34. Even when caseating lesions are present, the simultaneously developing submiliary transparent eruptions (granulie, of the older authors) are to be regarded as capable of being organized and spontaneously cured. They are much more numerous in man than has heretofore been assumed. This is shown, for example, by the fact that upon opening the abdominal cavity of such young individuals as showed no clinically diagnosticated symptoms of a miliary tuberculosis, these eruptions were by chance demonstrated.
It is of the highest interest to determine the fate of such individuals with a healed miliary tuberculosis of the peritoneum, that is, whether in virile period of life the disposition in them to pulmonary consumption is increased or diminished.
35. The clinical picture of scrofula in the puerile period of infection is etiologically complicated by other infectious processes, especially in the domain of the outer body covering. The functional alterations in the vascular system, due to an infantile Tb. infection, find their expression not only in the organism’s increased sensitiveness to tuberculin, but also in a marked instability [labilität] of the dynamic equilibrium of the circulation (lymphatic constitution). In consequence of this, eczematous eruptions due to parasitic and toxic agents result much more readily in these individuals than in those who have not suffered such an infantile Tb. infection (one incompletely healed).
36. The symptoms of the so-called “inclination to consumption” are the expression of a defective overcoming of the infantile and puerile infectious periods. The hindered development and weakness of the organs made up of smooth muscle fibres (muscles of the blood-vessels, intestinal wall, and bronchi) are comprehensible when we remember the great share that the smooth muscle tissue has in the reaction against the Tb. circulating in the blood. The question whether the weakened conditions and hindered development in the domain of the striped muscles are due directly or indirectly to the Tb. infection cannot be answered without further investigations. Similarly, we do not yet know the mechanism of the origin of the chest anomalies seen in candidates for consumption. A partial impoverishment of the intestinal lymphatic receptive apparatus is presumably accountable for the fact that even a plentiful supply of food is unable to increase the accumulation of fat.
37. The possibility must also be considered that in the course of the puerile period of infection the development of a caseating tubercle may proceed in the joint tissues between costal cartilage and breast-bone, and that such a scrofulous thoracic affection is clinically much less readily diagnosed than a similar affection in bones of the extremities. Further, that such a lesion in the lower extremity is much more readily recognized than one in the upper extremity, since even slight alterations in the bony tissues of the lower extremity, because of functional disturbances in walking and running, make themselves manifest.
38. For a detailed analysis of the origin of pulmonary consumption, beside the results of infantile and puerile infections, there must still be considered
(a) Additional virile Tb. infections (cf. Romberg, Deutsch. Arch. f. klin. Med., 1903).
(b) Combined action of a complicating infection.
(c) The co-action of general hygienic and dietetic injuries.
39. For my plans for suppression of tuberculosis, therefore, the following points are essential: