MILIARY TUBERCULOSIS OF TIIE SKIN. —This disease, according to Kaposi, is much more frequently met with than one would be led to suppose from the pub lications upon the subject, since he has seen twenty-two cases in his clinic and others in private practice. Clinically it is a well-defined disease, to be distin guished from lupus and all other tuber culous affections of the skin. It occurs almost entirely in individuals suffering from some other form of tuberculosis, usually of the lungs, but by no means only in the last months of life of such persons or in acute miliary tuberculosis of internal organs. Tuberculosis of the skin is very often associated with a like affection of the neighboring membranes, primarily or secondarily. Spontaneous healing may take place or it may follow appropriate local treatment.
Many of the cases are distinctly trace able to autoinoculation, while in some the inoculation seems to have originated from without. Whatever be their origin, they are due to the introduction of the tubercle bacillus into the skin. The cutaneous manifestation is often inaugu rated by an intense itching, which the tuberculous patient scratches and prob ably inoculates. Warty or papillomatous granulations then appear, which spread superficially, become ulcerated, etc., and otherwise assume a character recalling lupus. This form may proceed to spon taneous healing after a few months, and is apt to yield with more promptness to the measures indicated for lupus (q. v.).
On July 27. 1901, Dr. G., while per forming autopsies on two cows. the sub jects of experimental tuberculosis, wounded the flexor surface of one of his wrists. By September 10th there was a nodule in the skin at the scat of the wound, measuring 15 by S centimetres. This was excised on September 14th. Portions were inoculated into two guinea-pigs, both of which developed gen eralized tuberculosis. Sections of the nodule showed the characteristic histo logical picture of the tubercle and also large numbers of typical tubercle bacilli. Ravenel of Penna. Medical
Bulletin, Feb., 1902).
Lupus Vulgaris.
This affection is now recognized as a tuberculous lesion of the skin or mucous membrane, or both, which may proceed to ulceration (lupus exedens), observed in young from infancy to about the thirtieth year—or not, lupus exfoliativus, in which thin scales are thrown off from the lesion, also a tuber culous one.
Symptoms. — In both varieties lupus begins in the form of yellowish-red or copper-colored projections or blotches varying from the size of a to that of a split pea. At times these blotches disappear under pressure (lupus plan). When in the form of tuberculous nodules, they may, though rarely, become aggregated into patches which, by co alescing, in turn cover extensive sur faces; but, as a rule, they do not; they are indolent, soft, and elastic, and some times slightly sensitive to pressure. When they become the seat of several blood-vessels, they assume the form known as the myxomatous lupus, and, when exceedingly vascular, the angioma tous lupus. Their progress is exceed ingly slow. When the tubercles break down and ulcerate, they become covered with scabs, overlying a bed of sanious pus; under this the ulceration gradually extends, eating its way in all directions. The neighboring tissues are slightly tumefied, and a narrow, reddish areola is usually present. After a certain time, the ulceration involves the deeper struct ures, and all carti laginous, tendinous, etc.—are gradually invaded. The mucous membrane of the nose, mouth, pharynx, larynx, and the conjunctiva are often gradually included in the destructive process. and deformi ties cf the nose, mouth, lids, etc., result. Unfortunately, this terrible disease shows a distinct predilection for the face, though it may also develop in the skin of the limbs, buttocks, and trunk. Again, the ulcerative form almost invariably at tacks the nostrils, internally or exter nally, destruction of this organ being but a matter of time unless the disease is mastered.