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TUBERCULIN-POSITIVE CASES WITH NEGATIVE RADIOGRAMS
525 than those in standard leads. Dr. Freeman also reports, on p. 499, results obtained in acute coronary occlusion with another type of chest lead. His three patients, all with typical symptoms, showed limb leads characteristic of anterior infarction, and in all cases the chest lead was confirmatory, though because of the different position-he applies the left-arm electrode to the left foot and the right-arm electrode over the apex-the alterations in the waves were in the opposite sense to those recorded by Willcox and
Lovibond. The chest lead appears, therefore, to have a definite value in the diagnosis of effort angina and of acute coronary occlusion, since in a minority it shows significant changes that are absent from the curves obtained with the limb leads, though this may be true for only a limited period of the disease. It is also clear that the reverse occurs-that is, these changes may be confined to the limb leads. A confident diagnosis of both coronary occlusion and effort angina can of course be made from symptoms alone when these are typical, in the absence of change in the standard electrocardiogram ; but with an atypical clinical picture and a normal tracing from the limb leads, there is the possibility that valuable evidence may be obtained from a chest lead. There are now sufficient data to warrant using this lead in atypical cases, and further investigation may. justify its use as a routine. It is to be hoped that the exact disof the electrodes to the chest wall will position become standardised, and the method adopted by Willcox and Lovibond, with the left-arm electrode over the heart, seems to be the best
TUBERCULIN-POSITIVE CASES WITH NEGATIVE RADIOGRAMS
THE
pioneer work of Heimbeck and his Norwegian colleagues has taught others to seek in probationer nurses answers to some of the unsolved problems of early pulmonary tuberculosis. The more this material is examined, the more does it impress research workers with the facilities it provides for controlled tests. And it has become a rule in certain hospitals abroad for probationers to be tested with tuberculin and to be kept under X ray and skin-test supervision throughout, their hospital careers, during which the changes from a negative to a positive tuberculin reaction can sometimes be correlated with certain exposures to infection. In many hospitals in Finland, probationer nurses are tested with tuberculin as a routine measure ; and in a recent publication,1 Dr. Ivar Wallgren has reviewed his experiences with between 700 and 800 tuberculin-tested nurses. In the Finnish-speaking community, only about 13 per cent. gave a negative reaction to an intracutaneous injection of 1 mg. of tuberculin, whereas among the Swedish-speaking probationers, the proportion of negative reactors was about 70 per cent. The most instructive observations, however, concerned the 41 nurses whose tuberculin reactions changed from negative to positive during their training. In 30 of these there were no symptoms, no clinical phenomena indicative of a tuberculous infection ; but in the remaining 11 the transition was associated with such symptoms as fever, lassitude, headache, pain in the chest, and so forth. The radiological examinations of these 41 nurses were negative ; in only 3 cases could shadows indicative of intrathoracic tuberculosis be found. The primary focus of disease such as Ranke described a score of years ago would, therefore, seem to be seldom demonstrable 1
Finska LäkSällsk. Handl. November, 1936, p. 933.
in association with very early tuberculous infection. Yet in Wallgren’s view these nurses must have harboured a primary focus of tuberculosis in their lungs, however negative the radiological examinations may have been. In support of this opinion he gives an account of three cases in which the radiological examination proved negative although, a few days later, post-mortem examinations revealed recent primary tuberculous lesions in the lungs. These observations need not necessarily discredit the radiological examination as a guide to early tuberculosis. The evidence which the radiologist can adduce in favour of his speciality in this field is convincing enough. But between the first appearance of a positive tuberculin reaction and the first appearance of radiological shadows indicative of tuberculosis there seems to be an interval. PRONTOSIL IN ERYSIPELAS
THE clinical evaluation of Prontosil and its derivative p-aminobenzenesulphonamide is far from complete, and therapeutic studies on an adequate scale have so far fully demonstrated its capacity only in puerperal fever and in erysipelas. Further testimony to its value in erysipelas is presented by W. Becker,l who compares the results in 50 cases with those in the same number treated by other methods ; the spread of the disease was always arrested and its duration much reduced, more so by oral administration of prontosil than by intraLocal application was muscular or intravenous. found to be useless, as is fully to be expected. It is tempting to speculate on how far the amenability of different streptococcal infections to this treatment depends on their morbid anatomy ; the lesion in erysipelas is highly vascular, and since the drug circulates in the blood it seems reasonable to suppose that this is a factor favourable to its action. Its effects in other forms of surgical sepsis, on otitis media and its complications, including meningitis, and on scarlet fever, still remain to be studied on an adequate scale. We publish elsewhere in this issue two clinical notes on cases so treated, in one of which sulphaemoglobinasmia developed, and certainly contributed to a fatal result. This complication, which in previous records has been rare and only transient, must evidently be watched for; contributory causes may perhaps be identified and the condition thus avoided. Meanwhile, prontosil is being tried for a number of other purposes ; Becker himself records complete failure in the treatment of gonorrhoea, which is of interest in view of the fact that encouraging experimental results have been reported with the closely related meningococcus. He also briefly mentions good results in urinary tract infections, a claim recently made more forcefully by H. G. Huber2 who treated 14 such cases in children with what appeared to himself striking success. These more speculative therapeutic essays will be better interpreted when the experimental work which has placed the treatment of haemolytic streptococcal infections on so sure a foundation has been extended to other bacteria. Since this treatment is now being adopted on an increasing scale, and indeed should always be considered in puerperal and surgical sepsis due to Streptococcus pyogenes, it may be useful to state again in what forms this remedy is obtainable. The original prontosil, which was marketed in two forms for administration by injection or by the mouth, is now believed to act only by conversion 1 Derm. Wschr. Feb. 13th 1937, p. 221. 2 Münch. med. Wschr. Dec. 4th, 1936, p. 2014.
Lovibond. The chest lead appears, therefore, to have a definite value in the diagnosis of effort angina and of acute coronary occlusion, since in a minority it shows significant changes that are absent from the curves obtained with the limb leads, though this may be true for only a limited period of the disease. It is also clear that the reverse occurs-that is, these changes may be confined to the limb leads. A confident diagnosis of both coronary occlusion and effort angina can of course be made from symptoms alone when these are typical, in the absence of change in the standard electrocardiogram ; but with an atypical clinical picture and a normal tracing from the limb leads, there is the possibility that valuable evidence may be obtained from a chest lead. There are now sufficient data to warrant using this lead in atypical cases, and further investigation may. justify its use as a routine. It is to be hoped that the exact disof the electrodes to the chest wall will position become standardised, and the method adopted by Willcox and Lovibond, with the left-arm electrode over the heart, seems to be the best
TUBERCULIN-POSITIVE CASES WITH NEGATIVE RADIOGRAMS
THE
pioneer work of Heimbeck and his Norwegian colleagues has taught others to seek in probationer nurses answers to some of the unsolved problems of early pulmonary tuberculosis. The more this material is examined, the more does it impress research workers with the facilities it provides for controlled tests. And it has become a rule in certain hospitals abroad for probationers to be tested with tuberculin and to be kept under X ray and skin-test supervision throughout, their hospital careers, during which the changes from a negative to a positive tuberculin reaction can sometimes be correlated with certain exposures to infection. In many hospitals in Finland, probationer nurses are tested with tuberculin as a routine measure ; and in a recent publication,1 Dr. Ivar Wallgren has reviewed his experiences with between 700 and 800 tuberculin-tested nurses. In the Finnish-speaking community, only about 13 per cent. gave a negative reaction to an intracutaneous injection of 1 mg. of tuberculin, whereas among the Swedish-speaking probationers, the proportion of negative reactors was about 70 per cent. The most instructive observations, however, concerned the 41 nurses whose tuberculin reactions changed from negative to positive during their training. In 30 of these there were no symptoms, no clinical phenomena indicative of a tuberculous infection ; but in the remaining 11 the transition was associated with such symptoms as fever, lassitude, headache, pain in the chest, and so forth. The radiological examinations of these 41 nurses were negative ; in only 3 cases could shadows indicative of intrathoracic tuberculosis be found. The primary focus of disease such as Ranke described a score of years ago would, therefore, seem to be seldom demonstrable 1
Finska LäkSällsk. Handl. November, 1936, p. 933.
in association with very early tuberculous infection. Yet in Wallgren’s view these nurses must have harboured a primary focus of tuberculosis in their lungs, however negative the radiological examinations may have been. In support of this opinion he gives an account of three cases in which the radiological examination proved negative although, a few days later, post-mortem examinations revealed recent primary tuberculous lesions in the lungs. These observations need not necessarily discredit the radiological examination as a guide to early tuberculosis. The evidence which the radiologist can adduce in favour of his speciality in this field is convincing enough. But between the first appearance of a positive tuberculin reaction and the first appearance of radiological shadows indicative of tuberculosis there seems to be an interval. PRONTOSIL IN ERYSIPELAS
THE clinical evaluation of Prontosil and its derivative p-aminobenzenesulphonamide is far from complete, and therapeutic studies on an adequate scale have so far fully demonstrated its capacity only in puerperal fever and in erysipelas. Further testimony to its value in erysipelas is presented by W. Becker,l who compares the results in 50 cases with those in the same number treated by other methods ; the spread of the disease was always arrested and its duration much reduced, more so by oral administration of prontosil than by intraLocal application was muscular or intravenous. found to be useless, as is fully to be expected. It is tempting to speculate on how far the amenability of different streptococcal infections to this treatment depends on their morbid anatomy ; the lesion in erysipelas is highly vascular, and since the drug circulates in the blood it seems reasonable to suppose that this is a factor favourable to its action. Its effects in other forms of surgical sepsis, on otitis media and its complications, including meningitis, and on scarlet fever, still remain to be studied on an adequate scale. We publish elsewhere in this issue two clinical notes on cases so treated, in one of which sulphaemoglobinasmia developed, and certainly contributed to a fatal result. This complication, which in previous records has been rare and only transient, must evidently be watched for; contributory causes may perhaps be identified and the condition thus avoided. Meanwhile, prontosil is being tried for a number of other purposes ; Becker himself records complete failure in the treatment of gonorrhoea, which is of interest in view of the fact that encouraging experimental results have been reported with the closely related meningococcus. He also briefly mentions good results in urinary tract infections, a claim recently made more forcefully by H. G. Huber2 who treated 14 such cases in children with what appeared to himself striking success. These more speculative therapeutic essays will be better interpreted when the experimental work which has placed the treatment of haemolytic streptococcal infections on so sure a foundation has been extended to other bacteria. Since this treatment is now being adopted on an increasing scale, and indeed should always be considered in puerperal and surgical sepsis due to Streptococcus pyogenes, it may be useful to state again in what forms this remedy is obtainable. The original prontosil, which was marketed in two forms for administration by injection or by the mouth, is now believed to act only by conversion 1 Derm. Wschr. Feb. 13th 1937, p. 221. 2 Münch. med. Wschr. Dec. 4th, 1936, p. 2014.