4. SCROFULODERMA

Formerly this term was applied to all those various peculiar and
suppurative and ulcerative conditions of the skin occurring in strumous
subjects. While this still holds to a limited extent, it is now chiefly
restricted to the sluggish ulceration or involvement of the skin resulting
by extension from an underlying caseating and suppurating lymphatic
gland. Occasionally, however, it appears to have its origin as subcu­
taneous tubercles independently of these structures. Arising from the
former, the gland or glands, usually the cervical, are noted at first to be
somewhat swollen, sometimes attaining many times their normal size.
While they may be hard at first, they soon soften, and as the overlying
skin is distended, the latter becomes of a dull-reddish or violaceous hue.
In occasional instances, after reaching this stage, they gradually disap­
pear by absorption. Usually, however, the caseation and suppurative
changes finally involve the skin, which may show one or more points of
softening and destruction, resulting in the formation of sinuses which
lead down to the underlying diseased glandular structures. When this
ensues, more or less flattening takes place, and when the process is thus
advanced, the area is noticed to be of a purplish-red color, with pea- to

¹ See Pringle’s remarks supplementary to a report of a case by Cahill, Brit. Jour.
Derm., 1895, p. 1, reviewing the models of the malady in Baretta Museum, Paris.

718

NEW GROWTHS

dime-sized ulcerated openings, and the sluggish inflammatory infiltration
extending slightly beyond the immediate area of disease. The skin, once
thus involved, the process extends superficially, implicating the surround­
ing integument, often to a considerable extent. The intervening islets
of purplish-red, weakened skin occupying the original area often break
down completely, and the scrofulous ulcer is formed. This may also
result without much invasion of the adjacent integument. If be­
ginning as a subcutaneous nodule, independently of the lymphatic
glands, the induration increases in size in all directions, attaining the
dimensions of a large cherry or walnut (tuberculous gummata), then under­
going about the same changes noted when the glandular structures are
primarily involved; the skin breaks down over almost the entire mass, or
first at several points. Doubtless some of the cases of erythema indura-
tum represent this particular variety. In rare instances, too, after reach­
ing the size of a marble or pigeon’s egg, or larger the process remains
more or less stationary with practically no tendency to active destruct­
ive changes, sometimes undergoing gradual absorption, and disappear­
ing. Such growths may appear on almost any part of the body, their
nature at first often being unsuspected.¹

Instead of a preceding deep-seated nodule or gland enlargement,
there may appear one or several superficial pin-head­ to small pea-
sized indurations, which soon become pustular and enlarge peripherally,
forming a fairly large, flat, often irregularly shaped, yellowish or brown-
ish-yellow, flat, thin, crusted pustule, with an areola of a dull red or
violaceous color. The crusting is slow in formation, beginning centrally,
and quite scanty, entirely unlike that seen in the large flat pustular syphil-
oderm, which it slightly suggests. As the crusting takes place the lesion
may extend peripherally; or if two or three are in close proximity, coal­
escence sometimes ensues. On removing the crust, the superficial,
irregular edged, granular-looking, scrofulous ulcer, with uneven base
covered with thin purulent secretion, is disclosed. Their course is slow,
and they may remain for months; healing is followed by soft and super­
ficial scars. They may appear upon any region, but in the several cases
under my care were on the upper part of the breast or neck. This type
is that designated by Professor Duhring as the large flat pustular scrofu-
loderm.

The process rarely extends deeply; even when beginning in the glands,
the subsequent course after destruction of the overlying integument
is laterally, rather than deeply, although this latter can take place when
the caseating and suppurating glands or nodules are quite large (scrofu­
lous gummata, scrofulogummata, tuberculous gummata, tuberculides
gommeuses of the French). Involvement of the lymphatics, especially
when these tuberculous gummata are on the lower extremities, occa­
sionally is observed, lymphangitis resulting, and sometimes elephantiasic
enlargement.

The ulceration is usually superficial, has thin, dull red or purplish,
undermined edges, as a rule irregular in outline, and has an uneven

¹ A remarkable case is reported by G. W. Wende “Nodular Tuberculosis of the
Hypoderm”, Jour. Cutan. Dis., 1911, p. 1, the growths appearing first on the scalp.

TUBERCULOSIS CUTIS

719

base with sluggish granulations covered scantily with pus. Its spread
is generally gradual, and there is but moderate, and sometimes extremely
slight, outlying infiltration. Occasionally there is a tendency to heal
and form here and there weak cicatricial tissue; this is observed some­
times when the overlying skin has suffered only irregular and incomplete
destruction. In such cases, in some instances, there is later developed
a tendency in the outlying skin to the formation of lupus tubercles, and
the disease may later even assume the partial or complete clinical aspects
of lupus. As a rule, however, the practical absence of infiltration, the
weak, sluggishly red skin, with the violaceous hue and the superficial
ulceration typifying this variety of cutaneous tuberculosis, are maintained
throughout. Occasionally temporary crusting is noted. In some in­
stances, after the glandular structure softens and breaks down, the re-
parative process gradually sets in and healing finally takes place. Or the
caseating and suppurating glands, with the several resulting sinuses,
may continue almost indefinitely, the sinuses closing up now and then,
the disintegrating tissue and secretion collecting beneath and again
finding exit.

The condition is usually one of childhood and adolescence, and is
commonly associated with other symptoms of a tuberculous nature,
such as keratitis or its scars, chronic otitis, bone or joint disease, etc
It not infrequently follows in the wake of some severe systemic disease.
In old people, in whom the manifestation is rare, after ulceration results
a papillomatous or verrucous tendency sometimes develops, and the
picture of lupus verrucosus or tuberculosis cutis may be presented; or
later epithelial degeneration may set in. The course of this form of cuta­
neous tuberculosis is slow, but it usually responds rapidly to appropriate
treatment, which is practically the same as in lupus and other forms.

But first, if you want to come back to this web site again, just add it to your bookmarks or favorites now! Then you'll find it easy!

Also, please consider sharing our helpful website with your online friends.