








                 [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.                       |
    +-------------------------------------------------------------+





