218 ACTIVE IMMUNIZATION 



alternate with correspondingly high evening temperatures; then also 

 those in whom there is evidence of active involvement of the pleura; 

 further, all cases of pregnancy, diabetes, and epilepsy, heart and 

 kidney lesions, occurring in tubercular subjects, while a tendency to 

 hemorrhage does not in itself constitute a centra-indication. If, 

 moreover, every injection is followed by a marked reaction, and it 

 is impossible to obviate this, either by a suitable diminution of the 

 dose or by using one that is larger, after giving the organism time 

 to recover from the last reaction, it is evidently not advisable to con- 

 tinue the treatment. Generally speaking, Wright's method, or that 

 of Wolff-Eisner, should be employed in those cases in which we 

 are in doubt whether or not to use tuberculin at all. In fine, I would 

 add that in surgical tuberculosis the physician should never withhold 

 recognized surgical treatment, hoping that immunization treatment 

 alone will suffice. 



Reactions. The reactions which follow the use of tuberculin for 

 curative purposes are essentially the same as those which are noted 

 when the material is injected for diagnostic reasons (which see). 

 There are, however, certain points of difference. Generally speaking 

 the reactions develop after a shorter time, which varies with the 

 size of the dose. Following the injection of 3 to 20 milligrams there 

 is frequently a response as early as eight hours, and after doses 

 of 50 milligrams this may even develop within four or five hours. 

 The duration, moreover, is shorter, so that all the symptoms may 

 have disappeared within eight hours, counting from the time of 

 their development. The response, both local and systemic, more- 

 over, is more intense, the former preceding the latter. As in con- 

 nection w r ith the diagnostic test, local redness develops at the point 

 of injection after one or two hours; this is followed by pain and 

 infiltration, reaching its maximum after about twelve hours and 

 disappearing only after a number of days. The systemic response 

 manifests itself in an initial chill or chilly sensations, headache, 

 muscle pain, and fever. The reaction reaches its height after from 

 four to twelve or fourteen hours (according to the size of the dose), 

 and then subsides so that normal relations are restored within 

 twenty-four or thirty-six hours, the patient merely experiencing a 

 certain degree of lassitude and tendency to increased expectoration, 

 which may continue for several days. The height of the temperature 

 differs considerably, and while usually not exceeding 102 F. it may 

 reach 103 and 104. 



