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.
To prevent scrofula it is essential not to give the food of adults to
children during the first years of life; avoid exclusively solid food
and prepare the same in a pappy form as much as possible. Of course a
proper regulation of meal-time and a careful avoidance of overfeeding is
by all means to be observed.
It is of no less importance for a successful treatment of scrofula to
provide surroundings of as favorable conditions as possible.
First of all _pure air_ containing plenty of _oxygen_. Therefore the
_sea-coast_ is recommended as a proper place for scrofulous children.
The children ought to stay there until the signs of scrofula have
disappeared and the entire nutrition has been improved. The results
obtained in the sanitary stations (vacation colonies) along the
sea-shore for scrofulous children have received much favorable comment.
_Mountain air_ has a similarly favorable effect especially when _salt
water baths_ are used at the same time; even the plain, pure _country
air_ proves beneficial to scrofulous children. _Very dry_ locations and
dwellings ought to be selected. The children should remain _out of
doors_ as much as possible.