OLD TUBERCULIN. 6 1 



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 o. 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, head- 

 ache, 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. at which 

 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 of hyper- 

 susceptibility. 



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

 a second course in 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 suggestions 

 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 to so arrange the dilutions that the patient receives a frac- 

 tion of i c.cm. at each injection. 



3. The site of injection should be alternated between the back and the 

 breast. 



4. The temperature should be taken every two or three hours and a 

 chart of the same kept. 



5. Disturbances in the general condition of the patient without the 

 presence of fever are to be considered in the light of general reactions just as 

 fever without other disturbances. 



6. The patient's weight should be taken regularly every week, and then 

 the dose should be increased provided no loss in weight has taken place. 



7. In cases where the pulse increases in rate or becomes poorer in quality, 



