The discovery by von Pirquet of the cutaneous reaction, by Calmette and Wolff-Eisner of the ophthalmic, and by Moro of the percutaneous, have been hailed with joy and satisfaction. In reporting on them, men of wide experience and learning have been careful to observe that the usefulness of the tests is not fully established, but almost every one has expressed great satisfaction that they give no alarming general symptoms and that they are perfectly harmless. Together with others, I have been

more »

... husiastic over them and applied them in several cases, before resorting to the old method of injecting T. O., and I had the opportunity to observe two specific reactions after the application of the von Pirquet test. In both cases there was also the specific reaction in the foci of the disease. I, therefore, call them "focal reactions." Following is the history of the two cases: Case 1.\p=m-\November, 1908. Patient.\p=m-\F.,Irish-American; aged 27; bookkeeper; brother died of tuberculosis; sister was suffering from it; mother died young, cause unknown; father living, aged 64; healthy; two brothers living and healthy. The patient had a few night sweats during August; felt weak, but noticed no other symptom. He feared tuberculosis and was examined by several doctors; results were negative. Sputum was examined several times, by myself among others, with negative results. There was loss of one or two pounds of flesh during long intermissions, but rapid return to original weight. Present State.-Pulse, 84. Temperature, 98.2 to 98.6, taken for three days. Chest expansion, 3% inches. Respiration, 19. Height, 5 feet 5% inches. Weight, 152 pounds. Body well nourished; appetite and digestion good; no cough and no expectoration except on rare occasions in the morning. Physical examination revealed nothing of significance. Von Pirquet Test.-November 12, about noon, the von Pirquet test was applied in the usual manner, care being taken that there should be no extravasation of blood by the scarification. In the evening the patient complained of an uncomfortable feeling in the chest; coughed; temperature 100.4; pulse, 96. There was no evidence of a cutaneous reaction. I examined his chest, but noted no other signs outside of harsh breathing in the right apex. The fever left the patient about nineteen hours after the application of the test. He had a good night's rest, but felt somewhat tired in the morning. After having a good breakfast, however, he felt as well as ever. Cutaneous reaction was looked for, but not found. Before resorting to the T. 0. diagnosis, another specimen of patient's sputum was examined and revealed the presence of tubercle bacilli to the number of one to three in every third or fourth field. About thirty fields were examined. The sputum was centrifuged and washed. The fever, the harsh breathing in right apex, the oppressive feeling in chest and other phenomena were therefore due to the action of tuberculin absorbed through the skin. Case 2 .-March 29, 1909. Patient.-Mrs. M. B., American; aged 35; married; was engaged in light housekeeping; husband healthy; father died at 48; mother at 42; both of some lung disease; deaths abo :.t two years apart. Ono brother died recently of laryngeal tuberculosis. No other members of the family living. The patient's voice became husky some three or four months previous to examination. There was also some pain on deglutition, mostly a burning and lump sensation in the throat. The patient had night sweats for one week; lost some flesh, but regained it quickly; became hoarse for a day or two every ten or fourteen days; did not think she had had fever at any time. Present State.-Pulse, 108. Temperature for three days, 98, a. m., 98.6, p. m. Respiration, 20. Chest expansion, 2% inches. Height, 5 feet 3y2 inches. Weight 128y2 pounds. The patient complained of no pain; coughed sometimes in the morning; expectoration was scanty; appetite and digestion fair; microscopic examination of sputum revealed numerous streptococci and staphylocoeei, but no tubercle bacilli. Sputum was centrifuged and washed as usual. Physical examination of chest revealed nothing; laryngoscope showed just a slight pallor of tissues. Von Pirquet Test.-This was administered in the usual manner. Eight hours after the test I found the patient in bed. Her face was very much flushed with a cyanotic hue; she felt sick and vomited; her voice was hoarse; she complained of oppressive feeling in the chest, especially on the right side; had pain in her throat, even on drinking water; could not take food; coughed and expectorated thick "chunks." Pulse 140. Temperature, 102.6. Respiration, 28. Physical examination revealed moist rales in right apex. Laryngoscopic examination, made early next morning, about eighteen hours after inoculation, revealed hyperemic patches over epiglottis and the right rima glottidis; magnifying mirror was used and the hyperemic spots gave the appearance of papilla or small dots closely resembling the strawberry tongue in scarlet fever, but they had a bluish tint. Temperature went up to 104 within twenty-four hours, but declined rapidly. Within six hours (thirty hours after inoculation) it came down to 99.8. The decline afterward was more slow and in twelve hours it came down to normal (forty-two hours after the inoculation), and in fifty-six hours after the inoculation the patient felt well. This was certainly a specific reaction due to the tuberculin, the severity probably being increased by the mixed infection. After observing these two reactions, I concluded that they were due to the specific reaction of the tuberculin applied according to von Pirquet's method. When we analyze clearly what we administer in the von Pirquet test we need not be surprised at this reaction. One drop of a 25 per cent, solution of T. O. is usually employed. This represents 15 mg. of tuberculin, if all of it should be absorbed by the skin. One-half of the tuberculin, let us suppose, is left on the applicator, which is used to rub in the tuberculin; let us further allow that one-half of the remainder goes also to waste ; still there is left 3.75 mg. to be absorbed by the skin, if the skin absorbs it at all. If the skin does absorb it, an initial dose of 3.75 mg. is certainly too high. But observers have so far seen no ill effects from the cutaneous reaction. I have also employed it in several cases with no bad results. The question that I wish to raise is: What is really the effect of the tuberculin on the skin ? Has the reddened surface around the inoculated spot anything in common with the specific tuberculin reaction, or does it act only as an ordinary irritant on tiie skin that may possess more or less sensibility to its irritation? If so, we should get the cutaneous phenomena in positively non-tuberculous individuals, whose skin is sensitive to tuberculin. Bandelier and Roepke seem to hold that view. In their "Lehrbuch der spezifischen Diagnostik und Therapie der Tuberkulose" they make the following statement while discussing the von Pirquet test, though with another object than mine: Downloaded From: http://jama.jamanetwork.com/ by a UNIVERSITY OF SYDNEY LIBRARY User on 06/09/2015