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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: ISO-8859-1
+
+*** 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° 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
+scapulæ, 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° 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° 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° 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° 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° 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° 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°, often up to 40°
+and even 41°. 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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+
+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: ISO-8859-1
+
+*** 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.)
+
+
+
+
+
+
+</pre>
+
+
+
+<p class = "mynote">Inconsistent use of develops/developes, and centres/centers
+has been retained as in the original.<br /><br />
+The printed book did not have a table of contents,
+but has been added for this eBook. Page numbers in the "The first
+communication" and "Explanatory Notes" have a 'c' prefix.</p>
+
+<h3>Table of contents</h3>
+<table class = "toc" summary = "Table of contents" style="width:65%">
+<tr>
+  <td  colspan="2" class = "number" style="text-align:right">Page</td>
+</tr>
+<tr>
+  <td><p>Translators Preface.</p></td>
+  <td class = "number" style="text-align:right"><a href = "#Page_1">1</a></td>
+</tr>
+<tr>
+  <td><p>Pulmonary Consumption.</p></td>
+  <td class = "number" style="text-align:right"><a href = "#Page_7">7</a></td>
+</tr>
+<tr>
+  <td><p>The other forms of Tuberculosis.</p></td>
+  <td class = "number" style="text-align:right"><a href = "#Page_29">29</a></td>
+</tr>
+<tr>
+  <td><p>The first communication</p></td>
+  <td class = "number" style="text-align:right"><a href = "#Page_c1">c1</a></td>
+</tr>
+<tr>
+  <td><p>Explanatory Notes.</p></td>
+  <td class = "number" style="text-align:right"><a href = "#Page_c19">c19</a></td>
+</tr>
+</table>
+
+<hr />
+
+<div class="figcenter" style="width: 437px;">
+<img src="images/frontispiece_437.jpg" width="437" height="550" alt="Dr. Koch" />
+<div class="caption">DR. ROBERT KOCH.</div>
+</div>
+
+<h1><span class="smcap">Prof.</span> KOCH'S<br />
+<i><span style="font-size:66%">METHOD TO CURE</span></i><br />
+TUBERCULOSIS<br />
+<i><span style="font-size:66%">POPULARLY TREATED</span></i></h1>
+
+<p class="center">BY<br />DR. MAX BIRNBAUM.</p>
+
+<p class="center" style="margin-top:3em;"><i>TRANSLATED FROM THE GERMAN</i><br />BY<br />DR. FR. BRENDECKE.</p>
+
+<p class="center" style="margin-top:3em;"><i>With an Appendix being Prof. Koch's First Communication
+               on the Subject, translated from the</i></p>
+
+<p class="center"><i>DEUTSCHE MEDICINISCHE WOCHENSCHRIFT</i></p>
+
+<p class="center" style="margin-top:1.5em;"><i>and explanatory notes by the author.</i></p>
+
+<p class="center" style="margin-top:4em;">MILWAUKEE, WIS.,<br />H. E. HAFERKORN,<br />PUBLISHER.<br />1891.</p>
+
+<p class="center" style="margin-top:3em;">COPYRIGHT 1890,<br />BY<br />H. E. HAFERKORN.</p>
+
+<p class="center" style="margin-top:3em;">PRESS OF THE<br />HARTMANN PRINTING CO.,<br />126 Reed St.,<br />MILWAUKEE, WIS.</p>
+
+
+<hr />
+<p><span class='pagenum'><a name="Page_1" id="Page_1">[1&ndash;2]</a></span></p>
+
+<h2>Translators Preface.</h2>
+
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+
+<hr style="width: 65%;" />
+<p><span class='pagenum'><a name="Page_3" id="Page_3">[3]</a></span>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.</p>
+
+<p>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&ndash;13 have fallen prey to
+this sickness.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_4" id="Page_4">[4]</a></span>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.</p>
+
+<p>First of all we must explain: <i>What is tuberculosis?
+What relation does it bear to pulmonary
+consumption?</i></p>
+
+<p>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 <i>synonymous</i> terms.</p>
+
+<p>Tuberculosis is the <i>general</i> 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.</p>
+
+<p>Now these tubercle bacilli settle most frequently
+in the lungs and here cause serious derangements
+of the lung tissue. <i>Pulmonary consumption</i> is
+the result.</p>
+
+<p><span class='pagenum'><a name="Page_5" id="Page_5">[5]</a></span>But the tubercle bacilli will also settle in any
+other portions of the body and cause tuberculosis.</p>
+
+<p>Frequently the tubercle bacilli nestle in the
+<i>larynx</i> and the result is <i>laryngeal consumption</i>.</p>
+
+<p>They may infect the mucous lining of the tongue
+and nasal passages and cause the rarely occurring
+diseases&mdash;<i>tuberculosis of the tongue and nose</i>.</p>
+
+<p>More frequently tuberculosis of the intestines
+results, the well-known <i>intestinal consumption</i>.</p>
+
+<p>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 <i>tuberculosis</i> of the <i>cerebral membranes</i>,
+a disease that has heretofore unexceptionally resulted
+in <i>death</i>.</p>
+
+<p>Much oftener than is generally supposed the
+<i>kidneys</i> are the seat of tuberculosis; and also the
+<i>suprarenal capsules</i>, whose functions are as yet
+entirely unknown, have in postmortem examinations
+been found to be tubercularly degenerated.</p>
+
+<p>In the diseases of the <i>bones</i> and <i>joints</i> 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.</p>
+
+<p><span class='pagenum'><a name="Page_6" id="Page_6">[6]</a></span>Tuberculosis can also destroy parts of the <i>skin</i>.
+In this case it is called <i>Lupus</i>.</p>
+
+<p>Finally tuberculosis is found in the <i>generative
+organs</i>. Tubercular derangements are frequently
+met with in the <i>testicles</i> of men, less often in the
+<i>ovaries</i> of women.</p>
+
+<p>The well known children's disease <i>Scrofula</i> is
+considered a preceding stage of tuberculosis by many
+physicians. This much is certain that Scrofula
+inclines to tuberculosis.</p>
+
+<p>Let us study the several forms of tuberculosis
+after this general synopsis; we will begin with pulmonary
+consumption.</p>
+
+
+<p><span class='pagenum'><a name="Page_7" id="Page_7">[7]</a></span></p>
+<h2><a name="Pulmonary_Consumption" id="Pulmonary_Consumption"></a>Pulmonary Consumption.</h2>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_8" id="Page_8">[8]</a></span>These bacilli are infinitely minute, they are <small><sup>2</sup></small>&frasl;<small><sub>1000</sub></small>
+to <small><sup>8</sup></small>&frasl;<small><sub>1000</sub></small> millimeters long, and about <small><sup>5</sup></small>&frasl;<small><sub>100000</sub></small> 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.</p>
+
+<p>The temperature of boiling water destroys the
+vitality of the bacilli under all circumstances. Even a
+temperature of 70&deg;&nbsp;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.</p>
+
+<p>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.</p>
+
+<p>We are now confronted with two questions:</p>
+
+<div class="blockquot"><p>1. In what manner does the tubercle-bacillus enter into the human
+organism?</p>
+
+<p>2. Under what conditions is the tubercle-bacillus able to generate
+pulmonary consumption after it has entered the human organism?</p></div>
+
+<p><span class='pagenum'><a name="Page_9" id="Page_9">[9]</a></span>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_10" id="Page_10">[10]</a></span>
+because they often have the habit to put all sorts of
+things and also the generally dirty fingers into
+their mouth.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_11" id="Page_11">[11]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>The question, whether a consumptive can <i>infect
+his surroundings</i>, may be answered thus, that this
+does <i>not</i> 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.</p>
+
+<p>Pulmonary consumption is <i>not hereditary</i> in the
+strict sense of the word. Only an inclination to this<span class='pagenum'><a name="Page_12" id="Page_12">[12]</a></span>
+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.</p>
+
+<p>On the other hand it must be considered that the
+penetration <i>only</i> of the tubercle-bacilli into the
+body is <i>not</i> 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.</p>
+
+<p>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
+scapul&aelig;, long neck, clubby, knoblike appearance of
+the ends of the fingers.</p>
+
+<p>Furthermore it has been found, that pulmonary
+consumptives on an average have a <i>smaller heart</i>
+than is essential to a healthy body. On the other
+hand the volume of the lungs of consumptives is very
+often abnormally large.</p>
+
+<p><span class='pagenum'><a name="Page_13" id="Page_13">[13]</a></span>There are a large number of <i>diseases</i> that predispose
+to pulmonary consumption. It is mainly the
+<i>enfeebling</i> action of the same, which brings about
+such results. For this reason the <i>chronic</i> 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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_14" id="Page_14">[14]</a></span>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&ndash;50, millers 10, coal workers 1 per cent.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_15" id="Page_15">[15]</a></span>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.</p>
+
+<p>There seems to be no essential difference as
+regards sex.</p>
+
+<p><i>Insufficient</i> or <i>defective nourishment</i> 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.</p>
+
+<p>Pulmonary consumption is relatively more
+frequent among the <i>poorer</i> than the <i>well to do
+people</i>, 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.</p>
+
+<p><span class='pagenum'><a name="Page_16" id="Page_16">[16]</a></span>The <i>frequency</i> of pulmonary consumption increases
+with the <i>size of the cities</i>, or, which is the
+same, with the number of proletarians. Extreme
+hunger and want are less frequent in the country
+than in the city.</p>
+
+<p>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.</p>
+
+<p><i>Damp and windy climate</i>, 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.</p>
+
+<p>Now when the tubercle bacilli have settled in the
+lungs, they cause various symptoms. One of the
+most frequent is <i>cough</i>. 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.</p>
+
+<p><span class='pagenum'><a name="Page_17" id="Page_17">[17]</a></span></p>
+<div class="figcenter" style="width: 550px;">
+<img src="images/f01_550.png" width="550" height="545" alt="Tuberculous knot in the lungs" />
+<div class="caption">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.</div>
+</div>
+
+<div class="figcenter" style="width: 550px;">
+<img src="images/f02_550.png" width="550" height="216" alt="Tubercle bacilli" />
+<div class="caption">Tubercle bacilli, Enlargement 2000.<br />
+To the left bacilli without spores, to the right bacilli with colorless sections
+which are thought to be spores.</div>
+</div>
+
+<p><span class='pagenum'><a name="Page_18" id="Page_18">[18]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_19" id="Page_19">[19]</a></span>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.</p>
+
+<p>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 <i>hoarse</i> cough is a sure sign of a diseased <i>larynx</i>.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_20" id="Page_20">[20]</a></span>The <i>Expectoration</i> 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.</p>
+
+<p>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.</p>
+
+<p><i>Blood</i> 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 <i>pure
+blood</i> is indeed serious.</p>
+
+<p>The <i>quantity</i> 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<span class='pagenum'><a name="Page_21" id="Page_21">[21]</a></span>
+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.</p>
+
+<p><i>Blood coughing</i> seems to appear somewhat
+more frequently with the <i>female</i> 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.</p>
+
+<p>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.</p>
+
+<p>A number of the consumptives as a rule complain
+of <i>difficulty</i> in <i>deglutition</i>. This is caused by ulcers
+on the posterior wall of the larynx.</p>
+
+<p>With many patients the <i>appetite</i> is <i>undisturbed</i>
+for a long time, and there are consumptives that will
+eat a comparatively large dinner during an attack
+of fever reaching 40&deg;&nbsp;C. Generally the desire to eat
+disappears during the course of the disease, especially
+toward the end of the sickness.</p>
+
+<p><span class='pagenum'><a name="Page_22" id="Page_22">[22]</a></span>The <i>stool</i> 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.</p>
+
+<p>One of the most constant attendants during the
+course of consumption is the <i>Fever</i>. 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;&nbsp;C. With quick consumption the fever is
+generally high.</p>
+
+<p><i>Sweat</i> is also a characteristic sign. The exceedingly
+debilitating effect of night-sweats is well
+known.</p>
+
+<p>During the course of pulmonary consumption
+extreme <i>emaciation</i> 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.</p>
+
+<p><span class='pagenum'><a name="Page_23" id="Page_23">[23]</a></span>The <i>course</i> 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.</p>
+
+<p>Concerning the former <i>treatment</i> 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.</p>
+
+<p>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.</p>
+
+<p>Henceforth the sputum is also to be thrown in
+a <i>spittoon</i> 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.</p>
+
+<p>In the case of a <i>sudden attack</i> of <i>cough</i> a <i>cloth</i>
+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.</p>
+
+<p><span class='pagenum'><a name="Page_24" id="Page_24">[24]</a></span>As bits of the sputum easily stick to the <i>beard</i>
+especially the moustache overhanging the lips,
+therefore lung consumptives are advised to wear a
+short or no beard.</p>
+
+<p><i>Glasses</i>, <i>spoons</i>, etc. used by consumptives must
+only be used by other persons after a thorough
+cleaning with hot water.</p>
+
+<p>The lungdiseased person should abstain from all
+active and passive <i>kissing</i>, 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.</p>
+
+<p>In the case of <i>death</i> 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.</p>
+
+<p>Upholstered furniture, beds, clothes and wash
+should be cleaned in a disinfecting place.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_25" id="Page_25">[25]</a></span>This care ought to begin in a measure with the
+<i>birth of a child</i>. 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.</p>
+
+<p>An important precautionary measure consists in
+the supervision of the <i>food</i>. 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.</p>
+
+<p>The <i>meat inspection</i> must be strictly conducted
+especially with reference to tuberculosis in the case
+of beef, pork and chickens. Sheep are not subject to
+tuberculosis.</p>
+
+<p>The <i>associations</i> 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.</p>
+
+<p>The health of <i>servant girls</i> should receive greater
+attention than formerly, as the disease is often
+carried into the house by them as investigation has
+proven.</p>
+
+<p><span class='pagenum'><a name="Page_26" id="Page_26">[26]</a></span>In the <i>schools</i> 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.</p>
+
+<p>The <i>cleaning of the floor</i> of a room should always
+be done in a damp way.</p>
+
+<p><i>Moving</i> into another house it is advised to rub
+down the walls with fresh baked bread.</p>
+
+<p>As regards <i>societies</i>, 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.</p>
+
+<p>Especial attention should be given to the <i>sprinkling
+of the streets</i> during the dry season.</p>
+
+<p>The state and the larger congregations should
+make it a point to maintain <i>institutions for consumptives</i>,
+beyond the city limits if possible, a
+healthy location in the country preferred.</p>
+
+<p>Every one individually protects himself best from
+consumption by a methodic habit of <i>washing with
+cold water</i>, cold rubbing and baths. River and sea
+baths are generally of excellent results; short shower
+baths with cool water lasting 20&ndash;40 seconds are to<span class='pagenum'><a name="Page_27" id="Page_27">[27]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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".</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_28" id="Page_28">[28]</a></span>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.</p>
+
+<p>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.</p>
+
+
+<p><span class='pagenum'><a name="Page_29" id="Page_29">[29]</a></span></p>
+<h2><a name="The_other_forms_of_Tuberculosis" id="The_other_forms_of_Tuberculosis"></a>The other forms of Tuberculosis.</h2>
+
+
+<p>Of the other forms of tuberculosis <i>laryngeal consumption</i>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>The painful cough has a hollow, barking, harsh
+sound, provokes vomiting, and the sputum together<span class='pagenum'><a name="Page_30" id="Page_30">[30]</a></span>
+with foul breath consists of foamy, slimy, purulent
+lumps. Breathing gradually becomes more difficult
+and louder.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><i>Tuberculosis</i> of the <i>tongue</i> is relatively very
+scarce. The individual in such a case nearly always
+shows pronounced pulmonary tuberculosis. Sometimes<span class='pagenum'><a name="Page_31" id="Page_31">[31]</a></span>
+tuberculosis of the tongue is combined with
+tuberculous sores on the lips and also on the anus.</p>
+
+<p>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.</p>
+
+<p>The treatment before this consisted in cutting
+out all the diseased parts; now it will be much
+simpler.</p>
+
+<p><i>Nasal tuberculosis</i> 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.</p>
+
+<p>Until now nasal tuberculosis had been treated
+by applying caustics to the ulcerated portions.</p>
+
+<p><i>Tuberculosis of the intestines</i> or <i>intestinal consumption</i>
+is especially found in <i>children</i>. 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<span class='pagenum'><a name="Page_32" id="Page_32">[32]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><i>Tuberculosis of the brain and of the cerebral
+membranes</i> also attack children especially. Before
+this no attempts have been made to try whether it is
+now possible to cure the <i>tuberculous inflammation of
+the cerebral membranes</i> which has previously been
+unconditionally fatal. The decision will certainly
+soon be made.</p>
+
+<p>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."</p>
+
+<p>As a rule children of 2&ndash;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<span class='pagenum'><a name="Page_33" id="Page_33">[33]</a></span>
+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.</p>
+
+<p>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<span class='pagenum'><a name="Page_34" id="Page_34">[34]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Fever is not generally attendant, but the same
+may be present.</p>
+
+<p>The symptoms just described, separately or
+collectively, gradually increase; the children finally
+take to their bed and now the <i>real cerebral affection</i>
+developes.</p>
+
+<p>Now the principal symptoms are: vomiting, constipation,
+slow pulse, irregular abrupt breathing,
+increased temperature of the skin, contracted abdomen,<span class='pagenum'><a name="Page_35" id="Page_35">[35]</a></span>
+headache, great excitement alternating with
+drowsiness, beginning decrease of reason, and deranged
+ability of moving the limbs.</p>
+
+<p>As regards <i>vomiting</i>, 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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_36" id="Page_36">[36]</a></span>A second and nearly as constant a symptom is
+<i>constipation</i> 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.</p>
+
+<p>During the latter stages of the disease children
+will often <i>fail to pass urine</i> for twenty-four hours, so
+that the physician is obliged to draw it off with a
+catheter.</p>
+
+<p>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.</p>
+
+<p>The <i>fever</i> 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.</p>
+
+<p>The <i>pulse</i> is characteristic in many cases. In
+the beginning of the disease the pulse is quickened<span class='pagenum'><a name="Page_37" id="Page_37">[37]</a></span>
+only to slacken after a few days. The number of
+beats may be reduced to 40&ndash;60 a minute (normal
+90&ndash;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.</p>
+
+<p>The pulse again increases 1&ndash;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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_38" id="Page_38">[38]</a></span>If the pulse attains that extreme rate shortly
+before death the rate of breathing will also be increased.</p>
+
+<p>As regards the <i>skin</i>, 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.</p>
+
+<p><i>Headache</i> 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.</p>
+
+<p>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.</p>
+
+<p>The larger children complain of <i>pains in the
+bowels</i>, especially in the region of the stomach,<span class='pagenum'><a name="Page_39" id="Page_39">[39]</a></span>
+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.</p>
+
+<p>The shape of the <i>abdomen</i> 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.</p>
+
+<p>This contraction of the abdomen is attendant in
+every case of tuberculous meningitis.</p>
+
+<p>If the large <i>fontanel</i> on the head is not yet
+closed, the same will gradually bulge out as the
+disease progresses.</p>
+
+<p>The <i>mental activity</i> 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<span class='pagenum'><a name="Page_40" id="Page_40">[40]</a></span>
+indifference toward otherwise well-liked persons and
+things. Later on actual delirium sets in, but
+generally of a quiet nature.</p>
+
+<p>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&ndash;8 days at the most, and are succeeded
+by a deep <i>stupor</i>.</p>
+
+<p>If the children have once become <i>unconscious</i>,
+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.</p>
+
+<p><i>Convulsions</i> 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<span class='pagenum'><a name="Page_41" id="Page_41">[41]</a></span>
+convulsions subside, the children, now very pale, drop
+into a deep sleep and their general condition appears
+much reduced.</p>
+
+<p>Different muscular groups especially those of the
+face are subject to <i>local cramps</i>. 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.</p>
+
+<p>In the latter stages a squinting of one or both
+eyes may be noticed but this may again disappear.</p>
+
+<p><i>Grinding of the teeth</i> is another very peculiar
+symptom which is well-known and feared by experienced
+nurses. The <i>arms</i> 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.</p>
+
+<p>The <i>legs</i> are not subject to cramps as much as
+the arms; they are mostly bent and drawn up in a
+half paralyzed condition.</p>
+
+<p>The <i>muscles of the neck and back</i> are very much
+contracted and most children, when raised or laid on
+their side, bend the head far back.</p>
+
+<p><span class='pagenum'><a name="Page_42" id="Page_42">[42]</a></span>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 <i>insensibility</i>.</p>
+
+<p>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.</p>
+
+<p>The sense of <i>hearing</i> 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 <i>smell and taste</i> also
+are lost toward the very end of the disease.</p>
+
+<p><i>Paralytic</i> 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.</p>
+
+<p><span class='pagenum'><a name="Page_43" id="Page_43">[43]</a></span>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.</p>
+
+<p>The duration of the disease varies from 2&ndash;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.</p>
+
+<p>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.</p>
+
+<p>Besides tuberculosis of the cerebral membranes
+with which children are afflicted, <i>tuberculosis of the
+brain</i> 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.</p>
+
+<p>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<span class='pagenum'><a name="Page_44" id="Page_44">[44]</a></span>
+added, slackening of the pulse, vomiting, stiff neck
+and isolated cases of palsy; sometimes an attack of
+convulsions is the first manifestation.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Nutrition is more and more impaired as the disease
+progresses, in isolated cases only, a temporary
+improvement may be observed.</p>
+
+<p>The <i>end</i> of cerebral tuberculosis has been <i>death</i>
+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.</p>
+
+<p><span class='pagenum'><a name="Page_45" id="Page_45">[45]</a></span>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.</p>
+
+<p><i>Tuberculosis of the Kidneys</i> is met with from the
+earliest childhood till old age. Most frequently
+the male sex is afflicted during manhood.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>The <i>urine</i> may, but need not contain pus and
+blood. Sometimes small lumps are found in the
+urine.</p>
+
+<p><i>Pains</i> are only sometimes felt in the renal regions;
+<i>fever</i> may be occasionally attendant.</p>
+
+<p>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.</p>
+
+<p>The internal treatment of renal tuberculosis was
+ineffectual, surgical treatment has been attended<span class='pagenum'><a name="Page_46" id="Page_46">[46]</a></span>
+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.</p>
+
+<p><i>Tuberculosis of the suprarenal capsules</i> 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.</p>
+
+<p>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.</p>
+
+<p>A large space in the realm of disease is claimed
+by <i>tuberculous affections of the bones and joints</i>.
+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.</p>
+
+<p>Most frequently tubercular affections of the
+bones are found in the hip-joints, the knee and the
+spinal column.</p>
+
+<p><span class='pagenum'><a name="Page_47" id="Page_47">[47]</a></span><i>Tuberculous inflammation of the hip-joint</i> 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.</p>
+
+<p>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 <i>lameness</i>; among
+laymen tuberculous inflammation of the hip-joints is
+known as "voluntary limping."</p>
+
+<p>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".</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_48" id="Page_48">[48]</a></span>Yet <i>lameness only</i> 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.</p>
+
+<p>The second symptom, <i>pain</i>, 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.</p>
+
+<p>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.</p>
+
+<p>Later on painfulness of the hip-joint is experienced
+from pressure and at about the same time the
+movements are impeded.</p>
+
+<p>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<span class='pagenum'><a name="Page_49" id="Page_49">[49]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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,<span class='pagenum'><a name="Page_50" id="Page_50">[50]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><i>Rest</i> 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.</p>
+
+<p>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<span class='pagenum'><a name="Page_51" id="Page_51">[51]</a></span>
+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.</p>
+
+<p><i>Tuberculous inflammation of the knee-joint</i> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_52" id="Page_52">[52]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_53" id="Page_53">[53]</a></span>
+frequently the disease progresses and leads to death
+from exhaustion resulting from severe suppuration
+and continual attacks of fever.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>If after a certain period of rest and application
+of the above-named remedies no improvement in the<span class='pagenum'><a name="Page_54" id="Page_54">[54]</a></span>
+state of health could be noticed, the diseased joint
+was laid in plaster or confined with splints.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Aside from the hip- and knee-joint the <i>spinal
+column</i> 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.</p>
+
+<p>The tubercle-bacilli penetrate into the substance
+of the vertebrae, destroy the same and transform it
+into purulent matter. As a result the destroyed<span class='pagenum'><a name="Page_55" id="Page_55">[55]</a></span>
+vertebrae sink or rather settle down and cause a
+curvature of the spine, in other words a humpback.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_56" id="Page_56">[56]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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;&nbsp;C. and even such trifling
+increase of temperature may be wanting.</p>
+
+<p>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<span class='pagenum'><a name="Page_57" id="Page_57">[57]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_58" id="Page_58">[58]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>A certain disease of the skin called <i>lupus</i> (ringworm)
+must be counted in with the number of diseases
+generated by the tubercle-bacillus.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_59" id="Page_59">[59]</a></span>While the disease thus takes possession of greater
+area and developes new centers, a uniform scaling off
+of all knots begins.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_60" id="Page_60">[60]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_61" id="Page_61">[61]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_62" id="Page_62">[62]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_63" id="Page_63">[63]</a></span>
+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 <i>traumatic erysipelas</i>
+and possibly the appearance of <i>pulmonary consumption</i>
+may succeed the affliction. In cases of
+not too rare occurrence it has been observed that
+lupus has developed into <i>cancer</i>, which has always
+resulted fatally.</p>
+
+<p>The <i>treatment</i> of lupus has principally been a
+<i>local</i> 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.</p>
+
+<p>Our experiences relating to the mechanical treatment
+of lupus have taught us the following.</p>
+
+<p>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<span class='pagenum'><a name="Page_64" id="Page_64">[64]</a></span>
+within certain limits. Then again the secondary
+growths after an operation may be of serious consequences.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><i>Tuberculosis of the testicles</i> is not so very rare,
+it is found in about 2<small><sup>1</sup></small>&frasl;<small><sub>2</sub></small> per cent. of all men afflicted
+with pulmonary consumption. It is more rarely met
+with in children than in men.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_65" id="Page_65">[65]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>Striking changes appear only later and consist
+in the softening of the lumps and in the development
+of abscesses.</p>
+
+<p>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.</p>
+
+<p>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.<span class='pagenum'><a name="Page_66" id="Page_66">[66]</a></span>
+A hardening is often the first sign, this is followed by
+increase in size and then softening.</p>
+
+<p>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.</p>
+
+<p>Of other symptoms of tuberculosis of the testicles
+pain deserves especial mention. The same is slight
+in the beginning, but often becomes insufferable.</p>
+
+<p>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.</p>
+
+<p>According to the time in which the general
+derangements come about, a chronic and acute<span class='pagenum'><a name="Page_67" id="Page_67">[67]</a></span>
+tuberculosis of the testicles has been distinguished.
+The former is the more frequent, the latter of rare
+occurrence.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Finally we must include in our reflection the well-known
+disease of children, <i>scrofula</i>. 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.</p>
+
+<p>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<span class='pagenum'><a name="Page_68" id="Page_68">[68]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>In many cases this particular disease is <i>inherited</i>.
+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<span class='pagenum'><a name="Page_69" id="Page_69">[69]</a></span>
+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.</p>
+
+<p>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; <i>nutrition</i>,
+especially in the first year of life, has the greatest
+influence on the origin of scrofula.</p>
+
+<p>In <i>infancy</i> the most frequent cause of scrofula is
+the premature giving of <i>farinaceous</i> food besides the
+mother's milk, or the feeding of children with so-called
+pap, especially when this is done in the <i>first
+month of their life</i>.</p>
+
+<p>In later months the excessive eating of bread,
+potatoes or vegetables instead of milk has an injurious
+effect.</p>
+
+<p>Furthermore the development of scrofula is
+favored by the breathing of <i>foul damp air</i> such as is
+frequently found in newly built or damp houses and
+also by <i>deficient care of the skin</i>.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_70" id="Page_70">[70]</a></span>Frequently the development of scrofula has been
+observed to succeed measles, diphtheria, scarlatina
+or whooping-cough.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <i>torpid</i> and an <i>erethistic</i> scrofulous
+constitution.</p>
+
+<p>With a <i>torpid</i> 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<span class='pagenum'><a name="Page_71" id="Page_71">[71]</a></span>
+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.</p>
+
+<p>In the case of <i>erethistic</i> 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.</p>
+
+<p>In most cases, however, the characteristics of
+these two forms are blended.</p>
+
+<p>The phenomena of scrofula are manifold and
+extend over the entire body.</p>
+
+<p>The <i>skin</i> 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.</p>
+
+<p><span class='pagenum'><a name="Page_72" id="Page_72">[72]</a></span>Most frequently herpes appear, the parts especially
+affected are the scalp, face, auricular passages,
+eyelids and the nose with its surrounding parts.</p>
+
+<p>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.</p>
+
+<p>Of all <i>mucous membranes</i> that of the <i>nose</i>
+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.</p>
+
+<p>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<span class='pagenum'><a name="Page_73" id="Page_73">[73]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>The mucous membrane of the <i>throat</i> 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 <i>tonsils</i> also
+become inflamed frequently and become enlarged
+through the repeated rather chronic inflammation.</p>
+
+<p><i>Inflammations of the ear</i> 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.</p>
+
+<p>The <i>eye</i> 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<span class='pagenum'><a name="Page_74" id="Page_74">[74]</a></span>
+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.</p>
+
+<p>Swelling of the <i>glands</i> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Inflammation of the periosteum and of the bones
+is one of the instances of scrofula. Most frequently
+<i>spina ventosa</i> is found; the same consists of a
+gradual, painless swelling of the diseased bones,
+most frequently on the fingers and toes, so that they<span class='pagenum'><a name="Page_75" id="Page_75">[75]</a></span>
+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.</p>
+
+<p>The frequence of anaemia with scrofula is only a
+<i>result</i> of the disease and not a symptom. As a
+result of scrofula nutrition and assimilation become
+impaired, mostly in the cases of extreme suppuration.</p>
+
+<p>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.</p>
+
+<p><i>Fatal</i> 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.</p>
+
+<p>It has been frequently observed that <i>tuberculosis</i>
+succeeds scrofula. It is a well-known fact that
+scrofula furnishes the largest contingent for tuberculosis.</p>
+
+<p><span class='pagenum'><a name="Page_76" id="Page_76">[76]</a></span>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.</p>
+
+<p>Children 1&ndash;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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_77" id="Page_77">[77]</a></span>It is of no less importance for a successful treatment
+of scrofula to provide surroundings of as
+favorable conditions as possible.</p>
+
+<p>First of all <i>pure air</i> containing plenty of <i>oxygen</i>.
+Therefore the <i>sea-coast</i> 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.</p>
+
+<p><i>Mountain air</i> has a similarly favorable effect
+especially when <i>salt water baths</i> are used at the
+same time; even the plain, pure <i>country air</i> proves
+beneficial to scrofulous children. <i>Very dry</i> locations
+and dwellings ought to be selected. The children
+should remain <i>out of doors</i> as much as possible.</p>
+
+<p>Of great importance for scrofulous children,
+furthermore, is a suitable course in <i>gymnastics and
+rubbing-down with cold water</i>. To begin with the
+water may be 72&deg; but should gradually be reduced
+to the natural temperature of well water.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_78" id="Page_78">[78]</a></span>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 <i>beginning</i>
+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.</p>
+
+<p>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.</p>
+
+<div class="figcenter" style="width: 550px;">
+<img src="images/f03_550.jpg" width="550" height="321" alt="Tr. Koch in his laboratory" />
+<div class="caption">DR. KOCH IN HIS LABORATORY</div>
+</div>
+
+
+<p><span class='pagenum'><a name="Page_c1" id="Page_c1">[c1]</a></span></p>
+<h2><a name="THE_FIRST_COMMUNICATION" id="THE_FIRST_COMMUNICATION"></a>THE FIRST COMMUNICATION<br />
+<i><span style="font-size:80%">Relating to a Method to Cure</span></i><br />
+TUBERCULOSIS,</h2>
+
+<p class="center" style="margin-top:2em; margin-bottom:2em; line-height:2.5em;">BY<br />Prof. R. KOCH, Berlin.</p>
+
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_c2" id="Page_c2">[c2]</a></span>
+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.</p>
+
+<p>The experiments have been, and are still being
+made under my direction by Dr.&nbsp;A.&nbsp;Libbertz and
+Stabsarzt Dr.&nbsp;E.&nbsp;Pfuhl. The necessary subjects and
+material have been provided by Prof.&nbsp;Brieger from
+his Polyclinic, Dr.&nbsp;W.&nbsp;Levy in his Private Surgical
+Clinic, Geheimrath Fraentzel and Oberstabsarzt R.&nbsp;Koehler
+in the Charite-Hospital, and Geheimrath
+Herr v.&nbsp;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.</p>
+
+<p>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.<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a></p>
+
+<p>The curative is composed of a clear brown fluid,
+which in itself is not perishable, even without special<span class='pagenum'><a name="Page_c3" id="Page_c3">[c3]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_c4" id="Page_c4">[c4]</a></span>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.</p>
+
+<p>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&nbsp;ccm. are sufficient to produce intense
+results. In proportion to weight of body therefore
+<small><sup>1</sup></small>&frasl;<small><sub>1500</sub></small> of the amount which has no noticeable effect on
+the guinea pig has a decidedly strong effect on the
+man.</p>
+
+<p>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&nbsp;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<span class='pagenum'><a name="Page_c5" id="Page_c5">[c5]</a></span>
+lasted nearly an hour, at the same time nausea,
+vomiting, increase of the temperature of the body to
+39.6&deg;&nbsp;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.</p>
+
+<p>The lower limit of effect of the curative for a
+healthy man is about .01&nbsp;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;&nbsp;C. or a trifle higher.</p>
+
+<p>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.</p>
+
+<p>The most important of these qualities is <i>the
+specific action of this remedy on tuberculous processes
+of whatever kind they may be</i>. 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.</p>
+
+<p><span class='pagenum'><a name="Page_c6" id="Page_c6">[c6]</a></span>As we have seen, a healthy man reacts but little
+or not at all on .01&nbsp;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&nbsp;ccm.)<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a>.</p>
+
+<p>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&ndash;5 hours
+after the injection and lasts 12&ndash;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.</p>
+
+<p>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.<span class='pagenum'><a name="Page_c7" id="Page_c7">[c7]</a></span>
+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&ndash;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.</p>
+
+<p>The observation of the treatment of lupus with
+the remedy is so instructive and must be so convincing<span class='pagenum'><a name="Page_c8" id="Page_c8">[c8]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>The different forms of reaction described have
+appeared without exception in previous trials on the
+dose of .01&nbsp;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.<span class='pagenum'><a name="Page_c9" id="Page_c9">[c9]</a></span>
+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.</p>
+
+<p>But much more important are the specific qualities
+of the remedy than the aids it offers for the
+diagnosis.</p>
+
+<p>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<span class='pagenum'><a name="Page_c10" id="Page_c10">[c10]</a></span>
+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 <i>assimilation</i> 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.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_c11" id="Page_c11">[c11]</a></span>
+the remedy to protect the endangered living tissue
+from the immigration of the parasites.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_c12" id="Page_c12">[c12]</a></span>
+remain in the system, to protect the patient from a
+new infection.</p>
+
+<p>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:</p>
+
+<p>To begin again with the simplest case, namely
+lupus, we injected the full dose of .01&nbsp;ccm. in nearly
+all such patients to begin with, and allowed the
+reaction to take its full course, after 1&ndash;2 weeks we
+again injected .01&nbsp;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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_c13" id="Page_c13">[c13]</a></span>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&nbsp;ccm. as prepared for the
+phthisicist, and we found that as a rule he reacted
+strongly on a dose of .002 and even .001&nbsp;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&nbsp;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&nbsp;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&nbsp;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<span class='pagenum'><a name="Page_c14" id="Page_c14">[c14]</a></span>
+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&ndash;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
+<i>earliest stages of phthisis can with certainty
+be cured by this remedy</i>.<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a> This may also hold
+good in cases that are not too far advanced.</p>
+
+<p><span class='pagenum'><a name="Page_c15" id="Page_c15">[c15]</a></span>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<span class='pagenum'><a name="Page_c16" id="Page_c16">[c16]</a></span>
+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.<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a></p>
+
+<p>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<span class='pagenum'><a name="Page_c17" id="Page_c17">[c17]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<div class="footnote"><p><span class='pagenum'><a name="Page_c18" id="Page_c18">[c18]</a></span><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a>Physicians who wish to experiment with the remedy, can
+get the same of Dr.&nbsp;A.&nbsp;Libbertz (Berlin, N.&nbsp;W., Lueneburgerstrasse&nbsp;28&nbsp;II.),
+who has undertaken the production of the
+remedy with Dr.&nbsp;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.</p></div>
+
+<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a>We gave children of 3&ndash;5 years of age one tenth of this
+dose, that is .001 and very weak children .0005&nbsp;ccm. and obtained
+a strong though not alarming reaction.</p></div>
+
+<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a>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.</p>
+
+<p>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.</p></div>
+
+<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a>It was impossible to collect data referring to cerebral-laryngeal-
+and miliary-tuberculosis, as we did not have sufficient
+material.</p></div>
+
+
+
+<p><span class='pagenum'><a name="Page_c19" id="Page_c19">[c19]</a></span></p>
+<h2><a name="Explanatory_Notes" id="Explanatory_Notes"></a>Explanatory Notes.</h2>
+
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_c20" id="Page_c20">[c20]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_c21" id="Page_c21">[c21]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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&ndash;30 Marks about
+6&ndash;8 Dollars.</p>
+
+<p><span class='pagenum'><a name="Page_c22" id="Page_c22">[c22]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_c23" id="Page_c23">[c23]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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&nbsp;ccm. In case
+he is tuberculous the poisoning symptoms appear in
+a marked degree; if he is not, hardly any effect is
+noticeable.</p>
+
+<p><span class='pagenum'><a name="Page_c24" id="Page_c24">[c24]</a></span>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.</p>
+
+<p>We must call particular attention to the further
+statements of Koch, that through his remedy the
+tubercle bacilli are <i>not</i> 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.</p>
+
+<p>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<span class='pagenum'><a name="Page_c25" id="Page_c25">[c25]</a></span>
+thereby believes that he can protect the tissue,
+perhaps in the manner as vaccination protects from
+small pox.</p>
+
+<p>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 <i>smaller</i> 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.</p>
+
+<p>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&nbsp;ccm.; in other tuberculous cases
+.01&nbsp;ccm.</p>
+
+<p>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<span class='pagenum'><a name="Page_c26" id="Page_c26">[c26]</a></span>
+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.</p>
+
+<p>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:</p>
+
+<div class="blockquot"><p>"On the other hand it is possible, from analogy
+with other infectious diseases that those who are
+once cured become permanently exempt."</p></div>
+
+<p>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<span class='pagenum'><a name="Page_c27" id="Page_c27">[c27]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+
+
+
+
+
+
+<pre>
+
+
+
+
+
+End of the Project Gutenberg EBook of Prof. Koch's Method to Cure
+Tuberculosis Popularly Treated, by Max Birnbaum
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@@ -0,0 +1,2945 @@
+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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