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A simple method of estimation of the proteins of the blood-serum and its value in tuberculosis
454
TUBERCLE
[July; 1934
Correlatio~ of State o/ Teeth to Blood Pressure. (1) Very good t e e t h {2) Very c a r i o u s t e e t h (3) Pyorrhce~, Sanatorium Firs Home
B P syst. 116 B P ,, 114 B P ,, 121 B P ,, 116 B P ,, lfi5
Dias~. ,, ,, ,, ,,
79 Var. S7"0 73"6 :, 40"4 77"3 ,, 43"7 79"5 ,, 3 6 5 76"4: ,, 48"6
Av. age ,, ,, ,, ,,
26"2 33-7 46"3 42"0 50"3 "
R e m o v i n g from Group (I) 4 p a t i e n t s w i t h e x t r a h i g h blood pressure a n d f r o m G r o u p (2) 5 p a t i e n t s w i t h extra low blood pressure as m e n t i o n e d in t h e text, these figures become : - (1) B P 110 a n d 60. Variation 31. (9) B P 126 a n d 84. Variation 42.
Correlation o/ Tyt~e of Tubercle with Alkali Beserre. Aeid~emias ( S y m p a t h e t i c dominance). C. B., aged 46. Alk. res. 59"3 per cent. E.S., ,. 28. ,, 5S'4 ,, ~I. ]3. . . . 98. ,, 51"6 ,, S.B., ,, 40. ,, 54.5 ,, I t . S., ,, 27. ,, 54-5 ,, Alkalmmias ( p a r a s y m p a t h e t i c dominance). E. L., aged 39. hlk. res. 75"0 per c e n t . E.H., ,, 27. ,, 76"0 ,, W . N . , ,, 29. ,, 71"6 ,, J. C. P.; ,, 2t. ,, 86-5 ,, G: H . . . .
30.
,,
74-0
,,
U n i l a t e r a l early active lesions E a r l y active tuberculosis "Galloping consumption" Chronic, slowly progressing E x t e n s i v e , rapidly progressive
Prognosis Good Good Very bad Quite ~ood Very bad
Chronic, slowly progressive Poor R a p i d l y progressive, teeth perfect Poor E x t e n s i v e bilateral lesion Died s h o r t l y Chronic, long s t a n d i n g Died in 3 months Active, bilateral Poor
A SIMPLE METHOD OF ESTIMATION OF THE PROTEIHS ~OF THEBL00D-SERUM AND ITS VALUE IN TUBERCULOSIS. By W. PAOZL, ~I.D., and L. B. S T o ~ , M.B., Ch.B. From the Laboratory of the Papworth Village Settlement.
THE following paper is a report of examinations of the protein content in the blood-serum, and their value in the estimation of the activity o f tuberculous lesions. The method depends on the ability Of the bile to keep proteins in solution after the heating of the blood-serum. The reaction varies according to the quanti~y and behaviour o f proteins of the serum in different concentrations of bile. W e found this method r o b e quite reliable for ordinary clinical purposes ; it is simple, and it eliminates the necessity of expensive apparatus (such as refractometer). T e c h n i q u e - - 6 t u b e s . . I n t o all t u b e s is p u t 0"5 c.e. n o r m a l saline s o l u t i o n . T o t u b e 1 is a d d e d 0"5 c.c. f r e s h filtered ox-bile, f r o m w h i c h m i x t u r e is t r a n s f e r r e d 075 c.c. to t u b e 2. T h i s p r o c e s s is c o n t i n u e d u p to t u b e 5, a n d 0"5 c.e. f r o m t u b e 5 is d i s c a r d e d . T h e l a s t t u b e (6) b e i n g d c o n t r o l t u b e c o n t a i n s o n l y 0 . 5 s a l i n e s o l u t i o n . A f t e r t h i s , 0 " 5 of 1 : 7 d i l u t i o n of t h e s e r u m to be e x a m i n e d is t h e n a d d e d to e a c h t u b e a n d all t u b e s a r e h e a t e d u n t i l c o a g u l a t i o n of t h e p r o t e i n s a p p e a r s in t h e las~ t u b e . T h e r e s u l t s a r e r e c o r d e d immediately, and after twelve hours standing at reran temperature. T h e r e a r e all d e g r e e s of c o a g u l a t i o n f r o m i n t e n s i v e o p a c i t y like m i l k ( ' + + + + ) , less opacity (+++), faint t r a n s p a r e n c e ( + + ) , g r a d u a l l y f a l l i n g ( + 4 " ) , to e n t i r e c l e a r n e s s ( - - ) .
Over 100 cases of all forms and degrees of pulmonary tuberculosis have been examined and according to the result of the reaction they have been divided into five groups. A great majority of the cases are included in the first two groups. 9 In these, the intensity of the reaction agrees with
July, 1934J
enOTEI~s OF
TEZ
BnOOD SnRU~
455
the extent of the disease according to the X-ray picture and to the general clinical condition. The first group consisted of cases with advanced disease and a high degree of precipitation of proteins as evidenced by the bile reaction. Of 39 cases in this group 25 showed in t u b e . 3 - - 6 opacity, the majority having the greatest !ntensity in the last tube. Of these 25 cases 5 showed opacity in the second tube, whereas in the maiority the content of the second tube was faintly transparent (-t--t-)or showed a reasonable degree of clearness (H-). The content of the first tube was clear ; in three cases only was there a slight cloudiness (+), or faint transparence (-t-4-). It is usually found that less extensive lesions produce weak reactions in the individual tubes, especially in those containing a strong concentration of bile. Cases with quickly liquefying exudative infiltrations of the lung showed definitely stronger reactions and those of cirrhotic cases gave weaker results. The stronger reactions were not always connected with obvious clinical symptoms, e.g. fever. Fever, however, slightly increases the reaction. Thus slight differences appear in the reaction of cases in which the morbid anatomical changes are of the same degree. In 11 cases it was found that the ~weaker concentration of bile at the right side of the series of tubes held the proteins better in solution than the stronger concentration at the left side. In five of these cases the deposit in the tubes with the stronger concentration was greater than in the last control tube which contained no bile. This paradoxical result suggests that the graduation of our reaction does not result alone from quantitative differences in: the amount of proteins in the blood-serum. Gross cavitation and exudative processes in the upper lobes yielded t h e s e paradoxical results. In three instances there seemed to be h~ematogenous outspreads, twice because of the symmetrical site of the lesions and the thin walls of the cavities, and once on account of the presence of extrapuhnonary lesions. it was ~enerally found that h,'ematogenous processes in the lungs showed strong reactions even in cases with a fairly good clinical condition, and without the permanent or temporary presence of tubercle bacilli in the sputum. Of the 8 hmmatogenous cases 4 were classified under a special group (5), having increased anatomical changes as indicated by the X-ray picture and a very strong reaction although withoti~ the usual symptoms. The character of the lesion which indicates its hmmatogenous origin consists of the presence of symmetrical miliary outspread, of cavities with thin walls, and sometimes of discrete miliary disseminations with a tendency to become cirrhotic, and finally in the presence of repeated pleurisy (Pleurite h r~p~titio~O. Such cases, with the special pictures of hematogenous changes of the lungs as seen in generalisation of tuberculosis, are to be separated from the cases of common bronchogenic and isolated pulmonary tuberculosis. One of us has given a description of the anatomical and X-ray features of such cases} Of course, in old, definitely inactive cases of hmmatogenous outspread the reaction is not strong. Pagel, "Pathologie der h,'ematogcnen Streuungstuberkulosen. Ergebnisse tier gesamten Tuberkuloseforschg." V.p. 231-359, 1933, and " Tuberkulosc der Lungen" in " Handbuch der speziellen pathologischen Anatomie und Histologie," ed. by Henke and Lubarsch I I I , 2, p. 196-528, 1930.:
456
TUBE
aChE
[July, 1934
The secot~d group consisted of the mild cases of tuberculosis with a correspondingly weak reaction and contains 57 cases. There are blood examinations of normal persons, cases of artificial pneumothorax with a good collapse of the hmgs, 2 cases of thoracoplasty With a good clinical result, ten with definitely inactive partially calcified lesions. These lesions showed sharp and undulated Walls in the X-ray picture suggesting fibrosing changes of the loci. The rest are healed or inactive cases of bone tuberculosis. In these cases most of the tubes 1-5 showed no dullness, or nearly preserved transparence ( + , +). A small minority of cases showed small cloudiness in one or tile other tube. [-{-, + ( + ) ] . In these cases the clinical and radiological findings suggest a temporary activity of the changes or intercurrent disease. W e have to point out that in the cases of this group the tube 6, containing only the dilution of the serum without bile, showed often no less degrees of cloudiness than in the cases of the first group. Bug in all these mild cases of our second group the tubes containing the same dilutions of serum with varying bile dilutions became clear; in all the bad cases of the first group, however, the tubes with bile solutions and serum were opaque. In our third group were cases with good general condition, but definite anatomical changes, e.g. one cavity permanently secreting tubercle bacilli in the sputum, especially in cases of artificial pneumothorax, if the collapse o f the lung is not sufficient. Our reaction showed in one or two tubes, mostly with the stronger concentration of bile, faint transparence ( + + ) , in the other, transparence or clearness ( _ , - ) . This corresponds to the paradoxical result described previously. The last control tube showed opacity or faint transparence ( + + + , + +). I n the foztrth group of cases which gave a good reaction in spite Of gross anatomical findings and bad clinical condition we find only five cases. In four of them large amounts of protein are excreted from the body, in three cases by a strong albuminuria and in the other by a sinus in tuberculosis of the spine. Thus one can explain the failure of the reaction in the majority of these cases by the loss of proteins excreted by the body. ]3ut also in these cases one or two of the tubes, mostly with the stronger. reaction of the bile, showed a stronger reaction than the others ("paradoxical reaction "). The fifth group, containing cases with good clinical conditions, remarkable anatGmical changes of the lungs and a strong reaction, we have discussed above. We saw that these are chiefly cases iof chronic hematogenous processes of the lung. Our reaction sometimes agreed with the examination of proteins determined by the simple coagulation method u s i n g falling dilutions of the serum (1:5, 1 : 1 5 , 1 : 3 0 , 1 : 4 5 ) . But there were a great number of cases in which the reaction did not agree. Generally speaking our reaction was found to l~e more reliable and to give much better variation according to the special characteristics of the individual cases. Further, we compared our reaction with the so-called. "Koagulationsb a n d " of Weltmann. This reaction depends on the coagulation of the proteins with a 1 : 50 dilution of the patient's serum by adding varying strengths of an electrolyte. Solutions are prepared of a neut,'al electrolyte such as calcium chloride in falling dilutions of 0"1, 0"09, 0.08, and 0"01
July, 1934]
I'nOTEINS OF THE BLOOD SERUM
457
per cent. One places 5 e.c. of these dilutions in each tube and adds 0"1 c.c. of patient's serum, shakes and places the tubes fifteen minutes in a boiling water bath: One reads the reaction at once. The result is a definite flocculation with supernatant clear fluid. Cloudiness alone is not to be read. This reaction was recommended by E k h a r t , Trost-Scherleitner, Kaiser, and recently by Rohacowa and ~Veichherz for the estimation of the prognosis of tuberculosis. These last authors distinguished three groups of the reaction. The first contains cases of advanced disease with a coagulation only to 0-07. The second, the cases with good prognosis, have a "Koagulationsband" approaching to that of normal patients. It reaches as far as 0"06 or 0"04. The third group shows a " Koagulationsband" under the normal as far as 0"035. It belongs to patients without active tuberculosis. Actually, we found that this reaction can be of help in - the prognosis in very advanced cases. It can be stated that in cases with a coagulation of 0"07 .only, the prognosis is bad. But the conclusion arrived at is, t h a t a coagulation in lower concentrations of the electrolyte does not exclude a bad prognosis. The reason for this is that among our rather advanced cases we had those which had a favourable "Koagulationsband." Other cases which were not so advanced, but whose clinical and X-ray pictures suggested a bad ultimate prognosis, had the same favourable " Koagulationsband." I t was never possible to obtain by the determination of the " K o a g u l a t i o n s b a n d " differences according to the varying extent, the quality and act!vity of the anatomical lesions as we obtained them by our method; e.g., our cases of chronic h~ematogenous tuberculosis which gave a strong reaction in our bile test, had all a favourable " Koagulationsband." Thus the "Koagulationsband "does n o t depend on the amount and the quality of the proteins in the blood-serum as estimated by our test. W e can confirm the statement of Weichherz that the "Koagulationsband " can be useful only for prognosis, not for the diagnosis of tuberculosis. There is another possibility of employing the " Koagulationsband " in milder cases of chronic tuberculosis. I n cases with a non-specific exudative process, e.g. pneumonia or pleurisy, the bile reaction remains at first stationary while the " Koagulationsband " changes strongly. W e find in these bases that the coagulation fails completely or goes only to 0"09 per cent. of the calcium chloride solution for the " Koagulationsband." After the recovery from acute br0nchopneumonic processes the " K o a g u lationsband" becomes normal. The bile test may, however, show a gradual increase in proteins according to the extent of the anatomical changes and can remain strong if the tuberculosis becomes progressive. Finally, we compared the results of our reaction with the red blood-cell sedimentation. These two reactions always agreed in the group of the mild disease and normal control. We found the same agreement in our third group containing the cases with good general conditions in spite of remarkable changes in the X-ray picture. I n the group of bad cases about half the number agreed. In spite of gross changes in the X-ray picture in some instances the blood-cell sedimentation w a s low and our reaction strong. Equally, some of the chronic hmmatogenous cases with a strong bile test show a low blood-cell sedimentation. In our group 4, containing the cases with a weak bile test, gross anatomical changes and bad clinical
458
TUm~r~cr,E
[July, 1934
conditions, Lhe blood-cell sedimentation was much in advance of the bile test. B u t as above mentioned, only five cases belong to this group and the strong albuminuria in four of them ,nay explain the failure of the bile test. 9As an approximate measure of the protein content of blood-serum the bile t e s t c e r t a i n l y is a non-specific reaction, e.g., a case of syphilis of the lung with a positive Wasscrmann's reaction gave a strong bile test, while the blood-cell sedimentation was normal. In this case the bile test led to the correct diagnosis, while the blood-cell sedimentation had not excited any interest. A latent syphilis has been detected by the bile test i n several other cases. 9 Our findings concerning the protein content of the blood-serum of tuberculous patients agree with the well-known hyperproteinemia, especially hyperglobulinemia during acute and chronic infectious diseases. (Alder, :Peters, :Hurwitz and hIeyer, :Frisch and St arlinger, :Eichelberger and McCluskey, :Berger and Untersteiner, Lewin, :Luze, Achard, Bari~ty and Codounis, Courmont, Gard~re and Badinand, hIanicatide, :Bratesco and :Rosenkranz, de Carvalho and.Santos, Sezany and hIartinet, Olivier and Sliosberg, Masson, :Bbzam;on, Guillaumin, Weil and Wahl,') &c. A decrease of proteins in very serious cases (as described by :Luze, hleyer-Bisch, Frisch) we could not find. The great amount of protein in the serum of patients with hmmatogenous tuberculosis may be related to the peculiar condition of antibodies in such cases as have been shown by the studies of Witebsky.and Klingenstein. CONCLUSIONS.
(1) The bile test as a simple and approximate measure of the amount and behaviour of the proteins of the blood-serum gives a good indication of the extent and the activity of the anatomical changes in the majority of cases of pulmonary tuberculosis. (~) The bile test is in many cases in advance of the blood-cell sedimentation and the determination of the " Koagulationsband." The latter can be useful for prognosis in advanced cases. In combination with the 9 bile test the "Koagulationsband " can be of great help in the diagnosis of non-specific intercurrent exudative processes (pneumonia, &c.) in chronic tuberculosis. (3) Cases of hmmatogenous tuberculosis of the lung especially showed 9 a strong bile test. (4) :Exudative infiltrations with a tendency to liquefaction and the development of more than one cavity reinforce the reaction, while local fibrosis of the loci and cirrhotic changes decrease the reaction. (5) ~Iarked anatomical change, such as cavitation and cirrhotic tuberculosis, can show a favourable bile test, if the general condition is good. The number of such cases is small. In cases of albuminuria or loss of albumin from the body by any other w~y (sinuses, &c.) the bile test fails. In such cases the blood-cell sedimentation gives reliable results. * See the discussion in t I . G. Wells and E. R. Long, " T h e Che:nistry of Tuberculosis." Second Edition. London. 1932. P. 231. If.
July, 19S4]
PROTEINS OF THE :BLOOD SERUM
REFERENCES.
459
/
ACtIARD, CtI., BARIETY, M., and CODOUNIS,A. "Equilibre Prot~inique du S~rum Sanguin," Presse M~dicale, 1929, 93, 1509; Comptes Rend. Soc. Biol., Paris, 1930, t0~, 51, 257; 1930, t06, 346; Bull. Acad. M~dic., 1929, i01,725. ALDER, A. Deutsch. Arch. klin. Mediz., 1918, t26, 61 ; Zeitschr. Tubcrk., 1920, 3t, 10. BERGEn, H., and UNTERSTEINER, F. " Beeinflussung der SerumeiweisskSrper durch Inkubation. Fieber und Rekonvaleszenz akuter Infekte," Wiener Archly f. innere Mediz., 1925, 9, 2. I BEZAN~ON, F., \VEIL, P., GUILLAU~L',', M., and WAttL, .%.. " Etude Comparative des Prot6ines du Serum et du Plasma Sanguin dans la Tuberculose," l~ev. de la Tuberc., 1931, i2, 99=l. DE CARVALttO, L. and H., and SANTOS, N. DOS. " Les Modifications Physicochimiques du Serum ehez les Tuberculoses Pulmonaires," Comt~tcsRend. Soc. Biol., Paris, 1930, 105, 802. COURMONT, P., GARDERE, ]q., and BADINAND, F.A. " Signification des Variations des Prot~ines du Serum chez les Tuberculeux," Journ. de M~d. de Lyon, 1931, t2, 599. EICHELBERGER, L., and MCCLUSKEY,1~.. L. Arch. Intern. lied., 1927, 401 831. ERISCtt, A., and STARLINGER, H. Med. Klin., 192:2, t2,247 ; Beitr. z. KZin. tier Tubcrk., 1921, 48, 145. HURWITZ, S. H., and MEYER, K . F . Journ. Exp. l[al., 1916, 2~, 515. KAISER, TH. " Weltmannsche Serumkoagulation bei Lungentuberkulose," Beitr. z. Klin. Tuberk., 1933, 83, 3. LEWIN, H. Meal. Kliu., 1927, t7, 790. LUZE, :F. " Taguug Alpenland. Internisten. Innsbruek, 27.9.27," Miinch. ,zed. Woch., 1927, 1976. MANICATIDE, M., BRATESCO, A.: and ROSENKRANZ,B. " ]~quilibre P~'ot6inique du Serum darts les Tuberculoses Infantiles," Comptes Iicnd. Soc. Biol., Paris, 1930, t05, 45. MASSON, P . " Les Albumines du Serum dans la Tuberculose Pulmonaire," l~ev. Tub., 1931,'i2, 828. MEYER-BISCIt, R. Zeitschr. Exper. Pathol. Ther., 1919, 20,'5t. OLIVIER, :H. R., and SLIOSBERG. A. " Prot6ines du Serum au Cours de la Tuberculose Pulmonaire," l~ev. de la Tuberc., 1931, t2, 1. PETERS, E. "Viskosimetrische und Refraktometrische Serumuntersuchungen bei Lungentuberkulose," Zeitschr. Tuberk., 1921, 3ii, 3. Idem. "Serumeiweissuntersuchungen im tIoehgebirge," Zeitschr. Physikal. Diatet. Ther., 1921, 2~i, 548. ROHAKOVA, D., and W E I C H H E R Z , E . " Das Koagulationsband yon Weltmann," Meal. Klin., 1933, 29, 1410. SEZARY, A., and MARTINET, P. Soc..]fed. des H6pit. Paris, 1930, 9~t5. WELTMANN, F. Med. Klin., 1930, 241. 9NVITEBSKY, E., and KLINGENSTEIN, E. " Serologie der Tuberkulose, v ErgcbTz. ges. Tuberkforsch. Leipzig: Thieme, 1933, Band 5.
TUBERCLE
[July; 1934
Correlatio~ of State o/ Teeth to Blood Pressure. (1) Very good t e e t h {2) Very c a r i o u s t e e t h (3) Pyorrhce~, Sanatorium Firs Home
B P syst. 116 B P ,, 114 B P ,, 121 B P ,, 116 B P ,, lfi5
Dias~. ,, ,, ,, ,,
79 Var. S7"0 73"6 :, 40"4 77"3 ,, 43"7 79"5 ,, 3 6 5 76"4: ,, 48"6
Av. age ,, ,, ,, ,,
26"2 33-7 46"3 42"0 50"3 "
R e m o v i n g from Group (I) 4 p a t i e n t s w i t h e x t r a h i g h blood pressure a n d f r o m G r o u p (2) 5 p a t i e n t s w i t h extra low blood pressure as m e n t i o n e d in t h e text, these figures become : - (1) B P 110 a n d 60. Variation 31. (9) B P 126 a n d 84. Variation 42.
Correlation o/ Tyt~e of Tubercle with Alkali Beserre. Aeid~emias ( S y m p a t h e t i c dominance). C. B., aged 46. Alk. res. 59"3 per cent. E.S., ,. 28. ,, 5S'4 ,, ~I. ]3. . . . 98. ,, 51"6 ,, S.B., ,, 40. ,, 54.5 ,, I t . S., ,, 27. ,, 54-5 ,, Alkalmmias ( p a r a s y m p a t h e t i c dominance). E. L., aged 39. hlk. res. 75"0 per c e n t . E.H., ,, 27. ,, 76"0 ,, W . N . , ,, 29. ,, 71"6 ,, J. C. P.; ,, 2t. ,, 86-5 ,, G: H . . . .
30.
,,
74-0
,,
U n i l a t e r a l early active lesions E a r l y active tuberculosis "Galloping consumption" Chronic, slowly progressing E x t e n s i v e , rapidly progressive
Prognosis Good Good Very bad Quite ~ood Very bad
Chronic, slowly progressive Poor R a p i d l y progressive, teeth perfect Poor E x t e n s i v e bilateral lesion Died s h o r t l y Chronic, long s t a n d i n g Died in 3 months Active, bilateral Poor
A SIMPLE METHOD OF ESTIMATION OF THE PROTEIHS ~OF THEBL00D-SERUM AND ITS VALUE IN TUBERCULOSIS. By W. PAOZL, ~I.D., and L. B. S T o ~ , M.B., Ch.B. From the Laboratory of the Papworth Village Settlement.
THE following paper is a report of examinations of the protein content in the blood-serum, and their value in the estimation of the activity o f tuberculous lesions. The method depends on the ability Of the bile to keep proteins in solution after the heating of the blood-serum. The reaction varies according to the quanti~y and behaviour o f proteins of the serum in different concentrations of bile. W e found this method r o b e quite reliable for ordinary clinical purposes ; it is simple, and it eliminates the necessity of expensive apparatus (such as refractometer). T e c h n i q u e - - 6 t u b e s . . I n t o all t u b e s is p u t 0"5 c.e. n o r m a l saline s o l u t i o n . T o t u b e 1 is a d d e d 0"5 c.c. f r e s h filtered ox-bile, f r o m w h i c h m i x t u r e is t r a n s f e r r e d 075 c.c. to t u b e 2. T h i s p r o c e s s is c o n t i n u e d u p to t u b e 5, a n d 0"5 c.e. f r o m t u b e 5 is d i s c a r d e d . T h e l a s t t u b e (6) b e i n g d c o n t r o l t u b e c o n t a i n s o n l y 0 . 5 s a l i n e s o l u t i o n . A f t e r t h i s , 0 " 5 of 1 : 7 d i l u t i o n of t h e s e r u m to be e x a m i n e d is t h e n a d d e d to e a c h t u b e a n d all t u b e s a r e h e a t e d u n t i l c o a g u l a t i o n of t h e p r o t e i n s a p p e a r s in t h e las~ t u b e . T h e r e s u l t s a r e r e c o r d e d immediately, and after twelve hours standing at reran temperature. T h e r e a r e all d e g r e e s of c o a g u l a t i o n f r o m i n t e n s i v e o p a c i t y like m i l k ( ' + + + + ) , less opacity (+++), faint t r a n s p a r e n c e ( + + ) , g r a d u a l l y f a l l i n g ( + 4 " ) , to e n t i r e c l e a r n e s s ( - - ) .
Over 100 cases of all forms and degrees of pulmonary tuberculosis have been examined and according to the result of the reaction they have been divided into five groups. A great majority of the cases are included in the first two groups. 9 In these, the intensity of the reaction agrees with
July, 1934J
enOTEI~s OF
TEZ
BnOOD SnRU~
455
the extent of the disease according to the X-ray picture and to the general clinical condition. The first group consisted of cases with advanced disease and a high degree of precipitation of proteins as evidenced by the bile reaction. Of 39 cases in this group 25 showed in t u b e . 3 - - 6 opacity, the majority having the greatest !ntensity in the last tube. Of these 25 cases 5 showed opacity in the second tube, whereas in the maiority the content of the second tube was faintly transparent (-t--t-)or showed a reasonable degree of clearness (H-). The content of the first tube was clear ; in three cases only was there a slight cloudiness (+), or faint transparence (-t-4-). It is usually found that less extensive lesions produce weak reactions in the individual tubes, especially in those containing a strong concentration of bile. Cases with quickly liquefying exudative infiltrations of the lung showed definitely stronger reactions and those of cirrhotic cases gave weaker results. The stronger reactions were not always connected with obvious clinical symptoms, e.g. fever. Fever, however, slightly increases the reaction. Thus slight differences appear in the reaction of cases in which the morbid anatomical changes are of the same degree. In 11 cases it was found that the ~weaker concentration of bile at the right side of the series of tubes held the proteins better in solution than the stronger concentration at the left side. In five of these cases the deposit in the tubes with the stronger concentration was greater than in the last control tube which contained no bile. This paradoxical result suggests that the graduation of our reaction does not result alone from quantitative differences in: the amount of proteins in the blood-serum. Gross cavitation and exudative processes in the upper lobes yielded t h e s e paradoxical results. In three instances there seemed to be h~ematogenous outspreads, twice because of the symmetrical site of the lesions and the thin walls of the cavities, and once on account of the presence of extrapuhnonary lesions. it was ~enerally found that h,'ematogenous processes in the lungs showed strong reactions even in cases with a fairly good clinical condition, and without the permanent or temporary presence of tubercle bacilli in the sputum. Of the 8 hmmatogenous cases 4 were classified under a special group (5), having increased anatomical changes as indicated by the X-ray picture and a very strong reaction although withoti~ the usual symptoms. The character of the lesion which indicates its hmmatogenous origin consists of the presence of symmetrical miliary outspread, of cavities with thin walls, and sometimes of discrete miliary disseminations with a tendency to become cirrhotic, and finally in the presence of repeated pleurisy (Pleurite h r~p~titio~O. Such cases, with the special pictures of hematogenous changes of the lungs as seen in generalisation of tuberculosis, are to be separated from the cases of common bronchogenic and isolated pulmonary tuberculosis. One of us has given a description of the anatomical and X-ray features of such cases} Of course, in old, definitely inactive cases of hmmatogenous outspread the reaction is not strong. Pagel, "Pathologie der h,'ematogcnen Streuungstuberkulosen. Ergebnisse tier gesamten Tuberkuloseforschg." V.p. 231-359, 1933, and " Tuberkulosc der Lungen" in " Handbuch der speziellen pathologischen Anatomie und Histologie," ed. by Henke and Lubarsch I I I , 2, p. 196-528, 1930.:
456
TUBE
aChE
[July, 1934
The secot~d group consisted of the mild cases of tuberculosis with a correspondingly weak reaction and contains 57 cases. There are blood examinations of normal persons, cases of artificial pneumothorax with a good collapse of the hmgs, 2 cases of thoracoplasty With a good clinical result, ten with definitely inactive partially calcified lesions. These lesions showed sharp and undulated Walls in the X-ray picture suggesting fibrosing changes of the loci. The rest are healed or inactive cases of bone tuberculosis. In these cases most of the tubes 1-5 showed no dullness, or nearly preserved transparence ( + , +). A small minority of cases showed small cloudiness in one or tile other tube. [-{-, + ( + ) ] . In these cases the clinical and radiological findings suggest a temporary activity of the changes or intercurrent disease. W e have to point out that in the cases of this group the tube 6, containing only the dilution of the serum without bile, showed often no less degrees of cloudiness than in the cases of the first group. Bug in all these mild cases of our second group the tubes containing the same dilutions of serum with varying bile dilutions became clear; in all the bad cases of the first group, however, the tubes with bile solutions and serum were opaque. In our third group were cases with good general condition, but definite anatomical changes, e.g. one cavity permanently secreting tubercle bacilli in the sputum, especially in cases of artificial pneumothorax, if the collapse o f the lung is not sufficient. Our reaction showed in one or two tubes, mostly with the stronger concentration of bile, faint transparence ( + + ) , in the other, transparence or clearness ( _ , - ) . This corresponds to the paradoxical result described previously. The last control tube showed opacity or faint transparence ( + + + , + +). I n the foztrth group of cases which gave a good reaction in spite Of gross anatomical findings and bad clinical condition we find only five cases. In four of them large amounts of protein are excreted from the body, in three cases by a strong albuminuria and in the other by a sinus in tuberculosis of the spine. Thus one can explain the failure of the reaction in the majority of these cases by the loss of proteins excreted by the body. ]3ut also in these cases one or two of the tubes, mostly with the stronger. reaction of the bile, showed a stronger reaction than the others ("paradoxical reaction "). The fifth group, containing cases with good clinical conditions, remarkable anatGmical changes of the lungs and a strong reaction, we have discussed above. We saw that these are chiefly cases iof chronic hematogenous processes of the lung. Our reaction sometimes agreed with the examination of proteins determined by the simple coagulation method u s i n g falling dilutions of the serum (1:5, 1 : 1 5 , 1 : 3 0 , 1 : 4 5 ) . But there were a great number of cases in which the reaction did not agree. Generally speaking our reaction was found to l~e more reliable and to give much better variation according to the special characteristics of the individual cases. Further, we compared our reaction with the so-called. "Koagulationsb a n d " of Weltmann. This reaction depends on the coagulation of the proteins with a 1 : 50 dilution of the patient's serum by adding varying strengths of an electrolyte. Solutions are prepared of a neut,'al electrolyte such as calcium chloride in falling dilutions of 0"1, 0"09, 0.08, and 0"01
July, 1934]
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457
per cent. One places 5 e.c. of these dilutions in each tube and adds 0"1 c.c. of patient's serum, shakes and places the tubes fifteen minutes in a boiling water bath: One reads the reaction at once. The result is a definite flocculation with supernatant clear fluid. Cloudiness alone is not to be read. This reaction was recommended by E k h a r t , Trost-Scherleitner, Kaiser, and recently by Rohacowa and ~Veichherz for the estimation of the prognosis of tuberculosis. These last authors distinguished three groups of the reaction. The first contains cases of advanced disease with a coagulation only to 0-07. The second, the cases with good prognosis, have a "Koagulationsband" approaching to that of normal patients. It reaches as far as 0"06 or 0"04. The third group shows a " Koagulationsband" under the normal as far as 0"035. It belongs to patients without active tuberculosis. Actually, we found that this reaction can be of help in - the prognosis in very advanced cases. It can be stated that in cases with a coagulation of 0"07 .only, the prognosis is bad. But the conclusion arrived at is, t h a t a coagulation in lower concentrations of the electrolyte does not exclude a bad prognosis. The reason for this is that among our rather advanced cases we had those which had a favourable "Koagulationsband." Other cases which were not so advanced, but whose clinical and X-ray pictures suggested a bad ultimate prognosis, had the same favourable " Koagulationsband." I t was never possible to obtain by the determination of the " K o a g u l a t i o n s b a n d " differences according to the varying extent, the quality and act!vity of the anatomical lesions as we obtained them by our method; e.g., our cases of chronic h~ematogenous tuberculosis which gave a strong reaction in our bile test, had all a favourable " Koagulationsband." Thus the "Koagulationsband "does n o t depend on the amount and the quality of the proteins in the blood-serum as estimated by our test. W e can confirm the statement of Weichherz that the "Koagulationsband " can be useful only for prognosis, not for the diagnosis of tuberculosis. There is another possibility of employing the " Koagulationsband " in milder cases of chronic tuberculosis. I n cases with a non-specific exudative process, e.g. pneumonia or pleurisy, the bile reaction remains at first stationary while the " Koagulationsband " changes strongly. W e find in these bases that the coagulation fails completely or goes only to 0"09 per cent. of the calcium chloride solution for the " Koagulationsband." After the recovery from acute br0nchopneumonic processes the " K o a g u lationsband" becomes normal. The bile test may, however, show a gradual increase in proteins according to the extent of the anatomical changes and can remain strong if the tuberculosis becomes progressive. Finally, we compared the results of our reaction with the red blood-cell sedimentation. These two reactions always agreed in the group of the mild disease and normal control. We found the same agreement in our third group containing the cases with good general conditions in spite of remarkable changes in the X-ray picture. I n the group of bad cases about half the number agreed. In spite of gross changes in the X-ray picture in some instances the blood-cell sedimentation w a s low and our reaction strong. Equally, some of the chronic hmmatogenous cases with a strong bile test show a low blood-cell sedimentation. In our group 4, containing the cases with a weak bile test, gross anatomical changes and bad clinical
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[July, 1934
conditions, Lhe blood-cell sedimentation was much in advance of the bile test. B u t as above mentioned, only five cases belong to this group and the strong albuminuria in four of them ,nay explain the failure of the bile test. 9As an approximate measure of the protein content of blood-serum the bile t e s t c e r t a i n l y is a non-specific reaction, e.g., a case of syphilis of the lung with a positive Wasscrmann's reaction gave a strong bile test, while the blood-cell sedimentation was normal. In this case the bile test led to the correct diagnosis, while the blood-cell sedimentation had not excited any interest. A latent syphilis has been detected by the bile test i n several other cases. 9 Our findings concerning the protein content of the blood-serum of tuberculous patients agree with the well-known hyperproteinemia, especially hyperglobulinemia during acute and chronic infectious diseases. (Alder, :Peters, :Hurwitz and hIeyer, :Frisch and St arlinger, :Eichelberger and McCluskey, :Berger and Untersteiner, Lewin, :Luze, Achard, Bari~ty and Codounis, Courmont, Gard~re and Badinand, hIanicatide, :Bratesco and :Rosenkranz, de Carvalho and.Santos, Sezany and hIartinet, Olivier and Sliosberg, Masson, :Bbzam;on, Guillaumin, Weil and Wahl,') &c. A decrease of proteins in very serious cases (as described by :Luze, hleyer-Bisch, Frisch) we could not find. The great amount of protein in the serum of patients with hmmatogenous tuberculosis may be related to the peculiar condition of antibodies in such cases as have been shown by the studies of Witebsky.and Klingenstein. CONCLUSIONS.
(1) The bile test as a simple and approximate measure of the amount and behaviour of the proteins of the blood-serum gives a good indication of the extent and the activity of the anatomical changes in the majority of cases of pulmonary tuberculosis. (~) The bile test is in many cases in advance of the blood-cell sedimentation and the determination of the " Koagulationsband." The latter can be useful for prognosis in advanced cases. In combination with the 9 bile test the "Koagulationsband " can be of great help in the diagnosis of non-specific intercurrent exudative processes (pneumonia, &c.) in chronic tuberculosis. (3) Cases of hmmatogenous tuberculosis of the lung especially showed 9 a strong bile test. (4) :Exudative infiltrations with a tendency to liquefaction and the development of more than one cavity reinforce the reaction, while local fibrosis of the loci and cirrhotic changes decrease the reaction. (5) ~Iarked anatomical change, such as cavitation and cirrhotic tuberculosis, can show a favourable bile test, if the general condition is good. The number of such cases is small. In cases of albuminuria or loss of albumin from the body by any other w~y (sinuses, &c.) the bile test fails. In such cases the blood-cell sedimentation gives reliable results. * See the discussion in t I . G. Wells and E. R. Long, " T h e Che:nistry of Tuberculosis." Second Edition. London. 1932. P. 231. If.
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REFERENCES.
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