course in _gymnastics and rubbing-down with cold water_. To begin with
the water may be 72 deg. but should gradually be reduced to the natural
temperature of well water.
Just how far Koch's new method will take the place of former remedies
used for scrofula can not be told at present as experiments in this
direction are wanting. Nevertheless it will be possible to prevent the
dangerous transition of scrofula into tuberculosis and thus save the
lives of a great many persons.
Anyone who has informed himself through the foregoing as to the great
number of diseases and forms of disease that are directly or indirectly
connected with tuberculosis, will now be able to estimate the
farreaching import of Koch's discovery. It will now be clear to him that
pulmonary consumption constitutes only a part, although a great part of
tuberculosis and that there are a great many diseases besides that can
now be surely cured, it is hoped, with the aid of Koch's method. But
this much should be remembered by everyone that this remedy also acts
best and surest during the _beginning_ of a disease. We hope that no one
will allow valuable time to slip unimproved; it may easily happen that
it is too late for successful treatment. Everyone will be able to
recognize the symptoms of diseases, which Koch has taught to cure, from
the foregoing complete description, and it is better to apply the remedy
once too often than miss the proper time for application.
Koch's first communications relating to the subject have just been
published and will be given unabridged in the following pages. As these
communications are written for physicians we will add such explanatory
notes as are deemed essential for general intelligence.
[Illustration: DR. KOCH IN HIS LABORATORY]
THE FIRST COMMUNICATION
_Relating to a Method to Cure_
TUBERCULOSIS,
BY
Prof. R. KOCH, Berlin.
In a lecture, delivered by me several months ago, at the International
Medical Congress, I referred to a remedy, which makes animal subjects
impervious to the inoculation of Tubercle-bacilli, and in the case of
diseased animals, checks the progress of the tuberculous disease. In the
meantime experiments have been made with human subjects, about which I
will report in the following.
Originally I intended to complete my investigations and especially gain
sufficient experience concerning the practical application of the remedy
and its production on a larger scale before I published anything
concerning it. In spite of all precautions too much has already been
published about it, and that distorted and exaggerated, so that I was
obliged, in a way, to prevent false conceptions, to give even now a
synopsis of the method as far as it has progressed at the time being.
Under present circumstances it must necessarily be short and leave
unanswered many important questions.
The experiments have been, and are still being made under my direction
by Dr. A. Libbertz and Stabsarzt Dr. E. Pfuhl. The necessary subjects
and material have been provided by Prof. Brieger from his Polyclinic,
Dr. W. Levy in his Private Surgical Clinic, Geheimrath Fraentzel and
Oberstabsarzt R. Koehler in the Charite-Hospital, and Geheimrath Herr
v. Bergmann in the Surgical University Clinic. To all these gentlemen
and their assistants I here tender my heartfelt thanks for their
untiring interest which they manifested for this subject and also for
the disinterested help and aid which they have offered at all times and
without which it would have been impossible for me to make such progress
in a few months in this difficult and responsible investigation.
As my work is far from being completed, I can not as yet make any
statements relating to the origin and preparation of this remedy and
reserve these for some future time.[1]
The curative is composed of a clear brown fluid, which in itself is not
perishable, even without special precautionary measures. For use this
fluid must be more or less diluted and these dilutions are perishable
when made with distilled water; Bacterian vegetation soon develops in
them and they become turbid and are no longer fit for use. To prevent
this the dilutions must be sterilized through heat and be kept under
cotton batting or be prepared with a 5 per cent. phenol solution which
is much simpler. Through repeated heating as also through the mixture
with the phenol the efficiency of the diluted solution appears to be
curtailed after a time and for that reason I have always used solutions
as fresh as possible.
The remedy does not act through the stomach; to effect a reliable action
it must be applied subcutaneously. For our experiments we have
exclusively used a syringe decided upon by myself for bacteriological
purposes, which is supplied with a small india-rubber ball and which has
no stamp. Such a syringe can be easily kept positively aseptic by
rinsing with absolutely pure alcohol and on this we base the fact that
not a single abscess has sprung from over a thousand injections.
After trying various parts of the body as places for application we
selected the skin of the back between the shoulderblades and in the
lumbar region, because at these places the injection was almost painless
and caused the least and in most cases no local reaction.
Even at the beginning of our experiments we found that in one
particularly important point the human subject was affected by the
curative in a way decidedly differing from that of the animal subject
generally used, the guinea pig. Therefore another confirmation of the
rule for experimentors upon which hardly enough stress can be laid, not
to rely upon a like effect upon the human being from the experiments on
the animal without further confirmatory inquiry.
Man proved himself much more sensitive to the effects of the remedy than
the guinea pig. Up to two cubic centimeters and even more of the
undiluted fluid could be injected under the skin of a healthy guinea pig
without causing any particularly disparaging effect. In the case of a
fullgrown man on the other hand, 25 ccm. are sufficient to produce
intense results. In proportion to weight of body therefore 1/1500 of the
amount which has no noticeable effect on the guinea pig has a decidedly
strong effect on the man.
From an injection that I have made on my upper arm I have experienced
the symptoms which arise in man after an injection of 25 ccm., in short
they were the following: Three or four hours after the injection a
raking pain in the joints, languor, inclination to cough, oppressed
breathing, which rapidly increased; in the fifth hour I experienced
intense chills which lasted nearly an hour, at the same time nausea,
vomiting, increase of the temperature of the body to 39.6 deg. C. After
about 12 hours all these affectations ceased. The temperature sank and
reached the normal height the next day. Heaviness of the limbs and
languor lasted for a few more days, and for the same length of time the
place of injection remained red and painful.
The lower limit of effect of the curative for a healthy man is about
.01 ccm. (= 1 cubic centimeter diluted with a 100 parts) as numerous
trials have shown. The majority reacted on this dose with only light
pain in the joints and passing languor. With a few a slight rise in
temperature set in, to 38 deg. C. or a trifle higher.
Although there is a marked difference as regards the dose of the
curative (according to relative weight of body) between the animal
subject and man, an evident resemblance is shown in several other
qualities.
The most important of these qualities is _the specific action of this
remedy on tuberculous processes of whatever kind they may be_. I will
not relate the effects on the animal subject in this connection, as it
would lead too far, but will at once turn to the peculiar effects on
tuberculous human beings.
As we have seen, a healthy man reacts but little or not at all on
.01 ccm. The same is true of diseased persons, provided they are not
tuberculous. But the relations are entirely different with those
afflicted with tuberculosis; a marked general and also a local reaction
resulted from an injection of the same dose of the remedy (.01 ccm.)[2].
The general reaction consists of an attack of fever, which, beginning
mostly with chills, raises the temperature to over 39 deg., often up to
40 deg. and even 41 deg. Other noticeable symptoms are pains in the
joints, a tendency to cough, great languor, and often nausea and
vomiting. Several times we observed a faint icteric coloring and in some
cases the appearance on neck and breast of an exanthema resembling
measles. As a rule the attack begins 4-5 hours after the injection and
lasts 12-15 hours. In exceptional cases it may begin much later, but
then it is not nearly so intense. The patients experience remarkably
little weakness from the attack and feel relatively well as soon as it
is over, generally better than they did before it came on.
The local reaction can best be observed on those patients whose
tuberculose affection is plainly visible, for instance those afflicted
with lupus. In them changes take place that prove the specific
antitubercular action of the remedy in a most surprising way. The
diseased portions of the skin in the face, etc. begin to swell and turn
red even before the attack of chills set in, although the injection is
made under the skin of the back, a point decidedly remote from the
affected parts. The swelling and reddening increases during the fever
and can attain a very marked degree so that the lupus-tissue turns
reddish brown and necrotic. In the case of more sharply defined lupus
centres the more swollen and dark red parts were edged by a white seam
nearly a centimeter wide and this again was surrounded by a wide bright
red border. The swelling of the diseased parts gradually decreases after
the cession of fever and may have entirely disappeared after 2 or 3
days. A serum exudes from these lupus-centres and, drying, forms a crust
on them which changes into scabs that fall off in 2-3 weeks and
sometimes leave a smooth red scar after a single injection. Generally
several injections are necessary to effect a complete removal of the
lupose tissue, but of this I will speak further on. It is very important
to note that the changes during this process are exclusively limited to
the portions of the skin affected by lupus; even the faintest and
smallest bits of diseased tissue go through the entire process and
become visible on account of their swelling and reddening, while the
actual scab-tissue in which the various stages of lupus have been
completed remains unchanged.
The observation of the treatment of lupus with the remedy is so
instructive and must be so convincing as regards the specific nature of
the remedy that every one wishing to occupy himself with the study of
this remedy should if possible make his first experiments with lupus.
Less marked, but still apparent to the eye and touch are the local
reactions in tuberculosis of the lymphatic glands, of the bones and
joints, etc., in which case swelling and increased painfulness, and in
the more superficial parts also a reddening can be observed.
The reaction in the inner organs, especially the lungs is removed from
our observation unless we consider the increased coughing and
expectoration of the patients after the first injection a local
reaction. At the same time we must assume that these parts undergo
changes directly observed in the case of lupus.
The different forms of reaction described have appeared without
exception in previous trials on the dose of .01 ccm. when any form of
tuberculosis prevailed in the system, and therefore I trust that I am
justified in assuming, that in the future this remedy will constitute an
indispensible diagnostic auxiliary. We will be enabled to diagnose in
doubtful cases of phthisis even then, when it is impossible to obtain
reliable information concerning the nature of the ailment, by the
presence of bacilli or elastic fibres in the sputum or by a physical
examination. Glandular affectations, hidden tuberculosis of the bones,
doubtful tuberculosis of the skin and the like will easily and reliably
prove to be such. In case of apparently completed processes of
tuberculosis of the lungs or joints it will be possible to show whether
the process of the disease is in reality a complete one or establish the
existence of centres from which later on the disease may spread like a
fire from a live coal in the ashes.
But much more important are the specific qualities of the remedy than
the aids it offers for the diagnosis.
While describing the changes, that are caused by hypodermic injections
of the remedy, on the parts of the skin affected by lupus, attention was
called to the fact that the lupose tissue does not return to its
original condition after the swelling and reddening have ceased, but is
more or less destroyed and disappears. On some places, as observation
teaches, the process is such, that after a single injection the diseased
tissues undergo mortification and are cast off as dead matter later on.
On other places it seems that a diminution or rather a kind of melting
of the tissue is caused, and to effect a complete disappearance a
repeated application of the remedy is necessary. As the required
histological investigation is wanting, it is impossible at the present
time to state with certainty how this result is brought about. Only
this much is known that it is not a destruction of the tubercle bacilli,
but that only the tissue containing the tubercular bacilli is affected
by the application of the remedy. In this, as the visible swelling and
reddening show, greater circulatory derangements are caused and with
these vital changes in the _assimilation_ which result in a more or less
rapid and thorough mortification of the tissue according to the manner
in which the remedy is allowed to act.
To make a short repetition, the remedy therefore does not destroy the
tubercle bacilli, but the tuberculous tissue; on dead tissue, for
instance, gangrenous cheesy matter, necrotic bones, etc., it does not
act; nor on tissue that has undergone mortification through the action
of the remedy itself. Living bacilli can still linger in such dead
masses of tissue, which are either cast out with the necrotic tissue, or
may possibly migrate under special conditions into the adjoining living
tissue.
This quality of the remedy must be particularly observed, if its full
specific action is to be obtained. Therefore we must first cause the
mortification of the tuberculous tissue, and then effect its removal as
soon as possible, for instance, by means of a surgical operation; but
where this is impossible and the excretion by the organisms themselves
is necessarily slow, we must attempt by continued application of the
remedy to protect the endangered living tissue from the immigration of
the parasites.
As the remedy acts only on living tissue and causes mortification of
tuberculous tissue, we can readily explain another exceedingly peculiar
property of the remedy, namely, that it can be given in rapidly
increased doses. This may apparently be explained as being based on
inurement. But noting that in about three weeks the dose may be
increased to 500 times the strength of the first one, it is
unquestionably something more than habit, as we know of nothing
analogous confirming such a rapid and farreaching adaptation to any
powerful drug.
This fact can rather be explained thus: in the beginning there is an
abundance of living tuberculous tissue and only a minute quantity of the
effective substance is sufficient to cause a strong reaction; through
each injection a certain quantity of this responsive tissue disappears,
and then relatively larger doses are required to cause the same degree
of reaction as before. Aside from this adaptation may assert itself
within certain limits. As soon as the patient is treated with such
increased doses, and that he reacts no more than one not afflicted with
tuberculosis, we may assume that all the reactive tuberculous tissue is
dead. It is then only necessary to continue the treatment at intervals
and with gradually increased doses as long as any bacilli remain in the
system, to protect the patient from a new infection.
It remains to be learnt in the future whether this conception and the
deductions based thereon are correct. For the present I have directed
the manner of application of the remedy on this basis, which in our
experiments resulted as follows:
To begin again with the simplest case, namely lupus, we injected the
full dose of .01 ccm. in nearly all such patients to begin with, and
allowed the reaction to take its full course, after 1-2 weeks we again
injected .01 ccm. and so forth until the reaction became less and less
and finally ceased. In the case of two patients with facial lupus three
respectively four injections in this manner resulted in a clean, smooth
scar in place of the affected parts; the remaining patients of this kind
have also improved in a measure proportioned to the time of treatment.
All the patients have suffered from their afflictions for years and have
been treated by various methods without success.
Tuberculosis of the glands, bones and joints has been treated in a very
similar manner, as in these cases larger doses were applied at longer
intervals. The result was the same as with lupus, a rapid cure in the
lighter and milder cases and a slowly progressing improvement in the
severer ones.
With the majority of our patients, those suffering from pulmonary
consumption, the conditions are somewhat different, patients with
decided pulmonary tuberculosis are very much more responsive to this
remedy, than those afflicted with surgical tubercles. We were forced to
reduce the quantity of the first dose of .01 ccm. as prepared for the
phthisicist, and we found that as a rule he reacted strongly on a dose
of .002 and even .001 ccm., but that the quantity could be rapidly
increased from this low initial dose to that which could be easily
tolerated by the other patients. We generally proceeded in such a manner
that the patient at first received an injection of .001 ccm. and if a
rise in the temperature set in this dose was repeated once daily until
the reaction ceased. Only then the dose was increased to .002 ccm. and
applied till the reactions failed to appear. And so forth, always
increasing the dose only .001 or at the most .002 up to .01 ccm. and
higher. This mild procedure seemed to me imperative, especially with
such patient as were in a weak and feeble condition. Proceeding in the
manner just described we can easily attain the application of very light
doses with but slight attacks of fever and hardly perceptible to the
patient. Some of the stronger consumptives were treated with larger
doses from the beginning, partly with a forced increase in the dosing
when it seemed as though the favorable result was obtained in a
correspondingly shorter time. The action of the remedy on the
phthisicist generally seemed to be such that cough and expectoration
increased somewhat after the first injection, then gradually diminished
and in favorable cases disappeared entirely; the sputum lost its
purulent nature and became slimy. The number of bacilli as a rule did
not decrease until the sputum had attained a phlegmy appearance (only
such patients were selected for these experiments in whose
expectorations bacilli were contained). They entirely disappeared
temporarily, but were again met with from time to time until the
expectoration had completely stopped. At the same time the night-sweats
left off, and the patients improved in appearance and gained in weight.
All patients treated in the first stages of phthisis were freed from all
symptoms of disease in the course of 4-6 weeks so that they could be
considered as cured. Even patients with cavities not too large were
considerably improved and nearly healed. But in the case of such
consumptives, whose lungs contained many and large cavities no objective
improvement could be marked, although the expectoration diminished and
they appeared to feel much better. I am inclined to assume on the basis
of these experiences, that the _earliest stages of phthisis can with
certainty be cured by this remedy_.[3] This may also hold good in cases
that are not too far advanced.
In exceptional cases only will pulmonary consumptives, with large
cavities, derive continued benefits through the application of the
remedy, when other complications exist, for instance, the penetration of
other supurative micro-organisms, irremovable pathological changes in
other organs, etc. Even such patients were in most cases temporarily
improved. It must follow that even in them the original process of the
disease, tuberculosis, is influenced in the same manner by this remedy
as in other patients, but that it is impossible to remove the gangrenous
masses of tissue and also the secondary supurative processes. Naturally
we are led to think that perhaps in some of these severe cases cures may
be effected by means of a combination of this healing process together
with surgical aid (after the manner of operating empyema) or some other
curative means. I would not advise anyone however, to apply this remedy
without discrimination in every case of tuberculosis. The simplest mode
of application will certainly be required in treating the first stages
of phthisis and simple surgical affections, but in all other forms of
tuberculosis medical science should draw on all its resources and
individualize carefully to supplement and sustain the action of the
remedy. In many cases I have had the decided impression that the
attendance to and nursing of the patient was of no little influence on
the curative process, and therefore I would prefer the application of
the remedy in suitably adapted institutions, where a close observation
of the patient and the adequate attention to them is possible, to the
ambulant or home treatment. No estimate can at present be made as to the
extent in which a profitable combination can be made between this new
method to cure and those modes of treatment that have thus far been
considered beneficial, the application of mountain climate, the free air
treatment, specific nourishment, etc.; but I trust, that these remedial
factors will be of considerable use in conjunction with the new method
in many cases, especially the severe and neglected as also in the
convalescent stages.[4]
The nucleus of this new curative method lies in the earliest possible
application. The proper objects of treatment ought to be the first
stages of phthisis, because here the remedy can fully develop its
curative qualifications. Therefore it is of vital importance, more so in
the future, than it has been in the past, that practical physicians
employ all possible means to diagnosticate phthisis in as early a stage
as possible. Until lately the finding of tubercle bacilli existing in
the sputum was rather considered as an interesting incidental evidence,
which, although it insured the diagnosis, was of no further benefit to
the patient and therefore was only too often omitted, as I have only
lately discovered in numerous cases of phthisis which had passed through
the hands of several physicians without having their sputum examined
once. This must be different in the future. Any physician who fails to
search for tubercle bacilli in the sputum, to establish phthisis in as
early a stage as possible, commits gross negligence toward his patient,
because his life may depend on this diagnosis and the specific treatment
which has hurriedly been introduced on this basis. In doubtful cases the
physician should gain certainty as to the existence or absence of
tuberculosis through a trial injection.
Only then will the new mode of treatment truly become a panacea for
suffering mankind when that period is reached, where all cases of
tuberculosis are treated in as early a stage as possible, to prevent the
development of neglected severer cases which have heretofore formed a
continual unlimited source of new infection.