Part 7
2. Cases, with uncertain symptoms or inconclusive physical signs, pointing to possible existence of tuberculous infection, may be treated as "suspicious" cases (without resorting to subcutaneous tuberculin test), the treatment consisting of rearrangement of mode of life, diet, work, etc., that would tend to increase of general resistance of the patient. This can and should be done in the vast majority of suspicious cases.
3. The subcutaneous tuberculin test is indicated in cases in which, in the absence of conclusive symptoms or signs, an absolutely positive diagnosis is desired; then the test should be applied, with the consent of the patient, _after all other methods of diagnosis are exhausted_ (thorough study of the case, thorough physical examination, repeated examinations of sputum, etc).
4. The focal reaction (the reaction pointing to the seat of the disease) occurs in about 1/3, or less, of the general reactions following the subcutaneous tuberculin test; this enhances the value of the test in some cases where a focal reaction would clear the diagnosis.
Above all, the subcutaneous tuberculin test should be used rarely, and then only after all other methods of diagnosis were thoroughly applied.
II. CUTANEOUS TUBERCULIN TEST
1. SYNONYMS: Von Pirquet Test or Skin Test
2. APPARATUS AND DILUTIONS NECESSARY:
Inoculation needle of Von Pirquet
Koch's Old Tuberculin (undiluted or dilutions according to method).
A centimeter tape measure (divided to 1/10 cm.) to measure reactions
Ether
Alcohol lamp
Medicine dropper
3. APPLICATION OF TEST:
Inner surface of the forearm; clean the site with ether; place two drops of tuberculin 4 inches apart; stretch the skin and scrape off the epidermis (at a point midway between the two drops of tuberculin) by rotating the Von Pirquet needle between thumb and index finger, with slight pressure on the skin; repeat same through the two drops of tuberculin; let the tuberculin soak in for a few minutes. No dressing is necessary. The middle scarification is the control test. One tuberculin and one control test may suffice. A separate needle should be used for the control test.
After each inoculation, clean the needle of tuberculin and heat the point red hot in the alcohol flame before applying it again.
4. REACTION:
Gradual elevation and reddening of skin around the point of tuberculin inoculation, beginning in 3 hours or later; the reaction (papule) well developed, generally, in 24 hours and most distinct in 48 hours after inoculation.
Size of papule varies from a diameter of 10 millimeters in the average case to 20 mm. occasionally, and 30, rarely (Bandelier and Roepke).
At the end of 48 hours the swelling and redness subside gradually, with the subsequent bluish discoloration of the skin, remaining for various periods of time, and slight peeling of the epidermis. Individual reactions vary in degree of redness, elevation, size, contour of the border, etc. All these points should be observed and recorded.
Time of inspection--24 and 48 hours after inoculation.
Single inspection--best time in 48 hours.
5. CAUSE OF REACTION:
Interaction between inoculated tuberculin and the antibodies (bacteriolysins, according to Wolff-Eisner) present in the skin of a tuberculous individual; interaction results in hyperaemia and exudation (papule).
6. INTERPRETATION OF REACTION:
Occurrence of positive reaction signifies presence of a tuberculous focus somewhere in the body. No indication as to activity or location of the focus.
A negative reaction in adults (especially if repeated) signifies non-existence of tuberculosis (unless great deterioration of health, far advanced process, or tolerance to tuberculin established by tuberculin treatment).
A positive reaction in children under two years of age signifies, generally, active tuberculous process; with the advance of age the determination of active tuberculous processes by means of cutaneous tuberculin test becomes impossible.
III. CONJUNCTIVAL TUBERCULIN TEST
1. SYNONYMS: Eye Test; Ophthalmic Test; Wolff-Eisner's Test; Calmette's Test.
2. APPARATUS AND DILUTIONS NECESSARY:
1 cc. pipette graduated to 1/10 cc.
10 cc. pipette graduated to 1/10 cc.
10 cc. glass cylinder
Medicine dropper
Koch's Old Tuberculin
1/2% and 1% dilution of Old Tuberculin in .85% sterile normal salt solution.
To make 1% dilution, add .1 cc. Old Tuberculin to 9.9 cc. of diluent.
3. APPLICATION OF TEST:
Patient sitting, with head thrown back
Lower eyelid drawn slightly down and toward the nose--to form a small pouch of the lid;
One drop of 1% or 1/2% instilled in that pouch and the lower lid moved up gently over the eye until the lids meet;
Eye kept closed for one minute or so.
4. REACTION:
Onset in 12 to 24 hours (may begin earlier); acme in 24 to 36 hours; duration of reaction--3 to 4 days or even longer (in severe cases). Some reactions are of short duration. 3 grades of reaction, according to Citron:
1. Reddening of caruncle and palpebral (lid) conjunctiva.
2. More intense reddening, with involvement of ocular (eyeball) conjunctiva, and increased secretion.
3. Very intense reddening of the whole conjunctiva, with much fibrinous and purulent secretion, etc.
5. TIME OF INSPECTION:
12 and 24 hours after instillation; then once a day.
6. CAUSE OF REACTION:
Hyperaemia and exudation resulting from interaction between _instilled tuberculin_ and _antibodies in conjunctiva_ (bacteriolysin, according to Wolff-Eisner).
7. INTERPRETATION OF REACTION:
Wolff-Eisner maintains that positive conjunctival tuberculin reaction means _active_ tuberculosis, a conclusion accepted by but a few.
8. FIELD OF APPLICATION OF CONJUNCTIVAL TUBERCULIN TEST:
_Should not be used_; connected with _danger_ to the eye.
Conjunctival test used very rarely at present.
IV. PERCUTANEOUS TUBERCULIN TEST
1. SYNONYMS: Salve Test; Moro Test.
2. SALVE: Equal parts of Old Tuberculin and anhydrous lanolin.
3. APPLICATION OF TEST:
Site: abdominal wall below ensiform process, _or_ breast below nipple, _or_ inner surface of forearm.
Application: rub in with the finger (using moderate pressure) a small particle of salve about the size of a pea.
Rub it in into an area about 5 cm.; rub 1 minute.
4. REACTION:
In 24 to 48 hours--_either_ numerous small reddened spots which disappear in a few days, _or_ numerous small nodules, _or_ coalescing nodules on a red base, etc.
5. INTERPRETATION OF REACTION:
Positive reaction is assumed to indicate existing tuberculous infection somewhere in the body; does not indicate that the process is active.
6. FIELD OF APPLICATION OF PERCUTANEOUS TUBERCULIN TEST:
The percutaneous tuberculin test fails in a large proportion of tuberculosis cases.
The test is used rarely at present.
LIGNIERES TEST
A modification of the Moro Test
Instead of salve, a few drops of Old Tuberculin rubbed in.
Used rarely at present.
V. INTRACUTANEOUS TUBERCULIN TEST
1. SYNONYMS--Mantoux Test
2. APPLICATION OF TEST:
Injection into skin (needle parallel to skin) of 1/100 mg. of Old Tuberculin (according to Mantoux).
3. REACTION:
Onset in a few hours, well developed in 24 hours, acme in 48 hours. Reaction consists of a central nodule surrounded by a halo of redness.
This is the intracutaneous test as originally suggested by Mantoux.
CONCLUSIONS
Comparing the various tuberculin tests we find that:
1 _The Subcutaneous Tuberculin Test_ has the advantage of focal reaction, disclosing in a certain percentage of cases the seat of the disease.
The subcutaneous test should, however, never be employed unless _as a last resort_, and then only after all other methods of diagnosis are exhausted and an absolute diagnosis is very essential.
In the vast majority of suspected cases of tuberculosis, thorough study of the history of the case, combined with thorough physical examination, furnishes all the necessary data for diagnosis and an efficient plan of treatment.
2 _The Cutaneous Tuberculin Test_ is a very efficient diagnostic measure in children under two years of age in whom a positive cutaneous tuberculin reaction indicates active disease.
Positive cutaneous tuberculin reaction in adults indicates existence of a tuberculous process, somewhere in the body; it does not indicate that the process is active.
Negative cutaneous tuberculin reaction is one of the corroborative evidences of absence of tuberculosis, unless reaction is prevented by very advanced disease or tolerance to tuberculin established by tuberculin treatment.
3 Thorough study of the history and thorough physical examination of each individual case are more important and should precede the application of any test.
FOOTNOTES:
[1] For illustration, see Knopf, "Tuberculosis," Chap. IV, page 67.
[2] See Carrington, "Fresh Air and How to Use It," Chap. II, page 29.
[3] For illustration, see Carrington, "Fresh Air and How to Use It," Chap. II, page 37.
[4] For illustration, see Carrington, "Fresh Air and How to Use It," Chap. VIII, page 128.
[5] For illustration, see Knopf, "Tuberculosis," Chap. IV, page 58.
[6] For illustration, see Carrington, "Fresh Air and How to Use It," Chap. VII, page 108.
[7] See previous footnote.
[8] For illustration, see Journal of Outdoor Life, January 1914.
[9] For illustration, see Carrington, "Fresh Air and How to Use It," Chap. IV, page 55.
[10] For a diagrammatic presentation of Wolff-Eisner's theory, see "Tuberculin Treatment" by Riviere and Moreland, page 6.
[11] Not absolutely necessary: may get along with graduated cylinder and syringe.
[12] See previous footnote.
(END)
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Transcriber's Amendments
Transcriber's Note: Blank pages have been deleted. Paragraph formatting has been made consistent. The publisher's inadvertent omissions of important punctuation have been corrected.
Other changes are listed below. The listed source publication page number also applies in this reproduction except possibly for footnotes since they have been moved.
Page Change
7 the acute inflamatory[inflammatory] at the beginning, 9 systematic treatment was underaken[undertaken]. 9 Bodingon of Sutton, Coldfield[Sutton Coldfield], England, 10 The fundimental[fundamental] principle 19 fit to make to a printed questionaire[questionnaire]. 23 who visits the physican[physician] 28 Tuberculosis Sanitarium is extending sanatorum[sanatorium] care 35 [Split first footnote into two.] 36 in the shelter of a strong windbrake[windbreak]. 43 makes a family, ordinnarily[ordinarily] 58 [Split first footnote into two.] 58 Hyperdermic[hypodermic] needle suited to the syringe 62 absence of conclusive symptons[symptoms] or signs, 62 (thourough[thorough][et seq.] study of the case, 63 all other methods of diagnosis were thouroughly[thoroughly] 63 from a diameter of 10 millimeters in [the] average case 66 [Added (END).]
On page 50 of the original publication, the following portion of a paragraph has two extraneous lines here marked in brackets:
All of the cooking was done by the teacher. Careful attention to [is given. Children are weighed once in two weeks. Instruction] [is chiefly practical. Instruction in gardening is given twice a week] general cleanliness and hygiene of the teeth was insisted upon. Individual drinking cups and tooth brushes were provided. The children took turns in washing dishes, setting the table and helping....
The extraneous lines are duplicates of lines further up the page and have been deleted.
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End of Project Gutenberg's Nurses' Papers on Tuberculosis :, by Various