The Intradermal Tuberculin Reaction

The special interest of this paper centres around diseases of bones and joints and particularly the early diagnosis of tuberculosis of the hip joint. Tuberculosis of the hip presents a difficult problem; if the diagnosis is only made on definite text-book signs much valuable time may be wasted, yet if a provisional diagnosis is made early in the disease somenon-tuberculous conditions will be included. There seems little doubt that it is better to begin treatment at once even at the expense of occasionally treating as tuberculous such conditions as coxa plana, slipped epiphysis or subacute septic arthritis of the hip. In certain cases in spite of expert observation, good skiagrams and pathological investigations it is impossible to make a definite diagnosis for several months. The opening of the joint and demonstration of the tubercle bacillus is not always justified and the sceptic may point at the successfully cured cases and ask for proof that they were tuberculous. As this early treatment of hip disease by immobilization in hospital is a serious step involving diiscomfort to the child, loss of schooling and a considerable expenditure of public funds, it is necessary in addition to a very careful clinical examination to collect all evidence which will assist. I have used the intradermal tuberculin test since the beginning of 1928 and the results obtained until August, 1931, are used in this communication. More recent cases have not been used as their ultimate diagnosis may need revision. The intradermal test was introduced by Mantouxl working in Paris in 1908 and by Mendel in Berlin in the same year. Mantoux injected into the layers of the skin of the forearm the equivalent of 001 mgm. of old tuberculin prepared by the Pasteur institute. He claimed that the technique of injection was as easy as giving an hypodermic injectilon and described the results as follows: ' Immediately after injection there is a small " boule d'oedema," which becomes absorbed and reappears after some hours as a raised papule. Later it becomes visible either white or rose coloured and in twenty-four hours is red in colour and around it is a white oedematous granite-like surface, and further outside this a rosy halo. In forty-eight hours it reaches its maximum and begins, as a rule, to subside, the size varying from a 50 centime piece to a 2 franc piece. The skin remains cool, but there is some tenderness on pressure.'