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+The Project Gutenberg EBook of Prof. Koch's Method to Cure Tuberculosis
+Popularly Treated, by Max Birnbaum
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Prof. Koch's Method to Cure Tuberculosis Popularly Treated
+
+Author: Max Birnbaum
+
+Translator: Fr. Brendecke
+
+Release Date: November 7, 2008 [EBook #27181]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK METHOD TO CURE TUBERCULOSIS ***
+
+
+
+
+Produced by Bryan Ness, Norbert H. Langkau and the Online
+Distributed Proofreading Team at https://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+
+
+
+
+                 [Illustration: DR. ROBERT KOCH.]
+
+
+                           PROF. KOCH'S
+
+                         _METHOD TO CURE_
+
+                           TUBERCULOSIS
+
+                       _POPULARLY TREATED_
+
+                                BY
+
+                        DR. MAX BIRNBAUM.
+
+                   _TRANSLATED FROM THE GERMAN_
+
+                                BY
+
+                        DR. FR. BRENDECKE.
+
+     _With an Appendix being Prof. Koch's First Communication
+               on the Subject, translated from the_
+
+              _DEUTSCHE MEDICINISCHE WOCHENSCHRIFT_
+
+              _and explanatory notes by the author._
+
+
+                         MILWAUKEE, WIS.,
+                         H. E. HAFERKORN,
+                            PUBLISHER.
+                              1891.
+
+                         COPYRIGHT 1890,
+                                BY
+                         H. E. HAFERKORN.
+
+                           PRESS OF THE
+                      HARTMANN PRINTING CO.,
+                          126 Reed St.,
+                         MILWAUKEE, WIS.
+
+
+
+
+Translators Preface.
+
+
+Consumption is curable. From time to time the news of some great
+discovery rushes over the land like a mighty wave; but never before has
+the intelligence of a great achievement been received with such
+universal delight. There is hardly a man, woman or child that does not
+bewail the loss of some dear relative taken away by Tuberculosis, the
+most terrible of all foes. More terrible because it stealthily creeps
+into the system and takes a firm hold before its presence can even be
+surmised.
+
+Now the appearance of a deliverer is hailed as would the advent of the
+Messiah. Koch, formerly a poor and obscure student, being especially
+interested in bacteriology has plodded and worked for years. Even in the
+year 1882 he has made known to the world the evil spirit in describing
+the tubercle-bacillus as the specific generator of tuberculosis. We then
+knew the enemy but had no weapon to fight him. Now Koch has also
+manufactured the sword with which to combat the evil genius. The
+experimental tests thus far have not tended to lessen the merits of
+Koch's remedy. Added applications have resulted in additional success.
+The investigations are not yet complete; only meager particulars have
+thus far been given to the public from authorized sources. To guard
+against misleading representations the translator has undertaken to give
+to the American public only what has actually been achieved. He felt
+himself called upon to do this not only because he has followed the
+progress of Koch's labors with the keenest interest, but also because he
+himself has worked and labored on this field for many years.
+
+
+
+
+Justly has a vast excitement taken hold of all classes of the people, an
+excitement that has caused all other contemporary events to fall back.
+The search for an actual remedy for that exceedingly ravaging disease,
+tuberculosis, has at last been crowned with success, and even the most
+uneducated will be able to estimate the significance of this event.
+
+We need but consider, that pulmonary consumption, the most frequent form
+of tuberculosis, annually demands over 30,000 victims in the cities of
+the German Empire over 15,000 inhabitants, and out of every 100 deceased
+12-13 have fallen prey to this sickness.
+
+The number of sufferers from pulmonary consumption can not nearly be
+determined, it certainly exceeds all other diseases by far. In the case
+of many people we can only infer from their appearance and hereditary
+tendencies, before visible signs can be discovered, that they will
+succumb to this terrible disease.
+
+And this disease is now curable. Millions of people who have considered
+themselves doomed, will be given back to life; their regained strength
+will greatly increase the national wealth. In short, we look forward to
+an era, such as was not dreamt of even by the most vivid imagination
+only a few years back. But rather than be carried too far by our
+enthusiasm, let us study Koch's new method to cure, as far as we are now
+enabled to pass judgement on it.
+
+First of all we must explain: _What is tuberculosis? What relation does
+it bear to pulmonary consumption?_
+
+Pulmonary consumption is only one form of tuberculosis, by far the most
+frequent. This is the reason why pulmonary consumption, pulmonary
+tuberculosis, consumption and tuberculosis are used as _synonymous_
+terms.
+
+Tuberculosis is the _general_ expression. By that we understand a
+disease which is generated by a certain kind of organism belonging to
+the class of bacteria. These organisms are the tubercle bacilli, which
+were discovered by Koch in the year 1882.
+
+Now these tubercle bacilli settle most frequently in the lungs and here
+cause serious derangements of the lung tissue. _Pulmonary consumption_
+is the result.
+
+But the tubercle bacilli will also settle in any other portions of the
+body and cause tuberculosis.
+
+Frequently the tubercle bacilli nestle in the _larynx_ and the result is
+_laryngeal consumption_.
+
+They may infect the mucous lining of the tongue and nasal passages and
+cause the rarely occurring diseases--_tuberculosis of the tongue and
+nose_.
+
+More frequently tuberculosis of the intestines results, the well-known
+_intestinal consumption_.
+
+The spreading of tuberculosis in the brain is of especial importance on
+account of the importance of this organ. Very frequently small children
+are attacked by _tuberculosis_ of the _cerebral membranes_, a disease
+that has heretofore unexceptionally resulted in _death_.
+
+Much oftener than is generally supposed the _kidneys_ are the seat of
+tuberculosis; and also the _suprarenal capsules_, whose functions are as
+yet entirely unknown, have in postmortem examinations been found to be
+tubercularly degenerated.
+
+In the diseases of the _bones_ and _joints_ tuberculosis forms an
+important part. Those infinitely small and weak tubercle-bacilli have
+the power to destroy the hard and firm substance of the bones, to soften
+it and change it to pus. Whole portions of bone may disappear in this
+way.
+
+Tuberculosis can also destroy parts of the _skin_. In this case it is
+called _Lupus_.
+
+Finally tuberculosis is found in the _generative organs_. Tubercular
+derangements are frequently met with in the _testicles_ of men, less
+often in the _ovaries_ of women.
+
+The well known children's disease _Scrofula_ is considered a preceding
+stage of tuberculosis by many physicians. This much is certain that
+Scrofula inclines to tuberculosis.
+
+Let us study the several forms of tuberculosis after this general
+synopsis; we will begin with pulmonary consumption.
+
+
+
+
+Pulmonary Consumption.
+
+
+Even before the discovery of the tubercle-bacillus by Koch, different
+scientists had claimed that pulmonary consumption was caused by the
+immigration of bacteria into the lungs, and several of them had found
+bacteria of that kind. But it remained for Koch to bring light upon the
+conjectures of other scientists, and he established the fact, that the
+bacillus discovered by him was the real generator of pulmonary
+consumption. Millions of these bacilli exist in the lungs of the
+diseased, and millions of them are thrown out with the sputum.
+
+If we take a very small quantity of this thrown out matter and examine
+it with a microscope, we will find a greater or smaller number of these
+tubercle bacilli. Of course the preparation to be microscopically
+examined must previously be colored with some coloring matter, otherwise
+it is very difficult, well nigh impossible, to detect the infinitely
+small bacilli. The method of coloring now generally in use consists in
+discoloring the preparation after the coloring has been completed, it is
+found that the bacilli tenaciously cling to the coloring matter, and in
+this way it is easy to recognize the tubercle-bacilli under the
+microscope.
+
+These bacilli are infinitely minute, they are 2/1000 to 8/1000
+millimeters long, and about 5/100000 millimeters in width. Therefore it
+is absolutely impossible to recognize them with the naked eye. Generally
+they are somewhat bent, sometimes slightly nicked at one end.
+
+The temperature of boiling water destroys the vitality of the bacilli
+under all circumstances. Even a temperature of 70 deg. C. is able to
+lessen the efficacy of the bacilli. Unhappily this temperature is too
+high to be applied against the tubercle-bacilli in the human body without
+causing the most serious injury to it. Nevertheless it has been tried,
+we will speak of this later on.
+
+Then the drugs that kill the bacteria, such as Carbolic Acid, Alcohol,
+Iodoformether, Ether, Sublimate, Thymol, destroy the tubercle-bacilli so
+slowly and only in such high concentrations that their application is
+impossible without endangering the patient. Therefore the prospects of
+directly destroying the bacilli in the human body had to be given up as
+impossible.
+
+We are now confronted with two questions:
+
+  1. In what manner does the tubercle-bacillus enter into the human
+     organism?
+
+  2. Under what conditions is the tubercle-bacillus able to generate
+     pulmonary consumption after it has entered the human organism?
+
+All investigations, both of earlier and later date have established the
+fact that the tubercle-bacillus is inhaled with the air, and then it is
+mainly the foul air which is accused. But foul air is especially found
+in such places where people congregate, as in rooms, barracks,
+factories, etc. As it is a fact that there are always several
+consumptives among a number of people, so in this case there will always
+be occasion to inhale the tubercle-bacilli that have been cast out by
+the consumptives. Therefore it is not the foul air in itself which
+generates pulmonary consumption, but the circumstance that in this
+connection there are always people present which are able to spread and
+scatter the bacilli.
+
+Luckily the physical qualities of the tubercle-bacilli are such that
+they mostly adhere to the ground or floor and are rarely scattered in
+the air as dust; otherwise pulmonary consumption would be much more
+frequent than it is at present. Unfortunately the bacilli are very often
+spread through uncleanliness of the people, because they touch objects
+with their fingers to which the tubercle-bacilli chance to stick and
+then they touch their mouth or nose with these fingers. In this way
+bacilli can be taken into the system especially easily with the food.
+Children are particularly exposed to contamination, crawling about on
+the ground, on which, perhaps but recently, a consumptive has spit, and
+more so because they often have the habit to put all sorts of things
+and also the generally dirty fingers into their mouth.
+
+On the other hand there are various obstacles in the way of
+tubercle-bacilli entering the lungs. The distance from the mouth to the
+lungs is long and narrow; all sorts of projections check the further
+penetration of the bacilli. The trachea and the air-passages of the
+lungs possess equipments arranged for the purpose of ejecting small
+foreign substances, thus also to throw out the bacilli. In short it is
+not too easy a matter for the bacilli to penetrate into the lungs.
+
+And yet this happens only too often. For instance, in some people the
+passage from the mouth down may be a wide one, so that the bacilli can
+enter more easily; the protective arrangement by which foreign
+substances are removed may be deranged, it may be wanting in some place
+or its functionary qualifications may be bad; especially frequent this
+is the case after enfeebling diseases, which are associated with severe
+cough, as measles, whooping-cough, etc. This is the reason why pulmonary
+consumption is strikingly often observed to follow just these diseases.
+
+But the tubercle-bacillus can also enter the body with the food, as
+stated before. The acid gastric juice is a protective agent which
+considerably lessens the danger of infection by tuberculosis.
+
+It has not been definitely decided at the present time whether the
+drinking of milk from tuberculous cows brings with it the danger of
+tuberculosis for mankind. It will certainly be best to avoid such milk,
+especially when the cow's udder is found to be tuberculously diseased or
+when tubercle-bacilli can be traced in the milk.
+
+The use of meat as food may also become dangerous to man, but this is a
+rare occurrence. It is particularly dangerous to eat the liver, kidneys
+and lymphatic glands of tuberculous animals. The boiling heat while
+cooking generally destroys the bacilli contained therein and so lessens
+the danger from this source. It is of no little importance, to call
+particular attention to the fact that our chickens are very often
+severely infected with tuberculosis.
+
+The question, whether a consumptive can _infect his surroundings_, may
+be answered thus, that this does _not_ happen as a rule. Several unhappy
+circumstances must come together to make this possible. Above all things
+a direct transmission of tubercle-bacilli in some way into the body of
+the healthy person, then the bacilli must cling and propagate in the
+same, which is only possible when there is an inclination to this
+disease, of course this inclination is quite common.
+
+Pulmonary consumption is _not hereditary_ in the strict sense of the
+word. Only an inclination to this disease is transmitted. As the danger
+of contagion of those having such disposition is very great, so as a
+rule the disease makes its appearance sooner or later.
+
+On the other hand it must be considered that the penetration _only_ of
+the tubercle-bacilli into the body is _not_ sufficient to generate
+tuberculosis. If they do not find the ground adapted to their
+nourishment and propagation they perish. It may be assumed that every
+person is placed in such circumstances at some time that he will take in
+tubercle-bacilli; but only a certain percentage will get consumption. In
+the remainder the bacilli perish without leaving even a trace.
+
+Very often the inclination to pulmonary consumption may be recognized
+from the external characteristics. As a rule the respective individuals
+have a slight body, thin lean skin, weak muscles, delicate skeleton, a
+long, narrow, flat chest, flattening of the regions over and below the
+shoulderblades, wide intercostal spaces, a winglike projecting of the
+scapulae, long neck, clubby, knoblike appearance of the ends of the
+fingers.
+
+Furthermore it has been found, that pulmonary consumptives on an average
+have a _smaller heart_ than is essential to a healthy body. On the other
+hand the volume of the lungs of consumptives is very often abnormally
+large.
+
+There are a large number of _diseases_ that predispose to pulmonary
+consumption. It is mainly the _enfeebling_ action of the same, which
+brings about such results. For this reason the _chronic_ diseases
+contribute so much toward the multiplication of the number of
+consumptives, because they stipulate a continuous weakening of the
+organism and an emaciation of the system. To these belong Bright's
+disease, which very often turns into pulmonary consumption,
+greensickness or chlorosis, anaemia, continued febrile diseases, severe
+chronic suppuration, chronic catarrh of the stomach, frequent
+pregnancies, childbed diseases. Thus we may often see young chlorotic
+girls afflicted with consumption, especially when they marry young and
+enjoy the honeymoon to its utmost limits. Then also women will easily
+become consumptive when they give birth to a child every year,
+especially when the social conditions in which they live are of an
+unfavorable nature, and they are perhaps inclined to consumption
+already. Childbed on the whole inclines to arousing the dormant
+inclination toward pulmonary consumption.
+
+Of other diseases we have mentioned measles and whooping cough, as
+diseases that are only too easily succeeded by consumption. To these may
+be added typhus, especially when it is of a more protracted nature, and
+the reconvalescence is slow and incomplete.
+
+Furthermore all those workmen that have to do with dust, are exposed to
+the danger of being stricken with pulmonary consumption. The dust enters
+the lungs, irritates and injures the same and so produces a favorable
+soil for any tubercle bacilli that may happen to penetrate. On the whole
+metal dust is more injurious than mineral dust. Workmen, that are
+exposed to animal dust, as furriers, saddlers, brushmakers, fall prey to
+consumption much oftener than those, that fulfill their vocation in air
+pregnant with vegetable dust. According to statistics workingmen are
+stricken with pulmonary consumption as follows: of glass workers 80 per
+cent., needle grinders 70, filemakers 62, stone cutters 40, mill
+grinders, lithographers, cigarmakers, brushmakers, stone-polishers
+40-50, millers 10, coal workers 1 per cent.
+
+Pneumonia may culminate in pulmonary consumption: but on the whole this
+rarely happens. Much oftener it is the case with Pleurisy. But it is
+assumed and rightly, that most people who are attacked by pleurisy, are
+already consumptive.
+
+A hemorrhage of the lungs may nearly always be considered a sure sign
+that consumption has taken hold of the respective individual; but such a
+hemorrhage certainly forms considerable danger to falling a victim to
+tuberculosis, if the individual is as yet free from the same.
+
+Age has a particularly decided influence on the origin of consumption;
+it is extremely rare before the third or fourth year, from that to the
+seventh it is more frequent; it most frequently occurs in the age from
+the fifteenth to the thirtieth year, and from there on the chances are
+again fewer. In very old age it is again very rare.
+
+There seems to be no essential difference as regards sex.
+
+_Insufficient_ or _defective nourishment_ acts as a promoter in various
+ways. Even the nourishing of infants with poor milk, with bread or
+flour-pap increases the disposition to pulmonary consumption. If this
+defective nourishment is continued, scrofula will surely follow and this
+is a stage antecedent to consumption.
+
+Pulmonary consumption is relatively more frequent among the _poorer_
+than the _well to do people_, this is partly due to the meagre and
+scanty food of the poorer, and that they are obliged to subsist almost
+exclusively on vegetable diet. The higher the meat prices rise and the
+less the majority of the people can afford to procure meat, the larger
+will be the number of consumptives. The poorly nourished offer a good
+soil for the tubercle bacilli in consequence of their weakness. The
+tissue offers little or no resistance to the growth of the bacilli,
+these propagate and destroy the powerless and yielding organism with
+fearful rapidity.
+
+The _frequency_ of pulmonary consumption increases with the _size of the
+cities_, or, which is the same, with the number of proletarians. Extreme
+hunger and want are less frequent in the country than in the city.
+
+That the climate has an important influence on the appearance of
+pulmonary consumption has long been known. In certain elevated regions
+this disease seldom or never appears. This experience has been attained
+in Switzerland and many other mountain regions. Furthermore the Plateaux
+of Peru and Mexico are considered free from consumption, but also
+lowlands like Iceland, the Kirgheez steppes and the interior of Egypt
+are known to be exempt.
+
+_Damp and windy climate_, especially with very high temperature, or
+abrupt changes in the temperature promotes consumption; on the other
+hand it is less frequent in the more moderated climates, especially if
+they are dry.
+
+Now when the tubercle bacilli have settled in the lungs, they cause
+various symptoms. One of the most frequent is _cough_. In the beginning
+of the disease a short, clear but light, very often dry cough appears.
+During the further development of pulmonary consumption the cough
+becomes more periodic; it appears early after awaking, in the afternoon
+after dinner, and evenings at lying down; it may disappear entirely in
+the meantime or may be light only; but then as a rule it is no longer
+dry, but may be attended by expectorations of a varied nature.
+
+[Illustration: Section of a tuberculous knot in the lungs, in which two
+cavities are seen filled with numerous bacilli. The bacilli distinctly
+appear as dark lines as a result of the coloring. Enlargement 900.]
+
+[Illustration: Tubercle bacilli, Enlargement 2000.
+
+To the left bacilli without spores, to the right bacilli with colorless
+sections which are thought to be spores.]
+
+The tubercle bacilli destroy the lung tissue and change it into pus,
+which is coughed out. In this way larger and smaller cavities are formed
+in the lungs; finally the cavities may even take more space than the
+remaining lung tissue. When cavities have already been formed, coughing
+comes easy and with abundant expectoration. Toward the end of life the
+coughing and spitting stops as a result of the extreme feebleness and
+weakness.
+
+The violence and frequency of the cough depends mainly whether the
+larger bronchial tubes and the trachea are affected; the more this is
+the case, the more violent the inclination to cough. Further the
+strength of the cough depends on the excitability of the patient; the
+greater this is, the more as a rule will he cough. Sometimes the
+position of the patient is of influence; if he lies mostly on the
+diseased side the expectoration becomes more difficult and coughing
+increases.
+
+Coughing is generally that symptom which soonest attracts the attention
+of the patient and his surroundings. For that very reason consumption is
+in its beginning stages easily confounded with such other diseases as
+are also accompanied by cough.
+
+At the same time we know of exceptional cases where cough was entirely
+absent in the first stages of the disease, or was at least so slight
+that it was overlooked, and under such conditions the pale and poor
+appearance and reduced strength is mistaken for chlorosis or some other
+anaemic affection, also the existing febrile excitements are wrongly
+judged, or on account of lack of appetite or light derangements of the
+stomach a stomachic affection is surmised, until suddenly a hemorrhage
+of the lungs clearly defines the true nature of the ailment.
+
+On the other hand the cough may become so violent that vomiting is
+caused at the same time. Nevertheless many consumptives describe their
+cough as very unimportant on account of their innate sorrowless nature,
+and they will not even be discouraged by the gravest symptoms. Often
+however it is fear that induces the patients to make light of their
+coughing, their spitting blood, their losing flesh and to place but
+little importance on these circumstances. A _hoarse_ cough is a sure
+sign of a diseased _larynx_.
+
+Many consumptives complain of cutting pains between the shoulderblades,
+under the clavicles or in the side; but these are rarely intense and are
+often entirely wanting. Unfortunately it is unknown to the average
+layman that the internal organs may suffer extensive tearing down
+without an indication of pain.
+
+The _Expectoration_ of consumptives which is thrown out by coughing with
+great exertion, is but scant in the beginning, as a rule phlegmy, glassy
+transparent and sticky. It is one of the suspicious symptoms of
+developing pulmonary consumption if this lasts for any greater length of
+time. Sometimes sharply defined, yellowish stripes, at times branching,
+appear in the same. Later on the expectoration becomes more purulent,
+and of greenish-yellow or greenish-gray color.
+
+Still later the patients throw out rounded lumps of greenish yellow or
+yellowish green color, which flatten out like a coin in the spittoon.
+They sink in water which is a sign of forboding evil.
+
+_Blood_ appears in different quantities in the sputum of consumptives.
+Bloody streaks are of no importance; they may appear with every violent
+cough. On the other hand the casting out of _pure blood_ is indeed
+serious.
+
+The _quantity_ of blood thrown out during an attack may be very
+different, varying from a few drops hardly a teaspoonful, to hundreds of
+grammes, even more than a liter. It is generally light red, filled with
+airbubbles, foamy, and is largely coughed out in coagulated lumps. The
+coughing of blood is sometimes preceded by a feeling of oppression,
+rushing of blood to the head and palpitation. Some patients experience a
+sweet taste in the mouth even before the bleeding. In many cases all
+preceding symptoms are missing and the patient is suddenly attacked by
+blood coughing during some more vigorous movement, during the exertion
+of coughing or even without any direct cause.
+
+_Blood coughing_ seems to appear somewhat more frequently with the
+_female_ sex than with the male and has with them unmistakable relations
+to menstruation, as with the sick it often sets in before, often after
+or even during the same and at such times more frequently than at
+others.
+
+It is of great importance for the layman to know that a hemorrhage
+rarely leads to inevitable death. Fatal hemorrhages are always preceded
+by warning attacks. Blood coughing may appear at any stage of
+consumption. In some cases it is particularly lasting. Sometimes the
+patients experience considerable relief from their feeling of oppression
+after a hemorrhage.
+
+A number of the consumptives as a rule complain of _difficulty_ in
+_deglutition_. This is caused by ulcers on the posterior wall of the
+larynx.
+
+With many patients the _appetite_ is _undisturbed_ for a long time, and
+there are consumptives that will eat a comparatively large dinner during
+an attack of fever reaching 40 deg. C. Generally the desire to eat
+disappears during the course of the disease, especially toward the end
+of the sickness.
+
+The _stool_ may be normal or costive, but is very often diarrhoetic.
+Twelve or more evacuations may take place during a day; as a rule they
+are much increased by gasses and are of bad odor. They weaken the
+patient very much and hasten the end.
+
+One of the most constant attendants during the course of consumption is
+the _Fever_. It is rather irregular. In cases of slow process the fever
+is often very insignificant; often it is only a state of general
+excitement that takes hold of the patient afternoons, slight dizziness,
+increased lustre of the eyes, slightly flushed appearance, somewhat
+increased pulse, which invites to test the temperature of the body by
+means of a thermometer, which by the way shows it to be about 38 deg. C.
+With quick consumption the fever is generally high.
+
+_Sweat_ is also a characteristic sign. The exceedingly debilitating
+effect of night-sweats is well known.
+
+During the course of pulmonary consumption extreme _emaciation_ of the
+patient is brought about. All tissues are subject to the same, most
+marked is the disappearance of adipose tissue. This symptom is of the
+greatest importance as a continued increase in weight means improvement
+and even cure. Therefore weighing the patient from time to time gives a
+sure meter for the course of the disease.
+
+The _course_ of pulmonary consumption is very different. With quick
+consumption the end comes within two or three months. Chronic pulmonary
+consumption may last for years. With this improvements in the fine
+season alternate with deterioration in the winter.
+
+Concerning the former _treatment_ of pulmonary consumption, this will
+also be applied in the future in the same manner as far as preventive
+means and general hygiene is referred to.
+
+For every one will prefer to remain exempt from consumption although it
+may now be possible to cure those afflicted. The lately published and
+popularly treated precautionary measures, especially with reference to
+the expectoration of consumptives retain their full value.
+
+Henceforth the sputum is also to be thrown in a _spittoon_ which is
+either entirely empty or on account of easier cleansing has the bottom
+covered with a thin layer of water. It should not be permitted to fill
+the spittoons with sand or sawdust as the tubercle bacilli can be easily
+thrown up with the dust.
+
+In the case of a _sudden attack_ of _cough_ a _cloth_ should be held to
+the mouth to hinder spreading of the fine spray, the same should also be
+used for wiping the mouth. However the cloth must soon be dampened and
+cleaned.
+
+As bits of the sputum easily stick to the _beard_ especially the
+moustache overhanging the lips, therefore lung consumptives are advised
+to wear a short or no beard.
+
+_Glasses_, _spoons_, etc. used by consumptives must only be used by
+other persons after a thorough cleaning with hot water.
+
+The lungdiseased person should abstain from all active and passive
+_kissing_, in unavoidable cases kissing should be done on the forehead
+or cheek only, or hold out those parts only to be kissed. In the same
+way he should avoid to touch objects with his mouth that may possible be
+put in the mouth by other persons, especially children, for instance
+toy-trumpets.
+
+In the case of _death_ from pulmonary consumption, the walls of all
+rooms and apartments used by the deceased should be rubbed down with
+fresh baked bread, which is a sure method of removing the bacilli. The
+bread crumbs that may have dropped on the floor may be removed by a
+thorough scrubbing with soap, brush and lye.
+
+Upholstered furniture, beds, clothes and wash should be cleaned in a
+disinfecting place.
+
+Do not wait with precautionary measures till some member of the family
+has been attacked by pulmonary consumption, but make preparation to
+prevent the infection while everybody is still sound and healthy.
+
+This care ought to begin in a measure with the _birth of a child_. The
+same should not be nursed by a mother with diseased lungs nor by a
+wet-nurse with like affections. Generally wet-nurses are only tested for
+syphilis; scrofula and tuberculosis receive altogether too little
+attention.
+
+An important precautionary measure consists in the supervision of the
+_food_. The abattoirs and dairies should be placed under the supervision
+of practical physicians, and the sale of products derived from
+tuberculous cattle be prohibited. This refers to the milk in the first
+instance. Tuberculous cows should be excluded from dairy-farms. Raw milk
+should be avoided as much as possible as boiled milk has the same value.
+
+The _meat inspection_ must be strictly conducted especially with
+reference to tuberculosis in the case of beef, pork and chickens. Sheep
+are not subject to tuberculosis.
+
+The _associations_ of children in school and on the play-ground should
+be watched; do not let them visit in strange families before making
+thorough investigation as to their sanitary relations.
+
+The health of _servant girls_ should receive greater attention than
+formerly, as the disease is often carried into the house by them as
+investigation has proven.
+
+In the _schools_ and kindergartens the teacher ought to insist that
+children do not spit on the floor or in the handkerchief; in case of
+necessity he should keep sick children out of school and he should
+especially follow these precautionary measures as regards his own
+person.
+
+The _cleaning of the floor_ of a room should always be done in a damp
+way.
+
+_Moving_ into another house it is advised to rub down the walls with
+fresh baked bread.
+
+As regards _societies_, every society and every health resort without
+exception and if possible every hospital should be obliged to have its
+own apparatus for disinfection and to make extensive use of it. Smaller
+societies may unite to procure an apparatus of the kind.
+
+Especial attention should be given to the _sprinkling of the streets_
+during the dry season.
+
+The state and the larger congregations should make it a point to
+maintain _institutions for consumptives_, beyond the city limits if
+possible, a healthy location in the country preferred.
+
+Every one individually protects himself best from consumption by a
+methodic habit of _washing with cold water_, cold rubbing and baths.
+River and sea baths are generally of excellent results; short shower
+baths with cool water lasting 20-40 seconds are to be applied later
+on; they do not only harden the skin but excite deep inhalations and
+exhalations and in that way act as gymnastics of the lungs. More direct
+is the action of muscular exercise, such as gymnastics, riding horseback
+or bicycle, driving, skating, rowing, etc. The carriage of children must
+be regulated, the drooping forward of their shoulders must be corrected
+by strengthening the muscles of the back and shoulders by means of
+dumbbell and other exercises.
+
+All this must still be observed in the future. On the other hand above
+all the numberless remedies will be dropped that have heretofore been
+applied as presumably specific remedies for consumption.
+
+Creosote, which was so much praised at its appearance a few years ago
+and still applied, because of the non-existence of a better remedy, will
+be dropped into obliteration and with it Guajacol which was just getting
+to be the "fashion".
+
+All the various inhalation methods that have matured in later years will
+disappear from the picture plane as far as this has not ever now
+happened.
+
+The medical remedies, which were given for the torturing cough, for
+hemorrhage of the lungs, sweats etc., will in most cases be superfluous
+after this. Hemorrhages will now and then still be experienced as the
+same may set in unexpectedly.
+
+The diatetic cures with whey, koumiss, grapes etc. will retain their
+importance and also the bathing resorts will be hunted up by patients as
+formerly.
+
+The owners also of special institutes for curing pulmonary consumption
+need not despair with the idea that they will not be needed in the
+future. On the contrary, those needing cure will flock to them in all
+the greater numbers, as they now know that they certainly will be
+restored to health within a definitely limited time.
+
+
+
+
+The other forms of Tuberculosis.
+
+
+Of the other forms of tuberculosis _laryngeal consumption_ is very often
+combined with pulmonary consumption. It is estimated that this is true
+of at least one-fourth of all cases of pulmonary consumption.
+
+At first laryngeal consumption can not in any way be distinguished from
+an ordinary inflammation of the larynx. A certain weakness and
+sensitiveness of the organs however is suspicious, also great liability
+to hoarseness. On the other hand laryngeal consumption may exist without
+any sort of ailing to the patient.
+
+These appear later, however, when lung tuberculosis is progressing. The
+larynx shows more distinct outlines on the lean throat, difficulty in
+swallowing is experienced, pains radiate toward the ear. Food and drinks
+come up again after being swallowed.
+
+The painful cough has a hollow, barking, harsh sound, provokes vomiting,
+and the sputum together with foul breath consists of foamy, slimy,
+purulent lumps. Breathing gradually becomes more difficult and louder.
+
+As regards the duration of laryngeal consumption it generally runs
+parallel with pulmonary consumption. If the latter progresses more
+rapidly so also will the destruction of the larynx by the
+tubercle-bacilli be a more rapid one and vice versa. In several cases it
+has been observed that, if pulmonary consumption progressed or remained
+without any extraordinary symptoms, those with diseased larynx have
+lived for years, with alternating improvements and diminutions, and also
+an occasional suspension of all symptoms, till on account of often only
+a trivial, evil influence a new stimulus is given and the disease found
+an unexpectedly rapid completion of its course.
+
+Until now only few cases of laryngeal consumption could be looked upon
+as really cured. Lately it has been tried to accomplish cures especially
+by the application of caustics. This will not now be necessary. But
+those afflicted in this way, will henceforth be obliged to try and live
+in air free from dust, to travel south during the winter and to subject
+themselves to a general strengthening treatment.
+
+_Tuberculosis_ of the _tongue_ is relatively very scarce. The individual
+in such a case nearly always shows pronounced pulmonary tuberculosis.
+Sometimes tuberculosis of the tongue is combined with tuberculous sores
+on the lips and also on the anus.
+
+Tongue tuberculosis forms small ulcers, generally on the rim, very
+seldomly on the back of the tongue. They always are very small,
+generally about the size of lentils or peas. They often remain unchanged
+for months. At times they are very painful, though as a rule the pain is
+mild. The male sex is attacked by tongue tuberculosis especially
+frequently.
+
+The treatment before this consisted in cutting out all the diseased
+parts; now it will be much simpler.
+
+_Nasal tuberculosis_ appears similar to the common stopping up of the
+nose. But when ulcers are formed, the secretions from the nose take on a
+purulent somewhat malodorous character. But if the affection is
+neglected, the secretion becomes bloody and of very bad odor.
+
+Until now nasal tuberculosis had been treated by applying caustics to
+the ulcerated portions.
+
+_Tuberculosis of the intestines_ or _intestinal consumption_ is
+especially found in _children_. The appearance of the same is already
+characteristic; the limbs are emaciated and withered; the old-looking
+wrinkled face shows a harsh contrast with the immoderately expanded body
+(frog-belly) which is caused by an accumulation of gases in the limp
+intestines which are then filled to bursting. Many such children have
+succumbed to gradually progressing emaciation and weakness.
+
+Probably it will not be possible to save all children in the future that
+have been stricken with this disease as many are wanting in sufficient
+vitality to resist all external influences.
+
+With adults intestinal consumption makes itself known by everlasting
+diarrhoea, a result of the numerous ulcers in the intestines which have
+been caused by the tubercle-bacilli.
+
+_Tuberculosis of the brain and of the cerebral membranes_ also attack
+children especially. Before this no attempts have been made to try
+whether it is now possible to cure the _tuberculous inflammation of the
+cerebral membranes_ which has previously been unconditionally fatal. The
+decision will certainly soon be made.
+
+We will give a fuller description of the symptoms of this disease to
+thus enable timely summons of medical interference. This disease will be
+known to many as "acute hydrocephalus."
+
+As a rule children of 2-7 years of age are attacked by this fearful
+disease. The antecedents are extremely peculiar and manifold. Even two
+or three weeks before the outbreak of the real sickness, emaciation
+takes place from which the face is strangely enough entirely exempt, so
+that children, when dressed show no signs of a change. Attentive mothers
+and nurses, however, regularly notice the same and especially the
+appearance of the ribs causes no little anxiety. With this a slight
+pallor of the face is associated and a peculiar lustre of the eyes. The
+children lose their former feeling of gayety and activity. They sleep
+more than usual, withdraw from their favorite game, they become grumbly
+and shy toward their surroundings and cry for the slightest reason. It
+also is very peculiar that they avoid trying their former little tricks,
+such as climbing up on chairs, opening of door bolts that are almost out
+of their reach, they even will not try to look through a latticed window
+and asked to do so, decidedly refuse. Boys, that would not stand
+anything from their associates, that fought and wrestled as long as
+their strength permitted it, sneak away cowardly and crying from such
+attacks. Other children again become extraordinarily tender-hearted and
+affectionate, they hug their parents continually and can hardly console
+themselves when they leave them.
+
+In the case of older children that have already learnt something,
+teachers notice unusual inattention and indifference, committing to
+memory comes harder than usual and what is finally learnt is recited in
+an awkward and stammering way. The children sleep unusually much and
+often by day; on the other hand their sleep at night is less sound and
+is interrupted by horrid dreams, frequent turning over in the bed and
+frequent clamorous outcries.
+
+The appetite is lessened, and often a craving is noticed for stimulating
+food of which, however, little is eaten. Thirst is not increased. Urinal
+secretion is somewhat diminished and the urine is characterized by a
+brick-colored precipitate. The stool is rather costive, especially with
+larger children; but diarrhoea may attend this disease. The latter is
+principally the case with small children that are in the stage of first
+teething.
+
+Headache is rarely felt and hardly ever complained of even by larger
+children; dizziness and unsteady walking is frequently observed. The
+children quite often complain of stomach-ache, which is very much
+increased by pressure on the abdomen.
+
+Fever is not generally attendant, but the same may be present.
+
+The symptoms just described, separately or collectively, gradually
+increase; the children finally take to their bed and now the _real
+cerebral affection_ developes.
+
+Now the principal symptoms are: vomiting, constipation, slow pulse,
+irregular abrupt breathing, increased temperature of the skin,
+contracted abdomen, headache, great excitement alternating with
+drowsiness, beginning decrease of reason, and deranged ability of moving
+the limbs.
+
+As regards _vomiting_, this is almost a continuous symptom and generally
+appears in the earlier stages. But the duration of vomiting is very
+different. Some children vomit only for one or more days and not all
+they have eaten, while others vomit continuously from the beginning of
+the disease till they are relieved by death, and no food can be found
+that is not thrown up shortly after its being eaten. In this connection
+it is a peculiar fact that vomiting will not recur if it has once ceased
+for twenty-four hours.
+
+Very important for the recognition of the disease is the manner of
+vomiting. For a child suffering from a spoiled stomach will be troubled
+with nausea, belching, choking and cold sweat long before it is forced
+to vomit, while children with acute hydrocephalus will throw up without
+any previous symptoms of that kind, just as though they filled the mouth
+with water and spit it out again. Vomiting is facilitated when children
+are raised or placed on their side. It ceases for the time the stomach
+is empty, but as soon as fluid or even solid food is taken in it will be
+cast out at once without causing any particular distress or
+inconvenience to the child. Gall is very rarely mixed with the vomit.
+
+A second and nearly as constant a symptom is _constipation_ from which
+nearly three-fourths of the diseased children suffer. As a rule
+cathartics have no effect and are generally thrown out through the
+mouth. This constipation will not last till the end, for a few pappy
+stools appear later on whether purgatives are administered or not.
+Violent diarrhoea resulting from intestinal tuberculosis may be
+discontinued at the beginning of acute hydrocephalus. But the later
+stools will again be thin and of cadaverous odor.
+
+During the latter stages of the disease children will often _fail to
+pass urine_ for twenty-four hours, so that the physician is obliged to
+draw it off with a catheter.
+
+The appetite does not disappear entirely as a rule. There may not be any
+desire for food, but generally little difficulty is experienced in
+inducing children to take milk or broth, which is all the more
+surprising as vomiting regularly follows.
+
+The _fever_ is generally not very intense. The temperature of the head,
+especially the forehead, is considerably increased in all cases and
+remains so until death ensues, while the feet have great tendency to
+getting cold.
+
+The _pulse_ is characteristic in many cases. In the beginning of the
+disease the pulse is quickened only to slacken after a few days. The
+number of beats may be reduced to 40-60 a minute (normal 90-100),
+however it does not commonly remain at a certain figure, but varies,
+often inside of an hour, so that at one time 40, then 60 and again 80
+beats may be counted inside of twenty-four hours.
+
+The pulse again increases 1-3 days before death and then to such a rate
+that it is almost impossible to count it. It may reach 180 and 200 beats
+a minute. As soon as this rate of the pulse follows one of the
+reductions described above a speedy death may be predicted.
+
+Of great importance are the variations in respiration. In the beginning
+stages of the disease breathing is normal except in such case where
+tuberculosis has made great progress in the lungs and in the case of
+high fever. Then of course breathing becomes more rapid. Acute
+hydrocephalus influences respiration in such a way that it slackens and
+becomes irregular. In one minute children may breath fifteen times, in
+another thirty, then again 20 times; at one time breathing may be very
+slight with almost invisible expansion of the chest and without any
+noise whatever, then again it may consist of deep sighs; these are also
+characteristic of this particular disease. Sometimes breathing is
+completely discontinued for ten seconds and more.
+
+If the pulse attains that extreme rate shortly before death the rate of
+breathing will also be increased.
+
+As regards the _skin_, the same is generally damp from the beginning of
+the disease; severe sweats are observed on the head; with progressing
+disease the skin becomes dry, brittle, comes off in flake-like scales
+and only when the death-predicting increase of the pulse sets in, there
+appears a profuse sweat, the cold sweat of death.
+
+_Headache_ is also a prominent and pretty nearly constant symptom. As
+has been mentioned before, it does not as a rule attend the precursory
+symptoms. It generally begins with vomiting and soon becomes so violent
+that older children constantly cry aloud and lament, while the smaller
+ones put their little hands up to their head, pull their hair and ears
+and restlessly roll about on the pillow.
+
+These expressions of pain last as long as children retain consciousness,
+a particular part of the head is not commonly pointed out, but asked
+about it the majority point to the forehead. With small children
+automatic movements are noticed that also seem to refer to headache, and
+which consist in rapidly placing the hand on the head and then drawing
+it back.
+
+The larger children complain of _pains in the bowels_, especially in the
+region of the stomach, which remarkably often, though not regularly,
+become more intense by pressing and may become so violent that the
+children cry out aloud with pain, when the stomach or other portion of
+the abdomen is but slightly touched. But these pains do not last as long
+as the headache, they often stop suddenly, at times return.
+
+The shape of the _abdomen_ is extraordinarily characteristic. In the
+beginning nothing remarkable can be noticed, but after the symptoms of
+acute hydrocephalus, vomiting, constipation, etc., have lasted for some
+time, the abdomen gradually decreases in size, becomes wrinkled and
+collapses until it finally assumes a scaphoid shape and by slight
+pressure the large iliac artery can be felt on the spinal column.
+
+This contraction of the abdomen is attendant in every case of
+tuberculous meningitis.
+
+If the large _fontanel_ on the head is not yet closed, the same will
+gradually bulge out as the disease progresses.
+
+The _mental activity_ suffers premature derangements, such as have been
+fully mentioned in the description of the precursory symptoms. The most
+striking is the confused, staring look, the peevish and surly behavior,
+and again in other cases the extreme indifference toward otherwise
+well-liked persons and things. Later on actual delirium sets in, but
+generally of a quiet nature.
+
+A very common symptom is a loud, plaintive outcry, that is repeated at
+longer or shorter intervals. Children often cry out at partly regular
+intervals during a whole night; these cries are always accompanied by a
+loud sigh. These symptoms of excitement being extremely tormenting and
+depressing for the sympathizing relatives, fortunately last no longer
+than 6-8 days at the most, and are succeeded by a deep _stupor_.
+
+If the children have once become _unconscious_, they do not recover
+again as a rule but remain so until death; delirium and stupor may
+alternate with each other in certain cases, but the former process is by
+far the most frequent.
+
+_Convulsions_ appear only in the later stages. At first the interval
+between the attacks are long, often as many as three or four days
+intervene. Commonly however they come much oftener and may in some cases
+last for hours. All extremities are affected by these convulsions, the
+eyes become red, are rolled in every direction and turning way up are
+fixed so that nothing but the whites is visible. After several minutes,
+often after two or three hours, these general convulsions subside, the
+children, now very pale, drop into a deep sleep and their general
+condition appears much reduced.
+
+Different muscular groups especially those of the face are subject to
+_local cramps_. The upper lip may become distorted, convulsive smiles
+have been observed, also peculiar sucking motions. The children point
+their lips and flatten them again, sometimes for hours in succession.
+
+In the latter stages a squinting of one or both eyes may be noticed but
+this may again disappear.
+
+_Grinding of the teeth_ is another very peculiar symptom which is
+well-known and feared by experienced nurses. The _arms_ are subject to
+various motions, at times sweeping automaton like, then again convulsive
+contractions, sometimes trembling of the muscles, at others a throbbing
+of the tendons. Many patients put their hands to their sexual organs and
+make motions tending to onanism.
+
+The _legs_ are not subject to cramps as much as the arms; they are
+mostly bent and drawn up in a half paralyzed condition.
+
+The _muscles of the neck and back_ are very much contracted and most
+children, when raised or laid on their side, bend the head far back.
+
+In most children an extreme sensibility at being touched is observed.
+They may be handled with the greatest possible care and lifted most
+tenderly, a slight pressure on the head, body or hands in changing their
+position will be violently resisted with obvious expressions of pain. In
+the latter stages this extreme sensibility gives way to _insensibility_.
+
+Then the children may be pinched and poked, they may be turned and moved
+from one side to the other without any consideration, they will not
+resist and only give expression to the remaining sensibility by a low
+whimper. The lack of sensibility may be especially marked in the eyes;
+these can be touched with the fingers, without causing a closing of the
+lids.
+
+The sense of _hearing_ seems to continue its functions until very late.
+Children show that they hear as long as they are not completely
+unconscious; even when addressed in a low tone of voice they react
+somewhat. The sense of _smell and taste_ also are lost toward the very
+end of the disease.
+
+_Paralytic_ affections appear during the final stages. It has been
+observed in some cases that the arm and limb are paralyzed on one side
+only. Often one upper eyelid is paralyzed and hangs down on one side of
+the face and the muscles of the tongue may be affected.
+
+Generally the patient dies after violent general convulsions that last
+for hours. Exceptionally only the paralytic symptoms increase gradually
+and cause death without any agony or struggle, simply a discontinuance
+of the functions constituting life.
+
+The duration of the disease varies from 2-4 weeks from the beginning of
+the characteristic symptoms. Generally the day when the children take to
+the bed is fixed as the beginning of the disease.
+
+The former methods of treatment have been a signal and absolute failure
+in every case. Every child that has once been attacked with this disease
+has heretofore died. Until now Koch has not been able to make any
+experiments with acute hydrocephalus, so that it remains an open
+question whether it is now possible to cure this disease.
+
+Besides tuberculosis of the cerebral membranes with which children are
+afflicted, _tuberculosis of the brain_ may occur, although this disease
+is very rare. Tuberculosis of the brain appears in the shape of small
+tumors in all parts of the brain. After longer duration of tuberculosis
+of the brain, tubercular meningitis appears.
+
+The process of this disease may be varied. In some cases the development
+of cerebral tuberculosis is manifested by the sudden appearance of high
+fever temperatures or violent headache; to this may be added,
+slackening of the pulse, vomiting, stiff neck and isolated cases of
+palsy; sometimes an attack of convulsions is the first manifestation.
+
+In other cases the beginning can not be accurately determined, as the
+beginning symptoms of the disease are so slight as to escape notice.
+Impaired process of nutrition, languor and headache are symptoms from
+which the existence of some serious affliction may be inferred without
+being able to determine its nature in the earlier stages.
+
+Again in other cases the disease may proceed through all its stages
+without any cerebral appearances whatever. This is especially true of
+small tubercles and of diseases of infants. However, we more frequently
+observe in children than in adults convulsions of varied intensity and
+distribution.
+
+Nutrition is more and more impaired as the disease progresses, in
+isolated cases only, a temporary improvement may be observed.
+
+The _end_ of cerebral tuberculosis has been _death_ before this. Ten
+days to two weeks, even three weeks may pass from the first appearance
+of tubercular meningitis to the completion of the process of the
+disease, attended by feverish motions characteristic of this condition
+and by cerebral symptoms, first with the character of excitement, later
+on with that of palsy.
+
+The treatment of cerebral tuberculosis has been entirely insufficient
+before this. Let us hope that it will be possible to effect a cure by
+means of Koch's new method.
+
+_Tuberculosis of the Kidneys_ is met with from the earliest childhood
+till old age. Most frequently the male sex is afflicted during manhood.
+
+In most cases tuberculosis also exists in other organs, especially in
+the urinary and sexual apparatus. The existence of pulmonary or
+intestinal tuberculosis is not essential.
+
+The symptoms of renal tuberculosis are of such general and indefinite
+character, that it is often impossible to fully determine the disease.
+Now, however, it will be more easily possible on account of Koch's
+discovery.
+
+The _urine_ may, but need not contain pus and blood. Sometimes small
+lumps are found in the urine.
+
+_Pains_ are only sometimes felt in the renal regions; _fever_ may be
+occasionally attendant.
+
+The disease lasts for months and years; though before now it has
+inevitably resulted in death, though it has in exceptional cases taken
+ten years or more.
+
+The internal treatment of renal tuberculosis was ineffectual, surgical
+treatment has been attended with greater success. This consisted in
+removing the diseased kidney. Now good results will possibly be attained
+by the application of Koch's method to cure and resource to surgery will
+be taken in exceptional cases only.
+
+_Tuberculosis of the suprarenal capsules_ is of very rare occurrence. It
+leads to a peculiar change in the color of the skin; the same turns dark
+brown or bronze color. Sooner or later death results.
+
+Perhaps the application of Koch's method will, besides curing the
+disease, give us information regarding the functions of the suprarenal
+capsules about which nothing whatever is as yet known.
+
+A large space in the realm of disease is claimed by _tuberculous
+affections of the bones and joints_. These afflictions appear
+particularly in childhood though manhood is by no means exempt. They may
+appear in all portions of the body, although a marked preference is
+shown for certain parts. Although the tubercle-bacilli are infinitely
+small, they possess the power to cause suppuration of the bones and
+joints and to produce acute inflammation of these parts.
+
+Most frequently tubercular affections of the bones are found in the
+hip-joints, the knee and the spinal column.
+
+_Tuberculous inflammation of the hip-joint_ is principally a disease
+occurring in childhood; though it rarely appears before the third year.
+It is most frequent from the fifth to the tenth year.
+
+Inflammation of the hip-joint developes very slowly in children, it
+generally takes months before the slightest beginning symptoms reach a
+threatening appearance. The first sign is _lameness_; among laymen
+tuberculous inflammation of the hip-joints is known as "voluntary
+limping."
+
+By limping we understand that mode of walking in which one leg is spared
+and by this the trunk is supported only a short time by one extremity
+and all the longer by the other. In every painful affection of the lower
+extremity limping results as the weight of the body increases the pain.
+The lameness in the case of diseased hip-joint has something peculiar
+about it, inasmuch as not only a part of the extremity but the whole of
+it is dragged. For this very reason parents of children afflicted with
+inflammation of the hip-joint use the expression "the child draws" or
+"drags the leg".
+
+In the beginning even the examining physician finds no symptoms of
+disease in the joint. No swelling, no abnormal position, no restriction
+of the freedom of motion, no pain from pressure or while moving, in
+short nothing can be found that would otherwise indicate the beginning
+of an inflammation of the joints.
+
+Yet _lameness only_ is sufficient data from which we may infer the
+probable beginning of hip-joint inflammation. It is much better to
+overestimate the significance of this symptom than to miss the proper
+time for calling in the aid of a physician by placing too little
+confidence on it.
+
+The second symptom, _pain_, rarely attends the beginning of lameness,
+generally it comes several weeks later and in the case of very slow
+development of tubercularly inflamed hip-joint several months later. In
+very small children the attendance of pain is manifested by the fact
+that they will not play and they often wake up in the night and begin to
+cry.
+
+Children from the fourth and fifth year upward definitely point out the
+hip as the seat of pain, sometimes, however, the knee-joint on the
+diseased side is designated with great determination. This pain in the
+knee has often been the cause of mistakes.
+
+Later on painfulness of the hip-joint is experienced from pressure and
+at about the same time the movements are impeded.
+
+Then the leg takes a peculiar position. The thigh is slightly bent and
+rolls outward. For convenience the child drops the half of the pelvis
+corresponding to the diseased hip-joint, and naturally raises the other
+half. From this apparently a curvature of the spinal column results in
+the lumbar region. Apparently only, for when the child is laid down and
+the morbid position of the thigh is restored the curvature of the lumbar
+column disappears.
+
+During the further progress of the disease the pain is increased, and
+the sensibility may become so acute that the slightest movement of the
+limb, even a shaking of the bed in which the patient lies will cause the
+most intense pain. In the previous stage walking could only be done for
+short distances and then awkwardly, now it is entirely impossible.
+Children are obliged to lie in bed night and day, and under these
+altered conditions there is a change of the position of the extremity.
+The increased sensibility induces the child to seek the medium position,
+the leg is bent more than in the position mentioned above, it is halfway
+straightened.
+
+To this is added, that the child can not lie well on the sensitive and
+swollen hip; with right side hip-joint inflammation it turns on the
+left. As the diseased and bent thigh does not then rest on the mattress
+the same is placed on the healthy limb for support and for protection
+from movements, in the same manner as we lay one leg on the other in a
+healthy condition when we sleep on our side.
+
+The actual danger to life in tuberculous hip-joint inflammation begins
+with the time when the child takes to his bed. The fatal end comes
+almost without exception after suppuration has commenced, very rarely
+before that time. Total suppuration of the hip-joint is an almost
+absolutely fatal process. If this suppuration sets in suddenly, it may
+result in an early death with attendance of acute fever. In other cases
+several weeks may elapse from beginning suppuration till death.
+
+A complete cure of tuberculous hip-joint inflammation may come about
+spontaneously. But often the knee remains bent and unserviceable for
+walking, so that crutches or machines must be used.
+
+Even before this the beginning stages were treated with fair prospects
+of success, and it is a lamentable fact that in many cases the import of
+these seemingly trivial symptoms has been underestimated.
+
+_Rest_ is of the greatest importance during the very first stages of the
+disease in which the attending symptoms are of so indefinite a character
+that it is almost impossible to know whether hip-joint inflammation will
+develop or not; the child must not be allowed to walk. Aside from this
+the application of brine-, malt- and sea-water baths is advised. An
+abundance of nourishing food is of just as great importance. All this
+will also retain its significance in the future.
+
+Formerly recourse to surgery has been taken during the later stages of
+the disease in which suppuration of the internal parts of the joint has
+commenced and large parts of the diseased bones may have become
+mortified. An incision is made into the joint, the same is exposed and
+all diseased portions are carefully removed. In the future this
+operation must probably also be performed, although with the difference
+that the prospects of success are now much more certain than formerly
+when relapses only too often followed the operation.
+
+_Tuberculous inflammation of the knee-joint_ is, as said before, very
+frequent with children and is rather lingering in the beginning. Here
+also a slight dragging or limping of the diseased leg can be noticed.
+The child when asked about the limping, or of its own accord, complains
+of pain in the joint after walking or when the part is pressed; at first
+nothing abnormal can be seen on the knee by the layman.
+
+On closer examination, however, by comparing the two knees it will be
+found that the grooves on each side of the patella, which give the
+healthy knee-joint the beautifully modeled shape, have nearly or quite
+disappeared; nothing more can be noticed.
+
+The hinderance in motion may be so insignificant, that the children may
+slightly limp about for weeks and months and complain but little.
+Generally the physician is not called until the limb begins to hurt and
+swell after continued exertion.
+
+The swelling which in the beginning is hardly noticeable is now more
+plainly visible, the knee-joint is evenly rounded and quite sensitive to
+pressure.
+
+If the disease is not now properly treated, its further course will be
+as follows: the patient may perhaps linger for several months; then
+comes a period when he must keep to his bed uninterruptedly because
+moving results in too much pain; generally the limb becomes more and
+more bent.
+
+Now particularly painful points appear on the joint, especially on the
+inner or outer side or in the bend of the knee; on one of these points a
+soft portion distinctly developes, the skin becomes reddened and finally
+suppurates from the internal parts outward and breaks after a few
+months; thin purulent matter mixed with flakes is discharged. The pains
+now cease, and the condition is improved; but this improvement does not
+last; soon another abscess is formed and thus it continues.
+
+Meanwhile perhaps two or three years may have elapsed; the general
+condition becomes greatly reduced. The child, formerly strong and
+healthy, has now become lean, the discharges of matter have often been
+attended by acute febrile attacks; the patient becomes exhausted, loses
+his appetite and digestion becomes more impaired from week to week. Even
+now a spontaneous change for the better is possible, though this happens
+very rarely; more frequently the disease progresses and leads to death
+from exhaustion resulting from severe suppuration and continual attacks
+of fever.
+
+Restoration to health is indicated by decreased suppurative discharges;
+the openings of the fistulae contract, the general condition is
+improved, the appetite is restored, etc. Finally the fistulae heal, the
+joint becomes fixed at an angle or bent or otherwise crippled, but
+painfulness disappears and the patient escapes with his life and a stiff
+leg. This is the most favorable result known to have been obtained in
+severe cases. The joint may become a solid bony immovable mass or may
+admit of slight movements. The whole process may last from two to four
+years.
+
+The former treatment of tuberculous inflammation of the knee-joint was
+either of a general or a local nature. The general treatment was
+designed to strengthen and nourish, and will continue to be applied in
+the future.
+
+The local treatment consisted in the application of salves, brushing
+with tincture of iodine, spanish fly plasters, wet and dry bandages. As
+with inflamed hip-joint absolute rest by lying in bed is of the greatest
+importance.
+
+If after a certain period of rest and application of the above-named
+remedies no improvement in the state of health could be noticed, the
+diseased joint was laid in plaster or confined with splints.
+
+If even then, after such treatment for months, no improvement could be
+noticed but rather that the general state of health was reduced, nothing
+remained to be done excepting an operation, by which all the diseased
+parts of the knee-joint were removed, or amputation, that is, the taking
+off of the diseased limb. The latter method was generally adopted in the
+case of feeble and emaciated individuals and those who had passed the
+age of early manhood, as with these the removal of the diseased parts
+did not, as a rule, result in an improvement of the general condition,
+which was especially intended.
+
+Now tuberculous inflammation of the knee-joint will be treated by Koch's
+method and in extreme cases only will operation be necessary. At all
+rates, an absolute cure will be easily effected.
+
+Aside from the hip- and knee-joint the _spinal column_ is most
+frequently attacked by tuberculosis. Here also it is the youthful age,
+from the third year upward, that has to suffer most from this serious
+disease. Adults are rarely attacked by it and with them it generally
+appears in connection with general tuberculosis.
+
+The tubercle-bacilli penetrate into the substance of the vertebrae,
+destroy the same and transform it into purulent matter. As a result the
+destroyed vertebrae sink or rather settle down and cause a curvature of
+the spine, in other words a humpback.
+
+In the beginning the symptoms of diseased spine are very indefinite and
+misleading. The patient rarely complains of pain at first, and it is
+only noticed that the sick child easily tires of standing or walking and
+tends to hold on to chairs and similar objects with his hands to relieve
+the spinal column of the weight. From such uncertain data it is of
+course impossible to recognize the disease.
+
+Only then when the softened vertebrae give way under the weight of the
+body, that is when the humpback begins to develop, can tuberculous
+inflammation of the spine be surmised with any degree of certainty.
+
+As a rule two other characteristic phenomena appear which are dependent
+on the pain in the affected spinal column. The child, while standing,
+places his hand on the thighs and thus directly supports part of the
+weight of the trunk with the lower extremities; at the same time he
+avoids bending the spinal column forward. This anxious care for the
+diseased vertebrae is especially noticeable when the child attempts to
+pick up an object from the floor. While the healthy child bends freely
+forward, the sick one crouches down and while bending the knee and hip
+keeps the spinal column as straight and stiff as possible. Frequently a
+small spot on the spinal column is found to be extremely sensitive to
+pressure in this stage; but such a subjective symptom must be considered
+with caution especially with children.
+
+This humpback, which is a result of tuberculous inflammation of the
+spine, must not be confounded with the humpback caused by rickets. With
+the latter the curvature is more uniform as a rule, and in the start at
+least, disappears while in a horizontal position. Besides the humpback
+resulting from rickets appears between the first and fourth years of
+age, while tuberculous inflammation of the spine rarely begins before
+the fourth year. And finally rickets never causes suppuration while this
+is always the case with inflammation of the spine.
+
+The progress of suppuration is downward as a rule and does not admit of
+examination until it gets near to the surface of the body; before this
+the feverish conditions toward evening are the only signs that indicate
+beginning suppuration. Ardent fever is not attendant during this time;
+the temperature does not exceed 38 or 38.6 deg. C. and even such trifling
+increase of temperature may be wanting.
+
+As soon as the skin is reached by the originally deepseated centres of
+suppuration, it gradually becomes red and later on also suppurated. If
+the skin is broken and the matter discharged, great care must be taken
+to keep the wound clean, as otherwise the suppurative cavities may
+suddenly become ichorous and lead to rapid death. In other cases this
+extreme result is not caused and fistulae are formed from which the
+ichor constantly flows. Small bits of mortified and broken off bones may
+be thrown out with the matter.
+
+As a result of the sinking and settling of the vertebrae the spinal
+chord may suffer from pressure and contusion as it is contained in a
+channel formed by the vertebrae. Aside from certain pain it may result
+in paralysis of certain parts.
+
+Formerly the diagnosis of tuberculous inflammation of the spine in its
+beginning stages was very uncertain. A great number of afflicted are at
+present cured by surgical treatment; in former times this was not
+possible, as the majority of patients died in whose case the disease had
+progressed to suppuration. But the curvature of the spine could not be
+removed by any former treatment and can not be by Koch's new method.
+Vertebrae once destroyed can in no way be restored to their normal
+condition.
+
+Nevertheless the number of patients whose life is spared will be a still
+greater one and the number of complete cures will also be increased in a
+short time. Formerly tuberculous inflammation of the spine was treated
+as follows: the abscesses were opened and antiseptics carefully applied:
+mechanical apparatus and corsets were used to aid in a natural cure.
+These apparatus will surely be of inestimable value at the application
+of Koch's method.
+
+As has been stated before tuberculosis may attack all other bones and
+joints and there cause the most serious derangement. Formerly these
+tuberculous afflictions were treated surgically or by means of iodoform,
+which has produced pretty good results in certain cases.
+
+However it will certainly be possible to produce still better results
+with Koch's method of treatment, especially in the restoration of the
+functions of the afflicted parts. Here, as in all tuberculous
+affections, it is particularly essential to subject the respective case
+to treatment in as early a stage as possible and before incurable
+destruction of the tissues of the bones and joints have been caused.
+
+A certain disease of the skin called _lupus_ (ringworm) must be counted
+in with the number of diseases generated by the tubercle-bacillus.
+
+Lupus may begin in two different ways. Either in the form of a purple
+spot, which is raised above the level of the skin and which has no
+definite limits but blends with the healthy parts; or as a slightly
+raised, moderately firm, darkred grain, sharply limited and about the
+size of a pinhead or millet seed.
+
+If the disease has begun in the shape of spots, the afflicted portions
+of the skin gradually swell during the process of the disease. Several
+isolated knots appear around which the disease spreads more and more.
+
+While the disease thus takes possession of greater area and developes
+new centers, a uniform scaling off of all knots begins.
+
+After prolonged existence, sometimes after short duration, decay and
+casting off of the epidermis in its entire thickness supercedes the
+scaling process, and suppuration transforms the ringworm into an ulcer
+covered by a dirty-brown rind and disagreeably colored serum.
+
+The ulcers of lupus are of various, generally irregular shape, the rims
+not hard, the ground flat and covered with purulent matter and decayed
+tissue; they are commonly surrounded by a faint reddish areola. These
+ulcers gradually become epulotic and form irregular, generally slightly
+protruding white scars in which new tubercles may appear.
+
+Lupus appears most frequently in the face and especially frequent on the
+nose. Sometimes its appearance is indicated only by an inflammation and
+swelling of the mucous membranes of the nose and at the same time a
+reddening of the epidermis. The nostrils are stopped up by a thin rind
+which, if torn off, is replaced by a thicker one below which an ulcer is
+formed that spreads with greater rapidity on the mucous membranes of the
+nose than on the external epidermis of the same.
+
+Sometimes the whole process on the nose is so rapid, that very often the
+physician is not called to the patient, before a large part of the wing
+of the nose or of the nasal epidermis is destroyed and deep ulcers have
+developed under the rind. New tubercles of lupus are commonly noticed to
+spring up on the margins of these ulcers; the cartilage as a rule
+resists the progress of the disease for a longer period and may be
+unhurt, while the skin on the wing of the nose may be completely
+destroyed.
+
+Frequently the process is extended to the mucous lining of the hard
+palate and to the gums. Lupus generally appears on the lips in the same
+manner as in the nose. The upper lip especially appears very much
+swollen and covered with ulcers after a prolonged existence of the
+affection. Sometimes even the aperture of the mouth itself is reduced in
+size by the development of ulcers and scars on the surrounding parts.
+
+If the process extends to the lower eyelid, the connective tissue as a
+rule becomes much swollen and reddened. The malady especially attacks
+the inner angle of the eye, destroys the entrance of the lachrymal duct,
+and from there the lupous tubercles appear on the connective tissue.
+Gradually tubercular formations develop on the cornea and sight becomes
+impaired.
+
+On other parts of the face lupus generally appears in the form of small
+knots, about the size of millet seeds, which remain for a time then
+multiply and spread. The epidermis swells between these knots and
+irregular ulcers develop on a hard swollen and glossy ground, and are
+covered by dark brown rinds.
+
+Tubercles appear anew on the margins of the ulcers and in the spaces
+between them, isolated whitish spots of sunken or raised scab tissue are
+observed on which very frequently lupous tubercles again develop.
+
+Lupus appears on the throat, neck, back, breast, and the extremities,
+most frequently in serpentine form i. e. swellings of the skin develop,
+being arranged in curves, they progress in the same manner, these are
+transformed into just so many ulcers. Between these whitish scarred
+spots are noticeable on which small red lupous tubercles again appear.
+
+Lupus is more frequently found on the extremities than on the trunk. The
+surface of the skin is found to be tense and glossy on a firm base which
+is affected by lupus.
+
+Deep ulcerous formations of lupus are sometimes observed on the fingers
+and toes, particularly on the finger-joints, these may at times
+penetrate into the inner parts of the joints, secreting whitish pus and
+covered with a thick rind.
+
+As regards the difference between lupus and syphilitic diseases it has
+been found that lupus commonly developes before puberty while syphilis
+appears in the mature age.
+
+The ulcers of lupus are often round like those of syphilis with sharply
+defined margins, but at the same time they are flat accompanied by
+little or no pain; rim and base of the same are loose, red, rank, and
+bleed easily. On the other hand syphilitic ulcers are very painful and
+rim and base are covered with greasy matter.
+
+Lupus appears only in the form of knots, which are deeply inbedded, from
+size of a pinhead to that of a lentil, but never as large knots in the
+beginning. Syphilis produces large and palpable knots from the start.
+
+Loss of the bony part of the nose or destruction of the hard palate are
+observed, but rarely and after protracted existence of lupus, and often
+in the case of syphilis.
+
+The indicated peculiarities however refer only to typical cases of lupus
+and of syphilis. In other cases it was almost impossible to show a
+difference.
+
+As regards the course of lupus, the same begins, as has been stated
+before, in earliest childhood, sometimes only in the form of scaly spots
+and knots. Less often lupus developes after complete development of
+manhood. It is more frequent with women than with men. Sometimes some of
+the knots remain isolated and disappear again after a time; in other
+cases additions appear in the course of time, which may affect larger
+portions of the body and lead to more or less dangerous ulcers. As a
+rule the course of lupus, even of great extent, is not malignant and at
+the most the alliance with _traumatic erysipelas_ and possibly the
+appearance of _pulmonary consumption_ may succeed the affliction. In
+cases of not too rare occurrence it has been observed that lupus has
+developed into _cancer_, which has always resulted fatally.
+
+The _treatment_ of lupus has principally been a _local_ one. Caustics
+were applied to destroy lupous tubercles by direct action, and
+furthermore recourse has been taken to the so-called mechanical
+treatment, in which the ringworm was scraped out.
+
+Our experiences relating to the mechanical treatment of lupus have
+taught us the following.
+
+Lupus can not be cured without destroying and removing the diseased and
+affected tissue. That method which effects the most radical destruction,
+protects most from relapses. Therefore the best method of treating lupus
+is to cut out the diseased skin. But with the superficial spreading
+peculiar to many cases of lupus this method can only be applied within
+certain limits. Then again the secondary growths after an operation may
+be of serious consequences.
+
+Unfortunately it has not been possible before this to remove all
+diseased portions, no matter what method was applied, because often tiny
+lupous tubercles spring up which are almost invisible to the naked eye.
+These tubercles will again be the starting point for another spreading
+of lupus.
+
+We will see that Koch's new method to cure has the advantage both to
+make visible all tubercles, even those that have escaped our notice and
+also to effect a cure in the shortest time even in old chronic cases
+that have before this been considered incurable. It is especially
+possible in this form of tuberculosis to follow the specific action of
+the new remedy, as we will learn later on.
+
+_Tuberculosis of the testicles_ is not so very rare, it is found in
+about 2-1/2 per cent. of all men afflicted with pulmonary consumption.
+It is more rarely met with in children than in men.
+
+The conditions under which tuberculosis of the testicles and epididymis
+developes are various inflammatory processes with existing disposition.
+It is mostly gonorrhea or some other inflammation of the urethra, or
+injured testicle. It occurs less frequently without any apparent cause.
+
+According to the starting point of tuberculosis the symptoms are varied.
+If it starts in the testicle, this appears normal or larger in size, but
+never reaches extraordinary dimensions. The surface of the testicle is
+at first smooth in the case of increased tension, later only does it
+become irregular, bumpy and of unequal consistency.
+
+If the starting point is in the epididymis, hard, rounded lumps are
+formed generally in the head or tail of the epididymis, rarely in the
+body. These increase in size and cause a swelling often of extraordinary
+dimensions, the surface of which appears hard, irregular, bumpy and in
+certain parts yielding and elastic. If the process is extended to the
+testicle, this also increases in size. Then both together form an oval
+swollen mass and can not be distinguished from each other.
+
+Striking changes appear only later and consist in the softening of the
+lumps and in the development of abscesses.
+
+Very soon the lobuli are affected. The same are then thickened in the
+septa, are hard and form an irregular, bumpy swelling surrounded by more
+or less thickened tissue.
+
+Very soon tuberculous changes are caused in the prostate gland, an organ
+situated near the intestine and the functions of which are to dilute the
+semen. A hardening is often the first sign, this is followed by
+increase in size and then softening.
+
+With the affection of the prostate gland, that of the urethra also
+begins, which passes through the middle of the prostate gland. This
+disease often appears in the form of a yellowish secretion, which is
+more and more increased and becomes ichorous with the decay of the
+urethra and the prostate gland. This secretion must be distinguished
+from that which as a venereal affection caused the whole process. The
+tubercular derangements do not only extend forward but also upward. The
+bladder, the ureters and the kidneys are affected and show extreme
+derangements with altered urinal secretions and excretions.
+
+Of other symptoms of tuberculosis of the testicles pain deserves
+especial mention. The same is slight in the beginning, but often becomes
+insufferable.
+
+The symptoms here related often increase very slowly. Essential changes
+are caused during the chronic course of tuberculosis of the testicles if
+suppuration sets in. The skin is perforated and fistulae are formed. If
+there is no halt in the process, general tuberculosis results and this
+has until now always caused death.
+
+According to the time in which the general derangements come about, a
+chronic and acute tuberculosis of the testicles has been distinguished.
+The former is the more frequent, the latter of rare occurrence.
+
+The sexual functions may remain unchanged if only one testicle is
+diseased, but are generally ruined if both epididymes are affected,
+because the secretion of the semen is then interrupted by the stopping
+up of the vas deferens. In some cases the sexual function may be
+interrupted for a time only and may then be resumed.
+
+The treatment before this has been surgical, in which the diseased parts
+were carefully removed, and where this was impossible, even castration
+(removal of the testicle) was performed. Without doubt Koch's method
+will cause great changes in the method of treatment here also.
+
+Finally we must include in our reflection the well-known disease of
+children, _scrofula_. Although the same is not a form of tuberculosis in
+the sense of the diseases just considered, still tuberculosis and
+scrofula have the most intimate relations. Scrofula is only too often a
+precursory stage of tuberculosis.
+
+The manifold scrofulous affections, such as inflamed eyes, diseased
+ears, skin diseases, catarrh of the nose, pharynx or bronchials,
+inflammation of the joints and suppuration are not caused through the
+cooperation of tubercle-bacilli. But here the same find an excellent
+soil for growth and propagation, and they use the same to the full
+extent and so give the impetus for the development of tuberculosis.
+
+Scrofula is one of the most frequent diseases, it is spread over the
+whole world. It occurs more seldom in the tropics than in the north.
+Furthermore it is more frequent in a cold and damp climate than in a dry
+one. Elevation has no influence on the development of this disease.
+Scrofulous individuals are found in the mountains as well as in the
+plains.
+
+Scrofula principally attacks children; it occurs most frequently in the
+time from the second to the fifteenth year. Rarely earlier developed
+scrofula drags beyond the age of puberty or more advanced manhood. Sex
+has no particular influence on the development of scrofula.
+
+In many cases this particular disease is _inherited_. The following
+causes are considered in the inheritance of scrofula: great age, close
+relationship and infirmity of the parents; but the germ of scrofula is
+planted in the child by parents that are themselves afflicted with
+tuberculosis or scrofula. This is most frequently observed in children
+that have descended from parents, who were scrofulous in their youth and
+remained so, or that became tuberculous later on and at the time of
+generation were afflicted by advanced scrofula or tuberculosis, or that
+were suffering from oft-treated but never entirely cured syphilis. Some
+scientists claim to have observed the inheritance of scrofula by
+children, whose parents at the time of generation were afflicted with
+tuberculosis or were suffering from general debility resulting from
+hunger and want.
+
+In the majority of cases scrofula is acquired, as a rule the development
+of this disease is favored by indigence and poor hygienic conditions
+according to the coinciding experience of all scientists; _nutrition_,
+especially in the first year of life, has the greatest influence on the
+origin of scrofula.
+
+In _infancy_ the most frequent cause of scrofula is the premature giving
+of _farinaceous_ food besides the mother's milk, or the feeding of
+children with so-called pap, especially when this is done in the _first
+month of their life_.
+
+In later months the excessive eating of bread, potatoes or vegetables
+instead of milk has an injurious effect.
+
+Furthermore the development of scrofula is favored by the breathing of
+_foul damp air_ such as is frequently found in newly built or damp
+houses and also by _deficient care of the skin_.
+
+Scrofula thrives in the narrow tenement dwellings in which is found a
+close, overheated, foul air pregnant with smoke, kitchen fumes and
+mustiness from the damp walls.
+
+Frequently the development of scrofula has been observed to succeed
+measles, diphtheria, scarlatina or whooping-cough.
+
+The opponents of vaccination also designate vaccination as a frequent
+cause of scrofula. It is supposed that a poison is transferred into the
+system with the lymph which is enabled to generate the phenomena of
+scrofula. However the supposition has not as yet been proven.
+
+Of course the fact cannot be denied, that cases of developing scrofula
+have been at times observed as succeeding vaccination. But the
+circumstances are the same as in the case of the contagious diseases
+mentioned above. No one will probably maintain that in those cases in
+which the development of scrofula had been succeeding those diseases,
+that this has resulted from a poison generated by the preceding disease.
+
+The attempt to designate symptoms by which to recognize a scrofulous
+constitution has at all times been made. Many physicians have for a long
+time distinguished a _torpid_ and an _erethistic_ scrofulous
+constitution.
+
+With a _torpid_ constitution the body is pale, spongy and bloated, the
+nose and lips are thick, the abdomen swelled, there is plenty of fat and
+but weak muscles. Such children are indolent, at times peevish and
+indifferent, they do not sleep quietly, have no appetite or may be
+voracious and suffer from derangements of digestion. An examination of
+all organs indicates no change. The children are easily afflicted with
+eruptions of the skin, with inflammation of the eyes and ears, and
+catarrh of the mucous membranes, which are characterized by great
+obstinacy. The derangements in nutrition here described are caused by
+the lymphatic glands though a swelling of the same can not be found.
+
+In the case of _erethistic_ scrofula the children are found to be of
+slight and lean structure, with fine hair and long eyelashes; they are
+active, easily excited, gifted and extremely sensitive to physical pain.
+The face is pale and becomes easily flushed by physical or emotional
+excitements. They are easily subject to palpitation and short breath;
+and are attacked by high fevers from the slightest reason. The lymphatic
+glands, especially the deepseated ones, are as a rule more or less
+swelled.
+
+In most cases, however, the characteristics of these two forms are
+blended.
+
+The phenomena of scrofula are manifold and extend over the entire body.
+
+The _skin_ is frequently the seat of scrofulous affections. These are
+particularly found on the head and face and are characterized by great
+obstinacy and tendency to return.
+
+Most frequently herpes appear, the parts especially affected are the
+scalp, face, auricular passages, eyelids and the nose with its
+surrounding parts.
+
+Pustules are sometimes developed under the skin and may appear in great
+numbers. These pustules may either break through the skin or shrink into
+a caseous mass.
+
+Of all _mucous membranes_ that of the _nose_ becomes most frequently
+diseased; in a great number of cases this happens in the form of a
+chronic catarrh; the mucous membrane of the nose is reddened and swollen
+and a profuse, thick, purulent, ichorous and easily drying fluid is
+secreted. Often the external parts of the nose are swollen as a result
+of the catarrh and the nostrils are stopped up with thick
+yellowish-green rinds. Inflammation of the skin is caused by the flowing
+out of the purulent and ichorous liquid secreted.
+
+In many other cases the disease appears in the form of scrofulous ulcers
+on the mucous membranes of the nose; in such cases it is found that the
+nose is stopped up with numerous yellowish brown crusts; after removing
+the same the mucous membrane appears swollen and moderately reddened, on
+several places ulcers, the size of lentils, are found which are covered
+with a yellowish gray coating. At the slightest touch bleeding of the
+nose is caused; often also the external parts are reddened and swollen.
+In such cases erysipelas frequently developes, starting from the nose
+and spreading over the whole face. Frequently a repetition of erysipelas
+occurs.
+
+The scrofulous catarrh just described is generally of a very protracted
+nature and is marked by many relapses. Sometimes the fluid secretion of
+the nose is of very bad odor.
+
+The mucous membrane of the _throat_ becomes diseased at the same time as
+that of the nose. The same is found to be moderately reddened and
+swollen; the lymphatic glands especially those on the posterior wall of
+the throat are increased to swellings the size as large as peas. The
+_tonsils_ also become inflamed frequently and become enlarged through
+the repeated rather chronic inflammation.
+
+_Inflammations of the ear_ are a common occurrence with scrofula. These
+originate most frequently by means of the eustachian tube, which
+connects the ear with the back part of the mouth as a result of the
+catarrh of the nose and throat. In a majority of cases the inflammations
+of the ears lead to perforation of the tympanum and may even result in
+fatal cerebral meningitis.
+
+The _eye_ is as frequently affected by scrofula. Swelling of the lids
+and inflammation of the glands are the lighter forms. Pustules on the
+connective tissue of the eye and on the cornea, accompanied by
+photophobia, cramp in the lids and flowing of tears are those severe
+forms that are so frequently observed in scrofula, and that often leave
+opaque and incurable spots on the cornea of the eye.
+
+Swelling of the _glands_ has at all times been a characteristic
+phenomenon of scrofula. A swelling is merely the result of diseases of
+the mucous membrane of the throat or nose, of herpes of the scalp or
+face, of inflammations of the ears, eyes, periosteum, bones, etc. In the
+beginning the swelling of the glands is painless and results in flat
+swellings of about the size of filberts, which may be moved back and
+forth; such glandular swellings may exist for years, without showing the
+slightest alterations.
+
+With renewed attacks they enlarge and may become of considerable size.
+At times single glands become inflamed, hurt when pressed and develop
+abscesses which perforate the skin after it has become inflamed and
+reddened.
+
+These abscesses may heal within a few days. In the majority of cases,
+however, they remain for a longer period, months and even years and
+result in the well-known tumid, hard and immovable scars.
+
+Inflammation of the periosteum and of the bones is one of the instances
+of scrofula. Most frequently _spina ventosa_ is found; the same consists
+of a gradual, painless swelling of the diseased bones, most frequently
+on the fingers and toes, so that they become bottle-shaped. The skin
+covering these swellings is pale and tense. The swelling may gradually
+disappear or begin to suppurate. Besides this hip- and knee-joint
+inflammation are observed, also inflammations of the ankle, elbow-joint,
+spine, etc.; especially in the case of diseased bones it is extremely
+difficult to fix a dividing line between scrofula and tuberculosis.
+
+The frequence of anaemia with scrofula is only a _result_ of the disease
+and not a symptom. As a result of scrofula nutrition and assimilation
+become impaired, mostly in the cases of extreme suppuration.
+
+Scrofula is a chronic disease. In many cases it is completely cured, the
+lighter cases after several months and the more malignant after several
+years. Extreme scrofula may often remain until puberty and may be
+completely healed.
+
+_Fatal_ results are due to scrofulously diseased bones, joints or
+glands, and it can not be denied that a large number of children succumb
+in this manner. Fatal results may also be due to additional diseases,
+such as pneumonia, pleurisy, intestinal catarrh, etc.
+
+It has been frequently observed that _tuberculosis_ succeeds scrofula.
+It is a well-known fact that scrofula furnishes the largest contingent
+for tuberculosis.
+
+As a precautionary measure against scrofula a careful regulation of the
+diet is recommended. During the first nine months of life children
+should be fed with human milk exclusively if possible. If scrofula is
+hereditary in a family, or if the mother exhibits symptoms of the
+disease, she should not be allowed to nurse the child but a strong and
+healthy nurse should be engaged. Recourse to artificial nourishment must
+only then be taken, when nursing the child is absolutely impossible. For
+this purpose exceptionally pure cow's-milk ought to be selected. All
+substitutes, that appear under various names, such as infant's food,
+condensed milk, etc., contribute much toward the development of
+scrofula.
+
+Children 1-2 years of age are to be fed with milk, meat and eggs. Only
+strong children, that show no sign of scrofula may be fed once or twice
+a day with small quantities of rice, tapioca, sago, green vegetables,
+pulse, etc., beside the food above mentioned.
+
+To prevent scrofula it is essential not to give the food of adults to
+children during the first years of life; avoid exclusively solid food
+and prepare the same in a pappy form as much as possible. Of course a
+proper regulation of meal-time and a careful avoidance of overfeeding is
+by all means to be observed.
+
+It is of no less importance for a successful treatment of scrofula to
+provide surroundings of as favorable conditions as possible.
+
+First of all _pure air_ containing plenty of _oxygen_. Therefore the
+_sea-coast_ is recommended as a proper place for scrofulous children.
+The children ought to stay there until the signs of scrofula have
+disappeared and the entire nutrition has been improved. The results
+obtained in the sanitary stations (vacation colonies) along the
+sea-shore for scrofulous children have received much favorable comment.
+
+_Mountain air_ has a similarly favorable effect especially when _salt
+water baths_ are used at the same time; even the plain, pure _country
+air_ proves beneficial to scrofulous children. _Very dry_ locations and
+dwellings ought to be selected. The children should remain _out of
+doors_ as much as possible.
+
+Of great importance for scrofulous children, furthermore, is a suitable
+course in _gymnastics and rubbing-down with cold water_. To begin with
+the water may be 72 deg. but should gradually be reduced to the natural
+temperature of well water.
+
+Just how far Koch's new method will take the place of former remedies
+used for scrofula can not be told at present as experiments in this
+direction are wanting. Nevertheless it will be possible to prevent the
+dangerous transition of scrofula into tuberculosis and thus save the
+lives of a great many persons.
+
+Anyone who has informed himself through the foregoing as to the great
+number of diseases and forms of disease that are directly or indirectly
+connected with tuberculosis, will now be able to estimate the
+farreaching import of Koch's discovery. It will now be clear to him that
+pulmonary consumption constitutes only a part, although a great part of
+tuberculosis and that there are a great many diseases besides that can
+now be surely cured, it is hoped, with the aid of Koch's method. But
+this much should be remembered by everyone that this remedy also acts
+best and surest during the _beginning_ of a disease. We hope that no one
+will allow valuable time to slip unimproved; it may easily happen that
+it is too late for successful treatment. Everyone will be able to
+recognize the symptoms of diseases, which Koch has taught to cure, from
+the foregoing complete description, and it is better to apply the remedy
+once too often than miss the proper time for application.
+
+Koch's first communications relating to the subject have just been
+published and will be given unabridged in the following pages. As these
+communications are written for physicians we will add such explanatory
+notes as are deemed essential for general intelligence.
+
+[Illustration: DR. KOCH IN HIS LABORATORY]
+
+
+
+
+THE FIRST COMMUNICATION
+
+_Relating to a Method to Cure_
+
+TUBERCULOSIS,
+
+BY
+
+Prof. R. KOCH, Berlin.
+
+
+In a lecture, delivered by me several months ago, at the International
+Medical Congress, I referred to a remedy, which makes animal subjects
+impervious to the inoculation of Tubercle-bacilli, and in the case of
+diseased animals, checks the progress of the tuberculous disease. In the
+meantime experiments have been made with human subjects, about which I
+will report in the following.
+
+Originally I intended to complete my investigations and especially gain
+sufficient experience concerning the practical application of the remedy
+and its production on a larger scale before I published anything
+concerning it. In spite of all precautions too much has already been
+published about it, and that distorted and exaggerated, so that I was
+obliged, in a way, to prevent false conceptions, to give even now a
+synopsis of the method as far as it has progressed at the time being.
+Under present circumstances it must necessarily be short and leave
+unanswered many important questions.
+
+The experiments have been, and are still being made under my direction
+by Dr. A. Libbertz and Stabsarzt Dr. E. Pfuhl. The necessary subjects
+and material have been provided by Prof. Brieger from his Polyclinic,
+Dr. W. Levy in his Private Surgical Clinic, Geheimrath Fraentzel and
+Oberstabsarzt R. Koehler in the Charite-Hospital, and Geheimrath Herr
+v. Bergmann in the Surgical University Clinic. To all these gentlemen
+and their assistants I here tender my heartfelt thanks for their
+untiring interest which they manifested for this subject and also for
+the disinterested help and aid which they have offered at all times and
+without which it would have been impossible for me to make such progress
+in a few months in this difficult and responsible investigation.
+
+As my work is far from being completed, I can not as yet make any
+statements relating to the origin and preparation of this remedy and
+reserve these for some future time.[1]
+
+The curative is composed of a clear brown fluid, which in itself is not
+perishable, even without special precautionary measures. For use this
+fluid must be more or less diluted and these dilutions are perishable
+when made with distilled water; Bacterian vegetation soon develops in
+them and they become turbid and are no longer fit for use. To prevent
+this the dilutions must be sterilized through heat and be kept under
+cotton batting or be prepared with a 5 per cent. phenol solution which
+is much simpler. Through repeated heating as also through the mixture
+with the phenol the efficiency of the diluted solution appears to be
+curtailed after a time and for that reason I have always used solutions
+as fresh as possible.
+
+The remedy does not act through the stomach; to effect a reliable action
+it must be applied subcutaneously. For our experiments we have
+exclusively used a syringe decided upon by myself for bacteriological
+purposes, which is supplied with a small india-rubber ball and which has
+no stamp. Such a syringe can be easily kept positively aseptic by
+rinsing with absolutely pure alcohol and on this we base the fact that
+not a single abscess has sprung from over a thousand injections.
+
+After trying various parts of the body as places for application we
+selected the skin of the back between the shoulderblades and in the
+lumbar region, because at these places the injection was almost painless
+and caused the least and in most cases no local reaction.
+
+Even at the beginning of our experiments we found that in one
+particularly important point the human subject was affected by the
+curative in a way decidedly differing from that of the animal subject
+generally used, the guinea pig. Therefore another confirmation of the
+rule for experimentors upon which hardly enough stress can be laid, not
+to rely upon a like effect upon the human being from the experiments on
+the animal without further confirmatory inquiry.
+
+Man proved himself much more sensitive to the effects of the remedy than
+the guinea pig. Up to two cubic centimeters and even more of the
+undiluted fluid could be injected under the skin of a healthy guinea pig
+without causing any particularly disparaging effect. In the case of a
+fullgrown man on the other hand, 25 ccm. are sufficient to produce
+intense results. In proportion to weight of body therefore 1/1500 of the
+amount which has no noticeable effect on the guinea pig has a decidedly
+strong effect on the man.
+
+From an injection that I have made on my upper arm I have experienced
+the symptoms which arise in man after an injection of 25 ccm., in short
+they were the following: Three or four hours after the injection a
+raking pain in the joints, languor, inclination to cough, oppressed
+breathing, which rapidly increased; in the fifth hour I experienced
+intense chills which lasted nearly an hour, at the same time nausea,
+vomiting, increase of the temperature of the body to 39.6 deg. C. After
+about 12 hours all these affectations ceased. The temperature sank and
+reached the normal height the next day. Heaviness of the limbs and
+languor lasted for a few more days, and for the same length of time the
+place of injection remained red and painful.
+
+The lower limit of effect of the curative for a healthy man is about
+.01 ccm. (= 1 cubic centimeter diluted with a 100 parts) as numerous
+trials have shown. The majority reacted on this dose with only light
+pain in the joints and passing languor. With a few a slight rise in
+temperature set in, to 38 deg. C. or a trifle higher.
+
+Although there is a marked difference as regards the dose of the
+curative (according to relative weight of body) between the animal
+subject and man, an evident resemblance is shown in several other
+qualities.
+
+The most important of these qualities is _the specific action of this
+remedy on tuberculous processes of whatever kind they may be_. I will
+not relate the effects on the animal subject in this connection, as it
+would lead too far, but will at once turn to the peculiar effects on
+tuberculous human beings.
+
+As we have seen, a healthy man reacts but little or not at all on
+.01 ccm. The same is true of diseased persons, provided they are not
+tuberculous. But the relations are entirely different with those
+afflicted with tuberculosis; a marked general and also a local reaction
+resulted from an injection of the same dose of the remedy (.01 ccm.)[2].
+
+The general reaction consists of an attack of fever, which, beginning
+mostly with chills, raises the temperature to over 39 deg., often up to
+40 deg. and even 41 deg. Other noticeable symptoms are pains in the
+joints, a tendency to cough, great languor, and often nausea and
+vomiting. Several times we observed a faint icteric coloring and in some
+cases the appearance on neck and breast of an exanthema resembling
+measles. As a rule the attack begins 4-5 hours after the injection and
+lasts 12-15 hours. In exceptional cases it may begin much later, but
+then it is not nearly so intense. The patients experience remarkably
+little weakness from the attack and feel relatively well as soon as it
+is over, generally better than they did before it came on.
+
+The local reaction can best be observed on those patients whose
+tuberculose affection is plainly visible, for instance those afflicted
+with lupus. In them changes take place that prove the specific
+antitubercular action of the remedy in a most surprising way. The
+diseased portions of the skin in the face, etc. begin to swell and turn
+red even before the attack of chills set in, although the injection is
+made under the skin of the back, a point decidedly remote from the
+affected parts. The swelling and reddening increases during the fever
+and can attain a very marked degree so that the lupus-tissue turns
+reddish brown and necrotic. In the case of more sharply defined lupus
+centres the more swollen and dark red parts were edged by a white seam
+nearly a centimeter wide and this again was surrounded by a wide bright
+red border. The swelling of the diseased parts gradually decreases after
+the cession of fever and may have entirely disappeared after 2 or 3
+days. A serum exudes from these lupus-centres and, drying, forms a crust
+on them which changes into scabs that fall off in 2-3 weeks and
+sometimes leave a smooth red scar after a single injection. Generally
+several injections are necessary to effect a complete removal of the
+lupose tissue, but of this I will speak further on. It is very important
+to note that the changes during this process are exclusively limited to
+the portions of the skin affected by lupus; even the faintest and
+smallest bits of diseased tissue go through the entire process and
+become visible on account of their swelling and reddening, while the
+actual scab-tissue in which the various stages of lupus have been
+completed remains unchanged.
+
+The observation of the treatment of lupus with the remedy is so
+instructive and must be so convincing as regards the specific nature of
+the remedy that every one wishing to occupy himself with the study of
+this remedy should if possible make his first experiments with lupus.
+
+Less marked, but still apparent to the eye and touch are the local
+reactions in tuberculosis of the lymphatic glands, of the bones and
+joints, etc., in which case swelling and increased painfulness, and in
+the more superficial parts also a reddening can be observed.
+
+The reaction in the inner organs, especially the lungs is removed from
+our observation unless we consider the increased coughing and
+expectoration of the patients after the first injection a local
+reaction. At the same time we must assume that these parts undergo
+changes directly observed in the case of lupus.
+
+The different forms of reaction described have appeared without
+exception in previous trials on the dose of .01 ccm. when any form of
+tuberculosis prevailed in the system, and therefore I trust that I am
+justified in assuming, that in the future this remedy will constitute an
+indispensible diagnostic auxiliary. We will be enabled to diagnose in
+doubtful cases of phthisis even then, when it is impossible to obtain
+reliable information concerning the nature of the ailment, by the
+presence of bacilli or elastic fibres in the sputum or by a physical
+examination. Glandular affectations, hidden tuberculosis of the bones,
+doubtful tuberculosis of the skin and the like will easily and reliably
+prove to be such. In case of apparently completed processes of
+tuberculosis of the lungs or joints it will be possible to show whether
+the process of the disease is in reality a complete one or establish the
+existence of centres from which later on the disease may spread like a
+fire from a live coal in the ashes.
+
+But much more important are the specific qualities of the remedy than
+the aids it offers for the diagnosis.
+
+While describing the changes, that are caused by hypodermic injections
+of the remedy, on the parts of the skin affected by lupus, attention was
+called to the fact that the lupose tissue does not return to its
+original condition after the swelling and reddening have ceased, but is
+more or less destroyed and disappears. On some places, as observation
+teaches, the process is such, that after a single injection the diseased
+tissues undergo mortification and are cast off as dead matter later on.
+On other places it seems that a diminution or rather a kind of melting
+of the tissue is caused, and to effect a complete disappearance a
+repeated application of the remedy is necessary. As the required
+histological investigation is wanting, it is impossible at the present
+time to state with certainty how this result is brought about. Only
+this much is known that it is not a destruction of the tubercle bacilli,
+but that only the tissue containing the tubercular bacilli is affected
+by the application of the remedy. In this, as the visible swelling and
+reddening show, greater circulatory derangements are caused and with
+these vital changes in the _assimilation_ which result in a more or less
+rapid and thorough mortification of the tissue according to the manner
+in which the remedy is allowed to act.
+
+To make a short repetition, the remedy therefore does not destroy the
+tubercle bacilli, but the tuberculous tissue; on dead tissue, for
+instance, gangrenous cheesy matter, necrotic bones, etc., it does not
+act; nor on tissue that has undergone mortification through the action
+of the remedy itself. Living bacilli can still linger in such dead
+masses of tissue, which are either cast out with the necrotic tissue, or
+may possibly migrate under special conditions into the adjoining living
+tissue.
+
+This quality of the remedy must be particularly observed, if its full
+specific action is to be obtained. Therefore we must first cause the
+mortification of the tuberculous tissue, and then effect its removal as
+soon as possible, for instance, by means of a surgical operation; but
+where this is impossible and the excretion by the organisms themselves
+is necessarily slow, we must attempt by continued application of the
+remedy to protect the endangered living tissue from the immigration of
+the parasites.
+
+As the remedy acts only on living tissue and causes mortification of
+tuberculous tissue, we can readily explain another exceedingly peculiar
+property of the remedy, namely, that it can be given in rapidly
+increased doses. This may apparently be explained as being based on
+inurement. But noting that in about three weeks the dose may be
+increased to 500 times the strength of the first one, it is
+unquestionably something more than habit, as we know of nothing
+analogous confirming such a rapid and farreaching adaptation to any
+powerful drug.
+
+This fact can rather be explained thus: in the beginning there is an
+abundance of living tuberculous tissue and only a minute quantity of the
+effective substance is sufficient to cause a strong reaction; through
+each injection a certain quantity of this responsive tissue disappears,
+and then relatively larger doses are required to cause the same degree
+of reaction as before. Aside from this adaptation may assert itself
+within certain limits. As soon as the patient is treated with such
+increased doses, and that he reacts no more than one not afflicted with
+tuberculosis, we may assume that all the reactive tuberculous tissue is
+dead. It is then only necessary to continue the treatment at intervals
+and with gradually increased doses as long as any bacilli remain in the
+system, to protect the patient from a new infection.
+
+It remains to be learnt in the future whether this conception and the
+deductions based thereon are correct. For the present I have directed
+the manner of application of the remedy on this basis, which in our
+experiments resulted as follows:
+
+To begin again with the simplest case, namely lupus, we injected the
+full dose of .01 ccm. in nearly all such patients to begin with, and
+allowed the reaction to take its full course, after 1-2 weeks we again
+injected .01 ccm. and so forth until the reaction became less and less
+and finally ceased. In the case of two patients with facial lupus three
+respectively four injections in this manner resulted in a clean, smooth
+scar in place of the affected parts; the remaining patients of this kind
+have also improved in a measure proportioned to the time of treatment.
+All the patients have suffered from their afflictions for years and have
+been treated by various methods without success.
+
+Tuberculosis of the glands, bones and joints has been treated in a very
+similar manner, as in these cases larger doses were applied at longer
+intervals. The result was the same as with lupus, a rapid cure in the
+lighter and milder cases and a slowly progressing improvement in the
+severer ones.
+
+With the majority of our patients, those suffering from pulmonary
+consumption, the conditions are somewhat different, patients with
+decided pulmonary tuberculosis are very much more responsive to this
+remedy, than those afflicted with surgical tubercles. We were forced to
+reduce the quantity of the first dose of .01 ccm. as prepared for the
+phthisicist, and we found that as a rule he reacted strongly on a dose
+of .002 and even .001 ccm., but that the quantity could be rapidly
+increased from this low initial dose to that which could be easily
+tolerated by the other patients. We generally proceeded in such a manner
+that the patient at first received an injection of .001 ccm. and if a
+rise in the temperature set in this dose was repeated once daily until
+the reaction ceased. Only then the dose was increased to .002 ccm. and
+applied till the reactions failed to appear. And so forth, always
+increasing the dose only .001 or at the most .002 up to .01 ccm. and
+higher. This mild procedure seemed to me imperative, especially with
+such patient as were in a weak and feeble condition. Proceeding in the
+manner just described we can easily attain the application of very light
+doses with but slight attacks of fever and hardly perceptible to the
+patient. Some of the stronger consumptives were treated with larger
+doses from the beginning, partly with a forced increase in the dosing
+when it seemed as though the favorable result was obtained in a
+correspondingly shorter time. The action of the remedy on the
+phthisicist generally seemed to be such that cough and expectoration
+increased somewhat after the first injection, then gradually diminished
+and in favorable cases disappeared entirely; the sputum lost its
+purulent nature and became slimy. The number of bacilli as a rule did
+not decrease until the sputum had attained a phlegmy appearance (only
+such patients were selected for these experiments in whose
+expectorations bacilli were contained). They entirely disappeared
+temporarily, but were again met with from time to time until the
+expectoration had completely stopped. At the same time the night-sweats
+left off, and the patients improved in appearance and gained in weight.
+All patients treated in the first stages of phthisis were freed from all
+symptoms of disease in the course of 4-6 weeks so that they could be
+considered as cured. Even patients with cavities not too large were
+considerably improved and nearly healed. But in the case of such
+consumptives, whose lungs contained many and large cavities no objective
+improvement could be marked, although the expectoration diminished and
+they appeared to feel much better. I am inclined to assume on the basis
+of these experiences, that the _earliest stages of phthisis can with
+certainty be cured by this remedy_.[3] This may also hold good in cases
+that are not too far advanced.
+
+In exceptional cases only will pulmonary consumptives, with large
+cavities, derive continued benefits through the application of the
+remedy, when other complications exist, for instance, the penetration of
+other supurative micro-organisms, irremovable pathological changes in
+other organs, etc. Even such patients were in most cases temporarily
+improved. It must follow that even in them the original process of the
+disease, tuberculosis, is influenced in the same manner by this remedy
+as in other patients, but that it is impossible to remove the gangrenous
+masses of tissue and also the secondary supurative processes. Naturally
+we are led to think that perhaps in some of these severe cases cures may
+be effected by means of a combination of this healing process together
+with surgical aid (after the manner of operating empyema) or some other
+curative means. I would not advise anyone however, to apply this remedy
+without discrimination in every case of tuberculosis. The simplest mode
+of application will certainly be required in treating the first stages
+of phthisis and simple surgical affections, but in all other forms of
+tuberculosis medical science should draw on all its resources and
+individualize carefully to supplement and sustain the action of the
+remedy. In many cases I have had the decided impression that the
+attendance to and nursing of the patient was of no little influence on
+the curative process, and therefore I would prefer the application of
+the remedy in suitably adapted institutions, where a close observation
+of the patient and the adequate attention to them is possible, to the
+ambulant or home treatment. No estimate can at present be made as to the
+extent in which a profitable combination can be made between this new
+method to cure and those modes of treatment that have thus far been
+considered beneficial, the application of mountain climate, the free air
+treatment, specific nourishment, etc.; but I trust, that these remedial
+factors will be of considerable use in conjunction with the new method
+in many cases, especially the severe and neglected as also in the
+convalescent stages.[4]
+
+The nucleus of this new curative method lies in the earliest possible
+application. The proper objects of treatment ought to be the first
+stages of phthisis, because here the remedy can fully develop its
+curative qualifications. Therefore it is of vital importance, more so in
+the future, than it has been in the past, that practical physicians
+employ all possible means to diagnosticate phthisis in as early a stage
+as possible. Until lately the finding of tubercle bacilli existing in
+the sputum was rather considered as an interesting incidental evidence,
+which, although it insured the diagnosis, was of no further benefit to
+the patient and therefore was only too often omitted, as I have only
+lately discovered in numerous cases of phthisis which had passed through
+the hands of several physicians without having their sputum examined
+once. This must be different in the future. Any physician who fails to
+search for tubercle bacilli in the sputum, to establish phthisis in as
+early a stage as possible, commits gross negligence toward his patient,
+because his life may depend on this diagnosis and the specific treatment
+which has hurriedly been introduced on this basis. In doubtful cases the
+physician should gain certainty as to the existence or absence of
+tuberculosis through a trial injection.
+
+Only then will the new mode of treatment truly become a panacea for
+suffering mankind when that period is reached, where all cases of
+tuberculosis are treated in as early a stage as possible, to prevent the
+development of neglected severer cases which have heretofore formed a
+continual unlimited source of new infection.
+
+In conclusion I would remark, that I have intentionally omitted all
+numerical statistics and descriptions of individual cases in this
+communication, because the physicians to whose material the patients
+provided for our experiments belonged, have themselves undertaken the
+description of their respective cases and I did not wish to anticipate
+them in an objective representation of their observations.
+
+
+    FOOTNOTES:
+
+    [1] Physicians who wish to experiment with the remedy, can get
+    the same of Dr. A. Libbertz (Berlin, N. W., Lueneburgerstrasse
+    28 II.), who has undertaken the production of the remedy with
+    Dr. Pfuhl's and my assistance. But I must state that the present
+    stock is very limited, and that larger quantities can only be
+    disposed of at the end of several weeks.
+
+    [2] We gave children of 3-5 years of age one tenth of this dose,
+    that is .001 and very weak children .0005 ccm. and obtained a
+    strong though not alarming reaction.
+
+    [3] This statement is necessarily confined in so far as we have
+    no conclusive experiences, and can not have at present, that
+    show whether the cure is a permanent one, recidivations of
+    course are not excluded for the present. But we may assume that
+    these will be removed as easily and quickly as the first attack.
+
+    On the other hand it is possible from analogy with other
+    infectious diseases that those who are once cured become
+    permanently exempt. This must also be considered an open
+    question for the present.
+
+    [4] It was impossible to collect data referring to
+    cerebral-laryngeal-and miliary-tuberculosis, as we did not have
+    sufficient material.
+
+
+
+
+Explanatory Notes.
+
+
+Koch states that he can not at the present make any statement about the
+origin and preparation of the remedy, as his labors are not yet
+completed.
+
+We may assume that it is very probably a substance that corresponds in a
+way to the lymph used for vaccination. As vaccine lymph represents
+variolous poison greatly reduced in strength, as the remedy for
+hydrophobia is composed of a substance which is weakened hydrophobic
+poison, so Koch probably obtains his remedy for tuberculosis by
+artificially reducing the tuberculous poison by means of various
+processes.
+
+A number of years ago it has been tried with syphilis in a similar way
+to obtain a substance that would not only cure syphilis but would also
+guard against infection from it. At that time however the experiment was
+not successful.
+
+From several intimations I am inclined to believe that Koch was
+successful in finding a way in which a substance may be produced for
+contagious diseases, a substance that cures these diseases and also
+protects from infection. It is not impossible, since Jenner found the
+vaccine virus, Pasteur the hydrophobic lymph and now Koch the tubercle
+lymph.
+
+To be sure there is this difference for the present between the
+substances named, that the vaccine virus only protects healthy person
+from infection by small pox but it does not cure those sick, while the
+hydrophobic lymph and tubercle lymph cure the afflicted. However Koch
+seems to believe that his tubercle lymph has a certain power of
+producing immunity.
+
+According to Koch, his remedy, consisting of a brownish liquid, is
+easily perishable as soon as it is diluted with water; he recommends the
+preparation of the dilution of the remedy with a 5 per cent. phenol
+solution. Phenol is equivalent to carbolic acid. The dilution of the
+remedy for use must be considerable, as only small quantities of the
+same are used.
+
+Koch tells us that his remedy does not act through the stomach, that is
+taken in through the mouth. On one hand it may be that this is due to
+the extremely small quantities necessary for an effect, on the other
+hand and principally all the substances probably act only when they are
+directly applied and brought in contact with the circulation of the
+blood.
+
+For a long time small syringes with fine needle points were used to
+inject strong acting drugs under the skin. This is done in a measure to
+have a guarantee of a sure effect which is not had by giving through
+the mouth. For instance, it is known that emetics given through the
+mouth often remain without results; if however the emetic apomorphine is
+injected anywhere under the skin, vomiting surely follows within a very
+short time. It is well known that morphine is injected under the skin in
+preference to taking it through the mouth as its action as a pain killer
+is much prompter.
+
+Koch's liquid can also be injected under the skin with the aid of a
+so-called Pravaz syringe. Koch uses a somewhat differently formed
+syringe. The result remains the same, no matter what kind of syringe is
+used.
+
+At the same time it makes but little difference, on what part of the
+body the injection is made, as the fluid injected under the skin is
+distributed at once over the entire system. Koch chose the skin of the
+back between the shoulderblades and the loins because here the injection
+could be made without causing pain or inflammation.
+
+The production of the liquid must be attended with great difficulties as
+Koch plainly remarks that his stock at present is very limited and he
+can only furnish larger quantities at the end of several weeks. The
+price of a small bottle to be 25-30 Marks about 6-8 Dollars.
+
+The human being is much more sensitive to Koch's remedy than the guinea
+pig, which is commonly used for experiments of this kind. It seems that
+no experiments have as yet been made with other animals.
+
+Koch has tried the remedy on himself and has passed through all the
+symptoms of a poisoning. He certainly injected into his arm a
+considerable quantity of the liquid; twenty-five times as much as he
+injected in his patients.
+
+But here also there is a difference. In sick people much smaller
+quantities act than in the healthy. One cubic centimeter of the liquid
+has hardly any effect on a healthy person, but quite a marked one on
+those afflicted with tuberculosis.
+
+In the case of the latter one cubic centimeter produces about the same
+symptoms as twenty-five times the quantity would in a healthy person.
+The same must also be considered as symptoms of poisoning; but they are
+only of short duration and are accompanied with magnificent success.
+
+Of all diseases based on tuberculosis only ringworm or lupus is
+perceivable by the eye, as it is a disease of the skin, all other
+tuberculous diseases take their course in the internal parts of the
+body, and therefore are not perceptible to the eye. The symptoms that
+follow an injection of Koch's liquid can be best observed in the case of
+lupus.
+
+Koch therefore selected for his first illustration patients afflicted
+with lupus that is ringworm. Even a few hours after the injection the
+first perceptible changes begin to show in the diseased parts. These
+begin to swell and redden; in other words an inflammation is caused,
+through which the diseased tissue is obviously brought to mortification.
+Soon the inflammation stops. The gangrenous tissue changes into crusts
+or scabs which drop off in a short time and the patient is cured of his
+ringworm.
+
+Koch places particular importance on the fact that the inflammation is
+restricted to the diseased parts only, and that it does not attack sound
+and healthy parts. Even the smallest otherwise invisible knots are made
+perceptible through the inflammation.
+
+We have similar illustrations for this specific action of Koch's remedy
+for lupus (ringworm). So for instance a syphilitic ulcer on the thigh
+may be cured in a few days with iodide of potassium. In a similar
+manner a morbidly enlarged spleen may be reduced to the normal size by
+taking quinine.
+
+The observation is very interesting indeed, as it may be shown whether a
+person is tuberculous in any organ or not by the injection of .01 ccm.
+In case he is tuberculous the poisoning symptoms appear in a marked
+degree; if he is not, hardly any effect is noticeable.
+
+Although we have had excellent methods for a long time to detect
+pulmonary consumption, although Koch added the discovery of the tubercle
+bacilli, it occasionally happens that the disease can not be recognized
+in its beginning stages, because its progress is too slight. Now the
+reaction following an injection is to be the deciding medium. Also with
+other tuberculous affections physicians will welcome this diagnostic
+auxiliary, for in the beginning of the same it often happens that no
+certain diagnosis could be made and valuable time was lost.
+
+We must call particular attention to the further statements of Koch,
+that through his remedy the tubercle bacilli are _not_ killed. With this
+it is admitted that the remedy will not be able to effect cures, without
+any more ado, yes, even the tubercle bacilli may continue to infect
+parts of the body even in spite of the action of the remedy.
+
+Therefore the application of Koch's remedy only, is not sufficient to
+effect a cure. Provision must be made to remove the gangrenous tissue
+from the body as rapidly as possible, because it contains the still
+living tubercle bacilli. As a rule surgical aid is necessary to remove
+the mortified tissue. Where this is impossible Koch advises the
+continued application of the remedy to protect the endangered living
+tissue from the re-immigration of the tubercle bacilli. Koch thereby
+believes that he can protect the tissue, perhaps in the manner as
+vaccination protects from small pox.
+
+The rapid increase in the quantity of the remedy applied in the course
+of time is something that has no parallel. Koch gives an explanation,
+but leaves it to the future to be confirmed. We have no previous
+instance in case that his explanation should prove correct. Reasoning
+from analogous application of our remedy, we are led to assume that
+_smaller_ quantities of the substance would suffice to cause
+mortification of the remaining tuberculous tissue. Koch on the other
+hand uses larger and larger doses to reach a result. He admits inurement
+to the remedy within certain limits only.
+
+Koch has made a difference between pulmonary consumptives and those
+suffering from tuberculosis of the bones and joints, etc. He was able to
+inject larger quantities in the latter than the former, for the quantity
+injected in the case of pulmonary consumptives was .001 ccm.; in other
+tuberculous cases .01 ccm.
+
+Koch selected pulmonary consumptives for his experiments, whose sputum
+contained tubercle bacilli, so as to make no error in the diagnosis, and
+to ascertain by killing the bacilli contained in the sputum, whether the
+diseased tend toward restoration. As the remedy does not kill the
+bacilli, so a diminution of the bacilli can only be obtained in that
+manner, that the tissue of the lungs undergoes certain changes, which
+cause its properties to be such, that the bacilli are no longer able to
+exist or propagate in them. Then a so-called immunity results which we
+know of in other similar diseases. We know that anyone who has had the
+measles or scarlet fever rarely is again attacked by the same, as a rule
+he is permanently proof against them.
+
+In the same way as vaccination protects from small pox, an injection of
+Koch's remedy acts against pulmonary consumption. Koch makes a cautious
+statement:
+
+     "On the other hand it is possible, from analogy with other
+     infectious diseases that those who are once cured become
+     permanently exempt."
+
+Koch reaches this result, that beginning phthisis can with certainty be
+cured with his remedy. On the other hand, advanced consumptives, in
+whose lungs large cavities already exist, may possibly be improved but
+can not be cured. However he provokes the idea, that perhaps his method
+of treatment together with a surgical operation, that removes all
+gangrenous matter from the lungs, may yet have beneficial results in the
+end. The idea is not entirely new to treat lung diseases with the aid of
+surgery; unfortunately the operations have heretofore been thought too
+risky. Perhaps we will now have a new branch in operative technic,
+surgery of the lungs. Koch advises to conduct this lung surgery after
+the manner of operating empyema. This is an operation performed in the
+case of suppurative pleurisy to remove the pus from the pleural cavity.
+This operation has been successfully carried out for a long time.
+
+Koch makes it of especial importance, that while treating consumption
+with the new remedy, the general attendance and nursing is not to be
+neglected. Koch also calls attention to what has been said before, that
+the general hygienic factors, good hospital treatment, mountain climate,
+etc., will never be dispensed with, on the contrary will be
+indispensible to the furtherance of cure.
+
+In conclusion Koch again remarks that brilliant results are only
+promised in the early stages of pulmonary consumption (phthisis).
+Physician and patient must move all levers as to the existence or
+non-existence of tuberculous diseases.
+
+Then those daily pictures of extreme wretchedness from consumption will
+be a thing of the past. Then the danger of contagion will be lessened
+resulting from the decrease of the number of tuberculous persons and of
+the tubercle-bacilli, and perhaps it will soon be possible to name the
+day on which with the last tubercle-bacillus the ravaging pest,
+tuberculosis, will be extirpated.
+
+
+    +-------------------------------------------------------------+
+    | Transcriber's Note:                                         |
+    |                                                             |
+    | Inconsistent use of develops/developes, and centres/centers |
+    | has been retained as in the original.                       |
+    +-------------------------------------------------------------+
+
+
+
+
+
+End of the Project Gutenberg EBook of Prof. Koch's Method to Cure
+Tuberculosis Popularly Treated, by Max Birnbaum
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