Prof. Koch's Method to Cure Tuberculosis Popularly Treated Part 7

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 pa.s.sing 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 ant.i.tubercular 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 a.s.sume 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 a.s.suming, that in the future this remedy will const.i.tute 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 _a.s.similation_ 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 repet.i.tion, 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 ma.s.ses 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 a.n.a.logous 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 quant.i.ty of the effective substance is sufficient to cause a strong reaction; through each injection a certain quant.i.ty 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 a.s.sert 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 a.s.sume 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 quant.i.ty 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 quant.i.ty 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 a.s.sume 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 ma.s.ses 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 inst.i.tutions, 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 pa.s.sed 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 antic.i.p.ate 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., Lueneburgerstra.s.se 28 II.), who has undertaken the production of the remedy with Dr. Pfuhl's and my a.s.sistance. But I must state that the present stock is very limited, and that larger quant.i.ties 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 a.s.sume that these will be removed as easily and quickly as the first attack.

On the other hand it is possible from a.n.a.logy 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 a.s.sume 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 quant.i.ties 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 quant.i.ties necessary for an effect, on the other hand and princ.i.p.ally 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 quant.i.ties 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 pa.s.sed through all the symptoms of a poisoning. He certainly injected into his arm a considerable quant.i.ty of the liquid; twenty-five times as much as he injected in his patients.