798 PRISSICK AND MASSON: CERVICAL LYMPHADENITIS Canad. M. A. J.Nov. 15, 1956, vol. 75

FINBEP.G, L. AND HARRISON, H. E.: Pediatrics, 16: 1, 1955.GRABER, I. G., BEACONSFIELD, P. AND DANIEL, 0.: Brit.

med. J., 1: 778, 1956.HOLMES, J. H. AND GREGERSEN, M. I.: Amer. J. Physiol.,

162: 326, 1950.JONSSON, B.: Acta pxdiat., Stockh., 40: 401, 1951.KIRMAN, B. H. et al.: Arch. Dis. Childh., 31: 59, 1956.LUDER, J. AND BURNETT, D.: Ibid., 29: 44, 1954.MACDONALD, W. B.: Pediatrics, 15: 298, 1955.MCCANCE, R. A.: Proc. roy. Soc., B, 119: 245, 1936a.Idem: Lancet, 1: 643, 704, 756, 823, 1936b.MCCANCE, R. A. AND WIDDOWSON, E. M.: Proc. roy. Soc.,

B, 120: 228, 1936.Idem: Arch. Dis. Childh., 29: 495, 1954.Idem: J. Physiol. (Lond.), 133: 373, 1956.MCCANCE, R. A. AND YOUNG, W. F.: Brit. med. Bull., 2:

219, 1944aIdenm: J. Physiol. (Lond.), 102: 415, 1944b.PITTS. R. F.: Harvey Lect., 48: (1952-53) 172, 1954.

PITTS, G. C., JOHNSON, R. E. AND CONSOLAZIO, F. C.:Amer. J. Physiol., 142: 253, 1944.

ROBINSON, J. R.: Reflections on renal function, BlackwellScientific Publications, Oxford, England, 1954.

SCHULTZE, M. O.: Proc. Soc. exp. Biol., N.Y., 72: 613, 1949.SCHULTZE, M. 0. AND HALVORSON, H. O.: J. Anim. Sci.,

8: 629, 1949.SCHWARTZ, W. B., ORNING, K. J. AND PORTER, R.: J. clin.

Invest., 34: 918, 1955 (abst.).SINGER, R. B. et al.: Medici/ne, 34: 51, 1955.SNELLING, C. E.: J. Pediat., 22: 559, 1943.STANBURY, S. W. AND THOMSON, A. E.: Clin. Sci., 11:

357, 1952.SWAN, R. C., PirTs, R. F. AND MADISSO, H.: J. clin. Invest.,

34: 205, 1955.WARING, A. J., KAJDI, L. AND TAPPAN, V.: Amer. J. Dis.

Child., 69: 323, 1945 (abst.).WEIL, W. B. AND WALLACE, W. M.: Pediatrics, 17: 171,

1956.

CERVICAL LYMPHADENITISIN CHILDREN CAUSED BYCHROMOGENIC MYCOBACTERIA*

F. H. PRISSICK, M.D. andA. M. MASSON, M.D., -Montreal

INTRODUCMIONINTEREST IN THE pathogenic significance ofchromogenic acid and alcohol-fast rods has re-cently been increased through further reportsof their isolation from human infections. In thepast, strains from this group of microorganismshave been described on numerous occasionsfrom a wide variety of sources such as plants,reptiles, and warm-blooded animals, includingman. Many of the strains reported from humansources have shown markedly pigmented colo-nies, and some though not all of them have beenconsidered to be saprophytic.16 Since the roleof these microorganisms in the pathogenesis ofthe lesions from which they have been isolatedis not always established, we are contributing astudy of 14 strains of chromogenic acid-fast andalcohol-fast rods, 10 of which were obtained inpure culture from pus aspirated from suppurat-ing facial, submaxillary or cervical lymph nodesin children in whom the clinical picture sug-gested a tuberculous infection.

Previous investigations of the classification,cultural characters and pathogenicity of thegroup of chromogenic acid-alcohol-fast rodshave been referred to in a comprehensive studypresented by Tarshis and Frisch in 1953.7 Theycontribute informative details on the cultural,

*From the Montreal Children's Hospital and the Depart-ment of Bacteriology and Immunology, McGill University,Montreal.

pathogenic, and hypersensitivity-inducing char-acters of a collection of 26 chromogenic strainsobtained by several workers from sources whichinclude for the most part sputum, lung abscessand gastric lavage specimens.

Since the above paper appeared, there havebeen other reports of isolation from diseasedtissues12, 13, 16, 17, 21-23, 25, 36 and some studies onthe growth and metabolic characteristics.'4' 15

DERIVATION OF STRAINSSeries 1. Ten strains of the present study have

been isolated from pus aspirated from facial;submaxillary or cervical lymph nodes in youngchildren.

526 CMH.*-1/2-year-old female had a dark redpreauricular swelling for five months. Radiograph of lungsnormal. Oral BCG at birth. No family history of tuber-culosis. Lymph node not excised. Aspirated pus grewyellow pigmented colonies of acid-fast and alcohol-fastrods on Lowenstein's medium at 370 C.

1356 CMH.-3-year-old male in good health until hedeveloped a painless, red, soft lump on the right sideof the neck, three months before admission. Receivedoral BCG at birth; positive patch test; negative chestradiographs. No family history of tuberculosis. Acid-fastrods found on direct smear of aspirated pus, and yellowpigmented colonies grown slowly on L6wenstein'smedium at 370 C.

1637 CMH.-3-year-old boy with right-sided mandibu-lar fluctuant swelling. Patch test positive; no BCGvaccination; chest radiograph normal. No family historyof tuberculosis. Lymph nodes aspirated but not removed,and acid-fast rods appeared in cultures on Lowenstein'smedium after five weeks' incubation at 370 C.

2465 CMH.-7-year-old boy with four weeks' historyof right-sided mandibular and cervical lymph nodeswelling. Patch test, negative two years before, hadbecome positive. No BCG; chest radiograph normal;

*CMH-The Children's Memorial Hospital, Montreal, nowThe Montreal Children's Hospital.

Canad. M. A. J.Nov. 15, 1956, vol. 75 PRISSICK AND MASSON: CERVICAL LYMPHADENITIS 799

no family history of tuberculosis. Pus aspirated fromlymph node showed few acid-fast rods, which grew infour to five weeks as yellow pigmented colonies onLowenstein's slopes at 370 C. Guinea-pigs inoculatedwith pus developed no lesions in three months. Histo-logical picture of lymph node excised from patientdescribed as compatible with fibro-caseous tuberculosiswith beginning infiltration into subcutaneous tissues.

3327 CMH.-2-year-old boy with chronic otitis mediaand right preauricular adenitis of subacute type. Patchtest weakly positive; no BCG; chest radiograph showedperibronchial infiltration. Patient's father found to haveactive tuberculosis. Lymph nodes aspirated and laterexcised. Occasional acid-fast rods found in pus on bothoccasions, and slow growth of bright yellow colonies onLowenstein's slopes at 37° C. Guinea-pigs inoculatedwith pus showed no lesions in three months. Histologicalpicture of excised node reported as compatible with atuberculous infection.

623 RVH.*-3%-year-old female, with a lump the "sizeof a walnut" in right cervical region for one month.Skin over the area became reddened; Mantoux test posi-tive 1 in 1,000; BCG vaccination unknown. Radiographsof chest negative. Smear of pus aspirated from nodeshowed one acid-fast rod. Several pigmented coloniesof acid-fast rods grew in five weeks on L6wenstein'sslopes. Histological report on patient's lymph node notedtuberculous caseation, giant cells and chronic inflamma-tory cells.

3536 HSCT.t-Female child with unopened cervicalnode swelling and positive O.T. reaction. Pus aspiratedshowed no acid-fast rods, but orange pigmented coloniesdeveloped on media used for isolating Mycobacteriumtuberculosis; guinea-pig inoculation negative in threemonths' time.

4333 HSCT.-Female child with unopened cervicalnode swelling and positive Mantoux reaction. Aspiratedpus showed no acid-fast rods but they grew slowly asorange-yellow colonies. Guinea-pig inoculation negativeat three months.

5099 HSCT.-Male child with cervical node swellingand positive tuberculin test. Brother and great aunt saidto have had tuberculosis. Node excised unaspirated, andpus showed many acid-fast rods. These grew slowly inorange pigmented colonies on L6wenstein medium.Guinea-pigs inoculated with culture showed a fewcaseous lumbar nodes in which acia-fast rods were seenby smear and grown in culture as pigmented colonies.Histologically, the lymph node appeared tuberculous,though numerous polymorphs were present.

8053 HSCT.-Female child with closed cervical nodeswelling and positive tuberculin test. Smear of aspiratedpus showed two acid-fast rods after prolonged search.Cultures grew acid-fast rods in yellow-orange pigmentedcolonies. Guinea-pig inoculation negative.

Series 2. Two strains isolated from pus aspi-rated from the pleural cavity.

185 RVH.-Adult male with chronic cough and weightloss of 35 lb. in five months. Empyema of left chestoperated upon; pus removed grew smooth, orange-yellowcolonies of acid-fast rods on Lowenstein medium. Biopsy

*Royal Victoria Hospital, Montreal.tHospital for Sick Children, Toronto.

of pleura showed no histological evidence of tuber-culosis or malignant disease. Patient's condition improvedand he was discharged.

1540 RVH.-Adult malewithstaphylococcal empyema.Acid-fast rods not seen on direct smear, but yellowpigmented colonies of acid-fast rods grown in 3 weekson Lowenstein slopes. Patient regarded as cured by anti-biotic therapy and strain considered to be a contaminant.

Series 3. Two strains isolated from openlesions.

8829 HSCT.-Female child, old poliomyelitis patient,with negative tuberculin reaction. Bronchial fluid, ob-tained at bronchoscopy, grew acid-fast rods in deeporange-yellow, rough colonies on medium for isolation ofMyco. tuberculosis.

4344 CMH.-9-year-old female suspected of havingtuberculosis of the knee joint. Tuberculin test positive;no BCG; chest and joint radiographs suggestive of tuber-culosis. Father proven to have tuberculosis and mothersuspected but not investigated. Scrapings of tissue fromjoint lesion grew acid-fast rods in yellow pigmentedcolonies on L6wenstein slopes together with typicalMyco. tuberculosis. Tissue sections revealed a histologicalpicture compatible with tuberculosis.

Since a preliminary report on these 14 strainswas made in December 1951,39 an additional 15apparently similar strains have been recoveredin pure culture from facial or cervical lymphnodes.

HISTOPATHOLOGY OF THE LYMPH NODESThe following description and comment on the histo-

logical appearance of the lymph nodes which have beenexcised from these patients at the Children's MemorialHospital' is contributed by Dr. F. W. Wiglesworth,Director of the Department of Pathology.

"The gross and histological lesions of theresected lymph nodes in eight children couldnot be differentiated from those of tuberculosis.Tubercle formation, necrosis, caseation, granula-tion tissue, scarring and calcification were allseen, depending on the stage of the process.Numerous macrophages and multinucleatedgiant cells were present in most instances.Furthermore, in some instances the disease, liketuberculosis,, had spread to form subcutaneousnecrotic and caseous abscesses with involvementof the skin."The only finding of interest was the presence

of Schaumann bodies in occasional multi-nucleated giant cells. These were found in theroutine sections of the surgical specimens fromfive of the eight patients. These bodies are statedto be rarely, if ever, seen in unequivocal tubercu-losis but whether their presence in the lesions

*Now The Montreal Children's Hospital.

800 PRISSICK AND MASSON: CERVICAL LYMPHADENITIS

produced by chromogenic acid-fast organisms isof diagnostic significance, or not, is unknown."There follows a brief summary of the morpho-

logical, cultural and biological characters of thestrains. A detailed account is to appear in aseparate paper in the Canadian Journal of Micro-biology (February, 1957).

MORPHOLOGY AND STAINING PROPERTIESShort rods when found on direct smear from lesions,

granular, often filamentous on milk medium, cords incon-stant (Dubos' medium); no branching demonstrated;acid and alcohol fast, resisting 10 minutes' exposure toacid and alcohol and some resisting one hour's exposure.

Colony appearance.On primary isolation bright yellow colonies appeared

between the fourth and fifth week on L6wenstein slopesat 370 C. and the colour deepened with age. Colonieswere 1-2 mm. in diameter, smooth, convex and opaqueand emulsified easily in normal saline to give an homo-genous suspension; two of the strains were rough, how-ever. Growth on streak subcultures appears in 10-14days, tends to be confluent and becomes papillate onfurther incubation.

Optimum temperature.Optimum temperature 370 C.; growth also occurs,

but more slowly, at room temperature; no growth at470 or 500 C.

Oxygen requirements.Growth best under ordinary atmospheric pressure;

can grow under 15% C02 but more slowly than underatmospheric pressure; no growth obtained under anae-robic conditions, except for one strain.

Resistance to heat.Ten out of 14 resist one hour's heating at 560 C.;

six out of 14 resist 30 minutes' heating at 600 C.

Growth requirements.Optimum growth on egg media, Bordet-Gengou slopes

and Dubos' fluid medium; scanty growth on peptoneagar; scanty growth or no growth on Lbffler's serum;11 out of 14 utilize paraffin as a sole source of -carbon(paraffin-coated rod in Czapek base medium); no phenoltolerance (0.5%).

Biochemical characters.Sugars not fermented; gelatin not liquified, indol not

formed; nitrates not reduced to nitrites except for onestrain.

In vitro tests for appreciation of virulence.Neutral red test: negative in 13 strains out of 14.Para-aminosalicylic acid: one inhibited by 1 mcg., five

inhibited by 10 mcg., four inhibited by 100 mcg., fourinhibited by 1,000 mcg. of PAS per ml.

PATHOGENICITYEach strain was inoculated into four guinea-

pigs, three or four hamsters, four rats and twohens; hens were inoculated by the intravenousroute, half the smaller animals were inoculatedsubcutaneously and the other half intraperito-neally. Skin tests were made prior to inoculationand two months afterwards using human and

Canad. M. A. J.Nov. 15, 1956, vol. 75

avian old tuberculin (O.T.) and an extract pre-pared from the homologous chromogenic strain;only animals showing negative reactions to allmaterials on primary testing were used for inocu-lation.The animals were kept under observation for

a period of three months, at which time thesurvivors were sacrificed; those dying during thisperiod as well as the sacrificed ones wereautopsied, smears were made from any lesionfound and cultures to recover the strain wereattempted when sufficient material was available.

Localized lesions were consistently producedin guinea-pigs inoculated intraperitoneally withthe strains isolated from cervical lymph nodes;one of the guinea-pigs inoculated with the strainisolated from material obtained by bronchialaspiration showed an abscess at the site of inocu-lation but no lesions were produced by thestrains isolated from the empyema or knee jointfluid. Generalized lesions were rarely observedand did not lead to progressive disease. Localizedlesions were occasionally found in rats andhamsters inoculated with strains isolated fromcervical lymph nodes; one hen showed general-ized lesions of the pleura, lungs and pericardium,but no lesions were found in any other. Nolesions were found in rats, hamsters or hensinoculated with the strains from other sources.

Allergic reactions were elicited in most of theguinea-pigs tested with all the chromogenic ex-tracts except for one strain (185); positive re-actions to these extracts were likewise elicitedin most of the hens and in an occasional rat;hamsters showed in some instances doubtfulreactions only. No response to avian O.T. waselicited in rats, hamsters and guinea-pigs; how-ever, positive reactions were found in most ofthe hens. Doubtful reaction to human O.T.occurred in a few guinea-pigs, but no responsewas elicited in rats or hamsters; hens were nottested.

DISCUSSIONIt has been suggested that unusual strains of

acid-alcohol fast rods have been more frequentlyisolated since the introduction of streptomycintreatment of tuberculous conditions27 but it isdoubtful that the antibiotic has any connec-tion with the incidence of isolation of thesechromogenic microorganisms, for they were de-scribed long before streptomycin was availableand are now isolated from patients who have

Canad. M. A. J.Nov. 15, 1956, vol. 75 PRISSICK AND MASSON: CERVICAL LYMPHADENITIS 801

never received this drug, as was the case withour 10 strains from lymph nodes. It is morelikely that they are found with greater frequencynow because the number of cultures for isolationof Myco. tuberculosis has increased during thelast decade, with less reliance placed on directsmears for diagnosis. Reference can be made tovarious reports on this subject.1' 7, 10, 14, 23-26The significance of such findings has to be

evaluated as to taxonomic position and as topathogenicity.

1. DISCUSSION OF THE CULTURAL ANDBIOLOGICAL CHARACTERS

Acid-fastness and alcohol-fastness is not aproperty of one single family but of severalgroups of microorganisms belonging to theorder Actinomycetales. This order includes thefamily Mycobacteriacea- and the family Actino-mycetaceae; within this last-named family, somespecies of the genus Nocardia have been foundto cause disease in man.'9 Our chromogenicstrains differ from Nocardia. Most Nocardiashow branching on culture, although some havea tendency to break up into rod-like elements incultures, or in the tissues.18'19 As a rule, acid-fastness is partial in Nocardia, which do notlong resist exposure to acid and alcohol. Theyusually grow within a few days on primaryisolation and do not require any special mediafor their development. Branching could not bedemonstrated in any of our chromogenic strains,although filamentous forms were present tosome degree in all strains growing in litmusmilk. However, several (3327, 1637, 4344, 8829,4333) exhibited marked pleomorphism in thismedium, showing filaments together with shortcoccoid rods, marked beading and spindle-shaped thickening. All strains were stronglyacid-alcohol fast. They differ from Nocardiaasteroides by their strong acid-fastness and theabsence of branching; they differ from Nocardiaintracellularis by the lack of phenol toleranceand the absence of branching.By their morphological characteristics and

their staining reactions, they belong to the Myco-bacteriaceae.They differ from Myco. tuberculosis var.

hominis in at least one of the following charac-teristics: ability to grow at room temperature,resistance to heat, resistance to para-aminosali-cylic acid, and ability to utilize paraffin as asole source of carbon.

Another possible explanation is that they arechromogenic variants of Myco. tuberculosis var.hominis, bovis or avium; such variants have beendescribed by various authors.10 32-34 The charac-teristic of these variants is the decrease inpathogenicity for animals on experimental inocu-lation.Some observations very similar to ours were

published a few years ago35 leading to the con-clusion that the chromogenic strains isolatedfrom cervical lymph nodes were pigmentedstrains of Myco. tuberculosis var. avium. Ourstudies do not allow us to draw the same con-clusions because animals which showed lesionsdid not give any positive skin test with aviantuberculin; moreover, hens remained in goodhealth although inoculated with large numbersof bacilli by the intravenous route; they showed,however, an allergic response to aviantuberculin.Response of all inoculated animals to human

tuberculin has been poor or absent and this hasled us to support the viev that they belong toa different species of Mycobacterium. They aredifferent from the more recently describedpathogenic Mycobacteria, namely Alycobacte-rium ulcerans,23, 25 Mycobacterium balnei,36Mycobacterium fortuitum21, 22 and severalothers12<17 in their optimum growth temperatureat 370 C. or their pathogenicity for guinea-pigs.A last possibility to be considered is con-

tamination of the specimen by saprophytic Myco-bacteria introduced by technical error such asthe use of improperly sterilized glassware; theterm contaminant may be extended to includeMycobacteria normally present in certain partsof the body, such as Myco. smegmatis in urineor the various Mycobacteria ingested with food24which can be found in the gastric juice. Thelabelling of all findings of unusual and atypicalacid-fast strains as contamination is an easy ex-planation but not satisfactory or necessarily true.In most of the cases described in this paper,there is no evidence that the strains isolated wereintroduced through technical error or representsurface saprophytes since all except two wereobtained from non-fistulous lymph nodes or thepleural cavity, and in many instances were seendirectly in material from the closed lesions.

If contamination is eliminated, other possi-bilities remain. One is the chance mixture ofsaprophytic and pathogenic Mycobacteria.31 Inthe strains we have described, this has apparently

802 PRISSICK AND MASSON: CERVICAL LYMPHADENITIS

occurred in one instance only (4344). In no otherspecimen has a mixture of acid-fast bacilli beenfound and the chromogenic strains grew in pureculture from the lesions in man and were isolatedin pure cultures from lesions experimentally pro-duced in animals.

2. EVALUATION OF THE PATHOGENICITY

All our experimental animal data, which areadmittedly as incomplete as those amassed byother observers, emphasize the difficulty of evalu-ating with accuracy the pathogenicity of suchstrains. It is well to recall Pinner's5 summary ofthe situation in this respect. He reminds us thatthe term pathogenicity is nearly meaningless un-less it is strictly defined in terms of animalspecies, dosage, time interval between infectionand pathological examination. There is, more-over, no general agreement on what constitutesdisease in infected animals. "If any demonstrabletissue alterations be called disease, then anyorganism causing them is considered pathogenic"and "to assign the term pathogenic only to thosecausing progressive disease would exclude amajor portion of all so-called pathogenic (nonacid-fast) organisms". He suggests that theinterval between infection and autopsy may betoo long in experimental inoculations and thatthis may account for the absence of lesions inmany studies with these chromogenic acid-faststrains from human and animal sources. It maywell be also that the animals have not been keptlong enough.The four strains from lesions other than in-

fected lymph nodes are difficult to correlate withthe clinical picture of the patients from whomthey were isolated. Tests for their pathogenicityhave not been conclusive.The remaining strains, isolated from ten chil-

dren with subacute lymphadenitis, are of low-grade pathogenicity under our experimental con-ditions. The intraperitoneal injection of approxi-mately 600 million organisms has consistentlyproduced lesions in guinea-pigs, and the lesionshave been observed as early as two weeks afterinoculation and were present three months after-wards. These strains differ in pathogenic be-haviour from Myco. tuberculosis in not causingprogressive disease and by their lack of tendencyto produce ulcerative lesions in patients as inexperimental animals. Allergic response can beobtained in inoculated guinea-pigs and hens withtuberculin-like extracts of the strains, but the

Canad. M. A. J.Nov. 15, 1956, vol. 75

poor or absent response to human or avian tuber-culin suggests that they possess a componentof their own.

CONCLUSION

Because the morphology, staining character-istics, cultural behaviour and pathogenicity ofthese chromogenic strains differ markedly fromthe species of Nocardia and Mycobacterium withwhich they have been compared, it is suggestedthat they be distinguished from other acid-fastspecies by the name Mycobacterium scrofu-laceum (N. sp.).

SUMMARY

The present communication describes thesource, morphology, staining reactions and thecultural, biochemical and pathogenic charactersof 14 strains of chromogenic acid-alcohol fastrods isolated from pathological specimens fromhuman infections suspected of being tuber-culous in nature.Ten of the strains were isolated from suppurat-

ing facial, submaxillary or cervical lymph nodesin children. All were closed lesions. Two strainswere isolated from empyema, one from a bron-chial aspiration fluid and one from tissue of aknee joint proven to be tuberculous.Lymph nodes which were excised were de-

clared to be histologically compatible with tuber-culosis, although some differences were noted.The clinical course in these 10 patients wasbenign and healing occurred slowly vithoutsinus formation.The four other strains could not be correlated

with the clinical picture of the patients fromwhom they were isolated and tests for theirpathogenicity have not been conclusive. Allstrains consisted of strongly acid and alcoholfast, non-branching rods, and produced markedlypigmented colonies, their colour passing frombright yellow to deep orange. All grew best onmedia used for isolation of Myco. tuberculosis,although good growth was also obtained on awide variety of other media; 11 of the 14 strainsutilized paraffin as a sole source of carbon.Our findings suggest that the 10 strains isolated

from subacute lymph node infections in children,belong to a different species of Mycobacteriumand must be considered as the actual cause ofthe lymphadenitis, and the name Mycobacteriumscrofulaceum (N. sp.) has been proposed.

NOV. 15 1956A,vo. 7 5 Ross: TUBERCULOSIS 803

We would like to thank Professor E. G. D. Murrayfor his interest in this study and helpful advice, Dr. T.E. Roy, the Hospital for Sick Children, Toronto, forsupplying five of the 14 strains, and Dr. F. W. Wigles-worth, Montreal Children's Hospital, for his cour-tesy in providing a description of the histopathology ofthe excised lymph nodes.

REFERENCES1. BALDWIN, E. R.: Am. Rev. Tuberc., 45: 756, 1942.2. BRANCH, A.: Tutbercle, 14: 337, 1933.3. CUMMINS, S. I,. AND WILLIAMS, E. M.: Ibid., 15: 49,

1933.4. GRIFFITH, A. S.: Ibid., 15: 53, 1933.5. PINNER, M.: Anm. Rev. Tuberc., 32: 424, 1935.6. THOMSON, H. M.: Ibid., 26: 162, 1932.7. TARSHIS, M. S. AND FRISCH, A. W.: Ibid., 65: 278, 1952.8. GORDON, R. E.: J. Bact., 34: 617, 1937.9. GORDON, R. E. AND HAGAN, W. A.: Ibid., 36: 39, 1938.

10. GRIFFITH, A. S.: Tubercle, 5: 569, 1924.11. PINNER, M.: Proc. Soc. Exper. Biol. & Med., 30: 214,

1932.12. TIMPE, A. AND RUNYON, E. A.: J. Lab. i Clin. Med.,

44: 202, 1954.13. YOUNG, R. D.: Lancet, 2: 750, 1955.14. CABELLI, V. J., ELLIOT, W. E. AND MCELROY, R. J.:

Anm. Rev. Tuberc., 69: 604, 1954.15. SINGER, J. AND CYSNER, E.: Ibid., 65: 779, 1952.16. BUHLER, V. B. AND POLLAK, A.: Am. J. Clin. Path.. 23:

363, 1953.17. POLLAK, A. AND BUHLER, V. B.: Am. Rev. Tuberc., 71:

74, 1955.18. BERGEY, D. H.: Manual of deternminative bacteriology,

6th ed., Williams & Wilkins Company, Baltimore,1948, p. 892.

19. CUTTINO, J. T. AND MCCABE, A. M.: Am. J. Path., 25:1, 1949.

20. HAUDUROY, P. et al.: Bacilles tuberculeux et para-tuberculeux, Masson & Cie., Paris, 1950, p. 99.

21. WELLS, A. Q., AGIUS, E. AND SMITH, N.: Am. Rev.Tulberc., 72: 53, 1955.

22. GORDON, R. E.: Personal communication, 1955.23. BUCKLE, G. AND TOLHURST, J. C.: J. Path. & Bact.,

60: 116, 1948.24. FELDMAN, W. H. et al.: Am. Rev. Tuberc., 48: 82,

1943.25. MACCALLUM, P.: J. Path. & Boct., 60: 93, 1948.26. MORSE, W. C., DAIL, M. C. AND OLITZKY, I.: Am. J.

Pub. Health, 43: 36, 1953.27. SCHIFF, J. AND TARSHIS, M. S.: Northwest Med., 49:

451, 1950.28. LESTER, V.: Acta tuberc. scanditnav., 13: 251, 1939.29. SCHWABACHER, H: M. Res. ouwncil, Special Report

Series, No. 182, 1953, p. 124.30. SEGARD, E. C. AND THOMPSON, G. E.: Am. J. Clin.

Path., 22: 294, 1952.31. VIALLIER, J. AND BERTOYE, A.: Ann. Inst. Pasteur, 86:

376, 1954.VIALLIER, J.: Ibid., 87: 732, 1954.

32. JENSEN, K. A. AND FRIMODT-MULLER, J.: Acta tuberc.scandinav., 8: 153, 1934.

33. PETROFF, S. A., BRANCH, A. AND STEENKEN, W. JR.,Am. Rev. Tuberc., 19: 9, 1929.

34. STEENKEN, W. JR.: Ibid. (No. 1, B), 62: 22, 1950.35. MORIN, J. E. AND TURCOTTE, H.: Laval m6d., 13: 93,

1948.36. NORDEN, A. AND LINELL, F.: Nature, London, 168: 826,

1951.37. SissoNs, H. A.: J. Path. & Bact., 60: 110, 1948.38. TOLHURST, J. C. AND BUCKLE, G.: Ibid., 60: 102, 1948.39. PRISSICK, F. AND MASSON, A. M.: Canad. J. Pub.

Health, 43: 34, 1952 (abst.).40. LINELL, F. AND NORDEN, A.: Acta tuberc. 8candinav.,

Suppl. 33, 1954.41. WOOD, L. E., BUHLER, V. B. AND POLLAK, A.: Am.

Rev. Tutberc., 73: 917, 1956.

RESUMELes auteurs presentent une etude decrivant l'origine,

la morphologie, les reactions tinctoriales et les caracteresculturaux, biochimiques et pathogenes, de 14 types debacilles en batonnets chromogenes acido-alcoolo-resis-tants, isoles de specimens pathologiques d'infectionshumaines qu'on soupgonnait de nature tuberculeuse. Dixde ces types furent isoles de ganglions lymphatiques sup-pures des regions faciale, sous-maxillaire et cervicalechez des enfants. Toutes ces lesions etaient fermees. Deuxtypes proviennent d'empyeme, un autre de secretionsprelevees a la bronchoscopie, et un dernier de tissuarticulaire d'un genou tuberculeux. Les coupes histo-logiques des biopsies ganglionnaires furent trouvees afait compatibles avec l'apparence que presente la tuber-culose, bien que quelques differences furent notees.L'evolution clinique de ces 10 malades fut b6nigne et lacicatrisation se produisit lentement et sans fistule. On neput etablir de correlation entre les quatre autres typesde microbes et le tableau clinique des malades sur les-quels on les avait preleves; de plus, les 6preuves pour-en determiner la pathog6nicite ne furent pas concluantes.Tous les types consistaient en batonnets sans embranche-ments, fortement resistants a l'acide et a l'alcool etproduisant des colonies bien pigmentees, dont la couleurpassait du jaune clair a l'orange fonce. Tous se develop-paient le mieux sur des milieux de culture servant aisoler le M. tuberculosis, quoique de bons resultats furentaussi obtenus sur un grand nombre d'autres milieux; onzedes quatorze types utiliserent la paraffine comme uniquesource de carbone. D'apres les resultats de leurs travaux,les auteurs croient que les dix souches, provenant d'in-fections subaigues de ganglions lymphatiques chez des.enfants, appartiennent a un type particulier de Myco-bacterium et doivent etre consider6es comme la cause-reelle de l'adeno-lymphite. On a propose de le nommer:Mycobacterium scrofulaceum (N.sp.). M.R.D.

TUBERCULOSIS: ANINCOMPLETE VICTORY*

E. L. ROSS, M.D.,t Winnipeg, Man.

IN REVIEWING the annual reports of the Cana-dian Tuberculosis Association, some going backto its beginning in 1900, I was very much im-pressed with the many notable men who haveguided and have been associated with thecrusade against tuberculosis in Canada duringthe past half-century. Carlyle said, "The historyof the world is but the biography of great men."

*Presidential Address given at the Annual Meeting of theCanadian Tuberculosis Association, Niagara Falls, Ont.,May 1956.tMedical Director, Sanatorium Board of Manitoba.

It can also be said that the history of thecampaign against tuberculosis is the biographyof many great men. It is difficult now for us toappreciate the vision, courage and determinationof these pioneers. The task ahead was formid-able, and the way obscure. In 1905 the Presi-dent of the Canadian Tuberculosis Associationstated, "The Association does not and can-not deal with the erection of sanatoria. Its workis to educate the people of Canada as to thedesirability of doing certain things to preventthe spread of the plague which is causing suchravages in Canada." . . . "If this Associationreceives the encouragement to which it it en-titled, and well deserves, it will be the meansof doing one of the greatest works ever done