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Arnold C. (Arnold Carl) Klebs.

Tuberculosis; a treatise by American authors on its etiology, pathology, frequency, semeiology, diagnosis, prognosis, prevention and treatment online

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(on a water bath to one tenth volume), and filtered (through a
Chamberlain filter) " beef broth " (containing five per cent
glycerin, neutralized) culture, six to eight weeks old, of human
tubercle bacilli, irrespective of virulence or of strain, but usu-
ally much attenuated. The finished product contains fifty per
cent glycerin.



516 SPECIFIC TREATMENT

2. Tuberculin R. (Kocli). — An imlieated twenty-per-cent glycerin

emulsion of living, virulent, pulverized tubercle bacilli, which
have first been extracted with water (water extract named
tuberculin ohere), containing finally in each cubic centimeter
10 mgm. of solid substance.

3. Bacillen Emulsion, B. E. (Koch). — An unheated fifty-per-cent

glycerin emulsion of living, virulent, pulverized tubercle bacilli
containing 5 mgm. of solid substance in each cubic centimeter.
The coarser particles are removed by centrifugalization. Arlo-
ing believes that B. E. affects breathing more than old tuber-
culin, the effects of B. E. last longer than 0. T., and that the
severity depends upon the virulence of the bacilli in the emul-
sion and in the animal.

4. Tuberculocidin (T, C.) and Antiphthisin (Klebs).— The old

tuberculin is first precipitated with bismuth (tuberculocidin) or
potassium-bismuth-iodid in acetic acid (antiphthisin) and then
with alcohol.

5. "Watery Extract" (von Ruck). — Tubercle bacilli are washed

with water, then first extracted with alcohol and ether and pul-
verized, and finally extracted with water at 50° C.

6. Broth Filtrate (B. F.) (Denys). — The unheated, unconcentrated,

filtered (through porcelain) bouillon culture of human tubercle
bacilli. Denys believes this is ten to a hundred times as strong
as 0. T., but Baldwin has proved 0. T. far more toxic for
guinea pigs.

7. Beraneck's Tuberculin. — A twenty-per-cent solution of equal

quantities of the unheated precipitate (by sixty per cent alco-
Jiol) of a culture of tubercle bacilli of standard virulence on
glycerinated, nonneutralized, nonpeptonized bouillon and of an
orthophosphoric acid (one per cent) extract of untreated tuber-
cle bacilli. It is less toxic and less vaso-dilating than 0. T.

Living tubercle bacilli were found at first in T. R. and B. E. by
Thellung, in B. E. by von Meissen, and in T. R. by Huber. Many
other contaminating bacteria were present at first in some specimens
(Baumgarten and Walz).

Tuberculase, tulase, and tulaselaktin of von Behring are products
of or altered tubercle bacilli, whose preparation has never been made
known.

No accurate method of standardization of tuberculin has yet been
found, though Doenitz, Otto, and von Lingelsheim have all suggested
methods, the first two using tuberculous with subcutaneous, the latter
healthy guinea pigs with intracerebral injections.



CHEMISTRY OF TUBERCULIN 517

Comparison of the strengths of the various tuberculins were made
by von Behring on twenty tuberculous cattle, and he found —

1 part T. E. = 3 parts 0. T.

1 part tuberculin purified by partial alcohol precipitation = 4 to 6
parts 0. T.

1 part dried and pulverized tubercle bacilli r= 4 to 5 parts 0. T.
1 part nuclein substance = 3.5 to 4.5 parts 0. T.
1 part tuberkulosamin = 3 to 3.5 parts 0. T.
1 part tuberculinic acid =: 3.5 to 4 parts 0. T.

C. Spengler states bovine tuberculin causes a more intense skin and
" organ " reaction than 0. T.

As Guinard ('02) remarks, there are two principal objects in all
the work on tuberculin : ( 1 ) To free the tuberculin of its dangerous
constituents and to preserve its useful ones; (2) to obtain more of the
latter either by changing the media used for growth of the tubercle
bacillus or by employing a better method of extraction. On the whole,
the results do not permit us to think that a single tuberculous extract
bearing the name of tuberculin is able to be taken as a type or repre-
sents a fixed product, constant in its composition and in its effects. All
probably contain the specific nucleic acid. What Maragliano said in
1898 is still true to-day : " There is no tuberculous poison entitled to
the name because it has not been isolated in a state of purity. They
have always been in glycerin or aqueous solutions under different forms
of precipitates, dried or redissolved, more or less mixed Avith other
albumoses." Guinard also agrees Avith Arloing, who claims that how-
ever slightly the microbic products are treated, the active element may
be changed.

CHEMISTRY OF TUBERCULIN

Old tul)erculin, Kuehne found, differed only (luantitatively from the
broth-culture fluid. It gave all the proteid reactions, but resisted heat
(160° C. for two hours in 50 per cent glycerin solution), so differing
from all kno\\7i ali)uinosos and toxalbumins. The largest amount of
active substance was precij)itated by 60 per cent alcohol, and tbe crude
and precipitated tuberculin contained on an average 18.86 per cent ash,
chiefly K and Mg phosphate. Kuehne found in tuberculin by analysis no
alkaloids, but (1) an allniminate (nucleoproteid), (3) a peculiar (aero-)
albumose, (3) deutcro-albumose, (4) traces of peptone, and (5) trypta-
phane, a digestive product.

Ruppel, who examined broth filtrates heated only to 30° to 40° C,
found no specific substance differing in chemical reactions from the
proteids in the original broth.



518 SPECIFIC TREATMENT

The niuleoproteids and tubereulinic acid obtained by extracting
bacilli with water, with glycerinated water (three to five per cent), or
with weak alkaline solutions contained much of the active principle.
This substance is probably in proteid combination, and while peptic
digestion weakens its activity, tryptic digestion destroys it (Baldwin
and Levene) and it is not easily dial3^zable. Tuberculin obtained from
the bovine bacilli is strongest, that from the human weaker, while that
from the avian is weaker still (Euppel), a fact that Smith explains by
the increased alkalinity of the bovine cultures.

It has long been held that if only a more virulent toxin co|ild be
obtained from the tubercle bacillus, or from its culture fluid, immuni-
zation might be possible. Much work by Euppel, Levene, and others
has resulted, but no advance has been made along this line for some
time, and it is now, for the present, at least, abandoned (Ott, '03).

METHODS OF ADMINISTRATION

Intravenous. — While Koch at first advised tuberculin to be admin-
istered hypodermically, in 1901, when he announced his B. E. and in-
timated that it was necessary to obtain a high agglutinating power in
the blood to an emulsion of pulverized tubercle bacilli, he suggested
that as large doses of B. E. caused, when given subcutaneously, ab-
scesses, that these doses be given intravenously. Few, however, now
accept the importance Koch at that time attributed to agglutination
as the index of immunity and intravenous injection of tuberculin may
be said to be almost never used. Eothschild, M. ('06), and Heermann
('05) have reported good results in some patients with this method,
and Denys has used it. The dose is one tenth the amount given sub-
cutaneously, and the fact that the best immunity has been obtained
with living bacilli by this method should arrest attention.

Oral. — Tuberculin has been administered in nearly every conceiv-
able way. Freymuth ('05) has given it per os in the form of kaolin-
coated pills, after neutralization of the gastric juice with sodium bicar-
bonate to avoid digestion in the stomach, while Klebs takes no account
of this factor. Hubs ("07), who reacted severely to small doses sub-
cutaneously (100° F. after 0.00005 0. T.), took 1 gm. 0. T. by mouth
with and without neutralizing the gastric juice with a large amount
of sodium bicarbonate, and yet, although he had taken 20,000 times
the foregoing minimum dose, it had no effect whatsoever. Eecent work
on serums has shown that antibodies in serums are absorbed un-
changed from the alimentary tract only during the first two weeks
of life or when the epithelium is injured, but Calmette and Guerin
('07) have succeeded in vaccinating calves by feeding them tuberculous



METHODS OF ADMINISTRATION 519

milk, while Figari and Maragliano claim to have had excellent results
in guinea pigs from oral administration of blood clots from immunized
calves and horses. The work of Levene, Baldwin, and Kinghorn shows
that tuberculin is affected by the digestive processes in the stomach
and intestines. Furthermore, it is impossible to gauge accurately the
dose by this method (Loewenstein and Koehler) or by inhalation, and
consequently severe reactions may occur when least expected and hyper-
sensibility result.

Inhalation. — Kapralik ('04) and von Schroetter ('04) have em-
ployed tuberculin by inhalation in the form of a spray, first suggested
by Moeller, a method requiring large doses and incurring, therefore,
much expense. Bandelier obtained no results from inhalations, and
Huhs thinks them of little value.

Jacobs injected tuberculin intratracheally, to enable a large quan-
tity to reach the site of the lesion, and was severely criticised by his
confreres. Tuberculin in solution is well absorbed from the lungs,
but the dosage is inexact, and what can be hoped from saturating
with tuberculin an organ which already contains much of it is difficult
to see.

Dermic. — Administration by rubbing into the skin is only of value
in hypersensitive individuals and children. It has marked limitations
which Spengler ('03) has noted, and further may be accompanied by
disagreeable skin reactions. Spengler rubs into the forearm of patients
who are hypersensitive 1, 5, and 10 mgm. at intervals of two to four
days. In two weeks the subcutaneous injections can be recommenced.
Proper dilutions render this method entirely unnecessary.

The rectal and the intrapulmonary injection (Livierato) of tuber-
culin need only to be mentioned to be condemned.

Subcutaneously. — Tuberculin injected subcutaneously is nearly at
once absorbed by the lymphatics. It is of interest to bear in mind that
the large mononuclear cells which seem chiefly concerned in the process
of immunization in tul^erculosis are probably derived from the endo-
thelial cells of the lymph and blood-vessels, which are directly stimu-
lated by this method, and stimulated most intensely at a point far
distant from the area of infection. Beraneck, however, opposes this
view, and believes tuberculin should be injected directly into or imme-
diately about the focus. A careful consideration of all these methods
unquestionably leads to the conclusion that the subcutaneous method
is by far the most exact, the most reliable, the most elastic (adaptable),
and the most efficacious. The same arguments apply here that are used
in favor of the hypodermic administration of drugs. For tiiese reasons
the discussion here is limited entirely to the subcutaneous administration
of tuberculin.



520 SPECIFIC TREATMENT



DILUTIONS



Tuberculin in man}^ instances produces at the site of injection the
four classical signs of inflammation — tumor, roboi\ calor, and dolor.
It is natural to presuppose that the tissues are less resistant to infection
at this point, but care in regard to asepsis always prevents suppuration
unless large doses of B. E. have been given, when, in sj)ite of asepsis,
local sterile abscesses may occur. All emulsions or vaccines of tubercle
l)acilli should always, therefore, be well diluted, but this is not neces-
sary with many other forms of tuberculin.

Preservation in Dilution. — In all cases, except where large doses of
tuberculin are used, it is necessary to dilute the original tuljerculin, as at
present few tuberculins are put on the market in a form sufficiently di-
luted for the earlier doses. Furthermore, it lu\s not yet been determined
how long the high dilutions retain tlieir strength, especially when a small
percentage of some antiseptic has been added. High dilutions apparently
retain their strength for two weeks, and it is not improbable that they
may do so for a much longer period, but until sufficient proof of this is
adduced they should be made up fresh every two weeks. Jacquerod says
a ten-per-cent solution degenerates only after six weeks.

It is best to keep the tuberculin as well as all dilutions in a cool
place (ice box) protected from light. In making the dilutions the
greatest care should be used not to contaminate the original tul)erculin,
which should be in a paraffined, rubber-stoppered, dark bottle. If con-
taminations do occur — i. e., if the original tuberculin becomes more
cloudy (some forms are never clear) — it should be discarded and not
used. With care this is practically never necessary, and no instance
of any sort has ever suggested to the writer that the tuberculin he was
using should be resterilized.

Method of Diluting. — The dilution of tuberculin is a comparatively
simple process that demands little previous experience but great exact-
ness. If at any time during the process of dilution a question of error
arises, it is well to throw aside the dilutions and start anew.

The instruments necessary for making dilutions are a 1-c.c. glass
pipette, graduated into hundredths of a cubic centimeter, Avith a scale
at least 15 cm. long and a long, conical 10-c.c. graduate. These should
always be boiled before use, though some recommend keeping them in
a disinfecting solution (alcohol, etc.) and rinsing with a diluent before
using. A glass syringe with a capacity of 1 c.c, with a long, narrow
barrel, graduated into hundredths of a cubic centimeter, is mi;ch easier
to use, and, if accurately graduated, is more exact. It matters little,
however, whether either the pipette or syringe be accurately graduated,
provided that the same instrument be used each time. This syringe



DILUTIONS 521

is also the best for use in giving tuberculin. The actual dose is of far
less importance than the relative dose. If a syringe be used, it should




Fig. 147. — Ix-ti:umextarium for Tubercxtlix Injections. From left to right:
Sterilizer, large (1,000 c.c.) and small (100 c.c), measuring cylinders, flask with
sterile water, bowl, three small bottles holding tuberculin stock solutions (B. E.
and B. F.). On shallow glass dish with hj-podermic syringe, holding 1 c.c,
subdivided into lOOths c.c. In front calibrated pipette.

be freed carefully from water and rinsed several times in the solution
to be diluted (see Fig. 147).

Diluents. — The best diluent is probably one fourth per cent phenol
in physiologic saline solution. It should be carefully boiled and filtered
from time to time. Phenol may be replaced by lysol in the same
strength. For emulsions of the tubercle bacillus, which should always
be shaken before using, Koch recommended that the diluent should be
physiologic salt solution, but the ordinary diluent may be used.

Estimating Dilutions. — When a table for dilutions is not at hand,
the easiest method is to decide what content per cubic centimeter is
desired. For example, if 10 c.c. of a diluent, in which 1 c.c. =: 0.000001
c.c. of the original tuberculin, be required, with a pipette or syringe
0.1 c.c. of the original tuberculin is taken and the diluent added until
10 c.c. is reached. Then as 0.1 c.c. is in 10 c.c, 1 c.c. must contain
0.01 c.c. Repeating this, a solution is obtained of which 1 c.c. = .0001
c.c. of the original tuberculin. The amount desired of the final solution
determines how much of this solution should be used. As it is wished



522



SPECIFIC TREATMENT



to get 10 c.c. of a solution in which 1 c.c. = .000001, multiply .000001
by 10, obtaining .00001. This amount of tuberculin is contained in 0.1
c.c. of the last solution, which is measured out and diluted up to 10 c.c,
which gives the required strength — 1. e., 1 c.c. = .000001 of the original
tuberculin. This process may be continued until any required dilution
be obtained. By adding diluent until a volume of 100 c.c. is reached,
fewer intervening dilutions are necessary. It is unwise to attempt to meas-
ure less than 1 c.c. when making dilutions. The accompanying schema,
in which grams are equivalent to cubic centimeters, has long been used at
the Adirondack Cottage Sanitarium, and has given much satisfaction:



Variety
Strengt




O. T. OR B. F.

1 G. TO 1 C.C.


T. R.

.01 G. TO 1 C.C.


B. E.




.005 G. TO 1 r.c.






Solu-
tion
No.


To make 10 c.c. of

solutions of following

strengths —


Take


Take


Take





1 g. to 1 C.C.


10 c.c. Tuberculin.




i


I


.Ig. tolc.c.


1 c.c. Tuberculin.
9 c.c. Diluent.






11


.01 g. to 1 c.c.


0.1 c.c. Tuberculin
9.9 c.c. Diluent.

or
1 c.c. Solution I.
9 c.c. Diluent.


10 c.c Tuberculin.




III


.001 g. to 1 c.c.


0.1 c.c. Solution I.
9.9 c.c. Diluent.

or
1 c.c. Solution II.
9 c.c. Diluent.


1 c.c. Tuberculin.
9 c.c. Diluent.


2 c.c. Tuberculin.
8 c.c. Diluent.


IV


.0001 g. to 1 c.c.


0.1 c.c. Solution II
9.9. c.c. Diluent.

or
1 c.c. Solution III.
9 c.c. Diluent.


0.1 c.c. Tuberculin
9.9 c.c. Diluent.

or
1 c.c. Solution III.
9 c.c. Diluent.


0.2 c.c. Tuberculin.
9.8 c.c. Diluent.

or
1 c.c. Solution III.
9 c.c. Diluent.


V


.00001 g. to 1 c.c.


O.lc.c.Solutionlll
9.9 c.c. Diluent.

or
1 c.c. Solution IV.
9 c.c. Diluent.


O.lc.c.Solutionlll
9.9 c.c. Diluent.

or
1 c.c. Solution IV.
9 c.c. Diluent.


0.1 c.c. Solution III
9.9 c.c. Diluent.

or
1 c.c. Solution IV.
9 c.c. Diluent.


VI


.000001 g. to 1 c.c.


0.1 c.c. Solution IV
9.9 c.c. Diluent.

or
1 c.c. Solution V.
9 c.c. Diluent.





0.1 c.c. Solution IV
9.9 c.c. Diluent.

or
1 c.c. Solution V.
9 c.c. Diluent.



PREPARATION FOR INJECTIONS 523

PREPARATION FOR INJECTIONS

Cleansing of Skin. — The area of skin selected should be vigorously
rubbed with alcohol both before and after the injection. No other
cleansing is necessary, and the use of antiseptics, ether, cotton, col-
lodion, etc., is superfluous. In thousands of injections made by the
writer, alcohol alone has been used and no infection has ever oc-
curred.

Needles. — The needles used should be very fine, should be rinsed in
alcohol or ether after using and in boiling water before using. They need
not be boiled, nor need they be kept in alcohol if they are not used
for any other purpose. The platinum-iridium needles used by some
(Holdheim) are unnecessary.

Accidental Inoculation. — When tuberculin is given to a large num-
ber of patients, great care should be taken to avoid ejecting a spray
of tuberculin into the air when forcing out bubbles of air, as reactions
have been produced in this way. The boiling water used for rinsing
the syringes between injections should always be fresh, and graduates
or pipettes used for making dilutions should never be placed in this
water, nor should the water drawn up into the syringe be ejected back
into this pan. The physician, if tuberculous, should always wash his
hands after handling tuberculin.

Site of Injection. — During the rubbing for cleansing, the site should
be examined to see that it is free from indurations left from previous
injections. The occurrence of these indurations vary both for indi-
viduals and for the form of tuberculin used.

The usual site is 4 to 8 cm. from the midline opposite the seventh
to the tenth dorsal spines. The skin is usually thick, less vascular,
easily movable, and less sensitive in this area. It should be given well
under and not in the skin.

Beraneck believes that his tuberculin acts more favorably when
injected near or directly into the focus in surgical tuberculosis, as it
produces an increased phagocytosis and possibly sets free bacteriolytic
ferments from the cells. He has not advocated intrapulmonary injec-
tions. Crocker and Pernet advise local injection in lupus.

The toxin enters, often continuously, into the circulation about the
tuberculous foci, and the contiguous cells are constantly stimulated.
In tuberculin treatment it is injected at intervals into the lymphatics
(subcutaneous), far removed from the disease foci. The latter process
may call into play the whole body, especially the lymphatic system,
while the action of the former may be limited to the circulatory system,
possibly of a limited area.



524 SPECIFIC TREATMENT

DOSAGE AND INTERVAL

General. — The crucial point in the tuberculin treatment is the selec-
tion of the dose and interval. The literature of the period of tuberculin
delirium (1890-91) is filled with reports of patients who were excessively
overdosed, and in some instances undoubtedly killed by overdosing with
tuberculin. The few men who continued to use tuberculin were those
who from the first employed much smaller doses than were in current
use. To Guttmann and Ehrlich, to Goetsch particularly, to Denys, to
Trudeau, and to Wright do we owe the present recognition of the value
of small doses. Two men, hoAvever, Denys and W^right, deserve special
mention in this connection. Denys in his book, " Le Bouillon Filtre,"
has given the best exposition of the clinical value of beginning with
small doses of tuberculin in all forms of tuberculosis, and Wright,
basing his opinion on his studies of the opsonic index, has emphasized
the great benefit to be derived from small, repeated, or very slightly
increased doses of tuberculin in surgical tuberculosis. The method of
administration of tuberculin is far more important than the variety of
tuberculin, and he who fails to consider that tuberculin is a most potent
poison, is a dangerous man. Too great care cannot be exercised, and
carelessness may be equivalent to homicide. A beginner who presumes
on his inexperience is likely to have woeful results.

Beginning Lose. — The first dose of tuberculin should be so selected
that all possibility of reaction is excluded. Koch, C. Spengler, Bande-
lier and Roepke, and others have advocated that slight reactions (under
100.4° F.) are necessary for the best results, while the vast majority
of observers endeavor to avoid reactions whenever possible, but, in spite
of all precautions, slight reactions will occasionally occur during the
course of the treatment. In all patients who have recently been sub-
jected to the tuberculin test, in all who have a subfebrile temperature,
extensive pulmonar}^ involvement, a nervous temperament, or compli-
cations, more care about the dosage should be exercised at first. One
patient, a well-nourished, strongly built woman aged twenty-four years,
with extensive infiltration and slight apical consolidation of the left
lung, reacted to 0.0000001 c.c. of broth filtrate (B. F.). and for four
months was unable again to reach so large a dose. Another patient,
a strongly built male, aged forty, with extensive signs of infiltration
in both lungs, was given without reaction a first dose of 0.000005 c.c.
B. F., and in six weeks with biweekly doses reached 0.001 c.c. The
susceptibility to tuberculin varies greatly both in different patients
as well as in the same individual at different times, and cannot be
estimated accurately beforehand either irom the physical signs, the
symptoms, or, indeed, from any data at our command. Such facts



DOSAGE AND INTERVAL 525

emphasize the great necessity for careful individual treatment of each
patient, and beginners especially should studiously avoid producing any
evidence of reaction.

The size of the first dose has been directly affected by the idea that
the tuberculin treatment should extend over many months, and the final
dose still influences many men in the selection of the first dose. This
is especially true in sanatoriums, where oftentimes both patient and
physician feel as if they must begin with as large a dose as possible
and hurry on until a large final dose, often 1 c.c, is reached. (See
Duration of Treatment.) This is based on wrong premises, as all
patients need not be carried to the same dose to derive equal bene-
fit, and the final dose should have no influence on the first. It is
often well, as Sahli also holds, to repeat the first dose, especially if
there be any doubt about its causing a reaction. The initial subcu-
taneous dose for the tuberculins most frequently used are given on
pages 540-541.

Interval. — Wlien first used, tuberculin was given every day, a method
soon found to be wrong. Many to-day, however, advise that at first
it be given every day or every other day, and later every three or four
days. As even slight reactions may not be manifested until as late as
forty-eight or even sixty hours, the danger of giving tuberculin oftener
than every three or four days (biweekly) is apparent. Many patients,



Online LibraryArnold C. (Arnold Carl) KlebsTuberculosis; a treatise by American authors on its etiology, pathology, frequency, semeiology, diagnosis, prognosis, prevention and treatment → online text (page 55 of 97)