594 ANAPHYLAXIS IN RELATION TO INFECTION AND IMMUNITY 



3. Injections are made subcutaneously in the region of the back, 

 below the angle of the scapula, or in the arm. The skin needs no prep- 

 aration other than to be rubbed with alcohol. The injections are 

 best given during the late evening hours or early in the morning, in 

 order that the temperature and pulse changes may be observed, espe- 

 cially twelve hours after the injection. Records of temperature and 

 pulse should be made every two hours during the day and night for 

 forty-eight hours following an injection. Hamman and Wolman 

 recommend the "Tuberculin Sub 2 Syringe," made by the Randall, 

 Faichney Co. Each syringe should be sterilized by boiling prior to 

 use, and it is recommended that a separate syringe be provided for each 

 dilution. 



4. Considerable controversy has arisen over the size of the doses 

 to be employed. Koch's directions called for one milligram at first, 

 then for five, then for ten, and if no reaction followed this dose, it was 

 repeated. There is a decided tendency, however, to use smaller doses. 

 If the object is to establish the presence or absence of tuberculin hyper- 

 sensitiveness, mild reactions will suffice, and for this purpose small 

 doses repeated or in gradually increasing amounts may be given. If 

 one aims to produce a focal reaction, larger doses and more rapid in- 

 crease are desirable. Hamman and Wolman advise the following plan 

 for adults: For the first dose, -5- mg. is given. If there is a slight febrile 

 reaction of about one-half a degree, and especially if this is accompanied 

 by a local reaction at the point of injection, the second dose, which 

 is the same as the first, is given at the end of forty-eight hours. The 

 reaction will now most likely be more conclusive. If there is no appre- 

 ciable reaction after the first dose, the second, consisting of one milli- 

 gram, is given at the end of forty-eight hours, and the third dose, if 

 one is necessary, consists of five milligrams. Occasionally the third 

 dose must be repeated, or even ten milligrams given if the negative result 

 is at variance with the clinical impressions. 



If the temperature shows any irregularities, the intervals between 

 injections should be prolonged to three or four days or more. 



Roth-Schultz advise the following doses: 0.5 mg.; 1.25 mg., and 

 2.5 mg. as the terminal dose. 



For children under fifteen years of age smaller doses are indicated 

 an initial dose of one-tenth milligram and a terminal dose of one milli- 

 gram, with one or. two intervening doses. Baldwin has advised 0.05, 

 0.2, 0.5, and 1 mg. 



The Reaction. The constitutional reaction is quite variable. Fever 



