,
into
a

smooth,

pliable
in

Or,

surface of

be skiu

considerable

Thiersch's

method

transplantation
no

hesitation

in

employed with benefit. this use of (1) recommending

pyrogallol ointment,
a

I have

the

rette, cu-

(2)
mercurial
treatment

the

strong
of

and method

(3)
in

the

plaster as not only

which

most

admirable but
of

the It ob-

lupus
many

rodent and

ulcer. few

is

method

has

advantages
which

"tiouable

features, is
a

ilicylic acid

remedy

experience

has

proved
other

to

be

of of

service
cutaneous

iu

the

treatment
as

of

lupus
well
as

and iu the
in

forms

tuberculosis the

other affections of many Journal British Medical in the

treatment

skin.

In it is

a re

letter
com me

to

in 1884,

led

of

lupus vulgaris,by
published
its
iu
use

Dr.

J. G.

shall. Marin

1886,
terms.

paper Uiiriii advocates

a

In

the in

Loudon
most

Lancet enthusiastic of

He hut
oue

recommend* all

the

application
two

varying
tar

strength,
creosote to

containing
of is
to

parts
The
an"l

of

beech

part
alone

salicylicacid.
very
use. seven-,

pain

caused
a

by

the

acid

constitutes

serious

objection
anesthetic of
as

its

hut
the

it

is

greatly mitigated
which The

by the speaks
has
an

action

of

creosote,

Uuna
creosote

the'*

morpliiue

of the skin."

antiseptic and

haciilicide

t-ffuct, Mint

is

fore there-

acid. corrigent anil adjuvant to the salicylic A strong plaster is at Hrst applied to destroy the epidermic Iletore the covering of the lupus tissue. second face, a solution plaster is applied to the raw sui of cocaine be which will temporarily employed, may deaden the pain, which in a short time yields to the The effect of the creosote. more lasting anesthetic but cicatrix, remedy leaves a smooth according to Unua, redness of the is apt to persist for some scar
both

time,

owing

to

paresis of

the

capillaries or

destruc-

58

fered years.
or

from

lapas

of

the

right
had
no

ear

and

Deck

for

eight

Surgical

measures

been marked

employed
results.

two

dermatologists of Koch's lymph

with
were

by one tions Injec-

or

more

months employed for two St. Luke's at action Hospital, and although the recharged characteristic, the patient was was finallydiswith He no now improvement. apparent branch the been of the three

entered Skin
mouths

Fordham service the at my Cancer and for Hospital, where the

out

past

fuchsine

treatment

has The has twice of

faithfully
of the very superficially and a

carried affected

by
or

Dr.
a

A.

C.

Lewis.

surface

skin

scarified
one over

portion of it with a scalpel

alcoholic solution
treatment

been
a

week,
almost

per the

cent,

fuchsine

The part. nevertheless but

has elevated
now

been

painted less, painhas

the

lupus
dull
an

tissue red

completely
are

flattened, and
seen.

only
of

patches
and

to

be
cure

The this
case

prospect
seems

absolute

speedy
The

in

quite encouraging.
of
cutaneous

constitutional may be

treatment

losis tubercu-

conveniently

divided

into

the

specificaud

non-specific,the former aiming at a direct action upon the morbid growth, the latter .merely improving the of the patient and thereby modifying general condition which the tuberculosis is implanted. the soil upon of the term there is certainly Despite the vagueness It is an inherited such or a thing as scrofula. acquired
condition
of of

certain definite

tissues, which
and the of

leads

to

the

opment develIt

characteristic this

symptoms.
diathesis in the
assert

doubtless liable
sense

renders
to

the
term.
or

subject engrafting of
Although
iodine
or

ally especistrict that

tuberculosis
no one can

of
liver

this oil

cod
ever

the

produced
tuberculous value of

the

slightest direct
lesions, there
remedies in

other
the

have hypophosphites effect upon lupus or is no question as to

these

combating

the

scrof-

59

nlous

diathesis. these
as

In remedies

the

therapy

of

cutaneous

culosis, tuber-

may prophylactic, and shown that in

therefore clinical certain

be

ered justly considhas

observation
cases

repeatedly
valuable
measures.

I my

would firm

a they are and indisoensable often adjuvant to local Without discussing this subject at length, merely take thL opportunity of expressing

belief

in the

value in all
or use

of
cases

iodide of

of starch

as

constructiv re-

agent
tuberculosis Anderson be advocated

struma,
In

whether McCall

present
the and in

not.

1880,
in

of

this remedy

matous erythethat it
sisted con-

lupus,
was

of

no

value

strangely enough implied lupus vulgaris. His formula

of iodine with
to
a

of

twenty-four grains
to to

an

ounce

of

starch, the iodine

and dried bottle. the starch
a

be be

triturated added and

little water,
mass

slowly,
in he
a

the

to

be

by

gentle heat,
use

By

of

this

kept remedy,
used this

close-stoppered
that

claimed

the

largestamount
into the system. with

of iodine I have

could

be most

easilyintroduced remedy freshly prepared,

I think with

great

satisfaction, and
in
cases

great

benefit,
many and with We also

not

only
of
cases

cases

in

lupus vulgaris, but in acne occurring in lymphatic subjects, chronic where syphilis is combined
to

of

struma.
come now

of cutaneous treatment specific tuberculosis, and the method promulgated a year ago which Koch, is the only one seems worthy by Robert of tuberculin of discussion. As the precise action to in tuberculous and healthy subjects, there are many questions of greater or less scientific importance which unsettled, but sufficient time has elapsed as yet remain sufficient experience has and been acquired to enable of therapeutics to form at an unprejudiced student least an opinion, if not a definite judgment, upon this the

novel

method

of treatment.

60

In

Europe,
a

according
remarkable

to

the

various

published

ports, re-

lowed diversity of results has folthe of lymph injections in the employment As of tuberculosis. treatment geographical locality influence the uo therapeutic can certainly exert upon of science method in question, and as men profess to brotherhood aud Fatherland, one acknowledge but one such it is simply astounding that tions conflicting observamost

should the Rhine.

have While

been
some

made will

upon

different this

sides

of

explain

diversity of

national to pride and national opinion by reference from a perhaps conclude enmity, others may study of the published reports, that Koch's lymph is a divine death to German, but sure remedy for the tuberculous the tuberculous In has this Frenchman. the introduction
a

country
followed

of

Koch's reaction.

method The

been

by

most

decided

the startling went fairly wild over public press, which a now paragraph to a novelty, would scarcely devote The of its value. numerous dispassionate statement of the members thronged our public profession who jection, at a simple hypodermic inhospitalsand gazed in awe fabulous offered or prices for a few drops of with the lymph, are busied remedies, and now newer offered at ten cents would not buy the lymph if it were affect But this does in the least the not a gallon. tuberculin is or is not a remedy question as to whether of tuberculosis. of practical in the treatment value The experience of physicians in this country, where national feeling plays little or no part in determining of exthe final judgment in the matter, ought to prove ceptional value, and the expressed opinion of members of will side this

Association,
serve

however medical

various

it may
on

be,
this

doubtless of the
own

to

mould

opinion
of tuberculin

Atlantic.

My

experience

in

the

use

has

61

been York

limited

to

few

cases

in

my

service

at

the

New

Skin

few

by

Dr.

garis, Hospital, including lupus vuland leprosy, while lupus erythematosus, sarcoma of my more patients were kindly treated for me Kinnicutt, at St. Luke's, and Dr. Bailey, at the
cases

and

Cancer

These include Hospital. only of both forms of lupus, but also of eczema, and syphilis. I need not give detailed of any of these cases, but will simply speak the general results attained conclusions aud None of the

Post-Graduate

not

lioma, epithehistories

brieflyof
formed.

alarming
my
to
or

effects

reported by
from of small the

occurred I limited
one

among

cases,

probably
use

others many the fact that

myself milligramme,
very
nervous

the
even

doses, injecting
outset, and

less, at
ten
or

rarely

increasing the
In
one

dose

above

fifteen

milligrammes.

lupus patient with erythematous of the cheeks, the followed first injection was by an attack of hystero-epilepsy, the patient having a series of rather severe opisthotonotic convulsions during the hours. That the lymph, however, succeeding twelve direct the of these not was caute unexpected symptoms,
sions convullater by a series of milder proven which A followed the injection of pure water.
was

somewhat the the that the second

remarkable
or

subnormal

temperature

followed

third

tubercular the careful be

of leprosy of injection in a case the house-physician asserting type, of

a

use

reliable

thermometer

showed

figure to
In my the

94".
cases,

lupus

to

which

I shall reaction

restrict occurred the

was

my in

marks, rea

local but
no

and mild

general
curative

characteristic
two

form, but with

effect

exception
been

of

cases,
one a

decided

produced.
ployed em-

In

of

these,
time

vigorous
before,
which

curetting
aud the

had

short

of pinkish nodules group iu character. Reaction

occurred

presented a were largely cicatricial after the first inj*"*-

cheek

62

tions

and
was

then

ceased.

In

this

case,

though

the

could In treated burr and made

discharged as justlybe awarded

case,

cared,
to
a

bat

the

little if any action of the lymph.

woman

patient credit

another
for

of of the

young
nose,

whom the
a

had

lupus

and

without

affecting a

simply with complete cure,

occurred from

dental

decided
at

improvement
Post-Graduate
and

steady injections

the

flattened

cicatrix, and
the

small ules nodHospital. The gested disappeared, leaving only a confew a suspicious points. During

past few
but

months,
watch have the

however,
case

in which

have these

done
picious sus-

nothing
to

with the

interest,

points
be

faded, and

This permanently cured. been more speedily cured by curetting and the noticeable acid, but a more pyrogallol or salicylic would In doubtless other
no cases

lupus now appears patient might have

use

of
scar

have of

been

left. under my occurred aud

care

lupus
a cure

or

tion, observa-

approach to repetitionsof
reaction
as

both

local

erous spite of numgeneral reaction.

in

When

ceased
or

altogether,and
even

the than

lesions
at

peared apset, out-

prominent
natural and
to

more

so no

the had

it

was

conclude Koch's failure. I believe

some cases,

that

good
to

been
cases

accomplished
at
a

that
a

method,
I wish that

in these condemn results

least, had

proved

such have
were

hasty conclusion, been accomplished

not

for in

good
first

although they
The
case

apparent

injected in patch involving

She
and had been

upon New

the surface. York

ear was a a

of

lupus
a

young

woman

with

the

and for

portion
months

of
at

the the

cheek.

treated

several

Skin

but Hospital, with slight improvement, and St. Luke's, at was care placed in Dr. Kiunicutt's For month the for lymph treatment. of a prospects the reactions brilliant, as were a were speedy cure

Cancer

typical

and

decided, and

improvement

began

to

maui-

64

vulgaris. Id in producing
by
effected.
a

this disease
a

the

lymph

worked

promptly
lowed foland

superficial, temporary notable flattening,loss

a

inflammation,
of But will

color,
no

provemen imwas

within He other
asserts

few that

weeks. the

cure

lymph

not

take

the
must

place
still be

of

remedies,
and adds
manner

placed,
in

which upon that it remains and combination

to

reliance

yet
what

to

be

termined dea

what

degree
method

methodic with

alternation

and

of

Koch's

geous advantapreviously employed, may prove that Neumann in the therapy of lupus. states in the a repeated injections exert majority of cases lupus tissue, obtained specificaction upon by no other method heretofore of treatment employed, and the use of the of lupus produces cases an lymph in certain and localities effects in many a improvement, cure. He
test

those

add

that

from

henceforth

no

will specialist old

fail

to

tuberculin and

before

cauterizing
other method

resorting to the claims scraping, and

he succeeded in

methods with

of
no

that* four

has
an

months
cases as

in has

effecting such
resulted from
of

in certain improvement the lymph injections. In Universities

on

the the

official of
are

report
Koch's received

the

Prussian for the

action

remedy
from of

tuberculosis, favorable

reports

dermatological
u

clinics.

Doutrele-

pont,
the under

Bonu,

statements

says : of Koch.
of

Our
.
. .

observations Our

fully confirm
cases

lupus
The
. .

all heal of
one

the

use

Koch's Koch's

tuberculosis

by
all

remedy. lymph is

treatment
as

to

be considered both
as

surpassing
of
treatment

previous methods, and the beauty of

to

the

length
In fault de-

the

resulting scars."
decide? such authoritative for arrive each
at
an

When of
sources a
as

doctors

disagree,
been

who

shall from it

unanimous have

verdict

mentioned,
for

remains
to

to

tett

Koch's

remedy
conclusion.

himself, and

independent

il

Pf
"!
"i

? I
"

I linifHpfhif fffSlI"M?6l
"

"

stint

III

II

1
III
Hi

ill
llfp
liii J

Sir
?li
sf-L
"fljfS

ip ills I

II fli f -lU"

ft I?
"

lilf-i
?
!

S
*