TUBERCULOSIS TUBERCULIN THERAPY 725 



for several days preceding the initial dose, so that the patient's " normal"- 

 limits are known before the tuberculin is given. When the usual maxi- 

 mum temperature is reached, it is especially necessary to watch closely 

 for additional signs of reaction. Without some constitutional dis- 

 turbance a slight pyrexia is of less significance, and it is to be remembered 

 that tuberculous patients may have a flare-up of fever when they are 

 not being treated with tuberculin; Denys refuses to consider any 

 temperature reaction as due to tuberculin that comes on more than 

 forty-eight hours after the injection has been given. It is characteristic 

 of tuberculin reactions that the rise is abrupt, and not in step-like pro- 

 gression. Hamman and Wolman would hesitate to ascribe an elevation 

 coming on suddenly in the midst of a perfectly smooth course of tuber- 

 culin treatment, and unaccompanied by a local reaction, to the injections, 

 when the dose has not been unduly large. 



Loss of weight is a delicate sign more valuable as a symptom of 

 overdosage late in the treatment than as a protection against the sud- 

 denly appearing reactions. 



Bandelier and Roepke regard an increase in the pulse-rate as a sign 

 of great importance. Hamman and Wolman and Lawrason Brown 

 have not been able to observe this sign very frequently. 



The local signs are: Pain, tenderness, and swelling at the site of 

 injection. These may consist of all gradations from simple thickening of 

 the skin to a wide, deep, hard, and painful node, with or without in- 

 volvement of the neighboring lymphatics. 



The local reaction has assumed great importance in recent years, 

 especially since Denys drew attention to it as serving as a warning of the 

 approach of a general reaction. It is characterized by the development 

 of pain, tenderness, and redness about the site of a former injection. 

 It is more often solitary than any other sign, and, in the absence of a 

 temperature record, it is safe to proceed, the sole guidance being the 

 local reaction, both subjective and objective. A large dose of tuber- 

 culin may give a local reaction, due merely to its bulk and concentra- 

 tion (500 to 600 mg.), simulating a true reaction; this may be avoided 

 by dividing the dose into two injections, which are given at the same 

 time, but not into neighboring areas of skin. 



The focal signs in pulmonary tuberculosis are: increased cough, 

 dyspnea, expectoration, thoracic pain, hemoptysis, and extension of 

 the physical signs. 



Focal signs of a reaction are an indication that the treatment has 

 been conducted too rapidly. 



