204 ACTIVE IMMUNIZATION 



The Injection. If the vaccine has been put up in bulk a small 

 quantity is poured into a small medicine glass that has just been 

 boiled, and the (sterilized) syringe charged from this; or this is 

 filled from one of the ampules 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 avoid- 

 able 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 

 immunisator 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 



