The other forms of Tuberculosis.

Of the other forms of tuberculosis laryngeal consumption is very often combined with pulmonary consumption. It is estimated that this is true of at least one-fourth of all cases of pulmonary consumption.

At first laryngeal consumption can not in any way be distinguished from an ordinary inflammation of the larynx. A certain weakness and sensitiveness of the organs however is suspicious, also great liability to hoarseness. On the other hand laryngeal consumption may exist without any sort of ailing to the patient.

These appear later, however, when lung tuberculosis is progressing. The larynx shows more distinct outlines on the lean throat, difficulty in swallowing is experienced, pains radiate toward the ear. Food and drinks come up again after being swallowed.

The painful cough has a hollow, barking, harsh sound, provokes vomiting, and the sputum together with foul breath consists of foamy, slimy, purulent lumps. Breathing gradually becomes more difficult and louder.

As regards the duration of laryngeal consumption it generally runs parallel with pulmonary consumption. If the latter progresses more rapidly so also will the destruction of the larynx by the tubercle-bacilli be a more rapid one and vice versa. In several cases it has been observed that, if pulmonary consumption progressed or remained without any extraordinary symptoms, those with diseased larynx have lived for years, with alternating improvements and diminutions, and also an occasional suspension of all symptoms, till on account of often only a trivial, evil influence a new stimulus is given and the disease found an unexpectedly rapid completion of its course.

Until now only few cases of laryngeal consumption could be looked upon as really cured. Lately it has been tried to accomplish cures especially by the application of caustics. This will not now be necessary. But those afflicted in this way, will henceforth be obliged to try and live in air free from dust, to travel south during the winter and to subject themselves to a general strengthening treatment.

Tuberculosis of the tongue is relatively very scarce. The individual in such a case nearly always shows pronounced pulmonary tuberculosis. Sometimes tuberculosis of the tongue is combined with tuberculous sores on the lips and also on the anus.

Tongue tuberculosis forms small ulcers, generally on the rim, very seldomly on the back of the tongue. They always are very small, generally about the size of lentils or peas. They often remain unchanged for months. At times they are very painful, though as a rule the pain is mild. The male sex is attacked by tongue tuberculosis especially frequently.

The treatment before this consisted in cutting out all the diseased parts; now it will be much simpler.

Nasal tuberculosis appears similar to the common stopping up of the nose. But when ulcers are formed, the secretions from the nose take on a purulent somewhat malodorous character. But if the affection is neglected, the secretion becomes bloody and of very bad odor.

Until now nasal tuberculosis had been treated by applying caustics to the ulcerated portions.

Tuberculosis of the intestines or intestinal consumption is especially found in children. The appearance of the same is already characteristic; the limbs are emaciated and withered; the old-looking wrinkled face shows a harsh contrast with the immoderately expanded body (frog-belly) which is caused by an accumulation of gases in the limp intestines which are then filled to bursting. Many such children have succumbed to gradually progressing emaciation and weakness.

Probably it will not be possible to save all children in the future that have been stricken with this disease as many are wanting in sufficient vitality to resist all external influences.

With adults intestinal consumption makes itself known by everlasting diarrhoea, a result of the numerous ulcers in the intestines which have been caused by the tubercle-bacilli.

Tuberculosis of the brain and of the cerebral membranes also attack children especially. Before this no attempts have been made to try whether it is now possible to cure the tuberculous inflammation of the cerebral membranes which has previously been unconditionally fatal. The decision will certainly soon be made.

We will give a fuller description of the symptoms of this disease to thus enable timely summons of medical interference. This disease will be known to many as "acute hydrocephalus."

As a rule children of 2–7 years of age are attacked by this fearful disease. The antecedents are extremely peculiar and manifold. Even two or three weeks before the outbreak of the real sickness, emaciation takes place from which the face is strangely enough entirely exempt, so that children, when dressed show no signs of a change. Attentive mothers and nurses, however, regularly notice the same and especially the appearance of the ribs causes no little anxiety. With this a slight pallor of the face is associated and a peculiar lustre of the eyes. The children lose their former feeling of gayety and activity. They sleep more than usual, withdraw from their favorite game, they become grumbly and shy toward their surroundings and cry for the slightest reason. It also is very peculiar that they avoid trying their former little tricks, such as climbing up on chairs, opening of door bolts that are almost out of their reach, they even will not try to look through a latticed window and asked to do so, decidedly refuse. Boys, that would not stand anything from their associates, that fought and wrestled as long as their strength permitted it, sneak away cowardly and crying from such attacks. Other children again become extraordinarily tender-hearted and affectionate, they hug their parents continually and can hardly console themselves when they leave them.

In the case of older children that have already learnt something, teachers notice unusual inattention and indifference, committing to memory comes harder than usual and what is finally learnt is recited in an awkward and stammering way. The children sleep unusually much and often by day; on the other hand their sleep at night is less sound and is interrupted by horrid dreams, frequent turning over in the bed and frequent clamorous outcries.

The appetite is lessened, and often a craving is noticed for stimulating food of which, however, little is eaten. Thirst is not increased. Urinal secretion is somewhat diminished and the urine is characterized by a brick-colored precipitate. The stool is rather costive, especially with larger children; but diarrhoea may attend this disease. The latter is principally the case with small children that are in the stage of first teething.

Headache is rarely felt and hardly ever complained of even by larger children; dizziness and unsteady walking is frequently observed. The children quite often complain of stomach-ache, which is very much increased by pressure on the abdomen.

Fever is not generally attendant, but the same may be present.

The symptoms just described, separately or collectively, gradually increase; the children finally take to their bed and now the real cerebral affection developes.

Now the principal symptoms are: vomiting, constipation, slow pulse, irregular abrupt breathing, increased temperature of the skin, contracted abdomen, headache, great excitement alternating with drowsiness, beginning decrease of reason, and deranged ability of moving the limbs.

As regards vomiting, this is almost a continuous symptom and generally appears in the earlier stages. But the duration of vomiting is very different. Some children vomit only for one or more days and not all they have eaten, while others vomit continuously from the beginning of the disease till they are relieved by death, and no food can be found that is not thrown up shortly after its being eaten. In this connection it is a peculiar fact that vomiting will not recur if it has once ceased for twenty-four hours.

Very important for the recognition of the disease is the manner of vomiting. For a child suffering from a spoiled stomach will be troubled with nausea, belching, choking and cold sweat long before it is forced to vomit, while children with acute hydrocephalus will throw up without any previous symptoms of that kind, just as though they filled the mouth with water and spit it out again. Vomiting is facilitated when children are raised or placed on their side. It ceases for the time the stomach is empty, but as soon as fluid or even solid food is taken in it will be cast out at once without causing any particular distress or inconvenience to the child. Gall is very rarely mixed with the vomit.

A second and nearly as constant a symptom is constipation from which nearly three-fourths of the diseased children suffer. As a rule cathartics have no effect and are generally thrown out through the mouth. This constipation will not last till the end, for a few pappy stools appear later on whether purgatives are administered or not. Violent diarrhoea resulting from intestinal tuberculosis may be discontinued at the beginning of acute hydrocephalus. But the later stools will again be thin and of cadaverous odor.

During the latter stages of the disease children will often fail to pass urine for twenty-four hours, so that the physician is obliged to draw it off with a catheter.

The appetite does not disappear entirely as a rule. There may not be any desire for food, but generally little difficulty is experienced in inducing children to take milk or broth, which is all the more surprising as vomiting regularly follows.

The fever is generally not very intense. The temperature of the head, especially the forehead, is considerably increased in all cases and remains so until death ensues, while the feet have great tendency to getting cold.

The pulse is characteristic in many cases. In the beginning of the disease the pulse is quickened only to slacken after a few days. The number of beats may be reduced to 40–60 a minute (normal 90–100), however it does not commonly remain at a certain figure, but varies, often inside of an hour, so that at one time 40, then 60 and again 80 beats may be counted inside of twenty-four hours.

The pulse again increases 1–3 days before death and then to such a rate that it is almost impossible to count it. It may reach 180 and 200 beats a minute. As soon as this rate of the pulse follows one of the reductions described above a speedy death may be predicted.

Of great importance are the variations in respiration. In the beginning stages of the disease breathing is normal except in such case where tuberculosis has made great progress in the lungs and in the case of high fever. Then of course breathing becomes more rapid. Acute hydrocephalus influences respiration in such a way that it slackens and becomes irregular. In one minute children may breath fifteen times, in another thirty, then again 20 times; at one time breathing may be very slight with almost invisible expansion of the chest and without any noise whatever, then again it may consist of deep sighs; these are also characteristic of this particular disease. Sometimes breathing is completely discontinued for ten seconds and more.

If the pulse attains that extreme rate shortly before death the rate of breathing will also be increased.

As regards the skin, the same is generally damp from the beginning of the disease; severe sweats are observed on the head; with progressing disease the skin becomes dry, brittle, comes off in flake-like scales and only when the death-predicting increase of the pulse sets in, there appears a profuse sweat, the cold sweat of death.

Headache is also a prominent and pretty nearly constant symptom. As has been mentioned before, it does not as a rule attend the precursory symptoms. It generally begins with vomiting and soon becomes so violent that older children constantly cry aloud and lament, while the smaller ones put their little hands up to their head, pull their hair and ears and restlessly roll about on the pillow.

These expressions of pain last as long as children retain consciousness, a particular part of the head is not commonly pointed out, but asked about it the majority point to the forehead. With small children automatic movements are noticed that also seem to refer to headache, and which consist in rapidly placing the hand on the head and then drawing it back.

The larger children complain of pains in the bowels, especially in the region of the stomach, which remarkably often, though not regularly, become more intense by pressing and may become so violent that the children cry out aloud with pain, when the stomach or other portion of the abdomen is but slightly touched. But these pains do not last as long as the headache, they often stop suddenly, at times return.

The shape of the abdomen is extraordinarily characteristic. In the beginning nothing remarkable can be noticed, but after the symptoms of acute hydrocephalus, vomiting, constipation, etc., have lasted for some time, the abdomen gradually decreases in size, becomes wrinkled and collapses until it finally assumes a scaphoid shape and by slight pressure the large iliac artery can be felt on the spinal column.

This contraction of the abdomen is attendant in every case of tuberculous meningitis.

If the large fontanel on the head is not yet closed, the same will gradually bulge out as the disease progresses.

The mental activity suffers premature derangements, such as have been fully mentioned in the description of the precursory symptoms. The most striking is the confused, staring look, the peevish and surly behavior, and again in other cases the extreme indifference toward otherwise well-liked persons and things. Later on actual delirium sets in, but generally of a quiet nature.

A very common symptom is a loud, plaintive outcry, that is repeated at longer or shorter intervals. Children often cry out at partly regular intervals during a whole night; these cries are always accompanied by a loud sigh. These symptoms of excitement being extremely tormenting and depressing for the sympathizing relatives, fortunately last no longer than 6–8 days at the most, and are succeeded by a deep stupor.

If the children have once become unconscious, they do not recover again as a rule but remain so until death; delirium and stupor may alternate with each other in certain cases, but the former process is by far the most frequent.

Convulsions appear only in the later stages. At first the interval between the attacks are long, often as many as three or four days intervene. Commonly however they come much oftener and may in some cases last for hours. All extremities are affected by these convulsions, the eyes become red, are rolled in every direction and turning way up are fixed so that nothing but the whites is visible. After several minutes, often after two or three hours, these general convulsions subside, the children, now very pale, drop into a deep sleep and their general condition appears much reduced.

Different muscular groups especially those of the face are subject to local cramps. The upper lip may become distorted, convulsive smiles have been observed, also peculiar sucking motions. The children point their lips and flatten them again, sometimes for hours in succession.

In the latter stages a squinting of one or both eyes may be noticed but this may again disappear.

Grinding of the teeth is another very peculiar symptom which is well-known and feared by experienced nurses. The arms are subject to various motions, at times sweeping automaton like, then again convulsive contractions, sometimes trembling of the muscles, at others a throbbing of the tendons. Many patients put their hands to their sexual organs and make motions tending to onanism.

The legs are not subject to cramps as much as the arms; they are mostly bent and drawn up in a half paralyzed condition.

The muscles of the neck and back are very much contracted and most children, when raised or laid on their side, bend the head far back.

In most children an extreme sensibility at being touched is observed. They may be handled with the greatest possible care and lifted most tenderly, a slight pressure on the head, body or hands in changing their position will be violently resisted with obvious expressions of pain. In the latter stages this extreme sensibility gives way to insensibility.

Then the children may be pinched and poked, they may be turned and moved from one side to the other without any consideration, they will not resist and only give expression to the remaining sensibility by a low whimper. The lack of sensibility may be especially marked in the eyes; these can be touched with the fingers, without causing a closing of the lids.

The sense of hearing seems to continue its functions until very late. Children show that they hear as long as they are not completely unconscious; even when addressed in a low tone of voice they react somewhat. The sense of smell and taste also are lost toward the very end of the disease.

Paralytic affections appear during the final stages. It has been observed in some cases that the arm and limb are paralyzed on one side only. Often one upper eyelid is paralyzed and hangs down on one side of the face and the muscles of the tongue may be affected.

Generally the patient dies after violent general convulsions that last for hours. Exceptionally only the paralytic symptoms increase gradually and cause death without any agony or struggle, simply a discontinuance of the functions constituting life.

The duration of the disease varies from 2–4 weeks from the beginning of the characteristic symptoms. Generally the day when the children take to the bed is fixed as the beginning of the disease.

The former methods of treatment have been a signal and absolute failure in every case. Every child that has once been attacked with this disease has heretofore died. Until now Koch has not been able to make any experiments with acute hydrocephalus, so that it remains an open question whether it is now possible to cure this disease.

Besides tuberculosis of the cerebral membranes with which children are afflicted, tuberculosis of the brain may occur, although this disease is very rare. Tuberculosis of the brain appears in the shape of small tumors in all parts of the brain. After longer duration of tuberculosis of the brain, tubercular meningitis appears.

The process of this disease may be varied. In some cases the development of cerebral tuberculosis is manifested by the sudden appearance of high fever temperatures or violent headache; to this may be added, slackening of the pulse, vomiting, stiff neck and isolated cases of palsy; sometimes an attack of convulsions is the first manifestation.

In other cases the beginning can not be accurately determined, as the beginning symptoms of the disease are so slight as to escape notice. Impaired process of nutrition, languor and headache are symptoms from which the existence of some serious affliction may be inferred without being able to determine its nature in the earlier stages.

Again in other cases the disease may proceed through all its stages without any cerebral appearances whatever. This is especially true of small tubercles and of diseases of infants. However, we more frequently observe in children than in adults convulsions of varied intensity and distribution.

Nutrition is more and more impaired as the disease progresses, in isolated cases only, a temporary improvement may be observed.

The end of cerebral tuberculosis has been death before this. Ten days to two weeks, even three weeks may pass from the first appearance of tubercular meningitis to the completion of the process of the disease, attended by feverish motions characteristic of this condition and by cerebral symptoms, first with the character of excitement, later on with that of palsy.

The treatment of cerebral tuberculosis has been entirely insufficient before this. Let us hope that it will be possible to effect a cure by means of Koch's new method.

Tuberculosis of the Kidneys is met with from the earliest childhood till old age. Most frequently the male sex is afflicted during manhood.

In most cases tuberculosis also exists in other organs, especially in the urinary and sexual apparatus. The existence of pulmonary or intestinal tuberculosis is not essential.

The symptoms of renal tuberculosis are of such general and indefinite character, that it is often impossible to fully determine the disease. Now, however, it will be more easily possible on account of Koch's discovery.

The urine may, but need not contain pus and blood. Sometimes small lumps are found in the urine.

Pains are only sometimes felt in the renal regions; fever may be occasionally attendant.

The disease lasts for months and years; though before now it has inevitably resulted in death, though it has in exceptional cases taken ten years or more.

The internal treatment of renal tuberculosis was ineffectual, surgical treatment has been attended with greater success. This consisted in removing the diseased kidney. Now good results will possibly be attained by the application of Koch's method to cure and resource to surgery will be taken in exceptional cases only.

Tuberculosis of the suprarenal capsules is of very rare occurrence. It leads to a peculiar change in the color of the skin; the same turns dark brown or bronze color. Sooner or later death results.

Perhaps the application of Koch's method will, besides curing the disease, give us information regarding the functions of the suprarenal capsules about which nothing whatever is as yet known.

A large space in the realm of disease is claimed by tuberculous affections of the bones and joints. These afflictions appear particularly in childhood though manhood is by no means exempt. They may appear in all portions of the body, although a marked preference is shown for certain parts. Although the tubercle-bacilli are infinitely small, they possess the power to cause suppuration of the bones and joints and to produce acute inflammation of these parts.

Most frequently tubercular affections of the bones are found in the hip-joints, the knee and the spinal column.

Tuberculous inflammation of the hip-joint is principally a disease occurring in childhood; though it rarely appears before the third year. It is most frequent from the fifth to the tenth year.

Inflammation of the hip-joint developes very slowly in children, it generally takes months before the slightest beginning symptoms reach a threatening appearance. The first sign is lameness; among laymen tuberculous inflammation of the hip-joints is known as "voluntary limping."

By limping we understand that mode of walking in which one leg is spared and by this the trunk is supported only a short time by one extremity and all the longer by the other. In every painful affection of the lower extremity limping results as the weight of the body increases the pain. The lameness in the case of diseased hip-joint has something peculiar about it, inasmuch as not only a part of the extremity but the whole of it is dragged. For this very reason parents of children afflicted with inflammation of the hip-joint use the expression "the child draws" or "drags the leg".

In the beginning even the examining physician finds no symptoms of disease in the joint. No swelling, no abnormal position, no restriction of the freedom of motion, no pain from pressure or while moving, in short nothing can be found that would otherwise indicate the beginning of an inflammation of the joints.

Yet lameness only is sufficient data from which we may infer the probable beginning of hip-joint inflammation. It is much better to overestimate the significance of this symptom than to miss the proper time for calling in the aid of a physician by placing too little confidence on it.

The second symptom, pain, rarely attends the beginning of lameness, generally it comes several weeks later and in the case of very slow development of tubercularly inflamed hip-joint several months later. In very small children the attendance of pain is manifested by the fact that they will not play and they often wake up in the night and begin to cry.

Children from the fourth and fifth year upward definitely point out the hip as the seat of pain, sometimes, however, the knee-joint on the diseased side is designated with great determination. This pain in the knee has often been the cause of mistakes.

Later on painfulness of the hip-joint is experienced from pressure and at about the same time the movements are impeded.

Then the leg takes a peculiar position. The thigh is slightly bent and rolls outward. For convenience the child drops the half of the pelvis corresponding to the diseased hip-joint, and naturally raises the other half. From this apparently a curvature of the spinal column results in the lumbar region. Apparently only, for when the child is laid down and the morbid position of the thigh is restored the curvature of the lumbar column disappears.

During the further progress of the disease the pain is increased, and the sensibility may become so acute that the slightest movement of the limb, even a shaking of the bed in which the patient lies will cause the most intense pain. In the previous stage walking could only be done for short distances and then awkwardly, now it is entirely impossible. Children are obliged to lie in bed night and day, and under these altered conditions there is a change of the position of the extremity. The increased sensibility induces the child to seek the medium position, the leg is bent more than in the position mentioned above, it is halfway straightened.

To this is added, that the child can not lie well on the sensitive and swollen hip; with right side hip-joint inflammation it turns on the left. As the diseased and bent thigh does not then rest on the mattress the same is placed on the healthy limb for support and for protection from movements, in the same manner as we lay one leg on the other in a healthy condition when we sleep on our side.

The actual danger to life in tuberculous hip-joint inflammation begins with the time when the child takes to his bed. The fatal end comes almost without exception after suppuration has commenced, very rarely before that time. Total suppuration of the hip-joint is an almost absolutely fatal process. If this suppuration sets in suddenly, it may result in an early death with attendance of acute fever. In other cases several weeks may elapse from beginning suppuration till death.

A complete cure of tuberculous hip-joint inflammation may come about spontaneously. But often the knee remains bent and unserviceable for walking, so that crutches or machines must be used.

Even before this the beginning stages were treated with fair prospects of success, and it is a lamentable fact that in many cases the import of these seemingly trivial symptoms has been underestimated.

Rest is of the greatest importance during the very first stages of the disease in which the attending symptoms are of so indefinite a character that it is almost impossible to know whether hip-joint inflammation will develop or not; the child must not be allowed to walk. Aside from this the application of brine-, malt- and sea-water baths is advised. An abundance of nourishing food is of just as great importance. All this will also retain its significance in the future.

Formerly recourse to surgery has been taken during the later stages of the disease in which suppuration of the internal parts of the joint has commenced and large parts of the diseased bones may have become mortified. An incision is made into the joint, the same is exposed and all diseased portions are carefully removed. In the future this operation must probably also be performed, although with the difference that the prospects of success are now much more certain than formerly when relapses only too often followed the operation.

Tuberculous inflammation of the knee-joint is, as said before, very frequent with children and is rather lingering in the beginning. Here also a slight dragging or limping of the diseased leg can be noticed. The child when asked about the limping, or of its own accord, complains of pain in the joint after walking or when the part is pressed; at first nothing abnormal can be seen on the knee by the layman.

On closer examination, however, by comparing the two knees it will be found that the grooves on each side of the patella, which give the healthy knee-joint the beautifully modeled shape, have nearly or quite disappeared; nothing more can be noticed.

The hinderance in motion may be so insignificant, that the children may slightly limp about for weeks and months and complain but little. Generally the physician is not called until the limb begins to hurt and swell after continued exertion.

The swelling which in the beginning is hardly noticeable is now more plainly visible, the knee-joint is evenly rounded and quite sensitive to pressure.

If the disease is not now properly treated, its further course will be as follows: the patient may perhaps linger for several months; then comes a period when he must keep to his bed uninterruptedly because moving results in too much pain; generally the limb becomes more and more bent.

Now particularly painful points appear on the joint, especially on the inner or outer side or in the bend of the knee; on one of these points a soft portion distinctly developes, the skin becomes reddened and finally suppurates from the internal parts outward and breaks after a few months; thin purulent matter mixed with flakes is discharged. The pains now cease, and the condition is improved; but this improvement does not last; soon another abscess is formed and thus it continues.

Meanwhile perhaps two or three years may have elapsed; the general condition becomes greatly reduced. The child, formerly strong and healthy, has now become lean, the discharges of matter have often been attended by acute febrile attacks; the patient becomes exhausted, loses his appetite and digestion becomes more impaired from week to week. Even now a spontaneous change for the better is possible, though this happens very rarely; more frequently the disease progresses and leads to death from exhaustion resulting from severe suppuration and continual attacks of fever.

Restoration to health is indicated by decreased suppurative discharges; the openings of the fistulae contract, the general condition is improved, the appetite is restored, etc. Finally the fistulae heal, the joint becomes fixed at an angle or bent or otherwise crippled, but painfulness disappears and the patient escapes with his life and a stiff leg. This is the most favorable result known to have been obtained in severe cases. The joint may become a solid bony immovable mass or may admit of slight movements. The whole process may last from two to four years.

The former treatment of tuberculous inflammation of the knee-joint was either of a general or a local nature. The general treatment was designed to strengthen and nourish, and will continue to be applied in the future.

The local treatment consisted in the application of salves, brushing with tincture of iodine, spanish fly plasters, wet and dry bandages. As with inflamed hip-joint absolute rest by lying in bed is of the greatest importance.

If after a certain period of rest and application of the above-named remedies no improvement in the state of health could be noticed, the diseased joint was laid in plaster or confined with splints.

If even then, after such treatment for months, no improvement could be noticed but rather that the general state of health was reduced, nothing remained to be done excepting an operation, by which all the diseased parts of the knee-joint were removed, or amputation, that is, the taking off of the diseased limb. The latter method was generally adopted in the case of feeble and emaciated individuals and those who had passed the age of early manhood, as with these the removal of the diseased parts did not, as a rule, result in an improvement of the general condition, which was especially intended.

Now tuberculous inflammation of the knee-joint will be treated by Koch's method and in extreme cases only will operation be necessary. At all rates, an absolute cure will be easily effected.

Aside from the hip- and knee-joint the spinal column is most frequently attacked by tuberculosis. Here also it is the youthful age, from the third year upward, that has to suffer most from this serious disease. Adults are rarely attacked by it and with them it generally appears in connection with general tuberculosis.

The tubercle-bacilli penetrate into the substance of the vertebrae, destroy the same and transform it into purulent matter. As a result the destroyed vertebrae sink or rather settle down and cause a curvature of the spine, in other words a humpback.

In the beginning the symptoms of diseased spine are very indefinite and misleading. The patient rarely complains of pain at first, and it is only noticed that the sick child easily tires of standing or walking and tends to hold on to chairs and similar objects with his hands to relieve the spinal column of the weight. From such uncertain data it is of course impossible to recognize the disease.

Only then when the softened vertebrae give way under the weight of the body, that is when the humpback begins to develop, can tuberculous inflammation of the spine be surmised with any degree of certainty.

As a rule two other characteristic phenomena appear which are dependent on the pain in the affected spinal column. The child, while standing, places his hand on the thighs and thus directly supports part of the weight of the trunk with the lower extremities; at the same time he avoids bending the spinal column forward. This anxious care for the diseased vertebrae is especially noticeable when the child attempts to pick up an object from the floor. While the healthy child bends freely forward, the sick one crouches down and while bending the knee and hip keeps the spinal column as straight and stiff as possible. Frequently a small spot on the spinal column is found to be extremely sensitive to pressure in this stage; but such a subjective symptom must be considered with caution especially with children.

This humpback, which is a result of tuberculous inflammation of the spine, must not be confounded with the humpback caused by rickets. With the latter the curvature is more uniform as a rule, and in the start at least, disappears while in a horizontal position. Besides the humpback resulting from rickets appears between the first and fourth years of age, while tuberculous inflammation of the spine rarely begins before the fourth year. And finally rickets never causes suppuration while this is always the case with inflammation of the spine.

The progress of suppuration is downward as a rule and does not admit of examination until it gets near to the surface of the body; before this the feverish conditions toward evening are the only signs that indicate beginning suppuration. Ardent fever is not attendant during this time; the temperature does not exceed 38 or 38.6° C. and even such trifling increase of temperature may be wanting.

As soon as the skin is reached by the originally deepseated centres of suppuration, it gradually becomes red and later on also suppurated. If the skin is broken and the matter discharged, great care must be taken to keep the wound clean, as otherwise the suppurative cavities may suddenly become ichorous and lead to rapid death. In other cases this extreme result is not caused and fistulae are formed from which the ichor constantly flows. Small bits of mortified and broken off bones may be thrown out with the matter.

As a result of the sinking and settling of the vertebrae the spinal chord may suffer from pressure and contusion as it is contained in a channel formed by the vertebrae. Aside from certain pain it may result in paralysis of certain parts.

Formerly the diagnosis of tuberculous inflammation of the spine in its beginning stages was very uncertain. A great number of afflicted are at present cured by surgical treatment; in former times this was not possible, as the majority of patients died in whose case the disease had progressed to suppuration. But the curvature of the spine could not be removed by any former treatment and can not be by Koch's new method. Vertebrae once destroyed can in no way be restored to their normal condition.

Nevertheless the number of patients whose life is spared will be a still greater one and the number of complete cures will also be increased in a short time. Formerly tuberculous inflammation of the spine was treated as follows: the abscesses were opened and antiseptics carefully applied: mechanical apparatus and corsets were used to aid in a natural cure. These apparatus will surely be of inestimable value at the application of Koch's method.

As has been stated before tuberculosis may attack all other bones and joints and there cause the most serious derangement. Formerly these tuberculous afflictions were treated surgically or by means of iodoform, which has produced pretty good results in certain cases.

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 2¹⁄₂ 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.

Of great importance for scrofulous children, furthermore, is a suitable course in gymnastics and rubbing-down with cold water. To begin with the water may be 72° but should gradually be reduced to the natural temperature of well water.

Just how far Koch's new method will take the place of former remedies used for scrofula can not be told at present as experiments in this direction are wanting. Nevertheless it will be possible to prevent the dangerous transition of scrofula into tuberculosis and thus save the lives of a great many persons.

Anyone who has informed himself through the foregoing as to the great number of diseases and forms of disease that are directly or indirectly connected with tuberculosis, will now be able to estimate the farreaching import of Koch's discovery. It will now be clear to him that pulmonary consumption constitutes only a part, although a great part of tuberculosis and that there are a great many diseases besides that can now be surely cured, it is hoped, with the aid of Koch's method. But this much should be remembered by everyone that this remedy also acts best and surest during the beginning of a disease. We hope that no one will allow valuable time to slip unimproved; it may easily happen that it is too late for successful treatment. Everyone will be able to recognize the symptoms of diseases, which Koch has taught to cure, from the foregoing complete description, and it is better to apply the remedy once too often than miss the proper time for application.

Koch's first communications relating to the subject have just been published and will be given unabridged in the following pages. As these communications are written for physicians we will add such explanatory notes as are deemed essential for general intelligence.

DR. KOCH IN HIS LABORATORY