352 BACTERIOLOGY OF THE EYE 



diagnostic dose used in ophthalmology is, in the opinion of many bacteriologists, 

 not sufficiently large to allow of a decision as to whether or not a fresh or active 

 progressive tuberculosis is present. Koch and many others consider that when 

 a negative result is obtained the dose in an adult should be increased to 10 milli- 

 grammes, and only when no reaction then occurs should active tuberculosis be 

 excluded. 1 



To my knowledge such doses have hardly been used in ophthalmology. In the 

 Freiburg clinic at first we only exceptionally went as far as 5 milligrammes : we now 

 increase to 10 milligrammes, and in many cases obtain a positive result. 



There are appearances which, throughout their whole course, give the impression 

 of tuberculosis, but occur in persons who will not react to tuberculin. Are these 

 tubercular or not ? 



It is of great importance to take notice of this point. A case of tuberculosis of the 

 eye, confirmed either by inoculation or by histological examination, which would 

 give no reaction even with these large doses, would be of great value in settling this 

 question. 



2. The second question is, Having obtained the general reaction, to what extent, 

 and with what degree of certainty can we conclude that the case is one of tubercu- 

 *osis of the eye, there being no local reaction ? 



Considering the enormous prevalence of tubercular lesions in other parts, 2 it 

 possible that a general reaction may occur, even though the eye condition is not 

 tubercular. If the clinical appearances of the eye are very suspicious of tubercle, 

 this suspicion will be very much strengthened by the general reaction being 

 positive. But without a local reaction we can only assert a greater or less probability 

 according to individual judgment. In spite of this, when other means have not 

 had the desired result, we may carry out the tuberculin cure, so as to provide for 

 a possible etiology. Many valuable results are thus obtained in cases of chronic 

 uveitis, and they are the more permanent the longer the treatment has been 

 carried out. Recurrences are, however, not excluded. 



The following are the methods of diagnosis and treatment used in 

 the Freiburg clinic, which have been elaborated by Stock on the basis 

 of the work of A. von Hippel : 



I. The Diagnostic Injection of Old Tuberculin (Koch). 



The whole body should be examined before an injection for tubercle. If an 

 active tubercular process, of the lung especially, be found, the diagnostic injection 

 should not be made, on account of the danger of a renewed outbreak of the disease. 

 The two-hourly temperature should be taken for two days before the injection. 



If there should be any abnormality of temperature, an injection cannot be 

 recommended. 



The best time for the injection (1 milligramme) is about eleven o'clock in the 

 morning, when an evening rise in temperature wUl not interfere with that of the 

 reaction. 



The two-hourly temperature chart is continued after the injection. 



1 This is also of importance in the decision of the question, To what extent can the so- 

 called phlyctenular (eczematous) changes occur in non -tubercular patients without the 

 scrofulous diathesis. Reuchlin (K. M. f. A., 1906, i. 352) did not obtain any tubercular 

 reaction with 3 milligrammes in some of these cases, and therefore concluded that they 

 were non-tubercular. We have had a patient in the Freiburg clinic with kerato-conjunc- 

 tivitis phlyctenulosa, who only reacted when 10 milligrammes had been given, but did so 

 very acutely and typically. Further tests are necessary. 



2 Xaegeli examined 100 bodies in Zurich, and found tubercular changes in 90 per cent. 



