210 ACTIVE IMMUNIZATION 



reactions begin to appear (i. e., when amounts varying between 

 a tenth and one-hundredth part of a milligram are injected) at 

 intervals of eight days, in gradually increasing amounts, such as 

 TTO milligram; ^nnr> TOIT> i~iro> Tiro* TTO> rfcr* TTO"> TO* T 2 o~> T 3 o"> 

 etc., exactly as was customary with the old tuberculin. Koch advo- 

 cates that the immunization be continued until the patients can 

 take 20 milligrams of the dry powder without any reaction. 



Point of Injection. As in the case of the other bacterial vaccines 

 the injections can be conveniently given into the loose subcutaneous 

 tissue in the district over the triceps, or in the back on a level with 

 the angle of the scapula. Lowenstein states that the injections 

 may be advantageously given intravenously, that the infiltration 

 of the skin is thus obviated, and that the reactions are of briefer 

 duration. 



In advanced cases of pulmonary tuberculosis a combined treat- 

 ment with old and later with new tuberculin has been recommended. 

 In this connection, Bandelier advises that when the change from the 

 old to the new is made, to begin with the two-hundredth part of that 

 dose of the old tuberculin which produced no reaction. 



While Koch emphasizes the importance of steadily increasing the 

 dose, Wright does so only in the beginning; later on he continues 

 with a constant dose. His initial quantity is much smaller than 

 that recommended by Koch, viz., 1 c.c. of a dilution of the new 

 tuberculin of 1 : 200000. Each dose is repeated a week or ten days 

 apart, and then increased by one-fifth to one-sixth, until 1 c.c. 

 of a dilution of 1 : 50000 to 1 : 10000 is reached, after which the 

 final dose is continued (without further increase) for a number of 

 months. 



Time of Injection. As soon as reactions begin to appear, it is 

 advisable to give the injections in the morning, so that the patient 

 is not disturbed by the febrile movement during the night. If this 

 is at all marked, Koch recommends that the injections be stopped, 

 and resumed two or three days after the temperature returns to 

 normal, the same dose being given as the one preceding. 



Still another procedure has been recommended by Wolff-Eisner, 

 which was planned with the idea of developing receptors for the 

 tubercular poison in the cutaneous connective tissue, i. e., in vitally 

 unimportant structures, in which the poisons in question that are 

 formed in the diseased organs can be anchored. The method is the 



