672 ACTIVE IMMUNIZATION 



following the administration of tuberculin. He must know whether 

 he does or does not wish to obtain symptoms of a tuberculin reaction 

 during the treatment; the size of the initial and particularly of subse- 

 quent doses will depend upon his desire to obtain a reaction or upon his 

 anxiety to avoid it. 



Reactions. At the present time tuberculin is never used for the 

 purpose of obtaining strong reactions, such as Koch originally insisted 

 upon getting. Koch administered a dose large enough to elicit a strong 

 constitutional reaction, and repeated it at intervals of one or more days 

 until that dose no longer produced a reaction, after which a still larger 

 dose was given and the former procedure repeated. Many too many 

 were unable to pass through this therapeutic furnace unsinged, and, in 

 fact, the results obtained led to the period known as the " tuberculin 

 delirium," ending, as Hamman and Wolman stated, "to the consequent 

 downfall of the arrogant therapy to an humble position, whence it is 

 but just emerging, chastened and refined, to assert its modest but now 

 truthful claims to a therapy less spectacular but more healing, less 

 forceful but more gently persuasive: healing a few, helping many, and 

 hurting none. " 



While there is this general unanimity of opinion regarding the harm- 

 ful effects of strong reactions, yet tuberculin therapeutists may be 

 divided into those who scrupulously avoid all reaction, those who are 

 a little bolder and do not object to a very mild reaction, and to an 

 intermediate class. In the first group are Sahli and Trudeau; the former 

 claims that it is essential, first of all, to do no harm, and that cases 

 treated cautiously attain a tolerance for high doses as soon as, and even 

 sooner than, those that are rushed. Petruschky is an exponent of the 

 bolder method, believing that, by proceeding very cautiously, much 

 time is wasted and not enough focal reaction is produced to promote 

 healing. To the intermediate class, and approaching rather the timid 

 class, are Bandelier and Roepke, Hamman and Wolman, and many 

 others. These observers adopt no scheme of fixed dosage, but study the 

 individual patient, remembering what is to be avoided, rather than the 

 high dose to be reached. 



The constitutional symptoms of a reaction are: temperature, loss of 

 weight, rapid pulse, and general symptoms, such as malaise, headache, 

 chilliness, arthritic pains, gastric or intestinal disturbances, nausea, loss 

 of appetite, insomnia, and skin eruptions. 



Of these general signs, the most important are fever, loss of weight, 

 and symptoms of general depression. The temperature should be taken 



