STREET CAR ACCIDENTS. The Public Service Commission of New York City reports 444 people killed by the steam, subway, elevated and surface roads of the city during 1908. There were 56,481 accidents. Surface lines were responsible for 42,391 of this number.

NO AMBULANCE GONGS. The authorities of the Roosevelt and the Presbyterian Hospitals of New York have ordered the gongs removed from the ambulances of their institutions. The officials claim that the use of the gongs has tended to cause reckless driving.

THE NEW ORLEANS HEALTH BOARD, at its annual meeting, January 12, adopted a request to be sent to the Police Commission, asking that the board be furnished with fifty policemen who are to assist in the work of inspecting cisterns and enforcing the anti-mosquito ordinance.

PLAGUE RATS FOUND. Inspector Bowman, of the Hawaiian Territorial Board of Health, has reported to the board that he found 44 dead rats in near proximity to the city stables of Hilo, and that of these 32 were infected with plague.

THE COST OF WAGING A WAR of extermination upon rats in all. parts of Louisiana, which is planned by the State Board of Health, will be defrayed by the proceeds which will be derived from the sale of the Mississippi River quarantine station to the United States government.

IT IS REPORTED that the city health department of Toledo has notified the managers of hotels and restaurants that hereafter no cracked dishes, plates, cups and saucers and glassware must be used on the tables, and that they are a menace to good health. According to the health department disease germs lodge in cracked dishes.

BOOK REVIEWS.

Church & Peterson's Nervous and Mental Diseases. We heartily recommend this as one of the best and most popular text-books to be found upon the subjects of nervous and of mental diseases. It is really two books under one cover, for Dr. Church has contributed the monograph on nervous diseases and Dr. Peterson that on mental diseases. The work is clear, concise, well written and well arranged. It is also illustrated very profusely. This edition, which is the sixth, has been enlarged by about twenty pages. A new article on psychotherapy has been added. Church & Peterson is a deservedly popular book among students and general practitioners.

NERVOUS AND MENTAL DISEASES. The new (sixth) edition. By Archibald Church, M.D., Professor of Nervous and Mental Diseases and Medical Jurisprudence in Northwestern University Medical School, Chicago; and Frederick Peterson, M.D., Professor of Psychiatry, Columbia University. Sixth edition, revised and enlarged. Octavo volume of 944 pages, with 341 illustrations. Philadelphia and London: W. B. Saunders Company, 1908. Cloth, $5.00 net; half morocco, $6.50 net.

Davis' Obstetric and Gynecologic Nursing.

This book can safely be recommended to his nurses by the physician. It is one of the most useful works on obstetric and gynecologic nursing, and with the explicit directions, the original illustrations and the interesting manner in which the technie of ideal nursing is presented, the book cannot be recommended too highly.

OBSTETRIC AND GYNECOLOGIC NURSING. The new (third) edition. By Edward P. Davis, A.M., M.D., Professor of Obstetrics in the Jefferson Medical College, Philadelphia. 12mo volume of 436 pages, fully illustrated. Third revised edition. Philadelphia and London: W. B. Saunders Company, 1908. Polished buckram, $1.75 net.

Volume 29

Number 3

Memphis Medical Monthly

MEMPHIS, TENNESSEE, MARCH, 1909.

ORIGINAL ARTICLES.

THE THERAPEUTIC AND DIAGNOSTIC USE OF TUBERCULIN.*

L. P. BARBOUR, M.D.

ROCKY FORD, COL.

The premature surrender of tuberculin by Professor Koch; the unreasoning enthusiasm that followed; the use of the remedy by the inexpert and careless; its employment by even the expert in advanced cases, contrary to the advice of its originator; the inevitable reaction that followed, with its indiscriminating condemnation of tuberculin-all this is familiar history to the phthisiologist.

I was an interested reader of the reports following the first use of the remedy. Much of this literature was valueless, coming from men inexact and careless. But I found that the testimony of reliable men who severely sifted and tested their conclusions agreed that tuberculin did exert a specific effect upon tubercular tissue and did produce cures of tuberculosis. The number of these reported cases, together with the conditions surrounding the trial, was sufficient to prove that tuberculin was the cause of the cure. This was more than could be said of any remedy up to that time, and, I may add, even to the present time.

It should be remembered that during this first use of it tuberculin was used in what would now be considered immense doses. We shudder at the amount given. Koch, I believe, *Read by title before the Tri-State Medical Association of Mississippi, Arkansas and Tennessee, at Memphis, November 24, 25 and 26, 1908. Vol. 29-9

113

advised one milligram as the beginning dose. My first report of my own experience was published in the Therapeutic Gazette, of July, 1894. In that I said: "Enough was accomplished in the first year of the use of tuberculin to give me faith that when we had learned to select our cases properly and to use the proper dosage, tuberculin would prove our most valuable remedy in treating tuberculosis." So when I began to use it I gave much smaller doses than Koch had advised, though doses that I now consider altogether too large for best results. Another sentence from that same report is this: "I have seen results obtained, as a rule, that are exceptional under any other treatment." This report of my first experience the passing years have confirmed with emphasis. Increased experience with the remedy, and further knowledge of the disease, have given me continually better results and increased confidence. I now give tuberculin to cases that ten years ago I would not have expected to give good results. And not my results alone, but the work of others, has helped to increase my confidence. I know of no one who has "stayed with" the remedy, who has studied its effects and carefully watched his patients, but has obtained better results than could be obtained in any other way. Tuberculin, to be used successfully, must be given by one who is an expert diagnostician, and who has the time, or who will take time, to give his patient the closest, minutest attention. Here, in my opinion, is the cause of the failure of many good men in the use of tuberculin. They are not willing, or are too busy, to give sufficient time. to the study of each individual patient. But this close attention is undoubtedly the price of success. Possibly with laboratory facilities for continual taking of the opsonic index, this close study of the individual may be omitted. Personally, I believe clinical study of the patient gives a better guide for the use of tuberculin than the opsonic index can give.

Another cause of failure to obtain results with tuberculin has been the attempt to give stated doses at stated times. This ought never to be done. The physical and clinical, and even the psychical condition of the patient must all be weighed and the size of the dose gauged accordingly, or withheld altogether. There can be no "rule of thumb." Each patient is a guide to his own case, and each "dose day" must

decide the dose for that day. Towards the close of a "course" of treatment, when the patient is nearing recovery, one can usually foretell just what the size of the dose will be for days ahead. But not in the beginning of the treatment. I often find it wise to lessen the dose materially in cases that for considerable time have made a steady progressive increase.

I have known of cases where the remedy was given to the patient to administer to himself. This ought never to be done, not even to physician patients. One cannot properly interpret one's own symptoms; and, further, it is always difficult for the patient to resist the temptation to hurry.

I have no new theories as to how tuberculin produces results. It evidently has an immunizing and also a germicidal effect. Whether both of these are due to one and the same action upon the blood serum, according to Wright's opsonic theory, I question. I do not believe that the whole story of its immunizing, antitoxic and germicidal effects has yet been clearly told. I have often wished for the advantages of a laboratory that I might follow up, by animal experimentation, some of the clews I seem to get hold of in clinical study.

During the past fifteen years I have used several of the different preparations of tuberculin. Recently I keep in stock some of Kleb's "anti-phthisin," some of Koch's new tuberculin and some of the original (o. t.). If there is as much as one degree of fever, I begin treatment with anti-phthisin. After a time I change to T. R. (Koch). In incipient cases, and in more chronic cases without fever, or with not more than one degree of temperature, I begin with T. R. and use it throughout. I use the original for diagnostic purposes. When using anti-phthisin I begin with a dose of one two-thousandth part of a milligram. My beginning dose of T. R. is one twentythousandth of a milligram. A dose is given every second or third day. In most cases an increase of one twenty-thousandth mg. can be made with each dose till one five-thousandth mg. is reached. After that dose is reached I increase by one fivethousandth mg. till .001 mg. is reached. Thereafter, it is best to not give an increase oftener than once in seven to ten days; and after .01 mg. is attained I increase about every third or fourth dose, but fall back to .01 mg. in the intervals. For instance, I give today, say .04 mg. The next two doses