66 TUBERCULIN THERAPY 



If at any time a distinct or even doubtful reaction occurs, it is absolutely 

 necessary to await the complete subsidence of the latter, and then the same 

 dose is to be repeated. In such a case, an interval of at least eight to ten 

 days should elapse. The dosage should under no condition be diminished, 

 as thereby instead of immunity, hyper-susceptibility is the result. There- 

 fore, patients who at a short time previously had a diagnostic tuberculin 

 test performed should receive the highest dose employed in this 

 test as the initial prescription for their tuberculin therapy. The 

 following chart illustrates the condition of hyper-susceptibility occasioned 

 by a diminution in dosage. (Chart 2.) 



Patient had a localized one-sided apex tuberculosis. At a diagnostic tuberculin 

 injection, he reacted only when o.oi c.cm. T. was employed. After the interval of a 

 month the patient was advised tuberculin treatment. Contrary to the rule just cited, 

 he received as a first injection not o.oi tuberculin but 0.002 c.cm. T. With this small 

 dose he already had an increase of temperature, although coming rather late, and not 

 quite typical. After this reaction had disappeared, without any other manifestations, 

 the same dose of 0.002 c.cm. tuberculin was repeated and as evident from the chart, a 

 very marked response was inaugurated. This was accompanied by a chill, vomiting, 

 headache, general pains and weakness. In addition there was a slight relapse after 

 the aforementioned symptoms had disappeared. In order to immunize this patient 

 against his hyper-susceptibility, it was advisable to repeat the dose of 0.002 c.cm. T. ; 

 the reaction reappeared, but in a very much milder form. It was only after the fifth 

 inoculation of the same dose that no reaction was in evidence. Thus was the hyper- 

 susceptibility overcome and the patient treated in the general way. 



The danger of hyper-sensitiveness also exists if the same reactionless 

 dose is too frequently repeated; especially so if the quantities injected are 

 small. The higher the dosage, the less liable is the occurrence oj hyper- 

 susceptibility. 



This question is above all to be considered when after a certain interval, 

 a second course of tuberculin therapy is advised. In general it can be car- 

 ried out after a period of three months, even though sometimes certain 

 difficulties may be met with. Petruschky strongly recommended this 

 treatment in successive stages. (Etappenbehandlung.) The author is of 

 the opinion that it is best to retain the patient as long as possible at his 

 acquired immunity (tuberculin) by stretching the course of treatment over 

 a long period of time. He therefore repeats an inoculation of the maximum 

 dose, every three or four weeks and when hyper-susceptibility arises, he 

 changes the preparation and begins with a small dose again. 



As for the technical details of the treatment, several practical sugges- 

 tions may be made. 



1. The inoculation should, if possible, be given in the morning hours, 

 for a restless night usually follows an injection in the evening. 



2. It is best so to arrange the dilutions that the patient receives a frac- 

 tion of i c.cm. at each injection. 



