REMARKS ON THE NA- 
TURE AND TREATMENT 
OF TUBERCULOSIS. 
BY 
E. L. SHURLY, M. D., 
Detroit, Mich. 
REPRINT OF TRANSACTIONS OF 
MICHIGAN STATE MEDICAL SOCIETY, 
1892. [Reprint from Proceedings of Michigan State Medical Society, 1892.] 
REMARKS ON THE NATURE AND TREATMENT 
OF TUBERCULOSIS. 
E. L. SHURLY, M. D., 
Detroit. 
Mr. Chairman, Ladies and Gentlemen: I regret very much 
that I have not a written paper for this occasion, as I intended to 
have done. I shall therefore have to ask your indulgence for 
the deranged manner in which the subject will be presented. 
As I understand the topic I am expected to speak of, it is the 
Nature and Treatment of Pulmonary Tuberculosis. Of course, 
such a subject is of too wide a range, and will take up too much 
of your time for this occasion, and I shall therefore condense 
very much what I want to say, leaving out almost entirely any 
remarks upon the pathology, which is very important and inter- 
esting. 
Allow me to say first, that I think a great deal of confusion 
arising at the present time over the subject of tuberculosis comes 
from lack of recognition of the several different states of the di- 
sease met with. There is no doubt but that it will be a long 
time before all the problems connected with the subject can be 
solved, and that many theories will have to be evolved. We are 
in the habit of sneering a little bit, (if we be practical people), at 
the theories. After all, it is theory which must lead to the prac- 
tical solution of all such questions. 
Now, the prevalent theory is the bacillary one, that is, that 
the bacillus tuberculosis is the cause of all these several different 
states known as tubercular disease. We heard this morning a 
very excellent paper on Tuberculosis of the Joints, by Prof. Nan- 
crede, a very philosophical and instructive paper ; and you will 
remember that the author spoke of the bacillary action in the 
production of tuberculosis of the joints, although he did not in- 
sist upon it as inevitable. There are other surgeons, who be- 
lieve that the bacillus tuberculosis has nothing whatever to do 
with such diseases of the joints. There are still others, who do 2 
STATE MEDICAL SOCIETY. 
not believe that many of these cases are tuberculosis. Of late 
years, several bacteriologists have discovered differences in the 
form and behavior of these bacilli, in their morphology, and I 
think the present tendency of opinion is towards the view that 
there are really several kinds of tubercle bacilli. In a very able 
paper published in the Revue de Medicine last October, Dr. J. 
Courmont, who spent a great deal of time in the investigation, 
shows that he had isolated three or four different families of 
tubercle bacilli. Now, is it not possible that all of these differ- 
ent families or varieties of bacilli may have different physiologi- 
cal characteristics, so to speak. While the morphology may not 
differ one from the other very much, physiology or life of the 
microbe may. 
Then, again, there springs up, in an etiological sense, the great 
question of the ferments accompanying them. The universal 
decision that tubercular affections are due to operations of bacilli 
is based largely upon elaborate and convincing experiments, 
which are about as follows : The microbe is cultivated in a cer- 
tain organic medium, then transferred from that to an animal ; in 
the animal in turn is developed a tuberculosis, which again can 
be transmitted by inoculation to another animal, and so on ; the 
disease in each having the same pathological feature. Now, 
while this seems so plain, we lose sight of the fact which the 
chemist tells us, that there is present a ferment. What is the 
agency of the ferment ? Recently Prof. Tamman has brought 
forward some views which are quite new and seem well proven, 
viz. : that there are in many organic materials certain unformed 
ferments, which are in given instances, as it were, in a state of equili- 
brium, one with the other, that the least thing may disturb this 
equilibrium, and cause the formation of active products. Even a lit- 
tle acid added to one, or a little water to another, will materially set 
the action going or change the result. This is a very important 
point to consider in connection with inoculating experiments, so 
that when we come to think of transferring this culture or that 
to an animal, we do not know how much or little of this ferment 
we transfer also. I do not believe anybody can stand up and 
with absolute certainty say that he has transferred nothing but E. L. SHURLY. 
3 
the bacillus. He must have transferred with the microbe some 
unformed or active ferment, either the product of the bacillus, or 
extraneous to its life. 
And therefore we do not know how much or little the disease 
process depends upon the ferment which is transferred with the 
microbe or the microbe itself. Hence, I believe in the present 
state of our knowledge it is unsettled whether the microbe, or 
bacillus, is the only cause of the diseased condition generally 
classed as tuberculosis. I also believe, and I think the drift of 
opinion is in this direction, that there are distinct clinical and 
pathological differences in these cases. For instance, I do not 
think, from a clinical standpoint, that so-called tuberculous joints, 
so-called tubercular pulmonary disease, leprosy, lupus, and tuber- 
culosis of the peritoneum are identical diseases, I do not believe 
they are one and the same disease, although they may be 
closely related in some particulars. That brings us, then, to the 
practical consideration of the classification of such diseases. 
Every practitioner knows that there are certain forms or cases 
of disease, which he is unable to classify exactly by physical 
signs or by clinical history ; and that there are certain differ- 
ences clinically, no matter what identity laboratory examination 
may show regarding them. Some of these variations may be 
accounted for partly by the individual tendency to peculiarities, 
individual idiosyncrasies, but such consideration is not sufficient 
to account for the regular course of special cases. For instance, 
we have a case where there is no haemoptysis, where the cough 
comes on gradually but is a first symptom, while pyrexia and 
adynamia come on later and progressively, and after a while 
expectoration, etc. Upon physical examination of the chest, we 
find that there is gradual consolidation taking place in the upper 
part of one lung, and perhaps some lesion in the other lung, all 
of which progresses, the patient dies, and if an autopsy is made, 
there will be shown the ordinary morbid anatomy of a case of pul- 
monary tuberculosis. The course may cover a period of several 
months, a year or more, yet another form will cover a period of 
several years. There is still another form-the mechanical-such 
as miners and grinders are afflicted with, where a great many 
years are consumed in the course of the disease, and again, 4 
STATE MEDICAL SOCIETY. 
another very decided form, where the course is very rapid but 
differing from acute miliary tuberculosis in this respect, that the 
lesion initially, and all the time, is confined to the lung ; after a 
little time, the whole pulmonary tissue seems to liquefy. Such 
cases are typical. You will all recognize them. We meet with 
them frequently. But they are not one and the same thing, and 
moreover, it does not change the result whether the family his- 
tory be bad or good always, but if the domestic history has been 
good or bad it may modify the course of the disease. These 
cases, then, are so frequently typical that we must recognize t-hem 
at least as varieties of pulmonary disease ; in all of these exam- 
ples mentioned, the lungs have been the seat of the principal 
lesion, therefore, they must be cases of phthisis. Now, we 
believe that all of such cases of so-called phthisis pulmonalis are 
essentially inflammatory ; that the tubercular process is a sec- 
ondary one; that the majority are ordinary catarrhal pneumo- 
nias, and whatever of tuberculosis comes, is secondary. This 
view, however, does not militate against the prevalent theory of 
the bacillary origin of tuberculosis or phthisis pulmonalis, inas- 
much as it is said by everyone, that there must be a nidus for the 
germs to grow upon. Why they do not always occur and 
develop in all cases of catarrhal inflammation of the air pas- 
sages is a mystery. However, we know as a fact they do not. 
Allow me for a moment by way of diversion to call your atten- 
tion to laryngeal phthisis, one of the most horrible diseases that 
can affect the human being. This disease, as you know, is very 
obstinate. It appears in two general forms, and has peculiar 
features. There are very few cases of laryngeal phthisis which 
are secondary to pulmonary tuberculosis. It is often coincident 
with pulmonary disease, it is true, but it is not often secondary. 
Yet what a large number of cases of pulmonary phthisis occur 
without any laryngeal complication whatever, without laryngeal 
phthisis ? Is it not strange ? 
In chronic laryngitis, even with erosion, no pulmonary phthisis, 
no tuberculosis necessarily follows. Why should this be, if 
the bacilli are constantly traveling this tract, and only waiting for a 
little opening on good ground? Hence there must be other etiolog- 
ical factors to be taken into consideration in any description of the E. L. SHURLY. 
5 
nature of this disease, called pulmonary phthisis. To sum up, I 
should be inclined to think that the nature of pulmonary tuber- 
culosis, or pulmonary phthisis, was essentially inflammatory in 
the beginning, whatever subsequently may follow. This view 
does not seem unreasonable in the light of clinical history, but I 
admit it may seem unreasonable in the light of laboratory experi- 
ments as conducted at the present day. Deductions from these, 
however, are undergoing great change. If it be true that com- 
mon phthisis pulmonalis be an inflammatory affection, it gives 
us some encouragement toward endeavors to mitigate its inevit- 
able course and result. On the other hand, if it be always speci- 
fic, dependent upon the invasion and operation of bacilli alone, 
then there is no hope. Regarding treatment, which has been 
generally unsatisfactory, we find many difficulties. 
At the outset, in almost all cases, one of the most troublesome 
symptoms we meet with is anorexia, which precludes the estab- 
lishment of any sort of nutrition for the benefit of the patient, and 
which constitutes one great drawback to all treatment. Perhaps 
I am a little ahead of my story, for I ought to specify that we 
have three classes of cases to deal with: acute, sub-acute, and 
chronic. That is, excluding what is called miliary or general 
tuberculosis. 
But anorexia is common to all, and one of the first difficulties 
to be overcome and thought of. Those of us, who have had 
large experience with these diseases, become very much dis- 
couraged in attempting to keep up the nutrition of the patient on 
account of this symptom, especially if we are obliged also to 
administer by the stomach all sorts of medicines, oils, etc. 
But this has been the ordinary mode of treatment, the applica- 
tions of medicines in the usual way, by the stomach. And we 
know how very few patients will tolerate it for any great length 
of time without great increase of anorexia. This is especially 
true of the cough balsams and syrups and oils. Therefore, it 
seems very desirable to adopt any method of medication which 
may be useful other than stomachal. Now, we have two things 
before' us in this direction. One is climatic treatment, and the 
other is treatment by means of inhalation or hypodermic medication, 
or both. Climatic treatment is so efficacious and well known that I 6 
STATE MEDICAL SOCIETY. 
need not speak of it here. I would remind you, however, as a proof 
that the bacillus is not the only cause of the diseases in question, that 
this microbe will operate just as well in Colorado and California 
as in Michigan, notwithstanding the claim of enthusiasts that the 
atmosphere of the former states is aseptic, and, if not indigenous 
there, they are taken there, and probably flourish, since cases 
of phthisis pulmonalis or tuberculosis originate there and run 
the same course as in Michigan. But outside of this, we do 
know that a favorable climate is one of the most useful factors 
in treatment, for, by putting the patient into position to get plenty of 
fresh air (oxygen) as necessary as other nutrition; by putting the 
patient in the way of receiving plenty of heat and light, and the 
benefit of the actinic rays of the sun, together with dry atmo- 
sphere, undoubtedly we place him in a position of great advantage. 
Regarding medication, we consider of first importance the 
hypodermic method because the medicine is introduced into the 
system in its pure state, undergoing no change by contact with 
the secretions of the stomach or intestines; besides, whatever 
good it does in a selective way, the system may get the full bene- 
fit. This we believe is the preferable way, whether the disease 
be much localized in the lung or not. Notwithstanding particu- 
lar localization, there is always spontaneously generated from this 
source a certain amount of septic poison, so that cases of phthisis 
pulmonalis are essentially forms of septicemia, a general septi- 
cemia of some sort induced by the circulation of some toxic 
material which poisons the tissues generally. This seems per- 
fectly rational, and ought to be very generally accepted. Now, 
if we can introduce something into the economy that will neutral- 
ize the septic material, of course, we take a step forward. It is 
claimed by many that nothing but a colloid substance-organic- 
can be expected to act permanently in this way to neutralize an 
animal poison. We have not time to go into this question which, 
together with a great many other such questions, may be rele- 
gated to the chemist, who in the near future must settle many 
mooted points of pathology. I will only say that this is certainly 
not borne out in practice. For we may introduce an alkaloid 
into the general system with as much hope of its producing a 
permanent, prompt, and selective effect, as though it were col- E. L. SHURLY. 
7 
loid; it is not necessary, then, that it be an animal poison. How- 
ever, while we can produce such effects from an alkaloid just as 
well as a colloid, the effect is not as lasting, because there are no 
secondary or cumulative effects excepting upon the nervous 
system, so that the injections must be repeated. 
Therefore, I still believe that is the proper and rational method 
of systemic treatment. We prefer iodine and chloride of gold 
and sodium, but perhaps iodine and chloride of gold and 
sodium may not be the best chemicals. There may be found 
some others that will answer the purpose better. Undoubtedly 
there will be, but these two chemicals have done much good in 
pulmonary phthisis of the earlier stages. But, of course, they 
are not capable of controlling the septicemia which occurs in a 
large class of cases. Take, for instance, a case showing evi- 
dence of tuberculosis affecting the mesenteric glands as well as 
the lungs: it is very difficult to put enough of any chemical into 
the system without getting a toxic effect, to neutralize it. Besides 
this method, we may be able to modify the source of poisoning 
by proper inhalations, antiseptic inhalations of some sort. When 
there are patches of caseation that are accessible to the bronchial 
tubes, by the use of some gas which can reach that part, in this 
way a cutting off of the source of septic material may be obtained, 
and for that reason different gases have been used from time 
to time. Chlorine gas has been used at different times, but aban- 
doned because irrespirable; however, it has been found practic- 
able for inhalation when properly used, mixed with salt spray, 
and the cases properly selected for it. We may use also the 
antiseptic balsams for the same purpose. These not only have 
a local effect in quieting the immediate symptoms known as 
cough and so on, but certainly have the ulterior effect of cutting 
off the supply of septic material. So that, so far as the thera- 
peutic indications are concerned, there seems to be two : one 
to limit the extension of the disease, and the other to neutralize the 
septic material that is being generated from hour to hour in the 
course of the disease. One thing that for many years has given 
me great hope that we might achieve something in the treatment 
of phthisis pulmonalis, is that a great many of the local changes, 
the pathological changes, which take place in the lung, are really 8 
STATE MEDICAL SOCIETY. 
conservative. They are nature's efforts to limit the disease, and 
to throw off the materies morbi, whatever it may be. 
I don't think I will take up your time in giving the history of 
cases in extenso. I would simply like to mention two or three, 
illustrating the remarks. For instance, one case that I have 
only a synopsis of, is as follows: 
Mr. S., set. 37, farmer, German. Father and grandfather 
died of phthisis. One year before entering the hospital he had 
bronchitis, and for six weeks was quite sick with it, but finally 
grew better. He has had cough ever since, with expectoration 
increasing until it became abundant and heavy. When he was 
admitted to the hospital his pulse was small and rapid, 120, 
temperature 101.50. There were tubercle bacilli in sputum in 
great quantities. He was put upon a treatment of hypodermic 
injections of iodine, commencing with one-sixth grain, which 
was rapidly increased to a grain and a grain and a-half, together 
with chlorine inhalations. 
The physical signs showed the upper half of the right lung 
more or less consolidated, as shown by bronchial respiration, 
increased fremitus, bronchophony, and dullness on percussion. 
This condition extended down to about the fifth rib, in front and 
behind. The respiratory murmur on the other side was exag- 
gerated. Now, this is a type of case commonly met with, a case 
of phthisis beyond incipiency. This man also had a bad family 
history. The temperature and pulse range gradually, but quite 
rapidly, diminished under the treatment, so that, at the end of the 
second week, the evening temperature did not go beyond 99.6°, 
and the pulse subsided to 90. At the end of the fourth week the 
evening temperature ranged at 990, and the pulse at 84, and 
there were no other exacerbations through the day. There had 
been a return of appetite and all the physical functions were 
being performed very well. This man was in the hospital about 
eight weeks. He went home last week. Now, you can't say that 
the man is well. He may have a relapse, and some more inflam- 
mation of the lungs, and he may have tuberculosis yet, but I do not 
believe that his was a case of tuberculosis. I believe the diagno- 
sis betwen phthisis pulmonalis and tuberculosis must be made 
by some other method than those in vogue now. We shall have E. L. SHURLY. 
9 
to take into consideration other characteristics of the sputum 
besides bacilli. We have already found that in some cases there 
are certain precipitates from the sputum which will kill animals 
directly, while the precipitates obtained with the same reagents 
from other cases will not kill animals. Whether this arises from 
some deflections by chemical manipulation, or whether there is 
some peculiar toxine, we cannot say. As it occurs so uniformly, 
we believe there must be something in it of importance. Before 
we can arrive at the proper diagnosis, prognosis, and classifica- 
tion of these diseases, in all probability we shall have to call in 
the aid of the chemist to examine chemically the expectoration, 
and trust, as now, to the staining of bacilli. 
Another case I will relate where a man was under treatment 
three years ago, who seemed apparently to recover. Although 
throughout the course of his disease he had some looseness of 
the bowels, showing some intestinal disturbance, he improved 
and left the hospital after two months. He returned six weeks 
ago very much worse. He seems to be getting better again, 
although there is diarrhoea and tenderness of the abdomen. 
Now, the probability is, he will not recover under the treatment. 
He had also a bad family history. Now, whether this case is of 
a different nature, really a tuberculosis or a general glandular 
degeneration or not, we cannot say. I could relate another case, 
if there were time, bearing on the paper of the gentleman who 
preceded me, a case we now have in the hospital of general 
tuberculosis probably showing no lesions in the lungs. The 
physical signs show no consolidation. Respiration is simply 
rapid from pyrexia. We are unable to make the diagnosis 
exactly. We simply know it is not typhoid fever. The man is 
rapidly going to his death, there seems to be no lesions discover- 
able bv auscultation in the chest, which will at all account for the 
patient's condition. Neither are the abdominal lesions sufficient 
to account for the great pyrexia and adynamia. It seems to be 
a systemic infection. 
A case of this sort should be classified not as a case of 
phthisis pulmonalis, as is generally done. It is undoubtedly a 
case of tuberculosis. Therefore, I believe, that adopting the 
idea of phthisis pulmonalis being essentially a local inflamma- 10 
STATE MEDICAL SOCIETY. 
tory affection, while general tuberculosis is a primary, general 
affection, will very much aid us in setting the true relative 
value upon therapeutic measures and plans, and enable us to 
classify these diseases with more propriety than heretofore.