632 ANAPHYLAXIS IN RELATION TO INFECTION AND IMMUNITY 



6. In the diagnosis of tuberculosis of a serous membrane tuberculin 

 usually possesses a limited value. In tuberculous meningitis the sub- 

 cutaneous test is contraindicated, as a focal reaction may do harm. 

 Owing to the acute infection the cutaneous test may be negative, and 

 even if positive, would not aid greatly in the diagnosis because the 

 meningeal condition is always secondary to a primary focus. Tubercu- 

 lous pleurises, dry or with effusion, and unaccompanied by evident pul- 

 monary disease, are frequently associated with a low-grade tuberculin 

 hypersensitiveness. According to Hamman and Wolman, in a large 

 proportion of cases of pleurisy with effusion the conjunctival test is 

 negative and the cutaneous test but mildly positive. Bandelier and 

 Roepke assert that in a dry pleurisy increased pain and more pro- 

 nounced and extensive friction may occur during a constitutional 

 reaction to the subcutaneous test and indicate a focal reaction. In 

 tuberculous peritonitis the tuberculin test is frequently negative. A 

 positive reaction has far more value, especially in virulent types of the 

 disease, which come on insidiously with little or no constitutional dis- 

 turbance. 



The Value of Tuberculin in Prognosis. As previously stated, tu- 

 berculin may not react in the very early and very late cases of tubercu- 

 losis. In patients with rapidly advancing lesions the power to react 

 tends to decrease and frequently is absent. But this condition is 

 apparent without the aid of tuberculin. While Wolff-Eisner and Stadel- 

 mann 1 laid some stress upon the conjunctival reaction in prognosis, 

 others have been unable to confirm the results, and, as stated by Ham- 

 man and Wolman, 2 tuberculin fails to yield us information of prog- 

 nostic value that other methods of clinical observation do not bestow. 



The Dangers of Tuberculin. Practically, the only danger lies in 

 the subcutaneous and conjunctival tests. With the subcutaneous 

 test, the greatest danger in pulmonary tuberculosis is the possibility 

 of overdosage, with the production of an extensive focal reaction which 

 may bring on hemorrhage or lead to local extension of the lesion. Be- 

 cause of its very important bearing on tuberculin treatment, the sub- 

 ject will be discussed in the next chapter. The same danger of excessive 

 focal reaction holds for tuberculous meningitis (increased intracranial 

 pressure), in tuberculous laryngitis (edema), and in tuberculosis of the 

 ear and nasal accessory sinuses (extension to meninges) . 



The cutaneous, intracutaneous, and percutaneous reactions are 



1 Deutsch. med. Wochenschr., 1908, xxxiv, 180. 



2 "Tuberculin in Diagnosis and Treatment," 1912, 179. 



