Reprinted from the Therapeutic Gazette, June 13, 18Q3. 
A Contribution to the Treatment of Pul- 
monary Tuberculosis with Pro- 
fessor Koch’s Tuberculin. 
Supplementary Report, showing the Present Condition of 
Twenty-five Cases treated Two Years ago, read 
before the American Climatological 
Society, May 26, 1893. 
By Karl von Ruck, M.D., Asheville, N. C. 
REPORTS of cases showing the results of 
any particular procedure in therapeutics, 
made immediately or within a short time after 
their application, are current in medical litera- 
ture, and while they unquestionably throw light 
upon the utility or otherwise of the treatment 
employed, it is not to be doubted that many 
such reports would require modification, indeed, 
might show the reverse of the conclusions first 
arrived at, if a longer time had intervened by 
which the permanency of the results or the final 
issue of the case could have been established. 
We are the more ready with our reports if 
our work has apparently been successful and if 
the medical or surgical procedure is new and is 
attracting attention at the time; but if hasty 
reports and conclusions have ever been offered, 
it certainly was the case with the effects of Pro- 
fessor Koch’s tuberculin. Indeed, in many in- 
stances a few weeks of experimental employ- 
ment of the remedy was deemed sufficient for 
enthusiastic recommendation or for absolute 
condemnation. It is now two years since I wrote a report of 
my first twenty-five cases treated with Koch’s 
tuberculin, which report was presented to the 
American Medical Association at Washington 
on May 7, 1891, and subsequently published in 
the Therapeutic Gazette for June 15 of the 
same year. In making the report it was my 
earnest endeavor to be conservative, and I pur- 
posely published with it the detailed history 
and all important data in connection with the 
treatment of each case, so that the reader might 
be able to judge for himself the benefit each 
patient had derived. 
The cases were divided into three classes : 
Class A, five cases who had one or both 
upper lobes involved, but without destructive 
changes, the general health of the patient 
being still comparatively good. 
Class B, seven cases with more extensive 
disease or moderate destructive processes, but 
still in a fair physical condition. 
Class C, thirteen cases still further advanced 
in local disease, with considerable constitu- 
tional impairment, but still in a condition jus- 
tifying some hope for improvement. 
I concluded that report with the following 
remarks : 
“ First.—That, according to my experience 
with the patient under constant medical super- 
vision, and under the precautions used, the 
remedy can be given with the avoidance of all 
unpleasant symptoms or danger. 
“ Second.—That while I believe that I have 
derived material benefit, the experience of many 
additional observers, under a similar mode of 
management and administration to that adopted 
by myself, is required to establish the exact 
2 3 
value and range of applicability of the remedy ; 
and, 
“ Third.—That the combined means by 
which my results were obtained appear to de- 
serve the favorable consideration of the profes- 
sion.” 
It is now my purpose to show the outcome 
of these twenty-five cases two years later, as a 
supplement to my first report, with such ex- 
planatory remarks as may be essential for each 
individual case. To this end careful inquiry 
has been made as to the present condition of 
each patient. 
Case I., Class C, was reported as slightly im- 
proved when the treatment was discontinued on 
March u, 1891. 
This patient showed further improvement 
after the discontinuance of the remedy, and 
remained in the institution for fifteen months 
thereafter. Under a course of Liebreich’s 
cantharadin, the larynx made remarkable im- 
provement, the ulceration of the epiglottis 
healed, and the infiltration disappeared al- 
most entirely, and sufficiently so as to result 
in the complete restoration of the voice; her 
nutrition also improved. In March, 1892, 
active changes again recurred in the lungs, 
which were accompanied by the usual symp- 
toms of fever, increased cough and expectora- 
tion, and loss of flesh. The larynx remained 
unaffected. All these symptoms subsided under 
a second course of tuberculin, thirteen injec- 
tions, from one-tenth to one milligramme, and 
the patient left the institution in May greatly 
improved. 
At this writing a relapse of her lung-affection 
of recent date has come to my knowledge. 4 
Case II., W. S., Class B, was reported as ap- 
parently cured. This patient has remained well 
to this date, and is entirely free from all symp- 
toms. In April, 1892, he had an attack of la 
grippe, with an intense bronchitis of one week’s 
duration, from which he made a prompt and 
perfect recovery. 
An affection of the respiratory organs like 
la grippe may be looked upon as a crucial test 
of the permanency of recovery, and the fre- 
quency with which we note active symptoms 
to supervene in latent tuberculosis in connec- 
tion with la grippe is well known to every 
practitioner. 
The sputum during the existence of the acute 
bronchitis in connection with la grippe con- 
tained no bacilli. 
Case III., Class A, reported as improved, has 
made an entire recovery, and has remained free 
from all symptoms to this date. 
Case IV., Class C., was reported as im- 
proved and the laryngeal disease cured. This 
patient made still further improvement, re- 
turned home, relapsed as to his lung-affection, 
and died in July, 1892. The result as to the 
larynx was permanent until death. 
Case V., Class C, reported as not improved, 
died in 1891. 
Case VI., Class C, reported as not improved, 
died in 1891. 
Case VII., Class A., reported as cured, has 
continued free from all symptoms, and is en- 
tirely well at the present time. 
Case VIII., Class B, reported as apparently 
recovered, returned home; relapsed in fall of 
1891 ; returned, and was treated again with 
tuberculin in the winter of 1891-92. He was 5 
again materially improved, but not to the de- 
gree as in the first course of treatment. He is 
free from fever, but coughs and expectorates. 
His general health is fair. He is still greatly 
improved as compared with his condition be- 
fore his first treatment. 
Case IX., Class A, was reported as apparently 
cured. He has remained entirely free from all 
symptoms to the present time, and is enjoying 
perfect health. 
Case X., Class B, reported as greatly im- 
proved, returned home in May, 1891. His 
improvement has not only continued to the 
present time, but I have recently been informed 
of his entire recovery. 
Case XI., Class B, reported as apparently re- 
covered, has been free from all symptoms to 
the present time, and is entirely well. 
Case XII., Class C, reported as improved, 
relapsed, and died in 1891. 
Case XIII., Class C, reported as improved, 
relapsed in 1892, and died since. 
Case XIV., Class C, reported as greatly im- 
proved. No recent report obtainable. He 
continued in his improvement to the date when 
last heard from,—October, 1892. 
Case XV., Class C, reported as greatly im- 
proved, died in 1891. 
Case XVI., Class A., reported as apparently 
recovered, has remained entirely free from all 
symptoms, and is perfectly well to the present 
time. 
Case XVII., Class C., reported as improved, 
continued so when last heard from in No- 
vember, 1892. No response to my recent 
inquiry. 
Case XVIII., Class C, reported as greatly 6 
improved, continued so when last heard 
from. No recent report obtainable. 
Case XIX., Class C, reported as improved, 
relapsed, and died in 1891. 
Case XX., Class B, reported greatly im- 
proved, according to recent information has 
entirely recovered without resorting to further 
treatment. 
Case XXL, Class C., reported as improved, 
is about the same at the present time. 
Case XXII., Class B, reported as improved, 
has entirely recovered. 
Case XXIII., Class B, reported as appar- 
ently recovered, has continued in good health, 
free from all symptoms, to the present time. 
Case XXIV., Class A, reported as greatly 
improved, has entirely recovered, and is free 
from all symptoms. 
Case XXV., Class C, reported as improved, 
obtained still further improvement. He sub- 
sequently relapsed, but improved again, and is 
now free from all active symptoms. 
We find, therefore, that I reported in 1891, 
in the early stage, five cases treated, three of 
which were believed to have apparently recov- 
ered, one to have been greatly improved, and 
one to have been improved ; all of which have 
made an ultimate recovery, no relapse having 
occurred in two years. 
In the more advanced stage—Class B—I re- 
ported seven cases treated, four of which were 
thought to have apparently recovered, two to 
be greatly improved, and one improved. Of 
these seven cases we find six to have made a 
final recovery and to be well two years later, 
while one relapsed and is again improved. 
This gives us for the early stage one hundred 7 
per cent, of recoveries, and for the middle stage 
eighty-six per cent, of recoveries and fourteen 
per cent, of improvements, without a death in 
two years. 
In the far-advanced stage of Class C, I re- 
ported thirteen cases treated, four of which 
were greatly, six moderately, and one slightly 
improved; two had made no improvement. 
Of these cases, six are still alive, three of which 
have continued greatly improved and three 
others improved, while seven have died. 
As to the share attributable to the treatment 
with tuberculin in obtaining these results, I am 
still and always shall be unable to mathemati- 
cally demonstrate it. Every thoughtful reader 
who is free from prejudice must, however, admit 
that these results are such as have never been 
obtained by any mode or combination of treat- 
ment heretofore known. 
In a paper upon the prognosis in pulmonary 
tuberculosis, published in the Medical News, 
September 13, 1890, I reported eighty-one 
early-stage cases corresponding to Class A, of 
which a subsequent inquiry, similar to the 
present one, showed twenty-four per cent, of 
recoveries and twenty-one per cent, of im- 
provements. In a more advanced stage, of 
four hundred and thirty-four cases treated, 
nine per cent, recovered and eleven per cent, 
were improved. While a similarly large num- 
ber of my cases treated with tuberculin might 
have shown the present results modified, yet it 
cannot be conceived that such a difference as 
this would be possible. 
That it does not exist is, however, amply 
proven by my subsequent experience with a 
greatly increased number of cases treated since 8 
paired during the course and advance of the 
disease. 
Such application of the remedy had never 
been contemplated by Professor Koch, and all 
for which I blame him is that he permitted it 
in the hospitals of Berlin, and became aware 
of it through the literature of the profession 
elsewhere without entering his protest. 
Remembering, however, that he is not a 
practising physician, that all treatment of 
cases was carried out by his colleagues, and 
that he himself possesses no recent clinical ex- 
perience in the treatment of consumption or 
any other disease, it must at this time seem 
strange that no one for some time dared to 
depart from the original dosage based upon 
experience with half a dozen cases only, two 
of which were then said to have apparently 
recovered. 
With the greatest admiration for Dr. Koch 
and his labors, this appeared to me ludicrous, 
nevertheless, and when I mentioned my con- 
victions to one of the hospital chiefs in Berlin, 
he reproved me as though I had committed the 
“unpardonable sin.” “Would you instruct 
the master?” said he, in utter astonishment. 
All those who, after their first disappoint- 
ment, did not throw the remedy overboard, 
have since, at least in part, adopted my method 
of administration, and I believe that I have 
been the first one on either side of the water to 
enter a protest against its use as originally em- 
ployed. Since that time excellent results have 
been obtained from minute and slowly-increasing 
doses, some of which I cited in a paper pub- 
lished in the Southern Medical Record for Sep- 
tember, 1891, and my results have continued 9 
as favorable as ever under this method adopted 
by me within the first few weeks of its use. 
The most recent report of Dr. Thorner, in 
Berlin, presented to the “ Verein fiir Innere 
Medizin” on March 8, on his two years’ use of 
Professor Koch’s tuberculin, and which is highly 
favorable to the remedy, shows that he begins 
with milligramme, and increases ab«ut as I 
do. Under such doses he never saw any un- 
favorable effect. He emphasizes that the secret 
in its successful employment is the proper ap- 
plication of the remedy. My method of appli- 
cation is practically as follows : 
Cases must be properly selected, and no pa- 
tient is suitable for treatment with tuberculin 
who at the time presents symptoms of acute in- 
flammatory changes in tubercular areas or evi- 
dences of softening, with septic fever. 
Other modes of treatment, as indicated in 
my paper on the treatment of pulmonary tuber- 
culosis ( Times and Register, January 6, 1893), 
must be resorted to, by which these symptoms 
are first controlled. With these exceptions, 
patients in any stage where the disease is still 
confined to the lungs and throat are eligible 
to the treatment. 
The treatment should be carried out in a 
special institution or hospital, where sufficient 
control and oversight alone are possible. It 
certainly must not be delegated to junior as- 
sistants or to physicians who do not possess 
large experience in physical diagnosis of chest- 
and throat-affections, or who are not otherwise 
well experienced in the treatment and manage- 
ment of cases of pulmonary and laryngeal tuber- 
culosis. Close observation is indispensable. 
A week’s observation of local and general 10 
symptoms, fully recorded at frequent intervals, 
must precede the use of the remedy, to assure 
the absence of contraindications. 
A physical examination of the chest must 
precede and follow each dose given, the re- 
sults of which, to the minutest changes ob- 
served, to be carefully recorded upon a diagram 
for comparison. 
The difference between a local and general 
reaction must be clearly understood. The for- 
mer consists in an increase of the local ausculta- 
tory phenomena, with or without slight increase 
in cough or a sensation of fulness in the tuber- 
cular area of the lung. In the larynx or other 
visible tubercular processes there are observable 
increased vascularity, sometimes slight swelling, 
and always increase of the secretions from that 
part. 
Any effect beyond this is undesirable, and 
can be positively avoided if enough interest is 
taken in watching the case. 
A general reaction, on the other hand, shows, 
in addition to the local effect, rise of tempera- 
ture, increase in pulse-rate, sometimes nausea, 
even vomiting and diarrhoea. Those symp- 
toms, if well marked, are signs of positive 
danger, and repetition of the same dose, or an 
increase of the dose, is almost sure to be fol- 
lowed by relapse. 
No dose must be repeated until the effect 
from the previous dose has subsided, and then 
not until after twenty-four hours. 
If the local reaction has been well marked or 
prolonged, a return to the dose which had pre- 
viously been inoperative is required, and the 
increase must thereafter be the same as it 
would have been had a larger dose never been 11 
given. The same is of course equally true if 
general symptoms have been produced. 
The reaction occurs, as a rule, in from six to 
eight hours. I have, however, seen it as early 
as three hours and as late as thirty-oqe hours 
after a given dose ; this must be borne in mind, 
and frequent examinations, especially in the 
beginning of the treatment, are necessary, so 
that the effect may be recognized. The dura- 
tion of the reaction is, as a rule, about six 
hours, if only local; if general, it may last 
twelve hours and longer. I have found that 
the same patient reacts, as a rule, within about 
the same limit of time. 
A certain dose having been given without 
reaction following, this same dose is, neverthe- 
less, to be repeated once before an increase is 
permissible. 
If a too severe local or general reaction is 
observed, the patient must be put to bed and 
kept perfectly at rest until the reaction has en- 
tirely subsided. 
Beginning with milligramme as a trial 
dose,—to which I have never seen a response, 
—the next dose is milligramme, and the in- 
crease is thereafter until i milligramme is 
reached; then I increase i milligramme at a 
time until 2 milligrammes are reached. After 
that dose the increase is milligramme up to 
10; from 10 to 20 milligrammes I increase 2\ 
milligrammes, and thereafter 5 milligrammes, 
at a time. 
Periods will be observed when for weeks to- 
gether no local or general reaction is observed, 
while the subjective and objective improve- 
ment of the patient progresses favorably; and 
whenever a point has been reached where this 12 
improvement is radical and active symptoms 
have entirely subsided, this is the time to stop 
the use of the remedy, allowing an intermis- 
sion of from two weeks to a month. If no re- 
lapse has occurred in this time, if everything is 
highly satisfactory, and the recovery is appar- 
ent, we keep the patient under observation as 
long as possible, otherwise a repetition of the 
treatment is of course necessary. 
In the second course we begin again with 
milligramme, but increase after each dose so 
long as no local reaction is produced. 
My results have been obtained upon this 
plan ; and while other plans may also be safe 
and accomplish good results, and while some 
one may devise even a better plan, until better 
results than mine are shown by others, no 
change from my method is, in my judgment, 
permissible. 
I have thus treated over one hundred pa- 
tients with between six and seven thousand in- 
jections, and, with the exception of my first week 
or t\tfo of experimental use, I have never pro- 
duced any effect which has in any way been 
detrimental, nor has there been one single case 
in which the treatment has caused discomfort. 
I have not found any advantage from Hunter’s 
modification, and am of the opinion that it is 
in no wise safe to increase it faster than the 
original tuberculin. 
He who cannot have his patients under close 
and constant observation, or who gives the 
remedy with less care, simply takes chances, 
and if no disaster follows it is good luck, 
nothing more. 
As shown in the earlier part of this paper, I 
have one hundred per cent, of recoveries in the early stage ; in the second stage, recovery 
has resulted in eighty-six per cent, and radical 
improvement in fourteen per cent.; in the last 
stage, marked improvement in forty-six per 
cent.; and these results have lasted over two 
years. In the cases treated since, the results 
are equally good, and in the advanced cases 
promise to be slightly better still. 
It is true I have had the advantage of an ex- 
cellent climate. I have also made use of every 
other available means at my command whenever 
I believed that they could aid the patient’s im- 
provement. I have exercised the greatest vigi- 
lance in the use of the remedy, and have never 
allowed myself to take any chances, nor have I 
taken things for granted when I could satisfy 
myself by painstaking examination and inquiry, 
and the patients were all treated in my institu- 
tion and under my constant care. The special 
treatment has not been delegated to assist- 
ants, but was carried out by myself, without 
sparing time and labor; but, with all this, it is 
also true that I have been equally careful and 
interested with patients who were treated in 
the institution before the advent of tubercu- 
lin, and with those who, during the two years 
past, did not receive tuberculin for reasons 
stated before, and the results, as compared with 
those in connection with tuberculin, offer no 
chance for comparison. 
In my previous writings on tuberculin I have 
been exceedingly careful not to commit myself 
too far. I am now ready to stand by the rem- 
edy, not in recommending it as a cure-all, or 
under all conditions and manifestations of the 
disease, but certainly as a remedy of the great- 
est value when used as indicated in this paper. 
13 14 
With me now it is no longer on trial as an ex- 
periment. On the contrary, I find its effects 
as reliable and as uniform as I could hope them 
to be under the great variety of individual con- 
ditions, such as constitution, stage of the disease, 
organs involved, and complications present. 
If my precautions and methods in the use of 
tuberculin are really essential for good results, 
as I have found them to be, and which riper 
experience of two years or more of other ob- 
servers seems to confirm, we must not blame 
the remedy if it failed to come up to our ex- 
pectations under its erroneous use in unsuita- 
ble cases and in excessive and highly-dangerous 
doses. We should the less criticise it when 
the results were unsatisfactory in the hands of 
men with little experience in close physical 
diagnosis and in the management of the dis- 
ease, some of whom dealt out their doses at 
their office hours without again seeing their 
patient until he came for his next dose, or 
until the physician was summoned to find how 
ill an overdose had made his patient. 
Such experience was perhaps necessary to 
confine the use of the remedy to safe hands 
and to teach us the care and circumspection 
which are essential in its employment.