Chapter 2

The _quantity_ of blood thrown out during an attack may be very different, varying from a few drops hardly a teaspoonful, to hundreds of grammes, even more than a liter. It is generally light red, filled with airbubbles, foamy, and is largely coughed out in coagulated lumps. The coughing of blood is sometimes preceded by a feeling of oppression, rushing of blood to the head and palpitation. Some patients experience a sweet taste in the mouth even before the bleeding. In many cases all preceding symptoms are missing and the patient is suddenly attacked by blood coughing during some more vigorous movement, during the exertion of coughing or even without any direct cause.

_Blood coughing_ seems to appear somewhat more frequently with the _female_ sex than with the male and has with them unmistakable relations to menstruation, as with the sick it often sets in before, often after or even during the same and at such times more frequently than at others.

It is of great importance for the layman to know that a hemorrhage rarely leads to inevitable death. Fatal hemorrhages are always preceded by warning attacks. Blood coughing may appear at any stage of consumption. In some cases it is particularly lasting. Sometimes the patients experience considerable relief from their feeling of oppression after a hemorrhage.

A number of the consumptives as a rule complain of _difficulty_ in _deglutition_. This is caused by ulcers on the posterior wall of the larynx.

With many patients the _appetite_ is _undisturbed_ for a long time, and there are consumptives that will eat a comparatively large dinner during an attack of fever reaching 40 deg. C. Generally the desire to eat disappears during the course of the disease, especially toward the end of the sickness.

The _stool_ may be normal or costive, but is very often diarrhoetic. Twelve or more evacuations may take place during a day; as a rule they are much increased by gasses and are of bad odor. They weaken the patient very much and hasten the end.

One of the most constant attendants during the course of consumption is the _Fever_. It is rather irregular. In cases of slow process the fever is often very insignificant; often it is only a state of general excitement that takes hold of the patient afternoons, slight dizziness, increased lustre of the eyes, slightly flushed appearance, somewhat increased pulse, which invites to test the temperature of the body by means of a thermometer, which by the way shows it to be about 38 deg. C. With quick consumption the fever is generally high.

_Sweat_ is also a characteristic sign. The exceedingly debilitating effect of night-sweats is well known.

During the course of pulmonary consumption extreme _emaciation_ of the patient is brought about. All tissues are subject to the same, most marked is the disappearance of adipose tissue. This symptom is of the greatest importance as a continued increase in weight means improvement and even cure. Therefore weighing the patient from time to time gives a sure meter for the course of the disease.

The _course_ of pulmonary consumption is very different. With quick consumption the end comes within two or three months. Chronic pulmonary consumption may last for years. With this improvements in the fine season alternate with deterioration in the winter.

Concerning the former _treatment_ of pulmonary consumption, this will also be applied in the future in the same manner as far as preventive means and general hygiene is referred to.

For every one will prefer to remain exempt from consumption although it may now be possible to cure those afflicted. The lately published and popularly treated precautionary measures, especially with reference to the expectoration of consumptives retain their full value.

Henceforth the sputum is also to be thrown in a _spittoon_ which is either entirely empty or on account of easier cleansing has the bottom covered with a thin layer of water. It should not be permitted to fill the spittoons with sand or sawdust as the tubercle bacilli can be easily thrown up with the dust.

In the case of a _sudden attack_ of _cough_ a _cloth_ should be held to the mouth to hinder spreading of the fine spray, the same should also be used for wiping the mouth. However the cloth must soon be dampened and cleaned.

As bits of the sputum easily stick to the _beard_ especially the moustache overhanging the lips, therefore lung consumptives are advised to wear a short or no beard.

_Glasses_, _spoons_, etc. used by consumptives must only be used by other persons after a thorough cleaning with hot water.

The lungdiseased person should abstain from all active and passive _kissing_, in unavoidable cases kissing should be done on the forehead or cheek only, or hold out those parts only to be kissed. In the same way he should avoid to touch objects with his mouth that may possible be put in the mouth by other persons, especially children, for instance toy-trumpets.

In the case of _death_ from pulmonary consumption, the walls of all rooms and apartments used by the deceased should be rubbed down with fresh baked bread, which is a sure method of removing the bacilli. The bread crumbs that may have dropped on the floor may be removed by a thorough scrubbing with soap, brush and lye.

Upholstered furniture, beds, clothes and wash should be cleaned in a disinfecting place.

Do not wait with precautionary measures till some member of the family has been attacked by pulmonary consumption, but make preparation to prevent the infection while everybody is still sound and healthy.

This care ought to begin in a measure with the _birth of a child_. The same should not be nursed by a mother with diseased lungs nor by a wet-nurse with like affections. Generally wet-nurses are only tested for syphilis; scrofula and tuberculosis receive altogether too little attention.

An important precautionary measure consists in the supervision of the _food_. The abattoirs and dairies should be placed under the supervision of practical physicians, and the sale of products derived from tuberculous cattle be prohibited. This refers to the milk in the first instance. Tuberculous cows should be excluded from dairy-farms. Raw milk should be avoided as much as possible as boiled milk has the same value.

The _meat inspection_ must be strictly conducted especially with reference to tuberculosis in the case of beef, pork and chickens. Sheep are not subject to tuberculosis.

The _associations_ of children in school and on the play-ground should be watched; do not let them visit in strange families before making thorough investigation as to their sanitary relations.

The health of _servant girls_ should receive greater attention than formerly, as the disease is often carried into the house by them as investigation has proven.

In the _schools_ and kindergartens the teacher ought to insist that children do not spit on the floor or in the handkerchief; in case of necessity he should keep sick children out of school and he should especially follow these precautionary measures as regards his own person.

The _cleaning of the floor_ of a room should always be done in a damp way.

_Moving_ into another house it is advised to rub down the walls with fresh baked bread.

As regards _societies_, every society and every health resort without exception and if possible every hospital should be obliged to have its own apparatus for disinfection and to make extensive use of it. Smaller societies may unite to procure an apparatus of the kind.

Especial attention should be given to the _sprinkling of the streets_ during the dry season.

The state and the larger congregations should make it a point to maintain _institutions for consumptives_, beyond the city limits if possible, a healthy location in the country preferred.

Every one individually protects himself best from consumption by a methodic habit of _washing with cold water_, cold rubbing and baths. River and sea baths are generally of excellent results; short shower baths with cool water lasting 20-40 seconds are to be applied later on; they do not only harden the skin but excite deep inhalations and exhalations and in that way act as gymnastics of the lungs. More direct is the action of muscular exercise, such as gymnastics, riding horseback or bicycle, driving, skating, rowing, etc. The carriage of children must be regulated, the drooping forward of their shoulders must be corrected by strengthening the muscles of the back and shoulders by means of dumbbell and other exercises.

All this must still be observed in the future. On the other hand above all the numberless remedies will be dropped that have heretofore been applied as presumably specific remedies for consumption.

Creosote, which was so much praised at its appearance a few years ago and still applied, because of the non-existence of a better remedy, will be dropped into obliteration and with it Guajacol which was just getting to be the "fashion".

All the various inhalation methods that have matured in later years will disappear from the picture plane as far as this has not ever now happened.

The medical remedies, which were given for the torturing cough, for hemorrhage of the lungs, sweats etc., will in most cases be superfluous after this. Hemorrhages will now and then still be experienced as the same may set in unexpectedly.

The diatetic cures with whey, koumiss, grapes etc. will retain their importance and also the bathing resorts will be hunted up by patients as formerly.

The owners also of special institutes for curing pulmonary consumption need not despair with the idea that they will not be needed in the future. On the contrary, those needing cure will flock to them in all the greater numbers, as they now know that they certainly will be restored to health within a definitely limited time.

The other forms of Tuberculosis.

Of the other forms of tuberculosis _laryngeal consumption_ is very often combined with pulmonary consumption. It is estimated that this is true of at least one-fourth of all cases of pulmonary consumption.

At first laryngeal consumption can not in any way be distinguished from an ordinary inflammation of the larynx. A certain weakness and sensitiveness of the organs however is suspicious, also great liability to hoarseness. On the other hand laryngeal consumption may exist without any sort of ailing to the patient.

These appear later, however, when lung tuberculosis is progressing. The larynx shows more distinct outlines on the lean throat, difficulty in swallowing is experienced, pains radiate toward the ear. Food and drinks come up again after being swallowed.

The painful cough has a hollow, barking, harsh sound, provokes vomiting, and the sputum together with foul breath consists of foamy, slimy, purulent lumps. Breathing gradually becomes more difficult and louder.

As regards the duration of laryngeal consumption it generally runs parallel with pulmonary consumption. If the latter progresses more rapidly so also will the destruction of the larynx by the tubercle-bacilli be a more rapid one and vice versa. In several cases it has been observed that, if pulmonary consumption progressed or remained without any extraordinary symptoms, those with diseased larynx have lived for years, with alternating improvements and diminutions, and also an occasional suspension of all symptoms, till on account of often only a trivial, evil influence a new stimulus is given and the disease found an unexpectedly rapid completion of its course.

Until now only few cases of laryngeal consumption could be looked upon as really cured. Lately it has been tried to accomplish cures especially by the application of caustics. This will not now be necessary. But those afflicted in this way, will henceforth be obliged to try and live in air free from dust, to travel south during the winter and to subject themselves to a general strengthening treatment.

_Tuberculosis_ of the _tongue_ is relatively very scarce. The individual in such a case nearly always shows pronounced pulmonary tuberculosis. Sometimes tuberculosis of the tongue is combined with tuberculous sores on the lips and also on the anus.

Tongue tuberculosis forms small ulcers, generally on the rim, very seldomly on the back of the tongue. They always are very small, generally about the size of lentils or peas. They often remain unchanged for months. At times they are very painful, though as a rule the pain is mild. The male sex is attacked by tongue tuberculosis especially frequently.

The treatment before this consisted in cutting out all the diseased parts; now it will be much simpler.

_Nasal tuberculosis_ appears similar to the common stopping up of the nose. But when ulcers are formed, the secretions from the nose take on a purulent somewhat malodorous character. But if the affection is neglected, the secretion becomes bloody and of very bad odor.

Until now nasal tuberculosis had been treated by applying caustics to the ulcerated portions.

_Tuberculosis of the intestines_ or _intestinal consumption_ is especially found in _children_. The appearance of the same is already characteristic; the limbs are emaciated and withered; the old-looking wrinkled face shows a harsh contrast with the immoderately expanded body (frog-belly) which is caused by an accumulation of gases in the limp intestines which are then filled to bursting. Many such children have succumbed to gradually progressing emaciation and weakness.

Probably it will not be possible to save all children in the future that have been stricken with this disease as many are wanting in sufficient vitality to resist all external influences.

With adults intestinal consumption makes itself known by everlasting diarrhoea, a result of the numerous ulcers in the intestines which have been caused by the tubercle-bacilli.

_Tuberculosis of the brain and of the cerebral membranes_ also attack children especially. Before this no attempts have been made to try whether it is now possible to cure the _tuberculous inflammation of the cerebral membranes_ which has previously been unconditionally fatal. The decision will certainly soon be made.

We will give a fuller description of the symptoms of this disease to thus enable timely summons of medical interference. This disease will be known to many as "acute hydrocephalus."

As a rule children of 2-7 years of age are attacked by this fearful disease. The antecedents are extremely peculiar and manifold. Even two or three weeks before the outbreak of the real sickness, emaciation takes place from which the face is strangely enough entirely exempt, so that children, when dressed show no signs of a change. Attentive mothers and nurses, however, regularly notice the same and especially the appearance of the ribs causes no little anxiety. With this a slight pallor of the face is associated and a peculiar lustre of the eyes. The children lose their former feeling of gayety and activity. They sleep more than usual, withdraw from their favorite game, they become grumbly and shy toward their surroundings and cry for the slightest reason. It also is very peculiar that they avoid trying their former little tricks, such as climbing up on chairs, opening of door bolts that are almost out of their reach, they even will not try to look through a latticed window and asked to do so, decidedly refuse. Boys, that would not stand anything from their associates, that fought and wrestled as long as their strength permitted it, sneak away cowardly and crying from such attacks. Other children again become extraordinarily tender-hearted and affectionate, they hug their parents continually and can hardly console themselves when they leave them.

In the case of older children that have already learnt something, teachers notice unusual inattention and indifference, committing to memory comes harder than usual and what is finally learnt is recited in an awkward and stammering way. The children sleep unusually much and often by day; on the other hand their sleep at night is less sound and is interrupted by horrid dreams, frequent turning over in the bed and frequent clamorous outcries.

The appetite is lessened, and often a craving is noticed for stimulating food of which, however, little is eaten. Thirst is not increased. Urinal secretion is somewhat diminished and the urine is characterized by a brick-colored precipitate. The stool is rather costive, especially with larger children; but diarrhoea may attend this disease. The latter is principally the case with small children that are in the stage of first teething.

Headache is rarely felt and hardly ever complained of even by larger children; dizziness and unsteady walking is frequently observed. The children quite often complain of stomach-ache, which is very much increased by pressure on the abdomen.

Fever is not generally attendant, but the same may be present.

The symptoms just described, separately or collectively, gradually increase; the children finally take to their bed and now the _real cerebral affection_ developes.

Now the principal symptoms are: vomiting, constipation, slow pulse, irregular abrupt breathing, increased temperature of the skin, contracted abdomen, headache, great excitement alternating with drowsiness, beginning decrease of reason, and deranged ability of moving the limbs.

As regards _vomiting_, this is almost a continuous symptom and generally appears in the earlier stages. But the duration of vomiting is very different. Some children vomit only for one or more days and not all they have eaten, while others vomit continuously from the beginning of the disease till they are relieved by death, and no food can be found that is not thrown up shortly after its being eaten. In this connection it is a peculiar fact that vomiting will not recur if it has once ceased for twenty-four hours.

Very important for the recognition of the disease is the manner of vomiting. For a child suffering from a spoiled stomach will be troubled with nausea, belching, choking and cold sweat long before it is forced to vomit, while children with acute hydrocephalus will throw up without any previous symptoms of that kind, just as though they filled the mouth with water and spit it out again. Vomiting is facilitated when children are raised or placed on their side. It ceases for the time the stomach is empty, but as soon as fluid or even solid food is taken in it will be cast out at once without causing any particular distress or inconvenience to the child. Gall is very rarely mixed with the vomit.

A second and nearly as constant a symptom is _constipation_ from which nearly three-fourths of the diseased children suffer. As a rule cathartics have no effect and are generally thrown out through the mouth. This constipation will not last till the end, for a few pappy stools appear later on whether purgatives are administered or not. Violent diarrhoea resulting from intestinal tuberculosis may be discontinued at the beginning of acute hydrocephalus. But the later stools will again be thin and of cadaverous odor.

During the latter stages of the disease children will often _fail to pass urine_ for twenty-four hours, so that the physician is obliged to draw it off with a catheter.

The appetite does not disappear entirely as a rule. There may not be any desire for food, but generally little difficulty is experienced in inducing children to take milk or broth, which is all the more surprising as vomiting regularly follows.

The _fever_ is generally not very intense. The temperature of the head, especially the forehead, is considerably increased in all cases and remains so until death ensues, while the feet have great tendency to getting cold.

The _pulse_ is characteristic in many cases. In the beginning of the disease the pulse is quickened only to slacken after a few days. The number of beats may be reduced to 40-60 a minute (normal 90-100), however it does not commonly remain at a certain figure, but varies, often inside of an hour, so that at one time 40, then 60 and again 80 beats may be counted inside of twenty-four hours.

The pulse again increases 1-3 days before death and then to such a rate that it is almost impossible to count it. It may reach 180 and 200 beats a minute. As soon as this rate of the pulse follows one of the reductions described above a speedy death may be predicted.

Of great importance are the variations in respiration. In the beginning stages of the disease breathing is normal except in such case where tuberculosis has made great progress in the lungs and in the case of high fever. Then of course breathing becomes more rapid. Acute hydrocephalus influences respiration in such a way that it slackens and becomes irregular. In one minute children may breath fifteen times, in another thirty, then again 20 times; at one time breathing may be very slight with almost invisible expansion of the chest and without any noise whatever, then again it may consist of deep sighs; these are also characteristic of this particular disease. Sometimes breathing is completely discontinued for ten seconds and more.

If the pulse attains that extreme rate shortly before death the rate of breathing will also be increased.

As regards the _skin_, the same is generally damp from the beginning of the disease; severe sweats are observed on the head; with progressing disease the skin becomes dry, brittle, comes off in flake-like scales and only when the death-predicting increase of the pulse sets in, there appears a profuse sweat, the cold sweat of death.

_Headache_ is also a prominent and pretty nearly constant symptom. As has been mentioned before, it does not as a rule attend the precursory symptoms. It generally begins with vomiting and soon becomes so violent that older children constantly cry aloud and lament, while the smaller ones put their little hands up to their head, pull their hair and ears and restlessly roll about on the pillow.

These expressions of pain last as long as children retain consciousness, a particular part of the head is not commonly pointed out, but asked about it the majority point to the forehead. With small children automatic movements are noticed that also seem to refer to headache, and which consist in rapidly placing the hand on the head and then drawing it back.

The larger children complain of _pains in the bowels_, especially in the region of the stomach, which remarkably often, though not regularly, become more intense by pressing and may become so violent that the children cry out aloud with pain, when the stomach or other portion of the abdomen is but slightly touched. But these pains do not last as long as the headache, they often stop suddenly, at times return.

The shape of the _abdomen_ is extraordinarily characteristic. In the beginning nothing remarkable can be noticed, but after the symptoms of acute hydrocephalus, vomiting, constipation, etc., have lasted for some time, the abdomen gradually decreases in size, becomes wrinkled and collapses until it finally assumes a scaphoid shape and by slight pressure the large iliac artery can be felt on the spinal column.

This contraction of the abdomen is attendant in every case of tuberculous meningitis.

If the large _fontanel_ on the head is not yet closed, the same will gradually bulge out as the disease progresses.

The _mental activity_ suffers premature derangements, such as have been fully mentioned in the description of the precursory symptoms. The most striking is the confused, staring look, the peevish and surly behavior, and again in other cases the extreme indifference toward otherwise well-liked persons and things. Later on actual delirium sets in, but generally of a quiet nature.