The 029hthalmo-reaction in Tuberculosis. 91

ART. V.--The Ophthalmo-reaction in Tuberculosis. By REGINALD HO~MES, B.A., M.B., B.Ch., B.A.0. Univ. Dubl.

'TRE early diagnosis of tuberculous lesions is frequently .attended with great difficulty, and for this reason any new aids in diagnosis are worthy of our attention.

In June of last year Calmette, of Lille, brought out a new method. It consists in placing a drop of a specially prepared tuberculin in the conjunctival sac of the suspected patient. This preparation is composed of dried tuberculin precipitated

1 by 95 per cent. alcohol, and a ~-1 per cent. solution of this is made with sterilised water. The procedure described by Calmette is then as follows : -

The lower eyelid of one eye is slightly pulled down bv dragging on the skin just below the eye, and a drop of the solution is allowed to fall into the lower portion of the eye. In a patient with a tubercular lesion anywhere in the body the eye into which the tuberculin has been instilled com- mences to redden in about three hours, the conjunctiva becomes congested, slightly oedematous, and there may be some fibrinous exudation and increased secretion of tears. The maximum effect is observed between the sixth and twelfth hour from the commencement. There is no pain, and no rise of temperature, and very little inconvenience, the patient, complaining only of a feeling of " grit in the eye." and every- thing is normal again in the course of two, or, at most, three days. To observe the reaction it is useful to compare the two eyes, as the inflammation in some eases may be very slight, and only to be observed by comparison. It is important to see that the conjunctiva iCself is healthy before submitting it to the test.

In patients not the subjects of tuberculosis no effect Js observed in the eye, except, perhaps, a slight mechanical irritation immediately following the instillation, which passes off in an hour or so. The intensity of the reaction does not bear any relation to the stage or severity of the disease. The reaction does not occur in very advanced or moribund

92 The Ophthalmo-reaction in Tuberculosis.

cases. It seems to act equally well both in children and in adults.

I have myself tried the test in sixty cases, with results which compare very favourably with what is claimed for it. Forty-two of these were the subiects of tuberculosis, as evidenced by unmistakeable and recognised physical signs_ They were composed of- -

35 cases of pulmonary phthisis. 2 ,, tubercular glands in the neck. 2 . . . . osteo-myelitis. 1 case of iritis. 1 ,, spinal caries. 1 ,, lupus vulgaris.

The ages of the patients varied from three years to sixty- three years. They all gave the typical reaction described. except two--one of whom was practically moribund, and lived for only three days after the test was applied ; the other was a case undoubtedly of pulmonary tuberculosis, with tubercle bacilli in the sputum, but it did not react at all. That represents forty positive reactions out of a possible forty-one (neglecting the moribund case), which is equivalent to 97.5 per cent.

I noted that the reaction usually began in about three hours, reached maximum intensity in about twelve hours, and passed away completely in about three days.

The remaining cases I tested were suf[ering from various diseases other than tuberculosis, and none of them gave the reaction. They included cases of syphilis, locomotor ataxia, malignant disease, rheumatoid arthritis, enteric fever, empyema following pneumonia, healthy adults~ and one case of " cured tuberculosis."

The case which I have called one of " cured tuberculosis " is of special interest : -

The patient was a boy, aged nineteen, suKering from tuber- cular osteo-myelitis of the fibula, with discharging sinuses. When tested with the tuberculin, his eye gave a positive re- action. He was operated on, most of his fibula being removed,

]~rotozoal Diseases i~ Man. 93

and the diseased tissues being cut and scraped away. His leg healed up completely after some time, he put on flesh, and his general health improved considerably. On testing his eye again with the tuberculin at the end of last May it gave no reaction. This suggests that the test might be employed in consumptive sanatoriums to determine the length of time a patient should remain.

From these results I think it will appear that the test is a valuable, but, of course, not an infallible, aid in the diagnosis of tubercle.

ART. VI.--Protozoal Diseases in Man." By ARTHUR FRANCIS GEORGE KERR, B.A., M.D., Univ. Dub. ; Senior Moderator and Gold Medallist in Natural Science ; Government Medical Officer, Chiengmai, Siam.

IN recent years much work has been done on the protozoa causing disease in man. This work has chiefly been in con- nection with tropical diseases, but it is highly probable that many of the diseases of temperate climates, for which a bacterial origin has long and unavailingly been sought, will prove to be of a protozoal nature.

I propose to sketch briefly the general characteristics of protozoal diseases as far as they are known, leaving out of consideration purely local lesions, to note some of the difficulties met with in investigating these diseases, and finally to outline a provisional classification of the protozoa known to occur in man.

General Characteristics o] Protozoal Diseases.--Most pro- tozoal diseases are characterised by fever of a longer or shorter duration, which tends to be intermittent. Exacerbations of the fever are often connected with rapid multiplication of the parasite. This is well seen in malaria, the clinical varieties of which depend on the length of the life cycle of the parasite in the blood. In sleeping sickness also it has

~A Thesis read for the Degree of Doctor of Medicine in the University of Dublin, July, ! 908.