HYPERSUSCEPTIBILITY IN MAN 239 



addition there is likely to be headache, malaise, and sometimes a loss of 

 weight. At the site of inoculation there may be pain, tenderness, redness, 

 swelling, sometimes associated with tenderness and enlargement of the 

 regional lymph nodes. The contraindications to the employment of the test 

 include the presence of fever, if fairly high and continued, nephritis, gen- 

 eralized miliary tuberculosis, intestinal ulceration, epilepsy, acute infectious 

 diseases, either during the course of the disease or its convalescence. 



The Cutaneous Reaction. Von Pirquet, who first described this modifi- 

 cation of the tuberculin test, originally recommended the use of 25 per cent, 

 solution of the old tuberculin, but subsequently found that the undiluted 

 material is more suitable. He recommends the inner (flexor) surface of the 

 forearm, and suggests the use of three points of scarification about 4 to 5 cm, 

 apart. The skin is cleaned with ether or alcohol before making the abrasions. 

 These may be small scratches with a needle, a knife or with an instrument 

 which he describes as a borer, which has a sharp chisel point and is rotated 

 in order to make a small circular abrasion. A drop of tuberculin is rubbed 

 into the upper and lower abrasions; the middle one remains as a control. In 

 positive cases, the reaction about the point of inoculation is considerably 

 greater than that about the control point. The traumatic reaction in the 

 control may reach a diameter of 3 to 5 mm. in twenty-four hours and then 

 rapidly disappears. The positive reaction usually appears within twenty-four 

 hours, but may be somewhat delayed. Its diameter is ordinarily about 

 10 mm., but may reach 30 mm. It appears as a red, somewhat tender papule, 

 which in severe reactions may show small vesicles. According to Kolmer, it 

 is not to be interpreted as positive unless its diameter exceeds by 5 mm. that 

 of the control. Occasionally the so-called scrofulous reaction appears, in 

 which papules develop upon other parts of the extremities and the trunk. 



The Intracutaneous Tuberculin Tests. This was described by Mendel 

 and also by Mantoux. For this purpose old tuberculin is injected into the 

 corium in doses whose bulk is 0.05 c.c. Two injections are necessary, one 

 with salt solution and the other with tuberculin. The injection of tuberculin, 

 however, may include three doses of different strengths. The reaction is 

 very similar to that of the cutaneous test. Following a subcutaneous tuber- 

 culin test, a similar reaction may appear in the track of the needle. 



The Percutaneous Tuberculin Test. This test was devised by Moro and 

 Doganoff and is frequently spoken of as the Moro skin test. For this pur- 

 pose 5.0 c.c. of old tuberculin are thoroughly mixed with 5 grams of anhydrous 

 lanolin. This may be preserved for a long time in a light-proof container in 

 the refrigerator and may be obtained on the market in collapsible tubes. 

 About 0.5 gram of this ointment is rubbed into the skin of the abdomen, or 

 breast near the nipple, rather vigorously for one minute. The reaction usually 

 appears within twenty-four hours, but may be delayed from four to six days, 

 and it subsides in three to ten days. It usually appears as a number of small 

 papules reddened at the base. In severe cases the papules may become con- 

 fluent and vesicles may form. 



The Conjunctival Tuberculin Reaction. This is also referred to as the 

 ophthalmo-reaction and was described independently by Calmette and Wolff- 

 Eisner. Calmette recommended a special aqueous extract of the bacilli but 

 at the present time the test is usually applied with a I per cent, solution of 

 old tuberculin. One drop of this solution is instilled into the conjunctiva 

 near the inner canthus. The opposite eye serves as a control. Even in 

 normal individuals the instillation may induce a slight reddening of the 

 conjunctiva within six hours, but the positive reaction appears in from six to 

 eight hours, reaches its height in from twenty-four to forty-eight hours, and 

 then subsides in a few days or a week. The reaction may include simply a 

 slight reddening and swelling of the caruncle, including the neighboring 

 part of the lower lid, may extend over the scleral conjunctiva or may lead 

 to a purulent conjunctivitis. Following the introduction of this test, unfavor- 

 able reports were made because of the seeming danger of producing perma- 

 nent injury to the eye, but Hamman and Wolman state that this danger is 

 not considerable, provided proper precautions are taken in the selection of 

 patients. Diseases of the eye or of the skin near the eye, obvious scrofula in 

 children, and arterio-sclerosis are contraindications. The test should never 

 be applied twice in the same eye, and no stronger solution than I per cent, 

 should be employed for the first test. If the first test is negative a 5 per cent. 

 solution may subsequently be employed in the opposite eye. 



