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Medical Magazine. 
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OCTOBER, 1894 
PROPHYLAXIS IN THE TREATMENT OF TUBERCULOSIS 
LAWRENCE F. FLICK, M.D., 
PHILADELPHIA, PA. PROPHYLAXIS IN THE TREATMENT OF TUBERCULOSIS. 
Lawrknck F. Frick, M.D., 
Philadelphia, Pa. 
With the demonstration of the parasitic nature of tuberculosis 
began a new era in its treatment. In the past the medical profession 
has had no resources in its struggle with this disease except such as it 
could draw from empiricism, but in the future its combat will at least 
be founded upon a rational basis. All that has been found useful in 
the past can now be used more intelligently and more effectively because 
we can give a reason for its use, and can discriminate in its application ; 
and the new light has already enabled us to discover pathways which 
promise to lead us to the El dorado in which will be found the precious 
substances that will cure. 
From the organic theory of tuberculosis we can learn many valu- 
able lessons in treatment. The organic theory as now elucidated can 
be briefly summarized as follows : 
(i) Tuberculosis is a parasitic disease due to the implantation and 
development of a vegetable organism in the tissues of the body. 
(2) For the successful implantation and development of this organ- 
ism the tissues of the body must constitute a proper soil, which may 
either mean that they contain a certain something conducive to the 
development of the organism, or they lack a certain something which 
would interfere with the development of the organism. 
(3) The symptoms which we recognize as constituting the disease 
we call tuberculosis are partially due to the irritating presence of the 
parasite, partially due to the destruction of tissues which takes place 
during the effort of nature to cure, and partially to the absorption of 
poisonous products of the organism. 
(4) When death takes place from tuberculosis it is usually due to 
the ptomaines produced by the organisms causing the disease, but may 
be due to destruction of tissue, or to the inflammation set up by the 
parasite. 
(5) The severity and rapidity of progress of a case of tuberculosis 
is in proportion to the fertility of the soil and the number of organ- 
isms implanted. 
(6) The soil for tuberculosis is not exhausted, but, on the con- 
trary, is enriched by the growth and development of the organism pro- 
ducing the disease, and is likewise enriched by the growth and develop- 
ment of organisms producing other diseases. 
1 Read before the Pennsylvania State Medical Society, Philadelphia, June, 1894. 2 
Lawrence F. Flick. 
(7) Fertile soil for the development of tuberculosis can be trans- 
mitted from parent to offspring, and can be produced by mode of living 
and by occupation. 
(8) Tuberculosis cannot exist without the organism which pro- 
duces the disease, and therefore no new case can arise without having 
an old ome to spring from. 
A most valuable lesson taught by the organic theory of tubercu- 
losis, and one hitherto unrecognized, is prophylaxis in the treatment 
of the disease. Tuberculosis is strictly a parasitic disease, and as such 
is always a local disease. It is local, however, only in its cause, for the 
absorption of the products of the tubercle bacillus sets up constitutional 
symptoms, and death usually results from the absorption of those pro- 
ducts. It might therefore be termed a constitutional disease with a 
local cause. Nature makes a strong effort to get rid of all parasites, 
and in tuberculosis this effort manifests itself in the formation, break- 
ing down, and casting off of the tubercular nodule. Unfortunately, this 
very process may be the means of extending the disease. When a 
tubercular nodule breaks down the escaping organisms are liable to find 
their way back into the circulation, and to form new deposits. Re-en- 
trance into the circulation may take place at the seat of ulceration where 
the broken-down tissue seeks exit, through a denuded surface in the 
mucous membrane of the respiratory tract, through the peribronchial 
glands, and through the stomach. 
Were it not for auto-infection or re-entrance of the organisms into 
the system all cases of tuberculosis would get well. It is very rare 
that the first invasion of the organism is powerful enough to produce 
death. In those cases which are called acute tuberculosis, and in which 
death ensues in a few weeks, it is quite probable that the large number 
of organisms which are capable of producing such a result are not taken 
into the system at one time, but have been grown in the system in 
some gland, and have suddenly been set afloat in the circulation 
by the breaking down of that gland. Most cases of tuberculosis are 
simply a prolonged series of invasions of the organism in which 
each new invasion is the outcome of a former abortive effort at 
cure. This accounts for the long duration of tuberculosis, and also 
for the variation in its duration in different persons. Where the 
resisting power of the individual is good, the various invasions are 
apt to be mild and the breaking-down process slow, making the 
intervals between the invasions longer. The sanitary environments, 
and the habits of life also, are pregnant factors in determining re- 
infection, and consequently the duration of the disease. Hence we 
have the duration of tuberculosis ranging from a few months to many 
years. And yet the disease is the same in all persons, differing only Prophylaxis in the Treatment of Tuberculosis. 
3 
in the rapidity of the breaking-down process, and in the number and 
size of the invasions. 
A clear knowledge of the nature of tuberculosis and a full appre- 
ciation of the influences which bear upon its development are of pri- 
mary importance in its treatment. Auto-inoculation, whilst it cannot 
be absolutely prevented, can be, to a great extent, controlled, and the 
rapidity of the breaking-down process can in many cases be materially 
checked. Along this line lies all scientific treatment of tuberculosis so 
far known, and along this line all future effort in search of remedies or 
modes of treatment must be made. When we can absolutely stop all 
auto-inoculation we can cure the disease, and until we can do that 
deliberate and unfailing cure is impossible. In those cases in which 
recovery takes place this is the process by which it is brought 
about, and as far as we are now able to see it is the only process by 
which it is possible. 
Auto-inoculation can be largely controlled in twTo wa3-s, by build- 
ing up the system of the patient so as to enable it to resist new deposits, 
and by preventing the readmission of the organisms into the system. 
For the building up of the system every possible resource must be drawn 
on, and the food-supply, the digestion, the assimilation, and the elimi- 
nation all carefully studied and corrected, where faulty, so that the larg- 
est possible amount of nutrition be obtained with the smallest pos- 
sible consumption of force and energy. Increase in weight and strength 
and the restoration of the normal functions of the different organs 
of the body is the best evidence we can have that this is being accom- 
plished, Improvident expenditure of force must be guarded against. 
Violent or prolonged exercise, depressing mental influence,—anything, 
indeed, that makes an unusual demand upon the muscle or nerve re- 
sources of the body should be scrupulously avoided. Forced nutrition 
should be practised as far as it is compatible with the maintenance of a 
healthy condition of the stomach. Ample sleep should be taken, and 
the nervous system always kept in a good vigorous condition. 
The re-entrance of the tubercle bacillus into the system can be 
prevented to a large extent by the sterilization of all broken-down tissue 
as soon as it is given off. Of course re-entrance at the seat of exit, if 
there are broken blood-vessels at the place of ulceration, cannot be 
protected against; but fortunately the channel through which a broken- 
down nodule empties itself is frequently a non-absorbing surface. N Re- 
entrance through denuded mucous membrane of the trachea and through 
peribronchial glands is also difficult to guard against. But when the 
broken-down tissue has once made its exit from the body, it is compara- 
tively easy to prevent it from again infecting the patient. This can be 
accomplished by immediately sterilizing it whilst still in a moist condi- 4 
Lawrence F. Flick. 
lion. All sputa of tuberculous subjects should be ejected into a sputum 
cup, containing a liquid and, if possible, a germicide, and where this 
is not practicable into a paper handkerchief. Handkerchiefs made of 
other material should not be used, because the sputum dries too readily 
in them and the patient is very apt to rub it up or scatter it in pulling 
his handkerchief apart. When handkerchiefs are used they should 
not be allowed to become saturated, and should, after using, be burned. 
Under no circumstances should tuberculous matter ever be allowed to 
remain and dry on bedclothing or upon furniture, carpets, etc. In 
short, all tuberculous matter given off by a patient should be devitalized 
at the earliest possible moment after it has made its exit from the body. 
It is quite likely that reinfection sometimes takes place through 
the stomach. Tubercular matter is frequently swallowed by patients 
voluntarily and still more frequently by accident. Broken-down tuber- 
cular matter is apt to adhere to the pharynx and to be swallowed with 
food in eating. The living organisms in such matter may meet their 
death in the stomach through the agency of the gastric juice, but may 
also run the gauntlet of the stomach if the secretion of gastric juice is 
deficient or if protected by undigested food, and be carried into the cir- 
culation with the chyle, finding lodgement in whatever part of the body 
best fitted to receive them. It is therefore of the greatest importance 
that patients be instructed not to swrallow sputa. Where the expectora- 
tion is profuse, it is well to have the patient gargle the throat with an 
astringent before eating. Sometimes the hands and mouth are smeared 
with sputa, and for this reason the precaution of washing these ought 
to be taken before eating. 
Where a patient is living in a room in which preventive measures 
have not been practised, such room ought to be carefully disinfected. 
This disinfection does not consist of burning sulphur or whitewashing, 
but in completely renovating the room. The walls should be scraped 
and then washed with a five-per-cent, solution of carbolic acid. 
If the walls have been painted they should be rubbed dowrn wnth 
bread and then washed with carbolic-acid solution. The floor should 
be scrubbed with a carbolic-acid solution, and every particle of 
furniture, carpet, bedding, etc., in the room should be either subjected 
to a temperature above 158° F., or disinfected with a five-per-cent, 
solution of carbolic acid or a one-tenth-per-cent. solution of corrosive 
sublimate, to which must be added some tartaric acid, citric acid, 
hydrochloric acid, or muriate of ammonia, to prevent the coagulation 
of albumen. I have more than once seen the improvement of a patient 
date from his removal from infected quarters, and I have no doubt but 
that some of the benefit which is usually credited to change of climate 
is really produced by removal from infected homes. Prophylaxis in the Treatment of Tuberculosis.- 
5 
The importance of prophylaxis in the treatment of tuberculosis 
cannot be over-estimated. Whatever brilliant results may be obtained 
temporarily by drug treatment, upon prophylaxis must depend to a 
great degree permanent results. No case of tuberculosis should be 
called cured until it has withstood new invasions of the disease for 
four or five years. lam convinced that for fully that length of time a 
case of tuberculosis which has apparently recovered may carry the 
slumbering embers of the disease in a partially broken-down gland or 
secreting cavity, and is prone to new invasions of the disease. It has 
been shown that the tubercle bacillus can maintain its vitality for a 
very long period, probably a year, at least in dried-up broken-down 
tissue. A room containing such dried-up tissue is, therefore, a source 
of danger to the patient for a long time after he has apparently recov- 
ered from the disease, and may be the means of precipitating a fresh 
attack. The only safe thing for the patient in the light of modern 
science is, (i) To make his surroundings absolutely free from danger 
from infection, (2) and to prevent him from reinfecting himself by 
keeping him in the best possible state of health, so as to be able to resist 
the disease, and by inhibiting the reintroduction of ejected organisms 
into the system.