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 NOTES ON THE LUNGS OF ONE OF KOCH'S EARLIEST 
 TUBERCULIN PATIENTS. 
 
 BT 
 
 J. G. ADAMI, M.A., M.D., 
 
 Professor of Pathology McGill University, Montreal. 
 
 Reprinted from the Montreal Medical Journal, September, 1895. 
 
I 
 
I 
 
 >-» 
 
 NOTES ON THE LUNGS OF ONE OF KOCH'S EARLIEST 
 TUBERCULIN PATIENTS* 
 
 By J. G. Adami, M.A., M.D., (Cantab.) M.R.C.S., Eng., . 
 Prof essor of Pathology Mo9ill University, Montreal- 
 
 The lungs in the case about to be recorded possess a certain amount 
 of interest, inasmuch as according to the history given by the patient, 
 a highly intelligent man, thirty-three years old, he was one of the 
 first to undergo treatment under Professor Koch in Berlin. 
 
 The patient, A. Rickstrom, was born in Finland and was in good 
 health until 1890, when he suffered from hfemoptysis, followed by a 
 cough, night sweats and progressive emaciation. He was admitted 
 under Koch at the Victoria Hospital in Berlin and there continued for 
 fifty-two weeks undergoing periodic inoculations with tuberculin. 
 Under this treatment his appetite improved, he began to gain tlesh, 
 and the night sweats pfussed away. He returned to Finland, and his 
 health appeared to be restored. In June, 1893, he came to Canada 
 and was employed as a skilled mechanic in the engineering laboratory 
 at McGill University. He remained apparently in perfect health un- 
 til January of this yeai", when the cough returned, and all the old 
 symptoms — night sweats, loss of flesh and bodily weakness. On 
 March 20th there was an haemoptysis, about half a gallon of blood 
 being lost ; on the 28rd and 24th there were two severe hsemorrhages 
 From this time until April 18th, he being now a patient under Dr. 
 Stewart at the Royal Victoria Hospital, there was constant slight ex- 
 pectoration of blood with but little cough. On this last date severe 
 haemorrhages recurred, in all about a quart of blood being lost. Fol- 
 lowing upon this there was rapid loss of power, and the patient died 
 ten days later. 
 
 At the autopsy it was noticeable that there was no indication of 
 tuberculosis other than in the lungs, save for some quite recent and 
 minute ulcers in the jejunum and ileum. The lungs, however, pre- 
 sented very characteristic tubercular changes. There were firm 
 adhesions at both apices — so firm that on the left side the knife had 
 to be employed to separate them. Both apices showed old tubercu- 
 losis in the shape of well-encapsuled caseous masses and small con- 
 tracted cavities with dense envelopes and smooth but uneven internal 
 aspect. In addition, the upper two-thirds of the uppermost lobe of 
 the right lung and the upper half of the upper lobe of the left lung 
 were greatly consolidated, contractetl and presenting very well-marked 
 
 * Read before the Montreal Medioo-Cairurgical Sooietyi June 28th, 1895. * 
 
:\, 
 
 interstitial fil)roi<l change. Here evidently in both apices were to be 
 seen the results of treatment in 1890 91 — abundant signs of arrest of 
 the tubercular process. It was, however, clear that the process had 
 only been arrested — for the rest of the lung tissue was the seat of 
 nuniei'ous rather large miliary tubercles, which from their distribution 
 were broncho-pneuuionic — distributed along the; course of sundry 
 la-onchi. Injecting the pulmonary artei-ii's with water led to the escape 
 of the Huid through one of the main bronchi or the ujjper lobe of the 
 left lung. Following this up a long cavity was entered intcj containing 
 a globular laminated clot over what was the seat of rupture of the 
 artery. Some difficulty was experienced in finding the actual lesion, the 
 artery filled with thrond)Us escaping detection for some little time. 
 
 Bringing all these facts together it would .seem most probable that 
 the .second attack of advancing tul)erculosis was not a .second infec- 
 tion, or infection anew, but originated in the old arrested foci of the 
 disease, where the process lighting up again in the walls of one of the 
 old incom pletely contracted cavities had been followed by dissemina- 
 tion of the virus throughout the air passages, and had prepared the 
 way for rupture of arteries passing along the walls of the cavity. 
 
 The recent tubercles wex'e most numerous in the neighbourhood of 
 the old tubercular disturbance. It was interesting to note that upon 
 microscopical examination they were found to be surrounded with 
 very little pneumonic disturbance ; they were not of the rapidly 
 advancing type, but on the contrary were in genei'al fibroid, with dis- 
 tinct caseous centres and large outer zones of developing fibi'ous 
 ti.ssue. This would indicate one of two conditions — either the bacilli 
 causing the lesions were relatively attenuated, or the reaction on 
 the part of the tissues was relatively considerable. We should be 
 prepared to accept the latter altei'native if, as is not impo.s.sible, the 
 beneficial effects of long-continued tuberculin infection last for a 
 considerable period, but I icnow of no case in which this has 
 been demonsti'ated for periods longer than a few months. It should 
 here be added that the micro.scopical ajjpearances of sections of the 
 lungs were in harmony with the clinical history and with the general 
 results of the autopsy. The pectoi'al antl other muscles were fairly 
 well-developed and of good coloui" ; there was a fair amount of sub- 
 cutaneous fat. 
 
 But perhaps the most interesting feature of the specimen was the 
 evidence it gave of the extent of pulmonary tuberculosis capable of 
 being arrested by Koch's treatment. Both apices had clearly been 
 the seat of extensive tuberculous change. There was extensive tuber- 
 cular pleurisy, much caseation, and the development of numerous (five 
 or .six) cavities in the two apices. The treatment that the patient had 
 undergone during his ycfir's stay in the Berlin hospital had succeeded 
 in bringing the lesion to a standstill during four years. 
 
 ,.V