Chapter 3

A very common symptom is a loud, plaintive outcry, that is repeated at longer or shorter intervals. Children often cry out at partly regular intervals during a whole night; these cries are always accompanied by a loud sigh. These symptoms of excitement being extremely tormenting and depressing for the sympathizing relatives, fortunately last no longer than 6-8 days at the most, and are succeeded by a deep _stupor_.

If the children have once become _unconscious_, they do not recover again as a rule but remain so until death; delirium and stupor may alternate with each other in certain cases, but the former process is by far the most frequent.

_Convulsions_ appear only in the later stages. At first the interval between the attacks are long, often as many as three or four days intervene. Commonly however they come much oftener and may in some cases last for hours. All extremities are affected by these convulsions, the eyes become red, are rolled in every direction and turning way up are fixed so that nothing but the whites is visible. After several minutes, often after two or three hours, these general convulsions subside, the children, now very pale, drop into a deep sleep and their general condition appears much reduced.

Different muscular groups especially those of the face are subject to _local cramps_. The upper lip may become distorted, convulsive smiles have been observed, also peculiar sucking motions. The children point their lips and flatten them again, sometimes for hours in succession.

In the latter stages a squinting of one or both eyes may be noticed but this may again disappear.

_Grinding of the teeth_ is another very peculiar symptom which is well-known and feared by experienced nurses. The _arms_ are subject to various motions, at times sweeping automaton like, then again convulsive contractions, sometimes trembling of the muscles, at others a throbbing of the tendons. Many patients put their hands to their sexual organs and make motions tending to onanism.

The _legs_ are not subject to cramps as much as the arms; they are mostly bent and drawn up in a half paralyzed condition.

The _muscles of the neck and back_ are very much contracted and most children, when raised or laid on their side, bend the head far back.

In most children an extreme sensibility at being touched is observed. They may be handled with the greatest possible care and lifted most tenderly, a slight pressure on the head, body or hands in changing their position will be violently resisted with obvious expressions of pain. In the latter stages this extreme sensibility gives way to _insensibility_.

Then the children may be pinched and poked, they may be turned and moved from one side to the other without any consideration, they will not resist and only give expression to the remaining sensibility by a low whimper. The lack of sensibility may be especially marked in the eyes; these can be touched with the fingers, without causing a closing of the lids.

The sense of _hearing_ seems to continue its functions until very late. Children show that they hear as long as they are not completely unconscious; even when addressed in a low tone of voice they react somewhat. The sense of _smell and taste_ also are lost toward the very end of the disease.

_Paralytic_ affections appear during the final stages. It has been observed in some cases that the arm and limb are paralyzed on one side only. Often one upper eyelid is paralyzed and hangs down on one side of the face and the muscles of the tongue may be affected.

Generally the patient dies after violent general convulsions that last for hours. Exceptionally only the paralytic symptoms increase gradually and cause death without any agony or struggle, simply a discontinuance of the functions constituting life.

The duration of the disease varies from 2-4 weeks from the beginning of the characteristic symptoms. Generally the day when the children take to the bed is fixed as the beginning of the disease.

The former methods of treatment have been a signal and absolute failure in every case. Every child that has once been attacked with this disease has heretofore died. Until now Koch has not been able to make any experiments with acute hydrocephalus, so that it remains an open question whether it is now possible to cure this disease.

Besides tuberculosis of the cerebral membranes with which children are afflicted, _tuberculosis of the brain_ may occur, although this disease is very rare. Tuberculosis of the brain appears in the shape of small tumors in all parts of the brain. After longer duration of tuberculosis of the brain, tubercular meningitis appears.

The process of this disease may be varied. In some cases the development of cerebral tuberculosis is manifested by the sudden appearance of high fever temperatures or violent headache; to this may be added, slackening of the pulse, vomiting, stiff neck and isolated cases of palsy; sometimes an attack of convulsions is the first manifestation.

In other cases the beginning can not be accurately determined, as the beginning symptoms of the disease are so slight as to escape notice. Impaired process of nutrition, languor and headache are symptoms from which the existence of some serious affliction may be inferred without being able to determine its nature in the earlier stages.

Again in other cases the disease may proceed through all its stages without any cerebral appearances whatever. This is especially true of small tubercles and of diseases of infants. However, we more frequently observe in children than in adults convulsions of varied intensity and distribution.

Nutrition is more and more impaired as the disease progresses, in isolated cases only, a temporary improvement may be observed.

The _end_ of cerebral tuberculosis has been _death_ before this. Ten days to two weeks, even three weeks may pass from the first appearance of tubercular meningitis to the completion of the process of the disease, attended by feverish motions characteristic of this condition and by cerebral symptoms, first with the character of excitement, later on with that of palsy.

The treatment of cerebral tuberculosis has been entirely insufficient before this. Let us hope that it will be possible to effect a cure by means of Koch's new method.

_Tuberculosis of the Kidneys_ is met with from the earliest childhood till old age. Most frequently the male sex is afflicted during manhood.

In most cases tuberculosis also exists in other organs, especially in the urinary and sexual apparatus. The existence of pulmonary or intestinal tuberculosis is not essential.

The symptoms of renal tuberculosis are of such general and indefinite character, that it is often impossible to fully determine the disease. Now, however, it will be more easily possible on account of Koch's discovery.

The _urine_ may, but need not contain pus and blood. Sometimes small lumps are found in the urine.

_Pains_ are only sometimes felt in the renal regions; _fever_ may be occasionally attendant.

The disease lasts for months and years; though before now it has inevitably resulted in death, though it has in exceptional cases taken ten years or more.

The internal treatment of renal tuberculosis was ineffectual, surgical treatment has been attended with greater success. This consisted in removing the diseased kidney. Now good results will possibly be attained by the application of Koch's method to cure and resource to surgery will be taken in exceptional cases only.

_Tuberculosis of the suprarenal capsules_ is of very rare occurrence. It leads to a peculiar change in the color of the skin; the same turns dark brown or bronze color. Sooner or later death results.

Perhaps the application of Koch's method will, besides curing the disease, give us information regarding the functions of the suprarenal capsules about which nothing whatever is as yet known.

A large space in the realm of disease is claimed by _tuberculous affections of the bones and joints_. These afflictions appear particularly in childhood though manhood is by no means exempt. They may appear in all portions of the body, although a marked preference is shown for certain parts. Although the tubercle-bacilli are infinitely small, they possess the power to cause suppuration of the bones and joints and to produce acute inflammation of these parts.

Most frequently tubercular affections of the bones are found in the hip-joints, the knee and the spinal column.

_Tuberculous inflammation of the hip-joint_ is principally a disease occurring in childhood; though it rarely appears before the third year. It is most frequent from the fifth to the tenth year.

Inflammation of the hip-joint developes very slowly in children, it generally takes months before the slightest beginning symptoms reach a threatening appearance. The first sign is _lameness_; among laymen tuberculous inflammation of the hip-joints is known as "voluntary limping."

By limping we understand that mode of walking in which one leg is spared and by this the trunk is supported only a short time by one extremity and all the longer by the other. In every painful affection of the lower extremity limping results as the weight of the body increases the pain. The lameness in the case of diseased hip-joint has something peculiar about it, inasmuch as not only a part of the extremity but the whole of it is dragged. For this very reason parents of children afflicted with inflammation of the hip-joint use the expression "the child draws" or "drags the leg".

In the beginning even the examining physician finds no symptoms of disease in the joint. No swelling, no abnormal position, no restriction of the freedom of motion, no pain from pressure or while moving, in short nothing can be found that would otherwise indicate the beginning of an inflammation of the joints.

Yet _lameness only_ is sufficient data from which we may infer the probable beginning of hip-joint inflammation. It is much better to overestimate the significance of this symptom than to miss the proper time for calling in the aid of a physician by placing too little confidence on it.

The second symptom, _pain_, rarely attends the beginning of lameness, generally it comes several weeks later and in the case of very slow development of tubercularly inflamed hip-joint several months later. In very small children the attendance of pain is manifested by the fact that they will not play and they often wake up in the night and begin to cry.

Children from the fourth and fifth year upward definitely point out the hip as the seat of pain, sometimes, however, the knee-joint on the diseased side is designated with great determination. This pain in the knee has often been the cause of mistakes.

Later on painfulness of the hip-joint is experienced from pressure and at about the same time the movements are impeded.

Then the leg takes a peculiar position. The thigh is slightly bent and rolls outward. For convenience the child drops the half of the pelvis corresponding to the diseased hip-joint, and naturally raises the other half. From this apparently a curvature of the spinal column results in the lumbar region. Apparently only, for when the child is laid down and the morbid position of the thigh is restored the curvature of the lumbar column disappears.

During the further progress of the disease the pain is increased, and the sensibility may become so acute that the slightest movement of the limb, even a shaking of the bed in which the patient lies will cause the most intense pain. In the previous stage walking could only be done for short distances and then awkwardly, now it is entirely impossible. Children are obliged to lie in bed night and day, and under these altered conditions there is a change of the position of the extremity. The increased sensibility induces the child to seek the medium position, the leg is bent more than in the position mentioned above, it is halfway straightened.

To this is added, that the child can not lie well on the sensitive and swollen hip; with right side hip-joint inflammation it turns on the left. As the diseased and bent thigh does not then rest on the mattress the same is placed on the healthy limb for support and for protection from movements, in the same manner as we lay one leg on the other in a healthy condition when we sleep on our side.

The actual danger to life in tuberculous hip-joint inflammation begins with the time when the child takes to his bed. The fatal end comes almost without exception after suppuration has commenced, very rarely before that time. Total suppuration of the hip-joint is an almost absolutely fatal process. If this suppuration sets in suddenly, it may result in an early death with attendance of acute fever. In other cases several weeks may elapse from beginning suppuration till death.

A complete cure of tuberculous hip-joint inflammation may come about spontaneously. But often the knee remains bent and unserviceable for walking, so that crutches or machines must be used.

Even before this the beginning stages were treated with fair prospects of success, and it is a lamentable fact that in many cases the import of these seemingly trivial symptoms has been underestimated.

_Rest_ is of the greatest importance during the very first stages of the disease in which the attending symptoms are of so indefinite a character that it is almost impossible to know whether hip-joint inflammation will develop or not; the child must not be allowed to walk. Aside from this the application of brine-, malt- and sea-water baths is advised. An abundance of nourishing food is of just as great importance. All this will also retain its significance in the future.

Formerly recourse to surgery has been taken during the later stages of the disease in which suppuration of the internal parts of the joint has commenced and large parts of the diseased bones may have become mortified. An incision is made into the joint, the same is exposed and all diseased portions are carefully removed. In the future this operation must probably also be performed, although with the difference that the prospects of success are now much more certain than formerly when relapses only too often followed the operation.

_Tuberculous inflammation of the knee-joint_ is, as said before, very frequent with children and is rather lingering in the beginning. Here also a slight dragging or limping of the diseased leg can be noticed. The child when asked about the limping, or of its own accord, complains of pain in the joint after walking or when the part is pressed; at first nothing abnormal can be seen on the knee by the layman.

On closer examination, however, by comparing the two knees it will be found that the grooves on each side of the patella, which give the healthy knee-joint the beautifully modeled shape, have nearly or quite disappeared; nothing more can be noticed.

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 deg. 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.