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The value of the triboulet reaction in intestinal tuberculosis
~64
THE
BRITISH
JOURNAL
OF TUBERCULOSIS
THE V A L U E OF THE T R I B O U L E T R E A C T I O N IN INTESTINAL TUBERCULOSIS B Y H. J. R O B I N S O N , M.D.(DUB.), Assistant Medical Officer, Papworth Village Settlement. .AND
D. B. C R U I C K S H A N K ,
ANDS.(ED.), Member Research Staff, Papworth Village Settlement. (From the Laboratory of Papworth Village Settlement.)
An account of Triboulet's test for intestinal ulceration in a recent number of the British Medical Journal encouraged us to investigate the reaction with a view to determining the advisability of adopting the test as a routine a d j u n c t to the physical examination of the phthisical patient. Being impressed by the fact that a considerable number of fatal cases of pulmonary tuberculosis show evidence of intestinal ulceration, usually some months before death, we felt that some evidence of intestinal infection at an incipient stage would be of prognostic value. In the hope of diagnosing intestinal ulceration at this stage we utilised Triboulet's reaction and have performed this test on io 9 cases. M e t h o d of P e r f o r m i n g
the Test.
A lump of fa~ces as large as a walnut is dissolved in 2o c.c. of distilled water and filtered; 3 c.c. of the filtrate is diluted with I2 c.c. of distilled water; 20 minims of Triboulet's reagent (sublimate 3"5, acetic acid I, aqua dest. ad IOO) are added. As a control the same filtrate is used without Triboulet's reagent. The test tubes containing the two solutions are well shaken, and are compared after five and twenty-four hours. A positive reaction is indicated by a cloudy grey or brown deposit, above which the solution is clear. Biochemical Notes.
i. Albumen and globulin were detected in the faecal filtrates. Both these proteins are precipitated by the reagent. 2. T h e ratio of the albumen and globulin present in the filtrates was examined in 46 cases. This ratio showed wide variations, ranging from I.I 8 to 24"0. There was no definite relationship between the ratio and the
VALUE
OF THE
TRIBOULET
REACTION
i6 5
type of reaction, except that in the strong reactions ( + + 5 hours) the proportion of albumen tended to be high. 3. Alteration of the concentration of the f~ecal filtrate has little effect on t h e rate of precipitation, but modifies the degree of precipitation in proportion to the dilution (I/I, I/2, I/4)" 4" The effect Of the reagent on diluted blood serum was tested. Up to dilutions of J-4 5 .a positive reaction results. In greater dilutions the reaction is negative. Specimens of albuminuria and solutions of dilute egg white gave similar results. 5. The f~eces were repeatedly examined for occult blood by the benzidine test. The presence or absence of blood has apparently no influence on the reaction, presumably because the concentration never reaches the critical value of I : 5. 6. It is reported that, as a result of decomposition of the proteins, specimens off~eces obtained at post-mortem give negative reactions, although durin~ life the reactions may have been positive. We have failed, with the exception of the one case quoted below, which gave a dual reaction, to observe this phenomenon in the I6 post-mortem cases examined. Fifteen of these gave positive reactions, irrespective of the post-mortem condition; only one post-mortem specimen gave negative reactions, but the reaction was also negative during life. Further to investigate the point we kept specimens of f~eces for a period of four weeks, ample time to permit of decomposition. These were examined weekly. In every instance the reaction remained as at the commencement and, if anything, became slightly more marked as time advanced. 7. It is known that in intestinal tuberculosis f~ecal nitrogen excretion is considerably increased, and that an early sign of this infection is a drop in the total blood proteins as determined by refractometry. With a view to finding a possible connection between these factors and the Triboulet reaction, we compared in 2I cases the albumen globulin ratios of the f~ecal filtrate with the albumen globulin ratio of the blood serum. It was thought that the lowered blood protein might be the outcome of secretion from intestinal ulcers, and that a study of the respective albumen and globulin ratios of the f~eces and blood might enable one to establish the origin of the intestinal protein as a transudate from the blood fluids. No such correlation could be traced. This investigation was undertaken on the assumption that the Triboulet reaction is a true index of the intestinal condition, an assumption which the later analysis of our results showed to be unwarranted. The findings cannot therefore be regarded as significant proof one way or the other of the site of origin of the proteins which give rise to the Triboulet reaction (see Table III.).
• 16"6.
THE
BRITISH
JOURNAL
OF TUBERCULOSIS
At the commencement we realised that any clinical classification must be arbitrary, chiefly because it rested very largely on a symptomatic basis. From the point of view of investigating the test we agreed upon the following classification: i. Clinically Definite.~All those cases in which there was more or less constant abdominal tenderness and pain, nausea and intermittent constipation and diarrhoea. 2. Clinically Probable.--Those in which there occurred periodic attacks of abdominal pain, sometimes accompanied by vomiting and diarrhoea, and associated with a greater loss of weight than one would have expected from the pulmonary lesions alone. 3. Clinically Negative. All other cases were classed as negative. In every case the test was carried out without any knowledge of the clinical condition, and it was only at the end of the investigation that results were compared. T A B L E I. 93 Clinical Cases : Agreement Disagreement
. . . . . .
fT+,C+ =22~ 3 7 = ~ T - , C - -- I 5 J 39 .8 per cent.
. . . . . .
6 cT+, C5 =~T-,C+
- - 5 4 ) 6o.2 p e r cent.
8 Cases, P.M. only (Fzeces e x a m i n e d P.M.) : Agreement
. . . . . .
fT+, 3 = IT-,
P.M.+ =3) P . M . - = o f 37"5 p e r cent.
Disagreement
. . . . . .
(T+, 5=IT_,
P.M.p . M . + _ = o5} 62.5 p e r cent"
8 Cases examined Ante-mortem and Post-mortem : Agreement
. . . . . .
( Intestinal + = 6 7 = \ I n t e s t i n a l - = I j 87"5 p e r cent.
Disagreement
. . . . . .
x = fI P T .. M P ..M-. C, + T-, + )f x2"5 per cent.
T A B L E II. ANALYSIS OF 93 CLINICAL CASES.
Clinically. h
r
Triboulet T r i b o u l e t + (5 h o t ' s ) Triboulet + (24 hours)
.. .. .. .. . . . .
Negative.
Probable.
Positive.
x5 34 I8
3 8 7
I 7 o
°
VALUE OF THE TRIBOULET REACTION
"i6 7
TABLE III. i
Protein in Feces.
A I~G~ --__ A/GI
Case Wo.
Protein in Serum.
A:G.
A/G.
52 : 48 52 : 48 5 5 : 45 60 : 4 ° 68 : 32 56 : 44 52 : 48 48 : 52 63 : 37 6I : 3 9 72 : 28 56 : 44 42 : 58 56 : 44 56 : 44 58 : 42 6 3 : 37 4 4 : 56 74 : 26 65 : 35 54 : 46
t .08 1.08 I "24
Triboulet Test.
Clinical Findings.
b
4 5 7 IO
14 15 I6 2I
22 23 24 26 27 28 29 3° 32 33 34 38 4t
, !
78 : 22 82 : i8 6 5 : 35 70 : 3° 82 : i8 76 : 24 82 : i8 93:7 85 : 15 82:i8 7° : 3° 82:18 82 : 18 80 : 20 84:I6 7° : 3 ° 92:8 92:8 96:4 89: II
93:7
3"55 4"55 I'7
2"3 4"55 3"I5 4"55 I3"3 5"65 " 4"55 2"33 4"55 4"55 4"O 5"25 2"33 I 1.5 i 1.5
l
24"0 8"I I3"3
I. 5 9.,;, 1-27 I "08
0.92 1.7I 1.56
2"52 I'27 o'73 1.27 1.27 1.38
1.7I o'77 2.85 1.86
1.i 7
-
+
+ + ++
+ +
+ + + + + + + + -
+ + i I l
-
+
++ ++ ++ ++
I t will b e seen t h a t t h e r e is a d i s a g r e e m e n t b e t w e e n t h e test a n d t h e clinical diagnosis in 6o22 p e r cent. o f cases. T h i s g r o u p is chiefly c o m p o s e d o f those cases w h i c h s h o w e d n o clinical e v i d e n c e o f intestinal u l c e r a t i o n , b u t g a v e a positive T r i b o u l e t . W e w e r e p r e p a r e d for s o m e e r r o r in the clinical classification, b u t c a n n o t a c c e p t t h a t a n e r r o r o f 60.2 p e r cent. w a s present. T h e classification o f t h e clinical a n d p o s t - m o r t e m findings will be m a d e c l e a r f r o m a s t u d y o f T a b l e s I. a n d I I . O n e case w i t h definite s y m p t o m s o f intestinal u l c e r a t i o n a n d a positive T r i b o u l e t s h o w e d a t a u t o p s y a l a r g e t u b e r c u l o u s u l c e r a t i o n in t h e l o w e r e n d o f the caecum, w i t h slight i n v o l v e m e n t o f t h e a p p e n d i x . T h e T r i b o u l e t was p e r f o r m e d o n s p e c i m e n s o f postm o r t e m f~eces, a n d w h e r e a s t h a t f r o m the s m a l l intestine g a v e a s t r o n g positive r e a c t i o n , t h e h e a v i l y b l o o d - s t a i n e d s p e c i m e n f r o m t h e c o l o n was negative. It should be observed that the almost complete concord which obtains in the g r o u p o f 8 cases e x a m i n e d a n t e - m o r t e m a n d p o s t - m o r t e m is p a r t l y a c c i d e n t a l ; t h e total q u o t a o f I 6 p o s t - m o r t e m s s h o w a d i s c r e p a n c y o f 37"5 p e r cent. b e t w e e n T r i b o u l e t a n d p o s t - m o r t e m findings, a n d b y c o i n c i d e n c e o n l y I o f t h e a b e r r a n t cases a p p e a r s in the last g r o u p .
I68
THE
BRITISH JOURNAL
OF TUBERCULOSIS
Despite this it is interesting to note that in these 7 cases agreement was complete between clinical diagnosis, post-mortem findings, Triboulet in life and Triboulet post-mortem. Conclusion.
Our clinical finding and biochemical investigation disclose no rational basis for the adoption of the Triboulet test as an aid to the diagnosis of incipient tuberculous ulceration of the intestine. REFERENCES
i. Brit. Med. oTourn., i934, ii. ioo. 2. G. HERTZBERO: Norsk. M a g . f . L~egevid., April, 1934, P. 402. 3. WALLACE AND SALOMON: Med. Klin., i9o9, v. 579. (Quoted from Long and Wells, " Chemistry of Tuberculosis," p. 3 I6.)
THE
BRITISH
JOURNAL
OF TUBERCULOSIS
THE V A L U E OF THE T R I B O U L E T R E A C T I O N IN INTESTINAL TUBERCULOSIS B Y H. J. R O B I N S O N , M.D.(DUB.), Assistant Medical Officer, Papworth Village Settlement. .AND
D. B. C R U I C K S H A N K ,
ANDS.(ED.), Member Research Staff, Papworth Village Settlement. (From the Laboratory of Papworth Village Settlement.)
An account of Triboulet's test for intestinal ulceration in a recent number of the British Medical Journal encouraged us to investigate the reaction with a view to determining the advisability of adopting the test as a routine a d j u n c t to the physical examination of the phthisical patient. Being impressed by the fact that a considerable number of fatal cases of pulmonary tuberculosis show evidence of intestinal ulceration, usually some months before death, we felt that some evidence of intestinal infection at an incipient stage would be of prognostic value. In the hope of diagnosing intestinal ulceration at this stage we utilised Triboulet's reaction and have performed this test on io 9 cases. M e t h o d of P e r f o r m i n g
the Test.
A lump of fa~ces as large as a walnut is dissolved in 2o c.c. of distilled water and filtered; 3 c.c. of the filtrate is diluted with I2 c.c. of distilled water; 20 minims of Triboulet's reagent (sublimate 3"5, acetic acid I, aqua dest. ad IOO) are added. As a control the same filtrate is used without Triboulet's reagent. The test tubes containing the two solutions are well shaken, and are compared after five and twenty-four hours. A positive reaction is indicated by a cloudy grey or brown deposit, above which the solution is clear. Biochemical Notes.
i. Albumen and globulin were detected in the faecal filtrates. Both these proteins are precipitated by the reagent. 2. T h e ratio of the albumen and globulin present in the filtrates was examined in 46 cases. This ratio showed wide variations, ranging from I.I 8 to 24"0. There was no definite relationship between the ratio and the
VALUE
OF THE
TRIBOULET
REACTION
i6 5
type of reaction, except that in the strong reactions ( + + 5 hours) the proportion of albumen tended to be high. 3. Alteration of the concentration of the f~ecal filtrate has little effect on t h e rate of precipitation, but modifies the degree of precipitation in proportion to the dilution (I/I, I/2, I/4)" 4" The effect Of the reagent on diluted blood serum was tested. Up to dilutions of J-4 5 .a positive reaction results. In greater dilutions the reaction is negative. Specimens of albuminuria and solutions of dilute egg white gave similar results. 5. The f~eces were repeatedly examined for occult blood by the benzidine test. The presence or absence of blood has apparently no influence on the reaction, presumably because the concentration never reaches the critical value of I : 5. 6. It is reported that, as a result of decomposition of the proteins, specimens off~eces obtained at post-mortem give negative reactions, although durin~ life the reactions may have been positive. We have failed, with the exception of the one case quoted below, which gave a dual reaction, to observe this phenomenon in the I6 post-mortem cases examined. Fifteen of these gave positive reactions, irrespective of the post-mortem condition; only one post-mortem specimen gave negative reactions, but the reaction was also negative during life. Further to investigate the point we kept specimens of f~eces for a period of four weeks, ample time to permit of decomposition. These were examined weekly. In every instance the reaction remained as at the commencement and, if anything, became slightly more marked as time advanced. 7. It is known that in intestinal tuberculosis f~ecal nitrogen excretion is considerably increased, and that an early sign of this infection is a drop in the total blood proteins as determined by refractometry. With a view to finding a possible connection between these factors and the Triboulet reaction, we compared in 2I cases the albumen globulin ratios of the f~ecal filtrate with the albumen globulin ratio of the blood serum. It was thought that the lowered blood protein might be the outcome of secretion from intestinal ulcers, and that a study of the respective albumen and globulin ratios of the f~eces and blood might enable one to establish the origin of the intestinal protein as a transudate from the blood fluids. No such correlation could be traced. This investigation was undertaken on the assumption that the Triboulet reaction is a true index of the intestinal condition, an assumption which the later analysis of our results showed to be unwarranted. The findings cannot therefore be regarded as significant proof one way or the other of the site of origin of the proteins which give rise to the Triboulet reaction (see Table III.).
• 16"6.
THE
BRITISH
JOURNAL
OF TUBERCULOSIS
At the commencement we realised that any clinical classification must be arbitrary, chiefly because it rested very largely on a symptomatic basis. From the point of view of investigating the test we agreed upon the following classification: i. Clinically Definite.~All those cases in which there was more or less constant abdominal tenderness and pain, nausea and intermittent constipation and diarrhoea. 2. Clinically Probable.--Those in which there occurred periodic attacks of abdominal pain, sometimes accompanied by vomiting and diarrhoea, and associated with a greater loss of weight than one would have expected from the pulmonary lesions alone. 3. Clinically Negative. All other cases were classed as negative. In every case the test was carried out without any knowledge of the clinical condition, and it was only at the end of the investigation that results were compared. T A B L E I. 93 Clinical Cases : Agreement Disagreement
. . . . . .
fT+,C+ =22~ 3 7 = ~ T - , C - -- I 5 J 39 .8 per cent.
. . . . . .
6 cT+, C5 =~T-,C+
- - 5 4 ) 6o.2 p e r cent.
8 Cases, P.M. only (Fzeces e x a m i n e d P.M.) : Agreement
. . . . . .
fT+, 3 = IT-,
P.M.+ =3) P . M . - = o f 37"5 p e r cent.
Disagreement
. . . . . .
(T+, 5=IT_,
P.M.p . M . + _ = o5} 62.5 p e r cent"
8 Cases examined Ante-mortem and Post-mortem : Agreement
. . . . . .
( Intestinal + = 6 7 = \ I n t e s t i n a l - = I j 87"5 p e r cent.
Disagreement
. . . . . .
x = fI P T .. M P ..M-. C, + T-, + )f x2"5 per cent.
T A B L E II. ANALYSIS OF 93 CLINICAL CASES.
Clinically. h
r
Triboulet T r i b o u l e t + (5 h o t ' s ) Triboulet + (24 hours)
.. .. .. .. . . . .
Negative.
Probable.
Positive.
x5 34 I8
3 8 7
I 7 o
°
VALUE OF THE TRIBOULET REACTION
"i6 7
TABLE III. i
Protein in Feces.
A I~G~ --__ A/GI
Case Wo.
Protein in Serum.
A:G.
A/G.
52 : 48 52 : 48 5 5 : 45 60 : 4 ° 68 : 32 56 : 44 52 : 48 48 : 52 63 : 37 6I : 3 9 72 : 28 56 : 44 42 : 58 56 : 44 56 : 44 58 : 42 6 3 : 37 4 4 : 56 74 : 26 65 : 35 54 : 46
t .08 1.08 I "24
Triboulet Test.
Clinical Findings.
b
4 5 7 IO
14 15 I6 2I
22 23 24 26 27 28 29 3° 32 33 34 38 4t
, !
78 : 22 82 : i8 6 5 : 35 70 : 3° 82 : i8 76 : 24 82 : i8 93:7 85 : 15 82:i8 7° : 3° 82:18 82 : 18 80 : 20 84:I6 7° : 3 ° 92:8 92:8 96:4 89: II
93:7
3"55 4"55 I'7
2"3 4"55 3"I5 4"55 I3"3 5"65 " 4"55 2"33 4"55 4"55 4"O 5"25 2"33 I 1.5 i 1.5
l
24"0 8"I I3"3
I. 5 9.,;, 1-27 I "08
0.92 1.7I 1.56
2"52 I'27 o'73 1.27 1.27 1.38
1.7I o'77 2.85 1.86
1.i 7
-
+
+ + ++
+ +
+ + + + + + + + -
+ + i I l
-
+
++ ++ ++ ++
I t will b e seen t h a t t h e r e is a d i s a g r e e m e n t b e t w e e n t h e test a n d t h e clinical diagnosis in 6o22 p e r cent. o f cases. T h i s g r o u p is chiefly c o m p o s e d o f those cases w h i c h s h o w e d n o clinical e v i d e n c e o f intestinal u l c e r a t i o n , b u t g a v e a positive T r i b o u l e t . W e w e r e p r e p a r e d for s o m e e r r o r in the clinical classification, b u t c a n n o t a c c e p t t h a t a n e r r o r o f 60.2 p e r cent. w a s present. T h e classification o f t h e clinical a n d p o s t - m o r t e m findings will be m a d e c l e a r f r o m a s t u d y o f T a b l e s I. a n d I I . O n e case w i t h definite s y m p t o m s o f intestinal u l c e r a t i o n a n d a positive T r i b o u l e t s h o w e d a t a u t o p s y a l a r g e t u b e r c u l o u s u l c e r a t i o n in t h e l o w e r e n d o f the caecum, w i t h slight i n v o l v e m e n t o f t h e a p p e n d i x . T h e T r i b o u l e t was p e r f o r m e d o n s p e c i m e n s o f postm o r t e m f~eces, a n d w h e r e a s t h a t f r o m the s m a l l intestine g a v e a s t r o n g positive r e a c t i o n , t h e h e a v i l y b l o o d - s t a i n e d s p e c i m e n f r o m t h e c o l o n was negative. It should be observed that the almost complete concord which obtains in the g r o u p o f 8 cases e x a m i n e d a n t e - m o r t e m a n d p o s t - m o r t e m is p a r t l y a c c i d e n t a l ; t h e total q u o t a o f I 6 p o s t - m o r t e m s s h o w a d i s c r e p a n c y o f 37"5 p e r cent. b e t w e e n T r i b o u l e t a n d p o s t - m o r t e m findings, a n d b y c o i n c i d e n c e o n l y I o f t h e a b e r r a n t cases a p p e a r s in the last g r o u p .
I68
THE
BRITISH JOURNAL
OF TUBERCULOSIS
Despite this it is interesting to note that in these 7 cases agreement was complete between clinical diagnosis, post-mortem findings, Triboulet in life and Triboulet post-mortem. Conclusion.
Our clinical finding and biochemical investigation disclose no rational basis for the adoption of the Triboulet test as an aid to the diagnosis of incipient tuberculous ulceration of the intestine. REFERENCES
i. Brit. Med. oTourn., i934, ii. ioo. 2. G. HERTZBERO: Norsk. M a g . f . L~egevid., April, 1934, P. 402. 3. WALLACE AND SALOMON: Med. Klin., i9o9, v. 579. (Quoted from Long and Wells, " Chemistry of Tuberculosis," p. 3 I6.)