The hinderance in motion may be so insignificant, that the children may slightly limp about for weeks and months and complain but little. Generally the physician is not called until the limb begins to hurt and swell after continued exertion.

The swelling which in the beginning is hardly noticeable is now more plainly visible, the knee-joint is evenly rounded and quite sensitive to pressure.

If the disease is not now properly treated, its further course will be as follows: the patient may perhaps linger for several months; then comes a period when he must keep to his bed uninterruptedly because moving results in too much pain; generally the limb becomes more and more bent.

Now particularly painful points appear on the joint, especially on the inner or outer side or in the bend of the knee; on one of these points a soft portion distinctly developes, the skin becomes reddened and finally suppurates from the internal parts outward and breaks after a few months; thin purulent matter mixed with flakes is discharged. The pains now cease, and the condition is improved; but this improvement does not last; soon another abscess is formed and thus it continues.

Meanwhile perhaps two or three years may have elapsed; the general condition becomes greatly reduced. The child, formerly strong and healthy, has now become lean, the discharges of matter have often been attended by acute febrile attacks; the patient becomes exhausted, loses his appetite and digestion becomes more impaired from week to week. Even now a spontaneous change for the better is possible, though this happens very rarely; more frequently the disease progresses and leads to death from exhaustion resulting from severe suppuration and continual attacks of fever.

Restoration to health is indicated by decreased suppurative discharges; the openings of the fistulae contract, the general condition is improved, the appetite is restored, etc. Finally the fistulae heal, the joint becomes fixed at an angle or bent or otherwise crippled, but painfulness disappears and the patient escapes with his life and a stiff leg. This is the most favorable result known to have been obtained in severe cases. The joint may become a solid bony immovable mass or may admit of slight movements. The whole process may last from two to four years.

The former treatment of tuberculous inflammation of the knee-joint was either of a general or a local nature. The general treatment was designed to strengthen and nourish, and will continue to be applied in the future.

The local treatment consisted in the application of salves, brushing with tincture of iodine, spanish fly plasters, wet and dry bandages. As with inflamed hip-joint absolute rest by lying in bed is of the greatest importance.

If after a certain period of rest and application of the above-named remedies no improvement in the state of health could be noticed, the diseased joint was laid in plaster or confined with splints.

If even then, after such treatment for months, no improvement could be noticed but rather that the general state of health was reduced, nothing remained to be done excepting an operation, by which all the diseased parts of the knee-joint were removed, or amputation, that is, the taking off of the diseased limb. The latter method was generally adopted in the case of feeble and emaciated individuals and those who had passed the age of early manhood, as with these the removal of the diseased parts did not, as a rule, result in an improvement of the general condition, which was especially intended.

Now tuberculous inflammation of the knee-joint will be treated by Koch's method and in extreme cases only will operation be necessary. At all rates, an absolute cure will be easily effected.

Aside from the hip- and knee-joint the spinal column is most frequently attacked by tuberculosis. Here also it is the youthful age, from the third year upward, that has to suffer most from this serious disease. Adults are rarely attacked by it and with them it generally appears in connection with general tuberculosis.

The tubercle-bacilli penetrate into the substance of the vertebrae, destroy the same and transform it into purulent matter. As a result the destroyed vertebrae sink or rather settle down and cause a curvature of the spine, in other words a humpback.

In the beginning the symptoms of diseased spine are very indefinite and misleading. The patient rarely complains of pain at first, and it is only noticed that the sick child easily tires of standing or walking and tends to hold on to chairs and similar objects with his hands to relieve the spinal column of the weight. From such uncertain data it is of course impossible to recognize the disease.

Only then when the softened vertebrae give way under the weight of the body, that is when the humpback begins to develop, can tuberculous inflammation of the spine be surmised with any degree of certainty.

As a rule two other characteristic phenomena appear which are dependent on the pain in the affected spinal column. The child, while standing, places his hand on the thighs and thus directly supports part of the weight of the trunk with the lower extremities; at the same time he avoids bending the spinal column forward. This anxious care for the diseased vertebrae is especially noticeable when the child attempts to pick up an object from the floor. While the healthy child bends freely forward, the sick one crouches down and while bending the knee and hip keeps the spinal column as straight and stiff as possible. Frequently a small spot on the spinal column is found to be extremely sensitive to pressure in this stage; but such a subjective symptom must be considered with caution especially with children.

This humpback, which is a result of tuberculous inflammation of the spine, must not be confounded with the humpback caused by rickets. With the latter the curvature is more uniform as a rule, and in the start at least, disappears while in a horizontal position. Besides the humpback resulting from rickets appears between the first and fourth years of age, while tuberculous inflammation of the spine rarely begins before the fourth year. And finally rickets never causes suppuration while this is always the case with inflammation of the spine.

The progress of suppuration is downward as a rule and does not admit of examination until it gets near to the surface of the body; before this the feverish conditions toward evening are the only signs that indicate beginning suppuration. Ardent fever is not attendant during this time; the temperature does not exceed 38 or 38.6° C. and even such trifling increase of temperature may be wanting.

As soon as the skin is reached by the originally deepseated centres of suppuration, it gradually becomes red and later on also suppurated. If the skin is broken and the matter discharged, great care must be taken to keep the wound clean, as otherwise the suppurative cavities may suddenly become ichorous and lead to rapid death. In other cases this extreme result is not caused and fistulae are formed from which the ichor constantly flows. Small bits of mortified and broken off bones may be thrown out with the matter.

As a result of the sinking and settling of the vertebrae the spinal chord may suffer from pressure and contusion as it is contained in a channel formed by the vertebrae. Aside from certain pain it may result in paralysis of certain parts.

Formerly the diagnosis of tuberculous inflammation of the spine in its beginning stages was very uncertain. A great number of afflicted are at present cured by surgical treatment; in former times this was not possible, as the majority of patients died in whose case the disease had progressed to suppuration. But the curvature of the spine could not be removed by any former treatment and can not be by Koch's new method. Vertebrae once destroyed can in no way be restored to their normal condition.

Nevertheless the number of patients whose life is spared will be a still greater one and the number of complete cures will also be increased in a short time. Formerly tuberculous inflammation of the spine was treated as follows: the abscesses were opened and antiseptics carefully applied: mechanical apparatus and corsets were used to aid in a natural cure. These apparatus will surely be of inestimable value at the application of Koch's method.

As has been stated before tuberculosis may attack all other bones and joints and there cause the most serious derangement. Formerly these tuberculous afflictions were treated surgically or by means of iodoform, which has produced pretty good results in certain cases.

However it will certainly be possible to produce still better results with Koch's method of treatment, especially in the restoration of the functions of the afflicted parts. Here, as in all tuberculous affections, it is particularly essential to subject the respective case to treatment in as early a stage as possible and before incurable destruction of the tissues of the bones and joints have been caused.

A certain disease of the skin called lupus (ringworm) must be counted in with the number of diseases generated by the tubercle-bacillus.

Lupus may begin in two different ways. Either in the form of a purple spot, which is raised above the level of the skin and which has no definite limits but blends with the healthy parts; or as a slightly raised, moderately firm, darkred grain, sharply limited and about the size of a pinhead or millet seed.

If the disease has begun in the shape of spots, the afflicted portions of the skin gradually swell during the process of the disease. Several isolated knots appear around which the disease spreads more and more.

While the disease thus takes possession of greater area and developes new centers, a uniform scaling off of all knots begins.

After prolonged existence, sometimes after short duration, decay and casting off of the epidermis in its entire thickness supercedes the scaling process, and suppuration transforms the ringworm into an ulcer covered by a dirty-brown rind and disagreeably colored serum.

The ulcers of lupus are of various, generally irregular shape, the rims not hard, the ground flat and covered with purulent matter and decayed tissue; they are commonly surrounded by a faint reddish areola. These ulcers gradually become epulotic and form irregular, generally slightly protruding white scars in which new tubercles may appear.

Lupus appears most frequently in the face and especially frequent on the nose. Sometimes its appearance is indicated only by an inflammation and swelling of the mucous membranes of the nose and at the same time a reddening of the epidermis. The nostrils are stopped up by a thin rind which, if torn off, is replaced by a thicker one below which an ulcer is formed that spreads with greater rapidity on the mucous membranes of the nose than on the external epidermis of the same.

Sometimes the whole process on the nose is so rapid, that very often the physician is not called to the patient, before a large part of the wing of the nose or of the nasal epidermis is destroyed and deep ulcers have developed under the rind. New tubercles of lupus are commonly noticed to spring up on the margins of these ulcers; the cartilage as a rule resists the progress of the disease for a longer period and may be unhurt, while the skin on the wing of the nose may be completely destroyed.

Frequently the process is extended to the mucous lining of the hard palate and to the gums. Lupus generally appears on the lips in the same manner as in the nose. The upper lip especially appears very much swollen and covered with ulcers after a prolonged existence of the affection. Sometimes even the aperture of the mouth itself is reduced in size by the development of ulcers and scars on the surrounding parts.

If the process extends to the lower eyelid, the connective tissue as a rule becomes much swollen and reddened. The malady especially attacks the inner angle of the eye, destroys the entrance of the lachrymal duct, and from there the lupous tubercles appear on the connective tissue. Gradually tubercular formations develop on the cornea and sight becomes impaired.

On other parts of the face lupus generally appears in the form of small knots, about the size of millet seeds, which remain for a time then multiply and spread. The epidermis swells between these knots and irregular ulcers develop on a hard swollen and glossy ground, and are covered by dark brown rinds.

Tubercles appear anew on the margins of the ulcers and in the spaces between them, isolated whitish spots of sunken or raised scab tissue are observed on which very frequently lupous tubercles again develop.

Lupus appears on the throat, neck, back, breast, and the extremities, most frequently in serpentine form i. e. swellings of the skin develop, being arranged in curves, they progress in the same manner, these are transformed into just so many ulcers. Between these whitish scarred spots are noticeable on which small red lupous tubercles again appear.

Lupus is more frequently found on the extremities than on the trunk. The surface of the skin is found to be tense and glossy on a firm base which is affected by lupus.

Deep ulcerous formations of lupus are sometimes observed on the fingers and toes, particularly on the finger-joints, these may at times penetrate into the inner parts of the joints, secreting whitish pus and covered with a thick rind.

As regards the difference between lupus and syphilitic diseases it has been found that lupus commonly developes before puberty while syphilis appears in the mature age.

The ulcers of lupus are often round like those of syphilis with sharply defined margins, but at the same time they are flat accompanied by little or no pain; rim and base of the same are loose, red, rank, and bleed easily. On the other hand syphilitic ulcers are very painful and rim and base are covered with greasy matter.

Lupus appears only in the form of knots, which are deeply inbedded, from size of a pinhead to that of a lentil, but never as large knots in the beginning. Syphilis produces large and palpable knots from the start.

Loss of the bony part of the nose or destruction of the hard palate are observed, but rarely and after protracted existence of lupus, and often in the case of syphilis.

The indicated peculiarities however refer only to typical cases of lupus and of syphilis. In other cases it was almost impossible to show a difference.

As regards the course of lupus, the same begins, as has been stated before, in earliest childhood, sometimes only in the form of scaly spots and knots. Less often lupus developes after complete development of manhood. It is more frequent with women than with men. Sometimes some of the knots remain isolated and disappear again after a time; in other cases additions appear in the course of time, which may affect larger portions of the body and lead to more or less dangerous ulcers. As a rule the course of lupus, even of great extent, is not malignant and at the most the alliance with traumatic erysipelas and possibly the appearance of pulmonary consumption may succeed the affliction. In cases of not too rare occurrence it has been observed that lupus has developed into cancer, which has always resulted fatally.

The treatment of lupus has principally been a local one. Caustics were applied to destroy lupous tubercles by direct action, and furthermore recourse has been taken to the so-called mechanical treatment, in which the ringworm was scraped out.

Our experiences relating to the mechanical treatment of lupus have taught us the following.

Lupus can not be cured without destroying and removing the diseased and affected tissue. That method which effects the most radical destruction, protects most from relapses. Therefore the best method of treating lupus is to cut out the diseased skin. But with the superficial spreading peculiar to many cases of lupus this method can only be applied within certain limits. Then again the secondary growths after an operation may be of serious consequences.

Unfortunately it has not been possible before this to remove all diseased portions, no matter what method was applied, because often tiny lupous tubercles spring up which are almost invisible to the naked eye. These tubercles will again be the starting point for another spreading of lupus.

We will see that Koch's new method to cure has the advantage both to make visible all tubercles, even those that have escaped our notice and also to effect a cure in the shortest time even in old chronic cases that have before this been considered incurable. It is especially possible in this form of tuberculosis to follow the specific action of the new remedy, as we will learn later on.

Tuberculosis of the testicles is not so very rare, it is found in about 2¹⁄₂ per cent. of all men afflicted with pulmonary consumption. It is more rarely met with in children than in men.

The conditions under which tuberculosis of the testicles and epididymis developes are various inflammatory processes with existing disposition. It is mostly gonorrhea or some other inflammation of the urethra, or injured testicle. It occurs less frequently without any apparent cause.

According to the starting point of tuberculosis the symptoms are varied. If it starts in the testicle, this appears normal or larger in size, but never reaches extraordinary dimensions. The surface of the testicle is at first smooth in the case of increased tension, later only does it become irregular, bumpy and of unequal consistency.

If the starting point is in the epididymis, hard, rounded lumps are formed generally in the head or tail of the epididymis, rarely in the body. These increase in size and cause a swelling often of extraordinary dimensions, the surface of which appears hard, irregular, bumpy and in certain parts yielding and elastic. If the process is extended to the testicle, this also increases in size. Then both together form an oval swollen mass and can not be distinguished from each other.

Striking changes appear only later and consist in the softening of the lumps and in the development of abscesses.

Very soon the lobuli are affected. The same are then thickened in the septa, are hard and form an irregular, bumpy swelling surrounded by more or less thickened tissue.

Very soon tuberculous changes are caused in the prostate gland, an organ situated near the intestine and the functions of which are to dilute the semen. A hardening is often the first sign, this is followed by increase in size and then softening.

With the affection of the prostate gland, that of the urethra also begins, which passes through the middle of the prostate gland. This disease often appears in the form of a yellowish secretion, which is more and more increased and becomes ichorous with the decay of the urethra and the prostate gland. This secretion must be distinguished from that which as a venereal affection caused the whole process. The tubercular derangements do not only extend forward but also upward. The bladder, the ureters and the kidneys are affected and show extreme derangements with altered urinal secretions and excretions.

Of other symptoms of tuberculosis of the testicles pain deserves especial mention. The same is slight in the beginning, but often becomes insufferable.

The symptoms here related often increase very slowly. Essential changes are caused during the chronic course of tuberculosis of the testicles if suppuration sets in. The skin is perforated and fistulae are formed. If there is no halt in the process, general tuberculosis results and this has until now always caused death.

According to the time in which the general derangements come about, a chronic and acute tuberculosis of the testicles has been distinguished. The former is the more frequent, the latter of rare occurrence.

The sexual functions may remain unchanged if only one testicle is diseased, but are generally ruined if both epididymes are affected, because the secretion of the semen is then interrupted by the stopping up of the vas deferens. In some cases the sexual function may be interrupted for a time only and may then be resumed.

The treatment before this has been surgical, in which the diseased parts were carefully removed, and where this was impossible, even castration (removal of the testicle) was performed. Without doubt Koch's method will cause great changes in the method of treatment here also.

Finally we must include in our reflection the well-known disease of children, scrofula. Although the same is not a form of tuberculosis in the sense of the diseases just considered, still tuberculosis and scrofula have the most intimate relations. Scrofula is only too often a precursory stage of tuberculosis.

The manifold scrofulous affections, such as inflamed eyes, diseased ears, skin diseases, catarrh of the nose, pharynx or bronchials, inflammation of the joints and suppuration are not caused through the cooperation of tubercle-bacilli. But here the same find an excellent soil for growth and propagation, and they use the same to the full extent and so give the impetus for the development of tuberculosis.

Scrofula is one of the most frequent diseases, it is spread over the whole world. It occurs more seldom in the tropics than in the north. Furthermore it is more frequent in a cold and damp climate than in a dry one. Elevation has no influence on the development of this disease. Scrofulous individuals are found in the mountains as well as in the plains.

Scrofula principally attacks children; it occurs most frequently in the time from the second to the fifteenth year. Rarely earlier developed scrofula drags beyond the age of puberty or more advanced manhood. Sex has no particular influence on the development of scrofula.

In many cases this particular disease is inherited. The following causes are considered in the inheritance of scrofula: great age, close relationship and infirmity of the parents; but the germ of scrofula is planted in the child by parents that are themselves afflicted with tuberculosis or scrofula. This is most frequently observed in children that have descended from parents, who were scrofulous in their youth and remained so, or that became tuberculous later on and at the time of generation were afflicted by advanced scrofula or tuberculosis, or that were suffering from oft-treated but never entirely cured syphilis. Some scientists claim to have observed the inheritance of scrofula by children, whose parents at the time of generation were afflicted with tuberculosis or were suffering from general debility resulting from hunger and want.

In the majority of cases scrofula is acquired, as a rule the development of this disease is favored by indigence and poor hygienic conditions according to the coinciding experience of all scientists; nutrition, especially in the first year of life, has the greatest influence on the origin of scrofula.

In infancy the most frequent cause of scrofula is the premature giving of farinaceous food besides the mother's milk, or the feeding of children with so-called pap, especially when this is done in the first month of their life.

In later months the excessive eating of bread, potatoes or vegetables instead of milk has an injurious effect.

Furthermore the development of scrofula is favored by the breathing of foul damp air such as is frequently found in newly built or damp houses and also by deficient care of the skin.

Scrofula thrives in the narrow tenement dwellings in which is found a close, overheated, foul air pregnant with smoke, kitchen fumes and mustiness from the damp walls.

Frequently the development of scrofula has been observed to succeed measles, diphtheria, scarlatina or whooping-cough.

The opponents of vaccination also designate vaccination as a frequent cause of scrofula. It is supposed that a poison is transferred into the system with the lymph which is enabled to generate the phenomena of scrofula. However the supposition has not as yet been proven.

Of course the fact cannot be denied, that cases of developing scrofula have been at times observed as succeeding vaccination. But the circumstances are the same as in the case of the contagious diseases mentioned above. No one will probably maintain that in those cases in which the development of scrofula had been succeeding those diseases, that this has resulted from a poison generated by the preceding disease.

The attempt to designate symptoms by which to recognize a scrofulous constitution has at all times been made. Many physicians have for a long time distinguished a torpid and an erethistic scrofulous constitution.

With a torpid constitution the body is pale, spongy and bloated, the nose and lips are thick, the abdomen swelled, there is plenty of fat and but weak muscles. Such children are indolent, at times peevish and indifferent, they do not sleep quietly, have no appetite or may be voracious and suffer from derangements of digestion. An examination of all organs indicates no change. The children are easily afflicted with eruptions of the skin, with inflammation of the eyes and ears, and catarrh of the mucous membranes, which are characterized by great obstinacy. The derangements in nutrition here described are caused by the lymphatic glands though a swelling of the same can not be found.

In the case of erethistic scrofula the children are found to be of slight and lean structure, with fine hair and long eyelashes; they are active, easily excited, gifted and extremely sensitive to physical pain. The face is pale and becomes easily flushed by physical or emotional excitements. They are easily subject to palpitation and short breath; and are attacked by high fevers from the slightest reason. The lymphatic glands, especially the deepseated ones, are as a rule more or less swelled.

In most cases, however, the characteristics of these two forms are blended.

The phenomena of scrofula are manifold and extend over the entire body.

The skin is frequently the seat of scrofulous affections. These are particularly found on the head and face and are characterized by great obstinacy and tendency to return.

Most frequently herpes appear, the parts especially affected are the scalp, face, auricular passages, eyelids and the nose with its surrounding parts.

Pustules are sometimes developed under the skin and may appear in great numbers. These pustules may either break through the skin or shrink into a caseous mass.

Of all mucous membranes that of the nose becomes most frequently diseased; in a great number of cases this happens in the form of a chronic catarrh; the mucous membrane of the nose is reddened and swollen and a profuse, thick, purulent, ichorous and easily drying fluid is secreted. Often the external parts of the nose are swollen as a result of the catarrh and the nostrils are stopped up with thick yellowish-green rinds. Inflammation of the skin is caused by the flowing out of the purulent and ichorous liquid secreted.

In many other cases the disease appears in the form of scrofulous ulcers on the mucous membranes of the nose; in such cases it is found that the nose is stopped up with numerous yellowish brown crusts; after removing the same the mucous membrane appears swollen and moderately reddened, on several places ulcers, the size of lentils, are found which are covered with a yellowish gray coating. At the slightest touch bleeding of the nose is caused; often also the external parts are reddened and swollen. In such cases erysipelas frequently developes, starting from the nose and spreading over the whole face. Frequently a repetition of erysipelas occurs.

The scrofulous catarrh just described is generally of a very protracted nature and is marked by many relapses. Sometimes the fluid secretion of the nose is of very bad odor.

The mucous membrane of the throat becomes diseased at the same time as that of the nose. The same is found to be moderately reddened and swollen; the lymphatic glands especially those on the posterior wall of the throat are increased to swellings the size as large as peas. The tonsils also become inflamed frequently and become enlarged through the repeated rather chronic inflammation.

Inflammations of the ear are a common occurrence with scrofula. These originate most frequently by means of the eustachian tube, which connects the ear with the back part of the mouth as a result of the catarrh of the nose and throat. In a majority of cases the inflammations of the ears lead to perforation of the tympanum and may even result in fatal cerebral meningitis.

The eye is as frequently affected by scrofula. Swelling of the lids and inflammation of the glands are the lighter forms. Pustules on the connective tissue of the eye and on the cornea, accompanied by photophobia, cramp in the lids and flowing of tears are those severe forms that are so frequently observed in scrofula, and that often leave opaque and incurable spots on the cornea of the eye.

Swelling of the glands has at all times been a characteristic phenomenon of scrofula. A swelling is merely the result of diseases of the mucous membrane of the throat or nose, of herpes of the scalp or face, of inflammations of the ears, eyes, periosteum, bones, etc. In the beginning the swelling of the glands is painless and results in flat swellings of about the size of filberts, which may be moved back and forth; such glandular swellings may exist for years, without showing the slightest alterations.

With renewed attacks they enlarge and may become of considerable size. At times single glands become inflamed, hurt when pressed and develop abscesses which perforate the skin after it has become inflamed and reddened.

These abscesses may heal within a few days. In the majority of cases, however, they remain for a longer period, months and even years and result in the well-known tumid, hard and immovable scars.

Inflammation of the periosteum and of the bones is one of the instances of scrofula. Most frequently spina ventosa is found; the same consists of a gradual, painless swelling of the diseased bones, most frequently on the fingers and toes, so that they become bottle-shaped. The skin covering these swellings is pale and tense. The swelling may gradually disappear or begin to suppurate. Besides this hip- and knee-joint inflammation are observed, also inflammations of the ankle, elbow-joint, spine, etc.; especially in the case of diseased bones it is extremely difficult to fix a dividing line between scrofula and tuberculosis.

The frequence of anaemia with scrofula is only a result of the disease and not a symptom. As a result of scrofula nutrition and assimilation become impaired, mostly in the cases of extreme suppuration.

Scrofula is a chronic disease. In many cases it is completely cured, the lighter cases after several months and the more malignant after several years. Extreme scrofula may often remain until puberty and may be completely healed.

Fatal results are due to scrofulously diseased bones, joints or glands, and it can not be denied that a large number of children succumb in this manner. Fatal results may also be due to additional diseases, such as pneumonia, pleurisy, intestinal catarrh, etc.

It has been frequently observed that tuberculosis succeeds scrofula. It is a well-known fact that scrofula furnishes the largest contingent for tuberculosis.

As a precautionary measure against scrofula a careful regulation of the diet is recommended. During the first nine months of life children should be fed with human milk exclusively if possible. If scrofula is hereditary in a family, or if the mother exhibits symptoms of the disease, she should not be allowed to nurse the child but a strong and healthy nurse should be engaged. Recourse to artificial nourishment must only then be taken, when nursing the child is absolutely impossible. For this purpose exceptionally pure cow's-milk ought to be selected. All substitutes, that appear under various names, such as infant's food, condensed milk, etc., contribute much toward the development of scrofula.

Children 1–2 years of age are to be fed with milk, meat and eggs. Only strong children, that show no sign of scrofula may be fed once or twice a day with small quantities of rice, tapioca, sago, green vegetables, pulse, etc., beside the food above mentioned.

To prevent scrofula it is essential not to give the food of adults to children during the first years of life; avoid exclusively solid food and prepare the same in a pappy form as much as possible. Of course a proper regulation of meal-time and a careful avoidance of overfeeding is by all means to be observed.

It is of no less importance for a successful treatment of scrofula to provide surroundings of as favorable conditions as possible.

First of all pure air containing plenty of oxygen. Therefore the sea-coast is recommended as a proper place for scrofulous children. The children ought to stay there until the signs of scrofula have disappeared and the entire nutrition has been improved. The results obtained in the sanitary stations (vacation colonies) along the sea-shore for scrofulous children have received much favorable comment.

Mountain air has a similarly favorable effect especially when salt water baths are used at the same time; even the plain, pure country air proves beneficial to scrofulous children. Very dry locations and dwellings ought to be selected. The children should remain out of doors as much as possible.

Of great importance for scrofulous children, furthermore, is a suitable course in gymnastics and rubbing-down with cold water. To begin with the water may be 72° but should gradually be reduced to the natural temperature of well water.

Just how far Koch's new method will take the place of former remedies used for scrofula can not be told at present as experiments in this direction are wanting. Nevertheless it will be possible to prevent the dangerous transition of scrofula into tuberculosis and thus save the lives of a great many persons.

Anyone who has informed himself through the foregoing as to the great number of diseases and forms of disease that are directly or indirectly connected with tuberculosis, will now be able to estimate the farreaching import of Koch's discovery. It will now be clear to him that pulmonary consumption constitutes only a part, although a great part of tuberculosis and that there are a great many diseases besides that can now be surely cured, it is hoped, with the aid of Koch's method. But this much should be remembered by everyone that this remedy also acts best and surest during the beginning of a disease. We hope that no one will allow valuable time to slip unimproved; it may easily happen that it is too late for successful treatment. Everyone will be able to recognize the symptoms of diseases, which Koch has taught to cure, from the foregoing complete description, and it is better to apply the remedy once too often than miss the proper time for application.

Koch's first communications relating to the subject have just been published and will be given unabridged in the following pages. As these communications are written for physicians we will add such explanatory notes as are deemed essential for general intelligence.

THE FIRST COMMUNICATION
Relating to a Method to Cure
TUBERCULOSIS,

Originally I intended to complete my investigations and especially gain sufficient experience concerning the practical application of the remedy and its production on a larger scale before I published anything concerning it. In spite of all precautions too much has already been published about it, and that distorted and exaggerated, so that I was obliged, in a way, to prevent false conceptions, to give even now a synopsis of the method as far as it has progressed at the time being. Under present circumstances it must necessarily be short and leave unanswered many important questions.

The experiments have been, and are still being made under my direction by Dr. A. Libbertz and Stabsarzt Dr. E. Pfuhl. The necessary subjects and material have been provided by Prof. Brieger from his Polyclinic, Dr. W. Levy in his Private Surgical Clinic, Geheimrath Fraentzel and Oberstabsarzt R. Koehler in the Charite-Hospital, and Geheimrath Herr v. Bergmann in the Surgical University Clinic. To all these gentlemen and their assistants I here tender my heartfelt thanks for their untiring interest which they manifested for this subject and also for the disinterested help and aid which they have offered at all times and without which it would have been impossible for me to make such progress in a few months in this difficult and responsible investigation.

As my work is far from being completed, I can not as yet make any statements relating to the origin and preparation of this remedy and reserve these for some future time.[1]

The curative is composed of a clear brown fluid, which in itself is not perishable, even without special precautionary measures. For use this fluid must be more or less diluted and these dilutions are perishable when made with distilled water; Bacterian vegetation soon develops in them and they become turbid and are no longer fit for use. To prevent this the dilutions must be sterilized through heat and be kept under cotton batting or be prepared with a 5 per cent. phenol solution which is much simpler. Through repeated heating as also through the mixture with the phenol the efficiency of the diluted solution appears to be curtailed after a time and for that reason I have always used solutions as fresh as possible.

The remedy does not act through the stomach; to effect a reliable action it must be applied subcutaneously. For our experiments we have exclusively used a syringe decided upon by myself for bacteriological purposes, which is supplied with a small india-rubber ball and which has no stamp. Such a syringe can be easily kept positively aseptic by rinsing with absolutely pure alcohol and on this we base the fact that not a single abscess has sprung from over a thousand injections.

After trying various parts of the body as places for application we selected the skin of the back between the shoulderblades and in the lumbar region, because at these places the injection was almost painless and caused the least and in most cases no local reaction.

Even at the beginning of our experiments we found that in one particularly important point the human subject was affected by the curative in a way decidedly differing from that of the animal subject generally used, the guinea pig. Therefore another confirmation of the rule for experimentors upon which hardly enough stress can be laid, not to rely upon a like effect upon the human being from the experiments on the animal without further confirmatory inquiry.

Man proved himself much more sensitive to the effects of the remedy than the guinea pig. Up to two cubic centimeters and even more of the undiluted fluid could be injected under the skin of a healthy guinea pig without causing any particularly disparaging effect. In the case of a fullgrown man on the other hand, 25 ccm. are sufficient to produce intense results. In proportion to weight of body therefore ¹⁄₁₅₀₀ of the amount which has no noticeable effect on the guinea pig has a decidedly strong effect on the man.

From an injection that I have made on my upper arm I have experienced the symptoms which arise in man after an injection of 25 ccm., in short they were the following: Three or four hours after the injection a raking pain in the joints, languor, inclination to cough, oppressed breathing, which rapidly increased; in the fifth hour I experienced intense chills which lasted nearly an hour, at the same time nausea, vomiting, increase of the temperature of the body to 39.6° C. After about 12 hours all these affectations ceased. The temperature sank and reached the normal height the next day. Heaviness of the limbs and languor lasted for a few more days, and for the same length of time the place of injection remained red and painful.

The lower limit of effect of the curative for a healthy man is about .01 ccm. (= 1 cubic centimeter diluted with a 100 parts) as numerous trials have shown. The majority reacted on this dose with only light pain in the joints and passing languor. With a few a slight rise in temperature set in, to 38° C. or a trifle higher.

Although there is a marked difference as regards the dose of the curative (according to relative weight of body) between the animal subject and man, an evident resemblance is shown in several other qualities.

The most important of these qualities is the specific action of this remedy on tuberculous processes of whatever kind they may be. I will not relate the effects on the animal subject in this connection, as it would lead too far, but will at once turn to the peculiar effects on tuberculous human beings.

As we have seen, a healthy man reacts but little or not at all on .01 ccm. The same is true of diseased persons, provided they are not tuberculous. But the relations are entirely different with those afflicted with tuberculosis; a marked general and also a local reaction resulted from an injection of the same dose of the remedy (.01 ccm.)[2].

The general reaction consists of an attack of fever, which, beginning mostly with chills, raises the temperature to over 39°, often up to 40° and even 41°. Other noticeable symptoms are pains in the joints, a tendency to cough, great languor, and often nausea and vomiting. Several times we observed a faint icteric coloring and in some cases the appearance on neck and breast of an exanthema resembling measles. As a rule the attack begins 4–5 hours after the injection and lasts 12–15 hours. In exceptional cases it may begin much later, but then it is not nearly so intense. The patients experience remarkably little weakness from the attack and feel relatively well as soon as it is over, generally better than they did before it came on.

The local reaction can best be observed on those patients whose tuberculose affection is plainly visible, for instance those afflicted with lupus. In them changes take place that prove the specific antitubercular action of the remedy in a most surprising way. The diseased portions of the skin in the face, etc. begin to swell and turn red even before the attack of chills set in, although the injection is made under the skin of the back, a point decidedly remote from the affected parts. The swelling and reddening increases during the fever and can attain a very marked degree so that the lupus-tissue turns reddish brown and necrotic. In the case of more sharply defined lupus centres the more swollen and dark red parts were edged by a white seam nearly a centimeter wide and this again was surrounded by a wide bright red border. The swelling of the diseased parts gradually decreases after the cession of fever and may have entirely disappeared after 2 or 3 days. A serum exudes from these lupus-centres and, drying, forms a crust on them which changes into scabs that fall off in 2–3 weeks and sometimes leave a smooth red scar after a single injection. Generally several injections are necessary to effect a complete removal of the lupose tissue, but of this I will speak further on. It is very important to note that the changes during this process are exclusively limited to the portions of the skin affected by lupus; even the faintest and smallest bits of diseased tissue go through the entire process and become visible on account of their swelling and reddening, while the actual scab-tissue in which the various stages of lupus have been completed remains unchanged.

The observation of the treatment of lupus with the remedy is so instructive and must be so convincing as regards the specific nature of the remedy that every one wishing to occupy himself with the study of this remedy should if possible make his first experiments with lupus.

Less marked, but still apparent to the eye and touch are the local reactions in tuberculosis of the lymphatic glands, of the bones and joints, etc., in which case swelling and increased painfulness, and in the more superficial parts also a reddening can be observed.

The reaction in the inner organs, especially the lungs is removed from our observation unless we consider the increased coughing and expectoration of the patients after the first injection a local reaction. At the same time we must assume that these parts undergo changes directly observed in the case of lupus.

The different forms of reaction described have appeared without exception in previous trials on the dose of .01 ccm. when any form of tuberculosis prevailed in the system, and therefore I trust that I am justified in assuming, that in the future this remedy will constitute an indispensible diagnostic auxiliary. We will be enabled to diagnose in doubtful cases of phthisis even then, when it is impossible to obtain reliable information concerning the nature of the ailment, by the presence of bacilli or elastic fibres in the sputum or by a physical examination. Glandular affectations, hidden tuberculosis of the bones, doubtful tuberculosis of the skin and the like will easily and reliably prove to be such. In case of apparently completed processes of tuberculosis of the lungs or joints it will be possible to show whether the process of the disease is in reality a complete one or establish the existence of centres from which later on the disease may spread like a fire from a live coal in the ashes.

But much more important are the specific qualities of the remedy than the aids it offers for the diagnosis.

While describing the changes, that are caused by hypodermic injections of the remedy, on the parts of the skin affected by lupus, attention was called to the fact that the lupose tissue does not return to its original condition after the swelling and reddening have ceased, but is more or less destroyed and disappears. On some places, as observation teaches, the process is such, that after a single injection the diseased tissues undergo mortification and are cast off as dead matter later on. On other places it seems that a diminution or rather a kind of melting of the tissue is caused, and to effect a complete disappearance a repeated application of the remedy is necessary. As the required histological investigation is wanting, it is impossible at the present time to state with certainty how this result is brought about. Only this much is known that it is not a destruction of the tubercle bacilli, but that only the tissue containing the tubercular bacilli is affected by the application of the remedy. In this, as the visible swelling and reddening show, greater circulatory derangements are caused and with these vital changes in the assimilation which result in a more or less rapid and thorough mortification of the tissue according to the manner in which the remedy is allowed to act.

To make a short repetition, the remedy therefore does not destroy the tubercle bacilli, but the tuberculous tissue; on dead tissue, for instance, gangrenous cheesy matter, necrotic bones, etc., it does not act; nor on tissue that has undergone mortification through the action of the remedy itself. Living bacilli can still linger in such dead masses of tissue, which are either cast out with the necrotic tissue, or may possibly migrate under special conditions into the adjoining living tissue.

This quality of the remedy must be particularly observed, if its full specific action is to be obtained. Therefore we must first cause the mortification of the tuberculous tissue, and then effect its removal as soon as possible, for instance, by means of a surgical operation; but where this is impossible and the excretion by the organisms themselves is necessarily slow, we must attempt by continued application of the remedy to protect the endangered living tissue from the immigration of the parasites.

As the remedy acts only on living tissue and causes mortification of tuberculous tissue, we can readily explain another exceedingly peculiar property of the remedy, namely, that it can be given in rapidly increased doses. This may apparently be explained as being based on inurement. But noting that in about three weeks the dose may be increased to 500 times the strength of the first one, it is unquestionably something more than habit, as we know of nothing analogous confirming such a rapid and farreaching adaptation to any powerful drug.

This fact can rather be explained thus: in the beginning there is an abundance of living tuberculous tissue and only a minute quantity of the effective substance is sufficient to cause a strong reaction; through each injection a certain quantity of this responsive tissue disappears, and then relatively larger doses are required to cause the same degree of reaction as before. Aside from this adaptation may assert itself within certain limits. As soon as the patient is treated with such increased doses, and that he reacts no more than one not afflicted with tuberculosis, we may assume that all the reactive tuberculous tissue is dead. It is then only necessary to continue the treatment at intervals and with gradually increased doses as long as any bacilli remain in the system, to protect the patient from a new infection.

It remains to be learnt in the future whether this conception and the deductions based thereon are correct. For the present I have directed the manner of application of the remedy on this basis, which in our experiments resulted as follows:

To begin again with the simplest case, namely lupus, we injected the full dose of .01 ccm. in nearly all such patients to begin with, and allowed the reaction to take its full course, after 1–2 weeks we again injected .01 ccm. and so forth until the reaction became less and less and finally ceased. In the case of two patients with facial lupus three respectively four injections in this manner resulted in a clean, smooth scar in place of the affected parts; the remaining patients of this kind have also improved in a measure proportioned to the time of treatment. All the patients have suffered from their afflictions for years and have been treated by various methods without success.

Tuberculosis of the glands, bones and joints has been treated in a very similar manner, as in these cases larger doses were applied at longer intervals. The result was the same as with lupus, a rapid cure in the lighter and milder cases and a slowly progressing improvement in the severer ones.

With the majority of our patients, those suffering from pulmonary consumption, the conditions are somewhat different, patients with decided pulmonary tuberculosis are very much more responsive to this remedy, than those afflicted with surgical tubercles. We were forced to reduce the quantity of the first dose of .01 ccm. as prepared for the phthisicist, and we found that as a rule he reacted strongly on a dose of .002 and even .001 ccm., but that the quantity could be rapidly increased from this low initial dose to that which could be easily tolerated by the other patients. We generally proceeded in such a manner that the patient at first received an injection of .001 ccm. and if a rise in the temperature set in this dose was repeated once daily until the reaction ceased. Only then the dose was increased to .002 ccm. and applied till the reactions failed to appear. And so forth, always increasing the dose only .001 or at the most .002 up to .01 ccm. and higher. This mild procedure seemed to me imperative, especially with such patient as were in a weak and feeble condition. Proceeding in the manner just described we can easily attain the application of very light doses with but slight attacks of fever and hardly perceptible to the patient. Some of the stronger consumptives were treated with larger doses from the beginning, partly with a forced increase in the dosing when it seemed as though the favorable result was obtained in a correspondingly shorter time. The action of the remedy on the phthisicist generally seemed to be such that cough and expectoration increased somewhat after the first injection, then gradually diminished and in favorable cases disappeared entirely; the sputum lost its purulent nature and became slimy. The number of bacilli as a rule did not decrease until the sputum had attained a phlegmy appearance (only such patients were selected for these experiments in whose expectorations bacilli were contained). They entirely disappeared temporarily, but were again met with from time to time until the expectoration had completely stopped. At the same time the night-sweats left off, and the patients improved in appearance and gained in weight. All patients treated in the first stages of phthisis were freed from all symptoms of disease in the course of 4–6 weeks so that they could be considered as cured. Even patients with cavities not too large were considerably improved and nearly healed. But in the case of such consumptives, whose lungs contained many and large cavities no objective improvement could be marked, although the expectoration diminished and they appeared to feel much better. I am inclined to assume on the basis of these experiences, that the earliest stages of phthisis can with certainty be cured by this remedy.[3] This may also hold good in cases that are not too far advanced.

In exceptional cases only will pulmonary consumptives, with large cavities, derive continued benefits through the application of the remedy, when other complications exist, for instance, the penetration of other supurative micro-organisms, irremovable pathological changes in other organs, etc. Even such patients were in most cases temporarily improved. It must follow that even in them the original process of the disease, tuberculosis, is influenced in the same manner by this remedy as in other patients, but that it is impossible to remove the gangrenous masses of tissue and also the secondary supurative processes. Naturally we are led to think that perhaps in some of these severe cases cures may be effected by means of a combination of this healing process together with surgical aid (after the manner of operating empyema) or some other curative means. I would not advise anyone however, to apply this remedy without discrimination in every case of tuberculosis. The simplest mode of application will certainly be required in treating the first stages of phthisis and simple surgical affections, but in all other forms of tuberculosis medical science should draw on all its resources and individualize carefully to supplement and sustain the action of the remedy. In many cases I have had the decided impression that the attendance to and nursing of the patient was of no little influence on the curative process, and therefore I would prefer the application of the remedy in suitably adapted institutions, where a close observation of the patient and the adequate attention to them is possible, to the ambulant or home treatment. No estimate can at present be made as to the extent in which a profitable combination can be made between this new method to cure and those modes of treatment that have thus far been considered beneficial, the application of mountain climate, the free air treatment, specific nourishment, etc.; but I trust, that these remedial factors will be of considerable use in conjunction with the new method in many cases, especially the severe and neglected as also in the convalescent stages.[4]

The nucleus of this new curative method lies in the earliest possible application. The proper objects of treatment ought to be the first stages of phthisis, because here the remedy can fully develop its curative qualifications. Therefore it is of vital importance, more so in the future, than it has been in the past, that practical physicians employ all possible means to diagnosticate phthisis in as early a stage as possible. Until lately the finding of tubercle bacilli existing in the sputum was rather considered as an interesting incidental evidence, which, although it insured the diagnosis, was of no further benefit to the patient and therefore was only too often omitted, as I have only lately discovered in numerous cases of phthisis which had passed through the hands of several physicians without having their sputum examined once. This must be different in the future. Any physician who fails to search for tubercle bacilli in the sputum, to establish phthisis in as early a stage as possible, commits gross negligence toward his patient, because his life may depend on this diagnosis and the specific treatment which has hurriedly been introduced on this basis. In doubtful cases the physician should gain certainty as to the existence or absence of tuberculosis through a trial injection.

Only then will the new mode of treatment truly become a panacea for suffering mankind when that period is reached, where all cases of tuberculosis are treated in as early a stage as possible, to prevent the development of neglected severer cases which have heretofore formed a continual unlimited source of new infection.

In conclusion I would remark, that I have intentionally omitted all numerical statistics and descriptions of individual cases in this communication, because the physicians to whose material the patients provided for our experiments belonged, have themselves undertaken the description of their respective cases and I did not wish to anticipate them in an objective representation of their observations.