all-the-year-round school was realized in the Fall of 1909 by a grant from
the Elizabeth McCormick Memorial Fund to the United Charities for the
purpose of conducting such a school on the roof of the Mary Crane Nursery
at Hull House. This school was opened by the United Charities in October
with twenty-five carefully selected children, and was conducted throughout
the following winter and spring with the co-operation of the Board of
Education and the Chicago Tuberculosis Institute. During the same winter
the Public School Extension Committee of the Chicago Women's Club,
co-operating with the Board of Education, established two classes for
anaemic children in open window rooms--one in the Moseley and one in the
Hamline School. Here the regular regime was broken by a rest period, and
lunches of bread and milk were served twice each day. "Fresh Air Rooms,"
in which the windows were thrown wide open and the heat cut off, were also
established for normal children in several rooms in the Graham School. No
attempt was made here to furnish lunches and no rest period was provided.
There were, then, during the school year of 1909 and 1910, three distinct
classes of children cared for by three distinct agencies--the classes for
normal children in the low temperature rooms at the Graham School; anaemic
children, with rest period and two lunches, in the Moseley and Hamline
Open Window Rooms, and the Roof School for Tuberculous Children, with
specially provided clothing, sleeping outfits, three meals a day and
medical and nursing attendance, at the Mary Crane Nursery.
The same condition existed throughout the following year--1910-11--with
the addition of one Open Air School on the roof of the municipal bath
building on Gault Court, given rent free by the City Health Department,
and two Open Window Rooms for anaemic children in the Franklin School, all
maintained by the Elizabeth McCormick Memorial Fund.
In 1911 the Elizabeth McCormick Memorial Fund assumed the responsibility
for all the open air school work carried on in the Chicago Public
Schools, and began the standardization of methods which should be employed
in the conduct of such schools.
Through the initiative of the Elizabeth McCormick Memorial Fund the
Chicago Open Air School work has been rapidly developed during 1912 and
1913, the program being along the line of additional roof schools for
tuberculous children and an increasing number of open window rooms for
anaemic children and children exposed to tuberculosis. In all this work
the Elizabeth McCormick Memorial Fund has had the co-operation of the
Board of Education, the Chicago Tuberculosis Institute and the Municipal
Tuberculosis Sanitarium. The Board of Education has supplied teachers and
furnished rooms wherever there has been a distinct demand for such a
provision. During the past two years the Municipal Sanitarium has made
appropriations aggregating $12,000 to pay the cost of food for these
schools, in addition to furnishing the necessary nursing service.
At the present time four Roof Schools and sixteen Open Window Rooms, with
an enrollment of 500 pupils, are being maintained.
For full information concerning the Chicago Open Air School movement, see
"Open Air Crusaders," January, 1913, edition, published by the Elizabeth
McCormick Memorial Fund, 315 Plymouth Court, Chicago; or write Mr. Sherman
C. Kingsley, Director, Elizabeth McCormick Memorial Fund, for more recent
developments.
* * * * *
Space will not permit a statement of the development of the Open Air
Schools in other cities in the United States since this movement was
started in 1908. It is, however, encouraging to note what has been
accomplished and the comprehensive plans which are being made to further
this great movement for the good of the future citizens of America.
[Illustration]
NOTES ON TUBERCULIN FOR NURSES
VARIETIES OF TUBERCULIN--THEORIES OF TUBERCULIN REACTION--TUBERCULIN
TESTS.
By THEODORE B. SACHS, M. D.
VARIETIES OF TUBERCULIN AND METHODS OF PREPARATION
OLD TUBERCULIN--T. Announced by Koch in 1890.
Tubercle Bacilli of human origin.
Grown on beef broth containing 5% glycerine, 1% peptone, sodium
chloride; growths 6 to 8 weeks.
Sterilized by steam one-half hour.
Evaporated (at a temp. not higher than 70 deg. C.) to 1/10 its volume.
Filtered.
1/2% carbolic acid added. Let stand.
Filtered (porcelain filter).
Old Tuberculin contains:
1. 40 to 50% glycerine (a small percentage of glycerine is
evaporated)
2. 10% of peptones or albumoses
3. Toxic secretions of the tubercle bacilli into the culture fluid, or
such of them as are soluble in 50% glycerine
4. Substances extracted from the bacterial bodies by the alkaline
broth during the process of boiling and evaporation.
Appearance and Characteristics:
1. A clear brown fluid
2. Of syrupy consistency
3. Mixes with water in all proportions without producing any turbidity
4. Keeps indefinitely, but not advisable to use brands older than one
year.
BOULLION FILTRATE--B. F. Denys--1907.
Method of preparation same as Old Tuberculin, with the exception of
subjection to heat;
B. F. is a filtered, unconcentrated culture.
Contains less peptone and less glycerine than Old Tuberculin.
Contains no substances extracted from tubercle bacilli by heat.
Some toxic substances may be more active (not having been subjected to
heat).
TUBERCULIN RUCKSTAND (Residue)--T. R. Announced by Koch in 1897.
Ground, dried tubercle bacilli.
Distilled water added.
Centrifugalization.
Supernatant fluid removed (not to be used).
Sediment dried and ground; distilled water added; centrifugalization.
Fluid removed and _set aside_.
Sediment dried and ground again; distilled water added;
centrifugalization.
Fluid removed and set aside.
Sediment dried and ground, etc., as above.
The process continued until water takes up the sediment, then all the
fluids set aside (except the first one) mixed together.
Glycerine 20% added.
The mixture is T. R.
Koch was prompted by the following consideration in bringing out T. R.: He
thought that the Old Tuberculin conferred only a toxic immunity, not
bacterial. T. R. was supposed to confer bacterial immunity.
Each 1 cc. of T. R. contains 10 milligrams of dried bacilli.
BACILLEN EMULSION--B. E. Announced by Koch in 1901.
Finely powdered tubercle bacilli--1/2 gram.
50 cc. of water and 50 cc. of glycerine.
All mixed together--prolonged shaking.
B. E. is supposed to contain not only the extract of the body of the
tubercle bacilli, as in T. R., but also its soluble products (which in the
case of T. R. were discarded in setting aside the supernatant fluid).
THEORIES OF TUBERCULIN REACTION
_a_ ROBERT KOCH ascribes the tuberculin reaction to the increased
necrotic process around the tubercle, the histological changes
consisting of hyperaemia, exudation and softening.
_b_ EHRLICH considers the formation of antibodies an essential feature in
the mechanism of reaction. Formation of antibodies takes place in
the middle of the three layers encircling the tubercle, the layer
damaged by toxins, but not yet rendered incapable of reaction.
_c_ WASSERMANN maintains that the antituberculin found in the tuberculous
process draws the injected tuberculin out of the circulation to the
tuberculous focus. The interaction that takes place between
antituberculin and tuberculin results in formation of ferments which
digest albumin, resulting in the softening of tissue. Absorption of
softened tissue causes fever.
_d_ CARL SPENGLER--Toxins in the blood of the tuberculous are kept in
check by antibodies. Injected tuberculin unites with antibodies,
thus setting the toxins free. Result--autointoxication.
_e_ WOLFF-EISNER--Bacteriolysin is present in the organism of the
tuberculous, as result of previous infection; bacteriolysin sets
free the potent substances of the injected tuberculin; this acts on
the body and the tuberculous focus, producing a reaction.[10]
TUBERCULIN TESTS
I. SUBCUTANEOUS (hypodermic); introduced by Robert Koch in 1890.
II. CUTANEOUS; introduced by Von Pirquet in 1907.
III. CONJUNCTIVAL (ophthalmic); introduced about the same time by
Wolff-Eisner and Calmette in 1907.
IV. PERCUTANEOUS (inunction or salve); introduced by Moro in 1908.
V. INTRACUTANEOUS (needle track reaction); introduced as a test by Mantoux
in 1909. Described previously by Escherich.
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.
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.