TUBERCULOSIS CUTIS

709

1. TUBERCULOSIS ULCEROSA

This variety, also termed tuberculosis cutis vera, miliary tuberculosis
of the skin, tuberculosis cutis orificialis (and tuberculose ulcereuse of
the French), was at one time thought to be the only manifestation, of
integumentary tuberculosis, cases of which have been observed by
Jarisch,¹ Chiari,² Riehl,³ Schwimmer,⁴ Zeisler,⁵ Kaposi,⁶ and many others.
The disease is almost exclusively seated about or close to the mucous
outlets, from which, in most instances, it can be considered an extension
of an already existing process. The earliest formation consists usually
in the appearance of minute miliary tubercles, which undergo rapid
cheesy softening and ulceration. Cases are rarely seen before the char­
acteristic ulcers are present; these are superficial, sluggishly granulating,
irregularly rounded or oval, the edges soft and but very slightly infiltrated,
and, as a rule, covered with a thin crust which, on removal, discloses
the ulcer floor, somewhat uneven and of an indolent, reddish-yellow color,
with a scanty secretion of a thin, purulent character. They are rarely
painful. One or several may be present, and if the latter, after gradual
extension, often result in coalescence and serpiginous configuration.
There is no tendency to healing; on the contrary, there is usually pro­
gressive extension, sometimes so slow, however, as to be almost imper­
ceptible from day to day. Miliary tubercles can occasionally be detected
upon the surface, especially in the ulcers on mucous surfaces. It is met
with exclusively in those with internal tuberculosis, and chiefly of the
respiratory tract. According to Kaposi, however, its subjects are not
invariably those in the last months or cachetic stage of constitutional
tuberculosis, as generally believed. Contrary to general observation,
Kaposi also states that healing may occasionally take place, either spon­
taneously, which is rare, or as the result of combined systemic and local
measures. Almost without exception, however, the cutaneous disease
is a part of a general tuberculosis which goes on rapidly to a fatal end.
In the light of Kaposi’s experience (22 cases), the disease cannot be con­
sidered so extremely rare as commonly believed.

As to be inferred, the integumentary ulcers are the results of exten­
sion or inoculation from mucous lesions or from the discharges. Its most
common locality is the mouth and about the anus and genitalia. Ehr-

granules, requiring special methods to make them recognizable, may simplify future
study; Krüger’s (München. Med. Wochenschr., May, 31, 1910, p. 1165) experiments
and investigations are more or less corroborative of Much’s work; Friedlander,
“The value of Much’s Granules and the Antiformin Method in Determining the
Ætiology of the So-called Tuberculides, with especial reference to Lupus Erythemato-
sus“; Brit. Jour. Derm.., 1912, p. 13, gives his own confirmatory investigations, and
reviews the work done by Much and others, with references.

The term tuberculides includes not only the above named, but also the frank tuber­
culoses of the skin here to be described.

¹ Jarisch, Archiv, 1879, p. 265.

² Chiari, ibid., p. 269, and Mediz. Jahrbücher, Wien, 1877, p. 328.
³Riehl, Wien. med. Wochenschr., 1881, pp. 1229 and 1260.

⁴ Schwimmer, Archiv, 1887, p. 37 (5 cases).

⁵ Zeisler, North Amer. Practit., Mar., 1889.

⁶Kaposi, Archiv, 1898, vol. xliii and xliv (Festschrift for Pick), “Ueber Miliartu-
berkulose der Haut und der angrenzenden Schleimhaut—Tuberculosis miliaris seu
Tuberculosis propria cutis et mucosæ” (brief review of recorded cases and detailed
analysis of 22 cases under his own observation).

710

NEW GROWTHS

mann,¹ who has observed a number of these cases involving the genitalia,
states that in general there are three modes of origin: (1) By contiguity,
the disease extending from some part of the genital apparatus; (2) through
the blood circulation, tuberculous material from some internal focus
finding its way to the integument of these parts; (3) infection from with­
out, as from saliva of tuberculous individuals—as, for instance, in ritual
circumcision. In the first method the disease may spread along the
urethra on to the penis, or the urethra may excape and be simply the
passage through which morbid material finds its way from tuberculous
kidneys, bladder, prostate, or seminal vesicles.

The diagnosis of tuberculous ulcers is rarely one of difficulty, owing
to the presence of the constitutional affection and often the associated
patches on the mucous membrane. The ulcers themselves are, indeed,
quite characteristic. In doubtful cases, however, microscopic examina­
tion can be resorted to, as the bacilli are usually present in numbers; or,
if necessary, recourse can be had to animal inoculation.

Treatment.—Not much is to hoped for except in those rare
cases referred to by Kaposi, in which the patients are not in the last
stages of phthisis. General roborant and nutritive remedies, especially
cod-liver oil and nourishing food, are the best, and locally mildly stimu­
lating and antiseptic applications, such as silver nitrate stick or solution,
lactic acid, usually weakened with one to several parts water, cleansing
with weak corrosive mercury solutions, and, when advisable, the curet.

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