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Le systeme resticeuloendothelial dans la tuberculose
40
TUBERCLE
IMMUNIT3.r R E A C T I O N S I N TUBERCULOSIS. 9 u T. Comparaison entre la cuti-r~action ~. la tuberculine, la r6aetion de Vernes h la r~sorctne et la s6dimentation globulalre. Valeur pronostique de la cuti-r~aetion ~t la tubereulinc au eours de l a deuxi~me enfance. Th~se de Paris, 1933, No. 324. In children above the age of infancy the euti-reaction does not possess au absolute prognostic value, as is shown by the fact that a more or less intensely positive reaction may be found in children with no clinical or radiological evidence of tuberculosis as well as in those with decidedly active lesions. Feeble reactions are usually found, as in adults, in children with severe attacks, while well-marked reactions are often seen in patients withinactive lesions. I n the child the cuti-reaetion remains relatively constant for each individual as in only 5 out of 21 cases did it undergo any change. In 70 to 75 per cent. of the cases the Vernes resorcin reaction and the sedimentation rate corre. sponded to the clinical condition of the patient, and the two reactions agreed with one another in 71 patients. I n the same group of patients the average figures for the Vernes reaction and the sedimentation rate remained practically constant and.did not vary however intense the cuti-reaetion might be. In other words, there was no parallelism between the intensity of the cuff-reaction and that of the Yernes reaction and sedimentation rate. The thesis contains the histories of 75 eases in patients aged from ld: months to 12 years. SANFILIPPO, E. Potere agglutinante del stere dei tubereolitiei sui germt del gruffo Brucella. Gior. d~ 23atteriol. e Immunol., 1933, 11, 1. The writer tested the agglutinative action of 132 serums from various forms of pulmonary and extra.pulmonary tuberculosis on different strains of Br. vzelitensis and /3r. paramelitensis. A positive result was obtained in only three cases of typical strains of 13r. n,elitensis, whereas strains of ])r. lmramelitensis were agglutinated in from 26"8 to 78"8 per cent. according to the
[October, 1934
particular strain. In another series of experiments the author was able to obtain the appearance or increase of the agglutinating power of the sera in normal subjects from Br. paramelitensis by treatment with tuberculin or antis~reptococcal vaccine.
M O R B I D ANATOMY AND :HISTOLOGY OF T U B E R C U L O S I S . ZUMARRAGA, L. hi. Las formas seudotuberculosas de las lesiones pulmonaris en la fiebrc tifoidea, liev. .ESlm~. de Tuberculosis, 1933 4, 32. The writer, who records a case in a woman aged 25 and a man aged 37 with the autopsy findings, states that respiratory lesions may occur in typhoid fever which closely resemble those of tuberculosis in their naked eye appearance. Their true nature, however, is revealed by microscopical examination which shows that the causal organisms are the typhoid bacillus and other organisms which are usually pyogenic either separately or in combination. The path by which the organisms reach Lhe lungs is probably the blood stream, the portal of entry being the intestinal lesions DUVAL, .G. Le syst~me r6tieulo. endoth41ial darts l a tuberculose. Th2se de Paris, 1933, No. 162. The writer maintains that the reticule. endothelial system plays a very impor. tant part in the general pathology oJ tuberculosis. With a few exceptions: such as the spleen and serous mem. branes, it may be said that the organ., most frequently attacked by tubercu. losis are those ~hieh are richest ir reticule-endothelial elements, such a, the lymphatic glands, lungs and bones The fundamental tuberculous lesion namely, the follicle, is enr forme~ by the material belonging to the reticule endothelial system. As ageneral rule ir cases of clinical tuberculosis lesions of banal type become superimposed or tuberculous lesions and add to the gravit~ of the prognosis. The essential signifi canceof reticule-endothelial involvemen in tuberculosis is the fixation of tuberch bacilli without it being possible~t( determine the final issue of this fixation
October, 1934]
TUBERCULOUS
I t may be regarded on the one hand as a protection of the system by immobilisation of the pathogenic organisms or on the other hand as a means of preserving the virus which at any moment may become diffused throughout the body. It is impossible at present to speak of immunity to tuberculosis in man. The most successful method of defence is 9immobilization of the pathogenic agent by the reticule.endothelial system.
T U B E R C U L O U S BACILL/_'EMIA. CORPER, tt. J., and DAMEIIOW, A. P. Tlao Question of Tubercle Bacilli in the Blood in Advanced Pulmonary" Tuberculosis. Amer. ltev. Tub., 1933, 28, 118. For the purposes of this study, the blood of 120 patients with advanced puhnonary and general tuberculosis was examined for tubercle bacilli by guinea-pig inoculation and by three different culture methods. The results in each case were negative. Two specimens, however, yielded saprophytic acid-fast tubercle bacilli, which could be readily differentiated from pathogenic tubercle bacilli both culturally and by animal inoculation. I n 200 further specimens of blood from patients in a tuberculosis sanatorium examined by two reliable culture methods, not a single positive culture 9 was obtained. The writers conclude that there is no
CLINICAL
AND
BAOILIJ~MIA
evidence of a true baeillmmia " i n the sense that tubercle bacilli circulate in the blood for a fairly long time, or that the bacilli multiply in the blood," although there obviously may not only be occasional embolic showers of tubercle bacilli from disintegrating tuberculous feel, but also terminal periods in the course of the disease when showers of caseous products containing viable bacilli may be found in the blood of man and experimental animals. This condition is, however, probably most unusual, and in any case when embolic showers do occur in man they appear to be rapidly removed from the circulation. ]{ALLOS, P. Ueber die Ziichtung der Tuberkulosebazillen aus dem Blute nach LSwenstcin. Gior. d i Batteriol. e I m m u n o l . , 1933, 10, 1171. As the result of his own investigations and a study of the literature the writer comes to the conclusion that the tubercle bacillus can be grown from the blood in only about 4 per cent. of all eases in contrast with the high proportion (50-80 per cent.) claimed by LSwenstein. The author attempts to explain the discrepancy by the fact that the mere microscopical demonstration of acid-fast bacilli on the surface of the cultures is no evidence of their being tubercle bacilli. The growth must first be submitted to a thorough cultural and pathological examination.
LABORATORY
I. T I I E R A P E U T I C P N E U M O PERITONIUM.
A subphrenie method of inducing therapeutic pneumoperitoneum for the relief of intestinal tuberculosis eompli'eat{~ig advanced pulmonary tuberculosis is described by Dr. Andrew L. Banyai [1], of the Muirdale Sanatorium, Wauwatosa, Wisconsin. The teclmiquo is as follows : The patient; is placed in the same position as for artifici.'d pneumothorax with a sandbag under the lateral aspect of the chest. Local anmstbesia is induced with 1 per 9
4l
METHODS.
novocain. The skin is elevated between the index finger and the thumb and nicked with a fine scalpel. A 2"5 in.~t long needle, 19 gauge, without an obdurator, is used for injection, the needle being connected with the manometer of the pneumothorax apparatus. The p o i n t of entrance of the needle must be selected below 9the site of the eostopbrenic angle,, near the lower margin of the thorax. The needle must; be introduced slowly. The manometer indicates negative pressure as soon as the needle passes through the parietal
TUBERCLE
IMMUNIT3.r R E A C T I O N S I N TUBERCULOSIS. 9 u T. Comparaison entre la cuti-r~action ~. la tuberculine, la r6aetion de Vernes h la r~sorctne et la s6dimentation globulalre. Valeur pronostique de la cuti-r~aetion ~t la tubereulinc au eours de l a deuxi~me enfance. Th~se de Paris, 1933, No. 324. In children above the age of infancy the euti-reaction does not possess au absolute prognostic value, as is shown by the fact that a more or less intensely positive reaction may be found in children with no clinical or radiological evidence of tuberculosis as well as in those with decidedly active lesions. Feeble reactions are usually found, as in adults, in children with severe attacks, while well-marked reactions are often seen in patients withinactive lesions. I n the child the cuti-reaetion remains relatively constant for each individual as in only 5 out of 21 cases did it undergo any change. In 70 to 75 per cent. of the cases the Vernes resorcin reaction and the sedimentation rate corre. sponded to the clinical condition of the patient, and the two reactions agreed with one another in 71 patients. I n the same group of patients the average figures for the Vernes reaction and the sedimentation rate remained practically constant and.did not vary however intense the cuti-reaetion might be. In other words, there was no parallelism between the intensity of the cuff-reaction and that of the Yernes reaction and sedimentation rate. The thesis contains the histories of 75 eases in patients aged from ld: months to 12 years. SANFILIPPO, E. Potere agglutinante del stere dei tubereolitiei sui germt del gruffo Brucella. Gior. d~ 23atteriol. e Immunol., 1933, 11, 1. The writer tested the agglutinative action of 132 serums from various forms of pulmonary and extra.pulmonary tuberculosis on different strains of Br. vzelitensis and /3r. paramelitensis. A positive result was obtained in only three cases of typical strains of 13r. n,elitensis, whereas strains of ])r. lmramelitensis were agglutinated in from 26"8 to 78"8 per cent. according to the
[October, 1934
particular strain. In another series of experiments the author was able to obtain the appearance or increase of the agglutinating power of the sera in normal subjects from Br. paramelitensis by treatment with tuberculin or antis~reptococcal vaccine.
M O R B I D ANATOMY AND :HISTOLOGY OF T U B E R C U L O S I S . ZUMARRAGA, L. hi. Las formas seudotuberculosas de las lesiones pulmonaris en la fiebrc tifoidea, liev. .ESlm~. de Tuberculosis, 1933 4, 32. The writer, who records a case in a woman aged 25 and a man aged 37 with the autopsy findings, states that respiratory lesions may occur in typhoid fever which closely resemble those of tuberculosis in their naked eye appearance. Their true nature, however, is revealed by microscopical examination which shows that the causal organisms are the typhoid bacillus and other organisms which are usually pyogenic either separately or in combination. The path by which the organisms reach Lhe lungs is probably the blood stream, the portal of entry being the intestinal lesions DUVAL, .G. Le syst~me r6tieulo. endoth41ial darts l a tuberculose. Th2se de Paris, 1933, No. 162. The writer maintains that the reticule. endothelial system plays a very impor. tant part in the general pathology oJ tuberculosis. With a few exceptions: such as the spleen and serous mem. branes, it may be said that the organ., most frequently attacked by tubercu. losis are those ~hieh are richest ir reticule-endothelial elements, such a, the lymphatic glands, lungs and bones The fundamental tuberculous lesion namely, the follicle, is enr forme~ by the material belonging to the reticule endothelial system. As ageneral rule ir cases of clinical tuberculosis lesions of banal type become superimposed or tuberculous lesions and add to the gravit~ of the prognosis. The essential signifi canceof reticule-endothelial involvemen in tuberculosis is the fixation of tuberch bacilli without it being possible~t( determine the final issue of this fixation
October, 1934]
TUBERCULOUS
I t may be regarded on the one hand as a protection of the system by immobilisation of the pathogenic organisms or on the other hand as a means of preserving the virus which at any moment may become diffused throughout the body. It is impossible at present to speak of immunity to tuberculosis in man. The most successful method of defence is 9immobilization of the pathogenic agent by the reticule.endothelial system.
T U B E R C U L O U S BACILL/_'EMIA. CORPER, tt. J., and DAMEIIOW, A. P. Tlao Question of Tubercle Bacilli in the Blood in Advanced Pulmonary" Tuberculosis. Amer. ltev. Tub., 1933, 28, 118. For the purposes of this study, the blood of 120 patients with advanced puhnonary and general tuberculosis was examined for tubercle bacilli by guinea-pig inoculation and by three different culture methods. The results in each case were negative. Two specimens, however, yielded saprophytic acid-fast tubercle bacilli, which could be readily differentiated from pathogenic tubercle bacilli both culturally and by animal inoculation. I n 200 further specimens of blood from patients in a tuberculosis sanatorium examined by two reliable culture methods, not a single positive culture 9 was obtained. The writers conclude that there is no
CLINICAL
AND
BAOILIJ~MIA
evidence of a true baeillmmia " i n the sense that tubercle bacilli circulate in the blood for a fairly long time, or that the bacilli multiply in the blood," although there obviously may not only be occasional embolic showers of tubercle bacilli from disintegrating tuberculous feel, but also terminal periods in the course of the disease when showers of caseous products containing viable bacilli may be found in the blood of man and experimental animals. This condition is, however, probably most unusual, and in any case when embolic showers do occur in man they appear to be rapidly removed from the circulation. ]{ALLOS, P. Ueber die Ziichtung der Tuberkulosebazillen aus dem Blute nach LSwenstcin. Gior. d i Batteriol. e I m m u n o l . , 1933, 10, 1171. As the result of his own investigations and a study of the literature the writer comes to the conclusion that the tubercle bacillus can be grown from the blood in only about 4 per cent. of all eases in contrast with the high proportion (50-80 per cent.) claimed by LSwenstein. The author attempts to explain the discrepancy by the fact that the mere microscopical demonstration of acid-fast bacilli on the surface of the cultures is no evidence of their being tubercle bacilli. The growth must first be submitted to a thorough cultural and pathological examination.
LABORATORY
I. T I I E R A P E U T I C P N E U M O PERITONIUM.
A subphrenie method of inducing therapeutic pneumoperitoneum for the relief of intestinal tuberculosis eompli'eat{~ig advanced pulmonary tuberculosis is described by Dr. Andrew L. Banyai [1], of the Muirdale Sanatorium, Wauwatosa, Wisconsin. The teclmiquo is as follows : The patient; is placed in the same position as for artifici.'d pneumothorax with a sandbag under the lateral aspect of the chest. Local anmstbesia is induced with 1 per 9
4l
METHODS.
novocain. The skin is elevated between the index finger and the thumb and nicked with a fine scalpel. A 2"5 in.~t long needle, 19 gauge, without an obdurator, is used for injection, the needle being connected with the manometer of the pneumothorax apparatus. The p o i n t of entrance of the needle must be selected below 9the site of the eostopbrenic angle,, near the lower margin of the thorax. The needle must; be introduced slowly. The manometer indicates negative pressure as soon as the needle passes through the parietal