Chapter 4

However it will certainly be possible to produce still better results with Koch's method of treatment, especially in the restoration of the functions of the afflicted parts. Here, as in all tuberculous affections, it is particularly essential to subject the respective case to treatment in as early a stage as possible and before incurable destruction of the tissues of the bones and joints have been caused.

A certain disease of the skin called _lupus_ (ringworm) must be counted in with the number of diseases generated by the tubercle-bacillus.

Lupus may begin in two different ways. Either in the form of a purple spot, which is raised above the level of the skin and which has no definite limits but blends with the healthy parts; or as a slightly raised, moderately firm, darkred grain, sharply limited and about the size of a pinhead or millet seed.

If the disease has begun in the shape of spots, the afflicted portions of the skin gradually swell during the process of the disease. Several isolated knots appear around which the disease spreads more and more.

While the disease thus takes possession of greater area and developes new centers, a uniform scaling off of all knots begins.

After prolonged existence, sometimes after short duration, decay and casting off of the epidermis in its entire thickness supercedes the scaling process, and suppuration transforms the ringworm into an ulcer covered by a dirty-brown rind and disagreeably colored serum.

The ulcers of lupus are of various, generally irregular shape, the rims not hard, the ground flat and covered with purulent matter and decayed tissue; they are commonly surrounded by a faint reddish areola. These ulcers gradually become epulotic and form irregular, generally slightly protruding white scars in which new tubercles may appear.

Lupus appears most frequently in the face and especially frequent on the nose. Sometimes its appearance is indicated only by an inflammation and swelling of the mucous membranes of the nose and at the same time a reddening of the epidermis. The nostrils are stopped up by a thin rind which, if torn off, is replaced by a thicker one below which an ulcer is formed that spreads with greater rapidity on the mucous membranes of the nose than on the external epidermis of the same.

Sometimes the whole process on the nose is so rapid, that very often the physician is not called to the patient, before a large part of the wing of the nose or of the nasal epidermis is destroyed and deep ulcers have developed under the rind. New tubercles of lupus are commonly noticed to spring up on the margins of these ulcers; the cartilage as a rule resists the progress of the disease for a longer period and may be unhurt, while the skin on the wing of the nose may be completely destroyed.

Frequently the process is extended to the mucous lining of the hard palate and to the gums. Lupus generally appears on the lips in the same manner as in the nose. The upper lip especially appears very much swollen and covered with ulcers after a prolonged existence of the affection. Sometimes even the aperture of the mouth itself is reduced in size by the development of ulcers and scars on the surrounding parts.

If the process extends to the lower eyelid, the connective tissue as a rule becomes much swollen and reddened. The malady especially attacks the inner angle of the eye, destroys the entrance of the lachrymal duct, and from there the lupous tubercles appear on the connective tissue. Gradually tubercular formations develop on the cornea and sight becomes impaired.

On other parts of the face lupus generally appears in the form of small knots, about the size of millet seeds, which remain for a time then multiply and spread. The epidermis swells between these knots and irregular ulcers develop on a hard swollen and glossy ground, and are covered by dark brown rinds.

Tubercles appear anew on the margins of the ulcers and in the spaces between them, isolated whitish spots of sunken or raised scab tissue are observed on which very frequently lupous tubercles again develop.

Lupus appears on the throat, neck, back, breast, and the extremities, most frequently in serpentine form i. e. swellings of the skin develop, being arranged in curves, they progress in the same manner, these are transformed into just so many ulcers. Between these whitish scarred spots are noticeable on which small red lupous tubercles again appear.

Lupus is more frequently found on the extremities than on the trunk. The surface of the skin is found to be tense and glossy on a firm base which is affected by lupus.

Deep ulcerous formations of lupus are sometimes observed on the fingers and toes, particularly on the finger-joints, these may at times penetrate into the inner parts of the joints, secreting whitish pus and covered with a thick rind.

As regards the difference between lupus and syphilitic diseases it has been found that lupus commonly developes before puberty while syphilis appears in the mature age.

The ulcers of lupus are often round like those of syphilis with sharply defined margins, but at the same time they are flat accompanied by little or no pain; rim and base of the same are loose, red, rank, and bleed easily. On the other hand syphilitic ulcers are very painful and rim and base are covered with greasy matter.

Lupus appears only in the form of knots, which are deeply inbedded, from size of a pinhead to that of a lentil, but never as large knots in the beginning. Syphilis produces large and palpable knots from the start.

Loss of the bony part of the nose or destruction of the hard palate are observed, but rarely and after protracted existence of lupus, and often in the case of syphilis.

The indicated peculiarities however refer only to typical cases of lupus and of syphilis. In other cases it was almost impossible to show a difference.

As regards the course of lupus, the same begins, as has been stated before, in earliest childhood, sometimes only in the form of scaly spots and knots. Less often lupus developes after complete development of manhood. It is more frequent with women than with men. Sometimes some of the knots remain isolated and disappear again after a time; in other cases additions appear in the course of time, which may affect larger portions of the body and lead to more or less dangerous ulcers. As a rule the course of lupus, even of great extent, is not malignant and at the most the alliance with _traumatic erysipelas_ and possibly the appearance of _pulmonary consumption_ may succeed the affliction. In cases of not too rare occurrence it has been observed that lupus has developed into _cancer_, which has always resulted fatally.

The _treatment_ of lupus has principally been a _local_ one. Caustics were applied to destroy lupous tubercles by direct action, and furthermore recourse has been taken to the so-called mechanical treatment, in which the ringworm was scraped out.

Our experiences relating to the mechanical treatment of lupus have taught us the following.

Lupus can not be cured without destroying and removing the diseased and affected tissue. That method which effects the most radical destruction, protects most from relapses. Therefore the best method of treating lupus is to cut out the diseased skin. But with the superficial spreading peculiar to many cases of lupus this method can only be applied within certain limits. Then again the secondary growths after an operation may be of serious consequences.

Unfortunately it has not been possible before this to remove all diseased portions, no matter what method was applied, because often tiny lupous tubercles spring up which are almost invisible to the naked eye. These tubercles will again be the starting point for another spreading of lupus.

We will see that Koch's new method to cure has the advantage both to make visible all tubercles, even those that have escaped our notice and also to effect a cure in the shortest time even in old chronic cases that have before this been considered incurable. It is especially possible in this form of tuberculosis to follow the specific action of the new remedy, as we will learn later on.

_Tuberculosis of the testicles_ is not so very rare, it is found in about 2-1/2 per cent. of all men afflicted with pulmonary consumption. It is more rarely met with in children than in men.

The conditions under which tuberculosis of the testicles and epididymis developes are various inflammatory processes with existing disposition. It is mostly gonorrhea or some other inflammation of the urethra, or injured testicle. It occurs less frequently without any apparent cause.

According to the starting point of tuberculosis the symptoms are varied. If it starts in the testicle, this appears normal or larger in size, but never reaches extraordinary dimensions. The surface of the testicle is at first smooth in the case of increased tension, later only does it become irregular, bumpy and of unequal consistency.

If the starting point is in the epididymis, hard, rounded lumps are formed generally in the head or tail of the epididymis, rarely in the body. These increase in size and cause a swelling often of extraordinary dimensions, the surface of which appears hard, irregular, bumpy and in certain parts yielding and elastic. If the process is extended to the testicle, this also increases in size. Then both together form an oval swollen mass and can not be distinguished from each other.

Striking changes appear only later and consist in the softening of the lumps and in the development of abscesses.

Very soon the lobuli are affected. The same are then thickened in the septa, are hard and form an irregular, bumpy swelling surrounded by more or less thickened tissue.

Very soon tuberculous changes are caused in the prostate gland, an organ situated near the intestine and the functions of which are to dilute the semen. A hardening is often the first sign, this is followed by increase in size and then softening.

With the affection of the prostate gland, that of the urethra also begins, which passes through the middle of the prostate gland. This disease often appears in the form of a yellowish secretion, which is more and more increased and becomes ichorous with the decay of the urethra and the prostate gland. This secretion must be distinguished from that which as a venereal affection caused the whole process. The tubercular derangements do not only extend forward but also upward. The bladder, the ureters and the kidneys are affected and show extreme derangements with altered urinal secretions and excretions.

Of other symptoms of tuberculosis of the testicles pain deserves especial mention. The same is slight in the beginning, but often becomes insufferable.

The symptoms here related often increase very slowly. Essential changes are caused during the chronic course of tuberculosis of the testicles if suppuration sets in. The skin is perforated and fistulae are formed. If there is no halt in the process, general tuberculosis results and this has until now always caused death.

According to the time in which the general derangements come about, a chronic and acute tuberculosis of the testicles has been distinguished. The former is the more frequent, the latter of rare occurrence.

The sexual functions may remain unchanged if only one testicle is diseased, but are generally ruined if both epididymes are affected, because the secretion of the semen is then interrupted by the stopping up of the vas deferens. In some cases the sexual function may be interrupted for a time only and may then be resumed.

The treatment before this has been surgical, in which the diseased parts were carefully removed, and where this was impossible, even castration (removal of the testicle) was performed. Without doubt Koch's method will cause great changes in the method of treatment here also.

Finally we must include in our reflection the well-known disease of children, _scrofula_. Although the same is not a form of tuberculosis in the sense of the diseases just considered, still tuberculosis and scrofula have the most intimate relations. Scrofula is only too often a precursory stage of tuberculosis.

The manifold scrofulous affections, such as inflamed eyes, diseased ears, skin diseases, catarrh of the nose, pharynx or bronchials, inflammation of the joints and suppuration are not caused through the cooperation of tubercle-bacilli. But here the same find an excellent soil for growth and propagation, and they use the same to the full extent and so give the impetus for the development of tuberculosis.

Scrofula is one of the most frequent diseases, it is spread over the whole world. It occurs more seldom in the tropics than in the north. Furthermore it is more frequent in a cold and damp climate than in a dry one. Elevation has no influence on the development of this disease. Scrofulous individuals are found in the mountains as well as in the plains.

Scrofula principally attacks children; it occurs most frequently in the time from the second to the fifteenth year. Rarely earlier developed scrofula drags beyond the age of puberty or more advanced manhood. Sex has no particular influence on the development of scrofula.

In many cases this particular disease is _inherited_. The following causes are considered in the inheritance of scrofula: great age, close relationship and infirmity of the parents; but the germ of scrofula is planted in the child by parents that are themselves afflicted with tuberculosis or scrofula. This is most frequently observed in children that have descended from parents, who were scrofulous in their youth and remained so, or that became tuberculous later on and at the time of generation were afflicted by advanced scrofula or tuberculosis, or that were suffering from oft-treated but never entirely cured syphilis. Some scientists claim to have observed the inheritance of scrofula by children, whose parents at the time of generation were afflicted with tuberculosis or were suffering from general debility resulting from hunger and want.

In the majority of cases scrofula is acquired, as a rule the development of this disease is favored by indigence and poor hygienic conditions according to the coinciding experience of all scientists; _nutrition_, especially in the first year of life, has the greatest influence on the origin of scrofula.

In _infancy_ the most frequent cause of scrofula is the premature giving of _farinaceous_ food besides the mother's milk, or the feeding of children with so-called pap, especially when this is done in the _first month of their life_.

In later months the excessive eating of bread, potatoes or vegetables instead of milk has an injurious effect.

Furthermore the development of scrofula is favored by the breathing of _foul damp air_ such as is frequently found in newly built or damp houses and also by _deficient care of the skin_.

Scrofula thrives in the narrow tenement dwellings in which is found a close, overheated, foul air pregnant with smoke, kitchen fumes and mustiness from the damp walls.

Frequently the development of scrofula has been observed to succeed measles, diphtheria, scarlatina or whooping-cough.

The opponents of vaccination also designate vaccination as a frequent cause of scrofula. It is supposed that a poison is transferred into the system with the lymph which is enabled to generate the phenomena of scrofula. However the supposition has not as yet been proven.

Of course the fact cannot be denied, that cases of developing scrofula have been at times observed as succeeding vaccination. But the circumstances are the same as in the case of the contagious diseases mentioned above. No one will probably maintain that in those cases in which the development of scrofula had been succeeding those diseases, that this has resulted from a poison generated by the preceding disease.

The attempt to designate symptoms by which to recognize a scrofulous constitution has at all times been made. Many physicians have for a long time distinguished a _torpid_ and an _erethistic_ scrofulous constitution.

With a _torpid_ constitution the body is pale, spongy and bloated, the nose and lips are thick, the abdomen swelled, there is plenty of fat and but weak muscles. Such children are indolent, at times peevish and indifferent, they do not sleep quietly, have no appetite or may be voracious and suffer from derangements of digestion. An examination of all organs indicates no change. The children are easily afflicted with eruptions of the skin, with inflammation of the eyes and ears, and catarrh of the mucous membranes, which are characterized by great obstinacy. The derangements in nutrition here described are caused by the lymphatic glands though a swelling of the same can not be found.

In the case of _erethistic_ scrofula the children are found to be of slight and lean structure, with fine hair and long eyelashes; they are active, easily excited, gifted and extremely sensitive to physical pain. The face is pale and becomes easily flushed by physical or emotional excitements. They are easily subject to palpitation and short breath; and are attacked by high fevers from the slightest reason. The lymphatic glands, especially the deepseated ones, are as a rule more or less swelled.

In most cases, however, the characteristics of these two forms are blended.

The phenomena of scrofula are manifold and extend over the entire body.

The _skin_ is frequently the seat of scrofulous affections. These are particularly found on the head and face and are characterized by great obstinacy and tendency to return.

Most frequently herpes appear, the parts especially affected are the scalp, face, auricular passages, eyelids and the nose with its surrounding parts.

Pustules are sometimes developed under the skin and may appear in great numbers. These pustules may either break through the skin or shrink into a caseous mass.

Of all _mucous membranes_ that of the _nose_ becomes most frequently diseased; in a great number of cases this happens in the form of a chronic catarrh; the mucous membrane of the nose is reddened and swollen and a profuse, thick, purulent, ichorous and easily drying fluid is secreted. Often the external parts of the nose are swollen as a result of the catarrh and the nostrils are stopped up with thick yellowish-green rinds. Inflammation of the skin is caused by the flowing out of the purulent and ichorous liquid secreted.

In many other cases the disease appears in the form of scrofulous ulcers on the mucous membranes of the nose; in such cases it is found that the nose is stopped up with numerous yellowish brown crusts; after removing the same the mucous membrane appears swollen and moderately reddened, on several places ulcers, the size of lentils, are found which are covered with a yellowish gray coating. At the slightest touch bleeding of the nose is caused; often also the external parts are reddened and swollen. In such cases erysipelas frequently developes, starting from the nose and spreading over the whole face. Frequently a repetition of erysipelas occurs.

The scrofulous catarrh just described is generally of a very protracted nature and is marked by many relapses. Sometimes the fluid secretion of the nose is of very bad odor.

The mucous membrane of the _throat_ becomes diseased at the same time as that of the nose. The same is found to be moderately reddened and swollen; the lymphatic glands especially those on the posterior wall of the throat are increased to swellings the size as large as peas. The _tonsils_ also become inflamed frequently and become enlarged through the repeated rather chronic inflammation.

_Inflammations of the ear_ are a common occurrence with scrofula. These originate most frequently by means of the eustachian tube, which connects the ear with the back part of the mouth as a result of the catarrh of the nose and throat. In a majority of cases the inflammations of the ears lead to perforation of the tympanum and may even result in fatal cerebral meningitis.

The _eye_ is as frequently affected by scrofula. Swelling of the lids and inflammation of the glands are the lighter forms. Pustules on the connective tissue of the eye and on the cornea, accompanied by photophobia, cramp in the lids and flowing of tears are those severe forms that are so frequently observed in scrofula, and that often leave opaque and incurable spots on the cornea of the eye.

Swelling of the _glands_ has at all times been a characteristic phenomenon of scrofula. A swelling is merely the result of diseases of the mucous membrane of the throat or nose, of herpes of the scalp or face, of inflammations of the ears, eyes, periosteum, bones, etc. In the beginning the swelling of the glands is painless and results in flat swellings of about the size of filberts, which may be moved back and forth; such glandular swellings may exist for years, without showing the slightest alterations.

With renewed attacks they enlarge and may become of considerable size. At times single glands become inflamed, hurt when pressed and develop abscesses which perforate the skin after it has become inflamed and reddened.

These abscesses may heal within a few days. In the majority of cases, however, they remain for a longer period, months and even years and result in the well-known tumid, hard and immovable scars.

Inflammation of the periosteum and of the bones is one of the instances of scrofula. Most frequently _spina ventosa_ is found; the same consists of a gradual, painless swelling of the diseased bones, most frequently on the fingers and toes, so that they become bottle-shaped. The skin covering these swellings is pale and tense. The swelling may gradually disappear or begin to suppurate. Besides this hip- and knee-joint inflammation are observed, also inflammations of the ankle, elbow-joint, spine, etc.; especially in the case of diseased bones it is extremely difficult to fix a dividing line between scrofula and tuberculosis.

The frequence of anaemia with scrofula is only a _result_ of the disease and not a symptom. As a result of scrofula nutrition and assimilation become impaired, mostly in the cases of extreme suppuration.

Scrofula is a chronic disease. In many cases it is completely cured, the lighter cases after several months and the more malignant after several years. Extreme scrofula may often remain until puberty and may be completely healed.

_Fatal_ results are due to scrofulously diseased bones, joints or glands, and it can not be denied that a large number of children succumb in this manner. Fatal results may also be due to additional diseases, such as pneumonia, pleurisy, intestinal catarrh, etc.

It has been frequently observed that _tuberculosis_ succeeds scrofula. It is a well-known fact that scrofula furnishes the largest contingent for tuberculosis.

As a precautionary measure against scrofula a careful regulation of the diet is recommended. During the first nine months of life children should be fed with human milk exclusively if possible. If scrofula is hereditary in a family, or if the mother exhibits symptoms of the disease, she should not be allowed to nurse the child but a strong and healthy nurse should be engaged. Recourse to artificial nourishment must only then be taken, when nursing the child is absolutely impossible. For this purpose exceptionally pure cow's-milk ought to be selected. All substitutes, that appear under various names, such as infant's food, condensed milk, etc., contribute much toward the development of scrofula.

Children 1-2 years of age are to be fed with milk, meat and eggs. Only strong children, that show no sign of scrofula may be fed once or twice a day with small quantities of rice, tapioca, sago, green vegetables, pulse, etc., beside the food above mentioned.