A THIRD SERIES OF TWENTY CASES OF PULMONARY TUBERCULOSIS TREATED BY CONTINUOUS ANTISEPTIC INHALATION
Authors: D. B. Lees
Journal: BMJ (1912)

PULMONARY TUBERCULOSIS.I-TimBo X -767 Since the reactivity of patients varies enormously ac ording to their sensitiveness and how far this is covered by tolerance, it is well to begin with a do.;eso low that it is certain to be ineffective.Actual dosage I shall not mention here, since I have loncg discard( d the standards usually adopt( d a id measure my tuberchlin in cubic milli- metres of orig,in solution; and though this is the best and simplest of all methods, the doses in a new standard would be difficult to grasp in a lecture.Having begun with this small dose, it may be very rapidly raised till some effect is noted.This muLst be looked for in a local reaction, or, failing this i a some slight general effect, such as a flattening of the teumperature, or a slight rise, or slight symptoms in the paticnt.Having reached this point, the doses must be raised more gradually, and for the gradua- tion of dosage nothing is more stuitable than a geometrical progression such as that supplied by Lawrason Brown in Klebs's Textbook of T'uberculosis.By this means risk of large reactions is reduced to a minimum, and yet, with s;kilful adjuLstment, the dose may be kept sufficiently near the reacting point to eficiently call forth an immunizing response, the main points of whieh we have already laid down as the slight focal hyperaemia and the stilmulation of antibody formation.It is unlikely that fever reactions will be altogether avoided, and this brings us to a parting of the ways among v-ariouis exponents of the art of tuber- cuilit administration.There are, as you know, certain people who ignore reactions, and, in their struggle to establish tolerance to large doses, will allow the patient to react violently again and again.Those -who have treated localized tuberculosis, where the foci of disease are winder the eye, cannot look on this method witlh favour.They knowlhow caseous material will soften and discharge itself under large focal reactions, and though such a pro- cess in the lung may in certain cases be inevitable and lead to no harm, in other cases this is far from being the case.By avoiding such large reactions we are putting possible danger on one side.By allowing mild reactions occasion- ally, and keeping the dose near the reacting point we are fuLlfilling tllose conditions whiclh experience has taught us to rely on in the treatment of visible lesions.In this way the whole course of treatment is directed towards the healing of the tuberculous areas, and tolerance is but a valuable by-product of the tuberculin administration.This may be called the method of utilizing reactions.A third methocl in the administration of tuberculin aims at the avoidance of all reactions, and lhas not much to recom- mend it unless its safety.The consideration of the metlhod of pushing the dosage through reactions, with the aim of rapidly reaching tolerance to large' doses, tempts me to the question of the value of such tolerance.Is there sufficient evidence of its value to justify us in making it an aim?If we turn to animal experiment for a moment we find that tuberculous disease protects against further infection withl the tuberele bacillus.Experiments have been done.on cattle, guineapigs, and,more recently,; apes, which show that if virulent bacilli are injected into a healthy animal, no symptoms follow immediately, but after an interval symptoms of tuberculosis appear, and the animal dies.If similar injec- tions are given to a tuberculous animal, on the other hand, a violent "reaction" immediately follows, but the animal shows no fresh tuberculous disease.Here we find that sensitiveness to tubercle products (not tolerance) is asso- ciated with protection against fresh infection.We might, therefore, fear that by producing tolerance we were remov- ing a valuable safeguard against the further spread of disease.We are, it is true, removing from the patient, for a time, thle power of autoinoculating himself, and this might be a danger where tuberculin was withheld.It is, however, highly unlikely that tolerance removes in any way the power of the tissues of the tuberculous to deal with the ' In January, 1912, Dr. Ehrmann kindly informed me that this laly was still quite well and fully able to perform all her usual occupations, Case 69.A lady, aged 39, sent by Dr. Edwards of Fulham, May 31st, - 1911.Cough in winter time for some years-very subject to " colds going on to bronchitis."For about three years has had asthmatic attaciss, which recur about once a month.Since March, 1911, she has had-cantinual cough, with shortness of breath andl yellow phlegm, and has lost weight.Anorexia, dyspepsia, flatulence, and disturbed sleep.Weight.6 st.91 lb.On examinationl of her chest the signs