ALLERGIC REACTIONS 289 



Koch. Of this the patient receives from 0.1 to 1 milligram, accord- 

 ing to the condition of his general health. In feeble individuals 

 it is best to start with 0.1 milligram, while more robust persons 

 may take 1 milligram. The injections are conveniently given 

 in the back, below the angle of the scapula, and best during 

 the early forenoon hours. To wait until the evening is not advis- 

 able, as the reaction may occur already after six hours and might 

 accordingly be overlooked during the night. If no elevation of tem- 

 perature occurs after the first dose the quantity is doubled in forty- 

 eight hours, and so on until a dose of 10 milligrams, or in individuals 

 of feeble constitution, of 5 milligrams is reached. This Koch regards 

 as the limit, beyond which a reaction cannot be considered as specific. 

 Should elevation of temperature follow any one of the injections, 

 even though amounting to but three-tenths of a degree (C.), the 

 next dose should be of the same size, but it is not to be given until 

 the temperature has returned to normal. It will often be found, 

 then, that the second reaction is more marked than the first. Such 

 an occurrence Koch regards as particularly characteristic, and, 

 indeed, as an infallible indication of the existence of tuberculosis. 



Before beginning it is, of course, desirable to observe the temper- 

 ature of the patient for a while, and not to inject until it has been 

 found below 37.3 C. for a day or two. 1 The reaction is regarded 

 as positive if the temperature reaches a point that is at least 0.5 C. 

 above the highest noted before the injection. 



If small doses have been used the rise usually begins after ten to 

 sixteen hours, while with the larger doses it may occur after six 

 to eight hours. There is usually a slight chill which is accompanied 

 by headache and pains in the muscles, nausea, palpitation of the 

 heart, etc. An hour or two after the injection already there may also 

 be evidence of an inflammatory reaction at the point of inoculation 

 (redness and tenderness). At the expiration of about ten hours 

 there is marked infiltration at this point which may persist for two 

 to six days before resorption has taken place. After reaching its 

 highest point the temperature usually drops within a few hours, 

 so that normal relations are again restored at the expiration of 

 twenty-four to forty-eight hours following the injection. The 

 patient may experience a certain degree of lassitude yet for two or 



1 The temperature should be taken every three hours. 

 19 



