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[Illustration: DR. ROBERT KOCH.]
PROF. KOCH'S
_METHOD TO CURE_
TUBERCULOSIS
_POPULARLY TREATED_
BY
DR. MAX BIRNBAUM.
_TRANSLATED FROM THE GERMAN_
BY
DR. FR. BRENDECKE.
_With an Appendix being Prof. Koch's First Communication
on the Subject, translated from the_
_DEUTSCHE MEDICINISCHE WOCHENSCHRIFT_
_and explanatory notes by the author._
MILWAUKEE, WIS.,
H. E. HAFERKORN,
PUBLISHER.
1891.
COPYRIGHT 1890,
BY
H. E. HAFERKORN.
PRESS OF THE
HARTMANN PRINTING CO.,
126 Reed St.,
MILWAUKEE, WIS.
Translators Preface.
Consumption is curable. From time to time the news of some great
discovery rushes over the land like a mighty wave; but never before has
the intelligence of a great achievement been received with such
universal delight. There is hardly a man, woman or child that does not
bewail the loss of some dear relative taken away by Tuberculosis, the
most terrible of all foes. More terrible because it stealthily creeps
into the system and takes a firm hold before its presence can even be
surmised.
Now the appearance of a deliverer is hailed as would the advent of the
Messiah. Koch, formerly a poor and obscure student, being especially
interested in bacteriology has plodded and worked for years. Even in the
year 1882 he has made known to the world the evil spirit in describing
the tubercle-bacillus as the specific generator of tuberculosis. We then
knew the enemy but had no weapon to fight him. Now Koch has also
manufactured the sword with which to combat the evil genius. The
experimental tests thus far have not tended to lessen the merits of
Koch's remedy. Added applications have resulted in additional success.
The investigations are not yet complete; only meager particulars have
thus far been given to the public from authorized sources. To guard
against misleading representations the translator has undertaken to give
to the American public only what has actually been achieved. He felt
himself called upon to do this not only because he has followed the
progress of Koch's labors with the keenest interest, but also because he
himself has worked and labored on this field for many years.
Justly has a vast excitement taken hold of all classes of the people, an
excitement that has caused all other contemporary events to fall back.
The search for an actual remedy for that exceedingly ravaging disease,
tuberculosis, has at last been crowned with success, and even the most
uneducated will be able to estimate the significance of this event.
We need but consider, that pulmonary consumption, the most frequent form
of tuberculosis, annually demands over 30,000 victims in the cities of
the German Empire over 15,000 inhabitants, and out of every 100 deceased
12-13 have fallen prey to this sickness.
The number of sufferers from pulmonary consumption can not nearly be
determined, it certainly exceeds all other diseases by far. In the case
of many people we can only infer from their appearance and hereditary
tendencies, before visible signs can be discovered, that they will
succumb to this terrible disease.
And this disease is now curable. Millions of people who have considered
themselves doomed, will be given back to life; their regained strength
will greatly increase the national wealth. In short, we look forward to
an era, such as was not dreamt of even by the most vivid imagination
only a few years back. But rather than be carried too far by our
enthusiasm, let us study Koch's new method to cure, as far as we are now
enabled to pass judgement on it.
First of all we must explain: _What is tuberculosis? What relation does
it bear to pulmonary consumption?_
Pulmonary consumption is only one form of tuberculosis, by far the most
frequent. This is the reason why pulmonary consumption, pulmonary
tuberculosis, consumption and tuberculosis are used as _synonymous_
terms.
Tuberculosis is the _general_ expression. By that we understand a
disease which is generated by a certain kind of organism belonging to
the class of bacteria. These organisms are the tubercle bacilli, which
were discovered by Koch in the year 1882.
Now these tubercle bacilli settle most frequently in the lungs and here
cause serious derangements of the lung tissue. _Pulmonary consumption_
is the result.
But the tubercle bacilli will also settle in any other portions of the
body and cause tuberculosis.
Frequently the tubercle bacilli nestle in the _larynx_ and the result is
_laryngeal consumption_.
They may infect the mucous lining of the tongue and nasal passages and
cause the rarely occurring diseases--_tuberculosis of the tongue and
nose_.
More frequently tuberculosis of the intestines results, the well-known
_intestinal consumption_.
The spreading of tuberculosis in the brain is of especial importance on
account of the importance of this organ. Very frequently small children
are attacked by _tuberculosis_ of the _cerebral membranes_, a disease
that has heretofore unexceptionally resulted in _death_.
Much oftener than is generally supposed the _kidneys_ are the seat of
tuberculosis; and also the _suprarenal capsules_, whose functions are as
yet entirely unknown, have in postmortem examinations been found to be
tubercularly degenerated.
In the diseases of the _bones_ and _joints_ tuberculosis forms an
important part. Those infinitely small and weak tubercle-bacilli have
the power to destroy the hard and firm substance of the bones, to soften
it and change it to pus. Whole portions of bone may disappear in this
way.
Tuberculosis can also destroy parts of the _skin_. In this case it is
called _Lupus_.
Finally tuberculosis is found in the _generative organs_. Tubercular
derangements are frequently met with in the _testicles_ of men, less
often in the _ovaries_ of women.
The well known children's disease _Scrofula_ is considered a preceding
stage of tuberculosis by many physicians. This much is certain that
Scrofula inclines to tuberculosis.
Let us study the several forms of tuberculosis after this general
synopsis; we will begin with pulmonary consumption.
Pulmonary Consumption.
Even before the discovery of the tubercle-bacillus by Koch, different
scientists had claimed that pulmonary consumption was caused by the
immigration of bacteria into the lungs, and several of them had found
bacteria of that kind. But it remained for Koch to bring light upon the
conjectures of other scientists, and he established the fact, that the
bacillus discovered by him was the real generator of pulmonary
consumption. Millions of these bacilli exist in the lungs of the
diseased, and millions of them are thrown out with the sputum.
If we take a very small quantity of this thrown out matter and examine
it with a microscope, we will find a greater or smaller number of these
tubercle bacilli. Of course the preparation to be microscopically
examined must previously be colored with some coloring matter, otherwise
it is very difficult, well nigh impossible, to detect the infinitely
small bacilli. The method of coloring now generally in use consists in
discoloring the preparation after the coloring has been completed, it is
found that the bacilli tenaciously cling to the coloring matter, and in
this way it is easy to recognize the tubercle-bacilli under the
microscope.
These bacilli are infinitely minute, they are 2/1000 to 8/1000
millimeters long, and about 5/100000 millimeters in width. Therefore it
is absolutely impossible to recognize them with the naked eye. Generally
they are somewhat bent, sometimes slightly nicked at one end.
The temperature of boiling water destroys the vitality of the bacilli
under all circumstances. Even a temperature of 70 deg. C. is able to
lessen the efficacy of the bacilli. Unhappily this temperature is too
high to be applied against the tubercle-bacilli in the human body without
causing the most serious injury to it. Nevertheless it has been tried,
we will speak of this later on.
Then the drugs that kill the bacteria, such as Carbolic Acid, Alcohol,
Iodoformether, Ether, Sublimate, Thymol, destroy the tubercle-bacilli so
slowly and only in such high concentrations that their application is
impossible without endangering the patient. Therefore the prospects of
directly destroying the bacilli in the human body had to be given up as
impossible.
We are now confronted with two questions:
1. In what manner does the tubercle-bacillus enter into the human
organism?
2. Under what conditions is the tubercle-bacillus able to generate
pulmonary consumption after it has entered the human organism?
All investigations, both of earlier and later date have established the
fact that the tubercle-bacillus is inhaled with the air, and then it is
mainly the foul air which is accused. But foul air is especially found
in such places where people congregate, as in rooms, barracks,
factories, etc. As it is a fact that there are always several
consumptives among a number of people, so in this case there will always
be occasion to inhale the tubercle-bacilli that have been cast out by
the consumptives. Therefore it is not the foul air in itself which
generates pulmonary consumption, but the circumstance that in this
connection there are always people present which are able to spread and
scatter the bacilli.
Luckily the physical qualities of the tubercle-bacilli are such that
they mostly adhere to the ground or floor and are rarely scattered in
the air as dust; otherwise pulmonary consumption would be much more
frequent than it is at present. Unfortunately the bacilli are very often
spread through uncleanliness of the people, because they touch objects
with their fingers to which the tubercle-bacilli chance to stick and
then they touch their mouth or nose with these fingers. In this way
bacilli can be taken into the system especially easily with the food.
Children are particularly exposed to contamination, crawling about on
the ground, on which, perhaps but recently, a consumptive has spit, and
more so because they often have the habit to put all sorts of things
and also the generally dirty fingers into their mouth.
On the other hand there are various obstacles in the way of
tubercle-bacilli entering the lungs. The distance from the mouth to the
lungs is long and narrow; all sorts of projections check the further
penetration of the bacilli. The trachea and the air-passages of the
lungs possess equipments arranged for the purpose of ejecting small
foreign substances, thus also to throw out the bacilli. In short it is
not too easy a matter for the bacilli to penetrate into the lungs.
And yet this happens only too often. For instance, in some people the
passage from the mouth down may be a wide one, so that the bacilli can
enter more easily; the protective arrangement by which foreign
substances are removed may be deranged, it may be wanting in some place
or its functionary qualifications may be bad; especially frequent this
is the case after enfeebling diseases, which are associated with severe
cough, as measles, whooping-cough, etc. This is the reason why pulmonary
consumption is strikingly often observed to follow just these diseases.
But the tubercle-bacillus can also enter the body with the food, as
stated before. The acid gastric juice is a protective agent which
considerably lessens the danger of infection by tuberculosis.
It has not been definitely decided at the present time whether the
drinking of milk from tuberculous cows brings with it the danger of
tuberculosis for mankind. It will certainly be best to avoid such milk,
especially when the cow's udder is found to be tuberculously diseased or
when tubercle-bacilli can be traced in the milk.
The use of meat as food may also become dangerous to man, but this is a
rare occurrence. It is particularly dangerous to eat the liver, kidneys
and lymphatic glands of tuberculous animals. The boiling heat while
cooking generally destroys the bacilli contained therein and so lessens
the danger from this source. It is of no little importance, to call
particular attention to the fact that our chickens are very often
severely infected with tuberculosis.
The question, whether a consumptive can _infect his surroundings_, may
be answered thus, that this does _not_ happen as a rule. Several unhappy
circumstances must come together to make this possible. Above all things
a direct transmission of tubercle-bacilli in some way into the body of
the healthy person, then the bacilli must cling and propagate in the
same, which is only possible when there is an inclination to this
disease, of course this inclination is quite common.
Pulmonary consumption is _not hereditary_ in the strict sense of the
word. Only an inclination to this disease is transmitted. As the danger
of contagion of those having such disposition is very great, so as a
rule the disease makes its appearance sooner or later.
On the other hand it must be considered that the penetration _only_ of
the tubercle-bacilli into the body is _not_ sufficient to generate
tuberculosis. If they do not find the ground adapted to their
nourishment and propagation they perish. It may be assumed that every
person is placed in such circumstances at some time that he will take in
tubercle-bacilli; but only a certain percentage will get consumption. In
the remainder the bacilli perish without leaving even a trace.
Very often the inclination to pulmonary consumption may be recognized
from the external characteristics. As a rule the respective individuals
have a slight body, thin lean skin, weak muscles, delicate skeleton, a
long, narrow, flat chest, flattening of the regions over and below the
shoulderblades, wide intercostal spaces, a winglike projecting of the
scapulae, long neck, clubby, knoblike appearance of the ends of the
fingers.
Furthermore it has been found, that pulmonary consumptives on an average
have a _smaller heart_ than is essential to a healthy body. On the other
hand the volume of the lungs of consumptives is very often abnormally
large.
There are a large number of _diseases_ that predispose to pulmonary
consumption. It is mainly the _enfeebling_ action of the same, which
brings about such results. For this reason the _chronic_ diseases
contribute so much toward the multiplication of the number of
consumptives, because they stipulate a continuous weakening of the
organism and an emaciation of the system. To these belong Bright's
disease, which very often turns into pulmonary consumption,
greensickness or chlorosis, anaemia, continued febrile diseases, severe
chronic suppuration, chronic catarrh of the stomach, frequent
pregnancies, childbed diseases. Thus we may often see young chlorotic
girls afflicted with consumption, especially when they marry young and
enjoy the honeymoon to its utmost limits. Then also women will easily
become consumptive when they give birth to a child every year,
especially when the social conditions in which they live are of an
unfavorable nature, and they are perhaps inclined to consumption
already. Childbed on the whole inclines to arousing the dormant
inclination toward pulmonary consumption.
Of other diseases we have mentioned measles and whooping cough, as
diseases that are only too easily succeeded by consumption. To these may
be added typhus, especially when it is of a more protracted nature, and
the reconvalescence is slow and incomplete.
Furthermore all those workmen that have to do with dust, are exposed to
the danger of being stricken with pulmonary consumption. The dust enters
the lungs, irritates and injures the same and so produces a favorable
soil for any tubercle bacilli that may happen to penetrate. On the whole
metal dust is more injurious than mineral dust. Workmen, that are
exposed to animal dust, as furriers, saddlers, brushmakers, fall prey to
consumption much oftener than those, that fulfill their vocation in air
pregnant with vegetable dust. According to statistics workingmen are
stricken with pulmonary consumption as follows: of glass workers 80 per
cent., needle grinders 70, filemakers 62, stone cutters 40, mill
grinders, lithographers, cigarmakers, brushmakers, stone-polishers
40-50, millers 10, coal workers 1 per cent.
Pneumonia may culminate in pulmonary consumption: but on the whole this
rarely happens. Much oftener it is the case with Pleurisy. But it is
assumed and rightly, that most people who are attacked by pleurisy, are
already consumptive.
A hemorrhage of the lungs may nearly always be considered a sure sign
that consumption has taken hold of the respective individual; but such a
hemorrhage certainly forms considerable danger to falling a victim to
tuberculosis, if the individual is as yet free from the same.
Age has a particularly decided influence on the origin of consumption;
it is extremely rare before the third or fourth year, from that to the
seventh it is more frequent; it most frequently occurs in the age from
the fifteenth to the thirtieth year, and from there on the chances are
again fewer. In very old age it is again very rare.
There seems to be no essential difference as regards sex.
_Insufficient_ or _defective nourishment_ acts as a promoter in various
ways. Even the nourishing of infants with poor milk, with bread or
flour-pap increases the disposition to pulmonary consumption. If this
defective nourishment is continued, scrofula will surely follow and this
is a stage antecedent to consumption.
Pulmonary consumption is relatively more frequent among the _poorer_
than the _well to do people_, this is partly due to the meagre and
scanty food of the poorer, and that they are obliged to subsist almost
exclusively on vegetable diet. The higher the meat prices rise and the
less the majority of the people can afford to procure meat, the larger
will be the number of consumptives. The poorly nourished offer a good
soil for the tubercle bacilli in consequence of their weakness. The
tissue offers little or no resistance to the growth of the bacilli,
these propagate and destroy the powerless and yielding organism with
fearful rapidity.
The _frequency_ of pulmonary consumption increases with the _size of the
cities_, or, which is the same, with the number of proletarians. Extreme
hunger and want are less frequent in the country than in the city.
That the climate has an important influence on the appearance of
pulmonary consumption has long been known. In certain elevated regions
this disease seldom or never appears. This experience has been attained
in Switzerland and many other mountain regions. Furthermore the Plateaux
of Peru and Mexico are considered free from consumption, but also
lowlands like Iceland, the Kirgheez steppes and the interior of Egypt
are known to be exempt.
_Damp and windy climate_, especially with very high temperature, or
abrupt changes in the temperature promotes consumption; on the other
hand it is less frequent in the more moderated climates, especially if
they are dry.
Now when the tubercle bacilli have settled in the lungs, they cause
various symptoms. One of the most frequent is _cough_. In the beginning
of the disease a short, clear but light, very often dry cough appears.
During the further development of pulmonary consumption the cough
becomes more periodic; it appears early after awaking, in the afternoon
after dinner, and evenings at lying down; it may disappear entirely in
the meantime or may be light only; but then as a rule it is no longer
dry, but may be attended by expectorations of a varied nature.
[Illustration: Section of a tuberculous knot in the lungs, in which two
cavities are seen filled with numerous bacilli. The bacilli distinctly
appear as dark lines as a result of the coloring. Enlargement 900.]
[Illustration: Tubercle bacilli, Enlargement 2000.
To the left bacilli without spores, to the right bacilli with colorless
sections which are thought to be spores.]
The tubercle bacilli destroy the lung tissue and change it into pus,
which is coughed out. In this way larger and smaller cavities are formed
in the lungs; finally the cavities may even take more space than the
remaining lung tissue. When cavities have already been formed, coughing
comes easy and with abundant expectoration. Toward the end of life the
coughing and spitting stops as a result of the extreme feebleness and
weakness.
The violence and frequency of the cough depends mainly whether the
larger bronchial tubes and the trachea are affected; the more this is
the case, the more violent the inclination to cough. Further the
strength of the cough depends on the excitability of the patient; the
greater this is, the more as a rule will he cough. Sometimes the
position of the patient is of influence; if he lies mostly on the
diseased side the expectoration becomes more difficult and coughing
increases.
Coughing is generally that symptom which soonest attracts the attention
of the patient and his surroundings. For that very reason consumption is
in its beginning stages easily confounded with such other diseases as
are also accompanied by cough.
At the same time we know of exceptional cases where cough was entirely
absent in the first stages of the disease, or was at least so slight
that it was overlooked, and under such conditions the pale and poor
appearance and reduced strength is mistaken for chlorosis or some other
anaemic affection, also the existing febrile excitements are wrongly
judged, or on account of lack of appetite or light derangements of the
stomach a stomachic affection is surmised, until suddenly a hemorrhage
of the lungs clearly defines the true nature of the ailment.
On the other hand the cough may become so violent that vomiting is
caused at the same time. Nevertheless many consumptives describe their
cough as very unimportant on account of their innate sorrowless nature,
and they will not even be discouraged by the gravest symptoms. Often
however it is fear that induces the patients to make light of their
coughing, their spitting blood, their losing flesh and to place but
little importance on these circumstances. A _hoarse_ cough is a sure
sign of a diseased _larynx_.
Many consumptives complain of cutting pains between the shoulderblades,
under the clavicles or in the side; but these are rarely intense and are
often entirely wanting. Unfortunately it is unknown to the average
layman that the internal organs may suffer extensive tearing down
without an indication of pain.
The _Expectoration_ of consumptives which is thrown out by coughing with
great exertion, is but scant in the beginning, as a rule phlegmy, glassy
transparent and sticky. It is one of the suspicious symptoms of
developing pulmonary consumption if this lasts for any greater length of
time. Sometimes sharply defined, yellowish stripes, at times branching,
appear in the same. Later on the expectoration becomes more purulent,
and of greenish-yellow or greenish-gray color.
Still later the patients throw out rounded lumps of greenish yellow or
yellowish green color, which flatten out like a coin in the spittoon.
They sink in water which is a sign of forboding evil.
_Blood_ appears in different quantities in the sputum of consumptives.
Bloody streaks are of no importance; they may appear with every violent
cough. On the other hand the casting out of _pure blood_ is indeed
serious.
The _quantity_ of blood thrown out during an attack may be very
different, varying from a few drops hardly a teaspoonful, to hundreds of
grammes, even more than a liter. It is generally light red, filled with
airbubbles, foamy, and is largely coughed out in coagulated lumps. The
coughing of blood is sometimes preceded by a feeling of oppression,
rushing of blood to the head and palpitation. Some patients experience a
sweet taste in the mouth even before the bleeding. In many cases all
preceding symptoms are missing and the patient is suddenly attacked by
blood coughing during some more vigorous movement, during the exertion
of coughing or even without any direct cause.
_Blood coughing_ seems to appear somewhat more frequently with the
_female_ sex than with the male and has with them unmistakable relations
to menstruation, as with the sick it often sets in before, often after
or even during the same and at such times more frequently than at
others.
It is of great importance for the layman to know that a hemorrhage
rarely leads to inevitable death. Fatal hemorrhages are always preceded
by warning attacks. Blood coughing may appear at any stage of
consumption. In some cases it is particularly lasting. Sometimes the
patients experience considerable relief from their feeling of oppression
after a hemorrhage.
A number of the consumptives as a rule complain of _difficulty_ in
_deglutition_. This is caused by ulcers on the posterior wall of the
larynx.
With many patients the _appetite_ is _undisturbed_ for a long time, and
there are consumptives that will eat a comparatively large dinner during
an attack of fever reaching 40 deg. C. Generally the desire to eat
disappears during the course of the disease, especially toward the end
of the sickness.
The _stool_ may be normal or costive, but is very often diarrhoetic.
Twelve or more evacuations may take place during a day; as a rule they
are much increased by gasses and are of bad odor. They weaken the
patient very much and hasten the end.
One of the most constant attendants during the course of consumption is
the _Fever_. It is rather irregular. In cases of slow process the fever
is often very insignificant; often it is only a state of general
excitement that takes hold of the patient afternoons, slight dizziness,
increased lustre of the eyes, slightly flushed appearance, somewhat
increased pulse, which invites to test the temperature of the body by
means of a thermometer, which by the way shows it to be about 38 deg. C.
With quick consumption the fever is generally high.
_Sweat_ is also a characteristic sign. The exceedingly debilitating
effect of night-sweats is well known.
During the course of pulmonary consumption extreme _emaciation_ of the
patient is brought about. All tissues are subject to the same, most
marked is the disappearance of adipose tissue. This symptom is of the
greatest importance as a continued increase in weight means improvement
and even cure. Therefore weighing the patient from time to time gives a
sure meter for the course of the disease.
The _course_ of pulmonary consumption is very different. With quick
consumption the end comes within two or three months. Chronic pulmonary
consumption may last for years. With this improvements in the fine
season alternate with deterioration in the winter.
Concerning the former _treatment_ of pulmonary consumption, this will
also be applied in the future in the same manner as far as preventive
means and general hygiene is referred to.
For every one will prefer to remain exempt from consumption although it
may now be possible to cure those afflicted. The lately published and
popularly treated precautionary measures, especially with reference to
the expectoration of consumptives retain their full value.
Henceforth the sputum is also to be thrown in a _spittoon_ which is
either entirely empty or on account of easier cleansing has the bottom
covered with a thin layer of water. It should not be permitted to fill
the spittoons with sand or sawdust as the tubercle bacilli can be easily
thrown up with the dust.
In the case of a _sudden attack_ of _cough_ a _cloth_ should be held to
the mouth to hinder spreading of the fine spray, the same should also be
used for wiping the mouth. However the cloth must soon be dampened and
cleaned.
As bits of the sputum easily stick to the _beard_ especially the
moustache overhanging the lips, therefore lung consumptives are advised
to wear a short or no beard.
_Glasses_, _spoons_, etc. used by consumptives must only be used by
other persons after a thorough cleaning with hot water.
The lungdiseased person should abstain from all active and passive
_kissing_, in unavoidable cases kissing should be done on the forehead
or cheek only, or hold out those parts only to be kissed. In the same
way he should avoid to touch objects with his mouth that may possible be
put in the mouth by other persons, especially children, for instance
toy-trumpets.
In the case of _death_ from pulmonary consumption, the walls of all
rooms and apartments used by the deceased should be rubbed down with
fresh baked bread, which is a sure method of removing the bacilli. The
bread crumbs that may have dropped on the floor may be removed by a
thorough scrubbing with soap, brush and lye.
Upholstered furniture, beds, clothes and wash should be cleaned in a
disinfecting place.
Do not wait with precautionary measures till some member of the family
has been attacked by pulmonary consumption, but make preparation to
prevent the infection while everybody is still sound and healthy.
This care ought to begin in a measure with the _birth of a child_. The
same should not be nursed by a mother with diseased lungs nor by a
wet-nurse with like affections. Generally wet-nurses are only tested for
syphilis; scrofula and tuberculosis receive altogether too little
attention.
An important precautionary measure consists in the supervision of the
_food_. The abattoirs and dairies should be placed under the supervision
of practical physicians, and the sale of products derived from
tuberculous cattle be prohibited. This refers to the milk in the first
instance. Tuberculous cows should be excluded from dairy-farms. Raw milk
should be avoided as much as possible as boiled milk has the same value.
The _meat inspection_ must be strictly conducted especially with
reference to tuberculosis in the case of beef, pork and chickens. Sheep
are not subject to tuberculosis.
The _associations_ of children in school and on the play-ground should
be watched; do not let them visit in strange families before making
thorough investigation as to their sanitary relations.
The health of _servant girls_ should receive greater attention than
formerly, as the disease is often carried into the house by them as
investigation has proven.
In the _schools_ and kindergartens the teacher ought to insist that
children do not spit on the floor or in the handkerchief; in case of
necessity he should keep sick children out of school and he should
especially follow these precautionary measures as regards his own
person.
The _cleaning of the floor_ of a room should always be done in a damp
way.
_Moving_ into another house it is advised to rub down the walls with
fresh baked bread.
As regards _societies_, every society and every health resort without
exception and if possible every hospital should be obliged to have its
own apparatus for disinfection and to make extensive use of it. Smaller
societies may unite to procure an apparatus of the kind.
Especial attention should be given to the _sprinkling of the streets_
during the dry season.
The state and the larger congregations should make it a point to
maintain _institutions for consumptives_, beyond the city limits if
possible, a healthy location in the country preferred.
Every one individually protects himself best from consumption by a
methodic habit of _washing with cold water_, cold rubbing and baths.
River and sea baths are generally of excellent results; short shower
baths with cool water lasting 20-40 seconds are to be applied later
on; they do not only harden the skin but excite deep inhalations and
exhalations and in that way act as gymnastics of the lungs. More direct
is the action of muscular exercise, such as gymnastics, riding horseback
or bicycle, driving, skating, rowing, etc. The carriage of children must
be regulated, the drooping forward of their shoulders must be corrected
by strengthening the muscles of the back and shoulders by means of
dumbbell and other exercises.
All this must still be observed in the future. On the other hand above
all the numberless remedies will be dropped that have heretofore been
applied as presumably specific remedies for consumption.
Creosote, which was so much praised at its appearance a few years ago
and still applied, because of the non-existence of a better remedy, will
be dropped into obliteration and with it Guajacol which was just getting
to be the "fashion".
All the various inhalation methods that have matured in later years will
disappear from the picture plane as far as this has not ever now
happened.
The medical remedies, which were given for the torturing cough, for
hemorrhage of the lungs, sweats etc., will in most cases be superfluous
after this. Hemorrhages will now and then still be experienced as the
same may set in unexpectedly.
The diatetic cures with whey, koumiss, grapes etc. will retain their
importance and also the bathing resorts will be hunted up by patients as
formerly.
The owners also of special institutes for curing pulmonary consumption
need not despair with the idea that they will not be needed in the
future. On the contrary, those needing cure will flock to them in all
the greater numbers, as they now know that they certainly will be
restored to health within a definitely limited time.
The other forms of Tuberculosis.
Of the other forms of tuberculosis _laryngeal consumption_ is very often
combined with pulmonary consumption. It is estimated that this is true
of at least one-fourth of all cases of pulmonary consumption.
At first laryngeal consumption can not in any way be distinguished from
an ordinary inflammation of the larynx. A certain weakness and
sensitiveness of the organs however is suspicious, also great liability
to hoarseness. On the other hand laryngeal consumption may exist without
any sort of ailing to the patient.
These appear later, however, when lung tuberculosis is progressing. The
larynx shows more distinct outlines on the lean throat, difficulty in
swallowing is experienced, pains radiate toward the ear. Food and drinks
come up again after being swallowed.
The painful cough has a hollow, barking, harsh sound, provokes vomiting,
and the sputum together with foul breath consists of foamy, slimy,
purulent lumps. Breathing gradually becomes more difficult and louder.
As regards the duration of laryngeal consumption it generally runs
parallel with pulmonary consumption. If the latter progresses more
rapidly so also will the destruction of the larynx by the
tubercle-bacilli be a more rapid one and vice versa. In several cases it
has been observed that, if pulmonary consumption progressed or remained
without any extraordinary symptoms, those with diseased larynx have
lived for years, with alternating improvements and diminutions, and also
an occasional suspension of all symptoms, till on account of often only
a trivial, evil influence a new stimulus is given and the disease found
an unexpectedly rapid completion of its course.
Until now only few cases of laryngeal consumption could be looked upon
as really cured. Lately it has been tried to accomplish cures especially
by the application of caustics. This will not now be necessary. But
those afflicted in this way, will henceforth be obliged to try and live
in air free from dust, to travel south during the winter and to subject
themselves to a general strengthening treatment.
_Tuberculosis_ of the _tongue_ is relatively very scarce. The individual
in such a case nearly always shows pronounced pulmonary tuberculosis.
Sometimes tuberculosis of the tongue is combined with tuberculous sores
on the lips and also on the anus.
Tongue tuberculosis forms small ulcers, generally on the rim, very
seldomly on the back of the tongue. They always are very small,
generally about the size of lentils or peas. They often remain unchanged
for months. At times they are very painful, though as a rule the pain is
mild. The male sex is attacked by tongue tuberculosis especially
frequently.
The treatment before this consisted in cutting out all the diseased
parts; now it will be much simpler.
_Nasal tuberculosis_ appears similar to the common stopping up of the
nose. But when ulcers are formed, the secretions from the nose take on a
purulent somewhat malodorous character. But if the affection is
neglected, the secretion becomes bloody and of very bad odor.
Until now nasal tuberculosis had been treated by applying caustics to
the ulcerated portions.
_Tuberculosis of the intestines_ or _intestinal consumption_ is
especially found in _children_. The appearance of the same is already
characteristic; the limbs are emaciated and withered; the old-looking
wrinkled face shows a harsh contrast with the immoderately expanded body
(frog-belly) which is caused by an accumulation of gases in the limp
intestines which are then filled to bursting. Many such children have
succumbed to gradually progressing emaciation and weakness.
Probably it will not be possible to save all children in the future that
have been stricken with this disease as many are wanting in sufficient
vitality to resist all external influences.
With adults intestinal consumption makes itself known by everlasting
diarrhoea, a result of the numerous ulcers in the intestines which have
been caused by the tubercle-bacilli.
_Tuberculosis of the brain and of the cerebral membranes_ also attack
children especially. Before this no attempts have been made to try
whether it is now possible to cure the _tuberculous inflammation of the
cerebral membranes_ which has previously been unconditionally fatal. The
decision will certainly soon be made.
We will give a fuller description of the symptoms of this disease to
thus enable timely summons of medical interference. This disease will be
known to many as "acute hydrocephalus."
As a rule children of 2-7 years of age are attacked by this fearful
disease. The antecedents are extremely peculiar and manifold. Even two
or three weeks before the outbreak of the real sickness, emaciation
takes place from which the face is strangely enough entirely exempt, so
that children, when dressed show no signs of a change. Attentive mothers
and nurses, however, regularly notice the same and especially the
appearance of the ribs causes no little anxiety. With this a slight
pallor of the face is associated and a peculiar lustre of the eyes. The
children lose their former feeling of gayety and activity. They sleep
more than usual, withdraw from their favorite game, they become grumbly
and shy toward their surroundings and cry for the slightest reason. It
also is very peculiar that they avoid trying their former little tricks,
such as climbing up on chairs, opening of door bolts that are almost out
of their reach, they even will not try to look through a latticed window
and asked to do so, decidedly refuse. Boys, that would not stand
anything from their associates, that fought and wrestled as long as
their strength permitted it, sneak away cowardly and crying from such
attacks. Other children again become extraordinarily tender-hearted and
affectionate, they hug their parents continually and can hardly console
themselves when they leave them.
In the case of older children that have already learnt something,
teachers notice unusual inattention and indifference, committing to
memory comes harder than usual and what is finally learnt is recited in
an awkward and stammering way. The children sleep unusually much and
often by day; on the other hand their sleep at night is less sound and
is interrupted by horrid dreams, frequent turning over in the bed and
frequent clamorous outcries.
The appetite is lessened, and often a craving is noticed for stimulating
food of which, however, little is eaten. Thirst is not increased. Urinal
secretion is somewhat diminished and the urine is characterized by a
brick-colored precipitate. The stool is rather costive, especially with
larger children; but diarrhoea may attend this disease. The latter is
principally the case with small children that are in the stage of first
teething.
Headache is rarely felt and hardly ever complained of even by larger
children; dizziness and unsteady walking is frequently observed. The
children quite often complain of stomach-ache, which is very much
increased by pressure on the abdomen.
Fever is not generally attendant, but the same may be present.
The symptoms just described, separately or collectively, gradually
increase; the children finally take to their bed and now the _real
cerebral affection_ developes.
Now the principal symptoms are: vomiting, constipation, slow pulse,
irregular abrupt breathing, increased temperature of the skin,
contracted abdomen, headache, great excitement alternating with
drowsiness, beginning decrease of reason, and deranged ability of moving
the limbs.
As regards _vomiting_, this is almost a continuous symptom and generally
appears in the earlier stages. But the duration of vomiting is very
different. Some children vomit only for one or more days and not all
they have eaten, while others vomit continuously from the beginning of
the disease till they are relieved by death, and no food can be found
that is not thrown up shortly after its being eaten. In this connection
it is a peculiar fact that vomiting will not recur if it has once ceased
for twenty-four hours.
Very important for the recognition of the disease is the manner of
vomiting. For a child suffering from a spoiled stomach will be troubled
with nausea, belching, choking and cold sweat long before it is forced
to vomit, while children with acute hydrocephalus will throw up without
any previous symptoms of that kind, just as though they filled the mouth
with water and spit it out again. Vomiting is facilitated when children
are raised or placed on their side. It ceases for the time the stomach
is empty, but as soon as fluid or even solid food is taken in it will be
cast out at once without causing any particular distress or
inconvenience to the child. Gall is very rarely mixed with the vomit.
A second and nearly as constant a symptom is _constipation_ from which
nearly three-fourths of the diseased children suffer. As a rule
cathartics have no effect and are generally thrown out through the
mouth. This constipation will not last till the end, for a few pappy
stools appear later on whether purgatives are administered or not.
Violent diarrhoea resulting from intestinal tuberculosis may be
discontinued at the beginning of acute hydrocephalus. But the later
stools will again be thin and of cadaverous odor.
During the latter stages of the disease children will often _fail to
pass urine_ for twenty-four hours, so that the physician is obliged to
draw it off with a catheter.
The appetite does not disappear entirely as a rule. There may not be any
desire for food, but generally little difficulty is experienced in
inducing children to take milk or broth, which is all the more
surprising as vomiting regularly follows.
The _fever_ is generally not very intense. The temperature of the head,
especially the forehead, is considerably increased in all cases and
remains so until death ensues, while the feet have great tendency to
getting cold.
The _pulse_ is characteristic in many cases. In the beginning of the
disease the pulse is quickened only to slacken after a few days. The
number of beats may be reduced to 40-60 a minute (normal 90-100),
however it does not commonly remain at a certain figure, but varies,
often inside of an hour, so that at one time 40, then 60 and again 80
beats may be counted inside of twenty-four hours.
The pulse again increases 1-3 days before death and then to such a rate
that it is almost impossible to count it. It may reach 180 and 200 beats
a minute. As soon as this rate of the pulse follows one of the
reductions described above a speedy death may be predicted.
Of great importance are the variations in respiration. In the beginning
stages of the disease breathing is normal except in such case where
tuberculosis has made great progress in the lungs and in the case of
high fever. Then of course breathing becomes more rapid. Acute
hydrocephalus influences respiration in such a way that it slackens and
becomes irregular. In one minute children may breath fifteen times, in
another thirty, then again 20 times; at one time breathing may be very
slight with almost invisible expansion of the chest and without any
noise whatever, then again it may consist of deep sighs; these are also
characteristic of this particular disease. Sometimes breathing is
completely discontinued for ten seconds and more.
If the pulse attains that extreme rate shortly before death the rate of
breathing will also be increased.
As regards the _skin_, the same is generally damp from the beginning of
the disease; severe sweats are observed on the head; with progressing
disease the skin becomes dry, brittle, comes off in flake-like scales
and only when the death-predicting increase of the pulse sets in, there
appears a profuse sweat, the cold sweat of death.
_Headache_ is also a prominent and pretty nearly constant symptom. As
has been mentioned before, it does not as a rule attend the precursory
symptoms. It generally begins with vomiting and soon becomes so violent
that older children constantly cry aloud and lament, while the smaller
ones put their little hands up to their head, pull their hair and ears
and restlessly roll about on the pillow.
These expressions of pain last as long as children retain consciousness,
a particular part of the head is not commonly pointed out, but asked
about it the majority point to the forehead. With small children
automatic movements are noticed that also seem to refer to headache, and
which consist in rapidly placing the hand on the head and then drawing
it back.
The larger children complain of _pains in the bowels_, especially in the
region of the stomach, which remarkably often, though not regularly,
become more intense by pressing and may become so violent that the
children cry out aloud with pain, when the stomach or other portion of
the abdomen is but slightly touched. But these pains do not last as long
as the headache, they often stop suddenly, at times return.
The shape of the _abdomen_ is extraordinarily characteristic. In the
beginning nothing remarkable can be noticed, but after the symptoms of
acute hydrocephalus, vomiting, constipation, etc., have lasted for some
time, the abdomen gradually decreases in size, becomes wrinkled and
collapses until it finally assumes a scaphoid shape and by slight
pressure the large iliac artery can be felt on the spinal column.
This contraction of the abdomen is attendant in every case of
tuberculous meningitis.
If the large _fontanel_ on the head is not yet closed, the same will
gradually bulge out as the disease progresses.
The _mental activity_ suffers premature derangements, such as have been
fully mentioned in the description of the precursory symptoms. The most
striking is the confused, staring look, the peevish and surly behavior,
and again in other cases the extreme indifference toward otherwise
well-liked persons and things. Later on actual delirium sets in, but
generally of a quiet nature.
A very common symptom is a loud, plaintive outcry, that is repeated at
longer or shorter intervals. Children often cry out at partly regular
intervals during a whole night; these cries are always accompanied by a
loud sigh. These symptoms of excitement being extremely tormenting and
depressing for the sympathizing relatives, fortunately last no longer
than 6-8 days at the most, and are succeeded by a deep _stupor_.
If the children have once become _unconscious_, they do not recover
again as a rule but remain so until death; delirium and stupor may
alternate with each other in certain cases, but the former process is by
far the most frequent.