numerical statistics and descriptions of individual cases in this
communication, because the physicians to whose material the patients
provided for our experiments belonged, have themselves undertaken the
description of their respective cases and I did not wish to anticipate
them in an objective representation of their observations.
FOOTNOTES:
[1] Physicians who wish to experiment with the remedy, can get
the same of Dr. A. Libbertz (Berlin, N. W., Lueneburgerstrasse
28 II.), who has undertaken the production of the remedy with
Dr. Pfuhl's and my assistance. But I must state that the present
stock is very limited, and that larger quantities can only be
disposed of at the end of several weeks.
[2] We gave children of 3-5 years of age one tenth of this dose,
that is .001 and very weak children .0005 ccm. and obtained a
strong though not alarming reaction.
[3] This statement is necessarily confined in so far as we have
no conclusive experiences, and can not have at present, that
show whether the cure is a permanent one, recidivations of
course are not excluded for the present. But we may assume that
these will be removed as easily and quickly as the first attack.
On the other hand it is possible from analogy with other
infectious diseases that those who are once cured become
permanently exempt. This must also be considered an open
question for the present.
[4] It was impossible to collect data referring to
cerebral-laryngeal-and miliary-tuberculosis, as we did not have
sufficient material.
Explanatory Notes.
Koch states that he can not at the present make any statement about the
origin and preparation of the remedy, as his labors are not yet
completed.
We may assume that it is very probably a substance that corresponds in a
way to the lymph used for vaccination. As vaccine lymph represents
variolous poison greatly reduced in strength, as the remedy for
hydrophobia is composed of a substance which is weakened hydrophobic
poison, so Koch probably obtains his remedy for tuberculosis by
artificially reducing the tuberculous poison by means of various
processes.
A number of years ago it has been tried with syphilis in a similar way
to obtain a substance that would not only cure syphilis but would also
guard against infection from it. At that time however the experiment was
not successful.
From several intimations I am inclined to believe that Koch was
successful in finding a way in which a substance may be produced for
contagious diseases, a substance that cures these diseases and also
protects from infection. It is not impossible, since Jenner found the
vaccine virus, Pasteur the hydrophobic lymph and now Koch the tubercle
lymph.
To be sure there is this difference for the present between the
substances named, that the vaccine virus only protects healthy person
from infection by small pox but it does not cure those sick, while the
hydrophobic lymph and tubercle lymph cure the afflicted. However Koch
seems to believe that his tubercle lymph has a certain power of
producing immunity.
According to Koch, his remedy, consisting of a brownish liquid, is
easily perishable as soon as it is diluted with water; he recommends the
preparation of the dilution of the remedy with a 5 per cent. phenol
solution. Phenol is equivalent to carbolic acid. The dilution of the
remedy for use must be considerable, as only small quantities of the
same are used.
Koch tells us that his remedy does not act through the stomach, that is
taken in through the mouth. On one hand it may be that this is due to
the extremely small quantities necessary for an effect, on the other
hand and principally all the substances probably act only when they are
directly applied and brought in contact with the circulation of the
blood.
For a long time small syringes with fine needle points were used to
inject strong acting drugs under the skin. This is done in a measure to
have a guarantee of a sure effect which is not had by giving through
the mouth. For instance, it is known that emetics given through the
mouth often remain without results; if however the emetic apomorphine is
injected anywhere under the skin, vomiting surely follows within a very
short time. It is well known that morphine is injected under the skin in
preference to taking it through the mouth as its action as a pain killer
is much prompter.
Koch's liquid can also be injected under the skin with the aid of a
so-called Pravaz syringe. Koch uses a somewhat differently formed
syringe. The result remains the same, no matter what kind of syringe is
used.
At the same time it makes but little difference, on what part of the
body the injection is made, as the fluid injected under the skin is
distributed at once over the entire system. Koch chose the skin of the
back between the shoulderblades and the loins because here the injection
could be made without causing pain or inflammation.
The production of the liquid must be attended with great difficulties as
Koch plainly remarks that his stock at present is very limited and he
can only furnish larger quantities at the end of several weeks. The
price of a small bottle to be 25-30 Marks about 6-8 Dollars.
The human being is much more sensitive to Koch's remedy than the guinea
pig, which is commonly used for experiments of this kind. It seems that
no experiments have as yet been made with other animals.
Koch has tried the remedy on himself and has passed through all the
symptoms of a poisoning. He certainly injected into his arm a
considerable quantity of the liquid; twenty-five times as much as he
injected in his patients.
But here also there is a difference. In sick people much smaller
quantities act than in the healthy. One cubic centimeter of the liquid
has hardly any effect on a healthy person, but quite a marked one on
those afflicted with tuberculosis.
In the case of the latter one cubic centimeter produces about the same
symptoms as twenty-five times the quantity would in a healthy person.
The same must also be considered as symptoms of poisoning; but they are
only of short duration and are accompanied with magnificent success.
Of all diseases based on tuberculosis only ringworm or lupus is
perceivable by the eye, as it is a disease of the skin, all other
tuberculous diseases take their course in the internal parts of the
body, and therefore are not perceptible to the eye. The symptoms that
follow an injection of Koch's liquid can be best observed in the case of
lupus.
Koch therefore selected for his first illustration patients afflicted
with lupus that is ringworm. Even a few hours after the injection the
first perceptible changes begin to show in the diseased parts. These
begin to swell and redden; in other words an inflammation is caused,
through which the diseased tissue is obviously brought to mortification.
Soon the inflammation stops. The gangrenous tissue changes into crusts
or scabs which drop off in a short time and the patient is cured of his
ringworm.
Koch places particular importance on the fact that the inflammation is
restricted to the diseased parts only, and that it does not attack sound
and healthy parts. Even the smallest otherwise invisible knots are made
perceptible through the inflammation.
We have similar illustrations for this specific action of Koch's remedy
for lupus (ringworm). So for instance a syphilitic ulcer on the thigh
may be cured in a few days with iodide of potassium. In a similar
manner a morbidly enlarged spleen may be reduced to the normal size by
taking quinine.
The observation is very interesting indeed, as it may be shown whether a
person is tuberculous in any organ or not by the injection of .01 ccm.
In case he is tuberculous the poisoning symptoms appear in a marked
degree; if he is not, hardly any effect is noticeable.
Although we have had excellent methods for a long time to detect
pulmonary consumption, although Koch added the discovery of the tubercle
bacilli, it occasionally happens that the disease can not be recognized
in its beginning stages, because its progress is too slight. Now the
reaction following an injection is to be the deciding medium. Also with
other tuberculous affections physicians will welcome this diagnostic
auxiliary, for in the beginning of the same it often happens that no
certain diagnosis could be made and valuable time was lost.
We must call particular attention to the further statements of Koch,
that through his remedy the tubercle bacilli are _not_ killed. With this
it is admitted that the remedy will not be able to effect cures, without
any more ado, yes, even the tubercle bacilli may continue to infect
parts of the body even in spite of the action of the remedy.
Therefore the application of Koch's remedy only, is not sufficient to
effect a cure. Provision must be made to remove the gangrenous tissue
from the body as rapidly as possible, because it contains the still
living tubercle bacilli. As a rule surgical aid is necessary to remove
the mortified tissue. Where this is impossible Koch advises the
continued application of the remedy to protect the endangered living
tissue from the re-immigration of the tubercle bacilli. Koch thereby
believes that he can protect the tissue, perhaps in the manner as
vaccination protects from small pox.
The rapid increase in the quantity of the remedy applied in the course
of time is something that has no parallel. Koch gives an explanation,
but leaves it to the future to be confirmed. We have no previous
instance in case that his explanation should prove correct. Reasoning
from analogous application of our remedy, we are led to assume that
_smaller_ quantities of the substance would suffice to cause
mortification of the remaining tuberculous tissue. Koch on the other
hand uses larger and larger doses to reach a result. He admits inurement
to the remedy within certain limits only.
Koch has made a difference between pulmonary consumptives and those
suffering from tuberculosis of the bones and joints, etc. He was able to
inject larger quantities in the latter than the former, for the quantity
injected in the case of pulmonary consumptives was .001 ccm.; in other
tuberculous cases .01 ccm.
Koch selected pulmonary consumptives for his experiments, whose sputum
contained tubercle bacilli, so as to make no error in the diagnosis, and
to ascertain by killing the bacilli contained in the sputum, whether the
diseased tend toward restoration. As the remedy does not kill the
bacilli, so a diminution of the bacilli can only be obtained in that
manner, that the tissue of the lungs undergoes certain changes, which
cause its properties to be such, that the bacilli are no longer able to
exist or propagate in them. Then a so-called immunity results which we
know of in other similar diseases. We know that anyone who has had the
measles or scarlet fever rarely is again attacked by the same, as a rule
he is permanently proof against them.
In the same way as vaccination protects from small pox, an injection of
Koch's remedy acts against pulmonary consumption. Koch makes a cautious
statement:
"On the other hand it is possible, from analogy with other
infectious diseases that those who are once cured become
permanently exempt."
Koch reaches this result, that beginning phthisis can with certainty be
cured with his remedy. On the other hand, advanced consumptives, in
whose lungs large cavities already exist, may possibly be improved but
can not be cured. However he provokes the idea, that perhaps his method
of treatment together with a surgical operation, that removes all
gangrenous matter from the lungs, may yet have beneficial results in the
end. The idea is not entirely new to treat lung diseases with the aid of
surgery; unfortunately the operations have heretofore been thought too
risky. Perhaps we will now have a new branch in operative technic,
surgery of the lungs. Koch advises to conduct this lung surgery after
the manner of operating empyema. This is an operation performed in the
case of suppurative pleurisy to remove the pus from the pleural cavity.
This operation has been successfully carried out for a long time.
Koch makes it of especial importance, that while treating consumption
with the new remedy, the general attendance and nursing is not to be
neglected. Koch also calls attention to what has been said before, that
the general hygienic factors, good hospital treatment, mountain climate,
etc., will never be dispensed with, on the contrary will be
indispensible to the furtherance of cure.
In conclusion Koch again remarks that brilliant results are only
promised in the early stages of pulmonary consumption (phthisis).
Physician and patient must move all levers as to the existence or
non-existence of tuberculous diseases.
Then those daily pictures of extreme wretchedness from consumption will
be a thing of the past. Then the danger of contagion will be lessened
resulting from the decrease of the number of tuberculous persons and of
the tubercle-bacilli, and perhaps it will soon be possible to name the
day on which with the last tubercle-bacillus the ravaging pest,
tuberculosis, will be extirpated.
+-------------------------------------------------------------+
| Transcriber's Note: |
| |
| Inconsistent use of develops/developes, and centres/centers |
| has been retained as in the original. |
+-------------------------------------------------------------+