individuals who had not been specially associated with Koch in his work would be reduced to a minimum. It is satisfactory to see from latest reports from Berlin that Koch has now declined to supply the lymph for any other than hospital purposes. Still it is to be hoped that full instructions as to the preparation of the lymph will soon be in the hands of those who may be considered competent to prepare it.

We are glad to note that Koch is pursuing his investigations into diphtheria, and that they are progressing rapidly, as we should argue from this that he has now practically completed his method of preparation of the lymph for the treatment of tuberculosis; and we may anticipate that ere long he will make public the remainder of his discovery as regards its preparation in quantities sufficient to meet the enormous demand.

MORE CONCERNING KOCH'S METHODS OF INOCULATION.

(From the Medical Record of December 13, 1890.)

[By the kindness of Dr. A. Rupp, of this city, we are enabled to publish the following letter, sent to him by Dr. C. Graefe, of Sandusky, O., who is now in Berlin.-ED.]

BERLIN, November 20, 1890.-Dear Doctor:-Since the publication of Prof. Koch's paper the throng of patients and medical men has been so constantly increasing that now the hospitals and clinics where Koch's specific is used are so crowded with those afflicted with tuberculosis that other patients have to give way, and the visiting doctors crowd the clinics to such an extent that students cannot get their seats. Koch himself, after announcing that he was compelled to make his discoveries known somewhat prematurely on account of the false impressions created by newspaper articles, has withdrawn into his laboratory to continue his studies, leaving the preparation of the remedy in the hands of Drs. Pfuh and Libbertz, and the clinical experiments to Drs. von Bergmann, Fraentzel, Gerhardt, Cornet and Levy. These gentlemen are the only ones who at present have any of the lymph, though it is said small quantities have been sent to Rome, Davos, Vienna and London. Prof. Koch, when he announced in his paper that small quantities could be obtained by physicians, probably had no idea

of what the demand would be, for none can be obtained now, and the prospect for all, except large institutions, is very poor, as the present demands would take up the product of months with the present facilities and at the rate it is being prepared.

There is considerable speculation as to what the brownish liquid, smelling of carbolic acid, really is, and it has been thought to be toxalbumin, cyanide of gold or silver, a culture of the bacillus, or a ferment produced by such culture. It certainly takes some time to make it, will keep if kept corked in concentrated solution, turns white by the addition of pure alcohol, will bear a certain amount of heating, and in the diluted solution spoils by the formation of bacteria in it. It is diluted with boiled sterilized water, or a 1 per cent. solution of carbolic acid before using, and is usually injected between the scapula. Prof. Koch has invented a new syringe, composed of the usual needle and glass cylinder, but the piston is replaced by a rubber ball, which, being squeezed, forces the liquid out by the pressure of the air. He recommends that the cylinder be washed in alcohol after each injection, and the advantages are that it is so easily taken to pieces that it can readily be sterilized and cleaned, so avoiding the formation of abscesses.

Having seen quite a large series of cases and the records of others, I can testify to the results of the application of the remedy as given by Koch. Where there is tuberculosis, in from four to six hours there is a rise of temperature, reaching, in some of the cases at Prof. Bergmann's clinic, the height of 40.9° C., frequently accompanied by a chill, and sometimes by delirium. This gradually falls in from twenty-four to thirty-six hours, and the affected parts are congested, sore, and in lupus there is a serous exudation which dries into crusts. Sometimes the appearance becomes almost erysipelatous, and there is some necrosis of the skin, though usually the small tubercular spots are gone when the crusts come off, leaving a comparatively smooth surface. Prof. Fraentzel reports, in four cases of advanced tuberculosis of the lungs, that there was the usual rise of temperature after the injection, but otherwise the cases ran the usual course, and the post-mortems revealed nothing special except thick, slimy masses in the cavities.

The second series of eight cases were in the first stages, with induration of the apices of the lungs, and showed bacilli upon examination of the sputum. The patients were treated daily for

from fifteen to fifty-six days, had the usual fever after the injections, but the night-sweats left them, the cough grew less, and they gained in weight, while bacilli could not be detected in the sputum after a time. Dr. Levy has been using the lymph since September 22d, on lupus and bone troubles, and Drs. Koehler and Westphal report a large series of surgical cases where they have.nsed the remedy. I have seen about 20 cases of lupus during the past week, some of which have not been published. I to-day saw a case of lupus, at Dr. Lazzar's clinic, where a carcinoma had formed in the scar, and the lupus was affected in the usual manner (infiltration, exudation of serum, etc.), while the cancerous portion was not affected. Prof. von Bergmann showed a similar case last week. and in two cases where there was some doubt as to the diagnosis of a tumor of the cheek and a laryngeal trouble, there was no reaction, and the tumor was probably syphilitic and the laryngeal trouble

cancerous.

Drs. Koehler and Westphal made the injection in four cases of ordinary scars after burns, cuts and ulcers, and there was no reac. tion in these cases. Prof. von Bergmann did the same with a boy with scrofulous glands of long standing, and there was no reaction, while in four cases of the same trouble there was a decided reaction and the treatment was continued.

The fever usually gradually decreases after the first three or four injections, and after a varying time tolerance is established, which is considered as the sign that the tubercles are destroyed. But the cases have not been under observation long enough to show that after a short time the reaction will not take place again. In Prof. Bergmann's cases of bone trouble, abscesses, zonitis, coxitis, etc., the febrile reaction is accompanied with much pain in the affected parts and joints, which disappears more or less with the fever; and he will wait until the cases do not react after the injection before applying the usual plaster, fixation splints, etc.

The whole process is still in the experimental stage, and time alone will prove its true value. Koch is very modest in his claims for the remedy, and the most exaggerated reports of the cures effected by it fill the newspapers. As there is no lymph to be had, the process of its manufacture a secret, and the method of application so simple, it will scarcely pay to come to Berlin at present, and many who came have gone away.

There are a number of Americans on the ground, and they are not the least active and interested of the visitors.

(From the Boston Medical and Surgical Journal, Dec. 11, 1890.) During the past week very little new, authentic information has been received on the subject of Koch's method of treating tuberculosis. It is evident that there is little hope of a publication of the process of preparing the fluid for some time to come, and the clinical reports of cases treated are still very incomplete. There has been little important information on the subject that is not contained in the article by Koch in the Deutsche Medicinische Wochenschrift of November 14th.

The therapeutic action of the fluid seems to be different from anything which has, up to this time, been employed in medicine. It does not directly kill the bacilli, neither does it act as a preventive inoculation after the manner of cow-pox vaccination, but apparently tissue containing tubercle bacilli becomes violently inflated, and finally suppurates, and perhaps separates from the healthy underlying tissue, carrying the bacilli, still alive, with it. This induced inflammation is attended with constitutional disturbance more or less dependent upon the amount of tissue involved, and may be sufficient to cause death, especially where large portions of the lungs are affected. Hæmoptysis may occur, or the lung may swell to the exclusion of air. There seems to be no reason to believe that cavities are favorably influenced except by removal of the bacilli. It is remarkable that the constitutional symptoms are almost identical in character with those met with in abscess formation.

The excitement in Berlin is intense. The city is full of physicians trying to find out something, and trying to get a specimen of the so-called lymph. Although about a thousand cases are under treatment in the Berlin hospitals, the amount of the fluid obtainable seems to be very small, and very little has left the city.

The material used by Prof. Koch in his inoculations is a viscid fluid, the color of a dilute solution of iodiue, of a slightly syrupy consistence. It is prepared for use by adding 100 grammes of sterilized water, the maximum dose of injection being 1 gramme. No reaction appears locally, but at the end of four hours severe constitutional effects are manifest in the appearance of rigors with malaise, followed by a temperature which may reach 106° F., with a corresponding increase in the pulse-beat from 120 to 160. Vomiting may occur. Sometimes the reaction is attended with alarming symptoms, very great prostration (requiring the use of stimulants)

and severe dyspnoea. When the tuberculosis deposit is superficial, there is in and around it great tumefaction. The constitutional symptoms are usually of short duration. Subsequent injections are not attended with systemic disturbances. Over the surface and in the neighborhood of tuberculous swellings, scabs appear, which, on being separated, leave healthy granulating surfaces. Cases in that stage are said to be cured, inasmuch as they show no constitutional reaction.

A report has been in circulation that the German Government intends to purchase from Koch, and to keep secret, the method of manufacture of the fluid, except that, later, properly commissioned deputations of other governments may be taught the art with the understanding that the secret shall go no farther.

After going to press we received the following cable from Dr. Harold Ernst, in Berlin, under date of December 10th:

"The secret of making Koch's material has been turned over to, and kept by the German Government only until a thorough trial can be made. The effect in lupus and surgical tuberculosis is most striking, because the results can be seen. The most wonderful property is the selective affinity for tuberculous nidus, often making latent centres active. Pulmonary tuberculosis will have to be under observation for a long time still before permanent result is determined. The action of the material is certainly as wonderful as that of any known medicine."

THE KOCH FLUID.

(From the American Druggist.)

Nothing in the way of medical discovery during this century has equalled in importance the announcement made by Professor Robert Koch, of Berlin, in the Deutsche Medicinische Wochenschrift of November 14th, of a cure for tuberculosis; and were it not that the probity and scientific accuracy of its author are too well established to admit of doubt, much that is claimed for this new remedy would be incredible. Like most discoveries of great importance, the narrative is so simple and direct as to win our unqualified admiration.