Why the Sputa of Tuberculous Patients Should be Destroyed. An Observation on the Viability of the Bacilli of Tuberculosis. BY ARTHUR K. STONE, A.M., M.D., SURGEON TO THE BOSTON DISPENSARY. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, FROM March, 1891. Extracted from The American Journal of the Medical Sciences for March, 1891. WHY THE SPUTA OF TUBERCULOUS PATIENTS SHOULD BE DESTROYED. An Observation on the Viability of the Bacilli of Tuberculosis. By Arthur K. Stone. A.M., M.D., SURGEON to the boston dispensary. During the winter of 1886-87 I became interested in the growth and longevity of the tubercle bacillus, from the statement of a Washington gentleman that he had noticed a decided increase in the number of the tubercle bacilli in sputum which had been kept standing at the ordinary room temperature. (This was simply a verbal statement, and to my knowledge has never been published.) In order to verify this, a number of jars containing tuberculous sputum were set aside and examined after a period of about three months. The result of the examination was as follows: No. of case. Pate of first examination. Remarks. Date of second examination. Remarks. XIV. Jan. 5,1887 Few found. April 15, 1887 Same number. XVII. Dec. 15. 1886 Small number. April 15, 1887 Numerous, very numerous, even in masses. XVIII. Nov. 17, 188h None. April 15, 1887 None. XIX. Nov. 19, 1886 None. April 15, 1887 Numerous. XXV. Jan. 5, 1887 Small nu tnber ; one cover 3, one had only a very few (7 covers). April 15, 1887 Small number, but easily found in 8 covers. XXVIII. Jan. 7, 1887 Cystitis. Small number. April 18, 1887 Very few other bacteria, number about the same as in previous examination. XXIX. Jan. 10,1887 None. April 15, 1887 None. XXX. Jan. 19, 1887 Small number in every field. April 15, 1887 Small number to numerous; very few other bacteria present. Examination of this table would simply go to prove that for a period of three months the tubercle bacilli remained in sputa retaining their power of taking stain and so presumably alive and virulent. Case XVII. shows an increase from "small number" to "very numer- ous." Reference to notes of this case shows that in the examination of 2 STONE, BACILLUS TUBERCULOSIS. Dec. 15th five covers were examined, of which four were marked as " small number " and one " numerous." April 15th eight covers were looked through; two were marked "small number," two "numerous," four " very numerous "; and at the end of the note, " some masses, and where the preparation is well made the bacilli are present in great quantities." But on the whole, I am inclined to believe that the change was simply due to the increased density of the sputum, caused by evaporation, and to possible carelessness in selection of parts for the first examination. Case XIX. presents the remarkable statement that no tubercle bacilli were present at the first examination, while they were most easily found in every preparation at the second. The only possibility of error which could have been made in this case arose from the fact that, at the first examination, only four cover-glasses were looked over. The clinical history, as derived from the hospital records, shows that the patient left the hospital with well-marked signs of tuberculosis. From the winter of 1886-87 until December, 1889, a period of nearly three years, the various specimens of sputa remained upon the laboratory shelves quiet and undisturbed. In the meantime all the aqueous por- tions had disappeared, and there remained in some cases only a little dry dust about the edges of the glass jars, while in one or two cases there was a hard, dry, brown crust covering the whole bottom of the jar. To prove the presence of the tubercle bacilli, four examinations were made in the following manner : A drop of distilled water was put upon a cleaned and sterilized cover- glass, and then a bit of the dust or crust removed with a platinum needle rubbed over the cover-glass; usually the crusts would dissolve easily. Any crumbs were removed, the water evaporated, and the specimens stained by Ziehl's method. No. of ase. Date of first examination. Remarks. Date of second examination. Remarks. XIV. Jan. 8, 1887 Few. Dec. 7, 1889 Very few XVII. Dec. 15, 1886 Small number. Dec. 11, 1889 Small number. XX. Feb. 9, 1887 Very numerous. Dec. 11 1889 Very numerous, long, bead- ed, or in clumps. XXIV. Jan. 5, 1887 Numerous. Dec. 11, 1889 Numerous. Practically no other bacteria were present, though usually almost all sputum is especially rich in many forms of bacteria. The bacilli took the stain beautifully, and appeared as bright red as though they had been stained from a fresh specimen. Having demonstrated the presence of the bacilli in sputa kept for three years, the next thing was to prove their virulence. STONE, BACILLUS TUBERCULOSIS. 3 December 11, 1889, six rabbits were taken and two were inoculated with a mixture of the sputum dust in sterilized water from each of the following cases: XVIL, XX., XXIV. The inoculation was made beneath the skin of the abdomen. At the end of forty days, three of the rabbits were killed, and the result of the autopsies was as follows: Case XVII.-At the point of inoculation a small tumor two-thirds of an inch in diameter, tilled with a white semi-fluid substance, the con- sistency of very thick cream. Peritoneum, liver, spleen, and lungs normal. Cover-glass preparations were made from the contents of the tumor, and a few tubercle bacilli were found. Sections of the tumor made later showed no tubercle bacilli. Case XX.-Animal much thinner than when inoculated. A slight thickening was present at the point of inoculation with semi-fluid con- tents. Peritoneum, spleen, and lungs were normal; liver had several white nodules size of the head of a small pin. Cover-glass preparations from the contents of tumor at point of inoculation showed a few bacilli, though rather questionable in character and not well stained. Section of the liver nodules showed the presence of the coccidia oviformi. Case XXIV.-Nothing at the point of inoculation. Abdominal cavity more oedematous than usual. Peritoneum, spleen, and lungs were normal. Few white nodules in liver, which showed no tubercle bacilli on section. The results thus far prove nothing, as the few tubercle bacilli found might have simply been some which were put under the skin at the time of the inoculation in December. The three remaining rabbits were again used and inoculated with the same mixtures as before, but this time the inoculation material was put into the abdominal cavity, the previous experiment having proved that there was no danger of septic infection. The second inoculation took place February 2, 1890, and the rabbits were killed March 28th. Case XVII.-The seat of the first inoculation showed a small cyst with a few drops of semi-fluid substance, from which cover-glass prepa- tions were made. On opening the abdominal cavity, a white nodule (1 x 1.5 cm.) was found adherent to the abdominal wall at the point of inoculation. Another large mass lay in, and adherent to, a fold of the larger intes- tine. Several other smaller nodules were found at various parts of the omentum. Other organs normal. All these nodules had semi-fluid white contents, and of this cover-glass preparations were made with the following results: From the old seat of inoculation, tubercle bacilli lying in clumps of three or four; from mass in side of abdominal wall, four cover-glasses, all showing presence of tubercle bacilli; from the large nodule, several scattered bacilli and one clump of six or eight; from omental nodule, a clump of undoubted bacilli. Case XX.-Slight cyst at point of old inoculation ; cover-glass prepa- rations from the contents were made. No signs of general peritonitis, but adherent to the large intestine and the mesentery were numerous nodules the size of a pea, and having the general appearance of fat. 4 STONE, BACILLUS TUBERCULOSIS. Section, however, showed them to be cystic, and filled with soft, white material from which cover-glass preparations were made. Lungs were normal. The liver contained several small white nodules, which, how- ever, had the appearance of coccidia. Spleen contained one small white nodule. The cover-glass preparations from the cystic growths showed the presence of the tubercle bacilli, few in numbers, but per- fectly distinct. Six preparations from the contents of the old inocula- tion growth all showed the presence of the tubercle bacilli. Case XXIV.-All the internal organs were normal. At the point of the first inoculation was a nodule (2x2 cm. in diameter). Cover- glass preparations made from the contents showed the presence of a few bacilli. In this case there had always been some doubt whether any of the inoculating fluid had entered the abdominal cavity on account of the leakage of the syringe. Although the re-inoculation of an animal is a slightly irregular pro- ceeding, yet in this case it is one to which no exception can be taken. The second inoculation simply increased the dose of tubercle bacilli, and at the same time put them in a more favorable condition for absorption. The result goes to prove that the bacillus of tuberculosis is not only capable of receiving staining material, when three years old, even though the medium in which they were suspended had been reduced for a period of more than two years to absolute dryness, but that it is also surely alive and virulent. The virulence, to be sure, seems to have been modified by the general drying process, so that the animals were capable of resisting to a much greater degree than usual the poison when intro- duced. Another interesting point is in regard to the life-history of the tubercle bacilli. The bacilli, during all the process of drying, had managed to keep their original form and condition, and had not undergone spore- formation. Such, at least, is the fair inference to be drawn from the fact that all other forms of bacteria had disappeared from the sputa dust, while the tubercle bacilli remained and appeared as fresh as though coming from a recent specimen of sputum. The practical importance of this observation is simply to emphasize the need of the destruction of the sputa of all phthisical patients. The elaborate and painstaking article of Cornet1 put beyond the shadow of a doubt the fact that a large part of the present widespread tuberculosis was due to the constant exposure of persons who were in a state of low physical condition, or minimum resistance to inoculation with tubercle bacilli to pulverized sputa of tuberculous subjects. Bearing this fact in mind, and adding the results as above obtained, that the dried tuber- culous expectorations can remain for a long time-namely, three years -virulent, the practising physician can see the great importance of the destruction of all sputa which may contain the tubercle bacilli. 1 Zeitschrift fiir Hygiene, B. v., 1888. STONE, BACILLUS TUBERCULOSIS. 5 Experimenters and investigators have all pointed the profession in the same road. There has been no clash, no conflicting statements, and to-day practically everyone agrees to the infectious nature of tuber- culosis. But, as Dr. Shakespeare said in closing the discussion on his able paper upon the subject, " What can and should be done to limit the prevalence of tuberculosis in man ? " 1 " What use was it for Koch to have made his discovery of the infec- tious nature of the bacillus tuberculosis, if the practitioners of medicine, those who come in direct contact with the people, who are the natural agents for arousing such a public sentiment and enforcement of laws for the protection of public health, utterly neglect to act upon the ample and exact knowledge which we already possess concerning the etiology and prophylaxis of tuberculosis ? " And it may be added that the value of such careful work as that of Cornet and others, and the value of such a single small observation as the one recorded in this paper is entirely lost, if the practising physi- cians do not set themselves to work to do their part toward eradicating this great public danger. This is hardly a paper in which to enter into details of how prophy- laxis should be carried out, but at the same time a few hints may not be entirely out of place. All rooms which have been occupied by tuberculous persons should be most thoroughly cleansed before allowing them to be used again. As the best means to accomplish the destruction of the sputa, the physician should tell both the patient and the family of the danger which lies hidden in the expectoration. And then he should insist that all the expectoration shall be destroyed. In the houses of the rich, it is very easy to provide the small paper sputa cups which can be burnt, and thus absolutely destroy the bacilli. Poor people can be made to use pieces of newspaper, which can be thrown into the fire and so destroyed. Fire is by all odds the best means for de- struction. Corrosive sublimate solutions and carbolic acid require so long a time before they accomplish their work, that usually the cup containing the sputa is emptied before the bacilli are killed. Everyone will grant that if they are emptied into the sewer, their future harm- lessness is probably insured, yet as Volsch has found tubercle bacilli after six months in a foul fluid, and as the above experiments show that the resisting power of the tubercle bacilli is very great, it will be safer to rely on fire for the absolute destruction of tuberculosis ma- terial? 1 Transactions of the Association of American Physicians, 1890. 2 The above work was done in the Bacteriological Laboratory of the Harvard Medical School, and the paper read before the Massachusetts Medical Society, Suffolk District, Section for Clinical Medicine, Pathology, and Hygiene. THE AMERICAN JOURNAL of the MEDICAL SCIENCES. MONTHLY, $4.00 PER ANNUM. WITH 1891 The American Journal of the Medical Sciences enters upon its seventy- second year, still the leader of American medical magazines. 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