the age of six weeks and four months—a period that is prior to the irritation of teething and also subsequent to the extreme irritability of first infancy. Should, however, small-pox be very prevalent in the near neighbourhood, rather than expose the infant to its contagious influence it should be vaccinated at once. There will be but little risk in this measure, even if resorted to immediately after its birth.

The usual time and the best time, as fixed by the Vaccination Act, is at the age of three months. The child should be, as far as possible, in perfect health; if, however, any disease be present, such as skin eruptions, the thrush, wasting disease, abscesses in bones or joints, then vaccination may be postponed, provided there be no small-pox in the neighbourhood. But if, on the contrary, there should be small-pox, have your child vaccinated immediately: the dangers of small-pox are ten times worse than anything vaccination can

cause.

In giving you this advice, I of course presuppose that the vaccination will be well done; that the vaccine lymph will have been taken from a perfectly healthy child. Recently the Royal College of Physicians have required that all candidates for their diplomas shall have been thoroughly instructed in vaccination, and in all the medical schools systematic instruction is afforded; so that now-a-days there is little fear that the operation is not thoroughly and well performed. The experience, too, which has been gained during the past seventy years, has taught medical practitioners how to avoid the mistakes and fallacies into which want of experience led some of the earlier promoters of the proceeding.

It is a natural and very proper feeling which

prompts mothers to have their children vaccinated from the child of some neighbour or friend; indeed I strongly advocate this, and in order that some of the conditions most essential to successful vaccination may be well known, I append in the next paragraphs what I consider to be the chief general points, leaving, of course, to the surgeon and to his discretion to decide and advise in the individual case.

The best place is on the arm, three or four inches below the tip of the shoulder, and a little to the outer side.

Have the child vaccinated on both arms; three 'places' on each arm will suffice.

The matter should be taken on the eighth day; it is then at its best, and now confers the greatest immunity from small-pox. So that if you wish to have your child vaccinated from a friend's child, choose the eighth day, and arrange if possible to meet your medical man at the house, and have your child vaccinated 'direct.'

When the vaccine vesicle begins to rise, you must be careful not to rub it: the child's sleeves should be loosened also, as the arm inclines to swell. Rubbing interferes with the proper development of the 'place,' and renders it unfit to vaccinate others with.

The health and constitution of the child from whom the lymph is taken should always be carefully regarded. Not only should the child be in good health, but its parents also; it should have no cutaneous affection or vicious constitutional taint, and should be about three months of age.

The above precautions being adopted, your child may be vaccinated, and you may rest perfectly assured that no harm will come of it.

The Appearance and Progress of a genuine Vaocine Vesicle.-If the vaccination has been successfully performed upon a healthy infant, the puncture on the second day may be felt elevated; on the third or fourth a small red pimple is to be seen, and if examined with a magnifying-glass, surrounded by a slight efflorescence; on the fifth day a distinct vesicle becomes apparent to the eye, circular in form, having an elevated edge and depressed centre; on the eighth day it appears distended with a clear lymph, is either pearl-coloured or slightly yellow, and is at its greatest perfection. On the evening of this day an inflamed ring begins to form round the base of the vesicle, which continues to increase during the two following days; it is circular in form, and its diameter extends from one to three inches. It is at its height on the tenth day, when there is considerable hardness and swelling of the subjacent parts; on the eleventh day it begins to fade, generally from the centre to the circumference, sometimes forming two or three concentric rings of a bluish tinge. After the tenth day the vesicle itself begins to decline, the centre first turns brown, and the whole is gradually converted into a hard round scab of a dark mahogany colour. About the twenty-first day this crust falls off, leaving a permanent circular cicatrix, somewhat depressed, and marked with six or eight minute pits. Such is the course of a true vaccine vesicle; and if there be a shadow of a doubt that the vaccination is defective in any one of the above points, especially if the inflamed ring do not appear, the operation should be performed again.

Always suffer one or two of the vesicles at least to pursue their entire course untouched; if there be more

than two, then lymph may be taken from the supernumerary ones if required for vaccinating others.

Constitutional Symptoms and Management.Some children pass through the disorder without the slightest indication of constitutional disturbance, which is not to be looked upon as by any means essential to the success of the vaccine process. If constitutional symptoms do manifest themselves, it will be about the seventh or eighth day; the infant will be restless and hot, and the bowels more or less disordered. It is not an uncommon circumstance to find about the tenth day an eruption showing itself on the extremities of the child, sometimes extending to the trunk of the body. It continues for three or four days; occasionally until after the vaccine scab has fallen off. This eruption is chiefly met with in children of full habit, in whom numerous vesicles have been raised, which discharge freely.

Internal treatment is rarely required during vaccination, except now and then a mild aperient, such as a tea-spoonful of castor-oil; febrile symptoms, however, sometimes manifest themselves, and then something ought to be done. The chief point to be attended to, is to protect the vesicles from irritation and friction. Sometimes even without either, the arm will become very much inflamed, and it may perchance extend down as far as the hand. In such cases envelop the arm, above and below the vesicle, in a piece of soft linen well soaked in lead lotion, or cold water, and let it be kept well wetted. To the vesicles themselves you may apply a bread-and-water poultice until the scab drops off, and then cold-cream until they are quite healed.

Re-vaccination.-It is now known that vaccina

tion does not in all cases confer immunity from smallpox indefinitely, so that it becomes necessary after the lapse of a certain number of years to be re-vaccinated. Some authorities advise that a person be re-vaccinated every seven years; others every twelve years. I think, as this is such a simple matter, that it ought to be done; and especially so, if the vaccination marks have faded and become indistinct, or if there be any outbreak of small-pox ; or if the person be about to engage in any occupation which brings them in closer contact with any possible contagion, such as doctors, nurses, hospital servants, and the like.

A good vaccine cicatrix may be described as distinct, foveolated, dotted, or indented, in some instances radiated, and having a well, or tolerably well, defined edge.

An indifferent cicatrix as indistinct, smooth, without indentation, and with an irregular and ill-defined edge.

Constitutional Inaptitude.-Every effort to communicate the vaccine disease will now and then fail; the child will not take the vaccination. When a case of this kind is met with, after a fair number of trials with fresh and active virus, the little patient should be left for a few months, in the hope that some change may take place in the system, and then another trial be instituted. Experience has long proved that the predisposition to receive cow-pox is not equally great in all persons, nor at all times; and that in some individuals there exists through life an insusceptibility to the vaccine disease. The child of a weak and unhealthy constitution will not unfrequently be found indisposed to take the vaccination, but in this case the inaptitude is temporary; whilst, on the other hand,