Part 9

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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