possible in hospitals, whereas in schools one must be contented with the cutaneous trials, which can be made without any inconvenience to the children. In this way one could take note in the different towns of the percentage of infection, and the ages at which such infections occur, and, consequently, could form conclusions as to hygiene Some Clinical Observations on the v. Pirquet Reaction in Children. BY DR. HENRY HEIMAN, New York. Fifty-seven children were vaccinated according to the v. Pirquet method at the Mt. Sinai Hospital in the Children's Service of Dr. Koplik and myself. Twenty children showed a positive reaction, and 37 a negative one. The 20 children that gave a positive reaction suffered from the following morbid conditions: Tuberculous adenitis, 3 cases; tuberculous meningitis, 2; tuberculous peritonitis, 2; solitary tubercle of the brain, 1; pulmonary tuberculosis (probable), 2; pleurisy with effusion, 4; broncho-pneumonia, 1; glioma of retina and multiple dactylitis, 1; amaurotic family idiocy, 1; rickets, 1; intestinal intoxication, I, and sarcoma of the kidney, 1. The 37 negative cases included the following diseases: Amblyopia congenital, 1; chronic arthritis, 1; syphilitic arthritis, 2; intestinal auto-intoxication. 1; chronic bronchitis, 3; bronchopneumonia, 3; enterocolitis, 2; empyema, 3; pulmonary gangrene, 1; amaurotic family idiocy, 1; congenital idiocy, 1; marasmus, 1; tuberculous meningitis, 8; acute nephritis, 1; pleurisy with effusion, 1; dry pleurisy, 1; lobar pneumonia, 1; pseudoleukemia (v. Jaksch), 1; pyelitis, 1; syphilis, 1; cerebellar tumor, 1, and typhoid, 1. Special attention is to be drawn to the cases of tuberculous meningitis. Eighty per cent (8 out of 10) gave a negative reaction. This is probably due to the fact that the vaccination was performed during the terminal stage of the disease, when the absence of antibodies or bacteriolysins prevented the occurrence of a positive reaction. An Aid to the Diagnosis of Tuberculosis in Infancy and Childhood by Means of the Cutaneous Inoculation of Diluted Tuber. culin (Pirquet Method). BY DR. LOUIS FISCHER, The diagnosis of infantile tuberculosis is frequently obscure. Associated with the acute infectious diseases, or as a sequel to them, the diagnosis is difficult to make. Syphilitic manifestations frequently present clinical pictures greatly resem bling tuberculosis. The inoculation of the cutaneous or von Pirquet method has proved an aid in strengthening the suspicion of latent tuberculosis. The ocular reaction of Calmette has been attended by severe ocular complications, both in this country and abroad. No such danger has been recorded with the von Pirquet method. After scarifying three small areas of skin, two of which are inoculated and a third left as a control, there should be found in twenty-four hours, or at the latest forty-eight hours, an elevated papule, about ten millimeters in width, which may be called a positive reaction. There is no rise of temperature nor chill, and no general systemic disturbance. No unpleasant after-effects have been recorded. If no reaction takes place after the first inoculation, a second inoculation may be given several weeks later without any danger or ill-effects. The reaction, if positive, will be visible in very young infants in about five to seven days. In older children it will sometimes remain several weeks. The reaction was positive in tubercular meningitis, tubercular coxitis, as well as in pulmonary tuberculosis, an·l in a tubercular osteomyelitis. On the Ophthalmo-Reaction to Tuberculin. BY DR. FERNAND ARLOING, of Lyons. In this communication the author has confined himself to the report of persona! clinical and experimental facts. From the clinical standpoint, he was, in collaboration with M. Dumarest, one of the first to call attention to the thermic reaction and the general phenomena that follow the instillation of tuberculin into the eye. In some cases he has seen the conjunctival reaction accompanied at the time by more or less marked dilatation of the pupil; much more rarely myosis was observed under the same circumstances. In his earliest researches he also observed, without at the time offering any explanation, a phenomenon which he regarded as a kind of local anaphylaxis, namely, that a patient in whom the ophthalmo-reaction was negative at the first instillation may react to a second, or even a third test. With regard to the interaction of tuberculin treatment and the ocular test, it appears that a previous ocular reaction is frequently revived by the subcutaneous injection of medicinal doses of tuberculin; but this does not constitute a contraindication to the employment of the two procedures in the same subject. It also appears that a previous impregnation of a patient with tuberculin for therapeutic purposes has a very variable effect on a subsequent ocular test. The ocular reaction is not free from danger. It is occasionally accompanied by ocular complications, such as prolonged conjunctivitis and ulcerations of the cornea. The previous instillation of 1 to 3,000 adrenalin is capable of counteracting certain excessively violent or prolonged reactions. Fernand Arloing, in the second part of his communication, gives the result of his experimental researches on the pathogenic mechanism of the ocular reaction to tuberculin: Non-tuberculous rabbits impregnated with various microbic poisons (tuberculin, typhoid, staphylococcus and diphtheritic toxins) gave positive ocular 1eactions. The rabbit was, in fact, more actively sensitized by the typhoid toxin than by tuberculin, or at least to an equal degree. In the same manner, horses used for the production of antidiptheritic and antitetanic serum reacted positively under certain conditions. These experimental facts, which show that a positive ocular reaction to tuberculin may be obtained in non-tuberculous subjects, accord with the clinical cases of positive reactions in the non-tuberculous suffering from typhoid, staphylococcic, syphilitic, or some other infection. On the strength of these two series of observations, Fernand Arloing believes that the ocular reaction to tuberculin, which represents a local vasomotor reaction, may occur whenever the vasomotor centers of an individual are in a condition to react by vaso-dilatation by reason of their being impregnated with a microbic toxin. Hence the ocular reaction to tuberculin occurs in individuals who are in a state of intoxication, i. e., whose organism is impregnated and sensitized by a toxin of any kind. The ocular reaction is therefore not absolutely specific from a theoretical sense, but has merely a relative value. In the third portion of his paper the author takes up a comparative study of the ocular reaction and the bacterial serum-agglutination test. These two reactions are often found in the same individual; while on the other hand, one may be present when the other is absent; or, finally, one may be more intense than the other. The study of the symptoms and of the clinical course in these cases of contradictory reactions has led the author to attribute a different value to the ophthalmoreaction from that which belongs to the serum-reaction. The ophthalmo-reaction indicates that the organism is intoxicated with tuberculin; the serum-reaction on the other hand, like agglutination reactions, is generally recognized as showing a defensive reaction of the economy, while the intensity of the reaction measures the degree of immunity of the individual to the tubercle bacillus. It appears, therefore, that in practice, at a certain point in the evolution of a tuberculous disease, a positive ophthalmo-reaction with a negative serum-reaction indicates a doubtful prognosis; while the contrary would indicate a favorable outcome. When the two phenomena are practically equal in intensity, it shows that the organism is in a state of indifferent equilibrium, and that the disease may either end in recovery or the patient succumb to unfavorable influences. Such is the significance which Fernand Arloing attributes to the ocular reaction, but no positive conclusion can be drawn in such a complicated question. To sum up, the ocular reaction is a convenient and easily available diagnostic procedure; it sometimes fails in patients who are certainly tuberculous; and on the other hand may occur in subjects not suffering from a bacterial infection. Its diagnostic value, although quite considerable in practice is, nevertheless, not absolute. The test is not always harmless. It has not proved itself superior to the bacillary serum-agglutination, which has the advantage over the ocular test of being absolutely harmless, more constant, and more delicate. Finally, the ophthalmoreaction is an indication rather of the degree of intoxication of the organism, while the serum-reaction reveals the forces available for defense against the infection. Contribution to the Question of Percutaneous Infection. We know that Prof. Krehl, Heidelberg, discussing the furuncles produced by Garré through percutaneous application of staphylococci and the positive percutaneous infection experiments with guinea-pigs of the Austrian Pest Committee in his "Patho-Physiology" (1906), explains these successful infections through the apparently intact skin by considering it probable that the inunctions produced slight injuries of the surface of the body and of the epithelium of the skin-glands. Prof. Cornet also emphasizes in his book "Die Tuberculose" (1907), that the successful issue of the cutaneous infection experiments (sputum, etc., was rubbed into the skin of the cheeks, nose, etc.), depended entirely upon whether superficial injuries of greater or less extent preceded the infection. The experiments of C. Fraenkel, "The Activity of Tubercle Bacilli Through the Intact Skin, Hygienische Rundschau” (1907), again called our attention to the question, inasmuch as this investigator succeeded to produce general tuberculosis in guinea-pigs by treating them through the intact skin percutaneously. I performed my series of experiments with this mode of infection in the laboratory of the Königin Louise Sanatorium; I employed a type of animal less susceptible for tuberculosis, the rabbit. In this preliminary communication I can report only concerning the result with nine rabbits. The skin of the abdomen of these nine rabbits was first carefully shaven; fortycight to seventy-two hours afterwards portions of a well-tested, virulent, pure culture of the human tubercle bacillus were rubbed into this area with the greatest care; the procedure was carried out with such gentleness that even the slightest traumatic injuries of the skin and of the walls of the canals going into its depth (the hair follicles, sebaceous gland ducts) were avoided. One of the animals died after two and one-half months, but without development of tuberculosis. The other eight animals continued to live; four were killed after three months, and four after four months. Neither local nor regional changes could be demonstrated in any of them. Nor could tuberculosis be demonstrated in any of the internal organs. Neither did the kidneys nor lungs, which in rabbits are predisposed to the disease to an extent, show any changes. My experiments, which are not by any means finished, lead to the following conclusion thus far: If percutaneous infection is at all possible it certainly is the most unfavorable mode of infection for the tubercle bacillus; in the case of the rabbit particularly so, as it is decideddly refractory to the disease. Transcutaneous Inoculation of Tuberculosis. BY DOCTORS J. COURMONT AND LESIEUR, of Lyons. From a large number of experiments we draw the following conclusions: (A) The Facts: 1. In case of the guinea-pig, the calf and the rabbit, the skin, although apparently intact or deprived of the hair, readily allows the tubercle bacillus to pass through under certain conditions. 2. The principle conditions are the following: The bacillus must be sufficiently virulent; it must not be enclosed in sputum, in fecal matter or in (tuberculous) lesions; but even under these conditions the experiment may be successful, especially with sputum containing bacilli. 3. If inoculation is positive the skin reacts in one of three ways: In about onethird of the cases it shows no trace whatever of the passage of the bacilli-the skin has not been injured; in another third it presents merely a little induration or insignificant scabs; these lesions, however, are histologically tuberculous. Finally, in another third of the cases, warty tubercles, although very small and discrete, are observed. 4. In the case of the guinea-pig and the calf the neighboring glands become tuberculous even in the absence of any cutaneous lesion. In the rabbit the lymphatic system escapes, whether there be a cutaneous lesion or not. This was to have been foreseen. 5. General tuberculosis develops most frequently in the rabbit and in the guineapig if the bacilli are sufficiently virulent; but in any event it is much slower than after subcutaneous inoculation., 6. In the rabbit the local as well as the general lesions show a marked tendency to cicatrization. 7. In the guinea-pig, when inoculated on the inner aspect of the thigh, the inguinal glands are more severely involved than the crural glands; they become enormous, and very frequently suppurate. This constitutes a slight difference from what is observed in tuberculosis following subcutaneous inoculation. In addition, the glands on the opposite side become involved more quickly and more often than after subcutaneous inoculation. The glandular lesions from subcutaneous tuberculosis do not coincide accurately with the lesions observed in the transcutaneous form. (B) Observations: 1. The skin itself, although apparently intact, is far from offering an impassable barrier to the passage of the tubercle bacillus. (This is probably due to the hair.) Hence this portal of entry must not be neglected in medical and veterinary practice. Many tuberculous infections may result from a transcutaneous inoculation (abrasions, epilations, minute lesions, etc.). This principle should be utilized in prophylaxis. 2. Since the bacilli are capable of passing through the skin without leaving any trace, the absence of a cutaneous lesion is no argument against this mode of invasion. 3. These observations furnish additional proof how variable and unexpected may be the origin of visceral, especially pulmonary tuberculosis. In addition to the pulmonary and the more frequent intestinal origin, there is a possibility of entrance through mucous membranes and skin. A rabbit presenting pulmonary tuberculosis of transcutaneous origin without either cutaneous or lymphatic lesions furnishes an example of tuberculosis originating at a point far removed from the respiratory tract through a port of entry which it is impossible to discover. This is the most important deduction from our experiments. 4. By means of transcutaneous inoculation one can produce experimentally in man either warty cutaneous tuberculosis or the human scrofulo-tuberculous lesions (inoculation with bacilli of low virulence without general infection). 5. This method can not be substituted for subcutaneous or peritoneal inoculation, either for purposes of diagnosis or for inoculating organs in series. Conclusions from 1087 Conjunctival Tuberculin Tests by a Uniform Method. BY DR. EDWARD R. BALDWIN, Saranac Laboratory, Saranac Lake, N. Y. The author has collected reports from forty clinicians and sanatorium physicians to whom the same tuberculin was sent, together with directions to follow a uniformi method of testing and of recording the results. Two solutions of 3% and 2%, respectively, of dried, purified old tuberculin were issued, accompanied by an eyedropper graduated to 0.25 c.c. Contraindications to the test were suggested where eye disease was present. Repetition only in the opposite eye was advised with the 2% solution in case the weaker solution failed to react. The reports comprised 887 individuals, in 190 of whom a second instillation was made in the opposite eye, and 10 in the same eye. There were 310 cases of tuberculosis in some form, including 24 healed pulmonary cases. Of all these, 218, or 70%, reacted positively, the larger proportion (79.2%) being among the secondstage cases. Of 265 suspected tuberculous subjects, 35.9% reacted, and of 127 patients suffering with other diseases, 14.1% reacted. Finally, of 185 supposedly healthy individuals, 18.3% reacted. Of the total number, 15.2% were children under 15 years. Altogether there were 24 severe reactions reported, 10 of which persisted beyond five days. One instance of keratitis followed in a scrofulous patient. Eighteen per cent of the second instillations in the opposite eye produced reactions, and 100% of those in the same eye. The cutaneous test was subsequently applied in 52, and the subcutaneous in Sy cases, followed by a considerable increase in percentage of positive reactions in the suspected class. The conclusions are: I. The conjunctival tuberculin test performed with weak solutions by a single instillation has some value in confirming the presence of tuberculosis in the early stages. 2. It has little value when the symptoms of tuberculosis lead only to a suspicion. 3. Its value in distinguishing "active latent" from healed tuberculosis in apparently healthy persons has not yet been determined. |