252
THE INDIAN MEDICAL GAZETTE
Current The
Topics
Tuberculosis Problem among Nurses in a Tuberculosis Sanatorium By ERNEST S. MARIETTE, m.d., fa.c.p. (Abstracted from the Tubercle, Vol. XVIII, December 1936, p. 103)
Tuberculosis is an infectious disease that is spread by contact with the patient's sputum rather than by contact with the patient himself and therefore the danger of infection diminishes with the effectiveness of the measures used in the disposal of sputum, etc. Owing to the more rigid observance of the measures of disposal of sputum in a sanatorium, the chances of infection here are less than elsewhere. Nurses when caring for tuberculosis patients for a long time are sure to get the infection. Afterwards they will behave according to: (1) whether they are tuberculin-positive or negative, (2) the length of time of exposure, (3) the connections from which the nurses are drawn, and (4) the nature and conditioii of the hospital. Only 2 to 10 per cent of those infected with tubercle bacilli fall ill. A tuberculin-positive nurse is less likely to develop serious and fatal tuberculosis as a result of caring for tuberculous patients than the tuberculinnegative nurse, though some believe that primary infection is benign but it makes the individual hypersusceptible to reinfection. According to laboratory experimentation, a mild infection increases the animal's natural resistance to exogenous reinfection when it occurs not sooner than four to six weeks after the first infection, i.e., after allergy has developed. In allergic animals, though the reaction becomes more acute at first after reinfection, it gradually subsides and becomes localized; of course, the smaller the dose of reinfection the better is the chance. In this investigation all nurses were x-rayed at the beginning of their employment and yearly thereafter but later on they were z-rayed every three months. There were three" groups of nurses: (1) supervising nurses, (2) general duty nurses, and (3) student nurses. The results of z-ray examinations of the above three groups of nurses are as follows:? Group 1. Eighteen (16.5 per cent) had the adult type of tuberculosis at the beginning and another seven (8.3 per cent) subsequently developed the active, adult type of tuberculosis; there were two deaths in this group. Group 2. Thirty-six (8.9 per cent) had the adult type of tuberculosis at the beginning and another 25 (6.2 per cent) subsequently developed the adult type of tuberculosis. This was considered inactive in eight, or 2 per cent, and active in 17, or 4.2 per cent, of the entire group; there were six deaths in this group. Group 3. Sixty-eight (6.4 per cent) had the adult type of tuberculosis at the beginning and another 53 (4.9 per cent) subsequently developed the adult type of tuberculosis. This was considered inactive in 27 or 2.5 per cent and active in 26 or 2.4 per cent of the entire group; there were four deaths. Taking the three as one group 122 or 7.7 per cent had the adult type of tuberculosis at the beginning and another 85 or 5.4 per cent subsequently developed the adult type of tuberculosis which was considered inactive in 35 or 2.3 per cent and active in 50 or 3.1 per cent. There were 12 deaths, five in the initial tuberculosis group and seven in those who developed tuberculosis subsequently. Thus, we see that 3.1 per cent of the nurses developed tuberculosis in the sanatorium. To minimize this the nurses should be
[April,
1937
instructed liow to protect themselves and the patients should be instructed to be careful about spitting, coughing and sneezing. The nurses should be x-rayed at the beginning and at regular intervals thereafter. Their working hours should be reduced and only tuberculinpositive nurses should be taken in, and if tuberculinnegative nurses are taken in they should be vaccinated with B. C. G. N. G. M.
Determination of the Artificial Pneumothorax
Containing
a
Small
Quantity
of Gas
By E. SCHILL, mjj. (Abstracted from the Tubercle, Vol. XVII, September 1936, p. 549) To detect the presence of a small quantity of gas .'H the pleural cavity during the course of collapse therapy x-rays are usually used, but they are not always available, their frequent use is not safe, and, when the pleura is free from any adhesion, they may fail t? demonstrate a small quantity of gas. The simple method of percussion over the areas of: (1) the costophrenic sinus, (2) the absolute cardiac dullness, and (3) Kronig's area, will help in the matter. Instead of percussing over the Kronig's area Frisch recommends percussion of the apex of the lungs, as given below. Draw a horizontal line between the spinous processes of the first and second dorsal vertebra} and mark on it two points, one on each side, three-finger breadths from the mid-line. Join these two points to a point marking the lowest limit of the scalp in the mid-line. Light percussion on these connecting lines from mid-line outwards enables one to detect a limit of resonance nearer the spine, since the air occupying the cone of the apical pleura is capable of greater expansion. The lower limit of resonance is on the affected side. In left-sided pneumothorax a diminution of absolute cardiac dullness may be elicited. Gas disappears firs'' from the costo-phrenic sinus, though adhesions of the two layers of pleura make this sign useless, moreover in a bilateral pneumothorax no comparison can be made. The patient lying on his side with the affected side uppermost often helps. Begin percussion a little above the lower limit of resonance and go downward^ till dullness is reached, after percussing some time at this point resonance will reappear, go down till again dullness reappears and in this way in a case of pneumothorax you can reach the last rib. N. G. M.
A
Study of the Pathology Pulmonary Tuberculosis
Experimental
of in the Rabbit
By E. M. MEDLAR and K. T. SASANO
(Abstracted from the American Review of Tuberculosa> Vol. XXXIV, October 1936, p. 456) The seed, the soil and the lapse of time after the seed and soil are brought together are the three greatest important factors in any infectious disease, whethei naturally contracted or experimentally produced. the study of the problem of human pulmonary tuberculosis all these factors are beyond control, whereas in the field of animal experimentation they can be^ least partially regulated. So a thorough of the pathology of pulmonary tuberculosis is n? possible from uncontrolled and uncontrollable hums material. But if the important pathological processes of pulmonary lesions in man, such as, localization'
understanding
progression, cavitation, bronchogenic spreads an retrogression, can be duplicated in the experiments
253
CURRENT TOPICS
April, 1937]
Intensity Frequency of
of Tuberculin
animal then one should be able to understand more its human pathology. In this article the authors presented the type of , lesions obtained in the rabbit which simulate tne mai Pathological features of tuberculous lesions in tne human lung. The authors used intravenously in rabbits three strains of tubercle bacilli of three grades ot
The
medium and high?the three varians o single-strain B. C. G. and also investigated the effect ?f reinfection with bacilli of high virulence in animals vaccinated with both living bacilli of low virulence and bacilli of high virulence. The results obtame y them were as follows:?
(Abstracted from the American Review of Tuberculosis, Vol. XXXIV, September 1936, p. 425)
clearly
virulence?low,
a
Jelled
(o) Bacilli of low virulence?10 to 50 mg.very arely killed the animals; marked pulmonary disease
^eloped;
the majority survived for three years. Ine process in majority resolved within a yeai Qd this occurred more rapidly in the anterior and antral portions of than in the posterior and dorsal Portions and where lung the lesions persisted for three years of cavitation or bronchogenic spreads was
Pathological
fQy^jidence
(&) Bacilli of nig.:?death high virulence?1 curred within two months. 0.01 mg.:?death ensued s*x months. Lesions progressed evenly in ah hr? t0^ h'ng. Suppurating and ulcerating lesions and ?genic spreads most common?no gross cavita
the the
sfthat
Hot cavitA-
corn-
natural inhalation route of infection
i?
Pr^me importance in localizing the progressing havoaLlnS tuberculous lesions as all types of lesions anim ,een obtained by the intravenous inoculation in that the allergic condition of the tissue as a inf. primary infection with the subsequent retuhfr i cann?t determine the localization of cavita ting cul?us lesion as similar lesions (the so-called adult huTv, type) have been obtained in animals from first bacilli of every grade of virulence; and that u?ns, hl8her portions of the lung field appear to be tiono ,nt to tuberculous infection than the lower porOccnr^j m m?st progressing cavitatmg lesions W ecj these animals in the uppermost part ?f .the the animal is in the normal or upright Whef?er n' ,The authors concluded that a certain ba ance the resigtance of the host and the virulence of Parasite must be established "ther the or cavit subsequent infection to obtain localizing lesi?us and the so-called adult type of human tuberculosis is due in large part to the lode?n ai7 the tubercle bacilli in the. less resistant upper gf0f ?f the lung parenchyma. S. R. G.
rSIs;, ,.
Demonstrable Lesions
Reaction and Tuberculous
By C. W. WELLS and H. H. SMITH
The variation in the degree of reaction to the tuberculin test has long been observed. With the advent of intracutaneous tuberculin test, the extraneous factors which are operative with the cutaneous test being largely removed, sufficient interests have been aroused in this varying intensity of the reaction. Investigations have been conducted by various workers to interpret the meaning or importance of this variation in intensity and to correlate it with the degree of infection. The first study of this problem was made by Roemer and Joseph in the guinea-pig, using high dilutions of tuberculin, and they reported a definite correlation between the degree of infection and the intensity of tuberculin test. In recent years investigations were made to associate the more pronounced reactions to intracutaneous tuberculin test with active tuberculosis, on a quantitative basis, and to establish a critical threshold in the dilution of tuberculin which would in the majority of more or less definitely exclude negative reactors the possibility of active tuberculosis. The present authors conducted a tuberculosis survey in Kingston, Jamaica, from 1931 to 1934 in which 4,906 individuals (a random sample of the population) were tuberculin tested and received chest x-ray examinations. They found that in the 0 to 9 years age group tho per cent presenting lesions ranged from 0.5 per cent for negative reactors to 1 mg. to 14.1 per cent in two-, three- and four-plus reactors to 0.01 mg., in the 10 to 14 years age group, no lesion in negative reactor.-; and 14.2 per cent of lesions in the above class of positive reactors and for all ages over 15 years, 5.5 per cent of lesions in negative reactors and 12.1 per cent in the
positive
reactors.
The average percentages showing lesions are 1.6 in negative reactors to 1 mg., 4.0 in positive reactors to 1 mg., 8.6 in one-plus positive reactore to 0.01 mg., and 12.4 in two-, three- and four-plus positive reactors to 0.01 mg. Thus an increase in the percentage of demonstrable pulmonary lesions, both active and latent, was found by them with an increase in the severity of the tuberculin reaction. The results are shown to be comparable to those of Opie and his associates (1926) for individuals in the school age^ groups. It was also speciallv mentioned that a negative reaction does not absolutely exclude active or far advanced tuberculosis Opie and as pointed out by Rich and McCordock. others found 17.3 per cent while the authors found 1.6 per cent of lesions in the group of negative reactors ?two of the individuals of this group in the authors' series were suffering from far-advanced active disease. S. R. G. _
_
Posfti bSl ayeett
??!age Puh^tmg
UniS
Contact
as
a
Factor in the Transmission of Tuberculosis
By CHARLES SCHUMAN (Abstracted from the American Review of Tuberculosis, Vol. XXXIV, July 1936, p. 85) In this study an attempt was made to determine the relative importance of different types of exposure in the dissemination of tuberculosis with a view to its control. Three thousand and fifty-seven patients of a tuberculosis clinic, of whom 1,802 were adults and 1,255 children (up to 16 years of age), were the subjects for this survey. According to the history and sputum examination report of the sources of contact the types of exposure were differentiated under five categories: (1) positive sputum, (2) negative sputum, (3) unknown
*
THE INDIAN MEDICAL GAZETTE
254 sputum, (4) deceased
[April,
1937
cases of tuberculosis, and (5) no tuberculosis or non-tuberculous cases. The of tuberculosis in children contacts was made diagnosis by history and z-ray. No attempt was made to differentiate between so-called childhood tuberculosis and the adult type. The evidences of tuberculous infection in these children were determined by the intracutaneous Mantoux test, done in the usual manner, with 0.1 mg. OT. The degree of reaction to Mantoux test was also noted from the size of the weal and the swelling of the arm and interpreted as 1 +, 2 +, 3 + or 4 + There was a relatively large number (730) of definite cases of tuberculosis among adult contacts as compared to the striking small number (47) in children. Of these 33.5 per cent in the case of adults were in contact with known tuberculosis patients, in contrast with *80.9 per cent in the case of children. According to the author this latter high incidence is apparent as, in the case of a child, the family circle comprises almost the entire extent of his contacts. The incidence of tuberculous disease in adult contacts according to types of exposure was 23.9 per cent with 'positive sputum', 13.0 per cent with 'negative sputum', 17.3 per cent (which is almost an arithmetical ' mean between the previous two figures) with unknown ' deceased cases of tuberper cent with sputum36.7 ' culosis and 68.0 per cent with 'non-tuberculous'. In the case of child contacts 7.5 per cent of those exposed to positive sputum, 0.5 per cent of negative sputum group, 4.6 per cent of unknown sputum group, 1.0 per cent of deceased tuberculous group and 5.5 of nontuberculous group contracted the disease. Regarding Mantoux reactions 65.6 per cent were positive under ' negative positive sputum, 27.9 per cent under cent under unknown 60.0 sputum, 70.9 per sputum', per cent under deceased tuberculosis and 40.2 per cent ' under non-tuberculous group'. Regarding the intenof reaction the 2 + Mantoux reading was the most sity common and the 4 -f- reading the least common in all the groups. The largest number (17) of children exposed to positive sputum developed a 4 + reaction. Thus children exposed to positive-sputum cases show a high incidence to both tuberculous disease and tuberinfection. The intensity of the Mantoux culous reaction depends largely on the time interval between the period of exposure to positive sputum and the date of the test; the more recent the exposure, the greater the reaction to tuberculin. The author concluded that contact to positive sputum is the greatest single factor in the spread of the disease, that children exposed to positive sputum show an increased degree of sensitivity to tuberculin, that pulmonary tuberculosis is not very common in infant and children, and that the control of positive sputum is the most effective means of limiting the spread of the disease. S. R. G.
The author also added that out of 43 female domestics tested, 40 were Mantoux-positive at the beginning and all remained free from tuberculosis. Of the three negatives, one could not be followed up, one remained negative after the third test ten months later and the other was positive on second test a month later and all remained quite fit. Of the male outdoor staff only six were tuberculin tested. Five were positive at the beginning and the other was negative and remained so on third test after lour months. All these appeared fit at the time of report. N. G. M.
The Intra-dermal Tuberculin Test in Nurses
By C. KERESZTURI
known
.
_
By PETER W. EDWARDS, m.b., B.ch. (Edin.) (Abstracted from the Tubercle, Vol. XVIII, December 1936, p. 101) This study gives a record of a short series of intra-
dermal tuberculin test
Fifty-four
were
on nurses.
Mantoux-positive
on
joining the staff;
of these one became tuberculous in six months. Eleven were Mantoux-negative on joining the staff. Of these two left after the first test; three remained negative: one on third test after four months, one on third test after three months, one on second^ test after two months and all remained quite fit; six became positive: one on third test after three months, one on second test after eight months, two on second test after ten months (all these four were fit up to the time of report), one in the next month and the remaining one on third test after two months (these last two became tuberculous within two and three months,
respectively).
so
Results of the Sanocrysin Treatment of Tuberculosis By F. I. TERRILL (Abstracted from the American Review of Tuberculosis, Vol. XXXIV, July 1936, p. 156) Forty-one cases, the majority (30) of which were far advanced and the rest moderately advanced, showing no improvement under the usual care, were treated with the soluble gold-sodium-thiosulphate intravenously. The dose was 10 mg. to start with and was gradually increased to 250 mg. which was maintained for from five to eight injections before a rapid increase to 500 mg. was given. The repetition of the last dose depended upon the tolerance of the patient. The injections were given at weekly intervals unless there was some reason for a longer intermission. Weekly urine analyses were made during the course of treatment and for at least six weeks following its conclusionOnly a slight and transient albuminuria occurred iQ two cases necessitating only an increase in the timeintervals. After 18 months of treatment the results were quite conclusive as to the value of the drug j11 selected cases. Clinically improved?18, markedly results improved?10, not improved?10, and adverse 3. A gain in weight of over 5 lb. occurred in 16 cases, roentgenogram improvement in 15 cases, a diminished amount of sputum in 19 cases, and the sputum became negative for tubercle bacilli in 10 cases. Conclusions: intravenous gold is of value in the treatment of tuberculosis and has a definite place
the armament of a phthisiotherapist. It is applicable in selected cases only and should not be substituted for collapse therapy, even for a trial. The early bad result" of this treatment following its introduction by Mollgaaro in 1928 are thought to be caused by the injection 01 too large a dose (the customary maximum dose then
being
1
gm.).
S. R. G.
The Use of B. C. G. Vaccine Against Tuberculosis in Children and \V. H. PARK
(Abstracted from the American Review of Tuberculosas> Vol. XXXIV, October 1936, p. 437) This study was made under three heads: (1) Is the B. C. G. vaccine harmless? The vaccine was proved to be harmless by the following observations : (a) Four hundred to five hundred guinea-P1?9' rabbits and monkeys were injected with large quantities of living organisms and only one developed a moderate tuberculosis which might have been due to an accidental laboratory infection. (b) One hundred and seventy-five young infants were vaccinated with B. C. G. but not exposed to tuberculosis after vaccination. All did as well as the controls with the exception bf one case who developed clinica tuberculosis but whose autopsy was refused and hence the diagnosis not settled.
CURRENT TOPICS
April, 1937] .
(c)
Five hundred and fifteen children
cinated with
were
B. C. G.
Tuberculosis in Hospital Nurses
vac-
and exposed a human tuberculous source. Four of them died of tuberculosis and the rest did well as the controls. the organs of three out of the four dead cases, the human and not the bovine type of tubercle bacilli Was recovered. W) In 27 out of 31 instances of cold abscesses occurring at the site of vaccination, B. C. G. bacilli were recovered from the aspirated pus. In none of the instances could the bacilli be shown to have increased in virulence by stay in the human body for periods /??e to ten months. (2) Is the B. C. G. culture effective in the prevention of tuberculosis? To the immunizing effect the B. C. G. vaccinationgauge the tuberculosis death rate among the comparable groups of B. C. G. vaccinated cases and the controls was studied. The children known from birth were vaccinated by mouth with C. G. vaccines within the first ten days of life and nose that were not known from birth, had no evidence ?f tuberculosis and had negative initial Mantoux test, )v'ere parenterally vaccinated with B. C. G. vaccine untracutaneously or subcutaneously). Both these groups were studied with their corresponding control groups for periods up to eight years. There were 300 t0 400 cases in each group. The total number studied 1.445. It was also noted whether these children ^Vas vere exposed to a case of tuberculosis with positrve Put urn or to one with negative sputum or not exposed all to tuberculosis. Among the control children, nown from the tuberculosis death rate was ; birth, ound to be more than twice as high as among the rally-vaccinated ones, while among those not known ?m birth it was about four times as high as among the Parenterally vaccinated babies. Regarding non-tubercuious mortality which was 5.2 per cent in the total oKmjP' *t was lowest in the parenterally vaccinated (2.8 per cent). In all the groups compared, the ^nildren ?Posure to tuberculosis was remarkably similar, only "ne-third to half of all cases in each group were exposed o open tuberculosis; about cne-third to closed tuberone-third not exposed at all trw +S1l' an
THE INDIAN MEDICAL GAZETTE
Current The
Topics
Tuberculosis Problem among Nurses in a Tuberculosis Sanatorium By ERNEST S. MARIETTE, m.d., fa.c.p. (Abstracted from the Tubercle, Vol. XVIII, December 1936, p. 103)
Tuberculosis is an infectious disease that is spread by contact with the patient's sputum rather than by contact with the patient himself and therefore the danger of infection diminishes with the effectiveness of the measures used in the disposal of sputum, etc. Owing to the more rigid observance of the measures of disposal of sputum in a sanatorium, the chances of infection here are less than elsewhere. Nurses when caring for tuberculosis patients for a long time are sure to get the infection. Afterwards they will behave according to: (1) whether they are tuberculin-positive or negative, (2) the length of time of exposure, (3) the connections from which the nurses are drawn, and (4) the nature and conditioii of the hospital. Only 2 to 10 per cent of those infected with tubercle bacilli fall ill. A tuberculin-positive nurse is less likely to develop serious and fatal tuberculosis as a result of caring for tuberculous patients than the tuberculinnegative nurse, though some believe that primary infection is benign but it makes the individual hypersusceptible to reinfection. According to laboratory experimentation, a mild infection increases the animal's natural resistance to exogenous reinfection when it occurs not sooner than four to six weeks after the first infection, i.e., after allergy has developed. In allergic animals, though the reaction becomes more acute at first after reinfection, it gradually subsides and becomes localized; of course, the smaller the dose of reinfection the better is the chance. In this investigation all nurses were x-rayed at the beginning of their employment and yearly thereafter but later on they were z-rayed every three months. There were three" groups of nurses: (1) supervising nurses, (2) general duty nurses, and (3) student nurses. The results of z-ray examinations of the above three groups of nurses are as follows:? Group 1. Eighteen (16.5 per cent) had the adult type of tuberculosis at the beginning and another seven (8.3 per cent) subsequently developed the active, adult type of tuberculosis; there were two deaths in this group. Group 2. Thirty-six (8.9 per cent) had the adult type of tuberculosis at the beginning and another 25 (6.2 per cent) subsequently developed the adult type of tuberculosis. This was considered inactive in eight, or 2 per cent, and active in 17, or 4.2 per cent, of the entire group; there were six deaths in this group. Group 3. Sixty-eight (6.4 per cent) had the adult type of tuberculosis at the beginning and another 53 (4.9 per cent) subsequently developed the adult type of tuberculosis. This was considered inactive in 27 or 2.5 per cent and active in 26 or 2.4 per cent of the entire group; there were four deaths. Taking the three as one group 122 or 7.7 per cent had the adult type of tuberculosis at the beginning and another 85 or 5.4 per cent subsequently developed the adult type of tuberculosis which was considered inactive in 35 or 2.3 per cent and active in 50 or 3.1 per cent. There were 12 deaths, five in the initial tuberculosis group and seven in those who developed tuberculosis subsequently. Thus, we see that 3.1 per cent of the nurses developed tuberculosis in the sanatorium. To minimize this the nurses should be
[April,
1937
instructed liow to protect themselves and the patients should be instructed to be careful about spitting, coughing and sneezing. The nurses should be x-rayed at the beginning and at regular intervals thereafter. Their working hours should be reduced and only tuberculinpositive nurses should be taken in, and if tuberculinnegative nurses are taken in they should be vaccinated with B. C. G. N. G. M.
Determination of the Artificial Pneumothorax
Containing
a
Small
Quantity
of Gas
By E. SCHILL, mjj. (Abstracted from the Tubercle, Vol. XVII, September 1936, p. 549) To detect the presence of a small quantity of gas .'H the pleural cavity during the course of collapse therapy x-rays are usually used, but they are not always available, their frequent use is not safe, and, when the pleura is free from any adhesion, they may fail t? demonstrate a small quantity of gas. The simple method of percussion over the areas of: (1) the costophrenic sinus, (2) the absolute cardiac dullness, and (3) Kronig's area, will help in the matter. Instead of percussing over the Kronig's area Frisch recommends percussion of the apex of the lungs, as given below. Draw a horizontal line between the spinous processes of the first and second dorsal vertebra} and mark on it two points, one on each side, three-finger breadths from the mid-line. Join these two points to a point marking the lowest limit of the scalp in the mid-line. Light percussion on these connecting lines from mid-line outwards enables one to detect a limit of resonance nearer the spine, since the air occupying the cone of the apical pleura is capable of greater expansion. The lower limit of resonance is on the affected side. In left-sided pneumothorax a diminution of absolute cardiac dullness may be elicited. Gas disappears firs'' from the costo-phrenic sinus, though adhesions of the two layers of pleura make this sign useless, moreover in a bilateral pneumothorax no comparison can be made. The patient lying on his side with the affected side uppermost often helps. Begin percussion a little above the lower limit of resonance and go downward^ till dullness is reached, after percussing some time at this point resonance will reappear, go down till again dullness reappears and in this way in a case of pneumothorax you can reach the last rib. N. G. M.
A
Study of the Pathology Pulmonary Tuberculosis
Experimental
of in the Rabbit
By E. M. MEDLAR and K. T. SASANO
(Abstracted from the American Review of Tuberculosa> Vol. XXXIV, October 1936, p. 456) The seed, the soil and the lapse of time after the seed and soil are brought together are the three greatest important factors in any infectious disease, whethei naturally contracted or experimentally produced. the study of the problem of human pulmonary tuberculosis all these factors are beyond control, whereas in the field of animal experimentation they can be^ least partially regulated. So a thorough of the pathology of pulmonary tuberculosis is n? possible from uncontrolled and uncontrollable hums material. But if the important pathological processes of pulmonary lesions in man, such as, localization'
understanding
progression, cavitation, bronchogenic spreads an retrogression, can be duplicated in the experiments
253
CURRENT TOPICS
April, 1937]
Intensity Frequency of
of Tuberculin
animal then one should be able to understand more its human pathology. In this article the authors presented the type of , lesions obtained in the rabbit which simulate tne mai Pathological features of tuberculous lesions in tne human lung. The authors used intravenously in rabbits three strains of tubercle bacilli of three grades ot
The
medium and high?the three varians o single-strain B. C. G. and also investigated the effect ?f reinfection with bacilli of high virulence in animals vaccinated with both living bacilli of low virulence and bacilli of high virulence. The results obtame y them were as follows:?
(Abstracted from the American Review of Tuberculosis, Vol. XXXIV, September 1936, p. 425)
clearly
virulence?low,
a
Jelled
(o) Bacilli of low virulence?10 to 50 mg.very arely killed the animals; marked pulmonary disease
^eloped;
the majority survived for three years. Ine process in majority resolved within a yeai Qd this occurred more rapidly in the anterior and antral portions of than in the posterior and dorsal Portions and where lung the lesions persisted for three years of cavitation or bronchogenic spreads was
Pathological
fQy^jidence
(&) Bacilli of nig.:?death high virulence?1 curred within two months. 0.01 mg.:?death ensued s*x months. Lesions progressed evenly in ah hr? t0^ h'ng. Suppurating and ulcerating lesions and ?genic spreads most common?no gross cavita
the the
sfthat
Hot cavitA-
corn-
natural inhalation route of infection
i?
Pr^me importance in localizing the progressing havoaLlnS tuberculous lesions as all types of lesions anim ,een obtained by the intravenous inoculation in that the allergic condition of the tissue as a inf. primary infection with the subsequent retuhfr i cann?t determine the localization of cavita ting cul?us lesion as similar lesions (the so-called adult huTv, type) have been obtained in animals from first bacilli of every grade of virulence; and that u?ns, hl8her portions of the lung field appear to be tiono ,nt to tuberculous infection than the lower porOccnr^j m m?st progressing cavitatmg lesions W ecj these animals in the uppermost part ?f .the the animal is in the normal or upright Whef?er n' ,The authors concluded that a certain ba ance the resigtance of the host and the virulence of Parasite must be established "ther the or cavit subsequent infection to obtain localizing lesi?us and the so-called adult type of human tuberculosis is due in large part to the lode?n ai7 the tubercle bacilli in the. less resistant upper gf0f ?f the lung parenchyma. S. R. G.
rSIs;, ,.
Demonstrable Lesions
Reaction and Tuberculous
By C. W. WELLS and H. H. SMITH
The variation in the degree of reaction to the tuberculin test has long been observed. With the advent of intracutaneous tuberculin test, the extraneous factors which are operative with the cutaneous test being largely removed, sufficient interests have been aroused in this varying intensity of the reaction. Investigations have been conducted by various workers to interpret the meaning or importance of this variation in intensity and to correlate it with the degree of infection. The first study of this problem was made by Roemer and Joseph in the guinea-pig, using high dilutions of tuberculin, and they reported a definite correlation between the degree of infection and the intensity of tuberculin test. In recent years investigations were made to associate the more pronounced reactions to intracutaneous tuberculin test with active tuberculosis, on a quantitative basis, and to establish a critical threshold in the dilution of tuberculin which would in the majority of more or less definitely exclude negative reactors the possibility of active tuberculosis. The present authors conducted a tuberculosis survey in Kingston, Jamaica, from 1931 to 1934 in which 4,906 individuals (a random sample of the population) were tuberculin tested and received chest x-ray examinations. They found that in the 0 to 9 years age group tho per cent presenting lesions ranged from 0.5 per cent for negative reactors to 1 mg. to 14.1 per cent in two-, three- and four-plus reactors to 0.01 mg., in the 10 to 14 years age group, no lesion in negative reactor.-; and 14.2 per cent of lesions in the above class of positive reactors and for all ages over 15 years, 5.5 per cent of lesions in negative reactors and 12.1 per cent in the
positive
reactors.
The average percentages showing lesions are 1.6 in negative reactors to 1 mg., 4.0 in positive reactors to 1 mg., 8.6 in one-plus positive reactore to 0.01 mg., and 12.4 in two-, three- and four-plus positive reactors to 0.01 mg. Thus an increase in the percentage of demonstrable pulmonary lesions, both active and latent, was found by them with an increase in the severity of the tuberculin reaction. The results are shown to be comparable to those of Opie and his associates (1926) for individuals in the school age^ groups. It was also speciallv mentioned that a negative reaction does not absolutely exclude active or far advanced tuberculosis Opie and as pointed out by Rich and McCordock. others found 17.3 per cent while the authors found 1.6 per cent of lesions in the group of negative reactors ?two of the individuals of this group in the authors' series were suffering from far-advanced active disease. S. R. G. _
_
Posfti bSl ayeett
??!age Puh^tmg
UniS
Contact
as
a
Factor in the Transmission of Tuberculosis
By CHARLES SCHUMAN (Abstracted from the American Review of Tuberculosis, Vol. XXXIV, July 1936, p. 85) In this study an attempt was made to determine the relative importance of different types of exposure in the dissemination of tuberculosis with a view to its control. Three thousand and fifty-seven patients of a tuberculosis clinic, of whom 1,802 were adults and 1,255 children (up to 16 years of age), were the subjects for this survey. According to the history and sputum examination report of the sources of contact the types of exposure were differentiated under five categories: (1) positive sputum, (2) negative sputum, (3) unknown
*
THE INDIAN MEDICAL GAZETTE
254 sputum, (4) deceased
[April,
1937
cases of tuberculosis, and (5) no tuberculosis or non-tuberculous cases. The of tuberculosis in children contacts was made diagnosis by history and z-ray. No attempt was made to differentiate between so-called childhood tuberculosis and the adult type. The evidences of tuberculous infection in these children were determined by the intracutaneous Mantoux test, done in the usual manner, with 0.1 mg. OT. The degree of reaction to Mantoux test was also noted from the size of the weal and the swelling of the arm and interpreted as 1 +, 2 +, 3 + or 4 + There was a relatively large number (730) of definite cases of tuberculosis among adult contacts as compared to the striking small number (47) in children. Of these 33.5 per cent in the case of adults were in contact with known tuberculosis patients, in contrast with *80.9 per cent in the case of children. According to the author this latter high incidence is apparent as, in the case of a child, the family circle comprises almost the entire extent of his contacts. The incidence of tuberculous disease in adult contacts according to types of exposure was 23.9 per cent with 'positive sputum', 13.0 per cent with 'negative sputum', 17.3 per cent (which is almost an arithmetical ' mean between the previous two figures) with unknown ' deceased cases of tuberper cent with sputum36.7 ' culosis and 68.0 per cent with 'non-tuberculous'. In the case of child contacts 7.5 per cent of those exposed to positive sputum, 0.5 per cent of negative sputum group, 4.6 per cent of unknown sputum group, 1.0 per cent of deceased tuberculous group and 5.5 of nontuberculous group contracted the disease. Regarding Mantoux reactions 65.6 per cent were positive under ' negative positive sputum, 27.9 per cent under cent under unknown 60.0 sputum, 70.9 per sputum', per cent under deceased tuberculosis and 40.2 per cent ' under non-tuberculous group'. Regarding the intenof reaction the 2 + Mantoux reading was the most sity common and the 4 -f- reading the least common in all the groups. The largest number (17) of children exposed to positive sputum developed a 4 + reaction. Thus children exposed to positive-sputum cases show a high incidence to both tuberculous disease and tuberinfection. The intensity of the Mantoux culous reaction depends largely on the time interval between the period of exposure to positive sputum and the date of the test; the more recent the exposure, the greater the reaction to tuberculin. The author concluded that contact to positive sputum is the greatest single factor in the spread of the disease, that children exposed to positive sputum show an increased degree of sensitivity to tuberculin, that pulmonary tuberculosis is not very common in infant and children, and that the control of positive sputum is the most effective means of limiting the spread of the disease. S. R. G.
The author also added that out of 43 female domestics tested, 40 were Mantoux-positive at the beginning and all remained free from tuberculosis. Of the three negatives, one could not be followed up, one remained negative after the third test ten months later and the other was positive on second test a month later and all remained quite fit. Of the male outdoor staff only six were tuberculin tested. Five were positive at the beginning and the other was negative and remained so on third test after lour months. All these appeared fit at the time of report. N. G. M.
The Intra-dermal Tuberculin Test in Nurses
By C. KERESZTURI
known
.
_
By PETER W. EDWARDS, m.b., B.ch. (Edin.) (Abstracted from the Tubercle, Vol. XVIII, December 1936, p. 101) This study gives a record of a short series of intra-
dermal tuberculin test
Fifty-four
were
on nurses.
Mantoux-positive
on
joining the staff;
of these one became tuberculous in six months. Eleven were Mantoux-negative on joining the staff. Of these two left after the first test; three remained negative: one on third test after four months, one on third test after three months, one on second^ test after two months and all remained quite fit; six became positive: one on third test after three months, one on second test after eight months, two on second test after ten months (all these four were fit up to the time of report), one in the next month and the remaining one on third test after two months (these last two became tuberculous within two and three months,
respectively).
so
Results of the Sanocrysin Treatment of Tuberculosis By F. I. TERRILL (Abstracted from the American Review of Tuberculosis, Vol. XXXIV, July 1936, p. 156) Forty-one cases, the majority (30) of which were far advanced and the rest moderately advanced, showing no improvement under the usual care, were treated with the soluble gold-sodium-thiosulphate intravenously. The dose was 10 mg. to start with and was gradually increased to 250 mg. which was maintained for from five to eight injections before a rapid increase to 500 mg. was given. The repetition of the last dose depended upon the tolerance of the patient. The injections were given at weekly intervals unless there was some reason for a longer intermission. Weekly urine analyses were made during the course of treatment and for at least six weeks following its conclusionOnly a slight and transient albuminuria occurred iQ two cases necessitating only an increase in the timeintervals. After 18 months of treatment the results were quite conclusive as to the value of the drug j11 selected cases. Clinically improved?18, markedly results improved?10, not improved?10, and adverse 3. A gain in weight of over 5 lb. occurred in 16 cases, roentgenogram improvement in 15 cases, a diminished amount of sputum in 19 cases, and the sputum became negative for tubercle bacilli in 10 cases. Conclusions: intravenous gold is of value in the treatment of tuberculosis and has a definite place
the armament of a phthisiotherapist. It is applicable in selected cases only and should not be substituted for collapse therapy, even for a trial. The early bad result" of this treatment following its introduction by Mollgaaro in 1928 are thought to be caused by the injection 01 too large a dose (the customary maximum dose then
being
1
gm.).
S. R. G.
The Use of B. C. G. Vaccine Against Tuberculosis in Children and \V. H. PARK
(Abstracted from the American Review of Tuberculosas> Vol. XXXIV, October 1936, p. 437) This study was made under three heads: (1) Is the B. C. G. vaccine harmless? The vaccine was proved to be harmless by the following observations : (a) Four hundred to five hundred guinea-P1?9' rabbits and monkeys were injected with large quantities of living organisms and only one developed a moderate tuberculosis which might have been due to an accidental laboratory infection. (b) One hundred and seventy-five young infants were vaccinated with B. C. G. but not exposed to tuberculosis after vaccination. All did as well as the controls with the exception bf one case who developed clinica tuberculosis but whose autopsy was refused and hence the diagnosis not settled.
CURRENT TOPICS
April, 1937] .
(c)
Five hundred and fifteen children
cinated with
were
B. C. G.
Tuberculosis in Hospital Nurses
vac-
and exposed a human tuberculous source. Four of them died of tuberculosis and the rest did well as the controls. the organs of three out of the four dead cases, the human and not the bovine type of tubercle bacilli Was recovered. W) In 27 out of 31 instances of cold abscesses occurring at the site of vaccination, B. C. G. bacilli were recovered from the aspirated pus. In none of the instances could the bacilli be shown to have increased in virulence by stay in the human body for periods /??e to ten months. (2) Is the B. C. G. culture effective in the prevention of tuberculosis? To the immunizing effect the B. C. G. vaccinationgauge the tuberculosis death rate among the comparable groups of B. C. G. vaccinated cases and the controls was studied. The children known from birth were vaccinated by mouth with C. G. vaccines within the first ten days of life and nose that were not known from birth, had no evidence ?f tuberculosis and had negative initial Mantoux test, )v'ere parenterally vaccinated with B. C. G. vaccine untracutaneously or subcutaneously). Both these groups were studied with their corresponding control groups for periods up to eight years. There were 300 t0 400 cases in each group. The total number studied 1.445. It was also noted whether these children ^Vas vere exposed to a case of tuberculosis with positrve Put urn or to one with negative sputum or not exposed all to tuberculosis. Among the control children, nown from the tuberculosis death rate was ; birth, ound to be more than twice as high as among the rally-vaccinated ones, while among those not known ?m birth it was about four times as high as among the Parenterally vaccinated babies. Regarding non-tubercuious mortality which was 5.2 per cent in the total oKmjP' *t was lowest in the parenterally vaccinated (2.8 per cent). In all the groups compared, the ^nildren ?Posure to tuberculosis was remarkably similar, only "ne-third to half of all cases in each group were exposed o open tuberculosis; about cne-third to closed tuberone-third not exposed at all trw +S1l' an
