636 ANAPHYLAXIS IN RELATION TO INFECTION AND IMMUNITY 



local and a focal reaction. A definite febrile reaction due to tuberculin 

 is rare without the presence of a local reaction to the same or the pre- 

 ceding doses. General symptoms of headache, muscle pains, anorexia, 

 nausea, etc., may accompany the reactions. The local reaction consists 

 of redness and pain at the site of injection, with tenderness of the neigh- 

 boring lymph-glands, and is absolutely specific of tuberculin hyper- 

 sensitiveness. The focal reaction consists of an inflammatory reaction 

 with the production of rales, change in breath-sounds, etc. 



THE INTRACUTANEOUS TUBERCULIN REACTION 



Variety of Tuberculin. Koch's old tuberculin is used either in one 

 dose of 0.005 mg., or preferably in three different doses injected simul- 

 taneously; these will be described further on. 



Method of Conducting the Test. The skin of the forearm is cleansed 

 with alcohol and then dried. A small glass syringe fitted with a fine 

 needle is used. A separate syringe is used for the control fluid, con- 

 sisting of sterile salt solution, and three others for each of the different 

 dilutions used. In performing this test Hamman and Wolman make 

 four simultaneous injections: 



First: 0.05 c.c. of sterile normal salt solution (control). 



Second: 0.05 c.c. of a 1 : 1,000,000 dilution of old tuberculin, 



which equals 0.00005 mg. This equals a dose of 0.05 c.c. of 



dilution No. 4, just described in the preceding test. 

 Third: 0.05 c.c. of a 1 : 100,000 dilution, or 0.05 c.c. of dilution No. 



3, equivalent to 0.0005 mg. 

 Fourth: 0.05 c.c. of a 1: 10,000 dilution, or 0.05 c.c. of dilution No. 



2, equivalent to 0.0005 mg. 



Mantoux uses the last or fourth dose only. The injections are given 

 with the skin held taut or pinched up in a fold between the index-finger 

 and thumb. The needle is inserted superficially, with the aperture 

 directed toward the outer surface of the skin. If the point of the needle 

 is in the skin, a white elevation occurs immediately upon the introduc- 

 tion of the solution; if it is in the subcutaneous tissue, no infiltration is 

 apparent. Cohen 1 injects T. R., the first doses being one ten-millionth, 

 one millionth, and one hundred thousandth of a milligram. If these 

 injections provoke no reactions, he repeats the tests with doses ranging 

 as high as ten milligrams. 



The Reaction. The reaction consists of infiltration and hyperemia 

 about the site of injection similar to the reaction in the cutaneous test. 

 It appears in from six to eight hours, reaches its maximum intensity 

 1 Jour. Infect. Dis., 1917, xx, 233. 



