that of any other medicinal agent. The State insists upon vaccinal protection, and justly so, but under existing conditions it can do little or nothing towards assuming any responsibility for the quality of the vaccine used.

The testing or examination for purity and efficiency of animal products used in medicine is a problem of considerable difficulty. In the case of the antitoxins the task is somewhat simpler than for vaccine. There are to be considered (1) the animals yielding the product, (2) the process itself, and (3) the efficacy of the product as a protective agent. If the State should undertake to test the vaccine sold within its jurisdiction, it would be limited to such simple tests as the enumeration of the vulgar bacteria present and a microscopic examination of the vaccine itself. The animal test for stray tubercle bacilli would require four to eight weeks. The search for tetanus bacilli would be laborious and uncertain for small samples. Nothing could be inferred from such examination beyond, perhaps, the age of the virus and the original content of miscellaneous bacteria. No certain clue could be obtained as to the condition of the animals or the care used in preventing unusual and dangerous contamination. The protective power of the lymph could not be easily determined, owing to the many manufacturers and the large number of animals yielding the virus. In any case it would be impossible for the State to guarantee the purity of the many kinds of yaccine made within its border or sent in from without. The task would be enormously expensive and of uncertain value.

There are two ways out of the difficulty. One has been in vogue on the Continent for many years. Each small state or each subdivision of a large state assumes the responsibility of preparing the vaccine itself. I fully realize that in our country such public institutes, without the safeguard of absolute divorce from practical politics, without

the loyal, unselfish support of the medical profession, and without adequate financial support, would, in all probability, be a disappointment, But granting these conditions as attainable the advantages would be very great. There would be possible a close contact between the people using the vaccine and the institution preparing it. Its efficiency and safety would be subject to a continuous control at close range not obtainable otherwise,

Not less important is the advantage of publicity in improvements, as well as failures. There is a dearth of scientific publications upon vaccine in our country, which contrasts very unfavorably with the work done in Europe and the active interest manifested in the minutely detailed accounts of the vaccine institutes and the relative efficiency of their products, as announced annually by the German government. The advances made in this country in the preparation of antitoxins, for instance, have been published almost exclusively from laboratories under public authority.

According to the other alternative, the national government might appoint inspectors for the private vaccine plants, under whose supervision the virus is prepared, tested and officially stamped, just as all antitoxin sold in Germany is tested beforehand in large lots by government experts. The place where vaccine is tested most easily and economically, and where such testing would go hand in hand with a corresponding improvement of the product, is at the where it is made.

source

In conclusion, I may say that the vaccine is but one of three factors which determine the success or failure of vaccination. The others are a satisfactory inoculation technique and the proper care of the wound afterward. These important factors are to be discussed by those who are to follow me on this program.

The following are some of the more recent publications referred to in the text:

1. Ch. Haccius. Variolo-vaccine. Contribution à l'étude des rapports qui existent entre la variole et la vaccine. Geneve, 1892.

2. Die Thätigkeit der im Deutschen Reiche errichteten staatlichen Anstalten zur Gewinnung von Thierlymphe während des Jahres 1900. Berlin, Springer.

3. Bericht über die Impfstofffrage. Berichterstatter: Dr. P. Frosch. Berlin, 1896.

4. Zweiter Bericht. Berichterstatter: Vanselow und Freyer. Vierteljahrschrift für gerichtliche Medizin u. öffentliches Sanitätswesen. 1899, 17, p. 93.

5. M. J. Rosenau. Dry points versus glycerinated virus from a bacteriologic standpoint. American Medicine, 1902, 3, p. 637.

6. G. Paul. Ueber einige Fortschritte in der Gewinnung des tierischen Impfstoffes und der Aseptic der Schutzpockenimpfung. Wiener med. Presse, 1898, p. 129 et sqq.

7. R. N. Willson. An analysis of fifty-two cases of tetanus following vaccinia. Journ. Amer. Med. Assoc., 1902, 38, p. 1147, 1222. 8. Joseph McFarland. Tetanus and vaccination. An analysis of ninety-five cases of this rare complication. Journ. Med. Research, 1902, 7, p. 474.

9. Huddleston. Medical Record, March 8, 1902.

ARTICLE VI.

VACCINATION: THE TECHNIQUE.

BY EUGENE A. DARLING, M.D.

OF CAMBRIDGE.

THE two considerations which govern the technique of Vaccination are that the operation shall be successful and that it shall be safe. Danger may come from the use of impure lymph, from unsuitable conditions in the patient, from infection at the time of the operation or during the development of the vesicle. A description of the technique therefore divides itself into four parts, as follows: 1. The selection of the lymph. 2. The condition of the patient. 3. The operation. 4. The after treatment.

1. The selection of the lymph.

This is perhaps the most important factor of all as regards both success and safety, and yet it is the one condition which is beyond the control of the physician. It is well recognized by bacteriologists that lymph taken directly from the vesicles on the calf contains many contaminating bacteria. When the lymph is dispensed dried on bone points a large proportion of these bacteria remain active. Probably most of them are harmless, yet the common occurrence of the pyogenic staphylococci and streptococci in lymph so dispensed constitutes a real danger. The use of

glycerine as a slow bactericide has undoubtedly much diminished, if it has not wholly abolished the danger from this source; but the glycerinated lymph has certain disadvantages which have prevented its universal adoption, and many physicians still prefer the old unpurified lymph. The disadvantages of glycerinated lymph are the slowness with which it dries, and the difficulty which some have in making it "take." The latter may be due to too great dilution, since there are considerable variations in the proportion of successful vaccinations from different lots of lymph from the same source. However, with care in the insertion of the lymph and with proper protection while drying, the percentage of successful insertions may be very satisfactory, if not the 100% claimed by some producers.

In the absence of any feasible method of supervision by the health authorities, and of any practical test of the efficiency and purity of any given lymph short of actual inoculation of a susceptible individual, there must always be an element of uncertainty as to the care exercised in its preparation. There is no reason to doubt that many of the lymphs now on the market are prepared with due precautions, but this is certainly not true of all, and the physician has no means of discrimination. The State compels the child to be vaccinated, and should furnish the lymph for the operation, guaranteed to be pure and efficient. The reasons which justify the manufacture of diphtheria antitoxin by the State apply with even greater force to the production of vaccine lymph, and it is to be hoped that the present movement to place the control of this important matter in the hands of the State Board of Health will succeed.

2. The condition of the patient.

The best age for the primary vaccination of healthy children is between three and six months, i. e. after the child is well started in life and before it has begun the trouble