RESULTS IN NINETY CASES OF PULMONARY 
TUBERCULOSIS. 
Treated at the Winy ah Sanitarium at Asheville, N. C, 
from May 1, 1891, to May 1, 1892. 
WITH A COMPARISON OF RESULTS OBTAINED WITH AND WITHOUT 
THE USE OF TUBERCULIN. 
BY 
KARL VON RUCK, M.D. 
ASHEVILLE, N. C. 
EROM 
THE MEDICAL NEWS, 
September i6, 1893. [Reprinted from THE MEDICAL News, September 16, 1893.] 
RESULTS IN NINETY CASES OF PULMONARY 
TUBERCULOSIS 
Treated at the Winyah Sanitarium at Asheville, N. C., 
from May 1, 1891, to May 1, 1892. 
WITH A COMPARISON OF RESULTS OBTAINED WITH AND 
WITHOUT THE USE OF TUBERCULIN. 
By KARL VON RUCK, M.D., 
ASHEVILLE, N. C. 
In a paper presented to the American Medical 
Association, May 7, 1891, I reported my first series 
of 25 cases treated with tuberculin during the win- 
ter of 1890 and 1891. Of cases in the early stage, 
which I designated as Class A, I had 5, of which 
3 were reported as apparently recovered, 1 as 
greatly improved, and 1 as improved. 
Of cases in the middle stage, which I designated as 
Class B, there were 7 treated. Of these, 4 apparently 
recovered, 2 improved greatly, and 1 improved. 
Of the cases in the third stage, designated Class 
C, there were 13 treated; of these, 4 were greatly 
improved, 6 were improved, 1 was slightly im- 
proved, and 2 were not improved. 
During April of this year, two years later, a care- 
ful inquiry was made by correspondence with the 
patients, their friends or their physicians, as to their 
present condition, the object being to learn the 
permanency of the results obtained and the out- 
come of the cases after a period of two years. 
The results of this inquiry were presented in a 
paper read before the American Climatological 
Association on May 26th, and were as follows: 2 
The 5 cases belonging to Class A (early stage) 
have all recovered and report themselves perfectly 
well in every way. 
Of the 7 cases belonging to Class B (middle 
stage), 6 have made a final recovery and reported 
themselves perfectly well, while i case relapsed, 
was treated again, and was again greatly improved. 
Of the 13 cases belonging to Class C (advanced 
stage), 3 are still greatly improved, 3 others remain 
improved, and 7 have died. This gives, at the end 
of two years, among cases in the first stage, 100 
per cent, of recoveries; among those in the second 
stage, 86 per cent, of recoveries and 14 per cent, 
with improvement; and in the last stage, 46 per 
cent, with improvement. 
I desire now to report 36 additional cases treated 
with tuberculin between May 1, 1891, and May 1, 
1892, and to show their condition at the time of 
their discharge, and also to give the results obtained 
in 54 other cases not treated with tuberculin, but 
otherwise managed and cared for exactly in the 
same way as were the 36 patients who received 
treatment with tuberculin additionally. 
Before proceeding with these reports, permit me 
to state my general experience with tuberculin and 
my position as to the use of the remedy from the 
beginning to the present time. 
When in Berlin in November, 1890, I protested 
there against the manner of employment of the 
remedy, especially against the use of doses that 
induced general symptoms, such as fever, severe 
aching, headache, nausea, loss of appetite, etc., 
and which were called a reaction ; and immediately 
on my return to this country I warned the profes- 
sion, in three or four short articles, against doses 
that were followed by such symptoms; and although 
I did not then know that the remedy would or 3 
could determine beneficial effects in doses that 
caused no such disturbances, I felt that the first con- 
sidera'ion was to find a safe mode of administration. 
My protests were, however, little heeded, and the 
sad experience with this remedy is common knowl- 
edge, especially in the advanced stage of the dis- 
ease, to which its use was largely confined, because 
cases at an early stage held aloof after realizing 
that tuberculous patients did not all get well as was 
expected, and that deaths from pulmonary tubercu- 
losis continued to occur as before. 
The public press, which had raised false hopes 
among patients and their friends, reported cases of 
death, in which tuberculin had been given, in a 
manner which soon checked the enthusiasm. " Took 
Tuberculin and Died " was a frequent heading of 
such newspaper items. Those of the profession 
who had used the agent in large doses were neces- 
sarily disappointed, and those who looked on and 
watched became doubtful at first, and prejudiced 
next; so that, after the lapse of a few months, the 
patients themselves feared the remedy and would 
not have it administered except as a last resort; 
while the profession, with but few exceptions, abso- 
lutely condemned it as dangerous and useless, with- 
out even having given it a trial. 
This stage was practically reached when I reported 
my first 25 cases. 
Constant communication with the source of origin 
of the remedy, and the good results obtained by such 
men as Stricker, Langenbuch, Schmitt, Thorner, 
Schede, and others, assured me, however, that my 
results were, at least in a measure, due to the rem- 
edy ; the more so, as, in my past experience, I had 
not seen as good and satisfactory improvement and 
recoveries from other measures. At this pessimistic 
stage, disbelievers in the remedy attributed my re- 4 
ported results to climatic and general treatment and 
to the care and supervision of these patients while 
under treatment, and the prevalent prejudice forced 
me to restrict the use of the tuberculin to such 
patients as themselves requested it, and then only 
after obtaining the consent of the physician who 
had sent the patient to me. 
Report of go Cases of Pulmonary Tuberculosis 
Treated at the Winyah Sanitarium, Asheville, N. C. 
From May 1, 1891, to May 1, 1892. 
36 cases treated with tuberculin ; 
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Under such restriction the remedy was, from May 
i, 1891, to May 1, 1892, further applied in 36 
cases. During this period 54 patients were treated 
without it. The classification into stages is made 5 
as nearly alike as possible for both series of cases. 
In each case treated the sputum contained tubercle- 
bacilli. 
In Class A, I include all cases having one or both 
upper lobes involved, but without destructive 
changes and with the general health comparatively 
good. In class B, I include cases with circum- 
scribed softening or cavitation, but still in fair phys- 
ical condition. In Class C, the local disease was 
still further advanced, with more extensive breaking 
down and larger cavities, and with considerable 
constitutional impairment. If any doubt arose as 
to the proper classification, the patient's general 
condition determined the choice. 
The average duration of the treatment was 152 
days in cases treated with tuberculin, whereas it 
was 178 days in cases that did not receive tuberculin. 
Cases treated for less than a month are excluded 
from both classes, as are also such as arrived in such 
a condition that the case was absolutely hopeless. 
Cases reported as apparently cured were free 
from all subjective symptoms; there was entire ces- 
sation of cough and expectoration, and the last 
specimen of sputum examined did not show the 
presence of tubercle-bacilli. In other words, there 
was apparently an entire restoration to health. 
Locally, beyond the evidences of more or less re- 
traction of the affected portions of lung, there was 
no other evidence of the tuberculous process. 
As greatly improved, I report all cases in which 
the tuberculous process seemed to be arrested and 
in which the subjective symptoms subsided to a 
degree that but slight morning cough or expectora- 
tion remained, the patient regaining his general 
health. I have no doubt that ultimately some of 
these cases will completely recover. This could 
probably have been brought about by further treat- 6 
ment; but such patients are, as a rule, unwilling to 
remain longer and are satisfied to take their chances 
for the future, so long as they feel perfectly well. 
The terms "improved" and "slightly improved" 
are relative and depend upon a comparison between 
the conditions found on admission and those shown 
at the last examination. All patients reported as 
improved showed a gain in weight and strength. 
Of those treated with tuberculin (with the exception 
of one in C, reported stationary, who had 
made a gain of 3 pounds and lost it again), all 
gained in weight. The greatest gain was 31 pounds, 
the least gain, 2 pounds, with an average, for the 
first stage of 9 pounds; for the second stage, of 
T3% pounds; and for the third stage, of pounds. 
Of the patients treated without tuberculin, 39 gained 
in weight between and 26 pounds; in 8 others 
there was but a slight gain ; in 9 cases there was a 
loss. The average gain in weight in cases in the 
first stage was pounds; in cases in the second 
stage, 6 pounds; and in cases in the third stage, 
only pounds. 
Comparing now the results, we have 6 cases in 
the early stage in each series, but we find that, with 
the addition of tuberculin to the treatment, 5 
patients have apparently recovered and one has 
been greatly improved, while, without the remedy, 
there were only 2 recoveries, with 3 cases greatly 
improved and 1 improved. Still I consider the 
results practically the same, for I have no doubt 
that, by a continuance of the treatment in the cases 
that did not receive tuberculin, three greatly im- 
proyed cases would eventually have recovered. 
There is, however, this difference, that the average 
duration of residence in the Sanitarium of the 
patients in the early stage receiving tuberculin was 
133 days, whereas it was 184 days in those that did 7 
not receive tuberculin, and a completion of the 
treatment in the greatly improved cases would 
increase the difference still more. In the second 
stage, Class B, the utility of tuberculin appears 
much greater and a greater saving in time is also 
manifest. 
There were 53 per cent, of recoveries under 
tuberculin against 14 per cent, without it, and the 
difference in the improved cases is also equally 
manifest. 
The average residence in the institution of the 
patients taking tuberculin was 138 days, as against 
189 days for patients that did not receive it. 
No real recovery resulted in either series of 
cases in the third stage. Under tuberculin there 
were, however, 46 per cent, at this stage greatly 
improved, while without the remedy there were 
only 9 per cent, greatly improved, and 35 per cent, 
improved, showing more than twice as good results 
from the use of tuberculin. 
The average duration of treatment in the third 
stage in the institution under tuberculin is greater 
than for those who did not receive it; but this is 
owing to the fact that, on account of the less satis- 
factory progress of patients that did not receive the 
remedy, some of them became discouraged and 
returned home, whilst the patients having tuberculin 
were highly pleased and satisfied, and therefore 
remained longer. 
From the evidence accumulated during two and 
one-half years' use of the remedy, and from the. 
results obtained in my first series of 25 cases and 
those of the 36 cases reported in this paper, I believe 
myself justified in claiming that tuberculin has been 
a great aid in my work, and having seen no unfavor- 
able effect whatever from its administration upon 
the plan described by me,1 I believe myself justified 
1 See Therapeutic Gazette, Jun?, 1893. 8 
in recommending its use, not only in the earlier 
but in all stages of pulmonary tuberculosis, when no 
contra-indication exists. 
As the chief contra-indication to treatment with 
tuberculin, I consider the existence of septic infec- 
tion, and the fever due to it, which, unless controlled 
by other means, necessarily leads to exhaustion of 
the patient. Tuberculin has no power over such 
processes, nor over many other complications that 
may arise in the course of chronic pulmonary 
tuberculosis, and no effects must be expected from 
it except in the purely tuberculous affection that 
has not advanced to the stage of breaking down. 
From private information recently received it 
appears that Dr. Koch has by no means abandoned 
his endeavors for the improvement of this specific 
remedy for tuberculosis, and a substance is now 
being tested in the Institute for Infectious Diseases, 
in Berlin, which is eventually to supersede the 
present tuberculin. This is not given by inhalation, 
as reported in the journals, but is administered sub- 
cutaneously in the same way as tuberculin is now 
given, but it will not be presented to the profession 
until its advantage over the present tuberculin is 
clearly established in the clinical department of the 
Institute. 
I have seen no advantage in Hunter's modifica- 
tion, and its use requires the same circumspection 
as does the original remedy, while it seems less con- 
stant in its composition and effect. 
Neither was there any important advantage de- 
rived from the modification of Klebs, and I have 
come to the conclusion that if tuberculin is to be 
used at all, the original remedy, with wrhich we 
have now the greatest experience, both as to its 
dangers and benefits, is the preparation to be em- 
ployed. The Medical News. 
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