204 ACTIVE IMMUNIZATION 



Indications and Contraindications. Anyone who has seen some of 

 the disastrous results which followed the use of tuberculin in the 

 early days of its history will realize that not all eases of tuber- 

 culosis are suitable for the tuberculin treatment. Now we know 

 that it is best to exclude those cases in which there is any febrile 

 movement of note, and particularly those in which low morning 

 temperatures alternate with correspondingly high evening tempera- 

 tures; 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 contra- 

 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 continue the treatment. Generally speaking, 

 Wright's method, or that of Wolff-Eisner, should be employed in 

 those cases where 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 

 connection with 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 



