PAUL B.HOEBK MEDICAL BOOKS 69E.59thSt.,N.Y, 'I^C'^tiS (CnUnnbia HnturrBitg tn thr (Citu at Nrui ^nrk OluUrgr af llbiiairiana anh dur«rnna SrfrrFitrr ICtbrary SCROFULOSIS GERMAN TUBERCULOSIS CLASSICS Issued on the advice and under the directioii of EGBERT MORLAND, M.D., B.Sc. SCROFUl.OSIS KY Prof. Dr. G. CORNET BERLIN AND REICHENHAI.I. Translated from the Second German Edition I'.V J. E. BULLOCK, M.D. Assistant Mcdiial Officer, 7 lie Eveisfield Chest Hospital, St. Leoiiards-on-Sea NEW \" O R K WILLLAM WOOD AXD COMPANY MDCCCCXIV Digitized by the iiiternet Archive in 2010 with furiiding from Open Knowledge Commons http://www.archive.org/details/scrofulosisOOcorn PREFACE TO THE SECOND EDITION, The First lulilion of mv " vScrofulosis " has been exhausted for nearly seven years. Circumstances have prevented my following it up sooner with a new edition. During this time many of my observations have been based on firmer grounds through the assiduous work of numerous investigators, and many questions have found new and better elucidation. I hope this edition may find as friendly a reception as its predecessor. Professor Dr. Georg Cornet. Berlin and Reichenhall. March, 191 2. CONTENTS. PAGE INTRODUCTION ... .. ... .. . i DISTRIBUTION ... . . ... ... . 2 OCCURRENCE ACCORDING TO AGE AND SEX ... ... 2 l.-ETIOLOGY OF SCROFULOSIS .. ... 5 I.- Historical Survey ... ... ... ... ... 5 NAME ... ... ... ... ... ... ... 5 CONCEPTION OF SCROFULO.SIS 6 THE ACIDITY OF SCROFUT,O.SIS ... ... ... ... 6 .SCROFULOSIS AND TUBERCULOSIS ... ... ... 7 INJECTION RESEARCHES 8 KOCH'S RESEARCHES ... ... ... ... ... q FURTHER CONFIRMATION OF THE NATURE OF TUBERCULOSIS ... ... ... ... ... 10 NON-TUBERCULOUS SYMPTOMS OF SCROFULOSIS ... 12 II Conception and Classification of Scrofulosis ... ... ... 14 A.— EXOGENOUS CAUSES— CLASSIFICATION OF SCRO- FULA 15 Virulence of Bacteria generally ... ... ... ... 22 Virulence of Pus Bacteria ... ... ... ... 22 Virulence of Tubercle Bacilli ... ... ... ... 23 (a) Attenuated Virus ... ... ... ... ... 23 {t>) Bacilli of Human and Bovine Tuberculosis ... ... 27 Differences in Virulence ... ... ... ... 31 Cultural Differences ... ... ... ... 31 Change of Type ... ... ... ... ... 34 Significance of Bovine Infection ... ... ... ... 37 The Occurrence of the Bovine Type in Man ... ... ^y Bovine Type in Adults ... ... ... ... 39 Bovine Type in Pulmonary Tuberculosis ... ... 3Q Bovine Type in Mesenteric and Cervical Tuberculosis 41 Tuberculosis of the Bones and Joints ... ... 42 Lupus ... ... ... ... ... ... 43 B.— THE ENDOGENOUS FACTOR— PREDISPOSITION TO SCROFULOSIS 47 General Diathesis ... ... ... ... ... 47 Historical ... ... ... ... ... ... 47 Modern Hypotheses — Exudative Diathesis ... ... 49 Other Signs of Exudative Diathesis ... ... ... 53 EN130GEN0US FACTOR — LOCALIZED DIATHESIS ... ... ... 60 .Anatomical Explanation of the Tendency of Scrofulosis ... 61 (i) Permeability of the Skin and Mucous Membranes 62 (2) Variation in the Permeability of Skin according to Age ... ... ... ... ... 64 A. — Anatomical Differences, 64; (i) Skin. 64: (2) Mucous Membranes, 66. B.— Clinical Proofs of the Greater Permeability of the Skin in the Young. 66. (3) Different Permeability of Skin according to Sex ... 71 (4) Individual Differences ... ... ... ..'. 73 Vlll CONTENTS III — Genesis of Scrofulosis I.— CAUSATIVE AGENT OF PUS {a) Appearance (b) Mode of Infection II.— TUBERCLE BACILLI ... .A..— Human Type ... Occurrence Experiments on Animals (i) Subcutaneous Infection (2) Cutaneous Inoculation (3) Infection of the Mucous Membranes (4) Intraperitoneal Infection (5) Intravascular Infection... Clinical Observations (Scalp, 86; Eye, 86; Mouth an Pharynx, 86; Teeth, 87; Nose and Ear, 87) Law of Localization Objections to the Law of Localization Experimental Errors B.— Bovine Type ... Extent, Degree, and Danger of Bovine Infection Opportunities of Infection by Tuberculous Meat Opportunities of Infection by Milk ... Tubercle Bacilli contained in Milk Primary Tuberculosis of the Intestinal Canal ... Morbid Anatomy Experience Clinical Experience Collective Investigation The Difficulties of Intestinal Infection Conclusions Skin Infection through Bovine Bacilli Infection of the Lungs and Bronchial Glands Bovine Bacilli Latent Foci C. — Avi.an Type III.— THE DIFFERENT EFFECTS OF THE INFECTION The Histological Nature of the Tissue State of Nutrition of the Tissues... The Size of the Micro-organisms ... Biological Characters The Number of the Bacteria Virulence The Closeness of Contact IV. --THE DISPERSAL OF TUBERCULOUS INFECTION V.-THE PART PL.WED BY THE LYMPH GLANDS Anatomical Protective Effect of the Lymph Glands Toxic Protective Influence of the Lymph Glands VI.— MODE OF INFECTION IN MAN (i) Relative Frequency of various Localizations (2) The Causes of Different Localizations Skin ... Murous Membranes IV.- Infectiousness of Scrofulosis (Spread of the Disease) CON'll'iNIS >X PAOK v.— Heredity ... ... ... ... ... ... ... 149 Till': JNIII;KITANCE Ol«" TUBliKCULOSIS ... ... ... 150 TRANSMISSION OF THE GKKM ... ... ... ... 150 HKRI<:D1TARY tendency to TUMI-RCULOSIS 154 TRANSMISSION OK TIIK TKNORNCY TO SCKOl-'UI.O.SIS ... ... l6l VI. — Factors which favour Infection ... ... ... ... ... 163 SOCIAL POSITION ... ... ... ... ... ... 163 II.— MORBID ANATOMY .. ... ... ... ... 175 (i) PYOGENIC FORM ... ... ... ... ... 173 (2) TUBERCULOUS FORM : ... 175 III. -SYMPTOMS ... ... ... ... ... ... 180 A.— LOCAL SYMPTOMS IN THE SKIN . . ... ... 181 (i) Non-tuberculous Form ... ... ... ... 181 (2) Tuberculous Form .:. ... ... ... ... 183 Lupus ... ... ... ... ... ... 183 Scrofuloderma ... ... ... ... ... 184 Tuberculides ... ... ... ... ... ... 184 Folliculitis ... ... ... ... ... ... 186 B. —LOCAL SYMPTOMS IN THE MUCOUS MEMBRANES ... ig3 Nose ... ... ... ... ... ... ... 193 Mouth and Pharynx ... ... ... ... ... 194 Ear ... ... ... ... ... ... ... 196 Eye ... ... ... ... ... ... ... 199 Symptoms in the other Mucous Membranes ... ... 201 C— SYMPTOMS IN THE LYMPH GLANDS 202 Neck Glands ... ... ... ... ... ... 202 Inguinal and Axillary Glands ... ... ... ... 203 Bronchial Glands ... ... ... ... ... 203 Mesenteric Glands ... ... ... ... ... 207 D.— SYMPTOMS OF BONE AND JOINT AFFECTIONS ... 209 E.— GENERAL SYMPTOMS 213 AN.ffiMIA ... ... ... ... ... ... ... 213 Fever ... ... ... ... ... ... ... 213 Nourishment ... ... ... ... ... ... 214 F.— THE SCROFULOUS CONSTITUTION ... ... ... 315 IV.-COURSE AND DURATION OF THE DISEASE ... ... 219 A.— COURSE OF PYOGENOUS SCROFULOSIS ... ... 219 B.— COURSE OF TUBERCULOUS SCROFULOSIS ... ... 220 First Stage ... ... ... ... ... ... 220 Second Stage (Retrograde Dispersal, 222) ... ... ... 221 Third Stage Fourth Stage C— MIXED INFECTION v.— PROGNOSIS ... VI.— DIAGNOSIS ... 224 224 225 226 233 A.— THE PYOGENOUS FORM ... ... 233 X CONTENTS PAGE B.— THE TUBERCULOUS FORM 235 (i) Clinical Diagnosis ... ... ... ... ••• 235 Tuberculosis of the Glands ... ... ... ... 237 Tuberculosis of the Bronchial Glands ... ... ... 237 Clinical Differential Diagnosis ... ... ... 244 (2) Bacteriological Diagnosis ... ... ... ■.245 Proof of the Tubercle Bacillus ... ... ... ... 245 Much's Granules ... ... ... ... ... ... 247 Tuberculin Diagnosis — Allergie Reaction ... ... ... 250 Method OF THE Proof of Allergie ... ... ... ... 251 V. Pirquet's Cutaneous Method ... ... ... ... 251 Modification of v. Pirquet's Method ... ... ... 253 Ointment Reaction ... ... ... ... ... 253 Method of Using Moro's Ointment ... ... ... 253 Further Modifications of Allergie Reaction ... ... 254 Intradermic Reaction ... ... ... ... ... 254 Streak Reaction ... ... ... ... ... 254 Wolff-Eisner's Conjunctival (Ophthalmic) Reaction ... 255 Reaction in Other Mucous Membranes ... ... ... 256 Results of Allergie Reaction ... ... ... ... 257 A. — Clinical Tuberculosis ... ... ... ... 257 B. — Clinical Suspects ... ... ... ... 259 C. — Clinically Free from Tuberculosis ... ... 259 Subcutaneous Tuberculin Test ... ... ... ... 263 Allergie Reaction in the Scrofulous ... ... ... 2C4 Differentiation of the Human and Bovine Bacillus ... 265 Passage through Guinea-pigs Serum Culture ... Glycerine Bouillon Culture Testing on Animals VII. -PROPHYLAXIS I The Child in the Family ... AIR, LIGHT, CLEANLINESS .. ... ... ... 280 NOURISHMENT Mother's Milk Cows' Milk Milk and Food Preparations Faulty Nutrition — Exudative Diat HARDENING ... ... ... ... ... ... 2qq CAUTION DURING ILLNESS IN THE FAMILY ... ... 300 DIFFICULTIES OF PROPHYLAXIS ... ... ... 302 Instruction ... ... ... ... ... ••■303 Dwelling-houses ... ... ... ... ... ... 304 Institutions for the Care of Children ... ... ... 304 II The Child at School ... ... ... ... ... ... 315 SCHOOL BATHS 317 SCHOOL FEEDING ... ... ... ... ... ... 318 SCHOOL DOCTOR ... ... ... ... ... ... 31Q FOREST SCHOOLS ... ... ... ... ... ... 319 VIII.- THERAPEUTICS ... ... . 321 I. General Therapeutics .. ... . ... 322 NUTRITION ... ... ... ... . . ... 323 Helps to Nutrition ... ... ... ... ... 324 267 268 269 270 275 279 ... 283 ... 284 ... 285 ... 291 hesis .. ... ... 296 CONTENTS Xf PAGE OPEN-AIR TREATMENT ... ... ■• ••• •■• 327 A.-- Climatic JIkaltii Rksokts ... .•■ ••• •.•329 B.— MiNKRAi, Baths ... ... .•■ • •■ ■•• 33« EfTect ... ... ••• •■• ••• ••• 23i Indication ... ... ••• ••■ ••• •■• 333 Mode of Use ... ... .•• ••■ ••■ ••• 334 C— Sea Baths ... ... ' ... ••• ■•■ ••• 337 Effect 337 Indication ... ... ■•• ••• •■• • •■ 338 Mode of Use ... ... ••. ••• ••• ••• 338 D.— Sulphur AND Arsenic Springs ... ... ... ... 339 E.— Auxiliaries to Mineral and Sea-bathing Treatment ... 340 F.- "Choice of a Health Resort ... ... ... ... 343 Climatic Health Resorts ... ... ■•■ ••• 344 Watering Places ... ... ... ••• ••• 34^ G.— Holiday Settlements and Children's Convalescent Homes ... ... .•• ••• ■•• ••• 349 Children's Homes in Germany ... ... ... ... 350 School Sanatoria ... ... ... ... •■• 359 H.— Results in Mineral and Seaside Convalescent Homes ... 361 I. — Salt Baths at Home ... ... ... ... ••■ 368 II Medicinal Treatment ... ... ... ... ... ... 370 IODINE ... ... ... ... ..■ ••• ••• 370 IRON ... ... ... ... ■•■ ••• ••• 372 ARSENIC 375 CREOSOTE ... ... ... ... ••• 376 OTHER REMEDIES ... ... ... ... .-. .•• 378 TUBERCULIN 378 Mode of Use ... ... ... ... ... ... 383 CINNAMIC ACID 385 SAPO VIRIDIS 385 III. — Local Treatment ... ... ... ... ... ... 388 A.— SKIN DISEASES ... 388 Eczema ... ... ... ... ... ... ... 388 Lupus ... ... ... ... ... ... ... 393 Scrofuloderma ... ... ... .. ... ... 399 Tuberculides ... ... ... ... ... ... 399 B.— DISEASES OF MUCOUS MEMBRANES ... ... ... 399 Respiratory Organs and Pharynx ... ... ... ... 399 Ear ... ... ... ... ... ... ... 403 Eye ... ... ... ... ... ... ... 409 C— AFFECTIONS OF THE GLANDS ... ... ... 410 D.—SCROFULOSIS OF THE BONES AND JOINTS ... 416 ABBREVIATIONS USED IN THE BIBLIOGRAPHY ... ... ... 419 BIBLIOGRAPHY ... .. ... ... ... ... ... 422 INDEX ... ... ... .. ... ... ... 497 INDEX OF AUTHORS ... ... ... ... ... 506 ERRATA. p. 40, line 3 from bottom, for '' Sabotta," rend " Sobotta." P. 93, line ID from bottom, for •' Boch," read " Bock." P. 103, line 4 from top, for " Goehedini," read " Gchedini." P. 105, line 7 from top, for " Bidert," read " Bicdert"; and line 7 from bottom, for " Sabotta," read '' Sobotta." P. 143, line 17 from top, for '' Miiller," read " Mollcr." P. 148, line 23 from bottpm, for •• Bierdet," read " Biedert." P. 156, line 12 from top, for "Martin, Kircaner," read "Martin Kirchner." P. 160, line 7 from top, for " Mars," read " Martins." P. 187, line 16 from top, for " Spindler," read " Spieler." P. 200, line 4 from top, for " Hayshi," read "Hayashi"; and lines 3 and 4 from bottom, o/nit " (for further information, see vol. .\xi, ch. iv, pp. 403-406)." P. 201, line 7, for " Eangl," read " Tangl." P. 239, line 7 from top, for " Grover," read " Grober." P. 240, line 14 from top, for " Bacinsky," read " Baginsky." P. 243, line 14 from top, for " Tlan^enga," read " Platenga." P. 246, line 19 from bottom, for " Bren," read " Brem." P. 255, line 3 from top, for " .\rvonadc,'" read " .Aronade." P. 257, line 7 from bottom, for " Kictz," read "Krietz"; and line 12 from bottom, for " Pcschorner," read " Bcschorncr." P. 263, line 16 from bottom, for " Children under 10 are given o'2 — o'5 — I'S mg., ' read " Children under 10 are given o'2 — o"S — i — 5 mg." P. 264, line 3 from top, for " Hans," read " Hans Hans." P. 265, line 9 from top, after " connected with it " insert " (Citron and others)"; line 10, after "contra-indicated" insert "or only permissible in weak solutions (Comby, i per cent. ; Baldwin, 3 per cent. ; Citron, i per cent., and Calmette), and even absolutely contra-indicated for slighter cases." P. 288, line 12 from top, for " Plantcng," read " Platenga." P. 293, line 17 from bottom, for " Montin," read " Monti." P. 371, line 4 from top, for " Cantini," read " Cantani." P- ^03^ line II from bottom, for " Balmanns-Squirc,"' read ' Balmanno .Squire." INTRODUCTION Although tlie discovery of ihe lubercle bacillus has created a true conception of the nature of Tuberculosis, on which to construct a sure diagnosis and etiology of the disease, opinions as to the nature of Scrofulosis are still widely divergent. Some recognize in Scrofulosis nothing but a slowly progress- ing localized Tuberculosis, others consider it an independent disease from the beginning, due to a certain disposition or dyscrasia, which in its course often presents tuberculous com- plications. This difference of conception explains the con- tradictory nature of the clinical, statistical and experimental reports which it is not easy to put in a clear form. Step by step we seem to be coming nearer to this goal ; the differentiation of tubercle bacilli of human and bovine extraction has contributed to make many phenomena intelligible which hitherto have been unexplained. DISTRIBUTION, It is almost impossible to form even an approximately correct conception of the disiribtitit)n of scroftik)sis. Tlie reports of older writers do not help us, because they continually call struma and other diseases scrofulosis. Even at the present time the concejMion ot scrotulosis is loo vague for us to ascribe to it any special feature. One doctor regards almost every acute superficial inflam- mation or swelling of the glands as scrt)fulosis, whilst another ascribes to it only the affections of a distinctly scrofulous nature. According to Ritter, among 20,000 children there were generallv about 90 per cent, with scrofulotis symptoms; according to Volland, among 2,000 children about 90 per cent, had also scrofulous s\\elling of the glands of the neck. The statistics of mortality to which we owe such valuable conclusions concerning tuberculosis of the lungs, do not afford us much information respecting scrofulosis. In the Prussian statistics, which are otherwise so useful, scrofulosis and rickets were, until 1902, represented in common, and from that time onwards, as in the statistics of other states, those suffering from scrofulosis, who later have died from tuberculosis of the lungs or of bones, or of miliary tuberculosis, have been included under this heading. Owing to this state of affairs I would refrain from quoting statistics which would only lead to false conclusions. D'Espine has estimated the number of deaths from scrofu- losis, according to Lebert, at 21 per 1,000 of the total mortality, and 6 per 1,000 of the rich to 34 per 1,000 of the poor. If these figures were correct one might come to some conclusion about the decrease of scrofulosis; its extent in Ba^•aria amounts at the present time to about 5 per 1,000; in Prussia it forms, inclusive of rickets, 4 to 5 per 1,000 of the general mortality. OCCURRENCE ACCORDING TO AGE AND SEX. From clinical observation we are better acquainted with its occurrence according to age and sex than we are with its general distribution. DISTKJJiU'llON 3 Scrofulosis is almosl exclusively a disease (A the period of development, as is conliniied by doctors of all times; it d1X). In France, and especially in l^ngland (from the time of Edward the L\)nfessor), the power to heal scrofula hv huich was ascribed to kino-s and the seventh si)n in a faniil\-, ilic formula being : " Ja' roi U' idiu-lu', U' roi le giicrit." I-'roni ihc restoration of Charles lliill the reign of Oueen Anne tlu' number of persons so treated was reckoned at 100,000. WHiitt' was of opinion th.'it political moii\es underlay this treatment, and that onl_\- such illnesses were submitted to the touch of the King's hand as were so slight that they often disappeared without any treatment at all. Only in the reign of Louis Xl\' and w ith the reigning family in England respectively, this custom came to an end. As the King gave up the practice of medicine, and the idea became pre- valent that Scrofula was inherited, the name " Morbus regius " was lost and Scrofula took its place (White, \^irchow). CONCEPTION OF SCROFULOSIS. As to the conception of the disease to which we give the name of scrofulosis, from the first the importance attached to changes in the lymphatic glands were taken into account, and in the last century changes in other organs, such as the skin, mucous membranes, and joints. Besides the gland enlarge- ments, older phvsicians associated such diseases as goitre, carci- noma, syphilis, scabies, rickets, &c., with scrofula, so that in the studv of these diseases one must always distinguish whether one is really dealing w'ith those diseases which the name indicates. Kortum (1798) made a distinction between scrofula and struma, and a little later Baumes separated glands which were really scrofulous from swollen glands due to cold inflammation or pressure. THE ACIDITY OF SCROFULOSIS. Older writers ascribed changes in the lymphatic system id an idiopathic, faulty mixture of the body fluids, and especially, since Cullen's time, the cause was thought to be an acid sub- stance circulating in the blood (acrimonia scrophulosa). Many consider that scrofula is due to a retention of semen, hence it disappears on the outset of puberty, and they advise early marriage as a remedy. Others attribute it to a peculiar venereal poison, others again attribute the glandular enlargement to some specific change in nerve tissue, and especially to a deterioration in the eighth pair. Baumes holds the view that it is due to lymph deterioration ; according to him, in scrofulosis the lymph is faulty from the first, although one does not know \vhether the acid MISTORICAI. SCRVHY 7 principle; hy wliicli iIk' lymph (N'icrioraU-s is produccfj in thf- lymplialic vessels, lie Iivkcs iIk- .-uidiiy lo ;i i hu l.cnin^^ ot liie lymph. Iluleland considers dial s( rofnia is a local alTcction, sirofulous disease (Caclicsia scroftdosa) being a general di.sordered diathesis of the lymphatic system, due to atony and weakness of the vessels, of which scrofula is only a symptom. Allied to reslricled idio- padiic scrofula there is a false or sympathetic form, symptomatic of the effect of another disease, such as small-pox, measles, syphilis, injuries, and tooili irriiaiioii. When, however, such a sympathetic affection lasts long il can produce such an over- whelming disturbance of the affected lymph system that it becomes an independent disease. Writers attribute changes in the skin (eczema, impetigo), in mucous membranes (catarrh, suppuration), and caries of bones and joints, to the acidity circulating in the blood. When humoral pathology was discarded the doctrine of an idiopathic afTection of the lymph glands and some peculiar scrofulous substance lost more and more adherents. Broussais, Velpeau and Piorry recognized that the scrofulous gland affections were secondary and resulted from changes in the organs from which the glands derived their lymph, namely, the skin, peri- osteum and bones. Virchow supported this view with great emphasis. SCROFULOSIS AND TUBERCULOSIS. Originally the expressions scrofulous, strumous and tuber- culous were considered identical. Van Swieten called the tubercles of phthisical lungs strumae. Portal speaks of scrofulous phthisis; tubercle is for him a rounded tumour containing scrofu- lous matter. Bayle (i 774-1816) considers tuberculous phthisis a chronic specific disease of a scrofulous nature, and calls mesen- teric scrofulosis a mesenteric tuberculosis. Hufeland (1796) describes the " frequent scrofulous consumption of the lung" as phthisis scrophulosa, tuberculosa, or scrophulosis pulmonum, and considers it a metastasis of scrofulous acidity. Laennec most emphatically supports the identity of both affections, seeing in scrofula nothing more than a localization of tuberculosis in gland structures. This theor}^ of identity found many supporters. Lugol calls any patient scrofulous who suffers from tuberculosis. According to him tubercle is a definite structure having an independent existence (like liver, spleenV The development of the disease, which this constitution attaches to itself, embraces the whole life of the individual and that of 8 SCROFLLOSIS his relations and parents. Rilliet, Barthez and Cruveilbier were also supporters of the complete identity of the scrofulous and tuberculous diathesis; RokitansUy considered tubercle and scrofula the same structures. The most decided opposition to this view came from X'irchow. He emphasized the necessity of considering the nature rather than the structure of the disease. The caseous material from which Laennec argued is not a specific substance which is deposited and which might be styled either scrofulous or tuberculous, but rather decayed tissue material. Pus and typhoid substances, cancer, and other tissues rich in cells can also undergo a similar metamorphosis. There are thus several caseous substances, but it does not follow from their similarity that the processes which produced them are identical. Virchow took the specific character of the caseous material for tuberculosis, and considered the starting-point of tuberculosis to be the tubercle, a cellular, non- vascular, heteroplastic new formation. Scrofulous new formations, according to him, are not hetero- plastic but " irritative changes in tissues which sometimes take on a hyperplastic, and sometimes an inflammatory character." Under scrofula, in its limited sense, he understands a disease of the lymph glands — there may be ever so large a circle of other organic diseases included — which depends upon a weakness of single parts or regions, or a certain incompleteness in the arrange- ment of the glands. This dualistic doctrine of Virchow continually gained more support, in spite of individual opposition by Villemin, but it met with a serious repulse after similar tubercles were described by Koster in the granulations of fungous joint inflammations, by Schueppel in hyperplastic lymph glands, by Friedlaender in scrofulous skin abscesses, and always in lupus. Through Koch's discover}- of tubercle bacilli in scrofulous diseases the view of the oneness of the disease appeared to be again quite decided. INJECTION RESEARCHES. Long before the discovery of the tubercle bacilli a number of investigators had sought to establish the possibility of injec- tion of scrofulosis, its nature and its connection with tuberculosis. Kortum (1789) (" materies ex ulceribus scrophulosis benignis efifluens "), Hebreard (1802), Salmade (1805), Lepelletier (1816), Goodlad and Deygalli^res injected scrofulous matter into dogs, guinea-pigs, and a number of healthy children, as well as into their own bodies, without anv result. HISTORICAL SURVKY 9 It is diriicult lo trace tlie cause oi these negative results on account of tlie scanty records made of tliese ex|)erimenls. 'I'lie defective teclinicjue w.-is p.-iilly I" hlamc, p;iril\ ilie unsuitable selection of material and animals cliosi^n for ilic injcci ions, partly also the unduly short observation of tliesf .-minimis, or ilicir pre- mature death from oilu-r diseases. Villemin only gol one positive result by tlie inj(;ction of matter from caseating lymph glands into two guinea-pigs (in another case he had a negative result). Cohnheim and Salomonsohn reported miliary tuberculosis of the iris after the insertion of caseous particles from the glands of the neck removed from man into the anterior chamber of the eye. Schueller reported tuberculous joint affections after the injection of scrofulous caseating lymph glands; Kiener and Poulet always produced general tuberculosis after the injection of scrofulous tissue substance. Colas and H. Martin had the same experience. KOCH'S RESEARCHES. After the discovery of the tubercle bacillus by Koch we became possessed of a sure criterion as to the tuberculous or non-tuberculous nature of scrofulous affections. The importance of these researches demands closer consideration in order that we may comprehend the subject. Koch found tubercle bacilli in twenty-one glands, which histologically were proved to be tuberculous, often, I admit, only in small numbers and especially in or about the marginal zone, and twice only in the interior of the caseous focus. He found the same thing constantly in thirteen cases of bone and joint affections, which, both clinically and histologicallv, were characterized as tuberculous or scrofulous respectively. Koch could find no tubercle bacilli in the pus of one case of spinal caries, but in this case he could produce tuberculosis by injecting the pus. In the same way he found tubercle bacilli in four cases diagnosed as undoubted lupus, in an excised portion of skin, onlv once after the twenty-seventh section, and onlv once after the forty-seventh section. More recently, as is well known, it has been possible bv the antiformin method in combination with Gram's stain ro discover the bacilli much oftener in such structures. Further, from excised scrofulous neck glands in man, Koch has cultivated tubercle bacilli for many months in an artificial culture medium without being able to detect anv difference either lO SCROFLLOSIS in their growlh or virulence from those derived from a tuberculous lung. Finally he proved the tuberculous character of scrofuKnis structures by injection experiments. Scrofulous gland substance from three cases injected into ten guinea-pigs resulted in all cases in marked tuberculosis, first in the lymph glands in the neighbour- hood of the injection and then in the other organs. ()nl\- it was discovered iliai the cH)ursi' of (he tuberculosis was verv slow on account of the small ntimber of bacilli contained in the injection. Gland substance containing bacilli placed in the anterior eve-chamber of four rabbits also gave rise to the following well-known appearance : tuberculosis of the iris, casea- tion of the bulb and of the neck glands, and tuberculosis of the lungs. Inoculation of particles of tissue from six cases of lupus into eighteen rabbits and eight guinea-pigs gave similar positive results, as did also pus from a tuberculous elbow-joint injected into four guinea-pigs, and from a case of spinal caries injected into five guinea-pigs; finally injections from lupus and a fungous joint also from a scrofulous gland gave pure cultures. The opinion that Koch constantly found tubercle bacilli in scrofulous glands is generally held. This opinion, which led to quite false conclusions, is erroneous. Koch says as follows : " Altogether twenty-one cases were examined, the glands of which were proved to be ttiberculous," and means by this, " the presence of epithelioid cells which were grouped together and enclosed more or less numerous giant cells." " Only in glands which had such a tuberculous structure could any tubercle bacilli be proved to exist. On the contrary in a number of cases in which the glands were enlarged and had partly become soft and filled wMth pus foci, but in which the epithelioid cells and the giant cells as well as the characteristic tissue necrosis were wanting, no tubercle bacilli could be found." FURTHER CONFIRMATION OF THE NATURE OF TUBERCULOSIS. The researches of Koch which formed the basis of his theories were repeated and confirmed by other authors. Tn fungous bone and joint diseases described as scrofulous Demme found tubercle bacilli (always isolated) in the excised tissues fifteen times in seventeen cases, whilst Schuchardt and Krause found them in twenty-seven cases (including fourteen tuberculo- scrofulous abscesses), but in the cases of abscesses only in the abscess membrane, not in the pus. Muller found them in thirty lUSTOKICAI. SIRVKY ' I to thirly-five cases at most. The Init.r l<-avfs il an open (jucslif^n whether the negative cases ((uiM n-.i inrn oiii i<> I)'- positive by further search. Further, K;m/lcr IouikI i ii1)^ s enough. C. Fraenkel and Baumann could cause disease in guinea-pigs Avith a massive culture of i : 100,000 millions, and righth- supposed ''■ Thus, for example, Liebe refers to Gebhardt's experiments, which show that milk even with a dilution of i in 50 loses its power of infection. 26 SCROI-'LLOSIS thai with many baciUus cuUures the transplanting of one single germ (natmally a living one) sufficed, which coniirms my state- ment made in my lirsl issue, and which agrees with the t)pinion of Oehlecker. But if we have no lowest limit under which lulx'rcle bacilli are incapable of producing infection, still iIktc is no doubt that the number of bacilli influences the type and the course of the infection, as is proved by numerous experiments, many of which have been made by myself. If from the first a large number of bacilli enter into the tissues they will be dispersed over a large area through the lymph channels, and will immediately form numerous foci. Their pro- pagation is therefore more abundant, and the effect which with one bacillus it would have taken months to attain is in this case obtained in weeks. Thus it is that inoculation of animals with scrofulo-tuberculous matter from glands, bones, or lupus of the skin containing few bacilli has a much more tardy course than an inoculation with sputum, cultures, or pieces of tuberculous lungs containing many bacilli. Besides which, in the case of these inocu- lated particles of tissue, which are poor in bacilli, the bacilli are often covered or encapsuled, as one might say, by layers contain- ing no germs. I will only mention lupus, in which Koch found no- tubercle bacilli till after the 43rd section. The bacilli can only come into action when this dead layer is absorbed; it is on this account that the process is retarded. On dead soil these particles fail ta grow unless they are well rubbed in. If before inoculation such particles are carefully reduced in size, rubbed to powder and flushed with some fluid, the bacilli wdiich have been set free develop a much more virulent character, and cause, as I have been able to prove, much more speedy and intensive tuberculosis in the same time than if the piece had been inoculated whole. This difference in the nature and preparation of the material for inoculation may have contributed largely to the divergent results obtained by different investigators. It has, therefore, been required lately that when making tests for virulence only such particles of tissue shall be emploved as have been made uniform by culture (see p. 33), Recentlv a means has been found of simplifying these experiments in inoculation and of placing them on a surer basis by the antiformin method (see p. 247). Further, in the material for inoculation from such chronic processes as scrofulosis and tuberculosis which, intra corpus, do not appear to have nearly that length of life which the imagination of many authors has assigned to them, a considerable part have CONCEPTION ANJJ CLASSIMCA'JION OF SCROI'ULOSIS 27 died oil, and aL die same lime as die few living Ixicilli are inoculated there will be the debris of decaying bacteria — toxinswhicii will be inoculated in the sam(; place. This causes great irrilalion of the tissues. We have in them one of Nature's principal remedies, and reaction at once takes place, a sc^rt of healing process, or encysting, which hinders more or less the dispersal and multi- plication of the bacilli inoculat(;d at the same time. The slower progress of tuberculosis which Baumgarten, Gosselin, and Wesener obtained by inoculating tubercle bacilli, which had been attenuated by iodoform or other chemicals or putrefaction, may be explained in tlie same way. It is clear that the greater part of these must have been dead or decayed, and .so have anticipated the conditions of nature healing. We leave the question of how far the processes of immunity can be imitated by them out of the question. For all these reasons scrofulous materials when inoculated into other bodies may, now and again, show a slower and less active effect than that which has been obtained by acute or even virulent processes. So, although the statement has been so often made that there is reduced virulence in the bacilli from scrofulous foci, no proof has ever been forthcoming that is entirely conclusive; and even the work of Vagades, who was the first to make tests to dis- cover the difference in the virulence of tubercle bacilli, did not com- pletely succeed in removing the doubts entertained about it. (b) Bacilli of Human and Bovine Tuberculosis. The question of the virulence of the tubercle bacilli in scrofulosis has appeared in quite a new light since Koch (1901) demonstrated that the exciting causative agent in human tuber- culosis and of bovine in cattle is not identical, which had been the accepted theory up till then, but that they represent different types, if not different species, which act in a different manner on men than on animals, both in their biological and in their pathological behaviour. This gives us a clearer understanding of the etiology of scrofulosis and throws light on many a dark question ; but it seems strange to us that this point has been so little insisted on in the recent literature on scrofulosis. In Mllemin's time (1865) human and bovine tuberculosis were considered different, and were only identified after the great sensation caused by the discovery of the tubercle bacillus and the authoritative explanation of Koch in 1882. The merit of again drawing attention to certain differences in the morphologv, the cultural and animal pathologv of tubercle bacilli of human 28 SCROFULOSIS or bovine origin, is due to Theobald Sniiili. It was he who set the ball rolling; but who knows what would have been the fate of the conmuinication if Koch had noi been induced lo test the circunisiances more closely ? The remarkable circumstance, that fur iweniy years after the discoverv of the tubercle bacillus, the human and bovine types were considered identical and were acknowledged, or rather, re- discovered so late, in spile of the discoveries of Villemin, Langhans, Orth, von Baumgarten, which point to it, may be explained by the almost exclusive use of the guinea-pig as animal for experiment on tuberculosis, not only because these animals are cheapest and easy to obtain, but also because they react most exactly and most speedily on both types of tuberculosis. Rabbits were less often employed, excepting for intraocular experiments, on account of their susceptibility to other infectious diseases, which often had a disturbing effect on the experiments. Its lower susceptibility to human tuberculosis had been long remarked, and I remember the time when I was assistant at Goebersdorf (1885) making many fruitless experiments with Petri to infect rabbits with sputum, which finally made us doubt both our skill and the accuracy of the information imparted by others, and to support the incipient scepticism of Brehmer with regard to tubercle bacilli. The striking statements of many authors who relied on ex- periments on rabbits, which statements contradicted my practical experience, can now be satisfactorily explained. I will only men- tion the numerous therapeutic successes claimed by French investigators, who were deceived because they inoculated rabbits with human tuberculosis, to which they are almost insusceptible, whilst my after tests (see Zeitschr. /. Hyg., vol. vii) on guinea- pigs, which are decidedly tuberculous animals, were one and all without result. A revisal of the experiments in this direction is advisable. One great mistake was that they only took into account (as did Koch), when endeavouring to explain the individual dis- position of animals, the inconstant results obtained by inoculating rabbits with bacteria of different origin, which are always one- sided on account of the endogenous factor, instead of studying more closelv the exogenous factor which certain schools, more especially in recent times, seek, again so one-sidedly, to press into the background, vestigia terrent. It is not the place here to discuss this much-contested ques- tion more closely. Reference must be made to the voluminous literature on the subject, especially to the works of Kossel, Weber CONCIil'TION AND CLASSIMCATJON Ol' SCKOl'l. LOSIS 2(} and JlcLiss, TauLc, 'iilzc, Oclilcckcr, as layin^^ lli'- foundaiirm, and to the reports of the English Commission lor Investigating Human and Animal Tuberculcxsis, to the debates of tiie Congress on Tu1)erculosis at Wasliinglon, 1908, and the works f>f I-'ihiger and Jensen, i.ydia Kabinc^witsch, Beitzke, Eber, Uurckharrlt, &c., &c. The statements of Koch, as conclusive after tests, have been confirmed, that is to say, wilii some modificatirms. The results, which are of the highest impc^rtance, especially for the etiology of scrofulosis, may be thus summed up : — Tubercle bacilli obtained from tuberculous human or bovine structures cause immense tumours, from ilie size of tin; fist tfj that of a child's head, when subculaneously injected into cattle; these tumours appear either at the place of inoculation or the nearest prescapular gland and the neck glands, and lead almost without exception to progressive, and at last to general tubercuhjsis, with fatal ending. In apparent exceptions, as in the case of Kossel, where the process was conhned to the prescapular gland, an intra- venous injection revealed the same complete and high patho- genicity as in other cases. The tubercle bacilli obtained from tuberculosis in human beings are divided into two groups : the one, which comprises the great majority, when subcutaneously injected into cattle, causes no progressive tuberculosis; the animals continue to live, unless they succumb to some intercurrent malady. Considerable swellings, the size of the palm of the hand, appear at the place of injection, which often suppurate and break through the skin ; further lumps the size of a walnut, a hen's or a goose's egg are formed at the nearest prescapular gland, some- times beyond it, at the middle and lower neck glands ; in the course of time these reduce in size, or even disappear completely. If the animal be slaughtered after four to six months, either there are no modifications to be discovered, or, which is most fre- quently the case, swelling filled with caseous or creamy pus at the place of injection is noticed ; but in many cases a partial or even considerable swelling is discovered in the nearest prescapular gland containing caseous or chalky masses; and cvsts of connec- tive tissue are formed as a protection against the environment (see p. 117). The longer the animal lives the smaller are these pro- cesses, and the less often are they found. We are dealing here with processes which remain localized on the place of injection or deposit, and with the glands which lie nearest ; and where casea- tion sets in a spontaneous retrogression takes place after a longer or shorter period, or they become covered with chalk or lime. In a smaller group, the tubercle bacilli obtained from man ^O SCROFULOSIS coincide exactly with the bovine bacilli and cause general pro- gressixe tuberculosis in cattle. The counter test, the inoculation of bovine bacilli in man, is illustrated by some experiments. Baumgarten informs us that considerable quantities of bovine bacilli had been subcutaneously injected into more than half a dozen persons suffering from malig- nant tumours, and there was no resulting malady in consequence, with the exception of small abscesses. Spengier and Klemperer inoculated bovine bacilli into their own bodies unsuccessfully, Small as is the number of these experiments, they go to prove thai, as a rule, bovine bacilli possess no perceptible virulence, at least for adults. The different pathological behaviour of human and bovine bacilli corresponds clearly to morphological and cultural differences, which are emphasized on certain cultural media (serum) and on others are lost. The bovine bacilli are shorter, thicker, and more elongated, many are wedge-shaped and thickened out to a knob at the end, and more highly coloured. Human bacilli, on the contrary, are slimmer, somewhat curved, the ends of the same thickness, and are uniformly coloured; the former are more difficult to- cultivate, of slower growth, and have a tender covering, which later be- comes nodular, wdiilst the latter develop in culture an eminently thick covering and swollen folds. These differences in patho- genic and biological behaviour undergo no rapid change, but are stationary characteristics, which remain in the bacteria in later generations, whether they are further propagated in culture or in animals. It is clear, then, that we have to do with two different types : that which is as a rule found in cattle, the bovine type (bovine tubercle bacillus), which for cattle is highly pathogenic, but, judging from its rare occurrence amongst men, is of less virulence or avirulent for them ; and that which principally occurs in man, the human type (human tubercle bacillus), which is highly virulent for man, but for cattle is less pathogenic or non-pathogenic and causes no general and progressive tuberculosis. The method of their differentiation is fully discussed in the chapter on Diagnosis (p. 266). On account of the importance of the bovine type in the genesis and course of scrofulosis we must examine the question of the results of experiments above mentioned a little more closely. It may be presumed that ihe results brought forward are established facts; where they are contested it is with reference partly to unimportant matters, or when they are supported bv single observations which are subject to the chance accidents, CONCEPTION AND ri.ASSIl' ICA'I ION Ol' SCJiOI- ULOSIS 3 I •or by exj)cfiinen(.s wliicli do noL coiilorm lo ilic (k-mands ot exact experiments which Koch so precisely (Idincd ai \\\<: Wash- ington Congress (see |). 2O7;, and ih* rfforc rannoL claiin lo \)c of value. Thus it has been much dispulcd vvlicthfr die two groups represent one species or not. Arloing, von lichring, I'ibiger and Jensen, de Jong, Goggia, Maragliano and his school defend the unilary idea by designaling die luoiphological, cultural, and pathogenic characters as inconstant and insufricifnt for the separation into different species. The question whether there are two species is only scientific- ally interesting; in practice it is quite secondary. We best avoid deciding it by using the term introduced by Koch and saying two types, which binds to no distinctive characters. Differences in Virulence. — Some few authors do not dispute distinct differences in type in the sense that bovine bacilli repre- sent higher virulence, but this is contradicted by the simple fact that the species of bacilli which are highly virulent in cattle are non-virulent in man (von Baumgarten, Kiemperer, Spengler), or exhibit only a trifling amount of virulence, with the exception of a few cases where the issue has l^een fatal (see p. 39), and yet when re-inoculated in cattle develop their former complete viru- lence. Koch, Kossel, Oehlecker, Burckhardt, &c., think that a division into two types is justified, basing their theory on the results of exact experiments. Others state, on the contrary, that the cultural qualities peculiar to both types are not always clearly perceptible and do not ahvays coincide with the conclusive patho- genic characteristics. Thus Lydia Rabinowitsch introduces a third form, the atypical species, as an intermediate form between the human and the bovine type, wliich answers to what the English Commission termed the intermediate group. Beitzke. Theobald Smith, &c., think we cannot manage without such an intermediate form. As to cultural differences, these only appear clearlv, as Weber, Oehlecker and Koch have repeatedlv and emphaticallv insisted on, in the above-mentioned culture (see p. 26S), and onlv then when they are freshly taken from man and animals. Even differences which are hardly perceptible in the pre- paration of tlie culture medium as well as changes in temperature modify the cultural characters. Differentiation will also be caused by the choice of the material subject to experiment, wdiether w^e take the quite fresh, thin, peripheral portion of the culture film or the more central thicker part. This fact has been 32 SCKOFULOSIS emphasized by Fibiger aiul Jensen. It is possible to produce from the same strain culiures of completely different appearance. If several infltiences combine which are unfavourable to differentiation, the characteristic marks lend to disappear. The preliniinarv conditions of culture to obtain an exact differentia- lion are very delicate, and it may be readily understood that if they are not sufficiently observed it may lead to the appearance of atypical forms. These researches, made with the object of masking and effacing these cultural differences in artificial culture media and lo prove the relationship of the two types (a thesis which no one has doubted), in no way comply with these conditions. It is just as if we endeavoured to study the racial differences between a white man and a negro in pilch darkness. Our task should rather be to seek to make these differences more discernible than to do the contrary. If we chose for comparison from a series of parallel cultures the finest grown, as we naturally should, we should succeed without difficultv in introducing intermediate forms between the two types. The special character of these apparently atypical forms is also questionable from the fact that these deviations from tvpe, caused by unknown influences, mostly disappear on further culture (Burckhardt). Experiments in animals, too, will only lead to a clear com- prehension of these differences under certain sharply defined and subtle hypotheses. For example, if we subject an animal which is onl}' slightly susceptible to an intravenous injection Avith human bacilli a pathological appearance will ensue which will differ but slightly from virulent bovine infection. Now an exactly uniform arrangement of the experiment leads to a comparison against which there can be no objection, for besides the influence of the type, unintentional accessory circum- stances often exercise an influence, such as the quantity and the freshness of the culture, the fineness of the trituration, also the age and weight of the animal, the manner of inoculation, the unintentional piercing of a small vein ; added to this, stocks of the same type exhibit certain variations as to the amount of poisons contained and their activity; also animals varv much in their susceptibility, especially rabbits. If one of these agents which are favourable or unfavourable to infection be present during the experiment, there would naturally be deviations from the aver- age true pathological effect, even when the same tvpe is employed, which may lead even skilled investigators to false conclusions unless repeated experiments correct the error. CONCKP'IION AND CLASSI I- K A I ION OF SCKOI- LI.OSIS 33 The inlrndiiclion of idiop.-ii liic I iilxTciiloiis infn, and niisi<'ikiii|4 liihcn iilniis ( liaii<4c.s f-u- die .sympioms of intercurrent maladies — as niisiakinj^^ coccidian processes in rabbits for the sepliciLMnic processes (see p. 273)— frecjuendy give rise to faulty results, the more easily the fewer the experiments. ll cannot be loo ot'lcn insisifd on diat (;.\perimenis ber). If both types are combined in the original material, both will thrive in guinea- pigs, whereas in rulture the l)ovine type will be suppressevl h\- the human, but when furllicr iransplanled in a suitable species of animal — rabbit or cow — the bovine bacilli may, although there was no trace of them in the culture, gain the ascendancy over their non-\ irulent competitors. We know from ilu- experiments of C. Fraenkel and Baumann that infective material, even in the proportion of 1:100,000 millions, is capable of producing dis- ease. Stocks of the sarne type may show among themselves only slight lluciuations in growth and virulence which, especially under certain conditions, brings them apparently' nearer to the other tvpe; evidences based on a series of exact experiments and free from all objections which would make the introduction of an intermediate tvpe needful are at present lacking. Change of Type. — Manv authors, especially those who oppose the separation of the tvpes, think that both types represent only one varietv adapted to the species of animal (Dammann and ?\Iues- semeier, &c.), that thev may be cultivated one on the other, and that it is also possible that the changes can take place in the human bodv. The relative frequency of bovine tuberculosis amongst children and its rarity among adults was even endea- voured to be explained by this transformation of bovine into human bacilli. This question is also of the greatest importance on account of the possibility of bovine scrofulous infection resulting in pulmonary tuberculosis. According to the accounts of voaBehring. de Jong, Dammann and Muessemeier, the \irulence of the human tvpe mav be increased by passing through the goat. I prefer not to enter more closely into these accounts and will refer to the criticisms on them by Kossel, Weber and Burckhardt. I will only remark that in the experiments of von Behring, Roemer and Ruppel, besides three negati\e successes, in one case an increase of virulence was apparently obtained, but according to the condition of things the cause of the delusion may have ])een the introduction of bovine bacilli (Kossel). In the experiments of Dammann and Muessemeier, who observed an increase of virulence after passing three times through rabbits, and in another experiment five times through goats, the bovine bacillus appears to have been the unbidden agent in producing spontaneous infection, as the sudden increase of virulence seems to intimate, besides which infection was partly CONCIil'TION AND CLASSU'ICA 1 ION OF SCKOFLLOSIS 35 induced by organic malcri.-il, \vlii( li f.\|jcrimcnt.s, according lo die above analysis, are noL conclusive. Tlie J^iglish C'onmiission on 'riib\ die bacillus; but Gruner, on the other hand, found sponiam-ous re.-icijon in tuberculosis of the bone similar to that found in s( rofnlosis, duTcfore lii_L,di''r than that of tuberculosis. The English Commission gixcs ol)ser\ations on 20 eases of lupus; in 8 cases the tubercle bacilli culiivated from it had the cultural signs of bovine tuberculosis, Inii in the case of calves and rabbits they proved themselves in part less virulent. Besides these, isolated cases of Weber, Burckhardt (one case of 17 years) were of human type. Rosenberg, who observed that primary nasal and pharyngeal lupus was often found amongst women and girls in the country, raises the question whetlier the bovine type does not come into play here. The importance of bovine infection for tuberculosis in man is therefore in general very inconsiderable ; on the contrary, in tuberculosis of children, especially in tuberculosis of the mesenteric and neck glands, it plavs an Important part. Amongst the cases mostly regarded as scrofulous, according to observations hitherto made, it is the cause of more than a third of all the most severe cases, in an examination of the lighter ones the proportion in favour of bovine infection would be considerably increased. There is no basis for Abramowski's distinction, according to which torpid scrofulosis is of bovine, but irritant scrofulosis of human nature. A complete separation, such as Caw and Raw tried, by stating that tuberculosis caused by inhalation was of human origin — that intestinal tuberculosis, tuberculous peritonitis, tuber- culosis of the bone and joints, lupus, miliary tuberculosis, uro- genital tuberculosis, and tuberculosis of the middle-ear, were caused by the bovine type — is contrary to the fact that in intes- tinal, and especially bone tuberculosis, human iDacilli are fre- quently foimd. By the demonstration that bovine bacilli are frequently the cause of scrofulous tuberculosis, the knowledge of this disease has been much advanced, and manv striking svm- ptoms are explained bv it. Thus it is a well-known fact that scrofulosis appears, as a rule, towards the end of the first and second vears. Bovine 44 SCROFULOSIS iiifeciic)!! appears alnictsi wiiluiu: cxccpiion afler the first }ear ; primary tuberculosis of ihe mesenteric glands wiih the bovine characteristics is rare in infancy. Fibiger and Jensen have described two such cases (ii. 12) in which the consumption of milk from a partly tuberculous cdw was proved. As Eden's and others have remarked, the reason of this lies clearlv in the fact that in infancy, even amongst the poorer classes, the milk is generally boiled, whilst in later years, besides fre- quenilv consuming milk in ihe raw slate, butter and other milk products increase Ihe opponuniiics for infection. Contradiitions which have hitherto been found in treatises on scrofulosis ami tuberculosis now find a satisfactory explanation. The relation of scrofulosis to tuberculosis, including consump- tion, has been described in many ways in the course of time. For centuries it was a clinical axiom that scrofulosis predisposed to tuberculosis. Former clinical experience had taught that most of those who suffered from scrofulosis died later of tuberculosis of the lungs, and found in this fact support for the etiological identify of the tw^o diseases. According to a recent statement, which is as yet unproved, those who are predisposed to scrofulosis possess a certain amount of protection against tuberculosis on account of their violent re- action to unaccustomed irritation, which, according to INIoro, is an act of self-preservation, and the mild course of scrofulous tuberculosis is owing to this. But they forget in this instance that morbid over reaction has not the same effect as the reaction of healthv tissue, just as little as the flabby granulations of the weak, in tlie healing of a wound, have not the same efifect as robust granulation. Tn strict antithesis to this, Czerny states that just by com- bating this exudative agent he has changed such weaklings " into blooming children with tuberculosis." One sees how easv it is for (^linical experience to be iniluenced bv preconceived subjecti\-e opinions, which give rise to false conclusions unless based on temperate figures. When speaking of the ttiberculosis of childhood, Kar €to')(i)v (human infection), its great danger is unixersallv emphasized. In the period of infancy it is considered to be, almost without excep- tion, fatal ; but also in later years it has a decided tendencv to spread and attack other organs, as the experience of all patho- logists and phvsicians for children's diseases concur in proving. On the contrarv, in all treatises on scrofulosis, which is even attempted to be merged into tuberculosis, it is especiallv noted how favourable is the course it takes in the Inro-pst number of cases, CONCKI'TION AND CLASSIMCATION OF SCROFULOSIS 45 that no one dies of scrufulo.si.s, also oilif-r remarks \vlii( li hardly agree with ihe above sad pictures. Escherich calls the jmhc scrolnlosis caused by tuberculo-loxic changes in the inlegunienls the most harmless of infantile tuber- culosis, which even offers a sort of protection against later tuber- culous infection; and also scrofulous tiibfrciilosis occurring with manifest foci appears 1ii(li-l lirsf lil<-lrtion remains staiionary, sd tliai he considered them as one of the earliest constant symptoms of asthma. \'entura mentions hypertrophy ()f the liver as one of the s\mi")loms he has found with tolerable freqiienc}' in the extidative diailu'sis. It would lead us too far to go more closely into the relation of the exudative diathesis to the status lymphaticus of Paltauf- Kscherich, with which are included a series of symptoms; or the subordination of both, the diathesis and the siaius Uniphalicus, bv Eppinger and Hess in the infantile form to the condition of tone in the vagus; or tlie connection Axiih Comby's rheumatism in children, and similar questions which still need further discussion. Reference must be made to the interesting anatomical studies of Bartel and Stein, according to which, in the status Ivmphaticus of Paltauf-Escherich, a disturbance takes place in the develop- ment of the lymphatic gland system, and in the connective tissue; whether such a disturbance can be taken into account for the exudative diathesis, whether it rests on congenital inferiority, irrital^iliiy, and ready deterioration of the meso-ch^•me and its derivatives (Pfaundler) are suppositions, the proof of which covers a wide ground. As an external sign of the exudative diathesis Czerny in- cludes a mapped condition of tongue (not always a reliable sign), seborrhoea, milk-scurvy, prurigo or strofulus, intertrigo, sore- ness behind the auricle, in the folds of the neck and armpits, pro- nounced hairiness between the shoulder-blades, in the region of the elbows and on the thighs (Friedjung describes a similar con- dition as a sign of the tuberculous habitus). Freund also mentions stiff tufts of hair which Pfaundler describes elsewhere. Further indications are eczema, impetigo, vesicular eruptions, caries of the teeth, diffuse bronchitis and bronchiolitis, sometimes combined with asthma; further, catarrh of the nose and pharynx — symptoms which are not characteristic of themselves, but become so by frequent repetition; further, an increase of the lymphoid tissues of the gums, tonsils, and pharynx — blepharitis, vulvitis, balanitis — paleness of the skin beginning in infancy without haimatological indications of auc-emia and not caused by improper nourishment or preceding illness; loss of appetite at times, some- times fever lasting several days, and coated tongue, with or with- out disturbance of the general health, but without the stomach being affected. In the case of the intestinal canal, Czernv at first only acknowledged the mapped tongue (1905), and later hyperplasia CONCICPTION ANI> CLASSII' ICA'I ION OF SCKOI' CI/jSIS 55 of the inlcslin.'il follicles ns sij^Mis ol ilir cxudalivf- diallif-sis, bui Langstein and (iocppcii csinblislicd slimy stools cfjntaining pus to be an external indic.'ii ion ol ilic dial Ixsis (see also Sehlbach). Of the symptoms of exudative diadicsis here Ijrouglil forwarri some do not belong to scrofulosis in our sense, but they (such as milk-scurvy) are the Jicknowledged indications of disturbances in nutrition, and are sometimes the f)re(iirsors rtf scrofulosis by favouring infectious processes. In this connection Czerny (who purposely avoids ilie expres- sion "scrofulous"), to avoid controversy over the identity of scrofulosis with tuberculosis, comprises in his conc<-piion of tiie diathesis phenomena, such as vesicular eruptions, denial caries, blepharitis, with which there can be no f|uestion of diathesis, and readiness for illness, but which rightly and by general consent belong to fully developed scrofulosis, and are consequently pheno- mena of diathesis plus the infectious processes which have been facilitated and maintained by it. This is just as little justifiable as if we classed florid phthisis under our notion of the term tuberculous disposition. The exudative lymphatic diathesis with its manifestations can only be taken into account as a preliminary stage of real scrofulosis, as a favourable field for the development of further morbid reaction, which itself is induced by external irritation, and almost without exception by bacteria ; it is true many symptoms that stand on the boundary between diathesis and scrofulosis can be adduced, e.g., eczema amongst skin phenomena, amongst affec- tions of the mucous membrane, catarrh and hypertrophy of the tonsils, now and again perhaps induced by alimentary irritation, overfeeding, or errors of nutrition. In such cases bacteria play only a secondary part by keeping up the process, but it is a con- firmed fact that for the real scrofulous phenomena, and especially for the pathognomonic indication of scrofulosis, the exceptional pathological processes must be made answerable, and such pro- cesses are induced by bacteria and their toxins (see also previous chapter). When Pfaundler raises the question, whether exudative diathesis alone in concert with tuberculous infection is enough to induce the tv^pical phenomena of scrofulosis — when he at the same time emphasizes the universal experience that there are plenty of children, especially amongst the better classes, who, in spite of exudative diathesis, in spite of superabundant nourish- ment and overfeeding, and in spite of tuberculous infection and active disease, relatively seldom exhibit the pronounced signs oi scrofulosis — there is, in fact, an unintentional and unwilling 56 SCKOFLLOSIS acknowledgment of the important part played by the badly treated pyogenous scrofulosis, the infection by dirt, which is naturally more rare with the better classes, whereby the " pro- nounced cases," when it is not a question of tuluM-culous glands, are avoided. It will hardly be contested that much of the diathesis theory is completelv unproved and lacks exact foundation, that much remains to be explained before the path from Czerny's " innate defect " to the complete phenomenon of classical scrofulosis can be considered free from doubt. One thing that speaks in favour of this theory is the fact that preceding the development of scrofulosis there have been, almost without exception even in the infantile stage, certain indications of lymphatism, of mapped tongue, seborrhoea, and milk-scurvv conversely, that at the same time, especially in the first vear and frequently later, no tuberculous infection existed, as is proved by the negative result of the tuberculin test, even with these children who are so highly sensitive to reaction. Unfortunately, at present we possess no means similar to the tuberculin test to prove the presence or absence of pyogenous infection.^ We do not deny a certain exudative predisposition, a coin- cident increased readiness for disease — recognized by an increased tendency to react to irritation, especially bacterial irritation in children causing an obstinate and protracted reaction — but we must bear in mind that the facts which have up till now been obtained give us no insight into its nature ; whether we have to do with a chemical defect, or if it be really a disturbance of metabolism of the fatty matters, which is the gist of Czerny's theory, for it is especially in this direction that an exact basis is lacking. Thus, the older notion, still retained by the French, of a lymphatic constitution, lymphatism, has found new followers in Escherich, Moro, &:c., but with the interpretation that it is a constitutional anomaly which distinguishes itself by a " great tendency of the organism to inflammatory reaction of obstinate and recurrent nature (with exudation of lymph) in which the lymphatic tissues take a decided primary and secondary' part," a conception somewhat divergent from that of the older phy- sicians — Ilufeland, Bandeloque — who find in the lym|:)hatic tem- perament of the lymphatic constitution the only conclusive ^ When therefore Pfaundlcr thinks it is possible, by excluding such cases as react to tuberculin, to study the character of genuine diathesis without complicating infections, this is not to the point, as we cannot exclude pyogenous infection. CONCEP'IION ANIJ CLASSIFJCATKjN Ol- SCKOl- (.I/JSIS 57 reason for scrofulosis, and define scrofulosis as ilie liiglif-st degree of the slatLis lyinj)l)ali(:u.s. l\igli(ly nndcM'Slood, llie ( onibinal ion of ihe expression lymphatism willi iIk; etiology of s( rofiilosis is debatable; even as a designati(^n of the cc^llective s(rofuh)Lis tendency I consider it inappropriate, because by drawing attention lo the lymphatic system only, it is only a part of the tendency, a part of ilie readiness tliat is denoted; while it is recognized, as Virchow has emphasized in his defmiiion, (hat a certain abnormal preliminary state of the skin and the mucous membrane exists in a prominent degree, let the cause be what it may. But even if we accept the supposition, which is completely unproved, that lymphatic symptoms are really caused by the scrofulosis, that they are its cardinal point and essence and not symptoms, where can the boundary line between lymphatism and scrofulosis be drawn ? The designation " exudative diathesis " would be more suitable, inasmuch as it includes the symptoms of the disease and yet does not bind us as to the etiology ; it at least comprises the cycle of changes in the skin, mucous membranes and lymphatic glands, unless a strictly etiological term be preferred. The adherents of lymphatism, Escherich, Moro, as well as Czerny in his exudative diathesis theory, go beyond the mark when they, without due grounds, designate a part of the scrofulous phenomena simply as lymphatism, the greater part of which the the facult}^ have for centuries termed typical scrofulosis. Escheric and Moro remove the whole boundary line ; for them, Ivmphatism is no diathesis, no readiness for lymphatic processes, but the process itself ; thus they exclude the greater part of what everv one understands by scrofulosis, with the exception of those affections induced by tubercle bacilli. Scrofulosis is onlv Ivmphatism combined with tuberculosis ; the lymphatic constitution is the ground in which an accidental tuberculous infection will develop scrofulosis. Does Moro believe that all the cases of non-tuberculous scrofulosis (he uses this expression once) arise without bacteria, and if not, why does he not state it ? To what serious conse- quences, or rather inconsequences, may this not lead us ? Does not the clinical aversion to bacteria go too far, and is not a too important part ascribed to the exogenous factor ? Moro says it is frequently tuberculin reaction alone which enables us to discover the non-scrofulous cases in this class, for the external complex of symptoms which such children exhibit can, under certain circumstances, be so deceptively similar to those 58 SCROFULOSIS \vhich characterize scrofulosis, that at present no other means v^f distinction by clinical examination can l)e used. This is especially the c^se when children exhibit the dermatose habitus already described, in the form of chronic eczema on the face and ears, impetigo, or -an eruption resembling lichen on the trunk, or when inflammation of the lymph glands, the eyelids, and the conjunctiva are present at the same time. Moro terms children with, as he himself admits, all thc^ decided external symptoms of scrofulosis (with scrofulous habitus; not scrofulous but lymphatic, for the single reason that they do not react positively to the tuberculin test ; therefore, according to Moro, all the old classical cases of typical scrofulosis (one has only to read the history of his cases and their progress) (see above) are not scrofulous because no tubercle bacilli have come into contact with the organism is question; but these individuals (he describes two cases) belong to the scrofulous class from the moment when the reaction becomes positive. It is all the same even if the positi\e reaction (see my cases, pp. 18-21) is induced bv some latent focus, a small, completely inactive and already healed bronchial gland, caused perhaps by bovine bacilli, the allergic of which perhaps remains, and so by an accident that has nothing whatever to do with the phenomena of scrofulosis. Yet the behaviour of such glands in scrofulous children (according to Moro, lymphatic children) follows the same statistical law of frequency as in normal children. Is it not turning logic upside down to pull to pieces what clinical observation has taken centuries to build up, in response to what are, at least in many cases, irrelevant accidental circum- stances ? Moro supports his opinion by two cases^ affected with all the signs of scrofulosis which reacted positively after a previous negative reaction ; but in such cases, of which there are doubtless thousands, the infection which has taken place in the meanwhile, if it had been caused bv bovine bacilli, remains strictly localized in the primary focus, and after a while disappears without leaving a trace; but when virulent bacilli enter the lungs, phthisis or miliary tuberculosis may ensue, but whether the bacilli act upon the scrofulous phenomena already present and change them no one can say. In what way have the signs of scrofulosis which are now present — the eczema, the impetigo, and vesicular erup- tions — changed, that one must now call them In- another name? ^ ^Toro says after discussing the two cases, " Such observations lead us to think that there must be some genetic connection between lymphatism and tuberculosis." CONCICl'TK^N AND CLASSIl' ICATION OF SCROI' L LOSJS 59 To mv mind I lie .-u ( ci)!,-!! ion of Morn's pomi of view W(juld only bring nior*- (<»nlii,sion inio iliis alicad} ol)s< iir'- (|Mr-siion instead of making il nmif < Icar. vSollmann brings forward a completely (Jilferenl (Opinion- He considers scrofulosis an hereditary, non-bacillary toxic tuberculosis; according to his view the normal placenta forms a filter for corpuscular elements, which it retains, and alUnvs of no return when il is diseased, injured or eroded; but lo matter in solution the iniact placenta allows free passage. Soltmann thinks that in tuberculous persons ilu- products of the changes of the tissues and liie debris of bacilli uhich are in solution — the tuberculous toxins — pass over from the tuberculous mother in the foetal stage, and by their chemotactic effects induce lasting toxic symptoms. According to which, that which one designates hereditary disposition to tuberculosis is hereditary diathesis, and the time of its appearance, and the way the conse- quences will manifest themselves, depends on how much material for defence there is at the time of birth. Soltmann's idea has at first view something fascinatingly simple in it, for it is known that toxins can produce changes similar in many respects to scrofulosis. A plausible explanation was found for the sluggish course, different from that of the usual bacillary infections, for the appearance of tuberculides and a series of phenomena which present difficulties, also for the not rare fact of scrofulous children being descended from tuberculous parents and the fact of scrofulosis running in families. At the same time important considerations tell against it ; in the first place, scrofu- losis does not appear immediately after birth, but mostly at the end of the second half-vear and in the second year, and also tuberculin reaction (a fact which is of great importance) appears very seldom in the first year when the toxin must be most opera- tive, more frequentlv from the second vear, when an elimination of the toxin mav be expected; further, though truly scrofulous children often descend from tuberculous mothers, but very fre- quentlv from non-tuberculous also and judging from the total, relatively seldom from tuberculous mothers,^ so that the conditio sine qua non of Soltmann's representation of the matter does not agree with the generally accepted idea of the defensive action of the toxin ag-ainst fresh infection on the one hand, and the not infrequent later appearance of tuberculosis of the lungs in the scrofulous on the other hand; also the frequent proof of bacilli in the scrofulous changes contradicts a pure toxic genesis; 1 Mothers wlio are tuberculous at the time of the birth. 6o SCROFULOSIS a series of reasons which forces us to reject the hypothesis of Sohmann. A further hypothesis, based on the doctrine of Behring-, may 1h" mentioned, lie looks upim scrofulosis as the clinical expres- sion of tiie tuberculous diathesis induced by a special method of infection cither b\' rej^eatcd hycxTinfcciion or by a very long latent stage. ENDOGENOUS FACTOR— LOCALIZED DIATHESIS. For the present no conclusive proofs arc to hand to cause us to accept diathesis affecting the whole body as a preparation for an attack of scrofulosis, but at the same time, as there is no proof to the contrary, I have no reason to deny it. But, then, must the endogenous agent be dispersed over the whole organism ? Is it not more reasonable to seek, like Virchow, this anomaly in the nearest organ affected, and so, in the first place, in the lymph glands ? The erroneous opinion that the receptivity for the disease and the constitutional anomalies must always be universal in their nature is a legacy from the humoural pathology, and is caused by the fact that diathesis and dyscrasia are mistaken for one another. I have already mentioned in my former treatises on tuberculosis that — in opposition to the general disposition to tuberculosis mostly accepted, for which till now there are no proofs — for the local disposition a series of positive bases are to hand. Martius has recently, in his large treatise, laid special stress on these strictly localized constitutional anomalies. In scrofulosis the whole of the lymphatic system, and even the lymph glands of one region of the body, are not attacked at the same time but bv degrees, and the process always occurs at the outer or inner surface of the body which lie nearest. This observation leads us to further consider whether, because the noxious material intrudes itself from the periphery, the state if predisposition to scrofulosis is not to be placed at the periphery of the body, at the origin of the lymphatics, which is also often much earlier attacked than the glands. As a fact, the lymph glands are nothing more than passive reservoirs for the tribu- tary area and their behaviour and reaction is entirely dependent on that which is conducted to them by the vasa afferentia. It depends in the first place upon their anatomical position and their communication with the place of inoculation whether thev take part sooner or later in the infection. Do we ascribe a special long pre-existing tendency to glands wliicli become syphilitic CONCKPTION AND (;I,A.S.SIMC;A HON ()[• SCKOMLOSIS 6 I or cancerous, ov do wc noL rather see in it a c(;in[jli daily lite, as far as scrofulosis is concerned, is insufiicient . Even the perineability (A the covering in childhood suffices to a certain degree in individuals for the ordinary demands of Hfe, and gives ample protection against: dangers threatened from without, but it is often not sufficient when the agents of infection are ninnerous or the attacks too frequent. With many children the more the increased permeability of the skin and width of the lymph glands is abnormally increased, the less are they capable of withstanding the ordinary dangers of infection; and so much the more certainly, as a natural conse- quence, do they sufi:er from local skin or gland diseases caused by tubercle or other bacteria. In this we may see one of the principal causes of " predisposition to scrofulosis." The force of the lymph currents varies in exact proportion to the width of the openings of the lymph channels. The permeability of the skin and the mucous membrane, as well as the width of the lymph passages, do not always run parallel in their abnormality, but one may preponderate at one time and one at another, and so stamp the disease with its special mark. Virchow has called attention to the great individual variations due to the size and number of the lymphatics, variations which have no parallel in other systems. The number of the solitary glands of the intestine, and the mesenteric and bronchial glands, the size of Peyer's patches, the tonsillar glands, neck and inguinal glands vary immensely. As he remarks, it is clear that here we have to do with congenital circumstances, and in this sense we also speak of a lymphatic constitution. The individual variations in number and structure of the lymph passages naturally cause a difference in the propagation of the causative agent of the disease. The view of scrofulous diathesis here developed as a local readiness for disease confined to the skin, mucous membranes, and lymph systems, has been forced upon me by the results of numerous experiments on animals, and is, as we see, confirmed by abundant clinical facts and observations, which can only be explained by it. All these conceptions are only relative, and it would be m mistake to draw a hard and fast line and to say in one case it -is not possible to fall ill with scrofulosis and in another that it is unavoidable. An individual, were he ever so much predisposed to scrofu- losis, when the conditions for infection — the intimate contact with 74 SCROFULOSIS bacteria — are wanting, will never become scrofulous; such a person remains latently disposed. On the other hand, a child with almost no predisposition will so much the more readily become scrofulous the more he is exposed to opportunities for infection. In this respect a certain difference is brought to bear according to the nature of the cause of infection. We must strictly individualize not only in the case of the person attacked, but also as to the causative agent of the disease. The tubercle bacilli gain an entrance into the body much more easily than other bacteria on account of their minuteness. But by reason of their comparatively slight dissemination outside the body (Cornet, " Die Tuberculose," second edition, p. 99) this entrance is not so often repeated, therefore recurrences are more rare. But the disease caused by the bacillus has another symptom which is much more especially marked than in other bacteria, namely, persistency. As one single infection is sufficient, by being carried to the glands and from there to other organs, especially the bones, to produce the whole series of scrofulous symptoms, so the tendency does not play so important a part in producing the clinical phenomena of scrofulosis. Other bacteria, however, demand wider paths of entrv on account of their size, and are therefore more dependent on predis- position ; the symptoms, especially in cases of reduced virulence, are not so obstinate but disappear more easily, and have not so great a tendency to disperse over the nearest glands in such a high degree, or, in other words, the glands appear to have greater powers of resisting them. One infection will probably not suffice to produce the phenomena of scrofulosis. Only after repeated intrusion (which wnll be facilitated by their greater dispersal, but, on the other hand, which presupposes a greater predisposition) will the phenomena of scrofulosis with the repeated recurrence and the multiple external foci appear, which, owing to the fully developed lymph system, also attain to a high degree of per- sistency. Here also predisposition has great weight. If the tendency is not there, in spite of this, one tuberculous infection can cause the whole complexus of symptoms of scrofulosis ; but the picture of ordinary non-tuberculous scrofulosis, which betrays its connection less by its pertinacity than by its frequent recurrences and its sphere of action will hardly ensue from one single pyogenic injection. We differ here from Hueter, who attributes to ever}^ scro- fulous person an increased disposition; this conclusion could onlv have been attained post hoc. CHAPTER III. GENESIS OF SCROFULOSIS. ScROFULOSis arises from the combined effect of the scrofulous tendency with bacteria. Whence come the different bacteria which we find in the scrofulous changes? Under what circum- stances do they reach the body ? How does the infection begin ? 1. -CAUSATIVE AGENT OF PUS. (a) Appearance. The origin of the germs of infection which we have under consideration is different according to their species. The ordinary pus cocci and streptococci are almost ubiquitous in closed dwelling rooms. Wherever we leave saucers of gela- tine about some pyogenous colonies will be sure to be found developing in them. The Bacillus pyogenes aureus has frequently been demon- strated on the human skin, in the cavity of the mouth, in the saliva, in the nose, in the vaginal secretion, and in the normal contents of the intestine; pus cocci have also been found in the dust from factories and schools. It is more rare to find streptococci, at least in virulent condi- tion, outside the body. Probably, infection depends upon living in closed rooms, but more especially when- the opportunity is given of contact with persons with suppurating processes of any sort and when such persons do not sufficiently guard against the spread of the virulent pus cocci. But these pus cocci generally possess unequal and weak virulence, so that the danger is much less than a priori appears, and is often represented to be. Many of the pus bacteria lose their virulence, in part or com- pletely, as compared with tubercle bacilli. 76 SCROFULOSIS (b) Mode of Infection. The manner of infeclion by pus cocci, their localization, the spreading of the process to the next lymph glands, is the same in the case of the tubercle bacillus, and I must refer my readers lo the next page for further particulars on the subject. Numerous experiments prove that these pus bacteria not only introduce themselves into the skin through small wounds, but even the uninjured cutis of adults does not afford sufficient protection against them when well rubbed in ; much less protection is afforded by the skin and mucous membrane of a child, which is much more tender, and still less with that of a child who, with a morbid pre- disposition to scrofulosis, would be much more disposed to become infected. Garre rubbed cultures of pus cocci into the intact skin of his forearm, and produced a good-sized ulceration at the place of friction, accompanied by swelling of the lymphatic glands. Larr6 and Bockhardt produced typical carbuncle, boils, and pustules of impetigo bv friction with cultures of staphylococcus. Schimmel- busch also produced, bv rubl^ing in staphvlococcus, pustules in skin that was proved by microscopical examination to be com- pletely uninjured. By friction with Staphylococcus pyogenes aureus and S. albus on the uninjured skin of the forearm, Wasmuth produced flat red patches, and by more vigorous friction blisters containing pus. Fie also infected guinea-pigs on the carefully shaven skin by friction with anthrax, and confirmed the facts that the un- injured human skin (X.B. — In this case his own) is more, per- meable than that of animals. This permeability of the skin exists also for other bacteria. The permeability of the mucous membrane of the lungs for the anthrax bacillus was also demoristrated by Buchner; Roth succeeded in introducing Ribbert's bacillus into the bodies of animals by brushing them with a soft brush on to the uninjured mucous membrane of the nose. Infection was also obtained by rubbing in the anthrax bacilli on the bare skin behind the ears of guinea-pigs; but simply placing them on the same spot without friction produced no result; he found that fairly strong friction was necessary. Machnoff infected animals by rubbing anthrax cultures into the shaven skin of the back, using only light pressure. On examination afterwards no injury or defect of the skin could be discovered. Garre considered that in the case of staphylococci the point GENESIS OF SCROFIJLOSIS 77 of entry was the ducts heading- from the sebacecHis and sweat Hands. Rolh and Wasnuilli considered that the anthrax bacillus entered by the same route. All these experiments made on men were on adults, wliich explains the fact, the cause of which was shown above, that there was no superficial spread from the point of f-ntry, and that the propagation was towards the glands. Tlie frequency of swollen glands {e.g., in the neck), without being able to detect the place of entry of the bacillus which gave rise to the infection, is explained by the greater permeability of th.? skin in childhood. For clinical examples see p. 85. According to Bender, Bockhardt, and Gerlach, eczema can be induced, on the arm being irritated, by germ-free filtrates of staphylococci. Neisser and Lipstein do not confirm this toxic result, as the same effect may be obtained with alkaline bouillon C Handb. fiir Path. Mikr.,"'iii, p. 130). II.— TUBERCLE BACILLI. A.— HUMAN TYPE. Occurrence. It appears that shut-up rooms in a great measure account for the infection by tubercle bacilli of the human type. Formerly the tubercle bacillus was supposed to be everywhere (ubiquitous), but could not be discovered. By my researches it has been established that, as a rule, it is only found in numbers worth mentioning in shut-up rooms, which tuberculous persons either inhabit constantly or occupy for a time, and who in- cautiously disperse the bacteria contained in their secretions. At the head of these are those suffering from phthisis, but still patients with other open tuberculous foci can also afford oppor- tunities for infection. Mv experiments have been confirmed both positively and negatively by Rembold, especially Schliephake, v. Kriiger, V. Kastner, Bollinger, Kustermann, Enderlen, Prausnitz, Petri, Martin Kirchner, Gotschlich, Dudley (see also Wagner, Belli, Cacace, Kunz). From the convincing fact that tubercle bacilli are not ubiquitous, but are only found regularly in the immediate sur- roundings of persons suffering from phthisis who are careless in their habits, it would perhaps be well not always to speak in general terms of the " infinite dispersal of the bacilli from ^yhich no one can escape." 78 SCROFULOSIS rubercle bacilli are a source of clanger to children threatened with scrofulosis, either through the respiratory passages (infect- ing the bronchial glands), or by entering the mouth and digestive organs (infecting liie neck and mesenteric glands), either mixed with food, or by dirty lingers and such means; external contact also mav infect the neck glands, or other glands in the vicinity of the point of entry. Infection mav be caused by material in liquid or dry state. I still think that for introduction into the deeper respiratory passages the dried excreta are far more important than the particles dispersed by coughing, for a person suffering from phthisis excretes in the sputum a million times more than he, in most cases, ejects by coughing ; besides, dried sputum has much greater vitaUty than finely dispersed spray, and so forms a reserve of infectious material during a longer period. To go further into this question would take up too much time. (I refer to the second edition of my " Tuberculose," p. in.) Sputum or other excreta containing tubercle bacilli, when in fluid state, appear to be less dangerous for the spread of scrofu- losis, as well as for the spread of tuberculosis of the lungs, as the soiling of fingers and other objects is more easily avoided. When dry the bacilli often pulverize, and settle here and there on all sorts of objects, and on food, without betraying their presence to the eye, and when not inspired are deposited on un- covered parts of the body, such as the nose and mouth, and pass on to the regional glands. As scrofulosis appears at an early age infection principally takes place at home, and occurs in young children, most fre- quentlv, from the parents, sisters and brothers, grandparents, and relations who dwell with them or frequently visit them, or to whom the children are sent (" pseudo-heredity ") ; in better class families from the servants, especially nurses and wet nurses; in poorer classes, perhaps from boarders or lodgers. In later childhood infection may arise from schoolfellows, playfellow's, and teachers. And when they visit each other, from the homes of their friends or parents and relations. Those not biased by the ideas of heredity may see daily in their practice clinical proofs of such infection. Disease germs may be carried by the soles of the shoes, also by flies, but such causes are nothing in the total of infections. Just as opportunities for infection are numerous, so are also manner and place of infection. With a view to ascertaining the genesis of tuberculosis and scrofulosis, I endeavoured to study more closely these conditions and the path of the infection bv GKNIiSIS Ol' SCKOMLOSIS 79 expcrimcnls. My own (;x])(;rimcnl.s, wliicli w(::i"t; iilsM;i,OSIS 83 the vayin.'i ^ind iilcni.s, vvliicli dikc (x ( iini-d m llii- bladder also. But ill many cases die \agina r(;iTiaine(J iinalier(,-d. Alter ;i short time sweliinj^- and caseation of llie inguinal glan(Js ai}pearc(J in all (he animals; kilci' caseation ol die pcri-iiicriiic gl-'inds and of ihe glands lying near the \'ertebral coknnii, dicn 1 ubf-rcuU^sis of the spleen and li\er occurred. Injeclion ol piir<- culture into the vagina (of which I lirivc (luce records) produrcd similar results. fNincUisi\ rl\- pro\ecl ihai ihe group of olaiuls which la\ nearest lo the intlamnKition of the skin was always tlie tirsi lo be attacked. Other chnical e)l)ser\aiiiins i>n the mosi w iiU'l_\" ditterent regions of the l)ody accord with my opinions upon tliis. Scalp. — In connection with a tuberculous infection of the scalp bv iul)t'rculous uUers, after a few weeks there was a collec- tion of glands in the neck (Dencke). A\'ith eczema of the head, caseation of the retromaxillary glands and miliary tuberculosis occurs (Demme). Evi-:. — In luberctilosis of ilie i-onjuncti\a. cornea, and of the iris (llaab), it is generalU ilu- prc-auricular, the jaw and necic glands which are luberculoush- affected, antl only, or for the most part, on tlie side affected. Thus the left neck glands were much swollen in the case of tulierculous ulceration of the tarsal con- junctiva, which had parilv run its course, in the left eye of a bov aged 14 (Sattler). In tul^erculosis of the right conjtmctiva ilie pre-auricular glands were onlv swollen on the right side, although it was evident that the whole of tlie l\mi~)h gland s\sleni of the neck on ])oth sides was diseased and had partly suppurated from some other infection (Stolting). Further, swelling of auricular and submaxillary lymph glands on the side which was diseased was noted by Walb, Haab, &c. (in six cases). Mouth and Pharynx. — According to the researclies of Krtickmann and Schlenker, ^\ilh a tuberculous infection of the tonsils tuberculosis of the neck glands will follow as a secondary consequence. Sacaze notes that in tuberculous inflammation of the tonsils there will be at the same time severe swelling of the neck glands. Grawitz notes in connection with inflammation of the tonsils with diphtheritic membrane, a tuberculous infection of the neck glands. I'ckermann found in tuberculosis of the left \'elum palati a swollen and very sensitive gland (in a woman aged 35) under the left angle of the jaw on the hinder edge of the sternomastoid, and tinder the tip of the mastoid process. Wroblewski often found in fotirteen cases of tuberculosis of the pharynx (in persons from 22 to 59 vears of age) considerable affection of the lvm]5h glands, the cervical as well as the axillary, ulnar and inguinal glands. In tubercuk)sis of the tongue (median region), Poncet and Graser found swelling of the submaxillary glands. In a child which previouslv had been quite healthy, Steigen- berger noted that after it had been suckled four weeks bv a nurse who was phthisical, it developed at the end of two months a hard tuberculous swelling, the size of a hen's ef!;g;, in the neck glands of the right side (containing tubercle bacilli). Doutrele- GENESIS OF SCROFULOSIS ^7 pont found in tuberculosis of llic skin .-umI miKoir. inrnibraiie of the right cheek lha,( ilw ii!_;lii suhina \ill;ir\ ;_;laii'ls were also swollen, the glands on ihc Idi side w-ir liai(ll\ enlarged; laler tuberculosis of d)e lungs (»((nir<'d. Tkktii. — Odenlhal found in ^4(1 rhildn-n swelling of the submaxillary glands conse(|ueni upon denial (arir-s. Berten established a comjjlele coincidence noi only beiween the position of the caries, but also between ilie iniensiiy of ihe glandular swelling and the caries which caused ii. I loppe also established swelling of Ihe maxillary lymph glands as an extremely frefpient consecjuent symptom of caiies of die leedi ; Siar* k noiiced the same slricllv local dependence of the glandular swelling upon the situation of (lie carious loolli with which it cf)rresponds, not onl\' on the side of the body, but also that with caries of the hinder molars the glands in the vicinity of the angle of the jaw are. swollen; with caries of the canine teeth the glands farther forward or those of the other side are swollen. Korner proved in 1,646 children the correspondence of the glandular swelling with the affected tooth, both as to position and degree of affection. Grawitz remarked tubercular swelling and caseation of the neck glands on the same side in consequence of caries of a molar, and tuberculosis of the lungs showing itself months after the first appearance of the swelling. Nose and Ear. — Tn affections of the nose and ear we see the same involvement of the glands on that particular side, A. Jacobi refers to the frequent cure of scrofulous inflammation of the cervical" glands simply by treatment of the nose. Hang found in perichondritis of the auricle in four tuberculous persons that the Ivmph glands of that part were tuberculously intiltrated, and that in a chronic middle ear catarrh with tuberculosis of the mastoid process a small gland on the mastoid process was similarly affected ; in primarv central tuberculosis he regards the affection of these glands as one of the very earliest svmptoms. According to Ferreri, the salivarv glands, the cervical Ivmph glands, and the joint of the lower jaw are, especiallv in childhood, seldom svm- pathetically affected in diseased processes of the ears. Tn tuberculosis of the breast the axillary glands are, as a rule, aft'ected at the same time (Volkmann). Hoist observed tuberculous swelling of the axillary glands consequent upon indolent ulcers of the finger in the case of a sick nurse ; Tcherning, after an injury to the hand with a spittoon ; Colling and Murray observed in three cases pustular formations with consecutive swelling of the ulnar and axillarv glands after tattooing on the arm bv a person suffering from phthisis; Gerber, tuberculosis of the axillarv piands four months after tuberculous SIS SCROl-LLOSIS infeclitMi in a linger; Leloir noliced in connciiion willi lynipli- angieclaiic lu|nis tuberculo-scrofulous swellings in ilu" course of the thickened lymphatic vessels, with swellings of the ulnar and axillarv glands, and later, affection of the lungs; Koch, caseation of the ulnar glands after spina bifula; Schuchardt, tuberculosis of the inguinal glands on both sides consequent upon soft chancre, tuberculosis of the inguinal and pelvic glands after ulcers in the •vagina; Lindemann (in two cases), and Lehmann (in ten cases), tuberculous ulceration of the penis, and swelling and caseation with suppuration of the inguinal glands after circumcision by a person suffering from phthisis; Hamilton, tuberculosis of the inguinal glands consequent upon tuberculosis of the lesiicle. Severe swelling of the femoral glands is not infrequently found with affections of the foot and knee-joinls, and enlargement of ihe inguinal glands in case^iting processes about the hip-joini and the acetabulum (v. Bergmann). For further details I refer to the cliapter on " Infection of the Glands," Cornet, " Die Tuberculose," second edition, p. 353. These clinical experiences in man, which could be easily multiplied, justify us in assuming that the results of our experi- ments on animals would be the same in man, and wherever we come across a primary affection of the glands we may invariably seek for the point of entrv of the toxin in the peripheral region of the gland. In practice we have an apparent exception to this rule. Thus, f(^r example, a pre-auricular gland was swollen as the result of an affection of the eye, and at the same time the bronchial glands swelled, without the cervical glands lying between showing any changes. But in such cases we may always suspect a second independent infection in the lungs, the opportunity for vhich infection was given at the same time and under the same con- ditions as that of the eye. LAW OF LOCALIZATION The law of localization has been drawn up hv Cornel as I he result of experiments on animals, and confirmed b\- clinical experi- ence in man. Tubercle bacilli which have entered the body develop, as a rule, in the organ which is susceptible for that special virus, imme- diately at the point of entry, or at least in the Ivmph glands situated nearest (law of localization). The glands act as a filler, and retain the bacillus at first. Cohnheim called attention lo the connection between the point of entry and the localization of the tubercles. GKNKSiS Oi' .SCI<(jM.)-O.SI.S 89 TIk; furUicr sprc-ul 111 iIm- Ixidy docs iiol l;ii:c place by leaps .'ind hoiiiitls, bill sicp by sicp, I liugh the inlaci mucous mem- brane, and maintained there were always microscopic changes; de Vechi also believes the normal mucous membrane to be im- permeable; Klimenko maintains the same, but adds that fre- cjuentlv slight injuries are present which allow of the passage. Apart from older experiments (see Cornet, " Die Tubercu- lose," first edition), Ililgermann, I'ffenheimer and Plate have proved microscopically the penetraiion of the bacilli through the intact mucous membrane (see also pp. 81-84). The frequent pathological condition of tuberculosis of the bronchial and mesenteric glands, wiihoui any evidence of the slightest injur\- or tuberculous developments in the mucous mem- brane of the lung or intestine respectively, is in favour of the permeability of the mucous membrane. The objection that perhaps the tuberculosis of such glands mav have arisen in the blood passages is met by the experiment on completely health}- animals in which we can induce tuberculosis of isolated glands where we \\ill, in any gland system, in the bronchial or mesenteric glands, without injury to any part of the mucous membrane either by inhalation or feeding. As such results have been regularly attained by myself and other investi- gators in hundreds of cases, the objection that the animals may have been diseased and the mucous membrane not intact (Hornemann) is unsound. I refer further to the extensive experi- ments of Uffenheimer, ilie discoveries of Max Wolff, of Orth, and L. Rabinowitsch. I have proved (p. 82) the permeability of the mucous mem- brane of the eye, nose, vagina, and Galbo has confirmed the same in the vaginal mucous membrane of guinea-pigs. Further, in the above-mentioned feeding experiments, tubercle bacilli were proved (Barlel, Kovacs, Plate, Hermann, &c.) to be in the mesenteric glands even after a few hours or days, therefore before the tubercle bacilli which had been swallowed could have produced changes in the lining of the intestine. It was not necessary for v. Behring to base his theories of the entry of bacteria on Disse's inconiinuity of the mucous mem- brane in the new-born and in children a few weeks old, as long before the permeabilitv had been experimentall\- proxed to hold good in later life and in full grown animals. E\en the theory of the genesis of tuberculosis of the hing bv inhalation advanced by Tappeiner, Koch, and others, and con- firmed by me on more than i,o(X) animals (in over 700 official recf)rds), further extended and considered assured bv the law of GENESIS Ol" SCKOiLLOSIS QI localization, was a<;ain disputed and again re-tested on all sides. That which appeared to I he iin|)rejiidired so clear, that the bacilli floating in the air would Ix- iii.spire<■ drawn down the free and open air passages inio the lower pari of ihe lungs, and so arrive in I he minntesl air i)assages, appeared lo he doubtful, though wilhonl an\ e\ idem reason; it was niainiained that the bacilli which were swallowed in inlialaiion entered the Stomach and intestines and ihe niesenleric glands, and from there, without leavinrimary changes. Tliere were even some, such as Calnielie, who denied ihat the formation of anthracosis of the lungs was aerogenic and arose from direct inspiration, which up till now had been universally lilt- ini.nuU'.si bronchial luhcs; llryinanii also cicnionstraied them bv excision in alveolar and epithelial cells. After inhalation of a c|uaniitv of bacilli they were found imniedialely in the bronchial glands, btit when only a small quaniily were inhaled thev were o.nlv found to be present after three days. Ballin's experiments with aspergillus spores led to the same results. This penetration of the bacilli into the minutest air passages was again pro\ed, and has become e\idenl in L'almette's and Guerin's own experiments; their further objection that one cannot be sure that the bacilli they found were not induced by tuber- culosis needs no further discussion. Now it was endeavoured to prove b}- other means that the bacilli ingested with the food passed through the intestinal and mesenteric glands \\iihout j^roeliicing any changes, then arrived in the lungs bv wav of the thoracic duct and the right heart, there producing the primary foci. Calmette, who defended this opinion, believed that he and Guerin had demonstrated it, because he had observed in those animals into which he had introduced bovine bacilli by means of the oesophageal tube, besides intestinal tuberculosis, severe tuberculosis of the lungs, the bronchial and mesenteric glands. But just the fact that the other organs — liver, spleen, and kidney — which also take part in the circulation remained free is a clear proof that we are not here concerned with a ha^matogenous infection of the lungs, btit evidently that during the withdrawal of the tube, which by incautious handling might easily happen, infectious matter entered the trachea, and caused the infection of the lungs. But Calmette's young goats, which he allowed to be suckled in a natural manner by a mother sufifering from tuberculosis of the udder, only developed intestinal tuberculosis (see also Calmette, Guerin, Delarde). Beitzke raised the objection against Calmette's and Guerin's further ingestion experiments, as well as those of de Haan, as far as adult ruminants were concerned bv eructation of the bacilli w^hich had been introduced, and aspiration mav have induced infection of the lunps. To eliminate the source of error that in feeding by the tube a part of the bacilli might enter the lungs on its withdrawal, Schlossmann and Engel laparotomized young animals, injected bacilli into the stomach, and sewed up the place of injection ; when six hours later they excised the lungs, and by inoculating them induced tuberciilosis, they thought they had proved their theory that the bacilli might migrate through the regional glands with- out leaving a trace behind. But the after-test brought to light (iKNicsis OF .s(;k(jm;i,(>sis 93 tlie en-or of llic (■xpcrimcni . Si i;is.siicr pointed oiii ili;ii ilic very fcict of sewing lip llif lliin w.'ill (»l llic .stoiii.-icli ml r()(lii(,<-ii. llif {iiu-siion ot the most imporiani souriH- of intVcrmn in man. ilial ot inhalaiion hy ilic lun^s. is sflllt'il. Tendeloi), luiycn Alhrcclit, Cloklschniitl, \-.. Kaufinann. .Most, Spronck, Ribberl. i.uharscli recently dcclarccl themselves for ii on ihe i^round of liicir anatomical cxpcri- ences ; ^•. Schr(")itcr, Alonigom(M'\ , A. l''r;inkcl on the ^roinid ot clinical fads (at least for adults') ; and Gei|X'l, Beitzke, Winkler, McLJin, Mallinkrodt, &c., for children. The preponderance of tuber^-idosis of the lun^s o\-er intes- tinal infection, v\vn if we concede numerically ec|ual opportunities of infection, is to be explained by the fact that, among- all classes of animals which haxe up till now been experimented upon, con- siderably fewer germs of infection are necessary for infection of the lungs than the intestines. Thus in parallel experiments by Kuss and Lobstein extensive tuberculosis of the lungs appeared after inhalation, whereas animals fed with the germs remained healthy. Pfeiffer and Friedberger caused animals to inhale ,^,000 tubercle bacilli ; amongst twentv-nine animals, twentN-two had tuberculosis of the lungs, whilst among twenty-eight animals fed by means of the cesophageal tube with 3,000,000 tubercle bacilli three had slight tuberculosis of the mesenteric glands, four had isolated foci in the lungs from aspiration, and twenty-one showed no changes. According to Bongert, rats, which are hardly susceptible to tuberculosis, can with difficultv be infected subcutaneoush' or per OS, but with inhalation the}' were infected without exception. Reference must be made to the small quantity of tubercle bacilli required by Findel, Lafifert, Reichenbach, Alexander, \\>l)er, to induce infection by inhalation, against the enormous quantities which were, as a rule, required to produce intestinal infection. (For details and reasons, see p. 114.) li is an important question, especially with reference to the later fate of those suspected to be suffering from scrofulosis, who have tuberculosis of the tonsillar or neck glands, whether the tubercle bacilli can arrive by a more direct Kmphatic passage from the organs of the neck (besides their dispersal bv the blood passages through the usual anatomical channels, through the thoracic duct, and superior \-ena cava on the right side of the heart), either through the supraclavicular glands to the summit of the pleura and the apices of the lungs, or in a continued chain to the bronchial glands, and so produce lubennilosis of the lungs. GICNICSIS Ol' SCKOI-CLOSIS lOJ Aiifrcclil, (irolxT, kiiinpli, IW-ckrnann, M. VVasscrmann con- sider llic loiisils Id !)'• one ol ilic mosi frf-(|iicnl points oi enlry of tuberculosis, .-ind ili;ii i iilxTculosis ol iIk- 1iiii.l(s arises from iliem. (See also v. licliriui;, (iochcdini .-ind Koux, Josscr/ind, Freudcndiai.) Now die tonsils arc nol so irc(|ucnd\- t iihciv iiloiis dial tliey can be considered as a decisive [)oinl of cniry. VVex found in 2i() cases of pliarynj^'-eal tonsil X?> P"^"'' ''•ni.; Lubarsch in I'f)sen 1 '5 pel- ccnl. anions^' sixlv tonsils in (liildicn; |'"ri«-din,-inn only once found primary tuberculosis; Calm lomid prini.-iry tubercu- losis of the pharvnn-cal tonsils in about 4 p'-i- (cni. ot the cases of adenoids. ()nl\- (IcM-dclcr yi\cs hi<4li('r li^-urcs in pharyngeal and palatine tonsils 1275, but his cases are to(j few — f(jrty-seven in all — and therefore more subject to chances (see pp. 140, ike). G(")rdeler's discoveries (upon which Aufrccht takes his stand) of tuberculosis of the tonsils, neck, and bnjnchial glands, with and without tuberculosis of the lungs, are just as little con- firmatorv, as the tuberculosis of the lungs and bronchial glands mav just as well have arisen by inhalation, from the same source of infection, independently of the tonsils. Aufrecht, denying tuberculosis by inhalation, considers the path from the organs of the neck to the bronchial glands as " the onlv one that has been proved," and attempted to confirm this opinion bv se\'en experiments on rabbits, whose pharyngeal organs were " painted " with a swab of wadding dipped in the lung of a phthisical tul3erculous person. No theory can be con- firmed by seven experiments on animals. Besides which, two of these animals were healthv after a period of two years; one died' prematurely, so only four remain, of which two at most, by the most charitable interpretation, can be said to confirm the possi- bility of Aufrecht's path of infection, inasmuch as the neck glands and lungs exhibited isolated foci. But there can be no question of proof, for it is infinitely more probable in this case that these foci in the lungs were due to inhalation of the infective material, in consequence of the choking movements caused by painting the walls of the pharynx. It may be noted incidentally that the con- dition of the glands remarked by Aufrecht is contrary to our experience (Weber, Oehlecker), according to which rabbits, after infection bv the hiunan type of bacillus, exhibit no affection of the glands. Finally, anatomical reasons can be adduced against Aufrecht's path of infection, for both Beitzke and Most found in their examina- tion of the path of the lymph channels that no lymph vessel could be discovered leading from the neck to the bronchial glands (see p. 122). But supposing that now and again bacilli could reach 104 SCROl TLOSIS the bronchial glands by collateral paths, wc nuisi not think that. on the ground of this anatomical possibility, the ciiiiiiions rouit- is the rule. Grober supposes that llu- bacilli reach the sujiraclaxiciilar glands from the neck glands, and so arri\e direct to the siunniii of the pleura and the apices of the lungs. He refers to his experi- ments in which, after injecting Indian ink into the tonsils, he traced the granules to the pleura and apices ot the lungs. Beilzke's after-test, ho\ve\er, makes it probable that the result obtained bv Grober rests on an error in the experiment; anil this result mav be explained by the pt)ssibility of aspiration into the trachea of some of the fluid used or of some of the injection which had been again pressed out of the tonsil. Neither he, nor Hart, nor Most succeeded in infecting the lym]-)!! \(\ssels leading from the lower cervical glands in the pleura (see p. 124). \\'ood considers the advance of a tuberculous peri-adeniiis from the lowest cervical gland as possible, but rare, whilst Aufrecht, in opposition to Grober's experiments, emphasizes the differences between the unnatural, enormous inundation of the finest non-irritant granules, caused by the pressure of the injection, and infection l)y bacilli which irritates the tissues. So infection of the bronchial glands and lungs through the organs of the neck is, up to date, not proved with certaintv, and although from the results of experiments it is not to be entireh' denied (see p. 126), it cannot be taken as of frequent occurrence; for the simple fact that in tuberculosis of the lungs frequently, and with adults as a rule, tuberculosis of the neck glands is not present, refutes this idea. But if bacilli could reach the bronchial glands from the neck glands they would form a necessary connecting link. If children with scrofulous neck glands develop tuberculosis of the lungs later, we may consider, as a rule, that indejiendent further infection of the lungs has taken place by inhalation, unless we have to do with infection of the blood, an invasion of the bacilli into the blood channels, an admission which imposes increased caution, especially in its prophvlactic bearing. (It 's not the place here to enter into Aufrecht 's further hvpotheses on the h^emalogenous genesis of tuberculosis of the lungs.) B.— BOVINE TYPE. As we have seen in the spreaB of tuberculosis, the repre- sentative of which (consumption of the lungs) causes eleven- twelfths of all fatal cases, tuberculosis amongst cattle comes, in general, little into consideration. But it forms a very considerable source of scrofulous tuberculosis, especially tuberculosis of the GENESIS <)l' SCKOi'LLOSiS IO5 neck and mescnicric l^I.'ukIs. lim w- < ,-inn lungs, pla\' the principal |)ari in infe(tif)n. With tuberculous cattle this danger falls into the background, for, as a rule, we have here to do with foci, and where open foci appear, the expectoration is swallowed, and onl\- appear again in the excreta; the air of the sheds, which is usually moist, prevents pulverization of the hygroscopic, sticky conglomeration of bacilli ; in the open air the dispersal of the bacilli, in the enormous ocean of the air, hardly offers a real danger in the vicinity (Cornet, "Die Tuberculose," second edition, p. 105). Now and again by the coughing of the cattle, or b\- nasal secretions containing bacilli, the germs may be dispersed, and, in the case of close contact, may endanger the human respiratorx' passages. Adults are, however, protected from actual disease bv their high power of resistance to bovine bacilli ; but if children are much in the cowsheds or live with the animals, infection of the respiratory organs, especially of the bronchial glands, which runs a favourable course, mav take place. Doubtless meal, milk, and milk products are a far more important source of infection. Opportunities of Infection by Tuberculous Meat. — The least dangerous of these sources is the flesh of tuberculous animals, especially in its natural form, because as a rule the diseased parts lie at a distance; it is much more dangerous when chopped up, and especially in the preparation of sausages, in which unscrupu- lous manufacturers oft'er, with tempting appearance, to the con- fiding public, big and little, high and low, those parts of the io8 scRoruLOSis beasi which iire tuberculous, diseased, and loallisome. The secrets of the sausage machine, the extensive commerce in sausage meat, and the barrel upon barrel of uihcrculous lungs, liver, and scraps form a constant subject tor our law courts, and give us an idea of the quantities of meat in the market containing tubercle bacilli. Also the meat and refuse of tuberculous pigs, especially in sausages, must be included in the opportunities for infection, more especiallv as the pig is very susceptible to both types of tubercle (Kossel and Weber). The bovine infection is mostly found in consequence of the frequent feeding with tuberculous skimmed milk from dairies. According to the experiments of Tonzig, the tubercle bacilli retain their vitality a long time in sausages and smoked provisions. The danger of tuberculous infection by means of meat sup- plies is in general little considered, perhaps too little, for it seems just the slow mastication and swallowing of solid material, as sausages, although it may not contain so many bacilli as tuber- culous milk, must endanger the tonsils and neck glands to a greater degree than the transient passage of milk, and lead to the adhesion of small infectious particles in the recesses of the tonsils, especiallv when they are in a hyperplastic condition through a state of pyogenous irritation. Opportunities of Infection by Milk. — The greatest danger of bo\"ine tuberculosis occurs in man, especially in children, by means of milk and its products, butter, cheese, and curds and whev, in which the tubercle bacilli which were present in the milk retain their vitality. The following figures show the abundance of these sources of infection. According to Glage, there were in the German Empire in 1905, amongst the animals slaughtered, I7'39 per 1,000 cattle, o"9i per 1,000 calves, 4*26 per 1,000 pigs, which were affected with important forms of tuberctilosis, according to the veterinary inspectors; among the cattle the principal contingent was cows. Tubercle Bacilli contained in Milk. P'xamination of the milk itself gives us the best information; 54 per cent, tubercle bacilli were demonstrated in milk samples, and 47 per cent, in samples of butter (Noncwitsh, in Wilna). In 210 milk samples put on the market in Leipzig, Eber found tubercle bacilli in 22 (io"5 per cent.) ; in 150 butter samples, 18 (12 per cent.); in 50 cream and curds and whev samples 4 per cent. ; 150 margarine samples contained no tubercle bacilli. In the milk of New York, A. Hess, in 107 samples, could GliNIiSIS or SCKOMJLOSIS IO9 |)r()V(' virulcnl liilxTcii' h.-uilli in i'^) p'l' rcnl.; (iorion in 10 p(;r ccni. Ani()n<4Sl \ni) srniiplcs ol null; inv sale in London, KU-in foimd hibcrcU^ bacilli sc\cn limes, Kolx-rlson nixl Maholni in Birmingham (America) in mcjre llian lo per cent., and milk from railway stations in 14 per ca-iM. (See also IJndenslein's statistics.) We must realize in this connection that, according to Oster- mann, in 3 c.cm. of milk from a cow w^ilh a lubcrciilous udder, 50,000 to 100,000 tubercle bacilli are n<-it/k'e reckons amon^sl luhcrculous (liihhvn if) lo 20 per (cnl.; I'rice-Jones (I'ln^land) ahoul 25 per ccnl. who .suHri- Ironi primary inlcslinal tuberculosis ((|Uolc(l Ironi licilzk-e); I'-ibigcr and Jensen reckon dial priniarv inlestinnl Inhcrculosis is lo he found auiongsl (> jjer cent, of all patients, and 1 1 per ccnl. of
\- SCKOl'LLOSIS 1J3 Weber inloniis us, ;ilici iii\ csl igalifjiis lasting over eigiii years, and noL even lln-n conipliicd, ilial 113 cases were collected; of these there were, (xj in which raw nnik of COWS suffering from tuberculosis ol ihc uddeding wilh inleclcd milk' coniimicd from iIm- lime of weaning, and lasted from cnie }ear to one year and a half. Besides this, swelling of the neck glands occurred in six children and one adult ; in four other children and one adull suspicion c^f abdominal tuberculosis occurred, InU " disappeared " ! Another child was reported to be suffering from scrofulosis; in 133 other children and 151 adults who had taken milk, said to be cooked, oi a cow- suffering from tuberculosis of the udder, or had talcen mixed milk (in the form of butter) of many cows, tw-elve children and one adult showed swelling of the cervical glands. It cannot be denied that these results, in \-iew of the pro- nounced and long continuing opporlimity of infection, appear surprisinglv insignificant, even when we reckon all doubtful cases as tuberculous and of bovine origin. The collective investigation proves that the bovine bacillus in childhood is frequentlv non-^•irulent or only slightlv virulent. These researches naturally do not prove that in spite of them a number of persons, unknown to us, mav have had tuberculous mesenteric glands without any evident indication, and which, in accordance with the slight pathogenic nature of the bovine tvpe, after some time disappeared spontaneouslv. In the same way many small foci in the neck glands mav have escaped observation. That does not alter the fact of the circumscribed virulence of the bovine bacilli ; but for the under- standing of scrofulosis, and especially for the interpretation of apparently motiveless cutaneous reaction, we must keep in mind its possibility, and even its probabilitv. Unfortunately, at that time v. Pirquet's reaction was not known ; this would doubtless have given us manv interesting disclosures. The Difficulties of Intestinal Infection. — The reason of the relative infrequency of distinct infection rests partlv on the fact that the intestinal tract is, of all the organs of the bodv, the least accessible to a tuberculous infection of either bovine or human bacilli. 114 SCROFULOSIS Tluis, for example, Findel found thai by inoesling ig,ooo to 382,000 tubercle bacilli ihe animals did not become tuberculous, wliile twentv bacilli l)v inhalation were sufficient to produce tuber- culosis; after further experiments, he concluded that the minimimi fatal dose in ingestion is about six million times greater than the mininuirn fatal dose in inhalation. ■ Accortling to L£\.ifert, a single ingestion of 40,000 bacilli and a repeated dose of altogether 1,200,000 in guinea-pigs produces no iiiheriiilosis ; a t wd-millionth part of the dose, which in the intestine produced no tuberculosis, is suflicient to produce, by inhalation, a most severe lung tuberculosis (see also Kuss and Lobstein's researches). In rabbits, according to Alexander, an ingestion ()f 5 mg. of bacilli of human type repeated six times had no result ; an ingestion of even 10 mg. of bovine bacilli repeated five times crave a doubtful result ; whereas inhalation of 2>ooo to 50,000 bacilli of human t\pe, and of too of bo\ine t\pe, had a very decided result. Similarlv, according to Reichenbach, who attaches special importance to the repetition of infection, guinea-pigs become tuberculous after inhalation of three doses of 3 mg. tubercle bacilli, and after ingestion of o"02 mg., repeated fifty-one times, which e([uals i '02 mg. (see also pp. 102-3). Weber and Titze showed in cattle that for infection by ingestion at least 10 mg. bovine bacilli are necessary, while injection by inhalation, with a thousand times fewer (100 mg.), succeeded. The difference is reallv greater, for in the case of bacilli spraved for inhalation onlv a very small number get access to the deep recesses of the lungs in inspiration. V. Behring has repeatedly referred to the researches of \^allee, according to wliom tuberculosis in cattle is easily obtained by ingestion, but with inhalation is obtained with difficulty, or not at all. But these researches are not of much value; for, as vSpronck remarked at the Fifth International Conference on Tuberculosis, in these ingestion experiments milk of a cow suffering from tuberculosis of the udder was employed, therefore quite virulent material ; for the inhalation experiments, on the other hand, he employed a pure culture of bovine bacilli cultivated for a period of ten years in the laboratory, and so a material of very doubtful \iru1ence. Therefore, without doubt the intestinal tract is verv difficult to infect. Weber, Fliigge, and Oslermann conclude from this that, for infection of the digestive canal, repeated ingestion of an immense number of bacilli is often needed — a number which usually is not found in shop milk, or butter made from such milk. But I GENESIS 01-" s(:roi( i.osjs 115 consider ilic (lc(|ii( I iciii, ili.'il icpi-i ii ion plaws an iinportani jjart anti is more (•ric(li\c ilian wlicn llic wIujIc {|iiantily is <^\\('.n all in one dost", is nol pro\cd (sec; also Rciclicnhacirs researches). Why should llie repealed adminisi ralion iiirn ilie scale? Must we then conclude dial die next bacillus, or next but on(*, that is inoculated lakes ex:i( liv die same sjxtt for ils point oi attack in die enorniousK- large inieslinal siirlan are all the more forced to take a side course when the direct paths are more or less obstructed by previous processes (see p. 222). In this course no important intervening organ, connected with the glands, is ever passed over, tuberculous glands never appear in any part of the body without intermediate steps. It is only later that ha^matogenous dispersal takes place. Weleminsky, Westenhoeffer, Bartel, &c., share this opinion. When, however, AA^eleminsk_y states that the whole of the glands unite in the bronchial glands, and when he attributes to them the character of a heart for the whole lymph system, he doubtless goes too far; he must stand alone in his opinion, in which he has been strengthened no doubt by making the mistake of using human bacilli in rabbits (as shown by Oehlecker, see p. 100), and in the statement that organs infected h^ematogenously do not infect their glands. But I must agree with Weleminsky in the one case, that in subcutaneous injections in the region of the abdomen the chain of tuberculous glands can be traced in their proportionallv decreasing size, often as far as the bronchial glands and in isolated cases even farther ; so that one may get the impression of close connection between the conveving inguinal, iliac and bronchial glands; the spleen and liver glands are usually attacked before the lungs and the bronchial glands. It is the same in inoculation of the upper portion of the body, in experiments on the gums, nose or ear, after a few weeks a chain of glands of decreasing size goes from the neck glands to the bronchial elands, but the iliac £?'lands, &:c.. remain free. The 124 SCROFULOSIS legitimate path of the bacilli is from the glands to the thoracic duct or to the vein. Now, it is a much disputed question whether the tubercle bacilli can travel directly from the iliac and lumbar glands, and in the upper part of the body from the neck glands, into the Ivmph-vessels directlv to the bronchial glands, or if they must take the recognized path through the blood-vessels (see v. Behring, Harbitz, Pottenger, Weichselbaum, Leroux, Westen- hoeffer, Karlinski). \\"eiglilv anatomical grt)unds are given for ihe bK)od-vcssels as the only path. Recently extensive researches with respect to the lymph pas- sages have been made by injection into living animals and on dead bodies; in these investigations great credit is due to Most. We abridge his account as follows. According to these researches the whole of the Ivmpli of the entire human bodv meets on botli sides of the junction of the bulbus jugularis with the subclavian, and thus : — ■ (i) The deep cer\ical lymph glands which take up the whole of the hiiiph from the head in part directlv, and in part by means of the submental, submaxillary and subaurvcular glands, the mastoid glands, the pra^laryngeal, pra?tracheal, and paratrachea! glands. (2) The interthoracic Ivmph passages, namelv : — (a) Those of the tracheo-bronchial region, (b) Those of the lungs, (r) Those of the retrosternal Ivmpli \essels, and on ilie left (d) The thoracic duct. (3) The axillary lymph channels flow towards the above- mentioned junction through the truncus subclavius. According to Most, the separate lymph areas come into more intimate local connection at that point; but he considers an exchange of lymph in the different areas and a passing over of the germs from one region to another impossible, as this would presuppose a deficiencv and obliteration of the valves, which lie close together, and are efficient in their action. According lo anatomical researches a change in the direction of the stream, a forcing back or straining of the \alves, could not be obtained in spite of forced injection. The supposition of a rel re -grade passage is, therefore, to be accepted with great caution. According to ]\Iost, there is no proof of anv connection between the lymph vessels of the cervical Ivmphatic region and the summit of the pleura, or with the l^ronchial glands; the passage to those regions is anatomicalK' impossible, a regular or even a frecjuent transmission is not lo be lliou^ht of (see p. 103). GENESIS OE SCRUI'ULOSIS I 25 "All we can hcUcvf is, lli.-ii l)\ inmhiil .-inatoniical processfs n(;v. passages are crealed, m- ilic iiilcciioii is carried by conliguily from gland lo gland, from gland are.-i lo gland area " (Most). Jieil/k-e, basing his theory on researches (jblained by infec- tion ot the dead l)odies of children and guinea-pigs, considers that infection of the iritratlioracic glands frfjm liie deep cervical glands is impossi1)le, and denies a communication between the cervical, mesenteric and relroslernal glands. Kitamura lias arrived at the same results, and Albrecht expresses a similar opinion. But against this, llenle menti(jns a connection of (he lower deep cervical glands with the glands of the axilla and the thorax l)v branches which run in dilferent directions and act as vessels leading to and from them. In the lower half of the body the thoracic duct collects tlu- lymph of the abdominal organs and the lower extremities. 1; consists of three trunks : — The right and left lumbar trunks, which have their confluence at the level of the upper lumlxir vertebra, and which the intestinal trunk joins. The lumbar trunk collects the lymph of the pelvis and of the lower extremities (external and inter-inguinal glands), lumbar glands (about the iliac vessels), and the retroperitoneal glands (or para-aortal glands of Tendeloo). The efferent lymph vessels leading from the stomach reach the retroperitoneal glands. From the intestine the lymph goes into the mesenteric glands, which lie in several layers over each other, and then to the radix mesenterica and the retroperitoneal glands, which also receive the lymph directly from the testicles and ovaries. Intestinal infection, therefore, travels by way of the mesenteric and retroperitoneal glands and the duct into the vena cava superior, the right heart, pulmonary arteries and the lungs. Xo other passage from the abdominal organs to the bronchial glands exists (Most, Beitzke). How can the results of the experiments on animals be made to agree with anatomical facts? In manv cases after-infection mav take place during the con- finement of the animals bv sporadic germs (from ruptured subcu- taneous places of inoculation, Szc), by way of inhalation, or by swallowing food infected with the germs; the swelling of the neck and bronchial glands thus caused can give rise to the illusion that the Ivmph glands have taken a course contrarv to the anatomical course. Doubtless we are all now and again deceived bv such results, which are difficult to be avoided, and all the more so as by inhaling few^er eerms the lune itself often remains free. 126 SCKe)l-L I.OSIS One miglil also imagine an inspiration ot bacilli which have entered the mouth into the deeper air passages, as Nenninger, Paul, Ficker, and Bartel especially note; but these authors used such drastic methods (deluging the mouth with cultures of pro- digiosus, closing the wind-pipe 1)y pressure, sis ikj rounclings bill will !)<■ id.-iiiH'd in (jiu' pl.-ur. ( )n iIk- one li.-iiid, on a(x;<)iiiU ol llicir lii;;li (lc,L;rci- , among 288 tuberculous gland alTeciions, there were treated : — Cases Lateral cervical glands ... ... ... ... ... ... ... 132 Submaxillary and cervical glands ... ... ... 114 Axillary, lateral cervical, and submaxillary glands ... ... ... 10 Parotid glands ... ... ... ... ... ... ... ... ... 8 Popliteal 1 Multiple 23 Lcbcri, among 158 cases of scrofula of ilic c.xu-rnal glands, found the neck glands alone affected 108 limes, and in conjunciion widi clavicular axillary and sternal glands thirty times. If one excludes the bronchial and mesenteric glands, one can justly term the cer\ical giand.s " the true representatives of scrofula " (w liergmann). But according to the exjDerience of morbid anatomy, which affords us relati\-ely accurate information respecting the bronchial and mesenteric glands, though ihe\' often escape the most careful clinical observation, yet liiey surpass all other series of glands in fre(|uencv in tul^erculous scrofulosis. For instance, Miiller (Cornet, " Die Tuberctilose," second edition, p. 361) in 500 autopsies under 15 years of age found tuberculosis of the lymph glands 126 times, in which tuberculosis of the bronchial glands occurred 103 times. How far they occupy a more or less prominent place in the pyogenous form cannot be estimated; such swellings, although chronic, yet after a time again retrograde, and cannoi be easily demonstrated at the autopsy, and in most cases are onl\ brought to light if they have caused fatal complications. Biederi found in i ,346 aiUopsies of tuberculotis children, with or without tuberculosis at the seat of origin of the disease (i.e., the lungs and intestines), that the bronchial glands were affected in 78 per cent., and the mesenteric glands in 10 per cent, of the cases. Meeker in 96 per cent, of the cases of tul)erculosis in children which ended fatally found the Ivmph glands affected in 92 per cent., and the bronchial glands in 50 per cent. C'arr in 120 autopsies of tuberculous children found the l^ronchial glands implicated in 80 per cent., and the mesenteric glands in 54 per cent. Frobelius, in the foundling hospital at St. Petersburg, among 416 autopsies on cases of tuberculosis, found the bronchial glands tul^erculous in 99*2 per cent., and the mesenteric glands in i6'i per cent. Briining in 400 autopsies on children found tuberculous changes of the organs 44 times, of which 77 per cent, were in the bronchial glands, and 57 per cent, in the mesenteric glands. Stirniniann in 591 autopsies on children GENESIS OJ- SCKOFCLOSIS 1 35 under one year loiind 42 casfs I iilx r( nloiis, hni oiil\ dh'- < liild in whom (he orj^ans of rcspiial ion \\,fic nol rdlcflcd. Mendclsolin louiid lliai 2<)2 (or 2327 |)<-r (<-iii.; wrvc iuImt- CLilous oiil of 1,-^55 aiilo|).sir,s on ( liiKlrcn ; primary isolalffl tuberculosis ot llic orj^ans of i-cspiraiion onl\' (ini hiding'' llie bronchial ^dands) in 29 (1051 per rcni.j; primary tuberculosis of the organs of respiration, wiMi disseminaicd loci throughout th':; body, in ^> P<-'i" <"<"'ii.) ; primary (ulx-r* niosis of dif intestines only in 18 (6'52 per cent.); primary lulx-ii ulosis of \\\f intestines, with disseniinated foci throughoui ihc l)od\-, in 7 C2'54 per cent.). Albrecht had similar results. According to him, among 3,213 autopsies on children, of wliom 1,060 were tubercuUjus, the tracheo-bron(-hial glands were prominently affected. Feldmann also, among 752 autopsies on children, of whom 19 per cent, were tuberculous, found tuberculosis of the bronchial glands and lungs most frequentl\-. Schlossmann, who regards infection from f|uite a different standpoint, admits that the l)ronchial glands are withrjut exception affected in tuberculosis. Meubner sa\'S phthisis in children has its seat in the bronchial glands. Thus we see that the bronchial glands decidedly hold the llrst place in fref|uenc\- in tuberculosis. Watson Cheyne computes the frequency of diseases of bone on the basis of the reports of various authors (Billrodi-AIenzel, Jaffe, Schmalfuss, and his own cases). Vertebral column ... ... ... ... ... ... ... 23'2 per cent. Knee-joint ... ... ... ... ... ... ... ... i6'5 ,, Hip-joint ... ... ... ... ... ... ... ... i4'6 ,, Tarsus and anL^e-joint ... ... ... ... ... ... i4'4 ., Elbow-joint ... ... ... ... ... ... ... ... 6'3 Cranium and face ... ... ..: ... ... ... ... 5' 5 Breast-bone, clavicle, ribs ... ... ... ... ... ... 5'2 Pelvis ... ... ... ... ... ... ... ... ... 5'2 Femur, fibula, tibia ... ... ... ... ... ... ... 3' s Shoulder-joint ... ... ... ... ... ... ... ... I's Shoulder-blade, ulna, radius ... ... ... ... ... To According" to Sprengel, the frequency of bone and joint disease is as follows : Spondylitis, coxitis, tuberculous ostitis of the small bones of the hand and of the foot, inflammation of knee-joint, tuberculous ostitis of the long bones, tuberculosis of the ankle-joint, tarsus, elliow, shoulder and wrist. According to Jaffe the vertebral column was affected in 26 per cent., the tarsus in 21 per cent., the hip-joint in 13 per cent., the knee-joint in 10 per cent., the hand bones in g per cent., the elbow in 4 per cent. 1 j;6 SCROI-ULOSIS (2). THE CAUSES OF DIFFERENT LOCALIZATIONS. It would lead us luo tar lo enter iniu, and lo discuss^ here the occasions in which infection of the skin and mucous membranes takes place, and the conditions which favour and retard infections in particular parts of the body. A detailed account respecting the tubercle bacilli is to be found in the second edition of my " Tuberculosis." Almost the same conditions apply respecting the pus bacteria, with the differ- ence that the latter increase more quickly and locate themselves more easily. We will liniii ourselves here to a short sketch. As the skin on account of its first tissue is capable of retaining the whole or part of any germ which penetrates it, we can, in the case of the skin, establish much more easily by the local elTects the frequency with which certain places become the point of entry of the infecting germs than in the case of mucous membranes in which the position of the diseased glands must give the clue to the place of infection. When changes are met with in the glands we can, with greater probability, take for granted a bacterial invasion of mucous membrane. The diseased glands, and the knowledge of their seat of election, affords us the best guide as to the most frequent point of entry of infection, according to the law of localization (see pp. 63 and 88). According to Most, who has thoroughly investigated the matter, in two-thirds of the cases of scrofula and tuberculosis the deep cervical glands are most often affected, and especially the glands lying to the middle and side of the jugular vein, and the Ivmphatic glands at the angle of the common facial and internal jugular veins. The result of experimental infection of the palatine and pharyngeal tonsils tallies with this. Most lays special stress upon the regularly descending and rarelv disseminating course of the glandular swelling, which diminishes as they extend downwards. The glandular swelling ceases about halfway up the neck at about the crossing of the omohyoid and the jugular vein (where the middle of the deep cervicals divide and become the cervical trunk). I'he supra- clavicular, which lie deeper down, and which receive the lymph from the trachea, oesophagus and the lateral deep cervical glands, are very seldom affected, and only in \ery advanced cases. Tn a small number, in about one-third, (he glands rii the hDrder of the jaw are affected, the submental, submaxillary, ant! suhauri- cular alone, or with their effluents and the deep cervical glands. Thev point to a disease of the front half of the face, scrofulous eczema, affections of the mouth, teeth, nose, eyes and ears. GliNIiSIS Ol' SCROI'LI.OSI.S 137 SKIN. Ill (lie lrc(|ii('n(;)- ol |))()(^('ni(; .s( ml iilous diseases a striking dislinclion is incl wiili in iIk- \arioiis regions of llie skin. Most oflen llic skin ol' ilic Km (; iind scalp forms llie seat (jf scrofulous diseases, niiicii less ofu-n Uie hands, and very seldom the feet and trunk. In 1 lO cases ol scrofnloiis skin diseases observe(J by Lebert, 91 vvcrci situated on llic head, and of these 31 were on ihe scalp, in the tuberculous form alone, Neukirch f(jund in 55 cases of lupus 44 on the lace (in( hiding ihe forehead and nr>se), two on the neck, live on the hand and arm, one eacli on the leg and fool. According tf) Cramm's list of ( ases, 573 instances of lupus occur on non-iiairv parts, 69 on hair\- parts. In IJahn's 424 cases of lupus, onl}- 105 (occurred on the extremities, and singly only in eight cases, while 44 times in the 105 cases tfie face \\as first affected. The skin of the face in its cnitward ap|)earance is mucii softer, freer from wrinkles, and smoother than that of the hands, for instance, which, by use, often become quite indurated. The fact that the head and face are often uncovered and are thus more exposed to dirt and infection is of more importance. Added to this, children, especially under one year, rummage on the floor with their little hands, seize matters of a doubtful nature, and then in happy ignorance smear their dirty hands over their head and face or in their ears, or are " made clean " by their relations with dirty cloths or pocket-handlverchiefs. Thus a little girl got lupus of the nose from constantly using the soiled handkerchief of her tuberculous sister (Leloir, Baginsky). In another case chronic eczema in a child of a tuberculous mother was connected with crusts of bread sucked by the mother ; from, this act lupus developed. The researches of Preisich and Schiitz show us how the virus of tubercuU^us parents and relatives is conveved. In a polvclinic they found tubercle bacilli in the dirt under the finger-nails in 21 per cent, of consumptive children, amongst sixtv-six cases, and Baldwin, in twenty-eight consumptives whose hands were washed without warning, found bacilli in eleven cases. Graziani in eight consumptives found virulent bacilli in four cases. The latter found bacilli on his own hand after the exchange of a heartv handshake with a consumptive. Ostermann, however, had a negative result in a similar case. On the other hand, Ostermann examined the hands of forty-two children of phthisical families, and demonstrated tubercle bacilli in the water in which four children had washed, in fourteen adult consumptives onlv in seven cases, and similarlv on the hands of a nurse, and also 138 SCROI-'LLOSIS eslablisliL'd iluu ihc i^crni was easily set free by pulling ilie lingers in the mouth ami ni>sr, for instance. The same applies io pus ct)C(i. The scalp, as opposed to ilie fai'e, is i^roiecied by ihe hair, bui iliai is oft.en not kept clean, as the frei|uent nestnig of vermin shows. Special opporiuniiies of infi'cnion ofu-n oct'iir troni slings ol gnats and insects, irritation of scborrluva, acne pustules, which cause scratching with infected lingers, little scratches with sharp combs and hairjiins, b\- a fall, or in play. Of other parts, it is usuall\- the thin surlace of the baik ol the hand which is the seat t)f infection, especially the groove of the nails, which furnishes a lurking jilace h)r the l:)acleria. Compared w ith each other, the tuberculous form of scrofulosis of the skin is less frecpieni than the pyogenic form, because the tubercle bacilli are less widelv distributed, and especially because, bv the low temperature of the skin, they grow more slowly, and thus can be more easily eliminated than pus cocci and other bacteria. MUCOUS MEMBRANES. As from the greater permeabilitv of the (-hild's mucous mem- branes, isolated germs, especialK" tubercle l:)acilli (see p. 29), not infrequentlv reach as far as the glands, it is often only from the diseases of the glands that we can judge of the fre(|uency with which the mucous memljranes form the point of entr}' and also of the more exact position of ihe latter. Those mucous meml)ranes which are the points of entry of air and food which are so frequently infected, that is to say, tliose which come most into contact with the outer world, namely, the mouth and nose, b\' far surpass in the fref|uencv of the disease the usual outlets, the anus, urethra, and in certain cases the vagina. These differ among each other according to the degree in which thev are exposed to infection, and according to the sufficiency of the protection. In the case of the nose, the germ-laden ins]iired air forms the source of infection which, as has been explained elsewhere, is here exposed to a process of deposit by the vibrisscC and the various ridges and depressions, the side current formed bv these, and the sinuous course of the breath current, h^urtlicr (ipport unities are now and again given by the bad liabit of picking the nose, caused by the irritation of worms in the intestine, and the intro- duction of foreign bodies b\- clirtv lingers, wherebv bacteria adhering to them and tubercle bacilli are often undoubtedlv rubbed in. If w-e may take the seat of tuberculous changes in the nose (JENKSIS OJ' SCKOl'O.OSIS 139 of jululls as a slardard, iIk- scphini and ;i iiicrior narcs may be especiallv considered ;is poinis ol '•niiy lor scroluh^sis (sftf; vSymplonis, p. \<)^). In (lie case of liic naso-pliarynx, die inlialalion of bacleria nuisl be lakcn in(o consideration in ilie Tirsi place for this spol on analoniical grounds, and, a( ( < ndinL,^ lo Kayser's dusl experi- ments (p. 139), jusl diis position next lo the nostrils forms (lie chief depot for the deposit of dust. Resides which, the lymphoid tissue of Luschka's tonsil and die ,surfa(es full of rrypis arc* especially suitable for absorption and reieniii.n. From (his spot, bv couq'hin'^ and oHiei- toi(cd actions, by sneezing or retching, germ-laden secretions are driven througli the luislachian tube to the middle ear, the bacteria llourish on the mucous membrane, which may be either intact or weakened after measles or scarlet fever, &c., produce middle ear catarrh, or are carried to the glands by the clefts of Santorini (Ferreri), which are broader in children. For instance, in five cases of what wa.s apparently primary tuberculosis of the ear in infants, Ilaike has been able to trace the path of infection from the pharynx to the tympanum, sometimes through tuberculous deposit in the palate, and sometimes through affection of the Eustachian tube. For infection of the outer ear, which often is the seat of eruptions, dirty lingers, foreign bodies, ear scoops, play an important part, and now and again earrings of tuberculous persons, as in cases related by v. During, Unna, Leloir, and Schiele. In the mouth the sources of infection are principally from food which is derived from tuberculous or diseased animals or is decomposed, or is accidentally contaminated by pathogenic air- carried organisms. On the other hand, the bad habit of children of putting dirtv fingers (see Preisich and Schiitz, p. 137) or odier things into the mouth is the cause of infection. Tubercle bacilli and other germs can easily enter the open mouth with the respired air; bacilli mav be conveved by kissing tuberculous persons, for although the saliva is generally free from l^acilli, particles of sputum mav be hanging on the lips or moustache. Whether the bacteria can cause infection at all, and in what part of the digestive tract in the moutli or tiie intestines — apart from a weakening of the germ in the stomach — depends upon the rapidity of their passage. Fluids will more easily afYect the intes- tines ; solid foods, which have to be masticated, or micro- organisms, accidentally introduced into the mouth by the fingers or other objects, and whicli need no special act of swallowing and remain longer in the mouth, are more dangerous to the buccal cavity. Oehlecker gives a striking example : '' Bc^nbons, and the 140 sc'Roi rn)sis affect ioiiaie con.suinpii\ c tricnd," mu' who iH-iaiiu-el lill shortly before her death the appetizing custom of allowing chiUlren to lake bonbons, chocolates, .^c, out of her nioulh, whereby three children developed tuberculous glands. The fips, tonsils, and carious teeth are fa\-ouriie sites of scrofulous infection, the lips because diey are exposed to con- laniinaiit)n. especially in children who use them for cleaning their soiled lingers, and which hold dirty objects put info ilu-ir mouths, such as trumpets, baljy comforters, (S:c. Waldever's pharxngeal area is very im]:)ortant in infection as, being speciallv adapted for the retention of foreign l)otlies wliich mav have penetrated owing to its abundance of lymphoid tissue (Freudenthal and others), it may be looked upon as a series of achancetl ramj^arts and trenches. The tonsils are especially titled for the absorption of germs bv reason of their pilled structure, which gives a hold to infec- tious panicles, bv their defective sieve-like epithelium (Stohr), and by tliQ close contact into which they enter in the act of swallow- ing with all the ingesta passing down the oesophagus ; Dmochowski even attributes suction properties to the crypts. Goodale and Mendelsohn established these facts by various powders of tine substances, carmine, and soot which penetrated the tonsils. Pirera used pus cocci ; Lexer brushed on virulent streptococci. Hypertrophv of the tonsils is a regular accompani- ment of scrofulosis. Respecting tuberculosis, the researches of Strassmann, Schlenker, Dmochowski, Kriickmann, Walsham, Scheibner, Escomel, Schlesinger, Grawitz, &c. (Cornet, " Die Tuberculose," second edition, p. 223) have shown that, when the opportunity of infection is caused bv a large number of tubercle bacilli, the tonsils are alwavs attacked in the course of advanced consumption, that under such circumstances frequent occurrences of tonsillar tuberculosis, sometimes accompanied by tuberculous swelling of the glands, have misled certain authors into claiming the neck glands to be almost the only point of entry of the tuberculous virus. That tuberculosis of the tonsils is a primarv disease has been shown by Schlenker, Kriickmann, Orth, Goerdeler, Ito, in single cases; b\- Friedmnnn five times in ninelv-one tonsils of children after death, and by Lubarsch in twelve cases. Clinically, Abraham found apparent tuberculosis of the tonsils (in a scrofulous woman); Hopkins, Sacaze, Ruge, Hofmann relate similar cases (in the last case the patient, aged 18, was accustomed to use the pencil of her consumptive neigh- bour and to bite her finger-nails); Kingsford, among se\-enteen (JKNI'ISIS OI<- SCKOI'CI.OSIS • 14I children willi swollen (crvical glands, lininiJ 1 uhereulosis <>\ ihe tonsils in sf\cii cases, \)\\\ all iliese cases together are n(jl nnnier- ons, and go lo Ualancc I ic(|iiciii iicg,-ii i\c lnulings. in the sani(i way l'"riedniann never lonnd liibercnlosis of the tonsils among forty-six living children witli liyi)erlnj])hy ol the tonsils and pharyngeal tonsils, and among six children with decided tuberculosis of glands (excepting in f)ne child who showed evidences of lung disease). Ito, among 104 children, found after death secondarv liiberculosis of ilu- tonsils li\c limcs, but no case of primary tuberculosis (see also p. \ot,). ]3andelier, among 200 hypertrophied tonsils wliif li had been removed in luberculous jiersons, and eight pharyngeal tonsils, established tuberculosis in ten cases; only two cases were apparently primary tuberculosis. Tarchetti and Zanconi obtained negative results in fourteen cases during life by inoculation of hypertrophied tonsils and vegetations. Escomel had the same result in eleven non- tuberculous persons during life. Dieulafoy produced tuberculosis only eight times by injection of tonsils in sixty-one guinea-pigs. V. Scheibner, in sixty tonsils which he examined histologi- cally, declared four to show probably primary tuberculosis, but he also declared that he could not obtain an entirely convincing proof of the existence of primary tuberculosis of the tonsils. In the face of results wliich have hitherto been produced, we are not justified in attaching any great importance to the tonsils in tuberculosis or scrofulosis of the cervical glands, to say nothing of making theni almost entirely answerable for their causation. Without denying their considerable importance in scrofulosis, we have no ground for considering the permeability of all other parts of the mucous membrane, which has once and for all been established as of no special importance in conditions which come before us in practice, and which does not now and again give rise to actual infection. Rosenberger, among nineteen cases of severe tuberculosis with suppurating glands, found in nine cases no hypertrophy of neck area, and no tuberculosis macroscopically. This exclusive point of view has been refuted by the fact that the cervical glands connected with the tonsils are not always primarilv affected, but often, in about one-third of the cases, there is quite a dift'erent zone of absorption. The pharvngeal tonsils form by their irregular, uneven structure a favourable spot for the collection of bacteria, especially tubercle bacilli. In the vault of the pharynx the respired air 14^ SCROI'LLOSIS undergoes a change i>f direction, and tin- bacieria contained in n are diVecilv projected on lo ihe tonsils; the cihaied cpithcUnm, the office of which is to provide for their further progress, is, especialh in voung persons, often replaced by sc|uanious epuhe- Hum (Dmochowski), and is damaged in its functional capacity by frequent inflammation. The occurrence of tuberculous disease ot the pharyngeal tonsil is verv varioush estimated. Main writers do not record it once in loo cases; others record S, or even jo per cent, (see Suchannek, Dmochowski, Koschier, Brieger, Lewin and Gradenigo). Mv rcsuiuc of the works of I.ermoyez. Goltstein, Brindel, Broca. Pluder and Fischer, (iourc, Bride and 'riirner. llynitsch, Luzzato. Piffl. Pilliet, Wright, Brieger and Lewin, Ilo, Wex, Uffeni)rde, Poliakov, Rethi, Baup, Cornil, Zwillinger showed tuberculosis 71 times in 1,745 cases (41 per cent.); I.achmann found in a later collection of 2,065 eases 89 cases of tuberculosis (4-3 per cent.); Cahn found tuberculosis of the pharyngeal tonsil in 4 per cent, of persons affected with adenoids (see also Barstow, Escomel, Ivens, Lachmann). These figures reduce the ex- aggerated ccmception of the pharyngeal tonsil to a more modest proportion (Trautmann, jessel, Zarniko, Beckmann). A good number of swellings belong to the non-lubercular form of scrofulosis. Nebecourt and Tixier found quantities of adenoids, hyper- trophied tonsils, and enlarged glands in twenty-tw-o children, but nothing of a tuberculous nature (see also Simon, and others, p. 195). The glands of the lingual follicles and the other divisions of the tubal prominences of the pharynx seldom form an entrance for bacteria. Zickgraf's investigations do not sui^porl the hypothesis ]:)Ut forward bv Freudenthal respecting the lingual tonsils as a point of .entry for tuberculosis. Apparently the cavities of carious teeth are a focus of infec- tion, oftener than has hitherto been admitted. In the last few years Odenthal, Hoppe, Berten, Starck, and Kdrner have especially called attention to the connection of carious teeth with chronicallv swollen neck glands or hyperplastic lymphomata. Among 700 children with enlarged neck glands in whom Odenthal examined the teeth, 346 were found with carious teeth, and no other manifest cause for the enlarged glands, 79 with caries and other simultaneous affections at the roots of the teeth which could be considered as the cause. In 175, gaps between the teeth showed the former existence of decaved teeth. Accord- (;|';nI':s[.s (>\' sckoimi.osis 143 in<4' lo kosciii lial, sonx' .'iricclidii nl ilic icfih w.-is llic causf; ni ^o lo 60 per ccnl. ol (•nl,-ii'<;*-(l cervical glands (sec .-il.so Anscliiil/). As I'arlscli pninlcd mil willi caries, ciil'i it_;c(| i^l.-inds in tlif necl< only occur when llie process has invaded \\\c pidp and .uK'anced lo (he roots of ihe leeMi. l'"roni s\iiipadi\- die siihinaxillary and SLihmenlal j^lands become sj)ecialiy invoked. The siniiihaneous occurrence of caries and affecied ^dands does no( warrani of ilseh an\' causal conneclion, and from llie al)o\e figures il is nol perceplible how far ihe oc( iirrence of ihe r-nlar^^ed elands can hi' idenlified wiMi scrofiiln.sis. A near conneclion, however, cannol be denied, sinpo.silion lo ilu- clisciplfs of licrcdiiy cloclors have in al' times, ever since this term has been used in a sense nearly resem- bUng that of the present day. come lo very dilTerent resuhs on the ground oi their clinical observations. For example, Th. White (1788) contested the lieredity of scrofulosis, and said it was the same as if we should say that the children of lead-workers, who also work in lead, i;el lead poist)ning. Leberl (whose book on "Scrofulosis" is even now worth consideration bv reason of llie sharp criticism lo which it has been exposed) especiallv attacks heretliiy, which he considers to be not the chief cause, but only one of the conditions under which scrofulosis will be found with comparative frequency. " Strictly speaking," savs Leberl, "only this is certain, llial a number of scrofulous and tuberculous jjatients have children who suffer from the same affection as themselves. It is better lo rely on insufficient but real facts than to hide one's ioudrance under hy|:)otheses and high-sounding sentent-es." Birch-IIirschfeld. who considers heredity as one of the most important etiological factors, was obliged to admit that it cannot be confirmed bv statistics. We must endeavour in our di\ ision into the pyogenous and tuberculous form of scrofulosis lo keep the two distinct, also in considering the question of heredity. THE INHERITANCE OF TUBERCULOSIS. The inheritance of the tuberculous form of scrofulosis must be considered in the same light as the inheritance of tuberculosis itself. We distinguish congenital tuberculosis as a transmission of the germ itself, which may be either germinative or placenta! transmission of the bacilli as well as the transmission of a certain tendencv or disposition to tuberculosis; heredity in the proper sense of the term, according lo ]\Lariius. TRANSMISSION OF THE GERM. Our researches on tuberculosis (see the detailed account of the question of Heredity in my book, " Die Tuberculose," second edition, pp. 432-476) lia\e vielded tlu^ following results : — Germinati\-e transmission. A germinal i\-e transmission on the part of a tuberculous father presupposes that tubercle bacilli are to be found in the semen. The positi\-e finding of the tubercle bacilli in the semen, testicles, and seminal \'esicles in cadavers, especiallv with miliarv tuberculosis, communicated by Sirena and Pernice, Spano, Jackh, Nakarai, Simmonds, may just as well III'.KCDn Y 1.5' have Ix'cn llic conscciiK'iK <• ol disscin iii:il loii ol \>:\i illi m ili'- l>'i'iy before; (Icalli, and ihcrrlorc nn (diu liisions can !)<• drawn from these cases for living sexual Iv-.-m live hhmi. Besides, llieir importance is rediicd \)y ih'- n<'<^^-iti\e lindinj^^s of KoliIlT and Wcslcrmayer, Waltlier, Hohrf.ldonski, and tin- relatively rare occurrcncr of primary L,^cniial Inhr-rculosis in women, esi)eciallv in pudla' piihlicie, in s\)\\c of ilu- well-known sexual activity of iliousandsof men suffering- from plidiisis. Even in experiments on animals, where w(; can create the most favom-able conditions for such transmission and have at times inundated the testicles with enormous doses of bacilli, th.^ experiments of Cava^nis, Gartner, (i. Cornet, liinaghi have testified that the embryos and young bred from such semen were free from tuberculosis. Friedman n was tlie only one to obtain positive results, that is to say, he found tubercle bacilli in the embryos, but the arrangement of his experiments was far removed from natural conditions, and these experiments, on which v. Baumgarten, &c., rely so implicitly, were not confirmed by the after-tests of Seige. The experiments of Karlinski are also unconvincing; he inoculated the testicles of a he-goat with human bacilli and then caused it to cover a healthy she-goat ; the female remained healthy, but the voung exhibited tuberculous foci in the mesenteric glands, enlargement of the cervical glands, and peritoneal tuberculosis, a picture which does not coincide with what might have been expected from such a mode of transmission. We arrive, then, at this result, that up till now no conclusive cases are to hand which prove the possibility of the transmission of tuberculosis bv means of semen containing tubercle bacilli, to sav nothing of assuming that such transmission can take place with men under natural conditions. Bongert expresses a similar opinion in his critical reviews, as also do Crouzon and Villaret. Placental transmission. The case is somewhat different with placental transmission. The normal placenta forms an impenetrable filter to corpus- cular elements and bacteria, but under the influence of various infectious diseases, accompanied perhaps with high fever, lesions occur, epithelial defects which render the passage of the bacteria into the foetal organism possible. In the case of a tub.erculous mother such a passage is apparentlv onlv possible if a tuber- culous focus is in the placenta itself, as happens now and again in acute miliary tuberculosis. Tuberculous foci in the placenta have been demonstrated bv F. Lehmann, Schmorl and Cockel, Auche and Chambrelent, Runge, Sitzenfrev (among twentv-six 132 SCROl-l LOSIS moiht-rs suffering' fnuii pUu-t-nial iiihrrcuilosis scxcn linu'S wiili tuberculous changesj, Jung, Monaco, Schniorl and Cicipel ft)und tuberculous changes nine limes in iweniy cases of se\ere luben 11- losis and once in iiuipient phthisis (after 2,000 preparations, but the virulence was (lueslionable). The researches have been facilitated bv the aniiformin method, by the help of which Novak and Ran/.el demonstrated tuberculosis in ten placentas seven times bv antiformin and three times histologically (see p. 247). Amongst cattle, placental tuberculosis appears t(» be more frequent, and frcm this the relatively more numerous cases (according to Arvid Bergman o'42 per cent, of ne\\-l)i)rn calves are tuberculous) is to be explained. But even the tuberculous placenta appears, according to the histological findings of Schmorl and Cockel, to offer in many cases a protection against the entry of bacilji. Carl, Benecke, and Kiirbitz, Ilenke, Ilamm and Sclirumpf, Schlompert (five cases) ■could find no tuberculosis in the ftvlus in spite of placental tuberculosis. In other cases of Sclirumpf, AVarlliin and Cowie, Lobenstine and Wollstein a transmission of the bacilli to the foetus was consequent upon placental tuberculosis. Whether a transmission is possible without tuberculous changes in the placenta is doubtful (Geipel). Aschoff and Bernard, Courmont and Charier inf(^rm us of a placenta free macroscopicallv and microscopically, but tubercle bacilli were demonstrated in the liver of the foetus; in such cases small placental foci may have been overlooked. Bossi, who in twelve cases inoculated the placenta and liver of the miscarried foetus of tuberculous women, onlv found bacilli in one placenta w^hich was not intact. But it might alwavs be supposed that under the influence of high fever, especiallv in miliary tuberculosis, there may be breaks in the continuity, and it is just at these spots that the bacilli mav have entered (see cases by Schmorl and Birch-Hirschfeld, Hochsinger). The actual o(~eiu'rence of tuberculous fcrluses is more impor- tant especiallv in the new-born, in which tuberculous changes have been demonstrated so soon after birth that the seat of these changes and their degree of de\'el()pment entirelv exclude the idea of infection post partum, which therefore conclusively prove intra-uterine transmission. A few such cases in man which stand the test of critical demands more or less were recorded b\^ Charrin, Berti, Sabnurraud, Lannelongue, \'. Rindfleisch, Hoch- singer, TTonl. T^ugge. AucIk- and Chambrelent, TTenk'e, Brindeau, lleiLz, l.ylc, Stockcl, J Iaml)iir^ugol informs us that neither the besieging army, who were for a long period exposed to damp, all sorts of privations, most unwholesome food, famine, constant exertion by day and nigiit, discouragements, &c., nor the besieged, whose fate was still worse, had many cases of scrofu- losis, though they suffered from scurvy and dysentery. Concerning the spread of scrofulosis in towns and in the country, many authors confirm a decided difference in favour o*" the population of the country. The fact that country people suffer less from scrofulosis may be due to their li\ing more in the open air, and so incurring less risk of infection, either from tubercle bacilli or pus cocci ; and also in the country there are no narrow streets and dark courts. These advantages are, however, in many cases counterbalanced by the close, unventilated, small-windowed rooms of country cottages in which the people live day and night during the long winter months. In many cases there ,is barelv a division between the living rooms and cowsheds and stables, so that man and beast live amicably together; human and animal secretions are carelessly heaped up together in the country. Local conditions and customs are too various to set up a general rule, therefore authors making observations in narrow circuits arrive at results contradicting one another. Scrofulosis has even been described as a peasants' disease, and been put down to a too large consumption of milk and butter. Lebert and others find no difference between country and towns. The acknowledged fayourable influence of a sojourn in the country for townspeople can naturally lead us to no conclusions respecting the country people themselves, as the two liye under entirely different conditions. Scrofulosis appears to depend little on climate and soil. It has been stated that damp, cold, low-lving places are much more conducive to scrofulosis than dry, warm, highly-situated districts; indeed, formerly low-lying places were mentioned as a direct cause of it; but older authors referred to the contradiction of this theory in practice. Thus Lugol pointed out the frequency of scrofulosis l6S SCROFULOSIS in Spain on the lable-land of Castile, especially in Madrid, while (on the other hand) it is often little met Nvilh in the dampest districts. Here, as in tuberculosis, we must in the first place take into consideration how far the climate tends to cause the population ;o live in closed rOoms full of germs. This point of view leads us to consider that seasons must also exert a certain influence; winter would afford increased opportunities for infection, as the cold, cheerless weather would lead to staying indoors, and thus infection would declare itself after weeks or months, and according to the energv and growth of the germ in question would declare itself by a local or glandular affection. In fact, some authors mention that scrofulosis affects people more especially in the spring, that it gets worse about January to March, and then decreases. Scrofulosis is undeniably favoured by certain illnesses, especially the acute exanthemata; in fact, they appear now and again to induce a direct outbreak of the disease. For a long period measles and whooping-cough have had a bad name in this respect, and after an epidemic of these diseases an increase of scrofulosis has often been observed (Albrecht and others). Obstinate spasmodic cough consequent upon swollen bronchial glands, and the pressure on the nerves induced by it, has been erroneously mistaken for the pertussis which leads up to scrofu- losis. Scarlet fever, diphtheria and small-pox, frequently precede scrofulosis. In a case of Gougerot, for instance, lupus which had existed for sixteen years increased in size after small-pox. The epithelium becomes loosened, and the continuity of the protective covering is destroyed by the catarrh of skin and mucous membranes which constantly accompany these affections. Bacteria adhere then more easily, and thus penetrate and deposit them- selves. Such infection is specially favoured when children live in an environment full of germs, especially in tuberculous sur- roundings, and when the sick-room is scrupulously closed, darkened, not ventilated, and therefore full of germs. In a great number of cases affections of the glands have existed before the measles, &c., occur, especially latent (or even manifest) affections of the bronchial glands. Such have been demonstrated by Loomis, Pizzini, G. Cornet, Spengler, Harbitz, Weber and Baginsky, Weichselbaum and Bartel, Gaffky, and others, and as accidental conditions (see Cornet, " Die Tuber- culose," second edition, p. 370). The usual accompaniments of measles and other exanthemata. — namely, the swelling of the lymph glands already infiltrated I'ACTOKS WHICH FAVOUR INFECTION l6y wilh prc-exisLing foci- lonscn .-iiid inobili/.c (lie Ijacilli and incite new growth; the glands, liiilinio laicni, manifest themselves at this time. Mechanical and chemical pnjcesses, the softening of the tissues or the toxins of the secondary bacteria (measles), wash a few bacilli out of the gland. vSevere inflammation can even cause the tense capsule to burst; the bacilli thus freed disseminate them- selves over the hilum of the lung, and induce the exanthernatous phthisis of the lungs — so-called by the older physicians. Or they enter the bones and joints, or cause acute miliary tuberculosis, or induce in the skin multiple lupus, multiple tuberculosis, tubercu- lides, or scrofulides (Adamson, du Castel, Haushalter). It is often difficult to decide whether we have to do with a new infection or a manifestation of a pre-existing focus. In the tuberculous form multiple and rapid appearance points to the latter. The dissemination of scrofulous foci and metastases appears to be greatly facilitated by the speedy loss of flesh resulting from these diseases, also by faulty nourishment, for reasons explained before (see Cornet, " Die Tuberculose," second edition, p. 682), by the increased absorption of bacterial poison in the body, and the increased difficulty of healing consequent upon it and the easier propagation. In many cases slightly virulent bovine bacilli which have entered accidentally, and which have been held in check by the power of resistance, in consequence of a reduced power of resist- ance as a result of measles and similar affections, may develop and disperse. But I consider it unjustifiable to impute consider- able vitality to such latent foci of bacilli in case their further development is hindered ; at least, the reasons hitherto brought forward are not conclusive. I consider the explanation given by Henoch, and others, of the connection between scrofulosis and measles unsatisfactory, namely, that where a tendency to scrofulosis exists it will suddenlv break out under the influence of these acute maladies. The observation has been often made bv Happe that scrofu- lous children, or those whose parents are phthisical, show a verv great mortality from the above-mentioned diseases, whilst in children of healthy families, where the opportunity for infection is lacking, these diseases as a rule pass off well, and it is only in the rarest cases that tuberculosis is developed from them. Syphilis is accredited with a prejudicial influence on the pro- duction and course of scrofulosis (this is contested by others). (For vaccination as a possible promoting" agent, see p. 14S.') Rickets, struma, cretinism have been suspected, without due grounds, to be favouring agents. 170 SCROFULOSIS Erysipelas takes a special place. Sometimes it precedes scrofulosis, and mav form a point of entry for the partictdar germ. But in other cases it appears during the course of scrofulosis, and now and again has e\en a beneficial influence on the scrofulous processes localized in ils area for examplt', lupus (Berturelli, Winternitz, Koliath, Isnardi, Ilallopeau); this \vas also known to earlier physicians, for instance, Lugol, and reminds us of the similar temporarih- favourable effect on pulmonary phthisis (see Cornet, " Die Tuberculose," second edition, p. 779). Tratmia is often mentioned as a further accidental cause of scrofulosis. Superflcial injuries, stings of insects, and bites of vermin, scratches, burns, and chilblains, so frequent in scrofulosis, open a way of entrance for bacteria and tubercle bacilli. Staphylococci and streptococci especially a\ail themselves of everv injury to the tissues for depositing themselves, and easily induce mixed infection. Germs are washed away from larger wounds by the bleeding. Awkwardness, mischief, play, and daring cause numerous wounds during childhood, which are taken little notice of, and are hidden from the reproving eyes of the parents. In many parts it is customary to bind up small superficial wounds and contusions with rags smeared with a mixture of milk and cream, often from suspicious sources, or to smear them with saliva and blow upon them ; lupus can be induced in this manner. Leloir informs us of such a case. Special importance is attached to coarse forms of trauma in the production of tuberculosis of the bones and fungous joints. We can onlv refer to what has already been said of tuberculosis, especially as in bones and joints we have only to do with the tuberculous form of scrofulosis. V. Baumgarten supposes that inherited bacilli find in the lymph glands and marrow a suitable nidus, and there pass their larval existence till external conditions reduce the vitality of the tissues. But if only on account of the rarity we cannot agree with the opinion of this highly-esteemed investigator. Another hypothesis is that the bacilli circulate harmlessly in the blood of an individual suffering from scrofulosis of the bones caused by trauma, and only at the moment and in the place " where, on account of trauma, a suitable culture ground has been prepared for them " do they deposit themselves. Now as a rule virulent bacilli only appear in the blood in acute miliary tuberculosis, rarelv in phthisis, to say nothing of the blood of apparently healthv persons, therefore the conditio sine qua non is wanting. Surgical experience declares against bacilli circulating in the blood, a theory which has recently been pushed to the front, for we know FACTOJiS WHICH JA\0(;)< JMl-.CJIUN 171 thai, witli scrofulous .-md plilliisic .-il jj(;rsons a wound somfiirncs after severe trauma and cxlensive laceratifjn requiring nifjntlis to heal never becomes tuberculous. In my opinion, in some of the cases of bone and joint scrotu- losis which are associated with trauma tliere exists somewhere, and, as pathological experience teaches, most frequently in the bronchial glands, a latent tuberculous focus. The distended capsule of the swollen tuberculous bronchial glands can, either directly or by cunlrecoup,^ which is often Iransiniiled from a distance, be compressed or injured, and one or another of the biicilli squeezed out by the sudden shock and so reach the lymph and blood systems. At the exact place where the trauma has been effected, where the path of the vessels is disconnected by the con- tusion, the bacilli will be interrupted in their regular course, force themselves into the tissues, and there set up a metastasis. Accord- ing to the experiments of Schiiller, the bacteria which have entered the blood appear to deposit themselves more easily in a contused joint than in a non-contused joint. But we come across certain difficulties in this theory. The fact that such affections are caused especially by sprains and dislocations is to be explained by the fact that in greater injuries the bacilli are washed away by the haemorrhage. Our theory is supported by the proof of latent tuberculous foci as already mentioned, the presence of which, even in considerable numbers, must necessarily result from the following considera- tions : In Prussia, for instance, over 17,000 young persons under 20 years of age die yearly of scrofulosis and tuberculosis. We must suppose if only a three or four months' period of latency for this low age is accepted, there are about 4,000 or 6,000 persons in Prussia suffering from latent tuberculosis. Blows, falls, and contusions are such everyday occurrences in youth that latent foci and trauma must be everlastingly happen- ing together. Such coincidence has not always sad consequences, for how often does trauma happen to children without metastasis occurring, in spite of all hereditary affections, and in spite of manifest tuberculosis ? Therefore, great reserve is necessary in an estimate of a causative connection. In manv cases the trauma may be the effect and not the cause ; an alreadv existing bone and joint disease in its initial stages produces no svmptoms whatever, but after a certain time it inter- feres with concerted movement ; generally, at first unconsciously, it makes the movements uncertain, and on this account leads to a ^ Perhaps tearing of the knee-cap may be caused by excessively hasty movements, in a fall to preserve the balance. ^^~ SCROFULOSIS trann";'-,'"*", '' "'"'"'''l' '""'"' "'" ^^^^ ^^-^^^ importance of trauma, and supposes that a bone disease was already existing and the external influence only hastened its course, while in othf; cases any traumatic inBuence may be excluded with certainty 1 would also refer to the recent uorks of Friedrich Honsell and^ S,,rengel. who place the inOucnce of trauma on f mfn"'. SECTION II. Morbid Anatomy. In considering the morbid anatomy of scrofulosis we must separate the two principal forms, the pyogenic and the tuberculo- scrofulous, as we did in considering tlie etiology of the disease. (1). PYOGENIC FORM. We gather from former statements that the pyogenic form carries no pathological signs in itself which differentiate it in any pathognomonic sense from similar affections of a non-scrofulous nature. Scrofulous catarrh of the mucous membrane shows exactly the same changes as ordinary catarrh, distension of the vessels and hyper^emia, swelling and thickening of the mucous membrane, increased mucous secretion, and enlarged mucous glands, increased casting off of epithelium, and secretion of blood serum mixed with corpuscular elements of the blood. Analogous symptoms are met w'ith in eczema, in catarrh of the skin, whether it be of scrofulous nature or not, distension of the capillaries, often considerable swelling of the papillae, increased shedding of thickened epidermis, transudation of blood serum and corpuscles, infiltration and thickening of the epidermis and corium. The number of cells in the secretions mentioned b}' Rindfieisch as characteristic of scrofulosis, and the closer cell infiltration of the parenchyma rich in connective tissue, to which Rabl had before referred as characteristic, are found also in chronic non- scrofulous inflammations as noted by Birch-Hirschfeld. The swollen nose and upper lip are not specific, but occur also through congestion in other layers. The long duration and frequent invasion of germs bring the toxic principals to a climax, and induce a gradual intensifying of the svmptoms till the formation of ulcers occurs. A description of the morbid anatomy of the skin and mucous 174 SCROFULOSIS membranes in pyogenic scrofulosis woukl be, therefore, only .'t repetition of descriptions of simple catarrh of the skin and mucous nienibranes, simple conjunctivitis, rhinitis, adenoid growths, bronchitis, catarrh of the intestines, vaginal catarrh, &c., already given in other portions of this work. The peculiarity of the scrofulous form of disease consists in its very slow course, conse- quent upon anatomical conditions, its frequent temporary concurrence with similar affections in different places, its multi- plicity and frequent recurrence. We will devote a few words to the lymph glands only, on account of their dominating character in the phases of the disease. We have to do with those changes which were formerly called the tirst, or, according to Virchow, the hyperplastic stage. At this stage we rarely see scrofulous glands, because, as a rule, they rarely need surgical treatment, and in the cadaver advanced and combined processes are generally the objects of investigation. At first the gland is only slightly enlarged up to perhaps the size of a walnut, and is of a soft elastic fleshy consistence, the blood-vessels are injected, more especially in the capsule, and chiefly when the acute stage is investigated. On incision the surface is fiat and regular, marrow like, moist, glossy, and slightly transparent, of a blue-grey colour, but sometimes reddish on account of hvper^emia,' sometimes whitish owing to an increase of lymph corpuscles. At a later stage the surface is drier, the structure of the tissue is altered and more homogeneous, and the consistence firmer owing to the aggregation of cells. Under the microscope one sees besides a great distension of the blood-vessels, an enormous increase of lymph corpuscles, especially in the capsule. There- fore the scrofulous gland swelling is a " hyperplastic lymphoma abounding in cells " (Virchow). In many cases the inflammatory formation of connective tissue in the capsule is in excess of the connective tissue, septa, and the reticulum (fibrinous hyper- plasia induration). The swelling of the gland may continue for a long period in this condition. If it has not continued too long involution will take place, as the hyperplasia may be absorbed and disappear by the metamorphosis of fat (scrofula fugax), and only the thickened walls of the capsule and the denser fibrous septa of connective tissue, forming a slight enlargement and hardening of the gland, remain as evidence of what has taken place. Pus foci may be formed if the addition of virulent germs exacerbates the process ; these are recognizable on the incised surface as yellow .MOl\ ilic mucous in('inl)i\'in('S, llic h.iciili \\lii(li li,i\«- hccn dcposiicd upon tlieseare either washed awa}- by the ph^ntifid scrici inns of the surface, or else incrusted ; in any case, Ihey ar<- icudcicd harmless. Unna dislinj^uishcs in (hil(hi-n ,-i 1 iilxi' nlo-scrr^fulous or scrofulous, and a nervous d<'ntilion ec/.enia ; the former is mei with on the nose, eye, ear, head and mouth, with impetiginous characters; lIic lallcr on boih cheelvs, the back' of \\\(: hands, symmetrically on I he forehead and chin, hrst as ilching papules or swellings, which undergo further changes as a result of scratch- ing, and are repeated at each recurrence of dentition. Eczema and erythema arise on the nose and ear mving to the skin being irritated by the acid secretion which exudes with catarrh ; a thickening of the skin often supervenes. We often find, especially in children who are not kept clean, multiple small skin abscesses, suppuration in several places one after the other, caused by the staphylococcus aureus. Sittler mentions roundish, rather sharply-defined patches with small scales on the mucous membrane of the cheeks of scrofulous persons, which disappear after a few days. (2) Tuberculous Form. Lupus. — Lupus is chiefly situated on the face, the entrance to the nose, in the neighbourhood of fistula?, more rarely on the hands and other places. It appears as a nodule the size of a pin's head, or a hemp seed, of dark-red or vellowish-brown colour, at first isolated, but afterwards scattered in groups, or coalescing; at first deposited in the tissue of the skin as a reddish-brown patch (lupus maculosus), then projecting above the level of the skin. When pressed under a glass the lupus nodules are distinctlv con- trasted as yellowish-grey spots, reminding one of sugar-candv. The surface is smooth and shiny, or covered with scales, the epithelial growth warty. At the edges, which are generally semi- circular, a peripheral spread of the nodules may be observed (lupus serpiginosus), or the nodules may be in a state of disintegration ; ulceration may arise as the result of secondary infection (lupus exulcerans), having a soft circumscribed edge and suppurating base, which easily bleeds, granulates, or becomes covered with a yellowish-brown crust, or thick scab, whilst in the central parts a white irregular scar is formed. Xow and again we see prominent granulations resembling a tumour (lupus tumidus) ; on the extremities there may even be changes resembling elephantiasis. 184 SCROFULOSIS At a later stage of its very tedious course one side Avill often heal, whilst the lupus on the other side extends into the upper layers of the skin, or attacks the hypodermic tissues and the deeper parts; this leads to extensive destruction, and in the face to terrible disfigurement, such as ectropion of the eyelids and lips, falling in and deformity of the nose, pear-shaped enlargement of the lobes of the ears, destruction of the auricle, &c. Scrofuloderma. — Scrofuloderma, which by its structure and the demonstration of tubercle bacilli is, in contrast to lupus, more sharply defined, and is described by Neisser as a subcutaneous granuloma, is developed alone, or in groups, in the cellular tissues of the true skin, and appears at first as a hard nodule under the loose skin ; if there is no absorption, stretching and thinning of the skin slowly takes place later ; this either gives way or a roundish softened lump the size of a pigeon's egg appears, the so-called cold subcutaneous abscess — the gomme scrofuleuse of the French (Despres, Besnier) — and its further course proceeds with- out trouble or pain. Scrofuloderma is either associated with lupus, by the bacilli which have been taken up in the lymph- stream depositing themselves and proliferating in their normal course in the lymph vessels or in the subcutaneous lymph glands, or sometimes a tuberculous fistula is formed from a deep-lying scrofulous bone focus. At a further stage of its slow course the skin which has been raised from the tissues lying beneath it is blended with the scrofuloderma, becomes thin as paper, of a bluish-red colour, and breaks down, a thin fluid resembling whey is discharged, and afterwards a round tumour is formed, with flaccid walls and deeply undermined, a so-called scrofulous skin ulcer (scrofuloderma ulcerosum), which tends to serpiginous extension and occurs in the main as a spongy granulation tissue, with tubercles scattered about in it. According to the conditions found bv Leistikow, who demonstrated the Staphylococcus aureus (by a development in culture) as well as the tubercle bacillus in scrofuloderma, at the base of a nodule whose surface was entirely intact, it may be supposed that now and again we have to do with mixed infection. TUBERCULIDES. Besides the classical bacillary skin tuberculosis, lupus vulgaris and scrofuloderma, the scrofulous nature of which has long been attested, other skin diseases have very recently (hardly a decade since) acquired symptomatic importance for scrofulosis, which clinicians formerly passed over w-ithout noticing and which awakened but little interest even for dermatologists. SYMI'TO.MS 1H5 I refer lo lliose skin processes ilr-fined by C". Bbstruction in the nose the child is forced to breathe through the nlouth, anel thus infection of the deeper-seated respiratory organs is faciliiaied. if this condition last long the mucous membrane thickens, ihe wlu)le nose is permanently swollen, and l)ecomes sensiiixe to the touch, a stale of allairs wiiicli is considered peculiaiK- t-Jiaracteristic of scrofulosis (Pins). Some- times ulcers are formed, in rare cases the process attacks the peri- chondrium, the nasal cartilage, the septum nasi and muscles, and leads to deformity of the nasal framework. The extension of the destruction to the ethmoid and perforation of the hard j)alate has bee-n observed (Henoch and Stoerk), but in such deep-seated cases it may be supposed that we are dealing with lubercido-scrofulosis or lupus processes and not w itii pyogenous processes. Formerly oza?na (rhinitis atrophicans ftx'tida) was considered almost pathognomonic of scrofulosis. Some (Zaufal) attribute !t to an abnormal breadth of the nasal cavity and the faulty removal of the secretion, others (Loevenberg, Rohrer, and 'SI. Hajek) to a specific oz^na coccus. Scrofulosis is said to be distinguished from ordinary ozccna by the fact that in the former the atrophy proceeds more quickly. MOUTH AND PHARYNX. In intimate connection with this chronic nasal catarrh and suppuration, perhaps even afded and caused by it, we meet with the well-known growth of the pharyngeal tonsil, the so-called adenoid vegetations. Anatomical proofs are wanting for Erdely's supposition that adenoids are generally congenital (see also Czern\). Adenoids in a form resembling cones or berries deeply furrowed or spherical, reddish or pale red, sometimes covered with tough greenish-yellow mucus, fill the naso-pharyngeal space entirely or in part, and contract and embarrass the normal respira- tory path, and themselves induce further inflammatory processes in the vicinity of the Eustachian tubes, middle-ear, nose or pharynx. The principal well-known consequences are, open mouth, snoring, dull toneless speech, disturbances of hearing, and now and again enuresis nocturna, arrest of physical and menial de^'elopment (malformation of the palate, Guye's aprosexia). The tuberculous form of scrofula has less opportunitv of making itself noticeable in the nose and naso-phar^•nx than in S N.Mr I O.MS Jf^5 other inticoiis incinhr.'inc.s. 'llic low bacilli uitli which \v«* have* io do in naUiial inlc( linn |)cnci rale, a.s has been l"rc(|iicnlly r<'marly(igenic form, if virulent germs be the cause, the course is somewhat more speedy. A stationary condition for a long period and caseation are symptoms which are often found only in tuberculous glands. NECK GLANDS. Affections of the neck glands are prominent on account of their superficial position and their frequency, especially the sub- maxillary, sub-auricular, and cervical glands. The gland becomes harder, and swells so that it can be easily felt, and grows to the size of a pea, bean, hazel nut, or pigeon's egg. The swelling takes place slowly and imperceptibly without complications, and often without sensible pressure symptoms. On this account for a long time they are not noticed by the patient, and are only discovered accidentally. The skin over the glands is unchanged, can be easily moved and raised in folds. The gland remains without any particular changes for a long time, in this condition it can, especially when not of a tuberculous nature or the bacilli are avirulent, return spontaneously to a healthy condition, that is, if the affection arising from the source of infection (pro\-ided such had been discovered) heal, and so the supply of toxin and toxic matter ceases. It will, however, persist, although the original affection mav be long healed. In the meanwhile the neighbouring glands swell, and a chain like a row of beads, which is palpable and even visible, appears, the parts of which grow into large tumours with a nodular surface. From fresh inflammatory processes in the zone from which the affection arises or from unknown causes, softening and suppura- tion of the glands supervene, they adhere to their surroundings by periadenitic processes, lose their mobility, and surround the anterior part of th.e neck as a lump}- mass the size of an egg. At times they penetrate the soft tissues and the space between the auditory meatus, the mastoid process, and the posterior margin of the lower jaw, and may cause pressure on the carotids, the jugular vein, air passages, pharynx, and upper part of the oesophagus, and lead to cerebral congestion and to pain. The fluctuation in the softened glands extends to the sur- rounding parts, the skin over them adheres, becomes doutrhv or SYMJ'TOMS 203 ocdcmaloiis, slrcLclicd, .slimy .'ind - r.-ilour from ihe yellow-greenish pus of phlegmonous foci. Now and again, though seldom in children, a tuberculous hydrops forms, usually chronic, with exacerbation and remission of the discharge, seldom acute. The joint is painful, swells, the skin becomes red, the temperature of the body rises, and the discharge flows within a few hours in a patient apparently healthy (latent tuberculosis). The hydrops may again disappear, leaving a thickened capsule. In other but rarer cases suppuration takes place inside the joint (cold abscess of the joint), followed by fluctuation and burst- ing. Or mixed infection shows itself, especially when an external wound exists; severe septic processes may then increase the whole symptom complex. Often there is not onlv one bcMie or joint lesion ; several are formed, even four, five, or more, sometimes shortly after one another, sometimes at an interval of years. Bone and joint affections may run their course without any considerable disturbance or fever, yet when the process is further advanced fever of a remittent character usually appears (hectic fever of Konig) with low sub-febrile morning and evening tem- perature, but rising to 38° to 39° due to a chill. I wish here to emphasize that for earlv and exact knowledge of the fever it is necessary to take the temperature every two hours. All the affections described are mostly chronic, seldom acute. They mav exacerbate, remit, often be at a standstill for a long period, and may even after a long time definitely and spontane- ously heal. Abscesses may be again absorbed and disappear, the pain may be reduced, the swelling go down, the secretion from fistulc'e dry up, the fistul^e close, the muscles become strong, and the affected limb regains entirelv or in part, according to the degree of disturbance, its former mobilitv. In other cases bony or con- nective tissue ankyloses may remain (curvature of the spine. Potts' curvature, kyphosis). Such places are, on account of the changed conditions of circulation, specially adapted, when isolated bacilli at some time or other enter the blood and lymphatic vessels, to retain them, and to reinaugurate the previous processes. Therefore recur- rences must bv no means depend on reanimation of a few living bacilli, which have remained in the healed lesion, as many authors suppose, but it mav just as well be traced to a new batch or fresh infection. If healing does not take place the tedious processes exhaust ihe bodv and lead slowlv to amvloid defeneration of the kidneys SYMI'KhVIS ^1.^ (albiiminiii i;i), ol ilic li\cr ,-iih1 spleen (enlargciiieni ;iii(l li/nden- ing), and ol iIh; inlesline (profuse diarrJid'a), to genenil dropsy and dt'.'illi. ( )r bacilli are sel free, cnicr ilie blf)f)d passages, and induce according lo circunislances eillier miliary tuberculosis or local tuberculosis in the brain, in oilier bony parts, ike, and so bring the existence of the individual to a speedy end. Now and again surgical trealmeni has had fatal consequences, although extensive operation (res(>ction with complete elimination of tlie diseased parts) has been relatively more successful than small operations on the diseased tissue, such as scraping with a sharp spoon, &c. E.— GENERAL SYMPTOMS. Atnaemia. — Owing to the long continuation of the scrofulous processes and tlie continual absorpticjn of poisonous substances, the blood and the body generally is included to a certain degree in the aflfection, as we have already partly hinted at above. We often observe a high degree of anaemia in the scrofulous in the further course of the disease. Monti and Berggriin found in a boy of about 6, who was suffering from tuberculous glands, 38 per cent, of haemoglobin and 3,640,000 red corpuscles and 14,000 white corpuscles. Elze also noticed in scrofulosis that there is generally a reduction of haemoglobin and red corpuscles, and the former appeared to be more altered than the latter. Besides which, Elze, in eight cases of scrofulosis, instead of the normal proportion of white and red corpuscles, i : 500-800 for adults, found proportions of i :ii or 97 or 480, but we must take into consideration that the blood of young children is richer in white corpuscles, and, according to Gundobin, their relative number is about three times as large as in adults. Becker notes the increase of lymphocytes in the scrofulous. The generally reduced number of eosinophiles in the tuberculous increases apparently when the process takes -^ favourable turn. In surgical tuberculosis in children the eosino- philes were constantly found to be increased, and in inverse ratio to the severity of the affection. See also Rubino, Lanza, and others, and p. 54. ■ Fever. — Slight feverish attacks appear frequently, at least in the tuberculous form, which, on account of the rarity with which the temperature is usually taken, are easilv overlooked (see " Die Tuberculose," second edition, p. 727). The fever as a rule is only slight, because in consequence of the occlusion by the capsules of the glands the production and absorption of the toxins is on the whole less than, for instance, from a tuberculous 2 14 SCROFULOSIS lung focus which is in connection witli the lynipli vessels and lymph spaces in its whole periphery ; the more extensive the tui)ercuious lesions are ilie more frequently and the higher the temperature rises. \\'ith plentiful absorption of toxin, as in caseated bone and joint lesions, hstula, retained pus, &.C., hectic fever is reached, often with perspiration. The anatomical structure of the gland also encourages the pvogenic form, but the important quality of the tubercle bacillus, nameU', ilu- jiowcr of protlucing iliromliosis in the \"cssels and thus reslriciing the dispersal of the toxin, is wanling (see p. 126, and " Die 'i\il)erculose," second edition, p. ()Sj). The appear- ance of fexer depends al)o\e all on the greater or less \ irulence and toxic effect of the pus bacteria in cjueslion. Of earlier writers, Ilufeland has devoted a special chapter to fever in the scrofulous, and Virchow has spoken of the tendencv to febrile conditions, recalling the febricula of phthisical patients, whilst most aiuhors, with the exception of Birch-IIirsch- feld, hardlv mention the word fe\er. H. Neumann has recentl}-, and perfectl}- rightly, mentioned the frequency of fever tempera- tures, even if onlv slight o7'7° ^'> o^'3° (in the rectum), which he found in 62 per cent, of his scrofulous patients, and emphasizes it as an important symptom under certain circumstances, an opinion with which 1 entirely concur from my own experience. More attention should be paid to the frequent "cold shivers" in the morning and e\"ening and not just put it dow n to aniemia. It is often only a slight rise of temperature, once daily to 37"2° to 37'3° — axillary temperature — only to be recognized by taking it every two hours, whicli indicates tuberculosis of the bronchial and mesenteric glands (see Diagnosis, p. 237). I should mention that Ludke and Sturm, S. Chaldier and Poncet, Reyher, and (;thers, demonstrated orthostatic albuminuria in tuberculous or scrofulous patients, and Re\her sujDposes a direct causal connection between (he two. Lemoine found it also in five soldiers with all the signs of inherited tuberculosis. See also Benati and Max Wolf. Nourishment. — The longer and more severe the disease, the more, as a rule, the general nutrition of a scrofulous patient suffers. It exhibits itself chieih-. in spite of excessive hunger, now and then in those suffering from mesenteric scrofulosis, as well as in long-continued bone and joint suppuration. Frequently, however, the appetite is diminished. Fenwick notes a special form of scrofulous dvspepsia which he observed 42 times in 2,000 cases, and whicli he considered a neurosis of the intestine. Quite suddenly, in the middle of the SYMl'TOMS 215 nighl oi' iininc(|i;ilciy ;i.llci" .-1 iih-;iI, ihcic isp;iiii in Mi'- .'ibfloincD, vvliicli (Ik- [)a,ti('nL tiincics is in iIk; region oi lin; nuvcl, tin; pain begins al)()V(- iL and Lo lh(; right, llicn extends to the left as well, and has a boring character; it lasts from five minutes to several hours, and is relieved by pressure. Tlie stools are constipated, colourless, offensive, and slimy, and contain a quantity of unchanged matter. Need for evacuaticm comes on at meal-times, often after the first mouthful, nausea and vomiting are rare. The general health is ccjnsiderably upset. In the nervous system, besides the feeling of being easily tired at play or work, and (jccasional sleeplessness, a certain irritation and instability of temper is observed in many scrofulous persons. The amyloid degeneration — which we have already men- tioned as a consequence of protracted bone and joint suppuration — may also make its appearance in the course of suppuration of the glands only. F.— THE SCROFULOUS CONSTITUTION. A malady which lasts so long, and is connected with manifold disturbances, naturally stamps the body externally with a distinct mark of disease. As long as scrofulosis was traced back to dyscrasia dominating the whole body, the scrofulous constitution, the general bodily peculiarities which are so often observed in the scrofulous were considered precursors of the disease which doomed the individual to scrofulosis. Even a certain lack of harmony of the external form was put down by Lugol and others to scrofulous constitution, either " the limbs were too long or too short," " the body too small or disproportionally large," " the mouth small or much too large," " the appetite too small or voracious." As perfect harmony in the body is a rarity, it would not be difficult to demonstrate one of these defects in every scrofulous person as a sign of a scrofulous constitution. In contradiction to Lugol's statement, that every scrofulous child was weakly, and that scrofulosis excluded the attributes of strength and health, Louis has cast doubts on the predominating influence of constitution, and Lebert has questioned the criterion of a weakly constitution. The latter believes that unprejudiced observation has given us no right to look upon a weak constitu- tion as predisposing to scrofulosis, for the experience which apparently supports it was traced back to one-sided opportunities of observation in a children's hospital and on poor children. 2l6 SCROKULOSlS \irclu)w and others note ihc aiijii-arance oi scrolulosis in children otherwise healthy. Tlie fact that scrofulosis, like lubcrculosis, ot'ien heals in one organ such as the glands, and in ant)iher, sucii as ilie bones, con- tinues its course, while in ihc same organ ii will heal in one place and extend in another, is incompatible with such a general dyscrasia as a preliminary condition, also with the acceptance of a general diathesis. A strikingly perceptible sign of scrofulous constitution was believed to have been found in the scrofulous liahitus, a sign which was highly valued at the end of the century before last and the beginning of last century. Two primary forms were distinguished, the erethistic and the torpid hahiius. The erethistic form is characterized by a slim build, weak, wasted musculature; little adipose tissue, a soft, tender, pale skin, easilv becoming red, the veins are visible as a network of bluish colour, bright moist eyes with wide pupils, silky soft hair, blue- white well-polished teeth, an intelligent, active mind, a lively temperament but easily depressed, and often an early-developed sexual instinct. Many authors see further signs in fair hair and blue eyes (Birch-IIirschfeld), others in dark hair, long dark lashes and dark eyes (Henoch). These are for the fair sex, those phenomena of ephemeral beauty which the artist describes as " beaute du diable," and the country folk, as an apple "with a maggot at the core." The torpid type is characterized by a heavy build, puffy condition of body, pasty appearance, podgy limbs, with a quantity of spongy, adipose tissue, but without strong musculature, short thick neck, large head, pale complexion, unusually strong massive jaw bone, a swollen, thick broad nose, thick puffy upper lip, stupid expression, with signs of mental dulness and arrested development, phlegmatic temperament, dislike to bodily exercise, and, according to some, having fair hair and blue eyes (see above). As the greater part of the scrofulous could not, even with the best possible desire, be classed under either of these two heads, a third or " middle type " was introduced. Critical observation shows us that the scrofulous plu-siognomy exhibits itself in a great number of the scrofulous, not as a condition of body preceding scrofulosis, but, as Virchow has already noted, as an expression of disease already existing. The clinician, Lebert, who only found this habitus 8i times amongst 537 scrofulous patients, rightly remarks that " it is much less seldom found if the habitus be noted before the diagnosis," in other words, when the judgment is not prejudiced. SYMl'lOMS 217 Of all these so-called premonilory symptoms, tlie line skin might give us a certain clue, liui, iiniortunaiely, by combining too many symptoms tiie woiili and iniporiance of singl<; symplf^ns have been effaced. As for the rest of the signs oi the scrolulous habitus, one can easily understand that with extensive swelling of the glands, a compressi(jn (jf the vessels, and coiisccjiniiily a blockage of lymph may be induced, which causes a change in the outward appearance of the patient, and cxijlains the puify face, &c. It is just as readily understood lliai s( mlnlosis is more distributed amongst the po(jrer classes, because of tlieir crowded dwellings, witii increased opportunities of infecticjn, the conse- quences of poverty, Bad dwelling houses and bad nt^urishment ; also a pale complexion and defective bodily development must be oftener found without there being necessarily a causative con- nection with scrofulosis. Scrofulosis, especially when of long duration and higli degree, has an effect on the bodily and mental powers. Children exhibit a dishke to exercise and do not join their comrades in games which require bodily movement, they often complain of weariness, even on rising in the morning, and tliey hold tliemselves badlv, wiiich is accounted for by weakness of the spinal muscles. Instead of racing about like other children, they sit down quietly, even when not forced to do so, by reason of the type of their malad}' — bone and joint disease — and prefer to read or to give themselves up to the pictures of their imagination. Soltmann, in his further statements respecting his theories already laid down, traces the production of the erethistic and torpid habitus to the concentration and effects of the chemical changes and products of the tubercle bacilli on the blood and lymph systems. Czerny contests the connection of a scrofulous habitus with tuberculous infection, and looks upon it principally as the expression of the exudative diathesis which might be made to disappear by dieting with food containing little fat and no eggs or milk. But the habitus may be influenced and nullified by tuberculin treatment without change of diet (Escherich, Heubner. and others). It is clear that there are more factors which work together as causes. This, as well as the more frequent association of weakly children with older persons, instead of with companions of their own age, explains the advanced mental development, a certain precociousness, which we And in such children, and a more grave demeanour, which, if the disease runs a favourable course, is often retained during the whole life. 2lS SCROFULOSIS On ihc other hand, with many children the mental develop- ment is retarded by certain forms of scrofulosis, and this is often observed as a consequence of adenoid growths. Doubtless owing to the blocking of the lymph passages, which in brain and nose are connected, the children have difficulty in concentrating their altenlion t)n any object (Gu}e's aprosexia, Bresgen, and Seller). On this account they give cause for constant complaints from school and fall behind in ilicii' .sUKlies, unless steps are tak?n in time. riu' taci was noied frequenth', esi)eciall\' b\' older writers, thai in the scrofulous the development of the sexual organs was often considerablv later than in the normal. I have not remarked whether this is frequently the case, but in scrofulous girls men- struation appears in general later than in the healthy of the same generation, also troubles in menstruation are more frequent. An imusually early awakening of the sexual instincts is mentioned bv some authors (Baumes), by others exactly the opposite is stated. SKCTION IV. Course and Duration o5 the Disease. ScROFULOsis alnKjst always runs a chronic c(jurse, willi many exacerbations and remissions; it is only really comparatively acute in tiie tuberculous form, perhaps owing to multiple infection. Tiie course is determined by the number and species of the germs which have entered, Ihe intensity of their proliferation and dis- persal, by the organs attacked and by the anatomical peculiarities of tiie individual. We may in general distinguish four stages of scrofulosis : — (i) Superficial infection of skin and mucous membranes. (2) Affections of the glands. (3) Bone and joint affections. (4) The various terminations, including amyloid disease. The single stages play a more or less important part according to the form of the scrofulosis. In the pyogenous we meet, as a rule, with only the first two, in the tuberculous principally witli the last three. By tlie simultaneous existence of various stages and of both forms many combinations arise. The superficial phenomena of the pyogenous form belong in general to the first years of childhood and the crawling age. A.— COURSE OF PYOGENOUS SCROFULOSIS. In the pyogenous form of scrofulosis the local svmptonis are most marked at the point of entry, in tlie skin and mucous mem- branes, such as eczema, catarrh, &c., for the above-mentioned reasons. The symptoms will often be confined to the same place for a considerable time, or tliey repeat themselves constantlv, or appear now in one place, now in another, in continual changes. The affections may remain localized at the point of entry and the glands be affected only in this way, so that the diffusible poisons of the bacteria arrive at that point from the tributary area; irritation follows, with consequent swelling, inflammatory 220 SCROFULOSIS li) pi-rplasia, and e\en suppuraiiun. ihesc clianges in tlie glands, as well as the attection of the tributary area, are chronic; if the disease heal and the supply from the area traversed by the lymph passages meeting in that gland be thus cut off, then the changes in the glands disappear in a short time (scrofula fugax). If bacteria enter even into the glands and set up independent processes, these may continue an indeiinite time without suppura- tion after the healing of the surrounding zone, on account of the generallv slight virulence of the bacleria in question, and at last may retrograde. If highly virulent bacteria enter at the beginning or later, acute suppurating processes, abscess forma- tion and rupture occur. We see different combinations ; the skin affections may be healed yet the glands remain swollen, or the glands may be healing when a new process establishes itself in the area, or the glands of one part are healthy and the respective tributary area connected with that gland is diseased, or another region diseased and the area in connection with it healthy, and so on, with a multiplicity of variations. The glands form a more dependable cover for pyogenous bacteria than for tubercle bacilli, perhaps on account of their size, perhaps from other causes. A dissemination from the glands to the bones or other organs, the third stage, is, to say the least, one of the most extraordinarily rare occurrences; still, the possi- bility should not be denied. The disturbances in the general health are unimportant, both an account of the slight spread of the process into the interior of the body, and because of the less toxic characters of the bacteria, so that we may rightly term the disease a mild scrofulosis. B.— COURSE OF TUBERCULOUS SCROFULOSIS. As regards the course of tuberculous infection, the slower or quicker advance of the processes, and the possibility of spon- taneous retrogression, it is very important which type of bacillus, whether human or bovine, has caused the infection. For the present too few researches have been made in this connection to enable us to state the course precisely. The differences are apparently of a more gradual type (see Prognosis, p. 228) ; the general direction of the course remains the same. First Stage. — In the tuberculous form, as a rule, we rarely find svmptoms at the point of entry. The child's mucous mem- branes are easily penetrated by isolated bacilli, therefore the first stage, if the infection take place in them, is generally left out. In the skin the bacilli, if they have been able to penetrate, are retained on the spot by the firmer tissue and often so completely COIJRSK AND 1)1 KA'IION Ol' I 1 1 1'. DISKASK 221 that no second stage is reached. Lupus may cxisi for a lonj,^ liiTK! without the nearest glanrls being affected. These siipciricial .•ilTccl ions nrc generally extraordinarily (dironic. Ilaike, on the oilier hand, notes the sometimes extremely rapid course of tuberculous ear affections in infants. Thus, in a child 5 weeks old, a few days after suppuration had set in, facial paresis was observed, and at the post-mortem, which took place three weeks later, the whole of the temporal bone and the kibyrinth showed tuberculous changes. Acute miliary tuber- culosis can, with exacerbation, lead to death in twenty-four hours with high fever rmd coma (T^npowski). The natural path for the dispersal of (he process from the s]rnis a fisiula or an ulcer which secretes for months and years, and only heals after shedding all gangrenous tissue, often leaxing a disfiguring scar. In the meanwhile the protective and liltering power of the glands becomes insulTicient, either on account of the advanced process or under the influence of extraneous inflammation, such as measles, &c., or trauma; the bacilli spread further, and the more easily the younger the individual. Owing to centripetal spreading in the direction of the lymph current chains of glands are formed, for example, from the neck into tlu^ mediastinum. In the case observed by Marfan and Oppert, of a child 13 months old which had swelling of the neck glands and "angina," in a few days llu-rc was suppiiraiidii of numerous neck glands with the formation of a (|uaniii\- n\ pus, in which, according to the authors, a great many tubercle bacilli were found as the only inciters of the suppuration. The pressure of a large mass of glands on the vessels, nerves, trachea, bronchi and oesophagus may give rise to severe con- sequences, paralysis, dyspnoea, dvsphagia, rupture into the trachea, to pulmonarv tuberculosis and suffocation ; rupture into the vessels mav cause fatal haemorrhage. Various groups of glands which are not in immediate con- nection, which do not lie in the same centripetal direction, which even belong to different regions of the body, for example, the bronchial and mesenteric glands, may be affected simultaneously or shortlv after each other. It would be wrong to suppose that the affections of the different groups of glands were, as a rule or of necessity, dependent on one another. Such an idea con- tradicts clinical and experimental work, which teaches that tubercle bacilli not only pass through some glands, and avoiding others settle in the glands lying nearest in continual succession, step by step and not by bounds. The preponderating majority of such cases depends doubtless on multiple external infection. It cannot be contested that the opportunitv for this infection of the individual was given, as his disease shows, bv living in an environment rich in bacilli. Whv should not bacilli at the same time or at intervals be inspired or have entered the mouth or intestines at some other point in the interior of the bodv or on the external surface and have infected them ? RETROGRADE DISPERSAL. ExceptinnalK', single bacilli become detached from a gland lesion by compression, or some other obstacle, and are turned from their direct centripetal direction and drawn into collateral COUKSIO AND DIKAIION Ol' I 1 1 1-; DISIIASK 22.3 and cvv.u r(;lurnin_L;- hraiK lies, .-iiul (-illifr nloiu- or in cmnpany with migratory cells cnlcr llic ^dands vvhi* h li<' al ihc side <>v in iIm' opposite direclion ol llic Ivmpli ( iiiiimiI . 'I'liose cases poini lo (Ik- possihiliis nl rci rof^riadc lraiislcr<-ii< <• williin die lyini)li passag(^s wliirli, in die case ol ( arcinonialous or sarcomatous degenerahon ol die hronchial glands, also e.xliihil melaslalic cancerous or sarcomatous foci in the suhpleural net- work of the lymph vessels, whilsl in ilie inleri(»r of dif lungs, from which the cancer in the lym|)h \-essels mighi lia\e grown, tumours are wanting (Vogel). The ohsei"\ahons of I Idler, who found 'i cancerous ernhchis in the branches of the veins of the liver in a case of carcinoma of the cav-um which he had watched, proves that even llie venous blood-current, whic-h is expelled much more strongly, may take a reverse direction, at least at times and under cert'dn conditions. A reverse current in the Ivmph vessels of the head is facilitated bv the less development of the valves (Bonam\), therefore it is quite possible that bacilli also in the Ivmph spaces may be con- ducted further in a reverse direction.* In my experiments with animals I have several times been in a position to observe an undoubted reverse infection of the glands. Tn infection from one side of the navel, besides tuber- culosis of the inguinal glands, 1 have even been able to demon- strate now and then caseation of the further Iving peripheral skin glands, but this happened only once in about 4,000 cases which were always thoroughly examined for this very condition of glands, and that in animals which generallv exhibit extraordinarv facility for the dispersal of bacilli through the Ivmph passages. At any rate, it is not justifiable to make a rule of an exception. When Neumann supposes for the greater part of cases of scrofula that the neck glands are affected in ascending direction from the bronchial glands, this supposition is entirely without support from facts ; it is just as if we should state the paradox, that the normal direction of the lymph current is the reverse direction (see pp. T22-T26). The general health suffers more the more the processes extend, the more tubercle toxin is absorbed, the more loss of substance takes place from open lesions. Increasing pallor, lowering of temperature, loss of strength, betrav the severe internal disorganization ; with the gradual discharge of all tuber- culous matter the disease may be brought to a standstill, to healing, the patient can even develop into a completelv strong long-lived individual ; but usuallv a phvsical inferiority remains '*■ With regard to this I would refer to the work of Recklinghausen, (See Bibliography.) 224 SCROFULOSIS for years or for ihc whole life In oiher cases the general exhaustion increases and leads at last to death. Besides being carried into the nearest lymph glands, the liacilli which have been freed may pass into the blood passages or the organs of the body. Tuberculous meningitis may be induced or complicated pulmonary tuberculosis, the appearance of which so dominates the whole picture that scrofulosis falls into the background, or the bacilli may reach the kidneys, testicles, &c. But frequently the bacilli enter the bones and joints and so intro- duce the third stage of scrofulosis. Third Stage. — This can, it seems, also appear primarily, the t'lrst stage being passed over, the second (the formation of gland foci) not being demonstrated owing to the hidden position of the bronchial or mesenteric glands. The general symptoms become more and more evident. The bone lesions mav burst outwards, forming fistulas, which heal with great difficulty, or cold abscesses appear, the vertebra? may partly collapse, and Pott's deformity arise. The joint is attacked and disturbances of mobility take place in varying degrees up to complete fixation and uselessness of the joint. These processes may take years, and are often accompanied by aggravation or improvement. Even with extensive lesions "n the bones and joints a temporary or permanent standstill is possible, but generally with great loss of movement ; in spite of treatment the disease frequently advances, and this unfavourable issue introduces to some extent the fourth stage. Fourth Stage. — The extensive purulent processes cause amyloid degeneration of the abdominal organs, and death occurs after gradual exhaustion and oedema. Or the bacilli are further disseminated, as in the former stages, and induce brain, lung or general miliary tuberculosis. It is usually accidental pulmonary tuberculosis which brings about with relative frequency the unfavourable end of the sufferings in scrofulosis. It is not always a consequence of bone tuberculosis, but owes its existence more often and more probably to the same focus as bone tuberculosis, namely, the bronchial glands. Or it mav have arisen from a new infection, the infectious material for which mav have originateci with the patient himself l)y the dissemination of his secretions. Open glands or bone lesions ma\-, bv infection through the wound, lead to serious consequences and even to death. As the greater part of the scrofulous patients who have died of pulmonary tuberculosis are placed in the lists of mortality under that disease, we have few dependable records even for the genuine tuberculous form, as to ho^v often scrofulosis runs a fatal course, COURSI': AND IHiKAIKJN Ol' I III-, hlSlvASE 225 C— MIXED INFECTION. The pictures wliicli vv(' have li(-re re|)i(;senU;d of llie luber- culous cind the pyogenous form of scrofulosis are not always so clear, but often appear coincidenlally or arc mixed, both sorts of bacteria attacking the saiiK; region, somriinics the lubcrcjf- barilhis first, sometimes the pus cocci. They may act conjointly and each assist the work of the other. Thus, pus cocci may cause acute or subacute inflammation in a caseous gland which has existed for months, just at the time when the chronic tuberculous lesion was on the point of encysting. The lesion is invaded, irritated, the bacilli mobilized and their dissemination assisted, with all its dangerous consequences. Very frequently the course of tuberculous glands is influenced by accidental bacteria and suppuration caused by them. v. Brun's researclies have demonstrated that in thirt}'-nine cases of sup- purated tuberculous neck lymphomata, in twenty-eight of the cases streptococci co-operated simultaneously (this was demon- strated partly microscopically, partly by plate-cultures). Achard and Ramond observed secondary sporotrichosis in the fistuke of tuberculous glands. But mixed infection does not always result in harm to the patient. The inimical species compete against each other, mutually exhaust the nourishment in their narrow zone, injure each other bv the products of their changes and decomposition, and often incite the tissues to increased inflammatory reaction. As for the latter case, highly virulent pus-cocci may, if they should enter a gland already undermined by tubercle bacilli, act like a spark in a powder barrel. They cause acute suppuration which expels both intruders, the tubercle bacillus and the pus coccus, with partial or complete destruction of the gland it is true, but to the benefit of the whole organism ; thus it happens now and then that the whole of the symptoms of scrofulosis disappear after acute inflammation of the glands with abscess formation and removal of pus and caseous matter. It will be readilv understood, after all these statements, that it is hardly possible to fix a certain time for the duration of scrofulosis. It drags on for months and years, and in the tuber- culous form even long after the arrival of puberty ; but the non- tuberculous (the pyogenic) form, on the other hand, disappears, for the above-mentioned reasons, on arriving at the age of puberty. 15 •SECTION V, Prognosis. 'liiE prognosis of scroiulosis is cU'jieiulcni on its torni, ils duration, and the social position of the patient, as well as certain external conditions. On the whole, children at the breast are, with respect to scrofulosis, more favourably situated prognostically than those only partly suckled, and much more so than those artificially nourished. Pyogenic scrofulosis, in which there are no tubercle bacilli, admits of a favourable prognosis; quoad viUiin, it may be termed mild. Certainly at times it is followed by phenomena which disturb the functions of the body or in other ways indirectly endanger life. For example, disfiguring ectropia are formed, corneal ulcers with considerable restriction of vision, even blind- ness, restriction of hearing, or breathing through the mouth owing to adenoid growths ma\' cause se\ere infection of the respiratorv passages. But if such unfortunate consequences are not induced the scrofulous symptoms disappear spontaneously towards or after commencement of puberty, when, as it seems, the permeability of the tissues, and therefore the power of propagation of the bacteria is reduced, the body regains its strength, and the person mav for the ftiture enjoy excellent health. In the tuberculous form of scrofulosis the patient feels himself in a manner on the down path of his existence. One cannot tell whether or when the standstill wdll come. Tuberculous skin affections, lupus, &c., although they mav be extensive and cause disfiguring disturbances, do not present, as a rule, quoad vitam, any great danger when there are no com- plications. The glands, when only one group is attacked, give hopes that the process may be localized. The more glands attacked, or when several groups are affected, the less is the prospect of recovery, and the more are dangerous complications threatened. PROGNOSIS 227 In tlie lliird stage, when lIk; bcjiif-s are reached) ili'- jjiognosis must be grave. Even should improveinent lake place the jjalient still stands on a v(^lcan(j, is not sure for (Mie moment that a further dispersal of llie bacilli will iiol lake jjlace which may jjt-rhaps destroy life. Even if such a sad eveni should not occur, the h^ng-continued suppuration may undermine I he \iialii)-, and lead t(j the end by amyloid degenerati(jn. On the other hand, even extensive multiple bone affections can often heal comparati\'ely and only leave more or less consider- able functional disturbances to remind the patient later of the troublous times through which he has passed. In tuberculosis of the joints we may reckon that 75 per cent, will heal. The prognosis depends, loo, on age. With infants even tuberculosis of the bronchial glands runs a swift course, the child becomes thin, dyspnoea appears, and often suffocating symptoms and death ensue. The older the patient becomes the more will the tuberculous scrofulosis be localized, and the further spread of the bacilli in the body hindered. A favourable social position which allows of the arrangement of good hygienic conditions and the removal of the child from infectious surroundings decreases the danger of fresh infection and improves the prospect of cure, therefore the state of health of the family has considerable influence, for the more the child is in the companionship of tuberculous persons the greater the danger of constantly repeated infection. In any case the tuberculous form of scrofulosis, tuberculosis of the glands, skin, and bones takes a milder course with better prospects of return to health than tuberculosis of the internal organs ; for this, the so-called genuine typical tuberculosis, is rightly considered to be absolutely fatal in infancy, and during the whole of childhood as extremely unfavourable and much more dangerous than in adults (see Czerny). Recently we have been much inclined to take a less serious view of tuberculosis in children ; the under-current of error in this may be summed up in the sentence : " Our opinions of the prognosis of children's tuberculosis have improved since v. Pirquet's method was introduced"; that means, in other words, nothing more or less than that now we not only include all cases of (internal) tuberculosis which are clinically certain, but also all the doubtful phenomena if they have onlv been guaranteed bv V. Pirquet's reaction ; amongst these there will clearlv be manv which react positively on account of a non-dangerous focus alreadv 228 SCROFLLOSIS healed, a bo\ ine focus, which then gives the harmless pleasure of reacting prompily lo every treaiment, so leading us lo suppose that we may make the note " Standstill and improvement," and it is from such cases as this that Czern)- says, " the cases in institutions are recruited, for it is frequently no tuberculosis ai all." If we lake all the blank cartridges of tuberculous bovine infection as hitting" the mark, naturally the proportion that strike the target in the ball cartridges of human infection is much reduced. As opposed to the great mortality in the tuberculosis of child- hood, we frequently meet with persons who clearly have stiiTered formerly from scrofulo-tuberculosis — it may be that their dis- figuring scars betray it, or that at the time its nature was clearly demonstrated by the bacilli — persons who reach a great age in the enjoyment of perfect health. Endeavours have been made to explain in various ways this mild course of scrofulo-tuberculosis. Those authors who attribute to scrofulosis not onK' |)ariial diathesis within anatomical Hmils, but a general diathesis com- prehending the whole body, will have most difficulty in finding a reason for this, for how will they be able to explain that the mild course, due from their point of view to scrofulous diathesis, suddenly turns to the opposite when the bacilli establish themselves outside the glands, for example, in the lungs? How will they be able to explain that, for instance, in children suffering from pulmonary tuberculosis, scrofulous phenomena suddenly make their appearance with benign glandular course, whilst the pulmonary tuberculosis is hastening the end? Where is tlie protective, general scrofulous disposition which leads to a benign course ? ^loro and others consider the reason of the mildness to be in the irritability of lymphatic tissue which is disposed to scrofulosis, in the violent reaction, which they look upon as an act of self- defence by which the bacilli are hindered in their action. A healthily reactive tissue is without doubt a means of defence, but who w'ill make us believe that this unhealthv, excessive, plentiful lymphatic exudative reaction can be compared with the healthy, strong, normal reaction, and that its effects are of equal value? I have made the comparison in another place that the effect of scrofulous reaction can just as little be placed on the same plane as healthy reaction, as the spongy, limp granulation in a healing wound can be compared wMth healthy, strong granulation. Added to all this comes Czerny's assurance that he has put an end to exudative diathesis in the scrofulous (that is to say, I'KOGNOSIS 22fJ wlial Moro's " .'icl of scll-dclcncc " criccls) hs' liis (lidinj^f indluKls, and (ln'oLigli llicni lias changed lli<- foriiu'i" s* lolulfjus <:liildrfn " into line children wilh luljerculosis." \i\cn il we d(; nol need to lake this literally, it appears at least (hat the improvement in the exudative part of the scrofulosis did not I'-ad to an aggravation of the tuberculosis, and did not chang(' il inio flic " dreaded " genuine tuberculosis, yc\ ihis must have happened if Moro's theory was correct, 'rims ilic liicoiy of Moro does nf)l advance our knowledge. The difference in the course antl prognosis may be rather explained by the difference of localization by contrasting the harmless scrofulosis of the glands with the harmful tuberculosis of the internal organs in childhood ; at least here we have a basis of facts. It is all the same if we seek the cause in the anatomical peculiarities of the surrounding encysted glands, with their small inlets and outlets in opposition to a focus surrounded in its whole periphery by lymph paths and lymph spaces, for example, in the lungs or spleen, by which a dispersal of the processes is favoured from the first, or if we lay the principal stress on the retarding influence of the retained toxins and lymphocytes (mentioned on p. 128), or with Bartel impute to the gland tissue a special quality of checking development and perhaps of immunizing, the fact that the lymph glands advance the tuberculous process less than other organs is hardly to be contested. In a lesser degree and with a somewhat modified explanation this agrees too for skin and bone. Much is explained by this. But is this the only reason why scrofulo-tuberculosis takes a milder course ? Why does the tuberculous infection remain localized in the glands nearest to the point of entry in only a part of the cases, in the neck, mesenteric and bronchial glands, and frequently " heal spontaneously even under unfavourable circumstances " (Czerny) while in other cases it advances ? Perhaps animal medicine and experiment will give us infor- mation. Let us go into the cowsheds of the Imperial Health Bureau. Why in one of the calves does the tuberculous infection remain localized in the nearest neck gland, the prescapular gland? Why does it induce here a tumour as large as a hen's or goose's egg, as in scrofulosis w-hich retrogrades spontaneouslv, with or wnthout opening after some months ? Whv do these calves remain healthy later, Avhilst other calves get the same glandular processes, which become worse and lead to the death of the animal ? Is it 230 SCROrULOSIS perhaps because the calves are differenlly disposed and one has exudative tendencies? No. Because they are differently infected, the latter with the bovine bacillus, that of his own species; th? others with a foreign species, the human bacillus. Now we know inversely that the bovine bacillus in man behaves itself similarly to the human bacillus in cattle. We iind that, in spite of the numerous opportunities for infection with milk, butter, and cheese from tuberculous animals, that the bovine bacilltis is hardl\' ever present in adults; in children in cases running a severe course it is rarely the cause. On the other hand, in neck glands which necessitate operation we find them in about one-third of the cases, and in minor glandular changes which have hitherto been but lilllr t^xamincd \\t' mi^lit in all prohahililN fiiul them much oftener. Koch terms the cases in which the bovine bacillus is said to have caused general and fatal tuberculosis in man as not " free from doubt." Certain doubts seem indeed to be justified, but even if we do not share Koch's point of view, nor completely acknowledge the fatally ending cases in which bovine bacilli were (also?) found, it is clearly a very small number of strains which lead to such an issue in man or in children. But what is remarkable is the fact that in tuberculosis of bones and joints, which is also frequently noticeable for the benign course it takes, hitherto bovine bacilli have rarely been found, for if these affections had arisen from scrofulous neck and mesenteric glands, the bovine bacilli might be expected to be met with more often. Certainly Krompecher and Zimmermann formerly stated that the chronic course of tuberculosis of the bones did not depend upon the virulence of the bacilli. It would lead us too far to discuss here the extent to which special conditions, such as infection from the perhaps rarer bovine tuberculous bronchial glands or change in the hitherto little examined material from tuberculosis of the bones (greater age, &c., &c,), and other factors play a part. For a number of cases, about one-third, it is our fixed opinion, though the researches have really only just begun, that a consider- able part of scrofulosis is induced by the bovine bacillus, and that, being a bacillus of a foreign species, is the cause of the milder course. For the future, in any special case to make the prognosis as sure as possible on all sides, we ought not to fail to find out with which bacillus we are dealing. For the further question, which is very important for the prognosis, is, how far the primarv tuberculous infection in l'R(X,NO.SIS 231 scrolulusis, wheLlicr iL be Iniman or bt^vinc species, can iiilluence the later fate of the patienl il a li(-sh inbcrculous infection should take place, souk; authors have riKlcavoiircn lo \)y\n^ lo bglit some theories which appear Uj me lo be vry lar leLched, without for the present being able to support (Ihih by proved facts. We will give a few theories without slating any opinion about them. \-. Uehring has stated ihal a Inberciilous inteciion which has been conlracled in childhood and later arrested, cxijiains, on the one hand, the pr(jporlionalely great immuniiy of most adults to tuberculosis; on the other hand, it explains also the decidedly chronic course which, as a rule, tuberculosis takes in adults. The expected proofs of this theory have not been brought forward. Other authors lean to the point of view that the hrst infection chiefly renders the patient more or less immune, but with general individual tendency a scrofulous diathesis arises, so that the first infection is no longer able to protect from the second (Edens). Hamburger terms tuberculosis a child's disease which nearly every one takes, and which lends a certain immunity to infection. HiJtinel and LerebouUet suppose an early infection of the mediastinal and mesenteric glands. The first infection remains latent, and may^ either almost immunize or, on the contrary, render the patient more susceptible; the disease becomes manifest in connection with other illness or renewed tuberculous infection. Older children, because they are not affected so frequently as infants, are said to enjoy a certain immunity. Weber is inclined to believe that a body already infected by human bacilli is more capable of withstanding bovine infection instead of being more susceptible. He bases his theory on the case of two children who were infected by the human bacillus, and who, in spite of drinking milk from a cow with tuberculosis of the udder, on post-niortciu examination exhibited no lesions of bovine bacilli. But manv other children, not the subjects of human tuberculosis, who drink bovine tuberculous milk also do not exhibit bovine bacilli ; thus there is no visible foundation for the belief of greater power of resistance in Weber's children. Burckhardt, on the other hand, relies on experiments on rabbits to confirm whether the incorporation of human bacilli at an earlv age, when thev have not yet induced immunitv from bovine tuberculosis, does not favour spontaneous infection with bovine bacilli, or does not cause an already existing infection to burst forth. The facts that scrofulous persons frequently by taking a second infection are subject to pulmonary tuberculosis, when both diseases appear to merge into each other, that the scrofulous 23-2 SCROFULOSIS frequenih' recover, and yet sooner or later suffer from pulmonary tuberculosis, and again, others often remain lieallhy liirouglioui their whole life, that both types of bacteria, bovine and human, are very often found living apparently peacefully side by side, and yet working at the destruction of ihe body, cause us to pause with all these hypotheses before us, for up till now no support which can be accepted, to say nothing of no exact proofs, have been adduced; after all, they are chiefly mere variations of v. Behring's views. It is true the questions of the researches into immunity are combined with great difficulties, for the behaviour of the animal which has been infected with a quantit}- of weakened or otherwise changed bacilli in the attempt to immunize it affords us no certain conclusion about the conditions which man would show under natural circumstances after infection with a few bacilli. We have seen, for example, how far we have succeeded with the stamping out of tuberculosis in cattle w-hich years ago promising experiments led us to believe would be achieved, and how short a time the immunizing power remains. In this question we have erred too far from the path of exact research and have fallen into the channels of speculation. SrXTION VI. Diagnosis. The decision \vh('llH'r, in corlain casfs, we liave really to do with scrofulosis is not cilways easy, in spite of often striking symptoms in the beginning. Many processes manifest them- selves as tuberculous from the first; most of the symptoms, how- ever, especially those of pyogenous scrofulosis, may appear alone without scrofulosis. A.— THE PYOGENOUS FORM. Owing to our hitherto imperfect statistics (see p. 153), we cannot judge how far being descended Irom parents who at the time of generation were scrofulous or oliierwise weakened, influences the transmission of a local or general diathesis, and how far this influence may be diagnostically utilized in the history of the case. Further processes, such as mapped tongue, milk-scurvy, seborrhoea strofulus may raise the suspicion of scrofulosis. but we must be careful not to be too generous in our conception of scrofu- losis, and put down to it every rash and every swollen gland in children. Nearlv all the symptoms which pyogenous scrofulosis presents — eczema, impetigo, chronic rhinitis, oz£ena, adenoid growths, otorrhoea, chronic swelling of the l\-mph glands — are not of themselves characteristic, and appear singly in non-scrofulous persons who are otherwise healthy. But yet they exhibit peculiari- ties in their course in scrofulous persons which are missed in the healthv, though these peculiarities are only slow in their process, as is always the case in the scrofulous disposition, but which appear to be, as we have already explained, only a higher degree of anatomical characteristics peculiar to childhood. The differences in the course are the following : those pro- cesses have more opportunitv of establishing themselves on 234 SCROFULOSIS account of the more open and wider points of entry, therefore are extraordinarily apt to relapse (recurrence), and similar processes appear simultaneously or following each other (multiplicity), further, owing to the wider lymph passages they can more easily spread, and are more difficult to remove (pertinacity), and can especially invade the lymph glands. It is onlv these special signs which justify the conclusion that a focus is due to scrofulosis, and especially the multiplicity of places not directly dependent on each other or at short intervals is of great importance. On the other hand, otorrhoea may depend on eczema of the auricle, nasal catarrh on adenoid growths, with- out on this account imputing them to scrofulosis. In this CDnncclion the remains of former similar processes mav be valuable in diagnosis, for example, ulcers on the cornea, perforation and scars on the membrana tympani, high, narrow, boat-shaped palate with irregular teeth, scars about the glands in the neck, as well as certain consequent symptoms, which are often described in the picture of the scrofulous habitus, the thick puffy nose, the swollen upper lip, with a perpendicular crack in the middle. Eczema appears in quite healthy persons, is induced by pediculi, for instance, or other causes, but in the scrofulous it is especiallv frequent and obstinate. But this must not be mistaken for eczema seborrhoicum, which is caused merely by an accumu- lation of sebaceous matter. We must also keep impetigo contagiosa (pseudo scrofulosis of Chaumier) with its decidedlv contagious character distinct. Many forms of lichen scrofulosorum belong to pyogenous scrofulosis, if they have not a tuberculous basis and growths like tuberculides. The same may be said of chronic rhinitis which may have been induced by foreign bodies artificially introduced or other causes; this may be of long duration even in healthy persons, but is seldom permanent as in scrofulosis. Pins lays special weight on the continued and regular swell- ing of the nose, and a certain sensitiveness to pressure as a sign of scrofulous rhinitis. Oza^na, whether it is consequent on chronic rhinitis, or is directly induced by certain bacteria, is more frequent in scrofu- losis, and in children justifies suspicion of scrofulosis, otorrhoea also when it is of inordinately long duration, and is combined with eczema of the auricle and swelling of the cervical glands. Swelling of the tonsils, and especially adenoid growths, may in their later symptoms easily assume the semblance of tubercu- DIAGNOSIS 235 losis, buL llic'ir speedy discippi-arancc and die lack ol all di(;se symptoms after rational treatment and operative removal is against scrofulosis. I have referred alxn'e (see |). KjH) \() (lie j^r'-'-nisli-hiown colourinj^- of i\\(' leedi noted by Neumann. The marked dislike to light in pit! ycleniilar and odier affec- tions of the eyes has also been said l<> be a sign of scrofulosis. Skin affections in the tributary area of the glands are especially valuable as an indication of die nature of the glandular swelling. (vSe(; Topography, p. i.V'O One or two swollen glands in the neck or elsewhere is no sign of scrofulosis. Acute glandular swellings are naturally exempt from such significance as being caused by some infectious irritation near the seat of the swelling; they disappear in a few days (^r pass off with inflammation, fever, rapid breaking down, and suppuration. There are also a great number of chronic swellings which have nothing to do with scrofulosis, they are more painful, disappear more easily, especially when the exciting cause in the source of the disease is healed. B.— THE TUBERCULOUS FORM. (1) Clinical Diagnosis. The history may give important data for the diagnosis of the tuberculous form. The so-called heredity, that is to say, the existence of the disease in the family, is most significant in tuberculo-scrofulosis, certainly not in the sense used in former times and often also in the present day as indicating that the child was predestined to it, but on account of the opportunities of contagion arising out of it. The state of health of the parents at the time of the pro- creation and birth of the child would give us important informa- tion for the diagnosis, if only we could accustom ourselves not to dismiss everything with the watchword heredity (see Hereditary Influences, p. 154). We ha^■e not onlv to notice from the one point of view the state of health of the parents, but also that of the persons with whom the child comes most into contact (relations, servants, plav- mates), and must in this connection direct our attention to the mode and intensity of the spread of the infectious material. Besides which, we must confirm how far social conditions, certain diseases, measles, (Src, or other favouring factors make the diagnosis probable. Tuberculous scrofulosis exhibits principally a multiplicity of 236 SCROFULOSIS phenomena in ilic iniernal organs of ilu- hotly and a gieai perti- nacity, the pyogenoLis form a muliipliciiy on the surtace of the body and frequent recurrence. The diagnosis of the tuberculous form can be lurihcr sup- ported by the demonstration of specific skin chseases — kipus, scrofuloderma, lichen scrofulosorum — the external phenomena of which we described above, whilst for the differential diagnostic signs we must refer lo ihc special scciion of ihc work on Skin Diseases. We must especially refer to luptis of die mucous nicmlirane of the nose in the vestibule of the nose in the anterior angle as one oi the most frequent starting-points of lupus of the face, which, on account of its hidden position and its benign course, is frequent 1\' (ncrlooked or i:)ut down to eczema (Gerber and Senator). The demonsiralion of tuberculides, of lichen scrofulosorum, of erythema nodosum, of ft)lliculilis has doubtless hii^h diagnostic significance for scrofulous tuberculosis, as was most emphatically noted by Boeck many years ago. In tuberculosis of infants there were, according to L. F. Mever, tuberculides in 50 per cent. ; Leopold and Roseniern found the tuberculides described by Hamburger twelve times in thirty cases. But we are not justified in considering these lesions off- hand as a sign of general tuberculous infection, for they may arise as the result of a toxin, and especially by dead bacilli of both types, human and bovine. Now and again tuberculides may be mistaken for syphilitic exanthemata, and the diagnosis can only be confirmed by Wasser- mann's reaction; the refractory character of antisvphilitic treat- ment and the local tuberculin reaction establish the diagnosis (Konigstein), A case of Sergent shows what dif^culties now and then present themselves in diagnosis. A woman who was declared to be tuberculous seven years after her marriage, and who had a series of skin, gland, bone and joint affections, turned out to be syphilitic, and was cured by antisvphilitic treatment. The rest of the symptoms in the skin, eczema, impetigo — and in the mucous membranes, catarrh, ozrena, rhinitis, phlvctenc'e — owe their origin perhaps to the same scrofulous tendencv, but are not connected directly with tuberculous affections. If bacilli are present, as in some cases of eczema, ozasna, and adenoid growths has been demonstrated (see pp. ti, 12 and 141), thev denote a second infection; the proof of this is important in so far as they also confirm tlie character of the accompanving glandular swelling. DIAGNOSIS 2.37 Otorrlicjca, too, need iiol (Icpciid mi i iilxTcuUjsis, alilioiigli il often owes its origin lo n. I Ins is shown by the pn^senee of tubcrch; bacilli in llic scciclinn nl ilic r-;ir, .-md pointed to by its insidious [)ainless (^cciirrence, and es[)e(;ially by the aeefjnipanying caries of the petrosal bon(;. Also the (generally casealed) glands of tlie mastoid arc; in the pyogenic lorni not so frequently met with. Tuberculosis of the Glands. — The diagnosis is considerably mor(! dinicult when, as is so rrc(|uently the case, in (he tuberculous form there are no spc^cific synipionis at ilie point of entry, and we iiave only tlu; swelling of the glands as guides, thes<* having few signs which characterize them as specifically tuberculous. The fewer the superficial affections, of course with the excep- tion of specihc lupus, the more probable is it that the swelling of the glands is of a tuberculous nature. Thus we can understand the notion of older authors. Hufe- land, for example, greeted the phenomena of scaly eruptions, discharging ears and eyes as favourable signs, considering them a diversion protecting from internal scrofulosis. As long as the gland is closed the slow, painless course, which may remain stationary for months or years at the same stage of development, as well as the presence of large masses of glands or the absence of radiating hypertrophic scars as signs of processes (tistulce) which have already healed, all point to tuberculosis. The diagnosis is relatively easy in the case of the neck glands which have burst, where we can demonstrate tubercle bacilli microscopically in the pus, or by inoculation into animals which, on account of the small number of bacilli, is more reliable. But without this confirmation a thinner fluid secretion mixed with caseous fragments, the unusuallv long standing, and the formation of fistulai are in favour of tuberculosis, whilst thick yellow pus, acute course with prominent inflammatory symptoms, and a speedy scarring rather indicate a different origin. Tuberculosis of the Bronchial Glands. — Demonstrable swell- ings of the bronchial glands depend most on tuberculosis, for if they swell from other causes — Geffrier, for example, has noted such cases — experience has proyed that they seldom arrive at so great a size as to induce characteristic disturbances. General symptoms for which no other reason can be demon- strated often point to scrofulosis of the bronchial and mediastinal glands. Such symptoms are loss of weight, loss of appetite, often dyspeptic derangements, easily becoming tired, and " feeling limp," especially in the morning. We are often seduced by a pale face to content ourselyes with the diagnosis "anaemia," 238 SCROFLLOSIS although the stale of the blood gives no ground for this dictum. A correct record oi the temperature generally suffices to show the real state of things. In this case (see " Die rubercuk)se," second edition, p. 729) 1 must especially emphasize the fad thai only by a record every twt) hours is it possible to confirm slight increases of temperature. I have seen numerous cases of pulmonary and glandular tuberculosis which, altiiough accompanied by am- biguous general symptoms, escaped a certain diagnosis for months, only because the practitioners had been contented with taking the temperature two or three times daily, and were deceived by its being apparenilv normal, whilst on the first day by con- sistent record every iwo hours I confirmed an increase of tempera- ture of 37'2° lo 37'3° in the arm[)ii, and of over 37'3° in the rectimi, with occasional transitory slight feeling of chill, and by this means severe affection of lungs and glands was demonstrated. Man\- are still unilcr ihe delusion that fever onl_\- begins o\er 37'7° (rectum), and iluis miss the best time for rational irealment. Avellis has found in children from i to 8 years of age an evening temperature of sS'i'^' in the rectum for months together without tonsillar enlargement or physical examination giving any clue. Suspicion of tuberculosis has kept children for months in bed "to no purpose." Avellis attributes the cause of local rise of temperature in the rectum lo anaerobic bacteria, A\hicli increase the temperature locally, as the temperature of the armpit is 1° to I '2° lower. The bronchial and mediastinal glands point more clearly to infection. They cause a convulsive, reflex, rough, dry cough, coming on by fits and starts, lasting a short time, but frequently recurring, resembling whooping cough, though less seldom accompanied by vomiting and wheezing. The attacks resembling pertussis, which frequently occur after swelling of the bronchial glands, come on, as J. Simon notes, more in the morning and evening or after exertion, and are less frequent at night. The cough shows great variations in intensil}'. In whooping cough, on the contrary, the attacks are more rhythmic, the expiration forced and jerky, the inspiration gasping or wheezy. This condition returns after every five or six attacks of coughing, and finishes with mucous expectoration. The attacks are especially frequent at night. Other indications are hoarseness (cliiellv posterior j^aresis, Breeke), even complete aphonia, now and then a wheezy voice, followed by frequent catarrh, Avhich is favoured by the reduced reflex activity of the respiratory mucous membrane, in consequence of compression of the sensitive branches of the vagus. Hvper- Dl A(JNO.SJ.S 239 plasia of Lhc pliaryngcal vaull, swcllijig <>\ ili<- iif k gl;ui(l.s ;iii'l oilier scrofuh^us plienom(;na, jKil{)ila(ion, (jiik kciiing ol tin; piil.s<-, and varialion of llie pulse, now and ilnn enlargement ol ilie pujnl on the affected side, wliicli for the same reason ran also be men- tioned as an early symptom of pulm\ dw j^'-l,-iiidul--ii' swelling. The |)li('ni)incn()n ()bs