between the attacks are long, often as many as three or four days
intervene. Commonly however they come much oftener and may in some cases
last for hours. All extremities are affected by these convulsions, the
eyes become red, are rolled in every direction and turning way up are
fixed so that nothing but the whites is visible. After several minutes,
often after two or three hours, these general convulsions subside, the
children, now very pale, drop into a deep sleep and their general
condition appears much reduced.
Different muscular groups especially those of the face are subject to
_local cramps_. The upper lip may become distorted, convulsive smiles
have been observed, also peculiar sucking motions. The children point
their lips and flatten them again, sometimes for hours in succession.
In the latter stages a squinting of one or both eyes may be noticed but
this may again disappear.
_Grinding of the teeth_ is another very peculiar symptom which is
well-known and feared by experienced nurses. The _arms_ are subject to
various motions, at times sweeping automaton like, then again convulsive
contractions, sometimes trembling of the muscles, at others a throbbing
of the tendons. Many patients put their hands to their sexual organs and
make motions tending to onanism.
The _legs_ are not subject to cramps as much as the arms; they are
mostly bent and drawn up in a half paralyzed condition.
The _muscles of the neck and back_ are very much contracted and most
children, when raised or laid on their side, bend the head far back.
In most children an extreme sensibility at being touched is observed.
They may be handled with the greatest possible care and lifted most
tenderly, a slight pressure on the head, body or hands in changing their
position will be violently resisted with obvious expressions of pain. In
the latter stages this extreme sensibility gives way to _insensibility_.
Then the children may be pinched and poked, they may be turned and moved
from one side to the other without any consideration, they will not
resist and only give expression to the remaining sensibility by a low
whimper. The lack of sensibility may be especially marked in the eyes;
these can be touched with the fingers, without causing a closing of the
lids.
The sense of _hearing_ seems to continue its functions until very late.
Children show that they hear as long as they are not completely
unconscious; even when addressed in a low tone of voice they react
somewhat. The sense of _smell and taste_ also are lost toward the very
end of the disease.
_Paralytic_ affections appear during the final stages. It has been
observed in some cases that the arm and limb are paralyzed on one side
only. Often one upper eyelid is paralyzed and hangs down on one side of
the face and the muscles of the tongue may be affected.
Generally the patient dies after violent general convulsions that last
for hours. Exceptionally only the paralytic symptoms increase gradually
and cause death without any agony or struggle, simply a discontinuance
of the functions constituting life.
The duration of the disease varies from 2-4 weeks from the beginning of
the characteristic symptoms. Generally the day when the children take to
the bed is fixed as the beginning of the disease.
The former methods of treatment have been a signal and absolute failure
in every case. Every child that has once been attacked with this disease
has heretofore died. Until now Koch has not been able to make any
experiments with acute hydrocephalus, so that it remains an open
question whether it is now possible to cure this disease.
Besides tuberculosis of the cerebral membranes with which children are
afflicted, _tuberculosis of the brain_ may occur, although this disease
is very rare. Tuberculosis of the brain appears in the shape of small
tumors in all parts of the brain. After longer duration of tuberculosis
of the brain, tubercular meningitis appears.
The process of this disease may be varied. In some cases the development
of cerebral tuberculosis is manifested by the sudden appearance of high
fever temperatures or violent headache; to this may be added,
slackening of the pulse, vomiting, stiff neck and isolated cases of
palsy; sometimes an attack of convulsions is the first manifestation.
In other cases the beginning can not be accurately determined, as the
beginning symptoms of the disease are so slight as to escape notice.
Impaired process of nutrition, languor and headache are symptoms from
which the existence of some serious affliction may be inferred without
being able to determine its nature in the earlier stages.
Again in other cases the disease may proceed through all its stages
without any cerebral appearances whatever. This is especially true of
small tubercles and of diseases of infants. However, we more frequently
observe in children than in adults convulsions of varied intensity and
distribution.
Nutrition is more and more impaired as the disease progresses, in
isolated cases only, a temporary improvement may be observed.
The _end_ of cerebral tuberculosis has been _death_ before this. Ten
days to two weeks, even three weeks may pass from the first appearance
of tubercular meningitis to the completion of the process of the
disease, attended by feverish motions characteristic of this condition
and by cerebral symptoms, first with the character of excitement, later
on with that of palsy.
The treatment of cerebral tuberculosis has been entirely insufficient
before this. Let us hope that it will be possible to effect a cure by
means of Koch's new method.
_Tuberculosis of the Kidneys_ is met with from the earliest childhood
till old age. Most frequently the male sex is afflicted during manhood.
In most cases tuberculosis also exists in other organs, especially in
the urinary and sexual apparatus. The existence of pulmonary or
intestinal tuberculosis is not essential.
The symptoms of renal tuberculosis are of such general and indefinite
character, that it is often impossible to fully determine the disease.
Now, however, it will be more easily possible on account of Koch's
discovery.
The _urine_ may, but need not contain pus and blood. Sometimes small
lumps are found in the urine.
_Pains_ are only sometimes felt in the renal regions; _fever_ may be
occasionally attendant.
The disease lasts for months and years; though before now it has
inevitably resulted in death, though it has in exceptional cases taken
ten years or more.
The internal treatment of renal tuberculosis was ineffectual, surgical
treatment has been attended with greater success. This consisted in
removing the diseased kidney. Now good results will possibly be attained
by the application of Koch's method to cure and resource to surgery will
be taken in exceptional cases only.
_Tuberculosis of the suprarenal capsules_ is of very rare occurrence. It
leads to a peculiar change in the color of the skin; the same turns dark
brown or bronze color. Sooner or later death results.
Perhaps the application of Koch's method will, besides curing the
disease, give us information regarding the functions of the suprarenal
capsules about which nothing whatever is as yet known.
A large space in the realm of disease is claimed by _tuberculous
affections of the bones and joints_. These afflictions appear
particularly in childhood though manhood is by no means exempt. They may
appear in all portions of the body, although a marked preference is
shown for certain parts. Although the tubercle-bacilli are infinitely
small, they possess the power to cause suppuration of the bones and
joints and to produce acute inflammation of these parts.
Most frequently tubercular affections of the bones are found in the
hip-joints, the knee and the spinal column.
_Tuberculous inflammation of the hip-joint_ is principally a disease
occurring in childhood; though it rarely appears before the third year.
It is most frequent from the fifth to the tenth year.
Inflammation of the hip-joint developes very slowly in children, it
generally takes months before the slightest beginning symptoms reach a
threatening appearance. The first sign is _lameness_; among laymen
tuberculous inflammation of the hip-joints is known as "voluntary
limping."
By limping we understand that mode of walking in which one leg is spared
and by this the trunk is supported only a short time by one extremity
and all the longer by the other. In every painful affection of the lower
extremity limping results as the weight of the body increases the pain.
The lameness in the case of diseased hip-joint has something peculiar
about it, inasmuch as not only a part of the extremity but the whole of
it is dragged. For this very reason parents of children afflicted with
inflammation of the hip-joint use the expression "the child draws" or
"drags the leg".
In the beginning even the examining physician finds no symptoms of
disease in the joint. No swelling, no abnormal position, no restriction
of the freedom of motion, no pain from pressure or while moving, in
short nothing can be found that would otherwise indicate the beginning
of an inflammation of the joints.
Yet _lameness only_ is sufficient data from which we may infer the
probable beginning of hip-joint inflammation. It is much better to
overestimate the significance of this symptom than to miss the proper
time for calling in the aid of a physician by placing too little
confidence on it.
The second symptom, _pain_, rarely attends the beginning of lameness,
generally it comes several weeks later and in the case of very slow
development of tubercularly inflamed hip-joint several months later. In
very small children the attendance of pain is manifested by the fact
that they will not play and they often wake up in the night and begin to
cry.
Children from the fourth and fifth year upward definitely point out the
hip as the seat of pain, sometimes, however, the knee-joint on the
diseased side is designated with great determination. This pain in the
knee has often been the cause of mistakes.
Later on painfulness of the hip-joint is experienced from pressure and
at about the same time the movements are impeded.
Then the leg takes a peculiar position. The thigh is slightly bent and
rolls outward. For convenience the child drops the half of the pelvis
corresponding to the diseased hip-joint, and naturally raises the other
half. From this apparently a curvature of the spinal column results in
the lumbar region. Apparently only, for when the child is laid down and
the morbid position of the thigh is restored the curvature of the lumbar
column disappears.
During the further progress of the disease the pain is increased, and
the sensibility may become so acute that the slightest movement of the
limb, even a shaking of the bed in which the patient lies will cause the
most intense pain. In the previous stage walking could only be done for
short distances and then awkwardly, now it is entirely impossible.
Children are obliged to lie in bed night and day, and under these
altered conditions there is a change of the position of the extremity.
The increased sensibility induces the child to seek the medium position,
the leg is bent more than in the position mentioned above, it is halfway
straightened.
To this is added, that the child can not lie well on the sensitive and
swollen hip; with right side hip-joint inflammation it turns on the
left. As the diseased and bent thigh does not then rest on the mattress
the same is placed on the healthy limb for support and for protection
from movements, in the same manner as we lay one leg on the other in a
healthy condition when we sleep on our side.
The actual danger to life in tuberculous hip-joint inflammation begins
with the time when the child takes to his bed. The fatal end comes
almost without exception after suppuration has commenced, very rarely
before that time. Total suppuration of the hip-joint is an almost
absolutely fatal process. If this suppuration sets in suddenly, it may
result in an early death with attendance of acute fever. In other cases
several weeks may elapse from beginning suppuration till death.
A complete cure of tuberculous hip-joint inflammation may come about
spontaneously. But often the knee remains bent and unserviceable for
walking, so that crutches or machines must be used.
Even before this the beginning stages were treated with fair prospects
of success, and it is a lamentable fact that in many cases the import of
these seemingly trivial symptoms has been underestimated.
_Rest_ is of the greatest importance during the very first stages of the
disease in which the attending symptoms are of so indefinite a character
that it is almost impossible to know whether hip-joint inflammation will
develop or not; the child must not be allowed to walk. Aside from this
the application of brine-, malt- and sea-water baths is advised. An
abundance of nourishing food is of just as great importance. All this
will also retain its significance in the future.
Formerly recourse to surgery has been taken during the later stages of
the disease in which suppuration of the internal parts of the joint has
commenced and large parts of the diseased bones may have become
mortified. An incision is made into the joint, the same is exposed and
all diseased portions are carefully removed. In the future this
operation must probably also be performed, although with the difference
that the prospects of success are now much more certain than formerly
when relapses only too often followed the operation.
_Tuberculous inflammation of the knee-joint_ is, as said before, very
frequent with children and is rather lingering in the beginning. Here
also a slight dragging or limping of the diseased leg can be noticed.
The child when asked about the limping, or of its own accord, complains
of pain in the joint after walking or when the part is pressed; at first
nothing abnormal can be seen on the knee by the layman.
On closer examination, however, by comparing the two knees it will be
found that the grooves on each side of the patella, which give the
healthy knee-joint the beautifully modeled shape, have nearly or quite
disappeared; nothing more can be noticed.
The hinderance in motion may be so insignificant, that the children may
slightly limp about for weeks and months and complain but little.
Generally the physician is not called until the limb begins to hurt and
swell after continued exertion.
The swelling which in the beginning is hardly noticeable is now more
plainly visible, the knee-joint is evenly rounded and quite sensitive to
pressure.
If the disease is not now properly treated, its further course will be
as follows: the patient may perhaps linger for several months; then
comes a period when he must keep to his bed uninterruptedly because
moving results in too much pain; generally the limb becomes more and
more bent.
Now particularly painful points appear on the joint, especially on the
inner or outer side or in the bend of the knee; on one of these points a
soft portion distinctly developes, the skin becomes reddened and finally
suppurates from the internal parts outward and breaks after a few
months; thin purulent matter mixed with flakes is discharged. The pains
now cease, and the condition is improved; but this improvement does not
last; soon another abscess is formed and thus it continues.
Meanwhile perhaps two or three years may have elapsed; the general
condition becomes greatly reduced. The child, formerly strong and
healthy, has now become lean, the discharges of matter have often been
attended by acute febrile attacks; the patient becomes exhausted, loses
his appetite and digestion becomes more impaired from week to week. Even
now a spontaneous change for the better is possible, though this happens
very rarely; more frequently the disease progresses and leads to death
from exhaustion resulting from severe suppuration and continual attacks
of fever.
Restoration to health is indicated by decreased suppurative discharges;
the openings of the fistulae contract, the general condition is
improved, the appetite is restored, etc. Finally the fistulae heal, the
joint becomes fixed at an angle or bent or otherwise crippled, but
painfulness disappears and the patient escapes with his life and a stiff
leg. This is the most favorable result known to have been obtained in
severe cases. The joint may become a solid bony immovable mass or may
admit of slight movements. The whole process may last from two to four
years.
The former treatment of tuberculous inflammation of the knee-joint was
either of a general or a local nature. The general treatment was
designed to strengthen and nourish, and will continue to be applied in
the future.
The local treatment consisted in the application of salves, brushing
with tincture of iodine, spanish fly plasters, wet and dry bandages. As
with inflamed hip-joint absolute rest by lying in bed is of the greatest
importance.
If after a certain period of rest and application of the above-named
remedies no improvement in the state of health could be noticed, the
diseased joint was laid in plaster or confined with splints.
If even then, after such treatment for months, no improvement could be
noticed but rather that the general state of health was reduced, nothing
remained to be done excepting an operation, by which all the diseased
parts of the knee-joint were removed, or amputation, that is, the taking
off of the diseased limb. The latter method was generally adopted in the
case of feeble and emaciated individuals and those who had passed the
age of early manhood, as with these the removal of the diseased parts
did not, as a rule, result in an improvement of the general condition,
which was especially intended.
Now tuberculous inflammation of the knee-joint will be treated by Koch's
method and in extreme cases only will operation be necessary. At all
rates, an absolute cure will be easily effected.
Aside from the hip- and knee-joint the _spinal column_ is most
frequently attacked by tuberculosis. Here also it is the youthful age,
from the third year upward, that has to suffer most from this serious
disease. Adults are rarely attacked by it and with them it generally
appears in connection with general tuberculosis.
The tubercle-bacilli penetrate into the substance of the vertebrae,
destroy the same and transform it into purulent matter. As a result the
destroyed vertebrae sink or rather settle down and cause a curvature of
the spine, in other words a humpback.
In the beginning the symptoms of diseased spine are very indefinite and
misleading. The patient rarely complains of pain at first, and it is
only noticed that the sick child easily tires of standing or walking and
tends to hold on to chairs and similar objects with his hands to relieve
the spinal column of the weight. From such uncertain data it is of
course impossible to recognize the disease.
Only then when the softened vertebrae give way under the weight of the
body, that is when the humpback begins to develop, can tuberculous
inflammation of the spine be surmised with any degree of certainty.
As a rule two other characteristic phenomena appear which are dependent
on the pain in the affected spinal column. The child, while standing,
places his hand on the thighs and thus directly supports part of the
weight of the trunk with the lower extremities; at the same time he
avoids bending the spinal column forward. This anxious care for the
diseased vertebrae is especially noticeable when the child attempts to
pick up an object from the floor. While the healthy child bends freely
forward, the sick one crouches down and while bending the knee and hip
keeps the spinal column as straight and stiff as possible. Frequently a
small spot on the spinal column is found to be extremely sensitive to
pressure in this stage; but such a subjective symptom must be considered
with caution especially with children.
This humpback, which is a result of tuberculous inflammation of the
spine, must not be confounded with the humpback caused by rickets. With
the latter the curvature is more uniform as a rule, and in the start at
least, disappears while in a horizontal position. Besides the humpback
resulting from rickets appears between the first and fourth years of
age, while tuberculous inflammation of the spine rarely begins before
the fourth year. And finally rickets never causes suppuration while this
is always the case with inflammation of the spine.
The progress of suppuration is downward as a rule and does not admit of
examination until it gets near to the surface of the body; before this
the feverish conditions toward evening are the only signs that indicate
beginning suppuration. Ardent fever is not attendant during this time;
the temperature does not exceed 38 or 38.6 deg. C. and even such trifling
increase of temperature may be wanting.
As soon as the skin is reached by the originally deepseated centres of
suppuration, it gradually becomes red and later on also suppurated. If
the skin is broken and the matter discharged, great care must be taken
to keep the wound clean, as otherwise the suppurative cavities may
suddenly become ichorous and lead to rapid death. In other cases this
extreme result is not caused and fistulae are formed from which the
ichor constantly flows. Small bits of mortified and broken off bones may
be thrown out with the matter.
As a result of the sinking and settling of the vertebrae the spinal
chord may suffer from pressure and contusion as it is contained in a
channel formed by the vertebrae. Aside from certain pain it may result
in paralysis of certain parts.
Formerly the diagnosis of tuberculous inflammation of the spine in its
beginning stages was very uncertain. A great number of afflicted are at
present cured by surgical treatment; in former times this was not
possible, as the majority of patients died in whose case the disease had
progressed to suppuration. But the curvature of the spine could not be
removed by any former treatment and can not be by Koch's new method.
Vertebrae once destroyed can in no way be restored to their normal
condition.
Nevertheless the number of patients whose life is spared will be a still
greater one and the number of complete cures will also be increased in a
short time. Formerly tuberculous inflammation of the spine was treated
as follows: the abscesses were opened and antiseptics carefully applied:
mechanical apparatus and corsets were used to aid in a natural cure.
These apparatus will surely be of inestimable value at the application
of Koch's method.
As has been stated before tuberculosis may attack all other bones and
joints and there cause the most serious derangement. Formerly these
tuberculous afflictions were treated surgically or by means of iodoform,
which has produced pretty good results in certain cases.
However it will certainly be possible to produce still better results
with Koch's method of treatment, especially in the restoration of the
functions of the afflicted parts. Here, as in all tuberculous
affections, it is particularly essential to subject the respective case
to treatment in as early a stage as possible and before incurable
destruction of the tissues of the bones and joints have been caused.
A certain disease of the skin called _lupus_ (ringworm) must be counted
in with the number of diseases generated by the tubercle-bacillus.
Lupus may begin in two different ways. Either in the form of a purple
spot, which is raised above the level of the skin and which has no
definite limits but blends with the healthy parts; or as a slightly
raised, moderately firm, darkred grain, sharply limited and about the
size of a pinhead or millet seed.
If the disease has begun in the shape of spots, the afflicted portions
of the skin gradually swell during the process of the disease. Several
isolated knots appear around which the disease spreads more and more.