TUBERCULOSIS VERRUCOSA

The disease begins as one or more pea- to coin-
sized, distinctly circumscribed, round or oval, reddish
papules. Several may coalesce to form a patch of an
irregular or even a serpiginous configuration. The
surface of the lesion soon shows a tendency to be-
come knobby and furrowed, and the more prominent
parts of the growth between the furrows assume at
first a smooth warty and later a papillomatous ap-
pearance. The papillomata may be fine, pointed
and horny, or broad, flat and sclerotic. In the more
advanced lesions there is nearly always considerable
secondary pyogenic infection, and slight lateral pres-
sure will cause pus to well up between the papillæ.
Sometimes the pus dries to form superficial crusts.
The inflammatory element is often represented also
by a more or less bright red, erythematous halo
about the growth. The growth itself is usually a
duskier or brownish red. Occasionally the whole
lesion becomes acutely inflamed, swollen and pain-
ful, but that is exceptional. As a rule the disease
causes no subjective sensations. A plaque increases
in size very slowly by the accretion of new lesions
at its edge. In the great majority of cases the con-
dition persists indefinitely. There is no tendency to
ulceration. Sometimes resolution occurs. It usually
begins at the center of the lesion. The scar left is
smooth and scaly. The backs of the hands are the
favorite sites of the malady, though it may occur on
any part of the body. It is thought to be due to
a surface infection with the tubercle bacillus, which

would account for its relative frequency upon the
hands of butchers, pathologists, and all those whose
occupations bring them in contact with tuberculous
material from cadavers or from living subjects. The
lesion in this location is often described under the
title verruca necrogenica or anatomic tubercle.

**DIAGNOSIS:** *Syphilis tuberosa* may look like the early stage of tuberculosis verrucosa cutis, but the syphilitic lesions are less chronic, more deeply infiltrated, they spread by peripheral extension and show a much more marked tendency to occur in segmental groups, to coalesce with the formation of serpiginous patches, to travel over the skin, and to ulcerate in some part. Signs of an earlier eruption and the history may assist in the differentiation. *Dermatitis blastomycotica* may so closely resemble the later stage of tuberculosis verrucosa that only a microscopic examination will serve to distinguish them. The simplest method is to mix some of the pus with a drop of thirty per cent solution of potassium hydrate, wait about fifteen minutes until the leucocytes have disintegrated and then search with the oil immersion lens for the budding blastomycetes. **TREATMENT:** The smaller tumors yield very well to cauterization with a saturated aqueous solution of chromic acid. The same treatment may be employed on the larger growths, one section at a time, but these may be much more quickly cured by total excision and skin grafting.