210 ACTIVE IMMUNIZATION 



filled from one of the ampoules directly. The skin is scrubbed with 

 soap and water and then with alcohol, or, as is now recommended, 

 painted with tincture of iodin at the site of the injection. My favorite 

 site for this is the district over the triceps, into the loose subcutaneous 

 tissue. In this region the injections rarely give rise to painful local 

 reactions, while injections at a point where the skin is tightly bound 

 down is almost sure to cause a good deal of avoidable distress. For 

 this reason also intradermal injections are to be avoided. 



Dosage and Frequency of Injection. As I have already indicated, 

 we have as yet no satisfactory index to dosage. As the first principle 

 of therapeutics is noli nocere, it is advisable to begin with small doses, 

 i. e., with quantities which past experience has shown to do no harm, 

 so far at least as we can judge this by clinical evidence. 



At the present time the injections are usually given about a week 

 apart, the size of the dose being increased at each sitting. If no 

 change results from the treatment, larger doses may be tried; and I 

 may say that we have sufficient evidence to show that much larger 

 doses than the maximal quantities now recommended may be given 

 in most cases. In one or two instances I have indeed received the 

 impression that the patient owed his recovery from serious illness to 

 the injection of a quantity of organisms which was many multiples 

 of the maximal dose usually recommended. If the symptoms become 

 aggravated the dose should be diminished and the ascent carried 

 out less abruptly and possibly at somewhat longer intervals (ten to 

 fourteen days or longer). Generally speaking, in the more acute cases, 

 the smaller doses should be chosen to begin with, and the larger ones 

 reserved for the more chronic ones. There are, however, no hard- 

 and-fast rules to be laid down at the present time. The would-be 

 immunizator must learn from experience, and should not pay too 

 much attention to "negative and positive phases" when these are 

 based on the feelings of well-being and of depression on the part 

 of the patient. He should be neither of too optimistic nor of too 

 pessimistic a temperament, and should weigh the evidence with a 

 calm and unbiased mind; in other words, he must be an exceptional 

 individual. \ I really know of no field in medicine at the present day 

 where it is possible to draw so many erroneous conclusions regarding 

 the value of a therapeutic agent as in the domain of vaccinotherapy 

 in its application to chronic infections. Much good can unquestion- 

 ably be accomplished, but we must be careful not to attribute all 

 improvement to our immunizing efforts. 



