Chapter I: Subcutaneous Tuberculin Test

1. APPARATUS AND SOLUTIONS NECESSARY:

Glass cylinder graduated to cc.

1 cc pipette graduated to 1/10 cc.[11]

10 cc pipette graduated to 1/10 cc.[12]

Hypodermic needle suited to the syringe.

Two or more 1/2 oz. bottles.

1/2% carbolic acid solution.

Normal salt solution.

1 cc. Old Tuberculin.

2. PREPARATION OF APPARATUS:

Glass apparatus, syringe and needles boiled before use.

Some keep needles and syringe in 95% alcohol.

3. MAKING SOLUTIONS:

Tuberculin No. I: Tuberculin No. II:

Label one bottle Another

_.1 cc. = 1 mg. T_ _.1 cc. = .1 mg. T_

No. I { Put 0.1 cc. T in bottle No. I
{ Add 9.9 cc. of 1/2% carbolic acid solution

{ Put 1 cc. of Tuberculin solution from
No. II { No. I into bottle No. II
{ Add 9 cc. of 1/2% carbolic solution

In making dilutions you may use your syringe instead of pipette.

Dilutions can be kept _one week_ in a dark, cool place.

Discard turbid solutions.

4. PREPARATION OF THE PATIENT FOR THE TEST:

Patient to keep quiet in bed, or reclining chair, for two or three
days before injection.

Take temperature every two or three hours for two or three days
(daytime).

If the test is to be applied, highest temperature should not be above
99.1 F, by mouth, according to Koch; not above 100 F, according to
others.

Site of injection--back, below the level of the shoulder blades,
alternately on the two sides.

Rub skin with ether or alcohol.

An exact record of physical signs, _just before injection_, should be
made by the physician.

5. TIME OF INJECTION:

Between 8 and 10 A. M. (Bandelier and Roepke).

Late in the evening, 9 or 10 P. M., or later (others).

6. DOSE:

According to Koch: Begin with 1/2 mg., or 1 mg., according to
condition of patient; give larger dose if no reaction. Order of
increase: 1 mg.; 5 mg.; 10 mg. (last dose repeated if necessary).

Interval between injections: two or three days.

Present Usage: First dose in adults, 1/2 mg., or 1/5 mg., or smaller,
according to physical condition.

First dose in children: 1/10 mg., or 1/20 mg., or even smaller.

Thus, in adults: 1/2, or 1, 3, 5, 8, and rarely 10;

In children: 1/10, 1/2, 1, 3.

Loewenstein and Kaufmann's Scheme: Repetition of small dose, relying
on exciting hypersensibility--2/10 mg.; in 3 days, 2/10 mg.; in 3
days, 2/10 mg.; in 3 days, 2/10 mg.

Some use 1/10 mg., or 3/4, or 1-1/4, in same way.

This scheme is based on hypersensibility created by repetition of same
dose in tuberculous subjects. Scheme not used at present.

Some advise single dose: 3 or 5 mg., (on the ground that gradual
increase of doses creates tolerance).

7. RULES TO FOLLOW IN INCREASING DOSE:

_a_ If no reaction with one dose, give a larger one next time, according to _b_.

_b_ If temperature rises less than 1 degree F, repeat same dose; otherwise increase.

_c_ Avoid large doses in cases of weakness, nervous temperament, children, etc. In a majority of cases smaller doses suffice.

8. AFTER INJECTION:

_a_ Rest in reclining chair two or more days, unless severe reaction
requires absolute rest in bed.

_b_ Take temperature every 2 or 3 hours for 2 or 3 days.

9. GENERAL REACTION:

_a_ Rise of Temperature. Positive reaction, if temperature rises at
least .5 deg. C. (.9 deg. F.), higher than previous highest temperature.

Degree of reaction according to Bandelier and Roepke: Slight reaction
if temp. rises to 38 deg. C. or 100.4 deg. F. Moderate reaction if temp.
rises to 39 deg. C. or 102.2 deg. F. Severe reaction if temp. rises above
39 deg. C. or 102.2 deg. F.

Typical reaction temperature curve: Rapid rise, slower fall, normal
temperature after 24 hours.

Rise begins, in average case, 6 to 8 hours after injection (may begin
within 4 hours or be delayed for 30 hours).

Acme of rise in 9 to 12 hours.

Duration of reaction, 30 hours or longer.

Rise, acme and duration of reaction vary.

_b_ Symptoms:

May begin with rigor or chilliness, followed by feeling of
warmth.

Following symptoms may be present:

Malaise, giddiness, severe headache, pain in limbs, pain in
affected organ, palpitation, loss of appetite, nausea,
vomiting, thirst, sleeplessness, lassitude, etc.; in short, a
general feeling of "illness."

With fall of temperature--disappearance of symptoms.

10. REACTION AT POINT OF INJECTION: Area of redness, swelling,
tenderness; important as indicative of sensitiveness, pointing to
probable general reaction with repetition or increase of dose.

11. FOCAL REACTION: Reaction at site of process, due to congestion around
it.

Focal reaction is demonstrable by:

_a_ Change in physical signs; breath sounds, resonance, appearance of
rales, etc.

_b_ Localizing symptoms, pointing to location of the tuberculous
process.

Lungs--increase of cough, sputum, appearance of bacilli, pain in
chest, etc.

Kidney--pain in the region of kidney, changes in urine findings,
etc.

Joint--swelling, tenderness, etc.

Lupus--redness and exudation.

Focal reaction is an important feature of the subcutaneous tuberculin
test; it permits localization of the disease in a certain
percentage of cases.

Physical examination, sputum examination, urinalysis, etc., are very
important _during the course of the reaction_.

12. CONTRAINDICATIONS:

Subcutaneous tuberculin test should not be employed in:

1. Cases with temperature above 100 deg. F, by mouth (99.1 deg. F, by mouth,
according to Koch).

2. Cases in which the clinical history and physical signs make the
diagnosis certain (presence of tubercle bacilli in the sputum
render, of course, any other test unnecessary).

3. Cases of recent haemoptysis.

4. Grave conditions, as severe heart disease, nephritis, marked
arteriosclerosis, etc.

5. Convalescence from acute infectious diseases, typhoid fever,
pneumonia, etc.

13. INTERPRETATION OF THE POSITIVE SUBCUTANEOUS TUBERCULIN REACTION:

Occurrence of reaction, following the subcutaneous tuberculin test,
signifies the _existence of infection_; it does not signify that
the individual is _clinically tuberculous_. To quote E. R. Baldwin,
of Saranac Lake: "The tuberculin test is of very limited value in
determining tuberculous _disease_; it is of extreme value in
detecting tuberculous _infection_."

The test results in positive reaction in cases with latent as
well as active processes.

The decision as to the patient being clinically tuberculous (ill
with tuberculosis) must rest on the consideration of the
clinical history and the results of the physical examination.

It is maintained by some that the subcutaneous tuberculin
reaction is _more rapid in onset_ and _more marked in degree_
in cases of _recent_ infection. On the other hand, the test is
negative in a certain proportion of far advanced cases.

Occurrence, then, of a subcutaneous tuberculin reaction does not
indicate necessarily sanatorium or institutional treatment;
neither does it absolutely indicate the necessity of
tuberculin treatment. The decision rests on the consideration
of all the clinical features of the case.

_In the absence of any symptoms or physical signs of disease_, a
reaction should call for regulation of every day life, tending
to increase the state of general resistance (improvement of
nutrition, etc.) frequently without discontinuance of work.

The occurrence of reaction, _in the presence of slight symptoms
or physical signs_, calls, according to individual condition,
either for home treatment with or without discontinuance of
work, or sanatorium treatment.

14. INDICATIONS FOR THE SUBCUTANEOUS TUBERCULIN TEST:

The following considerations should guide its employment:

1. A thorough study of the history, thorough physical examination,
examination of sputum (if any) give sufficient data for a
reliable diagnosis in the vast majority of cases.

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.