tUith the Author’s Compliments. 
I iibcrcu Lin. 
The Value and Limitation of its 
Use in Consumption. 
BY 
Charles Denison, A. M., M. D. 
Of Denver, Colorado. 
Professor Diseases of the Chest and of Climatology Medical Department University 
of Denver.—Author of “ The Rocky Mountain Health j 
Preferable Climate,” “The Annual and Seasonal Chilians 
Charts of the United States,” Etc. < 
REPRINTED WITH REVISIONS UP TO DATE, EEB. 1st, 1892, FROM THE TRANS- 
ACTIONS OF THE COLORADO STATE MEDICAL SOCIETY 
FOR 1891. 
DENVER, COLO. 
PRESS OF MEDICAL TIMES PUB. CO., 
<509 17th Street. TUBERCULIN. 
THE VALUE AND LIMITATION OF ITS USE IN 
COSUMPTION. 
I assume that no apology is necessary for my chang- 
ing the subject of this paper from the Surgical Treatment 
of Lung Cavities to the discussion of Koch’s lymph; be- 
cause of late my mind and opportunities have 
been turned in the latter direction. Besides, my 
professional brothers expect some report of my in 
vestigations of the great German scientist’s new remedy, 
and now and here are the best time and place for it. Now, 
because time enough has elapsed for the expression of a 
great variety of opinions, and here, because no symposium 
on consumption is complete without a consideration of 
this recent invention for its amelioration. 
The questions which to my mind need most to be 
answered are. 
1. Was the description given us of the composition 
of Koch’s lymph sufficient for our gaining full knowledge 
as to its uses? 
2. Were the rules laid down by the author adequate 
and complete enough for the use of so powerful an agent? 
3. Is the knowledge of tuberculosis sufficient, or are 
the means and facility of its diagnosis adequate among 
the average of medical men for their use of tuberculin, as 
proposed by Koch, without a considerable chance of 
damaging the patients, as much as they would benefit 
them? 2 
TUBERCULIN. 
I have arranged these questions purposely that I 
might answer them as I do, with a decided No. It must 
then follow that this is not yet a remedy to be indiscrim- 
inately sold by druggists, and generally used by all sorts 
of doctors. 
The much to be desired time will come, if this remedy 
is not too soon consigned to oblivion, as it was at first 
placed on the top of the Mountain of Hope, that the 
knowledge of tuberculin and of tuberculosis likewise, will 
be adequate to satisfy a critical mind. But that time is 
not yet. 
Nevertheless, with all these doubts and suggested 
limitations,.the use of tuberculin, though unconsciously 
faulty, is not to be forbidden, if we can show that we are 
running only a ten to twenty per cent, chance of danger 
for the purpose of a thirty to sixty per cent, chance of 
benefit. The reason for this discussion is thus apparent, 
that through the process of exclusion, conditions only 
favorable to the use of tuberculin may obtain, and the 
percentage of danger be reduced to the minimum. 
This criticism of the German professor’s methods 
must not be considered as an under valuation of that 
scientist’s true worth. Robert Koch stands to-day with- 
out a living peer in the great and growing professsion of 
medicine, for he has originated more for scientific advance 
than any two men living. He has not only discovered 
the bacillus of tubercle so that physicians all over the 
world could easily demonstrate it as an essential feature 
in every tuberculosis, but in a few years thereafter he has 
produced a fluid which wars against the habitat of that 
germ, thus tending to eliminate its consequent disease. 
When we reflect that tuberculosis exterminates more of ITS VALUE AND LIMITATION OF ITS USE IN CONSUMPTION. 
3 
the human race than any other disease under the sun— 
that is, ever since Jenner’s vaccine virus “knocked out” 
small pox,—we say all honor to Robert Koch, the greatest 
physician of the age. 
We would, if possible, find out the inadequacies or 
mistakes in Prof. Koch’s procedure, that the perfection 
of his great discovery might be brought nearer to hand. 
For I believe that rightly directed criticism will do much 
to clear away the doubt and prejudice which largely per- 
vades the professional mind as to this means of cure. 
Let me then consider the questions previously pro- 
pounded, and see why they should be answered in the 
negative. I will use the cases I have experimented on 
for purposes of corroboration or reference, and try not to 
burden your minds or patience too much with their many 
details. We shall confine our attention wholly to pul- 
monary cases. These cases have been twenty in number. 
Numbers one to five of these, most people would call 
cured. I do not yet claim that term as applicable, yet 
they are probably better off than in a state of arrest, be- 
cause the tuberculosis has been in a process of elimina- 
tion. These twenty cases were serious enough; distinctly 
tubercular, yet only two of them acutely so. 
Nos. I, 2 and 3 were third stage cases, with both 
lungs more or less affected, while Nos. 2 and 3 had the 
dreaded laryngeal complication. 
No. 4 is interesting, as showing the diagnostic power 
of tuberculin. This was a case of fibrosis chiefly, evi- 
dently tubercular when he came to Colorado for his health 
three years previous. In March, 1891, his disease was 
apparently fully arrested, through the fibroid process and 
rarefied air. The question then arose, could he go back 4 
TUBERCULIN. 
East to live? I obtained from his parents permission to 
use the tuberculin to learn if latent tuberculosis remained. 
I was much surprised to find a considerable local reaction 
in the right infra-scapular space, where previous to the 
first injection I had not noticed anything abnormal. This 
reaction was over an area two by three or more inches, 
and was accompanied by the characteristic febrile rise 
to ioi°, and the appearance of bacilli in his sputum, (four 
to the field) which had not been found by a previous mi- 
croscopic examination. This reaction, which was marked 
after 2, 4 and 6 mgs., wore off with the lessening of fever 
as larger doses were reached. Finally there was no reac- 
tion after 20 mgs., and I consented to his return to Mas- 
sachusetts after a 30 mg. dose and about six weeks treat- 
ment. The characteristic rough breathing in the rear 
base of the right lung had moderated, assuming the 
slightly bronchial character usual in high altitudes in an 
arrested fibroid lung. 
Case 5, of my list, is to me very interesting, because 
it shows the undoubted agency of climate and lung ven- 
tilation in the cure, as well as the rapidity and ease with 
which his system took the tuberculin. Mr. F. T. P., age 
27, a lawyer from Toledo, .Ohio. In January, 1890, had 
had la grippe, followed by weakness, night sweats, cough 
and loss of 15 pounds in weight. In March, went to 
Asheville, N. C. Was thin and had decided p. m. hectic 
there for some time. Began to gain flesh in October. 
Arrived in Colorado October 18th, weight at least in 
summer 133 pounds. October 20, 150 pounds. Temper- 
ture ranged between 98° morning and ioo° evening. 
Spirometrical record 240. Manometer 85 M. M. Expan- 
sion 33 and 36. Sputum yellow, one-half cup chiefly THE VALUE AND LIMITATION OF ITS USE IN CONSUMPTION. 
5 
mornings. Depression, moist rales on coughing, and al- 
most “cracked metal” on stethoscopic percussion below 
right clavicle. Waivey and broncho vessicular respiration 
in left inframammary and lower axillary. All showing 
softening (2d stage) at right apex and arrested fibroid 
process at base of left lung. 
May 7, after spending the winter, much out of doors, 
in Colorado Springs, all the physical signs were found to 
be improved. Expectoration less one-third cup in 24 
hours. Expansion increased 1 inch, 3254 and 3654. 
Fewer rales at right apex. Bacilli in sputum, some slight 
probably compensative emphysema in lower half right 
lung. 
May 15, began tuberculin injections. Bacilli five to 
field, no general reactions {i. e., no fever), but slight local 
reactions shown by physical signs, so a rapid increase of 
dose was allowable, i. e., nearly doubling every other day. 
May 23, after 10 mg., thirty bacilli to field. 
June 2, after 45 mg., three or four scattered bacilli to 
the field, but still with slight remaining indications of the 
effect of the tuberculin local reaction, the characteristic 
harsh breathing in right infra-clavicular and left infra- 
scapular regions. Pulse, respiration and temperature 
normal, expansion and 37 inches. He declared he 
was well, and was bound to go home, to Toledo. I could 
not restrain him, and so with a parting 50 mg. “shot,” let 
him go, with the advice that he return, work up to 80 mg., 
and then thoroughly establish his cure by camping in the 
mountains during the hot months of the summer. We 
shall see. A letter just received from him says he does 
not feel as well down in Ohio, and he may return. [Later, 
Jan. ’92, writes that he thinks he is fully cured.] These 6 
TUBERCULIN. 
five cases have all lost the usual signs of tubercular 
state, have increased in vigor and no longer react to large 
doses of tuberculin, 30 to 50 mg. Their sputum, dimin- 
ished to the minimum in quantity, shows only the rem- 
nant of the vanquished bacillary army which was making 
war on the organism, at the commencement of this treat- 
ment, four months ago. 
Numbers 6, 7, and 8 are now under treatment, and 
will soon arrive at the favorable state of those previously 
mentioned. They are progressing evenly and finely, 
These are, No. 6, a lady from Greeley, with broncho-fibro- 
tuberculosis, having a very small softened or bronchietic 
spot in each lung, now completing a mid-way rest in the 
treatment at 30 mg. (Since graduated at 80 mg.) 
No. 7, a tolerated third stage fibro-tubercular case, 
with large cavity in left apex, who has slowly reached 7 
mg.; and No. 8, a more decidedly tubercular fibroid case, 
both lungs affected, with a bronchiectasis in the left and 
a softened spot on the right, and considerable dissemina- 
tion of the fibroid process, He is now getting used to 1 
and 2 mg. One mg. tuberculin was too much for this 
patient at first, and four lesser doses had to be given be- 
fore the reaction satisfied me as sufficiently mild. Nos. 
9 and 10, lately commenced a cautious or tentative plan 
of treatment, and are third stage cases progressing satis- 
factorily, but the final result is not yet in sight. No. 9 is 
a case of laryngeal phthisis, and a process of healing can 
already be noticed in a tubercular ulceration on the left 
side of the pharynx. 
Nos. 11 to 14 inclusive have ceased treatment temp- 
orarily for reasons given. They were favorable cases, THE VALUE AND LIMITATION OF ITS USE IN CONSUMPTION. 
7 
however, and reached an average of io mg. for last treat- 
ment. These four were all third stage cases, the evidence 
of that advance being very positive with large cavity in 
one case, much less positive, and in a small space in the 
others. I cannot consistently, with my notions of truth, 
classify the consumptives we have to deal with in Colo- 
rado and put many in the second stage. If softening 
has occurred that is usually the end of it, and it is the 
result in the tlrird stage with which we have to deal.. 
Of these four, Dr. , of Idaho Springs, reached 14 
mg. and reacted slightly at that increase; lost his fever, 
and gained in strength and physical signs. The effect of 
the tuberculin in shrinking of affected lung tissue was 
manifest in his case. The highest reaction was 102° F. 
after 4 mg. March 8, he returned home to his practice, 
and continued the injections himself with beneficial 
effect. 
Case 12.—N. J. F., a laborer, aged 30. Case of 
tremendous cavity in left lung reaching from clavicle to 
opposite left nipple, and lying on the anterior border of 
the lung. The regularity of his pulse 88, respiration 32, 
temperature 98° to 100 1-50, and my confidence in his un- 
excitable, steady temperament, led me to give way to 
his determination to try the new “lymph” treatment. I 
was from March 13, to April 9, reaching 9 mg., and on 
April 26, reached the highest point, 18 mg., when a rest 
of ten days was taken.* Then I returned to 10 mg. at a 
dose, and was cautiously increasing from that point with 
favorable effect, when he was offered an opportunity to 
take charge of a squad of men working on a railroad. I 
believed that climate, out-door occupation and time were 
as important for him as the remaining chance of benefit 8 
TUBERCULIN. 
from tuberculin injection, and so consentecito the change. 
His was, however, an interesting and exceptional case in 
more than one particular. His principal reaction came 
after the 6 mg. dose, when my attention was attracted to 
the characteristic rough respiration in the region of the 
right nipple, where before no abnormal sound was heard. 
This I have come to consider as symptomatic of the 
working of tuberculin in affected tissue, and is an addi- 
tional diagnostic evidence which physical diagnosis alone 
cannot impart. Another interesting feature of this case 
was the seeming contraction, as the treatment progressed 
of the large cavity in the left lung, due to the shrinkage 
of the surrounding, and probably tubercular, affected 
tissues. My note of the fourth recorded examination, 
April 23, reads, “The case has gotten along very evenly, 
and a marked abscence of tubercular change is manifest 
in an even average of pulse 94, respiration 26, and tem- 
perature The cavity is. if anything, less in size, 
and moved upward and toward the front. The lung, 
while somewhat inactive below and behind, shows only a 
few coarse rales. This closing up tendency of the lymph 
when acting in lung tissue between the main bronchus 
and the lung perphery, is particularly applicable to the next 
case, No. 13, Rev. J. T. S., age 37, who had, he says, a 
contracted left lung, even in childhood, haemorrhage 7 
years ago, pleurisy, 6 years ago, and la grippe, winter 
1889-1890. 
My diagnosis of his case, April 1, when I first saw 
him, was fibroid phthisis, probably third stage, left (be- 
cause of a small honey-combed spot under left clavicle), 
and first stage right. I have no doubt the poor ventila- 
tion marked on his chart at the second examination, THE VALUE AND LIMITATION OF ITS USE IN CONSUMPTION. 
9 
April 6, over the lower half of the left lung, the air mov- 
ing therein only a little except by forced breathing, was 
in no small degree due to the exaggerated reactions from 
the tuberculin injections which were manifest around the 
root of the left lung. I can conceive of tuberculin having 
this effect in a lung elsewhere unaffected, except around 
the largest bronchi. The previously contracted condi- 
tion of this left lung in question aggravated the effect; 
and headache and chilly feelings were added to the 
usual evidences of a decided reaction, even to as little as 
3 or 4 mg. I deemed it better, therefore, that measures 
should be inaugurated, chiefly left arm exercise, riding 
horseback, etc,, which would tend to improve the use of 
this left lung, before proceeding farther with the- Koch 
treatment. 
No. 14 of the series, the wife of a prominent Chicago 
real estate owner, was also of special interest, but for 
reasons I have not seen noted by any other observer. 
The highest point reached in fifteen tuberculin injections 
was g mg., yet all decided reactions were accompanied 
by such temporary depression of spirits, with a chilliness, 
the second day afterward (she took them every three 
days), that a cessation was deemed advisable. However, 
the appetite was increased as was the ability to exercise, 
and the local effects were not at all unfavorable. Curi- 
ously enough her feeling of depression of spirits while on 
board ship at sea had been just the same. 
The other six cases need also to have each a seper- 
ate reference, in order to understand why eventually each 
should be classified under the doubtful cases for com- 
pleting the tuberculin treatment. Every serious case has 10 
TUBERCULIN. 
some prominent feature about it which distinguishes that 
particular one from a thousand others. 
Case 15, age 36, brick mason from Massachusetts; 
came with extensive fibroid process in left lung, probably 
caused by or following tubercular softening. This pro- 
cess increased and was ’ made permanent, at different 
times after arrival in Colorado, by typhoid fever, pneu- 
monia and by pleurisy, The strengh of the fibroid tissue 
was shown by his pressure record on the manometer to 
be the normal for a man in health, 100 mm., while his 
spirometrical record was only 112 cubic inches, less than 
one-half of what it should be for a healthy man of his 
height. Nervous temperament, no fever, but bacilli in 
sputum By the rule I will lay down the ratio of move- 
ment of the affected as compared with the unaffected 
side, namely, 1 to 3, with so small a spirometrical record, 
makes him an unfavorable case for tuberculin treatment. 
His case is in arrest. Nature and high altitude climate 
have already accomplished what tuberculin might per- 
haps have done. They work together on somewhat the 
same lines. Of course reactions, both local and general, 
followed, up to the limit of 6 mg., which was reached in 
his case. He, undoubtedly, had fibroid tissue enough 
andany increase through tuberculin injections was undesir- 
able. He has since been doing first rate on mercurial in- 
unctions over the hardened lung, while camping out at 
about 7,000 feet elevation in the mountains. 
Case 16, a young man, age 20, from Scotland, a sub- 
acute case, diagnosed fibro-tuberculous, second stage, 
right, and first left. I believe the tuberculin treatment 
could r.ot compass this case, for the principal reason THE VALUE AND LIMITATION OF ITS USE IN CONSUMPTION. 
11 
which operates in many other serious cases, lack of ven- 
tilation of the chiefly affected lung, and also, in this case, 
because of a concealed septic state. Though 14 mg. 
were very gradually reached in the course of six weeks 
with some improvement, yet some times even a greater 
afternoon rise of temperature would be shown, 102.30 when 
the tuberculin had not been given than when it had. The 
abandonment of tuberculin and the substitution of iodine 
and chloride of gold and sodium injections for three 
weeks, greatly controlled the fever and he is now doing 
fairly well. 
Case iy, I think was peculiar from the too great 
amount of elastic tissue in his expectoration, which fol- 
lowed a diminution in amount of sputum from I pint to 4 
ounces per diem, during the first two weeks of tuberculin 
treatment. He was a blacksmith, age 35, from Omaha, 
Neb. His was diagnosed as a case of broncho-fibrosis, 
both lungs affected. Second stage right, and first, with 
large bronchiestasis left. 
This case prompted the suggestion that it is possible 
excessively to stimulate the production of fibrous or elas- 
tic tissue, which is, of course, unadvisable in those already 
having enough. So, although bacilli in decreasing num- 
bers were still found in his sputa tuberculin was discon- 
tinued at 12 mg. 
Case 18, age 30, Secretary of a Cattle Company in 
Canon City, originally from Kansas for his health. A 
large cavity in left lung with some slight fibroid involve- 
ment ot the rest of the left and part of the right lung. 
There was slight oozing of blood into the cavity, under 
one of the reactions, suggesting caution in advancing the 
treatment; and 12 mg. in a month was the highest point 12 
TUBERCULIN. 
reached. In his case, other than the cavity, there was de- 
cided local improvement—an increase and then a decrease 
in the number of bacilli to the field, an effect of treatment 
which was shown in nearly all of these cases. 
Case ig.—A young man aged 24, from Kansas. 
Disease originally started from left pleurisy with effusion. 
February 17, before tuberculin treatment, the diagnosis 
was, left third stage, fibro-tuberculosis and catarrhal phthi- 
sis and right first fibroid. During the next four weeks 17 
mg. the largest dose was reached. The patient increasing 
from to 135 pounds in weight, and being very much 
encouraged by his ability to do and his general improve- 
ment. He then had an attack of what seemed to be la 
grippe, and no more injections were given. A week after 
this he was taken down with a very bad attack of measles. 
After ten days these accumulated poisons seemed to have 
centered in his left lung, which broke down rapidly, and 
he died one month after discontinuing the use of the 
lymph. I do not regret the course taken in this or any of 
the cases to whom tuberculin was administered, for acci- 
dents like that last mentioned could not be foretold, and 
the only disparaging claim that could be made would be 
that this young man was perhaps less liable to stand the 
peculiar poison of measles than if he had not been under 
the Koch treatment. 
Case 20, much like No. 16, only worse as to febrile 
change and impossibility of thoroughly ventilating a con- 
tracted and partly honey-combed left lung. The pneu- 
matic cabinet might have been of use in this case in 
counteracting the shrinkage effect of tuberculin in upper 
half of the affected left lung. This, as before explained, 
shuts in the stagnant air and perhaps the exuded bacilli THE VALUE AND LIMITATION OF ITS USE IN CONSUMPTION. 
13 
in the lung below; and such a case is not a good one for 
pushing the treatment. 
On the whole, considering the very serious nature of 
the lung conditions in these, all of them tuberculosis cases, 
the result of the treatment is very encouraging, as proving 
tuberculin to be an important aid to climatic treatment in 
this region; or vice versa if you prefer it that way. 
I ought perhaps to say that during this time, covered 
by my tuberculin experiments, I refused or decided not 
to give the Koch treatment to more than twice as many 
patients, partly because they were unsuited, but in a ma- 
jority because they were incipient cases, especially suited 
to our climatic treatment. 
[Note, Feb. ist'92. ] Up to the middle of June,’91, the 
above twenty cases were all to whom I had administered 
tuberculin excepting isolated cases, for diagnostic pur- 
poses. Since that time I have had about fifteen more 
tuberculin patients, better chosen for this aid to the cli- 
matic cure and hence with more uniformly favorable 
results. 
These include several cases of large tolerated cavity 
in one apex the contraction or healing of which under 
tuberculin injections is being watched with much interest. 
In another case the tuberculin effect in shrinking and 
hardening of enlarged glands on the side of the 
neck, is manifest in a young lady in whom many bacilli 
were before treatment found in the sputum, but now none 
can be found. Of the cases under treatment and about 
graduated, previous to the time of presenting this paper 
the results have been very gratifying, especially is this 
the case with reference to Nos. 1, 4, 5, 6, 7. and 10. The 
gradual cessation of the treatment with a large dose 14 
TUBERCULIN. 
say once a week, seems to me to be indicated, and I have 
practiced this in leaving off at doses from 80 to 140 mgs. 
— C. D. 
We have been asked or have ourselves desired, to 
use this newly discovered agent—tuberculin—without 
any very distinct understanding being granted us as to its 
composition, its strength or its mode of preparation. In 
view of reported adverse experiences and statements in 
reference to its use, this enforced uncertainty as to detail 
naturally suggests the inquiry. Would it not have been 
better to have submitted the first use of tuberculin, with 
all available information with reference thereto, to care- 
fully selected experimenters for their separate determina- 
tion of rules of procedure, and then from these sources, 
send out to the world reliable directions as to detail? As 
it is, we now hear of Prof. Koch reducing his initial dose 
in certain cases to one-tenth of his first promulgated 
order. » 
The advisability of the method employed for putting 
the tuberculin into use, was questionable, that is, its only 
being sold to hospitals. Of course one could use the 
friendship of the Secretary of the Interior, as I did, and 
get some of the “desired stuff,” as he called it when he 
sent it to me. Nevertheless, the arbitrary restrictions to 
only hospital use, conjoined with the directions that pati- 
ents should be put to bed when reacting to the lymph, 
was, I believe, a mistake. It was suggestive of the use 
of too large doses in too serious cases, and a lack of a 
right conception of what was desired to be accomplished. 
I started out to follow the direction with a private hos- 
pital of ten beds, but soon found it unnecessary for the 
kind of patients who do best under this treatment. To THE VALUE AND LIMITATION OF ITS USE IN CONSUMPTION. 
15 
be out of doors, riding on tramway or cable cars, even 
while gently reacting, was not hurtful, and my most satis- 
factory Koch patients were those who regularly exercised; 
as No. i, who is a furniture polisher and has kept at his 
work ever since the first week of treatment; No. 2, who is 
all the time on the go; No. 5 ditto, whose expansion has 
increased to 4y2 inches; and Nos. 8 and 9, who, though 
reacting to less than one mg., have been averaging five to 
eight miles walking daily. 
As to the details of the necessary examination, pre- 
liminary to commencing treatment with tuberculin, I 
ha -'e not time to give all the particulars. You can see 
my own examination chart which I here present; but I 
know that ordinarily some of the most essential points are 
omitted by the average medical man. Take the mano- 
meter, spirometer, and mensuration, for instance. The 
manometer, which gives information in millimetres of 
mercury of the strength of new elastic tissue formation in 
the lungs, is very seldom used; the spirometer, which has 
been depreciated by some of our best authors, the late 
Dr. Flint, Sr., for instance, is not one-tenth appreciated 
by the medical profession; I do not know that the bilateral 
movements of the chest are generally taken, and the same 
can be said of proper stethoscopic percussion for deter- 
mining the commencement of softening or excavation of 
lung tissue. As I have made a careful use of these extra 
aids, to a proper understanding of these tubercular cases, 
I may perhaps be excused for referring to some thoughts 
which seem to me essential. 
PRECAUTIONARY MEASURES AND RULES. 
Understand the patient, the extent and character of 
his disease and its abridgement of his respiratory capacity 16 
TUBERCULIN. 
or the liability to such abridgement under this treatment. 
For this purpose compare the chest expansion and spiro- 
metrical record with the normal for his height; and if, as 
is most likely, the two sides differ in movement, compare 
the bilateral movements with the spirometrical record of 
this given individual. For instance, as in case 13 of my 
list, the movement of the left as to the right side was as 
one to three, and the spirometrical record 150 cubic inches, 
when it ought to be 250 for a healthy man of his height. 
Well, if we were to calculate that the right lung does its 
full share it would leave only 25 cubic inches for the left, 
or on the basis of one to three of what was breathed 37 
cubic inches should be allotted to the left lung, and this 
only on forced breathing to the extreme. Of course this 
left lung was not ventilated. If there has ever been any 
softening in such a case and it has reached such a station- 
ary stage, as to fever curve, that tuberculin would be 
otherwise safe to administer, then it must be that nature 
has been already at work through her own method of 
cure—the fibroid process. She has probably pasted up the 
lung by her plastic exudations of fibroid deposits, even to 
adhesions of that lung to the chest wall, so that the bacilli, 
though numbered by the million, lie embedded in natural 
prison vaults, almost effectually shut off from again in- 
vading the rest of the system. 
Among the records of arrested phthisis in this rare- 
fied atmosphere, we Colorado physicians have all seen 
this natural arrest. In fact, this fibroid process is so evi- 
dently Nature’s chief reliance in all successful, as well as 
all fatal cases, 'that we are led to ask—how can arrest 
after softening of lung tissue occur without the aid of 
this natural method? Why, then, since the character of THE VALUE AND LIMITATION OF ITS USE IN CONSUMPTION. 
17 
ausculation sounds, and the method of healing caused by 
mild reactions to tuberculin are so similar to the effects 
of the fibroid process, only more accurate, why, I ask< 
should we go outside of natural causes to explain the cura- 
tive process of Koch’s lymph? It is entirely unneces- 
sary. The lack of understanding of this matter is so 
queerly shown even by men of high repute. 
Dr. Bristowe, who opened the late discussion of 
Koch’s method in the Metropolitan Counties Branch of 
the British Medical Association, scouted at the idea that 
the bacilli were not killed but simply imprisoned “in an 
excess of inflammatory products,” and Dr. Hector Mack- 
enzie, equally antagonistic in his remarks, claimed that 
“Koch had led us to suppose that he had himself fully 
tested this wonderful remedy of his, that he had found 
that it prevented the growth of the bacilli in the test 
tube,” etc. Dr. S. K. Jackson, of Norfolk, Va., in his late 
article on Tuberculin, read before the Section of Practice 
at the May meeting of the A. M. A., in Washington, 
entered into a lengthy argument to show that the bacilli 
in situ are killed by the introduced ptomaines of artificially 
cultivated bacilli, in accordance with a law which he had 
some lime ago and several times since announced that 
“no organism can live in its own excreta.” I say the test 
tube has nothing to do with a natural process like that 
we are discussing, and yet as for “poisoning” the bacilli 
in possession of the battle ground in the lungs, by their 
ptomaines introduced into the blood hypodermically, I 
believe it would be disastrous to the human body, to do 
such a thing. It does not seem reasonable to me that 
enough of the ptomaines diluted by the blood would 
reach the bacilli to poison them. Koch himself says they 18 
TUBERCULIN. 
are not destroyed. It is now perfectly clear to my mind 
that that is what does occur where Koch speaks of the 
“imprisonment of the bacilli” in inflammatory tissue, pro- 
vided that inflammation is the proper term to use. But I 
am led to believe that Koch made a great mistake when 
he put it before the world that it was the “necrosis” 
(death) of the affected tissue which was effected, or ever 
desired to be effected. No, to kill the part, in order to 
destroy the enemy contained therein, would be such an 
aggravation, or rather perversion of the splendid healing 
process at the bottom of his discovery, that no one could 
gain an advantage from so doing, unless it would be Prof. 
Virchow, with his twenty-six post-mortems on bodies de- 
funct after tuberculin treatment. The renewal and heal- 
ing of tissue affected is not to be brought about by the 
death (necrosis) of that tissue, which means its extinction. 
It is not necrosis that takes place or is desired, but a 
stenosis through the substitution of new material or the 
quickened action of Nature’s fibroid process, in answer to 
a local demand. If it were not for an unusual cause, 
which is the tuberculin in the blood, nothing out of the 
ordinary would happen. But that which happens is un- 
usual. Here I am led to a confession of faith, which is 
sufficiently strong to support me in the further use of 
tuberculin in my practice, though every other physician 
t 
in America should pronounce against it. 
It is a beautiful idea, abundantly verified as the law 
of Nature in her warfare with disease, that every living 
tissue, is endowed with a certain power of protection against 
injury, and repair for the same. This power is inherent 
jn, and manifested in harmony with, the activity of the THE VALUE AND LIMITATION OF ITS USE IN CONSUMPTION. 
19 
life principle, So an acute injury of the delicate lung tis- 
sue, where the circulation of blood is five times as rapid 
as in the capillaries of the service of the body, must result 
in a correspondingly, greater systemic disturbance, and 
local demand for repair. Therefore, when an unused, 
poorly ventilated, catarrhally affected portion of lung be- 
comes the congenial and fruitful abode of man’s greatest 
enemy—the bacilli of tubercle—I believe the call is not 
unheeded by this independent thought of nature. The 
resources of the whole system are called upon to aid in 
the burning out of the enemy by combustion, drowning or 
washing him out in the rivers of catarrh, or burying him 
beneath or behind the ever-encroaching fibroid battle- 
ments. Where else will we find this protective influence 
more acute than at that point, especially in the lung, 
where the bacilli are lodged, and already surrounded by 
these sensitive, protective elements? It is not unreasonable 
to believe that the fibroid tissue which surrounds tuber- 
cular spots or ulcerations, and whose chief function and 
tendency is contraction, should be unusually susceptible 
to the ptomaines or juice of the bacilli, were these poisons 
to find their way there through the general circulation. 
I believe that this is the case, for I "have several times 
with my stethoscope verified the contraction of fibroid 
elements in affected lung tissue under the special stim- 
ulation of tuberculin. 
I know I shall be deemed delinquent in this article if 
I do not mention the action of the Philadelphia Commis- 
sion and the Johns Hopkins College Hospital, in discon- 
tinuing the use of tuberculin because they were disap- 
pointed with their results. 20 
TUBERCULIN. 
As to the Philadelphia physicians, whom I highly es- 
teem, I wish to say this: They were scrupulously follow- 
ing Prof. Koch’s directions as to dose and rules of confine- 
ment. I am not. The character of the cases chosen at 
both the above trials were serious enough, notwithstand- 
ing a lurking suspicion in my own mind that had they 
properly tried stethoscopic percussion in some of their 
cases “with tubular breathing and moist crackling rales 
at an apex,” they would have detected excavations before 
the treatment, instead of referring an advance in disease to 
the tuberculin injections. Of course, the contraction of 
affected tissues around a softened spot makes a small 
pre-existing cavity more evident. 
The Johns Hopkins College Hospital failure is not to 
be wondered at. They could not surely have expected 
to have a miracle performed; for had they started out to 
damn the Koch treatment they could not have done so 
more effectually than by selecting such a bad lot of cases, 
housing them in an hospital, and giving them such large 
doses of tuberculin. Look at the list of the first eleven 
cases reported. Five of them with both lungs consider- 
ably affected; sevea with large cavities, and the others 
with softening commenced or going on, i. e., according 
to the physical signs noted in the first report. Had these 
cases been set loose in the open country during the time 
of the Koch treatment, and reached the maximum of 4 
mg. instead of 12 to 20, they would probably have 
had enough for their needs and have done better. I can- 
not see that the essential precautions mentioned in this 
paper have been taken in any of the experiments thus far 
reported in the journals. The nearest approach to their THE VALUE AND LIMITATION OF ITS USE IN CONSUMPTION. 
21 
observance, which have furnished equally favorable re- 
sults to my own, have been by Dr. Karl von Ruck, of 
Ashville, N. C. I was very glad to see from his late 
paper in the Medical Record that he had been working on 
much the same line as I had. I do not notice in his re- 
ports the extravagant general and febrile reactions so 
grossly exaggerated in newspaper reports of certain so- 
called “Koch hospitals.” 
CONCLUSIONS. 
The following conclusions, however poorly elaborated 
in the body of this report, seem to me to be warranted at 
this stage of our investigations. 
1. Tuberculin furnishes a natural method of cure, to 
be classed with stimulants, hypophosphites, exercise, high 
altitudes and cold, dry air; yet it is too powerful to be 
indiscriminately used, and the proportion of consump- 
tives for whom its use would be advantageous remains to 
be determined. 
2. It is unreasonable to expect that tuberculin will 
be useful in sepsis, or any poisonous blood state other 
than tuberculosis. 
3. Use tuberculin not as a substitute, but as an aid to 
climate, and other uatural methods of cure—proper food, 
hygienic surroundings, mountain climbing, etc. Especi- 
ally are high altitudes and exercise indicated, if other- 
wise advisable, because they favor the ventilation of lung 
tissue, which is very necessary in giving tuberculin. 
4. Seek only local reactions in the affected tissues 
A high or prolonged febrile reaction is to be avoided, if 
possible. Use the minimum dose that will accomplish 
this purpose, and it is preferable to let at least a day 22 
TUBERCULIN. 
elapse between a subsidence of one reaction and the pos- 
sible creation of another. Remember that an increase 
from y to y$ of a mg. may be as great for a case already 
reacting to the smaller dose as an increase from 30 to 40 
mg. in a case that is far advanced in the treatment. 
5. The lack of ventilation in a lung, whether caused 
by tuberculin already used or pre-existing, is a decided 
contra-indication to pushing the treatment, i. e., according 
to this deficiency and the febrile state. 
6. The test for the proper ventilation of a tubercular 
or fibro-tubercular lung is to be found in the comparison 
of the spirometrical record with the bilateral measure- 
ments of the chest and with available physical signs. A 
fair way to express deficient ventilation is to say, if the 
normal spirometrical record for the height is abridged 
one-half, and the movements of the two sides are as one 
to two, then there is sufficient lack of ventilation in the 
weaker lung for exercising extra caution as to using tuber- 
culin at all. There is either too much elastic tissue al- 
ready there, or the bacilli, if loosened by tuberculin, may 
not be expelled, but remain to infect the system, therefore 
due caution must be exercised in the selection of sub- 
jects for this method of treatment. 
7. The stage of the lung disease has not so much to 
do with the question of using tuberculin at all, as has its 
extent and locality, the febrile course and the ventilation 
of the affected lung. If possible, have an average daily 
range of temperature of less than two degrees F. upon 
which to proceed, and the patient able to be much of the 
time in the open air. 
8. The diagnostic value of small hypodermics of 
tuberculin is shown with or without febrile reaction in the THE VALUE AND LIMITATION OF ITS USE IN CONSUMPTION. 
23 
appearance on auscultation with a good stethoscope at 
suspected or affected spots in the lung substance, of a 
more or less decided roughening of a previously existing 
broncho-vesicular respiration; or a high pitched, rude breath- 
ing where before only a feeble respiration was noticed. 
9. With the appearance of any unfavorable physical 
signs during the course of tuberculin treatment, such as a 
clogged up section of lung, or scattered moist rales sus- 
picious of softening, I think it would be well to intermit 
injections of tuberculin and substitute those of iodine for 
a while, or to give temporarily syrup hydro-iodic acid 
compound or to use inunctions of oliate of mercury over 
the affected lung, until a return to the use of tuberculin is 
quite safe. 
10. As to permanence of effects produced by tuber- 
culin injections, there is to me no apparent reason for expect- 
ing any more lasting residts than from any other agency zvhich 
will accomptisli as much. I do not see any reason why 
bacilli should not appear again in the sputum after their 
cessation under tuberculin treatment, as after their ces- 
sation under climatic change or the double chloride of 
gold injections. It is quite probable that the effect of 
tuberculin is temporary. We need not look for a guaran- 
teed immunity from lung tuberculosis except under such 
other conditions of healthful living as would insure it. 
11. In fine, tuberculin is not a remedy to be chosen 
for the great majority of pulmonary consumptives in pre- 
ference to a proper change of life and climate, for it does 
not equal the latter; but with such a change, it is an im- 
portant adjuvant to the cure of a large selected class of 
tubercular lung diseases.