NATIONAL LIBRARY OF MEDICINE NLfl DQ123bMb D NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service NLM001236460 RETURN TO NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN J A' -7 'ib 31 THE VALUE OF VACCINATION. PUBLISHER'S NOTICE. Before deciding to publish this little work, the publisher as usual placed the manuscript in the hands of two persons in whose judgment he felt that he could rely,—this time in the hands of two physicians directly opposed on the question of vaccination. The first, who was in agreement with the position taken by the author, pronounced it a most interesting and exhaustive treatise; the second, while he did not assent to the conclusions drawn, unhesitatingly declared it to be a scholarly effort and one that would be read with interest by many in the profession—"not a dull page in it," he said. Such comment from two physicians of opposite principles on this question, decided the publisher that the work could not fail to be of value to those interested in the subject, and under this belief it is now placed before the medical profession. F. E. Boericke, Publisher, THE VALUE Ur< VACCINATION A NON-PARTISAN REVIEW OF ITS HISTORY AND RESULTS.. GEORGE WILLIAM WINTERBURN, Ph.D., M.D., EDITOR OF THE AMERICAN HOMO30PATHIST ; PRESIDENT OP THE AMERICAN OBSTETRI- CAL SOCIETY; LATE LECTURER ON CLINICAL MEDICINE, AND PHYSICIAN-IN- CHIEF TO THE MANHATTAN HOSPITAL; FELLOW OF THE AMERICAN AKADEMEJ MEMBER OF THE ANTHROPOLOGICAL SOCIETY, THE NEW YORK ACADEMY OF SCIENCES, THE AMERICAN INSTITUTE OF HOMffiOPATHY, ETC. 'Gladly wolde he lerne and gladly teche."—Chaucer. PHILADELPHIA: F. E. BOERICKE, HAHNEMANN PUBLISHING HOUSE. 1886. \f\l7s7v Copyrighted, 1885, by G. W. Winterburn. Press of Globe Printing House, Philadelphia. 33?* 2* 3^ t^JSy > TO MY COLLEAGUE AND FRIEND, PROF. STEPHEN POWELL BURDICK, M.D., THIS MONOGRAPH IS, BY PERMISSION, DEDICATED. PREFACE. The following pages were primarily intended to form a chapter in an encyclopaedic work on the Practice of Medicine. Had it been my desire to write a popular treatise on Vaccination, I should probably have arranged my material in a somewhat different manner, and have given less space to tech- nical detail. Whether the result would have been more serviceable to the cause of truth, can only be determined by the reception which may be accorded to these pages. This subject is one in which all intelligent per- sons are rightly interested, and it seems wise to give the facts here collated a wider circulation than they would reach if printed, merely, as originally pro- posed. As I have elsewhere said, there is nothing essentially medical in the art of Vaccination, no phase of it beyond the comprehension of any ordi- narily educated person, and any attempt to hedge it about as a something with which the people have Vi PREFACE. nothing to do, but pay liberally and unquestioningly for, should be resisted. Vaccination became a question of public policy, when laws for its enforcement were enacted, and as long as people are taxed to support it, they have the common right of investigation. As a medical tenet, they might readily leave it to medical author- ities to dispose of; but when the ingenuity of the law is invoked to make it obligatory, then the public have a right to know what they get for their money. In this little book, which I now submit to the in- dulgence of the public and the tender mercies of the critics, is expressed the growth in knowledge of the subject, on which it treats, extending over many years, and in sending it forth, it is with the hope that it may prove both instructive and entertaining. G. W. W. No. 29 West Twenty-Sixth St., New York. December 10, 1885. CONTENTS. Page. Preface ..................... 5 Introduction,................... 9 The Eise of Vaccination as a Medical Dogma, . . 15 Cow-pox as Modified in the Human Subject, ... 27 The Nature and Origin of Vaccinal, Virus, .... 36 The Methods of Vaccinating,........... 45 The Extent of the Protection afforded by Vacci- nation,.................... 55 The Alleged Dangers from Vaccination,..... 115 Compulsory Vaccination,............. 145 Bibliography,.................. 151 Appendices,.................... 161 Index,...................... 175 "He who only knows his own side of the case, knows little of that."—John Stuart Mill, "I consider that the affirmation of facts is more powerful than the assertions of men."—Pascal. "Persistent misrepresentation of familiar facts must be set right. If people are allowed to hear what is untrue repeated often enough and confidently enough, they come, at last, to believe it, and that is a process, which one is bound to disturb."—Pall Mall Gazette, August 16, 1883. Introduction. The subject of Vaccination has engaged the atten- tion of a multitude of minds, both great and small, and its literature is as varied, in quality and com- plexion, as one need wish to find. It is one of those unfortunate topics, which seem to exasperate the most equably-tempered men, and to produce ebulli- tions of unreasonableness whenever and wherever broached. Conceived in ignorance of the real na- ture of disease, and born of fanaticism which brooked no questioning, fostered in the beginning by femi- nine conceit and courtly perogative, and later by governmental patronage and the conservatism of habit, it seems to have been so imbued with the spirit of intolerance and arrogance, that, even now in these modern days, when we pride ourselves on the impartiality with which we discuss scientific topics, every one who believes in vaccination looks with a sort of pitying scorn upon any one who does not. To doubt or discuss is, to their minds, con- vincing, nay irrefutable evidence of an impairment of that mental balance which we all pride ourselves in possessing. 2 (9) 10 INTRODUCTION. It is not singular, therefore, to find the densest ignorance on this subject among those who ought to know its origin and history; ignorance and preju- dice being the twin handmaids of tyranny. It has been my lot to stand in personal relations with num- bers of medical men during the past score years, and being somewhat curious upon this subject, I have, as opportunity presented, put the inquiry to some two hundred of them: Have you ever read Dr. Jenner's works. With two exceptions, the answer has been a negative. To be sure, one might know a great deal about a subject without having read a particu- lar author, but those who do not know what Jenner claimed, and upon what basis he is canonized as the Immortal, can hardly be in a convenient attitude to defend him, and his theories, upon logical grounds. This question, although affecting the welfare of untold millions, is calmly asserted to have passed beyond the domain of argument. Perhaps it has: but no truth was ever hurt by exposure to the rays of publicity, no matter how pitilessly they might beat upon it; nor, on the other hand, does truth ever gain by slinking behind vested interests and conventional phraseology. The object of this mono- graph is, therefore, to investigate fairly and dispas- sionately the claims of the Jennerian method, and the tentative basis upon which its theories were founded. It is hoped that sequestrating ourselves from the atmosphere of partisan strife, we may be able to perceive the just value of theories, and quietly study the history of their growth INTRODUCTION. 11 It seems ludicrous that a question of so much im- port, and of so purely a scientific nature, should be a matter of partisan clamor, but it ceases to be comic, and becomes painfully embarrassing, when men can- not discuss a question of vital importance to them- selves and the race without being accused of sinister motives or of mental unsoundness. And yet this is just what has happened ever since the earliest years of Vaccination. Jenner began it in his efforts to suppress every fact wThich told against his theory, and his mantle has passed with the passing years to men of like aptitude for the suppression of disagree- able truths. This is not philosophic, it is not scien- tific, but it is very human. Nevertheless, there has always been a widespread disapproval of the phil- osophy and practice of Vaccination; and acumen, probity, and learning have not been confined to the disputants on either side. The anti-vaccinists are neither more ignorant nor more fanatical than the pro-vaccinists, and neither side has been free from prevarication and unworthy methods. My own interest in the subject is by no means recent. During the war for the Union, many cases of smallpox were brought up from the front to Cin- cinnati, where I lived during my boyhood. Cir- cumstances brought me into contact with these cases to a considerable extent, and I became interested in the subject. Just previous to the war, I met an old lady, who had been vaccinated and re-vaccinated, and had had smallpox three times. This, as I then 12 INTRODUCTION. thought, anomalous experience, and my subsequent familiarity with the disease, awakened a natural curiosity as to the value of vaccination that did not protect. My interest in the matter was not lessened by finding, upon questioning them, that nearly all the smallpoxed-marked persons, whom I casually met, averred that they had been vaccinated prior to tak- ing the smallpox. When one's mind is awakened to a subject he naturally hears much about it, and what would otherwise slip by unnoted is read with attention, I might say with avidity. In this way, I have waded through much of the literature of Vac- cination, both pro and con, and it has been my en- deavor in the following pages to present such a re- sume of my reading as would commend itself to all lovers of truth for its impartiality and directness. Involving, as it does, the welfare of the race, either for good or for ill, Vaccination deserves the calm consideration of every thinking man or woman. The policy of presenting medical questions to the general public is vehemently condemned in certain quarters, and attempts to create a priestly craft in medicine are as persistently encouraged. The Leg- islatures of our various States are beseiged annually by men whose aim is to establish by enactment a medical priesthood, under the plea that the people are too ignorant to judge for themselves. I am not one of those who sympathize with mysticism in medicine. I believe that the more rational the pub- lic may be on these topics the better for themselves, INTRODUCTION. 13 for medical progress, and for the profession. Medi- cal men are no better, and never have been any better, than the public demand; and the surest, the most reasonable, nay the only way to raise the stand- ard of professional character and achievement is through the demands made by an intelligent and exacting public. I am, therefore, always glad to serve as a medium of instruction. It is with that purpose I send out this book, and it is for that rea- son that I have avoided a popular style of writing, and presented the matter from a purely scientific, but I hope not uninteresting, basis. If this be medi- cal heresy, I am pleased to be a heretic. The Value of Vaccination. THE RISE OF VACCINATION AS A MEDI- CAL DOGMA. Vaccination consists in the introduction of a specific virus into the system; and is performed as a prophylactic against the contagion of smallpox. It was invented by Jenner, in 1798, as a substitute for inoculation.1 Previous to this time, and indeed for many years subsequently, inoculation had been in vogue. Inoculation was brought from the Orient by Lady Mary Wortley Montagu, in 1721; and consisted of the introduction subcutaneously of smallpox virus.2 Writing from Constantinople she said: " The small- pox so general and so fatal amongst us, is here en- tirely harmless by the invention of engrafting, which is the term they give it. There is a set of old women who make it their business to perform the operation. Every year thousands undergo it, and the French 1 Inquiry into the Causes and Effects of the Variolce Vaccina, London, 1798. a Vol. II, Letter XXXI, dated April 1, 1717. (15) 16 INOCULATION. Ambassador observes pleasantly that they take the smallpox here by way of diversion, as they take the waters in other countries. There is no example of any one that has died of it, and you may believe I am well satisfied of the safety of the experiment since, I intend to try it on my dear little son. I am patri- otic enough to take pains to bring this careful inven- tion into fashion in England." And she did. Rumors of this method had been common enough in England for a score of years, but no one had been found brave enough to hazard the experiment, until Lady Mary had it tried on her own daughter; the operation was successful, and awakened great public interest. In the same year (1721) Dr. Boylston, in Boston, Mas- sachusetts, inoculated 244 persons, of whom six died. Other deaths followed inoculation in England, and it would probably have fallen into permanent discredit, had it not been for two circumstances. Robert and Daniel Sutton, two brothers, practitioners, one in Essex and the other in Suffolk, perceiving the ad- vantages in the method of treating smallpox as out- lined by Sydenham, applied it to inoculation, and won great celebrity by so doing. This consisted in giving most minute attention to the personal hygiene of the patient, and keeping the bowels open with purgatives. Immense sums were paid to them by the nobility for attendance, and it became the fashion to employ them. The other circumstance which tended to give permanence to inoculation was the establishment, in 1746, of the Smallpox and Inocu- SYMPTOMS PRODUCED. 17 lation Hospital, London; where inoculation con- tinued to be performed, on all applicants, until as late as 1822. In the Revue des Deux Mondes, Aug. 1, 1882, M. Daremberg says in an article on M. Littre:—" In- oculation of smallpox was practised in the second century. This is proved by the following lines from the Schola Salermtana:"— Pour eloigner d'un fils ce poison dele"tere Inocule en sa veine un virus salutaire." The phenomena of inoculation is thus described by Doctor Gregory, who had charge of the London Smallpox Hospital for many years: "On the second day after the operation, if the part be viewed with a lens, there appears an orange-colored stain about the incision, and the surrounding skin seems contracted. On the following day a minute papular elevation of the skin is perceptible, which on the fourth day is transformed into a vesicle with a depressed centre. The patient feels an itching in the part. On the sixth day, some pain and stiffness are felt in the axilla, proving the absorption of the virus into the general mass of blood. Occasionally on the seventh, but oftener on the eighth day, rigors occur, accom- panied sometimes with slight faintness, sometimes with pain in the back, headache, or vomiting. The patient complains of a disagreeable taste in the mouth, and the breath is offensive, soon after which the eruption shows itself."3 The disease then usually 3 Cyclopaedia of Practical Medicine, Vol. Ill, page 750. 18 INOCULATION SPREADS SMALLPOX. runs the natural course, in a mild form. Inoculated smallpox was as infectious as spontaneous small- pox; and therefore Dimsdale and other enterpris- ing inoculators recommended and superintended the inoculation of entire parishes, so that all having smallpox together, none might catch it. During the process, intercourse was, as far as possible, sus- pended with the outer world. Up to the time of inoculation variola had not been looked upon with particular disfavor, and was not considered any more dangerous than measles. In- deed, in the Health Reports these two diseases were classed together up to 1738, and until after that year it is impossible to determine just how much smallpox there may have been. From the most trustworthy sources, however, it is evident that just as now we have epidemics of measles, and other of the zymoses, varying greatly in intensity and fatality, so in the pre-inoculation period there were epidemics of small- pox of great fatality and others of very moderate intensity. But after the introduction of inocula- tion, the ravages of smallpox increased, not only directly as the result of inoculation, but each new case became, as it were, a centre of disease, from it spreading in every direction, often with great viru- lence. It spread smallpox just as the natural dis- ease did. It could be propagated anywhere by send- ing in a letter a bit of cotton thread dipped in the variolous lymph. In this way, not only the number of cases, but, also, the general mortality was very INOCULATION MADE CRIMINAL. 19 greatly increased.4 But so hard is it to alter'the ideas of a people after they have crystallized into habit, that although it was evident that epidemics of smallpox often started from an inoculated case; and although the most strenuous efforts were made to supersede it by vaccination, inoculation con- tinued to flourish for nearly a century and a half. It was found necessary in 1840 to make inocula- tion in England, a penal offense, in order to put an end to its use. Even that has not prevented its secret practice by the lower orders, where ideas die hardest, and the rite is even now probably more than occasionally performed. I have thus dwelt, with possibly undue prolixity, on this exploded medical dogma, because it throws a broad side-light on the rise and history of vacci- nation. Viewed from our present knowledge of zymoses, inoculation is seen to be a gigantic mis- take. Instead of being the entirely harmless inven- tion that it was claimed to be in 1721, it was found to be so pernicious a custom, and so destructive of public welfare, as to be branded as a crime in 1840. At the time of its introduction it was hailed as the greatest of medical discoveries, and the enconiums lavished upon it equalled those that have since been given to vaccination. Dr. Monteith relates:—"By the year 1777 the arguments, in favor of Variolation, had so far triumphed over the habits and prejudices Dr. ,T. T. Marson. 20 ORIGIN OF COW-POX. of the profession that there is no instance mentioned in our reports of any medical man in Newcastle opposing it. It is always spoken of as one of the best established facts of medical science. With the general public the case was different. Their prejudices were as strong as ever, and they exhibited a horror of Variolation which would satisfy the most ardent anti-vaccinator. To combat these prejudices, various means were tried—sermons from the pulpit, pathetic exhortations in the newspaper, etc.....In 1801, there had been in all 3268 operated upon."—Report of the Newcastle Dispensary, from its Foundation in 1777. Newcastle-upon-Tyne, 1878. And yet, alas for human prescience, what was pro- claimed as the savior, proved to be the destroyer. Probably, more than all other things combined, it has contributed to keep smallpox alive, by constantly disseminating the infection. The immediate deaths from inocculation were one per-cent. Owing to the spread of smallpox through inocu- lation, great fear of the disease had been produced, so that, when Jenner proclaimed vaccination as the certain and unfailing prophylactic against this dis- order, there were multitudes, especially of the edu- cated and wealthy class, who were ready to give credence to the discovery. Vaccinia (from vacca, a cow) or the Cow-pox, singular to say, never originates spontaneously in the cow, and is not one of its natural disorders. When found on that animal at all, it will be seen COW-POX AND GREASE. 21 that it is the milch cow that is almost invariable affected. The cause of this will presently appear, and it was well understood by Jenner. Ir'fact, he frequently declared, that, if a disease of similar appearance ever did occur spontaneously on the cow, that such was a spurious form of pox, and utterly worthless for vaccinal purpose. It is well that this should be understood clearly, as of late years great stress has been laid upon the supposed virtues of a particular virus-stock, as having been obtained from a spontaneous case of cow-pox.5 When Jenner established vaccination he was very particular to point out the importance of using only a certain kind of virus. The cow-pox, to which he ascribes these virtues, is a filth-disease, communi- cated to the udders of the animal by dirty stable- boys, who had gotten their hands soiled with the matter from the greasy heels of ill-kept horses. Al- though it is not in every case possible to trace the infection thus, there is the best authority6 for saying that it is always communicated in some such way. That it is not a disorder to which the bovine race is subject, is amply shown by the fact that bulls never have it; and a zymotic disease confined exclusively to one sex would be an anomaly in nature. But who ever heard of bull-pox? This disease, which is called cow-pox in cows, is known as grease in the horse. Grease is a disorder 5 A case of alleged spontaneous cow-pox at Beaugency, in France. 6 Prof. Simonds, Royal Veterinary College, 1879. 22 ORIGIN OF GREASE. resulting from inflammation of the sebaceous glands of the skin, about the heels of a horse, and is prop- erly called eczema pustulosum. The disease origi- nates from a scrofulous condition, supervenes from exposure to wet, and from subsequent lack of clean- liness, and is always the result of carelessness on the part of the groom.7 The discharge from these vesic- ular pustules is often profuse, very irritating to the surface over which it flows, and foetid. Prof. Hering has found in it large numbers of acari, called sarcop- tes hippopodus. The presence, however, of this para- site seems to be purely accidental, and is said to have nothing to do with the progress of the disease. This purulent matter, carried on the dirty hands of farm-laborers to the teats or other sensitive parts of the cow, produced the disorder which has been misnamed cow-pox. It was noticed that milk-maids or others, that be- came affected with this disorder, from absorbing the virus through cracks on the hands, were not, as a rule, subject to variola during epidemics of that dis- order, and, consequently, it became a matter of country-side gossip, that cow-pox was a preventive against taking small-pox. This coming to the ears of Jenner, led him to cogitate upon the best manner of securing such prophylactic protection at will, and to finally adopt vaccination. This was no hurried step on his part. For it was when, as a mere sur- 7 Kirby on Veterinary Medicine and Surgery JENNER'S EXPERIMENT. 23 geon's apprentice at Sodbury, near Bristol, in 1768, that his attention was called to the matter by a chance remark made by a country girl,8 and it was not until nearly twenty years later that he made his first vaccination. This was upon a lad named James Phipps, who subsequently died of pulmonary con- sumption. Two years later, in 1789, he vaccinated his own son, then a year and a half old, with swine-pox; and between that year and 1792, he repeatedly inoculated him with small-pox. This son was always delicate in health, and died in his twenty-first year, of pul- monary consumption, which many have claimed was induced by the repeated inoculations. It was natural that, having thus spent many years of his life in developing this idea, that he should claim perfection of security for those who submitted to this rite. It was, perhaps, just as natural that the medical profession should have been slow to accept a new medical dogma thus thrust upon them by an obscure, and not over-successful practitioner. Dr. John Hunter, the celebrated physiologist, and a for- mer preceptor of Jenner, thus voiced the medical opinion of the time: "The introduction by inocula- tion of mineral or vegetable poisons into the blood is hazardous, and in certain quantities may be destruc- tive; but the introduction of animal products from another living body, be it a man, a cow, or even an 8 Baron's Life of Jenner, Vol. II, page 122. 24 AMATEUR VACCINISTS. ass, is infinitely more pernicious, because allied to it in being vitalized." Jenner had, in 1797, made an ineffectual effort to gain admission for his treatise into the Transactions of the Royal Society; but he was given to understand that " he ought not to risk his reputation by present- ing to that learned body anything which appeared so much at variance with established knowledge, and withal so incredible."9 Happily for Jenner, he succeeded in persuading a number of aristocratic ladies to become amateur vaccinators among their tenantry and dependents. The method was novel and highly sensational, and thus furnished a pleasing diversion for the fashion- able world. Under the protection of the Earl and Countess of Berkeley, he was able to defy the medi- cal profession; and the art being alleged to be within the ability of any one to apply, many were found ready to spread the glad tidings. Lady Charlotte Wrottesley was one of the earliest devotees to the new rite and vaccinated thousands in Staffordshire. The clergy were pressed into the service, one of whom vaccinated three thousand persons in about three years. An enthusiastic friend of Jenner rec- ommended that "the christening and vaccination be always performed on the same day." The Duke of Clarence caused his household and farm-servants to be vaccinated. The Duke of York ordered the vac- Life of Jenner, Vol. II, page 168. JENNER REWARDED. 25 cination of a regiment. And in 1802 the King com- manded the prime minister to convey to Parliament his majesty's desire that a benefaction should be awarded to Jenner out of the public purse. When the bill came up the princes of the blood attended in its support. To the subservient Parliament of that day, an intimation of the royal wish in a matter of this kind was decisive. Jenner promised the credu- lous monarch and his faithful Parliament that vac- cination would put an end to smallpox forever. Not only were the people to be perfectly secure from death from smallpox, but they were to be equally secure from attack. There were absolutely to be no cases. In the anxiety of the Court to believe, and the readiness of Jenner to promise, the fact that vac- cination had been on trial for only six years, and that it was utterly impossible for Jenner or anybody to know whether it would protect for a lifetime, was lost sight of. Jenner's positive declaration was re- ceived as if proven. The Commons granted the £30,000. The Court breathed easily, they were to be made perfectly se- cure for life. To Jenner's high gratification, the medical profession, overawed by the attitude of the Court and the nobility, found it convenient to with- draw their opposition to the now triumphant method, and to publicly indorse what they had previously rejected. This, in brief, is the history of the establishment of vaccination as an accepted medical dogma. It 26 JENNER REWARDED. will be seen with how little of scientific research it was adopted, and how much the whim of a few fash- ionable folk shaped its destiny. Had it remained purely a medical question, it may well be doubted whether it would ever have attracted more than passing attention, and if remembered at all, it would possibly be as only one of the curiosities of medicine. In endeavoring to present as briefly as possible the present state of our knowledge of this very important subject, I shall describe cow-pox as modified in the human subject, the nature and origin of vaccine virus, the methods of vaccinating, the extent of pro- tection afforded by vaccination, and the dangers, if any, of vaccination. In doing this it is my honest desire to present the arguments advanced by those who thoroughly and unquestioningly indorse the method, as well as of those who decry and despise it, in such a manner as to elucidate the truth in this vexed question, so that each reader may come to a proper understanding of it. COW-POX AS MODIFIED IN THE HUMAN SUBJECT. If a small particle of the virus from a fully formed vesicle of cow-pox be taken upon the point of a lancet, and inserted by puncture beneath the cuticle of a person who has never had smallpox nor been previously vaccinated, certain phenomena will ap- pear in a definite order. If the person be in other- wise good health, no particular effects will be notice- able during the first forty-eight hours, except a temporary elevation of temperature, followed by a fall to a point below normal. Within a few hours a peculiar malaise, like that preluding the whole class of exanthems, overcomes the patient. He is dull and sleepy; pulse and respiration are both slowed for a time; the pulse soon quickens, but the respiration continues slow or shallow, with bronchial rales, or slight laryngismus. At the end of the sec- ond day, or surely during the third, there will be perceptible a papulous spot over the point of punc- ture, which, very slight at first, becomes by the fifth day a distinct vesicle, bluish-white in color, the edge raised and clearly defined, and the centre lowered, thus forming a peculiar and characteristic cup-like depression. This vesicle gradually fills with a clear and limpid fluid, which is misnamed lymph, and (27) 28 THE VACCINE VESICLE. by the eighth day, that is the day week from the in- sertion of the virus, it has become fully ripe, and while retaining the peculiar shape already noted, it is now pearl-like in color, round and plump. Pre- ceding this, however, by one or two days, there has begun to form about the base a thin ring of inflam- mation, called the areola, which rapidly spreads and takes on the character of erysipelas. This Jenner declared to be the chief sign of the true character of the virus, being even more important than the shape and appearance of the vesicle. He repeatedly said that without the accompanying erysipelas no vacci- nation could be counted upon as protective.10 The amount of erysipelas varies greatly. Sometimes it is a clearly circumscribed round spot of less than three inches diameter. At others, it extends irregu- larly, involving perhaps the entire limb. Even where it involves but a small cutaneous surface, there is much hardness and swelling of the subjacent con- nective tissue, while in extreme cases the arm may become enormously swollen, and so rigid as to be practicably immovable. In either case, the develop- ment of the areola is accompanied by the usual systemic symptoms of erysipelas. The temperature continues low until the fourth day, when it rises to 102° to 104° F., or even higher. On the eighth day there is usually a sharp rise of temperature, respira- tion and pulse. The pulse may even go as high as 10 Or, as he poetically expressed it, "The pearl upon the rose." SYMPTOMS OF VACCINATION. 29 200, and the respiration to 80; but these are excep- tional figures. Restlessness, heat and dryness of the skin, headache, nausea, diarrhoea, swelling of the axillary and other glands, are present in varying intensity, and are never altogether absent, even in the mildest cases. In fact, these secondary symptoms are looked upon, by all experienced vaccinators, as marking the effectiveness of the protection afforded by the vaccination. The duration of these symptoms vary with their intensity, but usually after the tenth or eleventh day, that is about five days after the setting in of the erysipelas, the period of recovery begins. The tem- perature returns to nearly normal, and then sinks slightly below it, the bowels become regular, the headache disappears, the swollen glands are less sensitive, the skin is more natural, the areola fades gradually, the vesicle, which during this process has changed to an opaque and pustular appearance, now begins to dry in the centre, and a process of desic- cation and incrustation follows, occupying four or five days, at the end of which time a hard, brown scab has formed. This process lasts about five or six days. The scab continues to dry, harden, and darken, and at the end of the fourth week spontane- ously separates, leaving behind a permanent, slightly- depressed cicatrix. This cicatrix, upon examination with a magnifying glass, is seen to be indented with a number of minute pits, from which radiate fine lines. 30 PERSONAL SUSCEPTIBILITY. In children, after vaccination, when the spots have nearly healed, an erysipelatous redness occa- sionally appears, spreading over the arm and a great part of the trunk. The redness is often intense, the tissues being very hard, painful and shiny; and this inflammation may continue for weeks.11 Some persons are found, who, while never having contracted smallpox nor been inoculated, yet are peculiarly insusceptible to vaccination. In these, even the most careful performance of the operation only results in a transitory illness, not incapacitating them from their ordinary vocations, and leaving be- hind slight evidence in the way of a "mark." Such persons seem to have the power to throw off the poison through inherent vitality, and would prob- ably not take smallpox in the natural way, if exposed to it. Occasionally, on the other hand, persons will develop extreme susceptibility, which shows itself by an eruption on a portion of, or upon the entire body. This eruption may be papular, vesicular, or pustular. Sometimes the sores are very similar to the one at the place of puncture. These eruptions are not generally long-lasting, ordinarily not extending be- yond the falling of the scab. In other cases, how- ever, persisting for weeks or months, or perhaps causing death. Vaccination directly from the cow is now very rarely performed. The usual plan is a modified ,y Ringer, M.D., Handbook of Therapeutics, 8th ed VARIATION IN PHENOMENA. 31 form, by which the dried virus either from a vesicle on the cow, or from another person who has recently been vaccinated, is used. In either case the viru- lence is very much lessened, and in consequence, the protective power greatly impaired. From this use of virus of varying degrees of viru- lence, decided variations in the phenomena of vacci- nation occur. Papulation is sometimes deferred un- til the eighth, ninth, or even eleventh day. The areola may not appear until after the second week. The vesicle is often wanting in that sharp definition of edge, plumpness of appearance, and glistening color which has been described. The areola may be only a faint pink, or deepening in shade, it may pass through a dusky brick-red to deep purple. In some cases it fades and brightens in color, while the swelling and hardness remain unchanged. The scab sometimes does not fall until the sixth week. None of these things necessarily impair the value of the vaccination, though a too wide variation from the normal phenomena will always subject the case to suspicion. There are three forms of variation which are rec- ognized, and which demand our attention: (1) accel- erated; (2) retarded; (3) irregular, or spurious. Those cases are denominated as accelerated where the symptoms all appear in quicker succession than heretofore described. If the symptoms are twenty or thirty hours in advance of their due course, and the vesicle is irregular in appearance, the areola but 32 VARIATION IN PHENOMENA. slight, and the general constitutional symptoms wanting, but little faith can be put in the protective power of the operation. If, however, the vesicle be normal in appearance, and the constitutional symp- toms present and only briefer in duration, the value of the vaccination is not impaired. Where the ordinary course of the vaccinal phe- nomena are modified by retardation, the circum- stances that cause it should, if possible, be deter- mined. In the wrinter season, especially if the pa- tient be exposed to the vicissitudes of weather, a de- lay of a couple of days is of no special moment. Retardation rarely occurs in those vaccinated directly from the cow, and though more common, is still in- frequent in immediate vaccination from arm to arm; but when dry virus is used it often seems to need several days of incubation before its specific charac- ter is aroused. Again, the state of the person's health at the time has much to do with the progress of the vaccine disorder. If they are so unfortunate as to take cold at that time, or if they are incubating some other disease, a marked delay in the develop- ment of the vesicle may result. Jenner noticed that the vesicles are often arrested in their course if un- wittingly a child was vaccinated just as it was falling ill of measles or scarlet fever, and that the areola did not appear until the morbillous or scarlatinal symptoms subsided.12 If, however, the patient be 12 Continuation of Injuiry, page 31. SPURIOUS VACCINATION. 33 incubating smallpox, the two diseases, vaccinia and variola, go on side by side, apparently unaffected by each other; unless previous to the formation of the vaccine vesicle the smallpox pustules appear, in which event the vaccination fails to take. There are still other cases where the natural march of the vaccinal-disorder is delayed, at one point or another. If, however, the major symptoms do occur, even though the whole progress of the disorder may occupy six or seven weeks, no suspicion need be thrown upon the character of the protection afforded. Spurious vaccination runs an entirely irregular course, the varieties being practicably unclassifiable. The vesicle instead of being cup-shaped, may be acu- minated or conoidal; the contained secretion may be straw-colored or bloody, instead of limpid and clear; the vesicle may have scabbed by the seventh day, or even sooner; or the scab "may be a thin scale, which drops off at the lightest touch. In other cases the vesicle breaks spontaneously, and be- comes an open and unhealthy ulcer. None of these forms can be relied upon as having the slightest pro- tective power. While these irregular appearances may be often due to inexperience or carelessness on the part of the operator, or to the inferior quality or impurity of the virus used, it is not always so. In the hands of the most skilful and experienced vaccinator it will happen, that in.a group of children operated upon at the same time and with the same virus, some will 3 34 SPECIAL SUSCEPTIBILITY TO VACCINIA. present perfectly formed vesicles, in due time, while perhaps on one it will not take at all, and on another a hideous ulcer will result. It is well known that in the vast majority of cases an attack of measles, scarlatina, pertussis, or variola renders the person insusceptible to the disease for- ever afterwards. There are, however, plenty of in- stances of individuals who have had one of these diseases two or more times. The same rule, to some extent, holds true of vaccination. The phenomena which I have described, can, as a rule, be produced but once in an individual. A second vaccination, providing the first has been thorough and severe, either fails to produce any local effect whatever, or else in a very modified form. There are persons, however, who are so susceptible to the influence of this virus that they will be severely affected by it whenever it may be re-introduced. It not infre- quently happens that persons who can show ex- cellent vaccination-marks, upon being re-vaccinated develop most severe constitutional disturbances, ac- companied with extensive phlegmonous erysipelas. Cases have occurred terminating fatally from pyse- mia. It is impossible to foretell what will be the result of a re-vaccination, as the severity bears no relation to the character of the primary disorder. It is simply and always a matter of good luck when, upon re-vaccmation, the patient escapes serious con- stitutional effects. VACCINIA A DISEASE. 35 Dr. Ballard observes13 in his work on vaccination that, " Vaccination is not a thing to be trifled with, or to be made light of; it is not to be undertaken thoughtlessly, or without due consideration of the condition of the patient, his mode of life, and the circumstances of season and of place. Surgeon and patient should both carry in their minds the regu- lating thought that the one is engaged in communi- cating, the other in receiving into his system a real disease—as truly a disease, as smallpox or measles; a disease which, mild and gentle as its progress may be, yet nevertheless now and then, like every other exanthematous malady, asserts its character by an unusual exhibition of virulence." 1:i Vaccina/ion, its Value, and Alleged Dangers, page 93. THE NATURE AND ORIGIN OF VAC- CINAL VIRUS. The history of vaccination is peculiar in several very important particulars. We are now to consider one of these. If it be asked, with what shall we vaccinate? the answer would seem to be simple enough—why, with vaccinal virus, of course. But* if we ask, What is vaccinal virus? the answer is not readily found; nor is there, even now, after nearly , a century of vaccination, any concord in the profes- sion as to the proper material to be used. When Jenner first performed the rite, he used cow-pox virus. We have already seen what was the origin of this disorder in the cow, viz., that it was a contagious disease transferred, by careless manipu- lation, from the heels of the horse to the udder of the cow. Jenner believed that smallpox, swine-pox, cow-pox and grease were merely varieties of the .same disease, as he implied by the name variolar, vaccinas. He vaccinated his own son with swine- pox. He employed the grease-virus (horse-pox) in ' a large number of cases, and furnished it to other vaccinators. Acting on his suggestion, the King of Spain, in 1804, ordered all the children in the Found- ling Hospital at Madrid to be vaccinated with goat- pox. Jenner claimed that the virus of these and (36) ORIGIN OF VACCINE. 37 various other animals were all equally efficacious with cow-pox in warding off smallpox. He also used arm-to-arm vaccination, derived both from the cow and from the horse. He therefore practiced five distinct things under the one name of vaccina- tion: (1) Cow-pox vaccination; (2) cow-pox-child vaccination; (3) horse-pox (grease) vaccination, which he denominated as the equination of the human subject; (4) horse-pox-child vaccination; and (5) swine-pox vaccination. Although he asserted that grease, cow-pox and smallpox were all one disease, he made no attempt to prove it by inoculating the cow with variola. But, as early as 1801, Gassner, of Giinsburg, inoculated with variolous virus eleven cows, producing on one of them vesicles having all the characteristics of vaccinal vesicles, and from which "a stock of genu- ine vaccine lymph was obtained."14 With this smallpox-cow vaccine four children were inoculated, and from them seventeen other children were in turn vaccinated. In the following year (1802) a number of cows were successfully variolated at the Veterinary College at Berlin.15 , In 1830, Dr Sonderland, of Barmen, by envelop- ing cattle in blankets taken from the bed of a pa- tient who had died of smallpox, and by also hang- ing the blankets up around their heads, and thus 14Seaton's Handbook of Vaccination, Chapter IV. Ij M. Viborg. 38 SMALLPOXING THE COW. forcing them to breathe the effluvia from them, suc- ceeded in variolating several poor animals. The cows, he says, "in a few days manifested the symp- toms of cow-pox, and lymph taken from them pro- duced genuine vaccine vesicles in the human sub- ject.16 These wantonly cruel experiments were repeated in various places in Europe and also in India. In 1836, by inoculation of variolous virus, Dr. Thiele,of Kasan, produced "the genuine vaccine disease." AVith this he vaccinated, through seventy- five transmissions, more than three thousand human beings. In 1839, Ceely, of England, induced "vac- cine vesicles in two young heifers (out of three oper- ated on), by inoculation of variolous lymph," and thus established vaccine-stock, which formed the basis of thousands of vaccinations. In 1840, Mr. Badcock, of Brighton, England, succeeded in small- poxing a cow, and derived therefrom a stock of "genuine vaccine lymph." He has since repeated the experiment about six hundred times, succeeding in thirty-seven cases. The vaccine virus thus ob- tained has been supplied to many hundreds of prac- titioners, and tens of thousands of vaccinations have been performed with it. In 1849, the experiments were repeated in this country, at Waltham, Massa- chusetts, by Dr. Adams, and at Boston, by Dr. Put- nam, and in 1852, by Dr. Wm. C. Van Bibber and Dr. Saml. Knight, of Baltimore, and the vaccine 16 Dr. Edward C. Seaton. THE BEAUGENCY STOCK. 39 matter thus obtained is still handed down from arm to arm. Beside this variola-vaccine lymph, as it is called, another, and as it is asserted, a new variety of lymph or virus has been imported. This is the celebrated Beaugency stock, which is claimed to be a spon- taneous case of cow-pox, untainted with variolation on one hand, or horse-grease on the other. Thus there are a number of strains of vaccine material: a. The original cow-pox of Jenner; b. Equine-pox stock; c. Swine-pox stock; d. Goat-pox stock; e. Variola cow-pox of Ceely, and others; /. Spontaneous cow-pox of Beaugency. Each of these have passed through many trans- missions, and to a certain extent have become crossed or intermixed, and with the exception of what is now called " calf-lymph," it is impossible for anybody to tell what he is using. This so-called "calf-lymph" is offered in two varieties. One of these is claimed to be inocculation from the Beau- gency stock, which it is confessed, is of unknown origin, and which from the mildness of the vaccine- disorder which it sets up, is of dubious value. If this Beaugency stock is what it pretends to be, then it is confronted with a direct denial of its efficacy by Jenner himself, who says: " Pustulous sores fre- quently appear spontaneously on the nipples of the 4Q CALF-LYMPH. cows, and instances have occurred, though very rarely, of the hands of the servants employed in milking being affected with sores in consequence. These pustules are of a much milder nature than those which arise from true cow-pox. No erysipelas attends them. This disease is not to be considered as similar in any respect to that of which I am treat- ing, as it is incapable of producing any specific effects on the human system. It is of the greatest conse- quence to point it out here, lest the want of dis- crimination should occasion an idea of security from the infection of small-pox, which might prove de- lusive." That would seem to settle the question as to the Beaugency stock. The other variety of "calf-lymph" is derived from smallpoxing a heifer, and from the vesicles thus produced calves are inoculated; these in their turn furnishing the "lymph" or virus for the human subject. This furnishes two more varieties of vaccine ma- terial : g. Calf-Beaugency stock; h. Calf-smallpox-cow-pox. Now, if as Jenner declared, these various poxes are really all one thing, and simply derivations of horse-grease, it can make little difference through what animal it comes, provided such animals are themselves free from disease. But just here authori- ties fail to agree. Drs. Drysdale, Seaton, Badcock, Ceely, Thiele, and Sonderland assert that smallpox SMALLPOX NOT VACCINIA. 41 inoculation of cows produces "genuine vaccine lymph." But other experimenters, equally entitled to respectful attention, have shown that it is a delusion to suppose that the inoculation of cows with small- pox has ever produced cow-pox; it produces small- pox and nothing else. The smallpox may be in- duced on the horse or cow by variolation, but the variolous inocculation is never transmuted into grease in the horse, or cow-pox in the cow.17 Ex- periments made in the United States, and also at the Veterinary School at Berlin, have verified these observations, originally conducted at Lyons, France. Dr. Seaton says: "It is quite out of the question that cow-pox on the human subject should have been transformed into smallpox." If, therefore, cow-pox cannot become smallpox, it would seem incredible that smallpox could become cow-pox. Dr. Geo. Wyld, of London, who is certainly compe- tent authority on any matter pertaining to vaccina- tion, and a man of unimpeachable integrity, indorses the conclusions of the French Academy. He says: " I find that many medical men are under the false im- pression that all that we require to do is to inoculate the heifer with smallpox matter, and thus get a sup- ply of vaccine lymph. This might become produc- tive of disastrous consequences. Smallpox inocula- tion of the heifer produces not vaccinia, but a modi- fied smallpox capable of spreading smallpox amongst human beings by infection."18 17 M. Chauveau. Report of Committee of the Academic des Sciences. 18 London Daily Xews, February 17, 1877. 42 SPONTANEOUS COW-POX. It would thus appear that a large proportion of the vaccination now performed is in reality but a modified form of inoculation, having smallpox as its basis, and containing nothing of the Jennerian method but the name. It is not cow-pox, neither spontaneous nor inoculated from horse-grease, but it is smallpox propagated from human beings, through calves, to human beings again. Much has been claimed for the Beaugency stock, and it has been given wide currency. There had been growing up for many years such a wide-spread dissatisfaction with the prevailing vaccine material, that when, in 1866, it was announced that a case of natural cow-pox had been discovered at Beaugency, in France, there were hundreds of practitioners who were willing to give the new brand a trial. It has thus been in use nearly twenty years, and it is al- leged can be had humanized or vitulated. That is a child was vaccinated directly from the cow, eigh- teen years ago, and the virus has passed through some four or five hundred transmissions, with the chance of having been corrupted at any one of them. The vitulated stock has, in like manner, been handed down from calf to calf in a long succession of ani- mals, and the evidences of its present genuineness would be deemed inconclusive in any court in Chris- tendom. It will thus be seen on what slight foundation the whole question of vaccinal virus rests. Millions of vaccinations are made every year, and nobody knows IS IT VACCINIA? 43 what they are made with.19 The whole process is a haphazard game with chance. Vaccination was ac- cepted on the simple dictum of Jenner that it would stamp out smallpox. The medical profession of to- day buys its vaccinal virus of those who make mer- chandise of it on their simple dictum that it is the right thing to use. 19 Dr. Charles Cameron, M.P. THE METHODS OF VACCINATING. In matters of experimental science, the'predic- tions of the greatest geniuses only show the imprudence of those who express them.— Warlomont. When Jenner introduced vaccination he believed that if the cow-pox virus was directly brought in contact with the cutis, so as to be acted upon by the absorbents, that it would necessarily find its way into the system, and produce its specific results. An operation so simple apparently required no particu- lar training, and could be performed by a layman just as well as by a legally qualified practitioner. In this way a large proportion of the earlier vacci- nations were performed by laymen and ladies. When, however, smallpox began to appear among the vaccinated, it was at first indignantly denied, then ignored, and at last when the failures of vacci- nation became too numerous to be hidden from pub- lic attention, it was claimed that those cases which smallpox subsequently attacked had been but im- perfectly vaccinated, and that the manner of the vac- cination was at fault, and not the thing itself. This was not only plausible, but in the main true. Vac- cination was seen to be a rite which required to be performed with due observance to detail in order to (44) MULTIPLE VACCINATION. 45 be effective. Thenceforth amateur vaccination was discountenanced, and the matter was relegated to pro- fessionalsupervision. Up to this time " one mark " was considered protective for life; but when it was found that persons who showed a "good" mark, which had been made by a competent surgeon, nev- ertheless took smallpox, it was admitted that the effect gradually wore off, and that those who had been vaccinated in infancy, should again submit to the operation at the dawn of puberty. The possible fallibility of the rite having been admitted, and smallpox continuing to show itself even among the re-vaccinated, double vaccination was recommended; that is vaccinating in two places, either on the same arm or one on each, at the same operation. This has been successively increased to seven or more, while the frequency of the operation has doubled up with each decade, until now there are many pro-vac- cinists who urge its annual performance. I am ac- quainted with persons who have been thus vacci- nated fourteen or fifteen times, with several distinct marks for each time. In this way, one starting early enough might be pretty well tattooed in the course of a moderately long life. Without attempting to decide how much of this is the eager partisanship of extremists, let us now consider what are the necessary conditions for the proper and successful conduct of a vaccination. There are three things which demand our attention, (1) the present state of health of the person to be 46 CARELESS VACCINATION. vaccinated; (2) the selection of the virus to be used; and (3) the thorough and effective manner of insert- ing it. The failure to thoroughly appreciate the im- portance of either of these three circumstances, and to carefully attend to them in performing the vacci- nation, may make the operation fruitless of good results, or fraught with danger and disaster to the vaccinated. I. I think it may be laid down as an invariable rule of practice, that no one should be vaccinated except after the most rigid physical scrutiny. The carelessness of the Health authorities in this par- ticular is amazing. Vaccination is performed, with the easy nonchalance of the impossibility of doing harm, upon multitudes without the slightest inquiry as to their physical condition or antecedents; and this among the very class, where the greatest danger always lurks—the tenement house population. Vac- cination to be effective, pervades and alters the en- tire constitution. Says Sir James Paget," The action of vaccine is to establish a permanent morbid con- dition of the blood."20 There are innumerable in- stances, in which vaccination has awakened a latent disease, whose fires were smoldering in the system. A lady, aged 33, who had had a small fibroid in- tramural uterine tumor for several years, was vac- cinated during the smallpox epidemic of 1881-82. The vaccination took nicely, went through a normal 20 Lectures on Inflammation. VACCINIA AND LATENT GERMS. 47 course, and the scab fell on the twenty-sixth day, leaving a perfectly characteristic cicatrix. The genuineness of the vaccine was thus duly attested. Previous to this time, the tumor had grown very slowly, and had for some months seemed at a stand- still. Within a few weeks after the vaccination, with no other perceptible reason for exacerbation, the tumor was noticed to be growing rapidly, and in six months it increased from three or four ounces in weight to seven or eight pounds. During the same epidemic a man, aged 39, in apparently good health, was vaccinated. The vac- cination ran an irregular course, leaving an open ulcer, which did not heal for several months. This could not be ascribed to faulty vaccine, as others were vaccinated with the same virus at the same time, and all these had the vaccine-disorder norm- ally. In this case, before the ulcer healed, diarrhoea set in, which persisted, with transient ameliorations from treatment received, until his death. He was vaccinated in January. In May, mesenteric tubercles could be easily perceived upon physical examina- tion. He lived until the following December, and died of tuberculosis intestinalis cum marasmus. These cases are not given as in any way reflecting on vaccination; but only as illustrating how vaccine may act in liberating the latent germs of a diathesis, and to enforce the necessity of extreme carefulness in performing the operation. It is self-evident, that where the person is suffer- 48 SKIN DISORDERS MODIFY VACCINIA. ing from an acute disease, as for instance, diarrhoea or bronchitis, vaccination must be delayed. Skin affections greatly modify and frequently nullify vaccination. A simple intertrigo may completely spoil the effects of an operation, and before proceed- ing to vaccinate, the operator should carefully ex- amine the folds of the neck, behind the ears, and about the buttocks for chafed patches, and if abra- sions be found, the lancet must be withheld. The same advice holds true in regard to all skin dis- orders, especially those of the eczematous or herpetic sorts, as vaccine is nearest allied to these, and is most frequently aborted by them on the one hand, or greatly adds to their virulence and chronicity on the other. In the case of infants, themselves apparently healthy, there always arises the interesting inquiry, whether there be any taint of syphilis in either parent. Should there be even the slightest well- grounded reason for believing there may be, vacci- nation should be postponed until the infant is six months old. As hereditary syphilis nearly invari- ably manifests itself before the child is four months old, this precaution will prevent a disease which was pre-natal in its origin from being ascribed to the vaccination. Nearly all writers on vaccination urge the per- formance of indiscriminate vaccination or re-vacci- nation during an epidemic of smallpox upon all classes and conditions of men (including the babies); VACCINIA A ZYMOSIS. 49 and it is the practice of the Health Board here in New York, on discovering a case of smallpox, to re- move the patient to Riverside Hospital, Blackwell's Island, disinfect the house, and indiscriminately re- vaccinate everybody in the vicinage. As to the moral right of the Health Board to thus enforce vac- cination, I have nothing to say in this place. Waiv- ing that point, altogether, at this time, and viewing the question solely from the physical point, this seems a mistake. It is well known that persons, re- covering from one of the zymotic disorders, are prone to take any other that may be prevalent at the time. A person weakened by scarlet fever is likely to take diphtheria, if it is about, or vice versa. It is then but fair to believe that if the vaccine-disease be made plentiful that it will turn the community into a convenient nidus for other zymoses, including smallpox. The error seems to be, in looking at vac- cination, not as a disease-bearer, but as a purifier, while the vaccine-disorder is as truly a disease as measles or typhus. As smallpox is so largely confined to infants and very young children, one-fourth of the deaths from that disease being of children under one year old,21 if the infant is to be vaccinated, health permitting, the earlier it is done, the better, The earliest period 21 Of 42,277 deaths from variola, in England, during the ten years, 18o6—1865, 10,223 were of children under one year of age. (Seaton.) In the variolous epidemic of 1837-8, when 9,762 perished in Eng- land, 9,008 of the victims were under fifteen years of age. 50 VACCINE SHOULD BE UNTAINTED. of life, that is during the first three months, is par- ticularly suitable to vaccination, for at that time the infant is free from the disturbing influence of teething, and if the health is otherwise good and the vaccine is selected with care, the probabilities are that the child will pass through the vaccine-disorder in a normal manner. Children vaccinated during den- tition often suffer severely from diarrhoeal com- plaints. Frequently the tooth-making process is in- terfered with, and the teeth are imperfectly devel- oped, or are subject to early decay. The chances of an adult taking smallpox are re- mote. Like measles, whooping-cough and scarlet fever, smallpox is mainly a disease of childhood. After the tenth year the probabilities of taking it rapidly lessen, and it is hardly worth while under- going the risks of vaccination, to ward off a danger so problematical. I know I am not in accord with most vaccinists in this conclusion, but the facts upon which it is based are admitted by all. II. The vaccine22 to be used should not only be free from all taint, but, like Caesar's wife, above sus- picion. The vaccinator should make assurance that the "lymph" that he introduces into the system of the helpless babe before him is from a perfectly healthy animal, or if it is humanized virus, that it is from a child of perfectly healthy stock. The vacci- 22 The origin of the word vaccine is thus described: "Dr. Odier, of Geneva, has baptized the new disease, la vaccine, or vaccinia; rejecting as absurd the name of the English, variola vaccina."—Br. Pearson, in Medical and Physical Journal; Vol. Ill page 100" 1800 VACCINE ACCIDENTS. 51 nator has no right to trust to chance in this matter of virusation. It involves consequences too perva- sive and long-lasting for a happy-go-lucky style of selection. The difficulties of the problem offer no valid excuse for evading its solution. Vaccine is an article of commerce, and has therefore a mercenary element, in addition to the uncertainties to which I have referred in speaking of the origin and nature of vaccinal virus. Many accidents have arisen from the use of impure vaccine,23 but vaccinists, as a rule, have been loath to admit the facts, fearing to preju- dice the public mind against the whole matter. It is often unpleasant to face the truth, but it is always cowardly to evade it. Arm-to-arm vaccination has almost ceased in New 23 The following communication from Dr. T. S. Hopkins, of Thom- asville, Ga., concerning the results which have followed the use of "patent solid lymph," is published for general information: "Our town authorities have employed a physician to vaccinate all persons who present themselves for the purpose. The virus was pro- cured from the New England Vaccine Company, Chelsea, Mass., as 'bovine matter.' The result has been fearful. Nearly every one vaccinated has suffered severely from Erythema or Erysipelas, the arm swollen from shoulder to wrist, and the point of puncture pre- senting the appearance of a sloughing ulcer, discharging freely sani- ous pus. Many of the sufferers have been confined to bed, with high fever, from five to ten days, requiring the constant application of poultices to the arm, and a free use of morphia for the relief of pain. I deem it my duty to inform you of the result here from the matter used and from whence it came. It came in cones, each cone said to contain enough to vaccinate one hundre persons, at a cost of one dollar per cone. Those who have tried it tell me they would much prefer to have smallpox,"—From the National Board of Health Bul- letin, Washington, D. C, March 4, 1882. 52 SOURCES OF VACCINE. York. Occasionally a doctor will ask to have a scab saved for him, but of immediate arm-to-arm operation from the vesicle, I have known of no in- stance for some years. I think this a misfortune, as when the doctor thus had a whole series of vaccina- tions under direct purview, he was enabled to judge of the quality of the vaccine he was using. It has now assumed a more purely commercial aspect, and the family doctor is simply a "middleman," between the vaccine dealer and the vaccinated; conveniently and dextrously shoving off upon the former any ill- effects which may appear in the latter. In New York our main supply of vaccine has long been the Health Board, which, through the energy of Dr. Taylor, has not only been able to keep up the supply for its own large corps of vaccinators, but has it on sale for all comers. Dr. Taylor first obtained his material from the Essex Market Dispensary, where it was gathered from the unwholesome dwell- ers in that populous but filthy quarter. At that time, the mother was required to report at the Dis- pensary, with the child, on the twenty-first day after the vaccination. The scabs were then taken off and dropped into an open-mouthed, glass fruit-jar. A sufficient quantity of water was added from time to time to soften these scabs into a paste, and into this filthy mixture the quills were dipped, then dried, then sold with the official aroma of true Jennerian cow-pox. Fortunately the medical fashion changed, and "calf" lymph came into vogue. Dr. Taylor, as public vaccinator, not to be behind the times, estab- METHODS OF VACCINATING. 53 lished a calf farm, and from this source, the city and surrounding towns have been supplied for eight or nine years. Just what is the genesis of this vaccine I have been unable to discover. It is said to be Beaugency, but I am inclined to think it is another instance of smallpoxing the cow. III. Various methods are employed for inserting vaccine, and various places on the body are selected for the operation. A favorite place, especially for girls, is on the inner surface of the thigh several inches below the groin; this prevents the marks from showing, many mothers objecting to having a girl's arm scarred. The point at which the vaccine is introduced is Of no moment, provided it is brought well in contact with an absorbing surface. The most common method here in New York is by scarification. Various instruments are manufac- tured by the surgical instrument makers for this purpose, but the best tool is a thin bladed and very sharp lancet. With this a number of scratches, about half an inch long and equi- distant, are made through the cuticle. The abrasion must be deep enough to draw a little blood in order to ensure that the true skin has been reached. Sometimes the abrasion is criss- crossed, in this manner. As soon as the blood appears, it is quickly wiped away, and the vaccine smeared over the wound. If fluid lymph is used, all that is necessary is to dip the point of the lancet into it before making the incision; but if dry matter is used, it is better to soften it with 54 METHODS OF VACCINATING. the smallest possible amount of water, and when it is of the consistency of cream, plaster it on with the flat of the blade. Many operators err by making the cuts too shal- low, fearing that if there is much oozing of blood, that the vaccine will be washed away, and the ope- ration prove a failure. This is a mistake, failures to "take" being commonly caused by insufficient scarification. There is a great difference in the vac- cinal successes, even of experienced vaccinators. A failure of more than one per cent, of primary vacci- nations should be considered prima facie evidence either of the poorness of the vaccine, or of the in- efficiency of the vaccinator. The best operators often make a couple of hundred successive vaccina- tions without a failure. One good operation, such as I have described, is all-sufficient; but some vaccinators prefer 5^ to make a line of small abrasions like this, ' ^# which, if close enough together, will, as the vesicles fill, run into one long compound vesicle, tied down at as many points as there were original punctures. There have been various ways proposed for accomplishing the same thing, but none of them possess any advan- tages over the method of scarification which I have described. Ths question of insusceptibility to vaccination is a mooted point. Probably there are few cases of in- susceptibility to real cow-pox, although they are un- doubtedly occasionally met with. THE EXTENT OF THE PROTECTION AFFORDED BY VACCINATION. When one meets a fact in opposition to a domi- nant theory, we must accept the fact and abandon the theory, even though, being sup- ported by great names, it may be generally acceftted.— Claude Bernard. In considering the amount of protection afforded by vaccination, naturally the first query which pre- sents itself for solution is, Does vaccination prevent smallpox in the vaccinated? If it does, without in any way endangering the system in other directions, or rendering it more liable to other diseases, then it is manifestly the duty of every one to submit to the operation, under the advice of their regular physi- cian. This question, simple as it may seem, is not to be answered off-hand. The testimonies as to its pro- tective power are so conflicting, in fact, so absolutely contradictory, and this from men of equal probity and experience, that it can only be by the most care- ful and impartial sifting of the evidence that we may be able to reach an authoritative conclusion. Cast- ing aside prejudice, therefore, let us first see what Jenner actually claimed; secondly, whether this claim has been substantiated by the eighty-five years of subsequent experience. (55) 56 JENNER VS. JENNER. When Jenner began the practice of vaccination, in 1798, he assumed that it was a preventative of small- pox for life.2* This, it will be readily seen, was mere theory on his part, because in the nature of things it was not possible to determine, at that time, except theoretically, that the artificial production of one disease, would surely prevent, forever afterward, in that person, the occurrence of another analogous disease. That he had abundant reason for his the- ory, I am quite ready to admit; and, probably, any of us so situated, would have been equally sure of the far-reaching quality of the discovery. But as- sumption is not law, and Jenner lived to see his error. He found that the vaccinated were not only subject to smallpox, but that it attacked them some- times twice.23 He thereupon advised (nearly sixty years since) re-vaccination. It was evident that he did not ascribe these failures to lack of care, or to the use of improper material, for he finally re-vacci- nated his own patients once a year. " It was only, however, to efficient vaccination," says Dr. Seaton, "that is to vaccination which had gone through all its stages with perfect regularity, and had given evidences of infecting the constitution, that 24 "What renders the cow-pox virus so extremely singular, is, that the person who has been thus affected is forever after secure from the infection of the smallpox.—Jenner. 25 During the recent epidemic, a man 89 years of age was admitted to the Wynberg Smallpox Hospital, and it was the fifth occasion of his being attacked by variola.— Port Elizabeth Telegraph, Dec. 9,1882. PROTECTION THROUGH VACCINATION. 57 he attributed protecting power. Observations made since Jenner's day, by Mr. Marson, of the London Smallpox Hospital, have conclusively established that, for thoroughly infecting the constitution, a cer- tain amount of local affection (i. e., erysipelas) is as necessary as a perfect character of vaccine vesicle. We must, therefore, so far extend the meaning of the words 'due and efficient' performance of vaccina- tion, as to make it include amount as well as quality of vaccine influence; and with this extension, the experience of seventy years tends to show the cor- rectness of Jenner's estimate."26 But which estimate does this refer to, that of 1798, when vaccination protected for life, or of 1821, when he was re-vacci- nating year by year? The context clearly infers the former, for nowhere is it suggested, in this long article from which the above is quoted, that Jenner advised re-vaccinations. It is claimed that all who do not have variola are preserved from it by vaccination. In other words, that all persons do have smallpox unless they have been vaccinated, with rare exceptions. This is a broad statement, and can hardly be true. Even if every person one or two centuries ago had smallpox, that would be insufficient evidence upon which to base a statement that all would have it now. Surely modern improvement in living, increased knowledge of hygiene, and advances in sanitation must be al- Reynolds' System of Medicine. Vol. I, page 166. 4 58 FLORENCE NIGHTINGALE'S OPINION. lowed to count for something, unless, indeed, we are willing to accept the dictum of the Public Vaccinator of New York (Dr. Taylor), that it is the robust, the healthy, the clean, who are most likely to be stricken with this disease. This latter view, separating, as it does, variola from its kindred zymoses, is neither common sense, nor in accord with the experience of the wise. Proofs that smallpox and other zymotic diseases originate in filth are almost innumerable. Florence Nightingale is good authority here. She says: " I was brought up both by scientific men and ignorant women to believe the smallpox, for in- stance, was a thing, of which there was once a first specimen in the world, which went on propagating itself, just as much as there was a first dog, or pair of dogs; and that the smallpox would not begin it- self any more than a new dog wou'ld begin without there having been a parent dog. Since then I have seen with my eyes smallpox growing up in first specimens, in close rooms or overcrowded wards, where it could not by any possibility have been caught, but must have begun. Nay more; I have seen diseases begin, grow up, and pass into one another; with overcrowding, continued fever; with a little more overcrowding, typhoid; with a little more, typhus, and all in the same ward or hut." I have myself seen diseases grow and develop in the same manner. About four years ago, I saw scarlet fever grow through four transmissions from an in- fluenza. Squalor, sewer-gas, cold and neglect were the factors in the case. MORTALITY FROM SMALLPOX. 59 Mr. John Simon, F.R.S., the able and zealous Medical Officer of the Privy Council (England), said: "When smallpox attacks an unprotected population after a lapse of years, it seizes all who come in the way of the contagion, who have not previously had the disease. Supposing there is an island, and it has not had a smallpox epidemic for fifty years, the epi- demic, when it comes, will take all up to the age of fifty."27 The facts, as far as we know them, do not warrant this assertion. According to Dr. Lettsom and Dr. Gilbert Blane, both ardent pro-vaccinists, the aver- age death-rate from smallpox, for the thirty years previous to the introduction of vaccination, was estimated at three thousand per million of popula- tion. This, it will be noticed, is a mere estimate, by those who were anxious to place the death-rate before vaccination as high as possible. A modern writer remarks that "Dr. Lettsom possessed the facile art of extracting suitable percentages from unknown numbers;" and Dr. Farr, the Registrar-General, when questioned whether there were any statistics that would warrant any such conclusion, said em- phatically: "No, it is a mere estimate; no statistics of the last century or the previous one are to be re- lied upon."28 What the average mortality from smallpox may have been during the last century, it is impossible 27 Parliamentary Vaccination Committee of 1871. 28 Parliamentary Vaccination Committee of 1871. 60 DEATH-RATE OF SMALLPOX. to determine, but the following table will give an approximate idea; and, as they are hospital cases, are likely to be above rather than below the mark, as it is well known that isolated patients do better than those collected into wards. Fatality of Hospital Smallpox before Vac- cination. DATE. AUTHORITY. CASES, DEATHS. PER CENT. OF DEATHS. 1723 1700-63 1779 Eees' Cyclopaedia . . . 17,151 24,594 400 2,848 4,635 72 16.6 18.85 18.0 1700-79 42,145 ; 7,555 17.64 Dr. Seaton, in his valuable work on vaccination, says: " Dr. Jurin, writing early in the last century, laid it down as the result of his investigations, that of persons of all ages taken ill of natural smallpox, there will die of that distemper, one in five or six. From returns made to the Epidemiological Society in 1852, by 156 medical practitioners in various parts of England who had kept numerical records of their smallpox experience, it appeared that the proportion of deaths to cases which they had met with in the natural form of the disease was 19.7 per cent., or as nearly as possible, one in five." A BOSTON EXPERIENCE. 61 In Newcastle-upon-Tyne 2616 cases, from 1777- 1877, caused 428 deaths, or 16.3 per cent.29 Admitting the correctness of Dr. Lettsom's esti- mates, and calculating all deaths at the hospital rate, there would be only an average of 18 cases per year of smallpox to every one thousand of popula- tion. With even this liberal count it is evident that not half the inhabitants could have had the disease. The claim, therefore, that vaccination alone preserves from smallpox, falls to the ground. One of the most reliable accounts of smallpox in the last century is that of a very severe epidemic in Boston, Massachusetts, in 1752, which may be found in the Gentlemen's Magazine of 1753. The popula- tion of Boston was then 15,684; its sanitary condi- tion was, like most cities of that period, extremely bad; and variolous inoculation was freely practiced, as it had been for nearly thirty years. One-third of the inhabitants, 5545, were attacked with smallpox. The mortality among these was 539, or 9.7 per cent. This was previous to vaccination. As inoculation is now freely admitted to conduce to the intensity of the disease, it is probable that natural smallpox, uninfluenced by inoculation, would have shown a lower death-rate. Smallpox during the fifty years prior to inocula- tion, that is during the latter portion of the seven- teenth and the beginning of the eighteenth century, Dr. Monteith, Handbook of Vaccination, ISfiS, page 191 et seq. 62 SMALLPOX LESS FREQUENT SINCE 1770. formed a variable, but considerable cause of death. During this period, in London, out of every one thousand deaths, fifty-six were from this disorder. After the introduction of inoculation the proportion of deaths steadily rose until it reached one hundred and eight out of every one thousand, in 1770. From this date, which was nearly thirty years before vac- cination, it began, in common with other diseases, to decline. As Dr. Farr, the Registrar General, ob- serves: "Smallpox attained its maximum after in- oculation was introduced; this disease began to grow less fatal before vaccination was discovered; indicating, together with the diminution in fever, the general improvement in health then taking place." Now, if smallpox declined while inoculation was disseminating the disease, it is reasonable to suppose, nothing else interfering, that the decline would be more marked at the partial discontinuance of inoculation about 1800, and again upon the prac- tice being made penal in 1840. The annexed table shows what did happen: Smallpox deaths Smallpox de 5Tear. per 1000 deaths. Year. per 1000 dei 1700-1720 . , . ... 56 1801-1810 . 1721-1740 . . . ... 65 1811-1820 . .... 42 1740-1750 . . . • . 80 1821-1830 . .... 32 1751-1760 . , , ... 100 1831-1840 . ...• 23 1761-1770. , . ... 108 1841-1850 . .18 1771-1780 . , , ... 98 1851-1860 . . ... 21 1781-1790 . . , ... 87 1861-1870 . .... 27 1791 1800 . . . ... 88 1871-1880 . • ... 19 TWO CENTURIES OF SMALLPOX. 63 Vaccination was introduced when smallpox was a diminishing factor, and by checking inoculation withdrew a fertile source of variolous propagation. Mr. Marson admits that the discontinuance of inocu- lation, rather than the practice of vaccination, was the cause of the lesser prevalence of smallpox dur- ing the first three decades of the present century.30 Sir Lyon Playfair, the scholarly representative of the Universities of Edinburgh and St. Andrews, in a speech before Parliament, in June, 1883, thus tab- ulates the death-rate from smallpox in Great Britain during the past two centuries: Deaths from smallpox Year. per lui.lion iuhabitauts. 1701-1800............. 3000 1801-1840............. 600 1841-1854 . . ........... 305 Under Compulsory Year. Vaccination. 1855-1871............. 223 1872-1882............. 156 Sir Lyon Playfair observes: "These great reduc- tions in the rate of smallpox mortality I believe to be due wholly to vaccination. Sanitation is not the cause, for it would diminish all other diseases likewise; but these have only diminished six per cent., whereas smallpox has diminished eighty per cent, in chil- dren under five." It is hardly fair to compare the mortality of small- pox with all other diseases, because a large propor- 30 Report of Parliamentary Committee, 1871. 64 SMALLPOX COMPARED WITH FEVER. tion of the total mortality arises from causes with which sanitation has nothing to do. But if we com- pare smallpox to the group of cases so nearly allied to it from a sanitary point of view, viz., typhus, ty- phoid, etc., the Registrar General's figures are (with the exception of 1847-49, for which he does not give the figures for fever): Deaths per Million Living Year. Smallpox. Fever. 1850-53.........310..........986 1854-70.........223..........940 1871-80 ......... 156 ...... .... 473 Sir Lyon Playfair is willing to allow six per cent. for sanitation, but if sanitation had done for small- pox what it did for fever, the last decennial death- rate would have been 140 and not 156; and this without allowing anything for vaccination. Dr. Farr states that fever has declined progress- ively since 1771, in nearly the same proportion as smallpox.31 These are his figures: Deaths per 10,000 Living. Year. Fever. Smallpox. 1771-80.........621..........502 1801-10.........264..........204 1831-35......... Ill..........83 The deaths in England from smallpox, per million living, are thus stated by the Registrar General. Those for the years 1843-6 are not given by him, but the number was small: McCulloch's Statistics of the British Empire. SMALLPOX DEATHS PER MILLION. 65 Year. Deaths. Year. Deaths. 1841........367 1863........293 1842........181 1864........373 1847........246 1865.........309 1848........398 1866........144 1849........264 1867........118 1850........263 1868 ....... 96 1851........396 1869........ 72 1852........409 1870........118 1853........174 1871........1022 1854........153 1872........831 1855........136 1873........102 1856........121 1874........ 92 1857........206 1875........ 40 1858........335 1876........ 99 1859........197 1877........174 1860........140 1878........ 74 1861........ 66 1879........ 21 1862........ 81 1880........ 25 Precise data has never been collected to enable us to state what proportion of the successfully vacci- nated are liable to take smallpox. The proportion will vary, of course, with the age of the person and the degree of exposure to the contagion. Some epidemics are much more virulent than others, and seize upon a much wider range of victims. Ameri- can statistics are utterly unreliable, and in many instances purposely misleading. There are few vital statistics in the United States worthy of credence, and none that are of any help in this inquiry. Only twenty-nine of the States have Boards of Health, and not more than a fourth of these have existed ten years. Some have never 66 AMERICAN STATISTICS. issued a report. Even in Massachusetts and Michi- gan, the only two States, where the reports on zymotic disorders have even an appearance of ac- curacy, the opportunity for comparative study of smallpox in the vaccinated and unvaccinated is meagre and unsatisfactory. The National Board of Health has done nothing, and evinces no disposition to do anything. Here in New York things would be in better shape, if funds were forthcoming to pay for the work. The Registrar of Vital Statistics (Dr. Nagle) is an accomplished and efficient officer, but he can do little unaided. From the imperfect re- turns which are made to him it is impossible to tell in any week of any year how many cases of measles, diphtheria, or any other disease may have occurred. This is not the Registrar's fault; but must be laid to the baneful influence of the political jugglers, who hamper every department of civil administration. No reports on vital statistics have been published in this city in the past eleven years. And take the country through, we are totally ignorant of vital statistics, as they are understood in Great Britain and Germany. Having had abundant opportunity to compare the work done here, with that of such men as Farr, of England, or Kolb, of Bavaria, I am obliged to confess with shame the shortsighted- ness of our various State Governments. I recognize the great advantages in a settled population like England, over a growing and migratory population such as we have here, in the matter of statistic col- LONDON HOSPITAL STATISTICS. 67 lection; but on the other hand, the general diffu- sion of intelligence makes the gathering of data easier here than in countries less favored in this re- spect. The Smallpox Hospital, London, is believed to be a fair representative of English experience.32 The number of cases of smallpox after vaccination has steadily risen from about 5 per cent, at the begin- ning of this century to 44 per cent, in 1845, 64 per cent in 1855, 78 per cent, in 1865, 90 per cent, in 1875, and is now about 96 per cent, of the whole number of cases admitted. The residual 4 per cent. is mainly composed of infants under one year of age, who on account of tainted constitutions, or the nomadic character of their parents have escaped the official lancet. They are the waifs and strays of civilization; the children of vagabonds; the natural victims of disease. That the deaths among this resid- ual per cent, of unvaccinated should be more than one to three, will excite no surprise. They would have died at the same rate from whatever disorder happened to strike them first, whether it was mea- sles, whooping cough, or diarrhoea; if they at all cor- respond to the same class as we see them here in our tenement-house life. During the last smallpox epi- demic in New York (1880-2) the number of vacci- nated cases very largely exceeded the unvaccinated, and of these latter the vast majority were infants. :i- Marson. 68 SMALLPOX AFTER COW-POX. In the first report of the Vaccine Pock Institution, in 1803, page 111, it is said: " It is not manifest that the vaccine inoculation has been of benefit to the public, however great a one it has been to individ- uals." In the second report of the Royal Jennerian So- ciety, 1806, is the following: "The Committee admit to having seen a few cases of smallpox by persons who had passed through the cow-pox in the usual way." In the same year (1806) the Royal College of Sur- geons issued a circular-letter to 1,100 of its members, asking their experience of vaccination. They re- ceived 426 answers, and the information of 56 cases of smallpox after vaccination, 66 cases of eruptions, and 24 bad arms. It may be interesting to compare the smallpox deaths, at this period, in New York and London. NEW YORK AND LONDON. 69 Comparison of smallpox deaths. NEW YORK. NO VACCINATION. LONDON. VACCINATION THE FASHION. YEAR. PER HUNDRED THOUSAND LIVING. 1804 .... 1805 .... 1806..... 1807..... 1808..... 1809..... 1810..... AVERAGE. 169 62 48 29 62 66 4 63 61 163 110 122 108 106 106 111 The London Medical Observer, Vol. VI, in 1810, published the particulars of 535 cases of persons having had smallpox after vaccination, the opera- tion in some instances having been performed by Jenner himself, including their names, with an index, pointing to the authorities as witnesses; also similar details of 97 fatal cases of smallpox after vaccination; and of 150 cases of injury arising from vaccination, together with the addresses of ten med- ical men, including two Professors of Anatomy, who had suffered in their own families from vaccination. 70 VACCINATION INEFFICIENT Whereupon,' Dr. Maclean, a well-known medical authority of that time, observes:—" Although numer- ous, they are few in comparison to what might be produced. It will be thought incumbent on the vaccinators to come forward and disprove the numer- ous facts decisive against vaccination here stated on unimpeachable authority, or make the am.ende honor- able by a manly recantation. But experience forbids us to expect any such fair and magnanimous pro- ceeding, and we may be assured that, under no circumstances, will they abandon so lucrative a practice, until the practice abandons them." In 1820, that is before Jenner's death, it was said: " Cases of smallpox after vaccination have increased to such an extent, that no conscientious practitioner can recommend vaccination as affording certain security against the contagion of smallpox."33 In 1828 there was a severe epidemic in Marseilles, when about 2000 were attacked with smallpox who had been vaccinated.3* In the epidemic, 1831, et seq. in Wirtemberg, 955 persons wTere attacked with smallpox after vaccination.35 The Registrar-General of Sweden in his official report, 1856, declared that to explain certain statis- tical data it is necessary to suppose, either that the effect of vaccination is little or none, or that the workings of the vaccination system are highly defec- 33 Gazette of Health, Vol. V, page 656. London, 1820. s*Marson. K Heira. SMALLPOX AFTER VACCINATION 71 tive.36 This is after forty years of compulsory vac- cination. Dr. Ducharme, speaking of an epidemic in 1868, which broke out in his regiment (Voltigeurs of the Guard) a few months after he had re-vaccinated it, says:—"To what should we attribute this epidemic in a regiment in which 437 re-vaccinations had been performed, and where the hygienic conditions, as to space, ventilation, and food, were excellent, when in the 2d Regiment of Voltigeurs—lodged in a precisely similar barrack situated in the same court, but on whom no vaccinations had yet been made—not a single case of smallpox existed?" The London Morning Advertiser, November 24, 1870, reports that "the smallpox is making still greater havoc in the ranks of the Prussian army, which is said to have 30,000 smallpox patients in its hospitals." These were all vaccinated and re-vacci- nated. The following are a few samples cases out of many, in the United States Navy Department Re- ports:— "In 1850, in the U. S. frigate Independence, with a ship's company of 560 persons, there were 116 cases of smallpox, seven fatal. Fleet-Surgeon Whelan writes:—'The crew of this ship almost universally presented what are regarded as genuine vaccine marks. The protection, however, proved to be quite imperfect.' Rektor P. A. Siljestrom, April, 1877. 72 VACCINATION INEFFICIENT. " Upon the U. S. steamship Jamestown, serving in Japanese waters, there occurred, in 1864, among a ship's company of 212 persons, 31 cases of smallpox, with four deaths. The entire crew had been vacci- nated after leaving the United States. " In 1870, sixty-one cases occurred on the U. S. steamship Franklin. The disease first appeared on a sailor with ' an excellent vaccine scar.' The officers and crew were immediately vaccinated with fresh vaccine matter obtained at Lisbon, this vaccination being the third one during the cruise. Nineteen days later, the second case occurred. ' The disease has been epidemic in many places in Europe during the past season, but I hoped our vaccinations would prevent trouble with it on board ship.' " In a cruise of the North Carolina up the Mediter- ranean, she shipped at Norfolk a crew of 900 men, most of whom had been vaccinated, or had the smallpox, but were nevertheless twice vaccinated prior to the ship sailing, a third time at Gibraltar, and a fourth time at Port Mahon. Dr. Henderson, who reports these facts, states that notwithstanding this ultra vaccination under such various circum- stances of virus, climate, etc., 157 of the crew had varioloid." In the Kingdom of Bavaria, where no one for many years, except the newly born, escaped vacci- nation, there were in the epidemic of 1871 no less than 30,742 cases of smallpox, of whom 29,429 had SMALLPOX AFTER VACCINATION. 73 been vaccinated, as is shown by the documents of the State Department.37 In the first Annual Report of the Health Depart- ment of the city of New York, 1870-71, it is stated: "This extraordinary prevalence of smallpox over various parts of the globe, especially in countries where vaccination has long been efficiently practiced; its occurrence in its most fatal form in persons who gave evidences of having been well vaccinated, and the remarkable susceptibility of people of all ages to re-vaccinations, are new facts in the history of this pestilence, which must lead to a re-investigation of the whole subject of vaccination and of its claims as a protecting agent." Smallpox continued epi- demic during this period in New York, in spite of the most rigorous enforcement of vaccination. In Baltimore, during 1882, there were 4,930 cases of smallpox, of which 3,506 were children. The deaths numbered 1184, of which 959 were children. Of the vaccinated 2853, 327 died. The victims were mainly Germans, colored persons, and sailors, hud- dled together in the worst quarter of the town. As many as twenty cases were taken from a single house. During one month (January) 162,414 were vaccinated by the city physicians, beside large numbers in the previous months. The Report of the Health Department of the city of Chicago, for the years 1881-82, shows the total 37 (r. F. Kolb, of the Eoyal Statistical Commission of Bavaria. 74 VACCINATION INEFFICIENT. mortality from smallpox for the last thirty years (the population having increased from 252,000 in 1868 to 560,000 in 1882) has been as follows:— Years. Smallpox deaths. Decade—1851-60......... 109 1861-70......... 778 1871-80.........1479 One Year—1881 ..........1180 " 1882 :.........1292 Thus as vaccination was more rigidly enforced, smallpox increased. In 1859-62 there were, in the British troops quar- tered in England, 430 cases of smallpox after vacci- nation. During the Franco-Prussian war (1870), there were 23,469 cases of smallpox, in the French army, all of them vaccinated, and the larger part re- vaccinated. Dr. Bayard, of Paris, says: "Every French soldier on entering a regiment is re-vacci- nated; there are no exceptions." In 1871 smallpox was epidemic in Milan; 17,109 cases were recorded, of which only 278 were classed as unvaccinated. In 1871-2 there were 11,174 cases of smallpox after vac- cination in the London hospitals. Of this year, Dr. Seaton said: "An epidemic of smallpox so intense as that which recently prevailed, has afforded a very severe test of the value of our present vaccination laws." If the Jennerian theory had been true, this virulent epidemic could not have occurred in a pop- ulation where ninety-six per cent of the births are SMALLPOX AFTER VACCINATION. 75 registered as officially vaccinated.38 As a portion of the remaining four per cent, must have succumbed to the hardships of living, the actual substratum of the unvaccinated must be very thin. Men are prone to see things much as they imagine they ought to be. In a controversial question few can be magnanimous, and fewer still impartial. As showing the different manner of looking at this sub- ject, I present side by side two statements, made by reputable men. Which shall we credit? John Leacroft, M.K.C.S., writ- Dr. Browning, the Medical ing from Fechenham, near Eed- Officer of Health, for Kother- ditch, Feb. 16, 1883, says: "I hithe, writing On Vaccination have been a Public Vaccinator of with Cilf-Lymph, 1882, says: several districts since the passing " That children and adults com- of the Compulsory Vaccination paratively recently vaccinated Acts, and have, during the past with humanized lymph, and some forty years, vaccinated many thou- showing good marks, may subse- sands of children, and am per- quently, within a few days, feetly satisfied that vaccination, months, or years, contract small- 38 "The deaths from smallpox have assumed the proportions of a plague. Over 10,000 lives have been sacrificed during the past year in England and Wales. In London, 5641 deaths have occurred since Christmas. Of 9,392 patients in the London Smallpox Hospitals, no less than 6,854 had been vaccinated, i. e., nearly 73 per cent. Taking the mortality at 17J per cent, of those attacked, and the deaths this year in the whole country at 10,000, it will follow that more than 122,000 vaccinated persons have suffered from smallpox! This is an alarming state of things. Can we greatly wonder that the opponents of vaccination should point to such statistics as an evidence of the fail- ure of the system? It is necessary to speak plainly on this important matter."—Lancet, July 15, 1871. 76 LEACROFT VS. BROWNING. properly and efficiently performed, is not only a protection against the confluent form of smallpox, but that in no case does it cause either sores or any disease likely to shorten life. Any such cases that may and do occasionally arise, are those where the operation has not been properly and with efficient care performed." Vaccination, when pro- perly and efficiently per- formed, prevents conflu- ent smallpox, and pro- duces neither sores or any disease likely to shorten life; and when vaccination does not pre- vent confluent smallpox, and does produce sores and diseases likely to shorten life, then vacci- nation has not been pro- perly and with efficient care performed. pox is an undoubted fact, probab'y known to all of us. I have my- self recorded 469 cases of persons, of all ages and both sexes, suffer- ing from smallpox after vaccina- tion, with 99 deaths—an average of 21 per cent.; and higher fig- ures are given by Dr. Collie. Now, many of these sufferers showed good vaccine marks of the kind that would be deemed worthy of an extra grant from the Gov- ernment-Inspector (at least, I used formerly to receive such grants for doing similar work); and yet they took smallpox—some within six days, some within six months, and some within six years of their vaccination." Dr. Browning, there- fore, recommends the dis- use of humanized lymph, and direct vaccination from the calf. The following candid view of the question is from the pen of one of the wisest physicians of his day, Sir Henry Holland : — Present Questions Regard- ing Vaccination. London, 1839. "The questions already stated bring us to those which regard the completeness of Vaccination as a preventive sir henry Holland's opinion. 77 remedy, the duration of its protecting power, and the changes its virus may undergo by long use and frequent transmission—the most momentous by far of all the inquiries affecting the subject. The events of the last 10 or 15 years have forced them strongly upon us, while apparently at the same time prepar- ing evidence for their final determination. Not only in Great Britain, but throughout every part of the globe from which we have records, we find that smallpox has been gradually increasing again in frequency as an epidemic, affecting a larger propor- tion of the vaccinated, and inflicting greater mor- tality in its results. I do not enter into any detail of these facts, as they are now generally admitted. We can no longer deny that the protection given by Vaccination is unequal in different cases, or that it may be lessened or lost by time. Experience has here confirmed a presumption, which some ventured very early to entertain, and which, indeed, was sanc- tioned, prior to experience, by various considera- tions. The early enthusiasm for the great discovery of Jenner swept those doubts away; and they re- turned only tardily, and under the compulsion of facts. . . And though more palpable at one time than another, according to the greater or less prev- alence of epidemic causes, yet every succeeding year has multiplied them, and every statement from other countries has attested their truth. The cir- cumstances, of late years, have greatly changed the aspect of all that relates to this question. It is no 78 vaccination delusive. longer expedient, in any sense, to argue for the present practice of Vaccination as a certain or per- manent preventive of small-pox. The truth must be told as it is, that the the earlier anticipations on this point have not been realized." Dr. G. F. Kolb, of Munich, Member Extraordinary of the Royal Statistical Commission of Bavaria, and the author of several statistical works of acknowl- edged value, says: "From childhood I have been trained to look upon the cow-pox as an absolute and unqualified protective. I have, from my earliest re- membrance, believed in it more strongly than in any clerical tenet or ecclesiastical dogma. The nu- merous and acknowledged failures did not shake my faith. I attributed them either to the careless- ness of the operator or the badness of the lymph. In the course of time, the question of vaccine com- pulsion came before the Reichstag, when a medical friend supplied me with a mass of statistics favorable to vaccination, in his opinion conclusive and unan- swerable. This awoke the statistician within me. On inspection, I found the figures were delusive; and a closer examination left no shadow of doubt in my mind that the so-called statistical array of proof was a complete failure." Dr. H. Boeing, for very many years a prominent vaccinator at Uerdingen, on the Rhine, says: "As I began these researches in the belief and with the hope to gain a sure guaranty for the correctness of the present protective theory of vaccination, nobody VACCINATION IN LONDON. 79 can regret it more than myself that their result proved unfavorable to compulsory vaccination. and every friend of humanity feels the constraint of being compelled to resign a prophylactic operation, the inventor of which is called yet to-day one of the greatest benefactors of mankind, and the real practi- cal effect of which has to be placed among Hart- man's illusions."39 Having thus been forced to admit that vaccination does not prevent smallpox in the vaccinated, let us now determine what is its power in mitigating the disease. There are two points to be here considered: the ratio of deaths from smallpox, and the amount of disfigurement in those who recover; the latter be- ing taken as a mark of the severity of the attack. On the first point, Mr. Marson, who has for thirty- five years had charge of the Smallpox Hospital at London, is excellent authority. During that time he has had more than seventeen thousand cases of smallpox under his immediate personal supervision, and has had ready means of knowing the exact par- ticulars of the entire English hospital experience. He has found, while the unvaccinated among these cases have died at the rate of thirty-five deaths to one hundred cases, the ratio among the vaccinated has only been about six to a hundred. But what is still more conclusive, as shown by this concensus of cases, is that the modifying power of vaccination Facts on the Smallpox and Vaccination Question, Leipzig, 1882. 80 LONDON HOSPITAL EXPERIENCE. is in direct ratio to the thoroughness and excel- lence of the operation, as shown by the cicatrices. The number of the vaccine-marks, and the quality of the vaccine, as proven by the appearance of the mark, enable him to determine beforehand the prob- able severity of the impending attack. The sub- joined table clearly presents the facts to the eye.40 Number of Deaths Classification of Patients afflicted with per Hundred in Smallpox. each Class Respectively. 1. Unvaccinated..................35. 2. Stated to have been vaccinated, but having no cicatrix . 23 57 3. Vaccinated— «. Having one vaccine cicatrix........7.73 b. Having two vaccine cicatrices........4.70 c. Having three vaccine cicatrices.......1.95 d. Having four or more vaccine cicatrices.... 0.55 A. Having well-marked cicatrices.......2.52 B Having badly marked cicatrices..... 8.82 4. Having previously had smallpox.........19. Among the vaccinated the influence of the quality of the cicatrix was remarkable. In those having one vaccine cicatrix, the death-rate, where the mark was good, was 3.83 per cent., while among the badly- marked it was 11.91. Those having two vaccine cicatrices, died at the rate of 2.32 per cent, when well-marked, and 8.34 when badly marked. In studying this interesting table, there are cer- tain points that should not be overlooked. The un- vaccinated died at the rate of thirty-five in the *° Seaton on Vaccination. Reynolds' System of Medicine. Vol. I page 168. SMALLPOX OBLITERATES VACCINATION. 81 hundred; but as I have already pointed out, this class was mainly recruited from infants who had failed to receive the benefit of vaccination, because of morbid physical traits which made the operation, to the mind of the parish vaccinator, undesirable. In other words many of them had been refused vac- cination. As far as we can know, the death-rate from smallpox prior to vaccination and inoculation was, on the average, one out of every five cases. It is, therefore, reasonable to suppose that the addi- tional deaths above that rate, viz., fifteen out of every thirty-five deaths, were due to the previous condi- tion of the patients. The second class includes persons who claimed to be vaccinated, but showed no evidence. Now, while it is possible that some of these patients may have tried to deceive the doctors by saying that they were vaccinated when they were not, men rarely lie with- out a motive, and it would hardly seem that there was here any adequate motive for prevarication. On the other hand, as the death-rate in this class was much above that of smallpox naturally, these were evidently severe cases; and as the disease in its virulent form effectually obliterates all traces of vaccination, we have at once the double explanation as to the reason these cases were fatal and why vac- cine cicatrices could not be found. They had been obliterated by the severity of the disease. Dr. Vacher, in a report of the smallpox epidemic at Birkenhead, in 1877, states "that there were 595 5 82 MR. MARSON'S TESTIMONY. cases, of whom 223 were vaccinated, 72 unvacci- nated, and 220 unknown. Of these there died 12 vaccinated, 53 unvaccinated, and 28 unknown. The mere assertions of patients or their friends that they were vaccinated, counted for nothing, as about eighty per cent, of the patients entered as unknown were reported as having been vaccinated." As a corollary to this I wish to refer to a report by Dr. Russell, of the Glasgow epidemic of 1871-72. "Sometimes per- sons were said to be vaccinated, but no marks could be seen, very frequently on account of the abund- ance of the eruption. In some cases of those which recovered, an inspection before dismission discovered vaccine marks, sometimes ' very good'." That this is the explanation of the high death- rate is evidenced by Mr. Marson's testimony: "The danger nearly always depends upon the amount of eruption upon the body. The unvaccinated who have confluent smallpox, die at the rate of 50 per cent., of semi-confluent smallpox the deaths among the unvaccinated are only 8 per cent. The death- rate from discreet smallpox among the unvaccinated is only 4 per cent., and even those 4 per cent, die of convulsions, or some other disease to which children are liable. Of 104 cases of corymbose smallpox 74 were vaccinated and died at 41 per cent., and 29 were unvaccinated, who died at 44 per cent., the remaining one being after inoculation. In corym- bose smallpox the protection would seem to be very small."41 41 Vaccination Evidence, page 248 and 265. THE VALUE OF MULTIPLE " MARKS." 83 It would be interesting to know in the cases of those having more than one cicatrix, how many represent distinct re-vaccinations. The value of sev- eral punctures at one operation would seem to be solely to give the vaccine disease in a severer form, while several re-vaccinations would represent so many successive attacks of the vaccine disease. The protection afforded by several cicatrices, is in a*iy event remarkable; those having four cicatrices in- curring but one-sixteenth the risk of those having only one.42 Numerous cicatrices, however, do not prevent persons from having the smallpox. Pa- tients entered the hospital having as high as seven- teen good marks; yet even they caught the small- pox. Thus it is true that the " well-marked" and the "badly marked" alike find their way to the hospital. Twelve hospital reports during the last decennium (1871-80) show 19,779 cases of smallpox. These classified according to their marks are as follows: 42 It is but fair to say that many Public Vaccinators protest against this large area of scars as necessary, useful or expedient. One of them in writing to the British Medical Journal, Dec. 9, 1882, says: "This practice, though supported by statistics, is pure fallacy, and has done more to make vaccination a bugbear than all the outcry of the anti- vaccinators. I believe an excessive amount of inflammation, as is caused by a large area of pustules, does more to damage the protect- ive quality of the vaccination than to improve it. Vaccine virus is known to be capable of unlimited auto-multiplication. The lymph taken from a case in which one small pustule only has been devel- oped, gives as good results as that taken from large and more inflamed pustules." 84 CLASSIFICATION OF CASES. Cases. With Good Marks— one mark........■.........1,408 two marks.................1,105 three marks................806 four marks or more.............768 With Imperfect Marks— one mark.................2,062 two marks.................1,733 three marks................1,211 four marks or more.............653 Some hospitals do not separate in their report the good from the imperfect marks, these are With Marks, Quality Not Specified— one mark.................1,124 two marks.................1,722 three marks................936 four marks or more.............741 Other Vaccinated Classes— Traces of vaccine marks...........938 Doubtful cases...............228 Number of marks..............1,205 Unvaccinated— No marks.................3,139 Total....................19,779 It will be seen, upwards of six thousand have three vaccine marks or more; or, 28.85 per cent. It would seem therefore that, from the stand- point of Dr. Seaton, while the protection afforded by thorough vaccination is unequivocal, and that the protection is in exact proportion with the thor- oughness of the vaccination, yet in certain consti- VACCINATED INFANTS DIE OF SMALLPOX. 85 tutions there is such a predisposition to the dis- order, that even the most careful and repeated vaccination only lessens the chances, and does not prevent an attack. That it does not protect invariably even for a year, is shown by the many instances where persons have smallpox within a few weeks or months after vaccination. Every table of smallpox statistics shows vaccinated deaths among the very young, where vac- cination ought to be protective, if any where. Thus, in the epidemic in Scotland of 1871-73, there died of smallpox 762 infants under one year of age, who are classified in the return of the Registrar-General as:— Year. Vaccinated. Unvaccinated. 1871 64 142 1872 314 64 1873 139 39 Total, 517 245 Thus 517 died of smallpox within less than a year after vaccination. Evidently vaccination did not mitigate the attack in these 517 cases. With regard to the duration of the protective power of vaccination, the experiments of City Physician Schuppert, of New Orleans, are instructive. Schup- perf vaccinated 30 boys, varying in age from 8 to 14; of these, 5 had had smallpox, and 4 others had been vaccinated. The vaccination succeeded with 7 only; of which 4 had had smallpox. The 25, who had proved insusceptible, were revaccinated every eight 86 schuppert's experiments. days, from the pustules of the successful cases, with the following results: 23 vaccinated, 14 insusceptible. t 14 " 9 9 " 6 6 2 Those who had been successfully vaccinated at the first three trials, were revaccinated three weeks after the scab had detached, with this result: 7 from the second trial, 0 insusceptible. 9 " " third " 3 5 " " fourth " 1 " Of the 7, who had been successfully re-vaccinated, 6 were again for the third time successfully vacci- nated. As a result, Schuppert lost faith in vaccina- tion, and consequently had to resign his position as City Physician.43 The following resume, by Mr. Alex. Wheeler, of the statistics of the Homerton Fever Hospital, shows the number of cases and deaths from smallpox in 1876-77. Homerton Fever Hospital. 1876-1877. Smallpox cases received into Hospital:— Total. Vaccinated,.................784 Unvaccinated,............... 131 ----* 915 Divided as follows:— Discreet cases—Vaccinated,.......499 Unvaccinated,..... 22 ---- 521 (Majority of vaccm.-fted, 477.) Prof. Deschere. SMALLPOX IN HOMERTON HOSPITAL. 87 Confluent cases—Vaccinated,......255 Unvaccinated,..... 99 (Majority of vaccinated, 159.) Malignant cases—Vaccinated, . Unvaccinated, (Majority of vaccinated, 20.) .",54 30 10 40 915 Deaths of Vaccinated;............102 " " Unvaccinated,........... 70 (Majority of vaccinated, 32.) 172 Summary. 499 22 Discreet—Vaccinated, ....... Unvaccinated,...... Confluent—Vaccinated,.........255 Unvaccinated,........ 99 Malignant—Vaccinated,......... 30 Unvaccinated,........ 10 Deaths Cases. Deaths, per cent. of cases. 2 .4 0 .0 70 27.0 60 60.0 30 100.0 10 100.0 915 172 18.7 Dividing these cases at puberty, shows the number of children who had smallpox and died of it.44 vaccinated. unvaccinated. ' Under 16 years of age. Over 16 years of age. Under 16 years of age. Over 16 years of age. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Discreet Smallpox. 177 2 322 0 20 0 2 0 Confluent Smallpox. 72 20 183 50 80 49 19 11 Malignant Smallpox. 9 9 21 21 8 8 2 2 44 British Medical Journal, April 14, 1883. 88 VACCINISATION VS. VACCINATION. Here evidently is a great mass of ineffective vacci- nation ; that is vaccination which does not protect. The figures are official and their reliability cannot be questioned. The vaccinations were performed under governmental inspection, and their genuineness can- not be impugned. Dr. Leon Colin, who is an acknowledged French authority, thus defines what really constitutes pro- tective vaccination:—" We must not stop with each subject at a single vaccination. We must have in the minds of our lawgivers, and in that of the pub- lic, a firm conviction that vaccine prophylaxy rests not upon one practice, and the success of a single operation, but that it is only real and complete by a series of inoculations which should be periodically renewed in order to mantain immunity during the entire life. It will be possible to first impose re- peated inoculations upon State officials, and then afterwards upon all classes of society."45 This very nearly corresponds with the recommen- dations so earnestly urged by Dr. Warlomont, the chief of Belgian vaccinators. Dr. Warlomont was the inventor of what is now called vaccinisation. He insists that vaccination, as usually performed, is little better than make-believe, and that vaccinisation is the only real protective. This consists in subject- ing the vaccinated again and again to the operation in quick succession, until vesicles cease to form after the insertion of virus. Then, and then only, is safety from smallpox thoroughly assured. La Variola. AUSTRIAN EXPERIENCE. 89 Dr. Leander Josef Keller furnishes vaccine statis- tics, which deserve attention. The Austrian system of railways is all under one management, and Dr. Keller is the physician-in-chief. In the epidemic of 1872-73, he carefully examined the relative effects of smallpox on those who had been vaccinated, and those who had not. These railways employ about 37,000 officials and workmen; and these with their wives and children give quite a sum total. Among these there were 2627 cases of smallpox, of which 469 died, or 17.85 per cent. The ratio of deaths at various ages was :— Vaccinated. Unvaccinated. Under 1 year,..............57.14 43.78 From 1 to 2 years............52.05 38.96 " 2 " 3 " ...........34.15 17.86 " 3 " 4 " ...........21.88 16.88 " 4 " 5 " ...........2.3.64 13.70 " 5 " 10 " ...........19.23 7.76 or " 3 to 15 " ...........15.41 10.32 These are the years usually considered fully pro- tected by vaccination; but it will be seen in every case that the unvaccinated had the advantage. Dr. Keller concludes his paper as follows:— 1. Generally more vaccinated than unvaccinated persons were attacked by smallpox. 2. Re-vaccination did not protect from smallpox, and did not lessen the general mortality. 3. Neither vaccination nor re-vaccination exer- cised a favorable influence upon the mortality of smallpox."46 Allgemeine Wiener Medizinische Zeitung, August, 1873, 90 SMALLPOX PRIOR TO VACCINATION. There is an unfounded opinion that smallpox was extremely virulent before the era of vaccination. It is true, there were mild epidemics and severe ones, but on the whole, in civilized communities, the death-rate was moderate compared with the total mortality. Dr. Lotz gives the statistics of smallpox during a epidemic in Posen, in 1798. The percentage of deaths to cases was under one year, 35.9 per cent.; under two years, 29.0 per cent.; under three years, 19.6 per cent.; under four years, 16.6 per cent.; under five years 13.4 per cent. That is of all the children under five years of age, who took smallpox, 22.9 out of 100 died. This corresponds very nearly to Eng- lish hospital experience already quoted. In the annexed table a comparison is instituted between two epidemics in the last century and that of 1871. A Comparison of Smallpox Mortality in Epidemics of Last Century with that of the Year 1871. ■•—There died of Smallpox in last century in a population of which a small proportion was inoculated. BERLIN, 174G. THREE TRUSSIAN 17 OX TOWNS, AGE-CLASSES. OBSERVATION. Persons living. No. of Deaths. Deaths per 1000. Persons living. No. of Deaths. 13 Deaths per 1000. 32.5 0-1 year . . . 2,000 41 20.5 400 1-5 " ... 6,560 129 19.5 1,386 124 89.5 5-10 " ... 7,120 15 2.1 1,493 44 29.5 Persons above the age o 10-20 ' ... above 20 years . . 13,360 50,960 1 0 0.1 0 2,626 7,425 4 0 1.5 0 20 did not at that time, as a rule, die of smallpox. Average..... 80,000 186 2.3 13,330 185 13.8 B. 1871.—In Berlin, Duisburg, and Hamburg among a population of which at least 90 per cent, were vaccinated, there died of smallpox 1871 IN BERLIN. 1871 IN DUISBURG. 1871 IN HAMBURG. AGE-CLASSES. Persons living. Deaths. Deaths per 1000. Persons living. Deaths. Deaths perlOOO. Persons living. Deaths. Deaths perlOOO. 0-1 year . . . 18,917 1.038 54.6 992 93 93.7 8,739 780 89.3 1-5 " ... 69,176 1,189 17.2 3,586 143 39.9 30,222 1,024 34.0 5-10 " ... 71,011 243 3.4 3,933 46 12.7 ■ 10-20 " ... 144,422 172 1.2 6,072 28 4.6 - 300,013 1,843 6.1 above 20 years . . 519,043 2,443 5.7 15,946 222 13.9 - Average..... 822,569 5,085 6.2 30,533 532 17.4 338,974 3,647 10.8 muller's orphan home. 93 It will be noticed that in the well-vaccinated Ber- lin, of 1871, the deaths were three times the rate of non-vaccinated Berlin of 1746. This, by no means, proves that vaccination was a cause of mortality, but it does prove that vaccination did not prevent it. Dr. Muller writes that out of 179 cases of vaccinated children under one year of age, which came under his notice in Berlin, in 1871, more than one-half, namely 99, or 55.30 per cent. died. That smallpox does not first attack the unvacci- nated, and from them spread to the vaccinated, is shown by the statistics of many local epidemics during the past twenty years. Thus in the Cologne epidemic, of 1870, 173 vaccinated persons were at- tacked before the first unvaccinated one; in Leignitz, in 1871, 224 vaccinated, before one unvaccinated; and in Bonn, in 1870, 42 vaccinated, before one un- vaccinated.47 This would seem to be the " protected " infecting the " residual dangerous class." Every one has heard of Muller's Orphan Home, at Bristol, England. As in all public schools in Eng- land, the children are all vaccinated. During the early months of 1872 an epidemic of smallpox pre- vailed, and 293 children had the disorder; with 19 deaths, or 6.66 per cent. This is a favorable show- ing, and would seem to be strongly confirmatory of the protective power of vaccination. But mild epi- demics of smallpox occurred before vaccination, and therefore we can hardly insist upon claiming mild- *7 Vv\ J. Collins, M.D. 94 smallpox a hundred years ago. ness as a logical sequence of vaccination. Jenner, on page 54 of his Inquiry, says: "About seven years ago (1791) a species of smallpox spread through many of the towns and villages of this part of Glou- cestershire. It ivas of so mild a nature that a fatal in- stance was scarcely ever heard of, and consequently so little dreaded by the lower orders of the community, that they scrupled not to hold the same intercourse with each other as if no infectious disease had been present among them. I never saw or heard of an instance of its being confluent. The harmless man- ner in which it showed itself could not arise from any peculiarity either in the season or the weather, for I watched its progress upwards of a year without perceiving any variation in its general appearance." And yet these were all unvaccinated cases. That this was not a solitary instance, is shown by the following quotation from a pamphlet published by Isaac Massey, apothecary to Christ's Hospital, in London, in the year 1723: "The children of Christ's Hospital are generally a flux body of about nine hundred or more; and I affirm that in that place not one out of fifty have died these last twenty years of that distemper, and but one the last nine years of the smallpox, although near six hundred have been constantly in the house, and I believe some hundreds have been down of it." Dr. Wag- staffe, writing in the previous year of the same epi- demic, states that the fatality amounted to hardly one in a hundred. If such a mild epidemic should SMALLPOX NOW. 95 occur in this year of our Lord, 1885, how many there would be who would exclaim, Behold and see what a goodly thing vaccination is. Very different was the epidemic at Birmingham, England, which culminated in 1874, and which called forth the remark, "Smallpox has lost its usual respect for vaccination." Dr. Alfred Hill, Medical Officer of Health for Birmingham, gives the total number of cases of smallpox during this epidemic, as 7,706, of which 6,795 had been vaccinated, 830 not vaccinated, and 81 doubtful. There had been 1,270 deaths, of which 840 had been vaccinated, 404 not vaccinated, and 26 doubtful.48 The 830 not vac- cinated, included 475 from the workhouse, mainly infants under one year of age, and too young, too weak, or too diseased to undergo vaccination. The 81 doubtful cases were persons claiming to be vacci- nated, but in whom, owing to the severity of the at- tack, ocular demonstration was impossible. The number of adults over forty years of age, who died " not vaccinated " was two. Dr. Henry Tompkins, of the Manchester Fever Hospital, reports 1,138 cases of smallpox; 932 were vaccinated, 46 claimed to be vaccinated, 64 were un- determined, and 96 were unvaccinated. Of the 1,138 cases, there died 195, or 17.13 per cent., which was about the ordinary death rate of smallpox before the vaccination era. Of the 932 vaccinated, 86 died, or 48 Daily News, August 25, 1875. 96 SMALLPOX DEATH-RATES COMPARED. 9.22 per cent.; and of the 96 unvaccinated, 60 died.49 The City of Manchester is vaccinated almost to the verge of its birth-rate, and these unvaccinated cases represent a class of infants which all tenement-house doctors recognize as hopeless cases, if overtaken by either of the zymoses. The following table shows very conclusively that the average death-rate from smallpox remains the same now that it was a century ago. BATE. AUTHORITY. CASES. VACCI-NATED. DEATHS DEATHS PER CENT. o M H M u u > o 1723 1746-63 1763 1779 Dr. Jurin quoted by Dr. Duvillard, . . . London Smallpox Hos-Lambert quoted by Dr. Eees' Cyclopaedia, . . 18,066 6,456 72 400 None. do. do. do. 2,986 1,634 15 72 16.53 25.30 20.8 18.0 24,994 4,707 18.83 o < * o O H OO «< H 5 1836-51 1870-72 1876 1871-77 1876-80 1876-80 1881 Mr. Marson's Hospital Metropolitan Hospitals, do. do. Homerton Hospital (Dr. Dublin Hospital (Dr. Grimshaw), .... Metropolitan (Jebb), . Deptford (McCombie) 5,652 14,898 1,470 5,479 2,404 15,171 3,185 3,094 11,174 4,236 1,956 11,412 2,654 1,129 2,764 338 1,065 523 2,677 552 19.97 18.66 23.0 19.43 21.7 17.6 17.3 48,169 34,526 9,048 18.78 49 The Amount of Protection Afforded by Vaccination against Small- pox. London, 1883. VACCINATED INDIANS DIE OF SMALLPOX. 97 This Table shows that before the introduction of vaccination, the percentage of deaths from small- pox was no higher than it is at present. Inasmuch as the deaths in the second division include a large majority of vaccinated persons, it is further shown that vaccination has had no effect in diminishing the percentage of mortality. Smallpox as treated now, and smallpox as treated by the medical men of the 18th century, is the same unmodified disease. It exacts the same ratio of victims to cases, runs the same course, and is as fatal now as then. Catlin, the historian of the North American In- dians, though a firm believer in vaccination, men- tions it as a curious fact, that amongst a tribe of In- dians all those who were vaccinated, during an epi- demic of smallpox died. Dr. H. Oidtmann says: " Our German municipal records show thousands of cases of attack or death from smallpox, even in newly-vaccinated persons. The modern analogical proofs drawn from the ex- periments of M. Pasteur with anthrax or splenic fever, have been proved by the counter experiments of Dr. Koch to be miserable illusions. Artificial in- oculation is one thing, the epidemic development of disease quite another; and.to base the right of the State to enforce vaccination on the variolous test a la lenner, is to occupy a position that cannot possibly be maintained."50 50 Address to the Reichstag. 98 SMALLPOX MORTALITY STATISTICS. The continued mortality from smallpox, in spite of the predictions of the more ardent pro-vaccinists to the contrary, drew from Joseph Baxendell, F.R. A.S., the following comparison: "As the best test of the value of vaccination, I have compared the results, in London, for the five years 1849-53, before vacci- nation was made compulsory, with those for the five years 1869-73, when compulsory vaccination had been twenty years in operation. In the former five years, when vaccination was voluntary, and the number of vaccinated persons probably did not amount to ten per cent, of the total population, the death-rate from smallpox in London was .292; but in the latter five years, when vaccination had been strictly carried out for twenty years, and the number of vaccinated persons was 95 per cent, of the popula- tion, the rate was .679, thus showing the extraordi- nary increase of 132.5 per cent." I do not quote this as indorsing it fully, but only as it bears on what is to follow. Smallpox being one of those diseases which appear in cycles, apparently dying out and then again gradually culminating, only again to diminish and then increase, and as it has been doing this for centuries, it is easy to so manipulate statis- tics as to prove either side of the question. By dex- trous elision of epidemic years, smallpox can appa- rently be shown to be constantly decreasing in viru- lence; while by re-arranging the statistics it can be demonstrated just as clearly that it is rapidly in- creasing. As for instance in the five years 1853-7, dr. Cameron's letter. 99 the smallpox mortality in London was 2,631, or an average per year of 526. In the five years 1868- 72, there were 11,543 deaths, or an average of 2,308 per annum. Such conjuring with figures is mis- leading, and therefore dishonest. Smallpox is not rapidly increasing in virulence, although it must be admitted that recent epidemics have shown an unex- pected malignancy. Dr. Charles Cameron, M.P., the able champion of vaccination in the House of Commons, in a letter to the London Times, in May, 1882, said: "Since 1836 our statistics have been compiled so as to enable us to compare the mortality not merely in smallpox occurring in all classes of vaccinated persons at dif- ferent periods, but in each separate class of vacci- nated persons—in persons, that is, with one, two, three, or four good or indifferent marks. I have gone into these details, and found that not merely has the mortality in smallpox occurring after vacci- nation progressively increased in the aggregate, but it has increased in each class of cases, and increased enormously in the best vaccinated class of cases." When it is remembered that these are the words not of an opponent but of a defender of vaccination, their import will be duly realized. During the ten years, 1870-9, the deaths from smallpox among the vaccinated in London was 10.10 per cent.51 This is undoubted evidence of in- 51 Lancet, Nov. 12, 1881. 100 AN ARMY OF VACCINATORS. efficient vaccination, and it is probably occasioned, in part, by using smallpox-cow virus instead of the true Jennerian cow-pox. The observations made by Drs. Edward C. Seaton and George Buchanan, dur- ing the epidemic of smallpox in London, in 1863, and published in the official report of the Privy Council, in 1865, shows this fact as to the quality of vaccination very plainly: " As the best means of ob- taining information on this point, we examined the cicatrices on the arms of 49,570 vaccinated children in various schools, industrial establishments, and workhouses of London. Of these 50,000 children, only 180 in a thousand were found to be properly vaccinated. In one-fifth of the whole number of children examined, vaccination was found to be wholly bad."52 During the past twenty years, since the above was penned, every possible effort has been made by the English government to secure perfect vaccination. An army of vaccinators have been deployed all over the kingdom, extra rewards for efficient service have been offered and paid, criminal prosecutions have been brought by the tens of thousands53 against those who object to being thus parentally guarded by gov- 52 Lord Lyttleton, in the House of Lords, on April 12, 1853, showed that in 1852 the ratio of vaccinated to the birth-rate varied widely in different parts of the kingdom. Birmingham, 91 per cent.; Derbv, 42; Leicester, 41; Loughborough, 18; Paddington, 16; Bideford, 11; Winchcomb, 6; Westminster, 4. 53 A thousand at one time in a single town. ZYMOSIS A CONSTANT QUANTITY. 101 ernment, a sum aggregating upwards of ten millions of dollars has been spent to accomplish—what? To "stamp out" smallpox. I low far all this parapher- nalia of governmental interference has succeeded, the statistics I have given show. But we will suppose it had succeeded. We will suppose the tens of thou- sands of the vaccinated who took smallpox and died of it in the past twenty years, and the other and greater multitude of vaccinated who were attacked by the disease and recovered, never had it; that they were actually and really "protected" from the dis- order. What then? One great fact stands behind all the statistics which have been brought forward during the past eighty years to prove the saving of life by vaccination. Nowhere has it been shown that less smallpox means fewer deaths, and it cannot be shown. Zy- mosis continues a constant quantity, though showing various and subtle changes in appearance; one epi- demic predominates for a time, during which the other forms of zymoses are in abeyance. As this particular form fades away, another takes its place, and the death-rate goes on with singular uniformity. The law of vicarious mortality is amply shown in every table of mortuary statistics. Living under certain conditions, the death-rate of a people will be a definite number every year per million living. Nothing will vary this number, to a sensible degree, excepting an alteration in the conditions of living. The prevalence of one disease means the subsidence 102 LAW OF COMPENSATION. of others, which again in its turn subsides to make way for another. The law of compensation is shown for instance in Sweden, where, in 1825, smallpox killed 1,243 persons, and typhus 3,962; but in 1829, smallpox killed only 53, while the deaths from typhus rose to 9,264. Again, in 1846 the mortality from smallpox was only 2; and the total deaths from all causes 72,683. In 1851, smallpox being epi- demic in spite of thorough vaccination, the deaths from that disorder was 2,488; and the general mor- tality 72,506. What is true of Sweden in this par- ticular, is true of every country. In Prague, from 1796 to 1802, the general mor- tality was 1 in 32, at a time when the death-rate from smallpox was 1 in 396f; but in 1832-55, when that from smallpox was only 1 in 14,741^, the general death-rate was still 1 in 32^.54 Dr. Robert Watt, in 1813, was astounded to find that though smallpox abated when vaccination came into fashion, yet the death-rate in general did not diminish. Considering the terrible devastation smallpox had wrought among the young, he says: " I began to reflect how different the case must be now; and to calculate the great saving of human life that must have arisen from the Vaccine Inocu- lation. At this time (1813) above 15,000 had been inoculated publicly at the Faculty Hall, and per- haps twice or thrice that number in private practice. Simon. Papers Relating to Vaccination, 1857. GLASGOW STATISTICS. 103 In eight years (1805-12) little more than 600 had died in Glasgow, of smallpox; whereas in 1784 the deaths by that disease alone amounted to 425, and in 1791 to 607; which, on both occasions, exceeded the fourth of the whole deaths in the city for the year. To ascertain the real amount of this saving of infantile life, I turned up one of the later years, and, by accident, that of 1808, when, to my utter astonishment, I found that still more than a half perished before the tenth year of their age; I could hardly believe the testimony of my senses, and therefore began to turn up other years, but I found it amounted to nearly the same thing. To make the facts clear, let us bring the results of the past three decades together, thus: Glasgow Mortuary Statistics. 1783-1812. Decade. From Smallpox. Measles. Whooping Cough. 1783-1792 1793-1802 1803-1812 3,466 2,894 1,013 211 398 1,655 854 914 1,151 Decade. Children under two. Children under ten. Total Deaths all ages. 1783-1792 1793-1802 1802-1812 7,293 6,277 7,120 9,919 9,050 10,913 17,607 16,685 20,175 To ascertain in what way the deficiency occa- sioned by the want of smallpox was supplied by other diseases, he divided the years 1783-1812 into five periods, of six years each, and thus set forth the proportionate mortalities:— 104 relative mortality. Glasgow Mortuary Statistics. 1783-1812. Years. From Smallpox. Measles. Whooping Cough. 1783-1788 19.55 .93 4.51 1789-1794 18.22 1.17 5.13 1795-1800 18.70 2.10 5.36 1801-1806 8.90 3.92 6.12 1807-1812 3.90 10.76 5.57 Children Children Total Deaths Years. under two. under ten. all ages. 1783-1788 39.40 53.48 9,994 1789-1794 42.38 58.07 11,103 1795-1800 38.82 54.48 9,991 1801-1806 33.50 52.03 10,034 1807-1812 35.89 55.69 13,354 " The first thing which strikes the eye on survey- ing the preceding table is the vast diminution in the proportion of deaths by the smallpox—a reduc- tion from 19.55 to 3.90 per cent.; but the increase in the measles column is still more remarkable—an in- crease from .93 to 10.76 per cent. In the smallpox we have the deaths reduced to nearly a fifth of what they were twenty-five years ago, whilst, in the same period, the deaths by measles have increased more than eleven times. This is a fact so striking, that I am astonished it has not attracted the notice of other practitioners." 55 In 1832, cholera replaced fever almost entirely as a cause of mortality, affecting the same class of per- sons who would have otherwise died of typhoid. 55 An Inquiry into the Relative Mortality of the Principal. Diseases of Children, and the Numbers who have Died under Ten Years of Age, in Glasgow, during the last Thirty Years. By Kobert Watt, M.D., Lec- turer on the Theory and on the Practice of Medicine in Glasgow. Glasgow, 1813, pp. 64. plague statistics. 105 In view of these facts what must be thought of such remarks as those made by Sir Spencer Wells, the world-famous ovariotomist, that " It may not be generally known, but it is true, that Jenner has .saved, is now saving, and will continue to save in all coming ages, more lives in one generation than were destroyed in all the wars of the first Napo- leon."56 This idea of the displacement of one disease, by another of the same class, has been very hotly con- tested. Seaton makes a very elaborate argument in disproof; but while an excellent specimen of special pleading, it does not cancel facts. Nor is this law of compensation a new thing. In 1665, John Graunt, a Fellow of the Royal Society, published a volume, giving the vital statistics of London yearly from 1604 to 1664, a period of sixty years. In the period 1604-11, there died of plague, 14,752 persons; of all other diseases, 50,242; total, 64,994; the proportion of deaths from the plague being 28 out of every 100 deaths. In the next period of eight years, 1612-19, there died of plague 171 persons; of all other diseases, 64,346; making a total of 64,517. Thus, when plague destroyed 14,700 persons, the general mortality was only 477 more than when plague killed the insignificant number of 171 persons.57 JohnGraunt very quaintly 66 To the Medical Officers of the Egyptian Expedition, Nov 21, 1882. " Charles T. Pearce, M.D. 6 106 MORTALITY FROM PLAGUE. remarks, that " a true account of the plague cannot be kept without the account of other diseases." It is interesting to note the similarity between the fluctuations in the death-rate of plague and small- pox. Compare the table on page 132 with this, showing the mortality from plague. Mortality from Plague in London, 1604—1651. Year. Deaths. 1604....... 896 1605....... 444 1606.......2,124 1607.......2,352 1608.......2,262 1609.......4,410 1610.......1,803 1611....... 617 1612....... 64 1613....... 16 1614....... 22 1615....... 37 1616....... 9 1617....... 6 1618....... 18 1619....... 9 1620....... 21 1621....... 11 1622....... 16 1623....... 17 1647 1624....... 11 1648 1625.......35,417 1649 1626....... 134 1650 1627....... 4 1651 Year. Deaths. 1628....... 3 1629....... 0 1630.......1,317 1631....... 274 1632....... 8 1633....... 0 1634....... 1 .1635....... 0 1636.......10,400 1637.......3,082 1638....... 363 1639........ 314 1640.......1,450 1641.......1,375 1642.......1,274 1643....... 996 1644.......1,412 1645.......1,871 1646.......2,635 3,507 611 67 15 23 Leprosy, the black death, plague, spotted fever, cholera, and influenza have followed each other down the centuries. Sometimes one the chief cause of mortality and again another. Sydenham ob- serves: "I conjecture that diseases have certain periods, according to the occult and unaccountable SIR THOMAS CHAMBERS ON SMALLPOX. 107 alterations which happen in the bowels of the earth. And as there have been other diseases which are now either utterly extinct, or at least almost wasted by age, fade away and very rarely appear (of which sort is a leprosy and some other), so the diseases which now reign, will vanish in time and give place to other kinds, whereof, indeed, we are not able so much as to guess." Addressing the House of Commons in 1878, Sir Thomas Chambers said: "You cannot show that vaccination has reduced deaths, or saved a single life. There may be no smallpox, but the disappear- ance of smallpox is by no means equivalent to a reduction of mortality." Illustrations of this are as "plentiful as black- berries." As, for instance, take the year 1796, which was the worst year for smallpox of that decade, when 3548 died of it in London, and the whole numbers of deaths were 19,288. In 1792, when the smallpox deaths were only 1568, the general mor- tality was 20,213. That is, though smallpox in- creased two thousand, the total deaths fell off one thousand. Again, comparing the forty years, 1841-80, and taking the three years when smallpox deaths were the lowest, and comparing them with the three years when it was the highest, we find, that while in the latter there were nine thousand more smallpox deaths, the average mortality remained unchanged. 108 ZYMOSIS AND CLEANLINESS. GENERAL SMALLPOX DEATHS. DEATH-RATE PER THOUSAND. Three lowest years . . . 1841 . . . 1,053 24.2 1851 . . . 1,062 23.4 1855 . . . 1,039 24.3 Average . . . 1,051 23.9 Three highest years . . . 1863 . . . 1,996 24.5 1871 . . . 7,912 2.46 1877 . . . 2,551 21.9 Average . . . 4,153 23.6 The only thing which has been found competent to contend with zymosis is cleanliness. As a people learn to keep their houses clean, their streets and by-ways clean, their water-supply pure, their food free from adulteration, their persons free from ac- cumulations of effete tissue, they rise superior to the thraldom of zymotic disorders. Under unfavorable sanitary conditions a person insusceptible to one type of disease-element will fall a victim to some one of the other zymotic disorders to which his peculiar dyscrasia renders him liable. To protect him against any one of this class of diseases, still leaves him subject to the others, until by a complete change of his personal surroundings and habits, he is rendered proof against them all. The London Lancet said during the epidemic of DR. FARR'S REPORT. 109 1871: "Those who have been building up in their imagination a great and beneficient system of State medicine, under which the great causes of disease were to be controlled, must abate their hopefulness. It must be admitted that the existing system of public vaccination has been sadly discredited and almost mocked by the experience of the present epi- demic."58 The Registrar General (England) puts this whole question of the relativity of the zymoses to sanitation very tersely, when he saj^s in his official report for 1880: "The decennium which closed with the year 1880 was one of lower mortality in London than any of the preceding decennial periods.....These facts are strong evidence that the sanitary efforts of recent years have not been unfruitful.....The evidence in support of this position is rendered still stronger, if, instead of fixing our attention upon the total mortality, we take into consideration its causes. For it will be found that the saving of life was al- most entirely due to diminished mortality from causes whose destructive activity is especially 58 At the Conference on Animal Vaccination, in London, December, 1881, Dr. Ballard, who gets thirty-five hundred dollars a year as a public vaccinator, in a speech, said: "That if it were not for the in- terference of such smallpox epidemics as that of 1871, the records of vaccination would be perfectly satisfactory;" whereon Dr. Enoch Robinson observed, "that Dr. Ballard reminded him of a bankrupt who avowed that he would be perfectly solvent, if it were not for his confounded losses," 110 FLORENCE NIGHTINGALE'S OPINION. amenable to sanitary interference—namely, the so- called zymotic diseases.....The death-rate from fever fell nearly fifty per cent.....that of scarla- tina and diphtheria fell 33 per cent. ..... One dis- ease alone in this class showed exceptionally a rise, and no inconsiderable one. This was smallpox, which, owing to the two great outbreaks of 1871-2 and 1877-8, gave a death-rate nearly 50 per cent, above its previous average. Thus it will be observed the only disorder which vaccination could mitigate; the only one for which it was considered necessary to provide a special pro- phylactic; the only one for whose prevention im- mense sums were voted out of the public funds; was the very one, and the only one, that failed to be ameliorated by the general improvement in the con- dition of the people. Florence Nightingale observes that "every one 59 Here are the figures: Smallpox Deaths in London. 1851-60.............7,150 1861-70.............8,347 1871-80............15,551 The deaths in England from the last three great epidemics of small- pox were: Deaths. 1857-9.............14,244 1863-5.............20,059 1870-2.............44,840 Dr. W. B. Carpenter, M.P., excuses the heavy mortality in the last epidemic by saying that never before had smallpox swept so ter- ribly over the country. The protective power of vaccination which is only useful when the danger is absent is of singularly little value. SMALLPOX IN INDIA. Ill who knows anything of public health questions, will agree as to the practical unity of epidemics and their determining causes, and that exemptions from all alike must be sought, not by any one thing, such as vaccination, but by inquiring into and removing the causes of epidemic susceptibility generally." In the official report on sanitation in India, we read: "The vaccination returns in India show that the number of vaccinations does not bear a ratio to the smallpox deaths. Smallpox in India is related to season, and also to epidemic prevalence. It is not a disease, therefore, that can be controlled by vaccination, in the sense that vaccination is a speci- fic against it. As an endemic and epidemic disease, it must be dealt with by sanitary measures, and if these are neglected smallpox is certain to increase during epidemic times. Vaccination has no power, apparently, over epidemic smallpox. It would scarcely answer, in the face of these facts, to go on vaccinating the people to protect them from small- pox, while leaving them surrounded by such disease causes as the reports would show to exist in all the villages affected."60 Again, in the following year, the same idea is en- forced: "It must not be forgotten that the amount of smallpox depends not only on the proportion of un- vaccinated people in a country, but also, and prima- rily, on the sanitary condition of the people and their 60 Report on Sanitary Measures in,India, 1879-80, Vol. XIII, 1881. 112 lord Shaftesbury's opinion. surroundings, and the influence exercised by these elements on their general health and resisting power against epidemics.....The whole history of In- dian smallpox appears to show that it is essentially an epidemic disease, and, as such, it ought to admit of mitigation by ordinary sanitary procedure, like other maladies of the same nature."61 The last proposition that I set out to prove was that the less disfigurement now from smallpox, shows that it has been mitigated by the practice of vaccina- tion. I have endeavored to find evidence that small- pox-marked faces are less frequently seen now-a-days than formerly. I supposed I would have no trouble to do so; but though I have ransacked every library in New York since beginning this chapter, I have been able to find not a particle of real evidence. I believe it to be so, but of evidence wTorth the name there is not a particle. It would seem then that it is to sanitation alone that we can turn for any real solution of this prob- lem. Lord Shaftesbury, whose death has but re- cently been chronicled, observed: "It is perfectly true that smallpox is chiefly confined to the lowest classes of the population; and I believe that with improved lodging houses, the disease might be all but exterminated^ No doubt if, by some magical means, this entire class, as we see them, for instance, here in New York, could be lifted out of their present abodes and S1 Report on Sanitary Measures in India, 1880-1, Vol. XIV, 1882. • infantile mortality. 113 put into nice, clean dwellings, a large number of them would be permanently benefitted; but, fortu- nately, no such radical means can be adopted. The elevation of the lower classes of the population can only be practicably accomplished by opening wider the possibilities of self-advancement. Then, as is in fact being done now, the more thrifty and vital will work upward to a state of independence. Any ele- vation of the masses, which comes not from active acceptance on their part of enlarged opportunity, but from artificial, outside pressure, would be dele- terious. It is not inhumane to say, that things being as they are, the extravagant death-rate among these classes is a National blessing. For if these thou- sands of diseased and weakly children, who now die because they have not vitality to sustain themselves under the circumstances into which they are born, were by a radical change in their surrounding kept alive, they would in a few years marry and multiply to such an extent as to overwhelm the thriftier and hardier portion of the race. Cruel as the fact may seem; lay the blame where you will; nevertheless, it is terribly true that the excessive mortality among the children of the vicious and degraded, alone pre- vents our civilization from being crushed out by them. In conclusion, I think we are warranted in main- taining, that an impartial and comprehensive study of vital statistics proves, that the extension of the prac- tice of vaccination cannot be shown to have any 114 sanitation a preventive. logical relation to the increase or diminution of cases of smallpox; and that these same vital statistics, gath- ered from every quarter of the world, establish the fact that smallpox, like the other zymoses, originates from unsanitary modes of life, and can only be effectually conquered by removing the cause; and that, finally, vaccination is inoperative on the gen- eral death-rate where sanitation is defective, and superfluous where sanitation is efficiently enforced. THE ALLEGED DANGERS FROM VACCI- NATION. I have clearly perceived the progressive dangerous influence of Vaccination in England, France, and Germany.—Alexander von Humboldt. Having thus determined the actual value of Arac- cination as a prophylatic power, we come now to the consideration of the dangers, which it has been alleged, await those who are subjected to the opera- tion. These are of two kinds; first, the immediate danger from the operation, and secondly, the re- mote. The persons who die from the immediate effects of a vaccination are inconsiderable, when taken in relation to the millions who are vaccinated. Still, taken by themselves, they make quite a ghastly list, extending down from the beginning of the century, and hailing from every clime. Dr. William Rowley, F.R.C.P., London, Physician to Her Majesty's Lying- in Hospital, Lecturer on the Theory and Practice of Medicine, wrote in 1805: "Out of 504 persons vacci- nated, 75 died from the consequences. There is no question here of supposition, or calculation of prob- ability—it is truth. It is evidence which seems to speak, and leaves no doubt. Now, if in the space of seven or eight years (from 1798 to 1805) Vaccina- tion has shown itself so grievous to society, what may we not fear for the future." (115) 116 DR. HENRY MAY'S OPINION. In the year 1807, Mr. Birch, of St. Thomas Hos- pital, and Surgeon Extraordinary to the then Prince of Wales, mentions a number of cases as occurring at Chelsea, in Hertford, at the Lambeth AVorkhouse, and elsewhere. It is needless to give the details here. I compiled a list of upwards of a thousand instances of persons who had suffered permanent injury, or death, but I cannot give space for them. Of these, nine have been personally known to me. It is no infrequent thing, however, to hear a public vaccinator say that he has vaccinated a certain number of thousands and has never seen the slightest evil resulting. Well, one need not see the sun, if he will only resolutely shut his eyes. Again, I am sorry to say, that many medical men who recognize evil results, imagine that they may be covered up by prevarication. As if any good was ever done by a lie. But it is rarely that one is so outspoken as Dr. Henry May, who, in an article on "Certificates of Death," in the Birmingham Medical Review, Jan- uary, 1874, thus expresses himself: " In certificates given by us voluntarily, and to which the public have access, it is scarcely to be expected that a medical man will give opinions which may tell against or reflect upon himself in any way, or which are likely to cause annoyance or injury to the survivors. In such cases he will most likely tell the truth, but not the whole truth, and assign some prominent symptom of the disease as the cause of death/ As instances of cases which may tell against the medical man himself, I will SILLY CHARGES AGAINST VACCINATION. 117 mention erysipelas from vaccination, and puerperal fever. A death from the first cause occurred not long ago in my practice, and although I had not vaccinated the child, yet in my desire to preserve vac- cination from reproach, I omitted all mention of it from my certificate of death." Dr. May but voices the practice of many of his cis-atlantic colleagues. On the other hand, the most silly and extravagant charges are brought against vaccination. Mothers, in our tenement-house class, are prone to refer back to '"the time when baby was vaccinated," as from whence came every subsequent ill which might hap- pen to the child. In a lengthy hospital and dispens- ary experience, covering more than eighteen thousand cases, it has been my lot to hear many such pre- posterous charges. I have investigated at least fifty such that I have thereupon been able to declare utterly without foundation. It is alleged that vaccinated children are more liable to die from other diseases (than smallpox) than those who have not been vaccinated. We have seen that the average death-rate has not declined with the lessened frequency of deaths from small- pox ; but the proposition here advanced is, that vac- cination, by weakening the child's constitution, or by implanting other diseases, tends to shorten life. Let us see if there is any warrant for this assertion. It has been noticed that the death-rate from cer- tain diseases has very greatly increased since vacci- nation has become universal, and that this increase 118 HERBERT SPENCER'S OPINION. has been proportional to the extension of vaccina- tion. Now, although this is true, it is by no means positive evidence that the doctrine post hoc ergo propter hoc applies, for many other influences are constantly at work, and these must be duly con- sidered before passing judgment. There are two classes of diseases which are sup- posed to be spread by vaccination. Those which are distinctly inoculable, as syphilis and scrofula, and those to which persons may be predisposed by a lowering of physical force, such as pneumonia, or typhoid. Herbert Spencer, speaking of the deplorable ill- health of the rising generation, says: "We are not certain that the propagation of subdued forms of constitutional disease through the agency of Vaccina- tion is not a part-cause. Sundry facts in pathology suggest the inference that when the system of a vaccinated child is excreting the vaccine virus by means of pustules, it will tend also to excrete through such pustules other morbific matters; especially if these morbific matters are of a kind ordinarily got rid of by the skin, as are some of the worst of them. Hence it is very possible—probable even—that a child with a constitutional taint, too slight to show itself in visible disease, may, through the medium of vitiated vaccine lymph taken from it, convey a like constitutional taint to other children, and these to others."62 Education, page 181.—1881. VACCINAL-SYPHILIS. 119 Vacctnal-Syphilis. The existence of vaccinal-syphilis was until re- cently most strenuously denied. Says Simon (1857), " if syphilis could be diffused by the vaccine lymph of children with an hereditary taint of that disease, this possibility must long ago have been made evi- dent on a scale far too considerable for question;"63 and this was unquestionably the opinion of almost all competent practitioners down to that date; al- though Mosely, in Jenner's time, and other writers of later years had insisted upon the possibility of the propagation of syphilis in arm-to-arm vaccina- tion. This opinion has since been very much modi- fied. In 1802, M. Ricord, who up to that time was a disbeliever in vaccinal-syphilis, in a lecture in Hotel Dieu, in Paris, said: "it is not impossible that the disease [syphilis] was transmitted with the vac- cine lymph, but in the estimation of facts which seem to establish such transmission, it is necessary to distrust the evidence of our senses; ... let us admit a careful inquiry into these cases, and let us guard against any predetermined notions on the subject; but as to the interpretation offered, let it be received with an amount of hesitation and doubt, increased by the obvious fact, that if ever the trans- mission of disease with vaccine lymph is clearly demon- strated, vaccination must be altogether discontinued; for in the present state of science, we are in possession Papers Relating to the History and Practice of Vaccination, p. 66. 120 RICORD ON VACCINAL SYPHILIS. of no criterion which may permit the conscientious practitioner to assert that the lymph with which he inoculates, is perfectly free from admixture." In the following year (May 19, 1863) standing in the same place, this eminent syphilographer said: "At first I repelled the idea that syphilis could be transmitted by vaccination. The recurrence of facts appearing more and more confirmatory, I accepted the possibility of this mode of transmission, I should say, with reserve, and even with repugnance; but to-day I hesitate no more to proclaim their reality." In 1864, Dr. 0. Kratz, a surgeon in the Confeder- ate army, reported some cases of vaccinal-syphilis.64 In 1866, W. B. Collins, M.D., of St. Bartholomew's Hospital, London, reported some cases. In 1867, M. Depaul, the Chief of the Vaccination Service of the French Academy of Medicine, pub- lished an essay on the danger of syphilitic infection through vaccination. He enumerated half a dozen outbreaks of vaccinal-syphilis, in the course of which 160 children had been infected.65 In 1868, Prof. Joseph Jones, M.D., of Nashville, Tenn., reported a large number of cases as occurring at Andersonville, and elsewhere, during the war.66 64 Confederate States Medical and Surgical Journal, Vol. I, page 104, 1864. 65 Address at the Calf-lymph Medical Congress, by Charles Came- ron, M.D., M.P., 1879. 66 Abnormal Phenomena accompanying and following Vaccination in the Confederate A rmy. BALLARD ON VACCINAL-SYPHILIS. 121 In 1868, Dr. Ballard, one of Her Majesty's Vaccine Inspectors, observed: " There can be no reasonable doubt that the vaccine virus and the syphilitic virus may both be drawn at the same time, upon the same instrument, from one and the same vesicle. The vesicle which is thus capable of furnishing both vaccine and syphilitic virus may present, prior to being opened, all the normal and fully developed characters of a true Jennerian vesicle, as ordinarily met with."67 In the same year (1868), B. F. Cornell, M.D., President of the Homoeopathic Society of this State, declared in his Annual Address, that "to no medium of transmission is the wide-spread dissemi- nation of this class of disease so largely indebted as to Vaccination."68 Dr. Heim, public vaccinator, Wurtemburg, said: "I have myself transplanted syphilis from a child which seemed at the time per- fectly healthy."69 In 1871, Dr. Chas. T. Pearce, London, testified before the Parliamentary Commit- tee, that "he had unwittingly transferred syphilis from lymph supplied by the Royal Jennerian In- stitution; had twenty such cases within four years at Northampton." He also quotes Whitehead, of Manchester, a very distinguished practitioner, "who had seen several instances of syphilitic taint, trans- ferred from a true Jennerian vesicle." John Simon, 67 Essay on Vaccination. 68 Address delivered before the Homoeopathic Medical Society of the State of New York, February 11, 1868. 69 Horrors of Vaccination, page 26. 122 MARSON ON VACCINAL-SYPHILIS. F.R.S., testified that there was " not the least doubt that syphilis has been communicated in what has purported to be vaccination." Dr. Bakewell, Vac- cinator-General of Trinidad, "had seen leprosy and syphilis communicated by vaccination. Leprosy is becoming very common in Trinidad; its increase being co-incident with vaccination. Sir Ronald Martin, M.D., agreed with him that the leprosy arose from vaccination." Mr. Marson, of the Smallpox Hospital, London, "had never seen syphilis after vaccination, but M. de Meric, who is a very clever man, believes in it. Mr. Rollet holds a similar opinion. The fact that syphilis may be conveyed by vaccination has been proved in the Rivalta cases, also in France, and Germany." Dr. Wood, F.R.C.P., Edinburgh, "never listens to alleged cases of syphilis or scrofula. If those diseases show themselves soon after vaccination, they are unjustly ascribed to vac- cination." Sir William Jenner, M.D., "has never seen syphilitic affections resulting from vaccination. Considers the assertion, that syphilis has been com- municated by the lymph, of very little worth; though he admits that Ricord and Hutchinson are men of scientific position." Sir William Gull, M.D., "had never seen vaccinal-syphilis, and thought it would be the most insane thing to give up vaccina- tion. Hunter, and others, maintained that syphilis could not be communicated by vaccination. Thinks Ricord's conclusion a very hasty one." Dr. West, as Physician to the Children's Hospital, had seen HUTCHINSON ON VACCINAL-SYPHILIS. 123 60,000 cases [all diseases], "never had a case of syphilis in consequence of vaccination." Jonathan Hutchinson, M.R.C.S., "has seen the syphilitic con- tagion conveyed by vaccination in eleven cases; has had great experience in syphilis; has another series of cases strongly suspected to be of the same kind now under investigation, and has had many sus- pected cases sent him during the last fortnight. Ricord is certainly an authority. Is not sure the 540 medical men, quoted in the Blue Book of 1857, denied the possibility of syphilitic communication by vaccination; they expressed their own non- familiarity with it, and said they had never seen it happen. The general opinion held by the profession must doubtless greatly affect their interpretation of facts. Would attribute much less force to mere negative than to positive evidence. Having worked at the subject of syphilis specially, was able to de- tect appearances of that disease, which, possibly, might not be done by most medical men." E. C. Seaton, M.D., thinks the above "mistaking sequence for consequence. The danger of syphilitic com- munication quite infinitesimal. No doubt, the mode in which persons deal with facts is largely affected by the views they hold, and the profession would have been much less inclined to believe in such possibility than they would be in the future."70 70 All the above from the words " Parliamentary Committee," page 121, line 19, condensed from testimony before a Committee of the House of Commons, 1871. 124 HUTCHINSON ON VACCINAL-SYPHILIS. In 1872, William Hitchman, M.D., D.C.L., of Liverpool, said: " That he had seen impure conse- quences following vaccination, even in the hands of Mr. Marson himself;" and speaking of certain ulcers, he said: "They owe their disgusting origin to the foul exudations of that indefinite, nameless, hideous thing now in course of active propagation through- out the land, yclept vaccinal-syphilis."71 In 1873, Mr. Hutchinson again came forward, at a meeting of the Medico-Chirurgical Society, with the details of new cases of vaccinal-syphilis. "He also drew some general deductions from the facts as already ascertained, which, together with others elic- ited in the course of the discussion that followed, constitute the most important practical suggestions yet made in regard to this most unsatisfactory sub- ject. That syphilis could be communicated by vac- cination, was, though admitted abroad, long disputed in this country. Since the publication of Mr. Hut- chinson's paper, and a communication by Mr. Thomas Smith to the Clinical Society, where the patient was exhibited, it can no longer be so. We have now emerged from the region of doubt, to one of belief in the possibility of such an untoward oc- currence.....The facts now before the public will tend to rouse them, if they have not been roused already from the false security, into which they had been lulled."72 71 The Anti- Vaccinator, December 16, 1872. 72 Medical Times and Gazette, P'ebruary 1, 187 . TROUSSEAU ON VACCINAL-SYPHILIS. 125 In 1874, Prof. A. Trousseau, M.D., Physician to Hotel Dieu, Paris, observes: "The transmission of syphilis by vaccination appears now to be an estab- lished fact. To the examples, which since the be- ginning of this century have been reported, and of which the number is singularly augmented of late years, I could add that which has come to our notice in our hospital.....If there are still some doctors, who doubt the possibility of the transmission of syphilis by vaccination, the greater number have succumbed to the evidence.....The assertion that blood only conveys the disease, is hypothetical. It is difficult to understand that what the blood serum contains the vaccinal serum does not contain also."73 Prof. Germann, M.D., said: " Above all, the "dire fatality, which lately occurred at Lebus, a sub- urb of Frankfort-on-the-Oder, would alone warrant the abolition of the vaccination laws. Eighteen school girls, averaging twelve years of age, were re- vaccinated, and thereby syphilised, and some of them died.....Yet the lymph, the syphilitic lymph, used in this case, was obtained from the Official Royal Establishment, and was the new regenerated or 'annualized' vaccine lymph so warmly recom- mended for the revaccination of schools."74 In 1877, Brundenell Carter, F.R.C.S., L.S.A., etc., Surgeon to St. George's Hospital, London, observed: 73 Clinique Medicale, Vol. I, pages 116-18, Paris, 1874. 74 From an address to the Diet of the German Empire. 126 CARTER ON VACCINAL-SYPHILIS. " I think that syphilitic contamination by vaccine lymph is, by no means, an unusual occurrence, and that it is very generally overlooked because people do not know either when, or where to look for it. I think that a large proportion of the cases of apparently inherited syphilis are in reality vac- cinal; and that the syphilis in these cases does not show itself until the age of from eight to ten years, by which time the relation between cause and effect is apt to be lost sight of."75 In the same year, Mr. Hutchinson, in a work on Surgery, again said: "There can be no doubt that the danger of trans- mitting syphilis by vaccination is a real and a very important one."76 Prof. Robert Alexander Gunn, M.D., of New York, declared that, " the appalling evils that have been' and are still produced by it, are sufficient to con- demn the practice as a crime."77 In 1878, the eminent and beloved Constantine Hering, M.D., of Philadelphia, wrote: "I have more than once plainly seen, and often heard of, cases where children remained ailing from the time of vaccination, who were previously in robust health."78 In 1879, J. R. Newton, M.D., of Boston, said: " AVere I to relate a few of the cases that have fallen 75 Medical Examiner, May 24,1877. 76 Illustrations of Clinical Surgery. 77 Vaccination, its Fallacies and Eri/s, page 13. 78 From a letter to the Homoeopathic Practitioners of Great Britain, Philadelphia, August, 1878. SIMON ON VACCINAL-SYPHILIS. 127 under my observation of persons injured by this practice, it wTould fill the mind with horror." Sam'l Eadon, M.A., M.D., of Gloucester, said: "The sins of the fathers to the third and fourth generation is im- ported into the young organism." Prof. Alexander Wilder, M.D., etc., observed: "Hence a vaccinated people will always be a sickly people, shorter lived, and degenerate." Prof. Niemeyer, M.D., etc., of Tubingen, said: "It cannot be denied that vaccina- tion sometimes leaves permanent impairment of health."79 John Simon, F.R.C.S., etc., wrote: "Thus the vaccine lymph of the syphilitic may possibly contain the syphilitic contagion in full vigor, even when the patient, who thus shows himself infective, has not on his own person any outward activity of syphilis."80 In 1880, A. G. Springsteen, M.D., of Cleveland, Vice-Eresident of the National Eclectic Medical As- sociation, said: "No one, who has given the subject the least consideration, doubts that impurities may be conveyed in this manner."81 Sir Thomas Watson, M.D., F.R.S., D.C.L., wrote: "There has fallen an ugly blot.....Such facts as Mr. Jonathan Hut- chinson has demonstrated, constitute a rational ex- cuse for objecting to compulsory vaccination. I can readily sympthise with, and even applaud a father who, with the presumed dread or misgiving in his 79 Text-Book of Medicine. 1879. 80 British Medical Journal, December 13, 1879. 81 Xew York Medical Tribune, January, 1880. 128 DESJARDINS ON VACCINAL-SYPHILIS. mind, is willing to submit to multiplied judicial penalties, rather than expose his child to the risk of an affection so ghastly."82 In 1881, Dr. Desjardins gives a complete account of the syphilisation of 58 French recruits in Algeria. The most cautious silence was preserved by the mili- tary authorities; and not without reason, if vaccina- tion is to retain its hold on popular credulity. Dr. Desjardins proposed to solace these soldiers by pen- sions for injuries which the Government cannot re- dress.83 In 1882, S. B. Munn, M.D., of Waterbury, Conn., Ex-President of the National Eclectic Medical Asso- ciation,' declared: "That if medical men were made pecuniarily responsible for the ill-effects, no physi- cian would ever vaccinate."84 In 1883, Dr. Brereton reports cases of invaccinated leprosy in Hawaii. In 1883, Ch. Pigeon, M.D., of Fourchambault, addressed a letter to the Deputies of the French Chamber, relative to the proposed bill upon compul- sory vaccination, in which he speaks of having then under his care some cases of vaccinal syphilis. This chronological record of invaccinated syphilis is brief but conclusive. If need be, it could be swelled to a portly volume. Upwards of nine hun- 82 Nineteenth Century. June, 1880. 83 Journal d'Hygiene, Aug. 25, 1881. Edited by Docteur de Pietra Santa, a scientific gentleman, of eminent reputation. 84 Address before the Eclectic Medical Association of Connecticut. A CASE OF VACCINAL-SYPHILIS. 129 dred well-attested cases are on record; and when it is remembered with what difficulty even a single case can be indubitably sustained, the mind realizes the probably thousands, which have been overlooked or ignored. My own dispensary experience leads me to aver that a systematic, impartial, Govern- mental investigation wrould reveal an undreamt of multitude of cases. Such an investigation will never be permitted. I have only space to give the details of one case which has come under my observation. In Decem- ber, 1879, there came to the out-patient department of the Manhattan Hospital a mother with her little girl, twenty-one months old. The woman was a widow, whose husband had died some time previ- ously, of pneumonia, leaving three children aged three years, twenty-one months, and seven months respectively. The two oldest were girls, and the in- fant, a boy, born I believe after his father's death. The mother supported them all by odd jobs of laundry work. Although very poor, they were neat, and attracted my attention thereby, before I had in- quired into the cause, which brought them to my clinic. The woman's story was this: some seven or more weeks previously, the three children had been forcible vaccinated by a public vaccinator, in a house- to-house visitation. The arms of all the children had remained sore ever since. About a week ago she had noticed ulcers on the baby, and had obtained a salve from a drug-store; but the child continued 7 130 A CASE OF VACCINAL-SYPHILIS. to get worse day by day. Yesterday she noticed places, breaking out on the second child, and she had, therefore, come to find out what was the matter. On examining the child, I found the place of inser- tion of the vaccine virus, a shallow, clean-cut ulcer, filled with a dirty exudation. The cellular tissue round about it was infiltrated and very hard, ex- tending over nearly one-half of the upper arm. The axilla was tender, and the glands swollen. There were six ulcers on the body; four of them very small, just forming that day, and two somewhat larger, having appeared thirty-six hours previously. These ulcers began, like a blister, the size of a split pea, with a swollen indurated base of a copperish hue, and in all respects resembling syphilitic rupia. The ulcers were so characteristic, that I ordered the whole family to appear before me on the morrow. When, on the following day, I saw the infant strip- ped of its clothes, revealing no less than thirty dread- ful ulcers, some of them as large as a silver dime; it made me heart-sick. Some of these had already begun to scab, showing the peculiar wratch-crystal formation, so characteristic of this eruption. On the oldest child I found four small blisters on the back, and she also, in a day or two, had a full share of syphilitic sores. Here were three children, which a very careful investigation in the neighborhood, where they lived, showed that they had been, up to the time of their vaccination, in very good health, suddenly stricken with the most incontestable evi- INFANTILE SYPHILIS. 131 dences of. this dreadful disorder. As many other children in the same neighborhood were vaccinated by the same vaccinator, I was loath to admit to my- self that the vaccine could have caused the disaster. I therefore tried to discover some other means of in- oculation. I examined the men whose clothes the woman had laundered, the woman herself most par- ticularly, but was, at last, obliged to admit that there was no apparent means of infection, except through the vaccination. The infant was the most severely affected, and the oldest child the least. I had them under treatment for about four months, during which time they were seen by a number of physicians. At the end of that time the ulcers had all healed and the children were apparently well, but I unfortunately lost all trace of them by the mother moving out of the neighbor- hood. Meanwhile, syphilis is a constantly increasing factor in infantile mortality. In the appendix to the 37th Annual Report of the Registrar General of Eng- land, Dr. Farr, page 221, writes: "Syphilis . . . was twice as fatal in the five years, 1870-74, as it was twenty years ago. Its most fatal recorded forms occur in children under one year of age."85 The fol- lowing table gives the relation between vaccination, smallpox and syphilis during a period of 44 years. 85 Since the above was written Dr. Farr has died. His memory de- serves a tribute of respect from all who are interested in sanitation. Although a believer in vaccination, the labors of his long official life furnish a repertory of statistical facts, which show its futility as at present practiced. A Table of Mortality in England and Wales, SHOWING The Deaths from Smallpox and Syphilis; also the number of Successful Public Vaccinations. Compiled from the Reports of the Kegistrar-General, from the First Year of Official Registration, by W. T. Stephen, 61 Victoria Eoad, Finsbury Park.* Population. 1838 15,287,699 1839 15,514,255 1840 15,730,813 1841 15,929,492 1842 16,130,326 1843 16,332,228 1844 16,535,174 1845 16,739,13(5 1846 16,944,092 1847 17,150,018 1848 17,356,882 1849 17,564,656 1850 17,773,324 Successful Vaccinations at the ex- pense of the Poor Rates. Deaths from Smallpox in Periods. No official account of vaccina- tions before 1852. 35,833 (3 vears) 1838-40 29,522 | (6 vears) \ 1841-50 Deaths Deaths from Smallpox. from Small-pox per Million Pop. 16,268 9,131 1,064 589 10,434 663 6,368 400 2,715 168 Deaths from Smallpox. Annual Average for each five Years. 576.8 1838-42 Deaths from Syphilis. 159 142 195 177 178 Deaths from Syphi- lis per million of Pop. 10 9 12 11 11 Deaths from Syphilis. Annual Average for each five Years. 10.6 1838-42 From 1843 to 1846 inclusive the causes of deaths were not analysed by the Registrar-* ieneral. 4,227 6,903 4,644 4,665 246 398 264 263 292.7 (4 years) 1847-50 565 32 575 33 595 34 554 31 33.0 (3 years) 1847-49 CO to * From Uth Annual Report of Local Government Board, p. 346. smallpox and syphilis. 133 r-O CO iQ OO © iC oo CO © © CO 00 00 CO 00 ' * ' ■» ' * ' ^ ■^ IC -* CNI i-H CO CO CO lO lO t- © e<) co -^ ■^ lO lO i-C lO © Ol 00 lO i-H lO © © I— CO © © 00 lO -*. t-- CO O0 00 CO © •m oi co -v i-O CO CO © © © i- co■ © t-t— >0 © X CO 00 © © © © t^ io © © r-t- "* 00 lO -* i—1 CO CO lO CO 0-1 00 © © 00 © © OO iC "3 CO © 00 O0 00 CO lO ^ 00 © © CO "--1 GC 00 © °°^ ^ 00 © oo r-©^ 2 © ^ 00 1 ' * ' * ' * 396 409 174 153 136 - (M © oi ©. co r-1 (M CO i—1 i—i t M CO iO H © t~ 00 © © C) CO CO © ■* rH r- CO CO —i © © »-l 6,997 7,320 3,151 2,808 2,525 i- co -* c© ec t^ CO i—1 © i—1 Ol ©,-t1 l~- l-~_ ofco~©"co~of O © i-H -* -H © r~ © oi © oi lo oo © co t^ t^ ■* N N t~ CO © 00 -tf © -* © "* lO ofc."©~r-~c©~ of—~io"iOio~ © CO I- -f Ol — iO -* X eo co © •* -f -* -r -*i -* © CO -f © CO iCGOOMrt CO © © I^ 00 OO © -*1 T* 00 t ~ co -f<_ -t1 io oq_ io_ ©. i-^oq_ ioTr-~©"©"x~ -r~©~co"^~oi" Ol CO -P Ol 1^ i0 © >—i (M t- -v -r © 'O ic -f -* lc io ■* "*©©—(' 1> » X 'X CO i-i 0 [^ O0 © © Ol -f © © © t^ X © © lO lO iO lO © 00 00 X X CO ** CO 'O © ~ CO © OO X -^ ©"—"io"co"io" .— CO © X ^ -H io CO © © X :i rH » - © io r^ f O W VACCINATION ACTS. 1840.—To extend the practise of Vaccination. 1841.—To amend the Vaccination Act. 1853.—Vaccination made Compulsory. 1861.—To facilitate prosecutions. 1867.—To consolidate and amend the Acts. 1871.—To amend and more rigorously enforce the Act. 1874.—To explain the Act of 1871. VACCINAL- PHTHISIS. 135 Vaccinal-Phthisis. It is alleged that phthisis has greatly increased since vaccination, and in consequence of it. This is totally denied by some authorities, and others, such as Mr. Seaton, while admitting that tuberculo- sis has greatly increased, say that children, who would have died of smallpox, are saved by vaccina- tion until adolescence, to die of consumption. Now it is evident that whatever may be true of phthisis, this last assertion cannot be true. For we have seen that the death-rate among young children has not been lowered, to any considerable extent, by the diminution in smallpox mortality; but that those who formerly were killed by smallpox, now die of measles, scarlatina, whooping-cough, bronchitis, or syphilis. The increased ratio of deaths from tuber- culosis must, therefore, be explained in some other manner. Those who state that vaccination is a cause of phthisis, bring forward the following arguments in favor of this position: That vaccine-virus, having its basis in horse-grease, is a product of scrofula, and that scrofula and tuberculosis are interchangeable terms; that vaccine-lymph taken from a tuberculous person will convey both viruses, just as it has been shown that vaccine-lymph taken from a syphilitic subject, will transfer to the inoculated both vaccinia and syphilis; and that an attack of smallpox, if re- covered from, extinguishes the tendency toward scrofula and tubercle, and that therefore vaccina- 136 GLANDERS, farcy and grease. tion, so far as it keeps such persons from taking smallpox, reserves them for a more lingering and painful death. Let us examine critically these three propositions. Glanders, farcy, and grease are claimed by some veterinary surgeons to be varieties of the same thing, and that they are the equine analogue of scrofula; that farcy buds and grease grapes are essential manifestations of the same disorder, just as scrofula shows itself in multiform appearances. This virus, which is the true Jennerian cow-pox, engrafted upon a healthy human being might pro- duce no effects, except at the point of puncture. But in a person predisposed to scrofula, it would very likely light up the latent disorder, and show itself in no uncertain form. Nor must it be forgot- ten, that as invaccinated and hereditary syphilis may lie latent and unsuspected through many years, so tubercle, engrafted into the system, may remain quiescent until some critical period enables it to assert ascendency over the heretofore restrain- ing vital force. That tubercle or scrofula can be engendered or intensified by vaccination is no new theory. Dr. Squirrel suggested the idea some seventy years ago, and the experiments of Connheim, Fox, and Tous- saint confirm his hypothesis. That the danger is a real one, probably as important as its cognate, vac- cinal-syphilis, seems now, in the presence of recent investigations into the inoculability of tubercle, al- SCROFULA AND TUBERCLE. 137 most affirmed as a scientific fact. Professor Conn- heim has declared that the test for tubercle is, that virus inoculated on a guinea-pig will produce tu- bercle. Wilson Fox has shown that vaccine virus inoculated on a guinea-pig does produce tuberculo- sis; that vaccine is tubercle. Toussaint took lymph from a tuberculous cow and vaccinated various ani- mals, who all subsequently became tuberculous, proving that the quality of the lymph, which was not previously tuberculous, was altered by the media (i. e., the tuberculous animal) through which it passed. That scrofula and tubercle have an increasing in- fluence in the ratio of the extension of vaccination, is shown by successive Reports from the Registrar General's office (England). I give the figures, and leave the reader to draw his own conclusions. The annexed table, compiled from a Parliament- ary Return (No. 392, 1880), gives the figures in three periods, corresponding with the changes that have been made in the Vaccination laws, whereby a more thorough vaccination has been secured: England. Vaccination Vaccination Vaccination Voluntary, Obligatory, Enforced, 1847-1853. 1853-1867. 1867-1878. Deaths under one year of age, an- nually, per million births, from— Scrofula..........351 611 908 Syphilis..........564 1206 1738 Skin Diseases........183 253 343 Pyaemia.......... — 155 180 Mesenteric tuberculosis .... 2981 3371 4373 138 INOCULABLE DISEASES. Mean Annual Rate of Mortality in England from Smallpox, and from six directly or indirectly inoculable causes, during each Quinquennial of 30 years, 1850-80. (P. lxxix, Table 34, of the 43d Annual Report of the Registrar-General, 1882.) N. B.—Vaccination made compulsory,-1853; more stringently so, 1867. CAUSES ANN0AL DEATHS PER MILLION LIVING. Increase of Mortality OF DEATH. 1850-4 1 I 1855-9.1S60-4 1S65-9 1S70-4 1875-9 187 S-80 1880 over 1850. Smallpox* .... 279 199 190 i 147 433J 81 40 Tabes Mesenterica Phlegmon and Py-Skin Disease . . . Bronchitis f .... 37 302 264 20 11 1,016 50 327 261 18 15 1,358 63 368 272 23 15 1,658 82 404 315 23 17 1,839 81 442 298 29 .18 2,105 85 492 330 39 23 2,464 84 510 340 40 23 2,505 127 per cent. 70 per cent. 29 per cent. 100 per cent. 109 per cent. 144 per cent. Total 6 causes . . 1,650 2,029 2,399 2,6S0 :2,973 3,433 3,502 112 per cent. Increase 1,852, or, in round numbers, 48,000 annually. J * Smallpox is an epidemical disease, and there has occurred but one great outbreak (1871-72), 18 years subsequent to the introduction of enforced vaccination, and four years after the further and more stringent act. f Bronchitis, though not, perhaps, directly inoculable, is often ob- served by intelligent medical authorities to supervene upon, or soon after, vaccination; and it is obvious that diminished constitutional vitality will render recovery from any disease more precarious; hence PROGRESSIVE INFANTILE MORTALITY. 139 As showing how infant mortality on the whole has steadily increased during these same periods, I quote from the Parliamentary Return, No. 433,1878, the following statistics:— Average number of deaths per annum of Infants under one year of age from 15 specified diseases which are inoculable, or presumably intensified by vaccination: Prior to Vaccination Act—1847-53— Infants died, 1847,................ 62,619 Out of a'population of 17,927,609. Vaccination obligatory—1854—67— Infants died, 1854,................ 73,000 do. 1867,................ 92,827 Out of a population of 20,066,224. Vaccination enforced—1868-75— Infants died, 1868,................ 96,282 do. 1875,................106,173 Out of a population of 22,712,266. Thus, while the population of England had in- creased from 18 millions to 23 millions, the deaths of infants from 15 diseases had risen—in the same period—from 63,000 to 106,000. Had the mortality kept pace with the population, the deaths in 1875 the benefit derived by newly-born children from improved sanitation is nearly neutralized by vaccination. X The single epidemic (1871-72) carried off 44,000 only, the gen- eral death-rate of the years being somewhat under the average of the period. There was, therefore, no loss thereby, because, had smallpox not been the epidemic, more would have died from other causes; nevertheless, we see that in the vain attempt to prevent this errone- ously supposed loss in two years out of thirty, 48,0U0 lives are now annually sacrificed. 140 NEWCASTLE DISPENSARY. would have been only 80,000; that is to say, in 1875 there perished in England, 26,000 infants under one year of age more, than should have died under the ratio of 1847; and this in spite of greater attention to sanitation, and the consequent lowering of the total [all ages] death-rate from 22.4 for the decen- nium 1841-50, to 21.4 in 1871-80. The difficulty of obtaining reliable statistics, ex- tending over a long period of time, is very great. The following figures, however, from the Newcastle, England, Dispensary, extending over a period of a century, are trustworthy. During this period, the Dispensary has treated 250,637 cases, of which 2,616 were of smallpox, or about one per cent. The total deaths during the century were 14,088, of which 428 were caused by smallpox or about 1 in 33, whilst scalatina killed 1 in 18; diarrhoea 1 in 30; and whooping-cough 1 in 3S.86 Newcastle, England. 1777-1802 1803-27 1828-52 1853-77 Smallpox— Cases............ 365 273 925 1053 Deaths....... ... 90 57 152 129 Scarlatina— Cases ...•........ 355 795 1856 3659 Deaths........... 33 30 155 567 TVTph files__ Cases ........... 186 435 1572 2537 Deaths........... 16 22 83 123 Whooping Cough— Cases . 7......... 245 220 743 1716 Deaths.....•..... 22 23 112 241 Diarrhoea— Cases ........... 1390 1529 3995 6117 Deaths........... 67 7 43 362 B6 Report of the Newcastle Dispensary, from its Foundation in 1777. Printed by order of the Committee. Newcastle-upon-Tyne, 1878. ANIMAL VIRUS. 141 The increase, beyond actual expectancy of various other disorders, have been ascribed to vaccination, with some slight show of evidence; but it is not necessary to enlarge upon such here. What more nearly concerns us is to rescue vacci- nation, if possible, from this reproach. Dr. Charles Cameron, Dr. Lyon Playfair and other distinguished gentlemen have commended the use of animal virus; that is direct inoculation from the cow. In this way it is hoped to get rid of the danger of inoculating other diseases along with vaccinia. But it must not be overlooked that domestic animals are as likely to suffer from constitutional disorders as human beings; and that an incipient tuberculosis in a cow, or a latent farcy in a horse, may be just as readily en- grafted upon a child, as it is now admitted a latent syphilis or phthisis, of human origin, may be unwit- tingly invaccinated along with vaccinia. We have seen that so good an authority as Prof. Simonds, after forty years experience among ani- mals, declares that the bovine race do not suffer nat- urally from pox; that, if they have it, it must be in- oculated upon them. In order to obtain animal virus, therefore, it is absolutely necessary to inocu- late a calf with smallpox or horse-grease. The use of virus obtained by smallpoxing a calf spreads, ac- cording to Sir Thomas Watson, M.D., a mitigated smallpox by infection; and not so very mitigated either, for people take it, and die of it. And if, upon the other hand, we adopt horse-virus, there is con- 142 ceely's experiments. stantly the liability of a recurrence of such horrible outbreaks as was seen in Italy, in 1879.87 Nor are the authorities by any means agreed as to the advisability of the use of animal virus. Says Dr. John Shorthouse: "Some crazy enthusiasts rec- ommend that lymph be taken direct from the cow. They cannot surely have seen those frightful pictures of the disease so produced which were published by Ceely, of Aylesbury, some thirty years ago. Ceely carried out numerous experiments at the instance of the Provincial Medical and Surgical Association. Those experiments were carefully and minutely ob- served, and their results faithfully and graphically recorded. Those observations and experiments are illustrated by a great number of beautifully executed plates drawn from life. Some of the pictures are something frightful. There is one which shows the back of the hand and arm of a youth who got inoc- 87 The following is from the Lyon Medicate, of June 22,1879: "On April 26 and 28, the local doctors vaccinated with this lymph (animal virus) thirty-eight children, all aged less than twenty months. Whilst they were awaiting the incubation of the vaccine pustules, they soon perceived that they had inoculated one of the most horrible of maladies, and that they were the involuntary authors of a real massacre of the innocents. The gentleman who sent these particu- lars to The Gazette a"Italia betook himself to San Quirico. He saw the victims. He observed vast phlegmons laying bare the muscles and penetrating into the joints, accompanied by eclamptic symptoms. To him it appeared very probably to be an epidemic of glanders." See also The Gazette d'Italia, for May 21, 1879. The disaster occurred at Castiglione d'Orcia, in the Province of Siena, and among the vic- tims was the granddaughter of the Syndic. BOVINE TUBERCULOSIS. 143 ulated accidentally while milking a cow. There is another which depicts a corroding ulcer on the thumb of a man who got inoculated in the same manner. If these enthusiasts inspected the pictures, I think they would be induced to pause before they advocated the practice of inoculation direct from the cow." Having studied these illustrations, I can fully agree with Dr. Shorthouse. The possibility of the transmission of bovine tu- berculosis is admitted.88 Even Simon says: "When a given body is possessed by one of these constitu- tional diseases, no product of that body can be war- ranted safe not to convey the infection." As to the probability of its transmission, one has but to remem- ber that bovine tuberculosis is hereditary, and occurs in 4.75 per cent, of any given number of cows. The risk, therefore, of invaccinating this formidable dis- ease by the use of the so-called " calf-lymph," is evi- 88 " M. Touissaint vaccinated a cow in an advanced stage of tuber- culosis with lymph absolutely pure. The vesicles progressed nor- mally, and with the lymph obtained from them he vaccinated differ- ent animals, all of whom subsequently became tuberculous. The significance of these experiments can scarcely be over-rated, for though a judicious vaccinator would not use lymph taken from a child who exhibited already evidence of the disease, the chances of cows in whom spontaneous vaccinia may appear, and whose lymph would at the present time be eagerly sought after, being, like so many of their species, tuberculous, would be great; and it would seem in con- sequence that the dangers of animal vaccination may be greater than those of human, which are supposed to be avoided by having recourse to the cow."—3[edical Times and Gazette, Sept. 3, 1881. 144 VACCINE A MENACE TO HEALTH. dently very great, and its use inexpedient and dan- gerous. It is evident, therefore, that we are unable to measure the dangers which may lurk in any speci- men of vaccine; that it can only be tested by its re- sults; that these results are not immediate and ob- vious, but are often not completely developed until years after the vaccination; and that no amount of care on the part of the vaccinator will obviate the possibility of danger and disaster. COMPULSORY VACCINATION. I am strongly opposed to Compulsory Vacci- nation.—Herbert Spencer. It is an intolerable tyranny to compel vacci- nation by law.—Coiistantine Hering. Whatever may be the verdict in regard to the value of vaccination, there can be but one opinion, among lovers of human liberty and equal justice, as to its compulsory enforcement. Even though vaccination had proven all that Jenner, in the flush of his early triumph, so confidently claimed for it, to make it compulsory would be a wrong without justification in law or morals. Vaccinia is a disease, and no man has a right to disease another against his will. Disease is a crime, and never anything but the result of the disobedience of law. To, there- fore, command the infraction of law, in the name of law, is a complete subversion of the very prin- ciple upon which law is based. Vaccinia perma- nently impairs the integrity of the body; as does every attack of disease. A man once ill is more vulnerable for every other ill. And while every man has a right to chose for himself, what appears to him, the lesser of two evils, no man, nor any assemblage of men, no matter by what name called, nor with what powers vested, have the right to vio- late by force the physical integrity of another human 146 COMPULSORY VACCINATION. This system of compulsory vaccination is founded upon a formulary too preposterous for a moment's serious argument. It arose from the curious dogma that a healthy person was a focus of disease; and that not having been diseased (i. e., vaccinated) he would be the propagator of disease (smallpox) to those who had been diseased (vaccinated). If vac- cination protected the vaccinated, they would have no occasion to fear infection. While, if vaccination does not protect the vaccinated from taking small- pox from the unvaccinated, it is a monstrous fraud on human credulity. In either event the vaccinated have no reason to find fault. If they really believe that vaccination protects them, all is well; while if they do not so believe, then they have not the shadow of an excuse for forcing it upon others who do not believe. No American can dispassionately view our com- pulsory vaccination laws without a blush of shame. For while vaccination is not here openly enforced as it is in England, yet we have permitted a meaner kind of compulsion to crawl into our statute books; more repulsive to every humane mind, for it is a law that bears only upon the poor. Vaccination is the key that opens Castle Garden to every immigrant that comes into this port, and the public school to every poor man's child. Be re-vaccinated, or stay out, we shout aloud to every immigrant that approaches our shores; be vacci- nated, or grow up in ignorance, is commanded to COMPULSORY VACCINATION. 147 » every child who knocks at the school-house door. But vaccinated with what? Shall it be with syphi- litic lymph, or tuberculous lymph, with horse-grease, or smallpox, or shall it be with some innocuous pre- paration from a spontaneous cow, that bears no rela- tion to smallpox other than as a charm or a fetich? In this, the law is conveniently silent. No man knows what lies latent on the vaccinator's lancet, and no man less than the vaccinator himself; but be vaccinated, and take the chances, is the fiat nailed on every poor man's door. To command a person to do that of which the results can only be known after they have occurred, and which involve conditions so serious to the in- dividual and to society, is a monstrous tyranny; and that such a law has been permitted to find a place on our statute books, I believe is solely due to the fact that neither the laity nor the medical pro- fession have ever really seriously considered the matter. I have faith in the medical profession—in the noble, self-sacrificing, humane men of which its body is composed—to believe, if they could be in- duced to study this subject, as I have done, unbiased by the fanatical clamor of a few, or the specious rea- soning of those interested pecuniarily in the spread of the dogma, that they would demand the abroga- tion of all vaccination laws, with overwhelming unanimity. To my colleagues everywhere, I appeal for a sober, t 148 COMPULSORY VACCINATION. thoughtful consideration of this subject, as one of the most momentous questions of the day. A ques- tion which no man can rightfully set aside. The silence of medical men who are skeptical as to the value of vaccination, gives opportunity to ardent pro-vaccinists to claim that the medical profession are unanimously in its favor; that the argument is closed; that vaccination is proven beneficient beyond peradventure. But it is not closed; it is a wide open question. And we, who have patiently studied its history and results, will never be silenced, until every compulsory vaccination law is swept away, and sani- tation recognized as the only scientific protective. If anybody choses to be vaccinated, like Dr. Cory, the chief of the Lamb's Conduct Street (London) Vaccine Station, let him be vaccinated. This in- credulous gentleman, desiring to prove that vaccine lymph could not convey syphilis, invaccinated him- self from a syphilitic subject, with such serious re- sults, as to forever silence disbelief. If, on the other hand, anybody chooses not to be vaccinated, the whole history of vaccination, from its inception to the present hour, gives him amply warrant. How true it is, that every wrong,' in seeking to perpetuate its power, commits felo de se. The surest way to destroy faith in the vaccination dogma, was to resort to compulsion. The attempt to enforce re- peated vaccination upon those who were skeptical as to its prophylactic value, has aroused fierce opposi- tion in every land where it has been tried. An COMPULSORY VACCINATION. 149 opposition, which having reason and history upon its side, has conquered in Switzerland, and will surely triumph everywhere. Vaccination is destined, sooner or later, to take its place by the side of In- oculation as an exploded medical theory. It has been tried and found wanting, and the frantic efforts of its devotees may postpone for a time, but cannot avert the downward plunge of the sword of Damocles. Die Weltgeschichte ist das Weltgericht. Bibliography. Academie Imperiale de Medicine, Rapport sur les Vaccinations. Paris, 1860. Joseph Adams, M.B.C.S., M.D., F.L.S., Observations on Morbid Poisons. London, 1807. ----An Inquiry into the Laws of Epidemics, with Remarks on the Plans lately proposed for Exterminating the Smallpox. 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Sir Henry Holland, M.D., etc., Medical Notes and Reflections. London, 1839. ----Essay on the Present Question Regarding Vaccination. London, 1839. Hume-Eothery, The Exceeding Wickedness of the Compulsory Vacci- nation Law. London, 1880. M. Hussan, M.D., Dictiqnaire des Sciences Medicale, tome lvi. Jonathan Hutchinson, F.E.C.S., etc., Vaccinal Syphilis (Illustra- tions of Clinical Surgery). London, 1877. --- Vaccinal Syphilis, in the Lancet, Dec. 13, 1879. Edward Jenner, M.D., F.E.S., Inquiry into the Causes and Effects of _ Variola Vaccinae. London, 1798. ----Continuation of Facts and Observations on the Vaccina Variolce. London, 1800. ---and Woodville, A Comparative Statement of Facts and Obser- vations Relative to Cow-pox. London, 1800. ---- On the Origin of the Vaccine Inoculation. London, 1801. --- On the Influence of Artificial Eruptions on Certain Diseases. Lon- don, 1822. Kahlert, Du Javort Preservative. Prague, 1833. Anna Kingsford, M.D., Pasteur's Inoculations. London, 1882. 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Parliamentary Ataccination Committee, Report. London, 1871. M. de Paul, M.D., etc., Rapport de I'Academie Imperiale de Medicine sur les Vaccinations pendant I'Annee, 1864. Paris, 1865, et seq. ----Experiences faites d I'Academie Imperiale de Medicine croec le Cow- pox ou Vaccine Animate, 1866. Paris, 1867. BIBLIOGRAPHY. 157 Charles Thomas Pearce, M.E.C S., etc., Vaccination; its Tested Effects on Health, Mortality, and Population. London, 1868. ---Smallpox Prior to and Since Vaccination. London, 1880. ----Smallpox and Vaccination in London. London, 1881. ---- Vital Statistics. London, 1883. G. Pearson, M.D., F.E.S., etc., The Principal Historical Facts of the Vaccination. London, 1802. John Pickering, The Anti-Vaccinator and Public Health Journal, 1872-73. L. S. Pilcher, Variola in the United States Nary. Washington, 1875. Henry Pitman, Prison Thoughts on Vaccination. London, 1881. Sir Lyon Playfair, M.D., LL D., F.R.S., M.P., etc. ----The Vaccination Question. London, 1882. Henry Port, F.S.A., The Terrible Effects of Vaccination and Re-vacci- nation. London, 1880. Edmund Proctor, Essay on Vaccination. London. Benjamin Ward Richardson, F.R.S., LL.D., etc., Contagious Dis- eases and Pasteur's Inoculations. London, 1881. John Ring, M.R.C.S., Treatise on the Cow-pox. London, 1801. Enoch Robinson, M.R.C.S., etc., Causes of High Infantile Mortality. Dukinfield, 1870. ---- Can Disease Protect Health f London, 1879. Royal Jennerian Society, Report. London, 1806, etseq. Royal Jennerian Institution, Report. London, various years. Sacco, Trattato die Vaccinazione. Milan, 1831. ----De Vaccinal. Necessitate Medicin. Milan, 1832. Samuel Scofield, M.D., A Practical Treatise on Vaccina or Cow-pox. New York, 1810. Valentine Seaman, M.D., An Account of the Introduction of Vacci- nation or Kine-Pock Inoculation into New York. New York, 1802. Edward Cator Seaton, M.D., etc., Smallpox and Vaccination. 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Robert John Thornton, M.D., LL.D., F.M.S., Facts Decisive in Favor of the Cow-Pox; Iucluding an Account of the Inoculation of the Village of Lowther. London, 1802. Henry Tomkins, M R.C.S., etc., The Amount of Protection afforded by Vaccination against Smallpox. London, 1883. Dr. R. T. Trall, in Hydropathic Encyclopaedia, pages 96 and 97. New York, 1855. BIBLIOGRAPHY. 159 Prof A. Trousseau, M.D., etc., in Clinique Medicate, pp. 116-18. Paris, 1874. Vaccine Pock Institution, Report. London, 1803, et seq. Vacher, Smallpox and Vaccination. Birkenhead, 1877. M. Vattemarr, M.D., Rapport presente d M. le Ministre de Agricul- ture et du Commerce, par I'Acad. Roy. de Med. sur les Vaccinations pratiquees en France pendant I'Annee, 1843. Paris, 1845. Verde de Lisle, De la Degenerescence Physique et Morale de VEspece Humaine Determine par le Vaccine. Paris, 1835. Verheyen, Memoire sur la Vaccine Primitive, in Memoires de I''Academie Royal de Medicine de Beloique, tome xxi. Bruxelles. Prof. Rudolph Virchow, M.D., etc., The Freedom of Science in the Modern Stale. Berlin, 1878. Robert Walker, M.D., An Inquiry into the Smallpox. London. 1880. E. Walomont, M.D., Traite de la Vaccine, et de la Vaccination Hu- maine et Animate. Paris, 1883. Sir Thomas Watson, M.D., F.R.S., D.C.L., Smallpox and Compul- sory Vaccination, in Nineteenth Century, June, 1878. Robert Watt, M.D., etc., An Inquiry into the Relative Mortality of the Principal Diseases of Children. Glasgow, 1813. William White, The Cow-Pox Imposture. London, 1883. --- The Story of a Great Delusion. London, 1884. Prof Alexander Wilder, M.D., F.A.S., in Scientific Man. New York, 1879. J. J. Garth Wilkinson, M.R.C.S., Vaccination Tracts. London, 1878. ---Human Science and Divine Revelation. London, 1881. ----Pasteur and Jenner. London, 1883. Robert Willan, M.D., F.A.S., Report of the Diseases in London. London, 1801. --- On Vaccine Inoculation. London, 1806. W. Woodville, M.D., Report of a Series of Inoculations for the Vari- olar Vaccinae. London, 1799. ---- Observations on the Cow-Pox. London, 1800. George Wyld, M.D., and Alexander Wheeler, Both Sides of the Vaccination Question. London, 1879. William Young, The Vaccination Reason Why. London, 1879. ---- Testimonies of Medical Men on Vaccination. London, 1881. --- The Smallpox Nurses and Re-vaccination. London, 1882. ----Medical Authorities on Vaccination. London, 1882. Appendices. APPENDIX A. I. The Vaccination of Immigrants. I left Bremen, on the Neckar, of the North German Lloyd line, in the midst of a severe rain-storm, which was accompanied by a strong wind. During the voyage two accidents occurred, the first being the death of an eight- year old child in the steerage from the effects of brandy. The parents being very sea-sick, the child, unobserved, ob- tained possession of a bottle of brandy which they had, and drank sufficient of its contents to cause death. A young lady also died, from heart disease it was said; but we brought into port the same number of passengers as we left with, for there were two births on board. Besides 110 cabin passengers, the Neckar carried between 700 and 800 in the steerage. The United States law provides that every immigrant, without regard to age or physical condition, shall be vaccinated within twenty-four hours after leaving the foreign port. Many of those on board were exceedingly ill, and to any one who has ever suffered the pangs of sea- sickness, it will be apparent that that was not a favorable nor a proper time for vaccination. But it must be done, for the law is clear and peremptory; there is no evading it, for on arrival at New York, all those who cannot show a certificate from the ship's surgeon are consigned to Black- well's Island. (101) 162 VACCINATION OF IMMIGRANTS. During the three days following our departure from Bremen, vaccination was the order of the day in the steer- age. I was enticed thither by curiosity, and what I there saw was suggestive, to say the least, to me, and may be of interest to you. The surgeon sat on a box in the store- room, lancet in hand, and around him were huddled as many as could be crowded into the confined space, old and young, children screaming, women crying; each with an arm bare and a woe-begone face, and all lamenting the day they turned their steps toward "the land of the free." The lymph used was of unknown origin, kept in capillary glass tubes, from whence it was blown into a cup into which the lancet was dipped. No pretence of cleaning the lancet was made; it drew blood in very many instances, and it was used upon as many as 276 during the first day. I inquired of the surgeon if he had no fear of inoculating disease, or whether he examined as to health or disease be- fore vaccinating. He replied that he could not stop for that, besides, no choice in the matter was left with him. The law demanded the vaccination of each and every one, and he must comply with it or be subjected to a fine. I thought it a pitiful sight, and am persuaded that could the gentlemen through Avhose instrumentality the law was enacted, see what 1 saw of the manner in which it was car- ried into effect, they would be as zealous in seeking its re- peal. As conducted the law is an outrage, and no one can estimate the number of helpless, innocent children, as well as adults, who are inoculated with syphilis or other foul disease, on every ship bringing steerage passengers to our shores. G. H. Merkel, M.D., In the Massachusetts Eclectic Medical Journal, November 18-82. VACCINATION OF IMMIGRANTS. 163 II. The Vaccination of Immigrants. When there is an outbreak of smallpox in the United States, it is frequently ascribed to the presence of unvaccinated immigrants, and quarantine is said to be defective. It so happens, however, that im- migrants are carefully vaccinated, and often re-vaccinated, as will be seen by Dr. Merkel's statement, above; but it is not unlikely, through overcrowding on shipboard, aggravated by vaccination, and un- wholesome quarters on shore, they are peculiarly liable to variolous disease. The following letter, describing the painful treatment to which immigrants are subjected, is from a layman. While not agreeing with some of its harsh expressions, I give it place here, as a picturesque description of an every-day occurrence. It is needless to say, cabin passengers are exempted from this brutal imposition. Brooklyn, New York, May 7, 1883. Dear Sir.—I found the vaccination tyranny much more than sentiment on board the "Adriatic." Aboard- ship, as everywhere, it has attained terrible proportions, which makes it probable that in the near future it will be- come The Great Terror that shall "cause that as many as will not worship the image of the beast shall be killed," and that "no man may buy or sell save he that has the mark of the beast." The first intimation that I had that vaccination was a requisite for free travel in America was an "Important Notice" on the stairway to the effect that passengers not provided with certificates of vaccination were liable to be detained in quarantine on arrival, and that the ship's medical officer was prepared to give certificates to those unprovided on showing marks of successful vaccination. In a few days I heard of this ship's medical officer mag- nifying his office down among the women and children. I conversed with one young woman who had submitted to 164 VACCINATION OF IMMIGRANTS. the great ordinance, and after characterizing the whole business as the most idiotic folly of the times, I begged of her to suck the poison out of her arm. But many hours had elapsed, and the endeavor failed. Day by day she had to carry her burden of pain until she landed. Whether she is now rejoicing in enhanced health as a consequence of the smallpox proofing process, or whether she is suffering from the weary illness that is often its "accident," I have no means of knowing. I was anxious to know to what extent the immigration vaccination law was enforced at New York, and had a chat on the subject with the chief steward. His informa- tion was terrifying. Said he, "when we get to New York the doctor comes aboard, sometimes with half-a-dozen po- licemen, and you have to be vaccinated." "But," said I, "suppose you refuse to be vaccinated, what then?" "Then they'll sling you into the tender, and clap you in gaol till you submit." "But I won't be vaccinated. I'll stay out of New Yoi'k forever first." He replied: "No use; you'd have to be. Five of our crew, once, refused to be done; but they just put 'em into quarantine and kept 'em there until they came to. They might as well have been done first as last; they only delayed the vessel." One morning it was rumored that the doctor was coming to examine the passengers, and I went with two friends to the surgery to state our objections. I told him that as we had been vaccinated, if that fact would let us pass without further trouble, we could satisfy him; but if not, vaccina- ted we would never be. Like most doctors, he was with- out capacity to understand our conscientious objections, and the degradation involved in submission to the rite. He curtly told us the law was not his; it was United States VACCINATION OF IMMIGRANTS. 165 law. He should come forward at two o'clock, and if we showed him that we had been vaccinated, he would give us a certificate, and if not, he would vaccinate us if we chose; if not, we must take the risk of passing the doctor at the port. It mattered nothing to him. About two o'clock there was a great commotion for'ard. Such a stripping of clothes, rolling up of sleeves, and searching for "marks." Some were craning their necks over their shoulders in a half-hopeless search after obliter- ated or invisible scars; some calling in the help of a neigh- bor to make them out; and some raising an excited dis- cussion as to whether a certain indentation was a vaccina- tion mark, or a forgotten boil, and going into an ecstasy of satisfaction when they had settled it was exactly what was wanted. Others, in despair of vaccination marks, re- collected that they had had smallpox, and set up a search for pock-marks. Some, after a protracted quest for marks, vaccine or variolous, put on their coats sadly, with the air of criminals about to be hanged. It was a sight to make men blush with shame for the devilish superstition that has taken possession of the Christian civilization of the uine- teenth century. By-and-by came the doctor in his gold-laced cap, with his bottle of " lymph," pure from the sores of children or heifer's buttock, and commenced operations. First a rope was stretched from a post, and held by two stewards in a horse-shoe form, and into this enclosure passed, one by one, the victims of an insane medical legislation, and bared their arms to the Medical Ignoramus, who stood on the other side. If he there saw the orthodox scars, he forthwith bestowed a ticket like this:— 166 VACCINATION OF IMMIGRANTS. White Star Line. S.S. "Adriatic." VACCINATED. C S. Murray, 14th April, 1883. Surgeon. Which further had this exhortation on the back :— PASS. Keep this card to avoid detention at quarantine, and on railroad in the United States. If a poor wretch could not show vaccine or pock marks, he got no ticket, and was asked whether he would be vac- cinated, or risk being stopped at landing. All preferred the first alternative as the lesser evil. The doctor, dipping his lancet in the bottle of mystery, wiped it on a spot on the arm, and cut and cross-cut the skin, and then, after rapidly stretching and closing the incisions with his thumbs, gave the wretch his ticket and passed him on. Such was the ordinance of vaccination—a sight not to be forgotten. A crowd of hundreds passiug forward to prostrate their conscience or manhood, or lack of them, at the shrine of the most outrageous humbug of these latter days! A VACCINATION OF IMMIGRANTS. 167 mixed crowd of big and little, fat and lean, dirty and clean, reputable and disreputable, sober and drunken, healthy and diseased, all ground down to the dead level of vacci- nated. There was nothing in common among them save their degradation, aud, as I thought, the most degraded of the lot was the Vaccinator. How a man with any sense of decency and the congruity of things, could for mere pay consent to the folly that the individuals of such a hetero- geneous crowd were all alike liable to smallpox, and were all alike saved by his performance, passes my understand- ing. It is hard to believe in a man's sincerity in view of such absurdity; and yet he may be sincere. When a lie is taught, and still more when a lie is practised, it con- founds the intellect, and is ultimately taken for the truth of truth. Yours truly, F. Scrimshaw. III. Vaccination of Immigrants. The abuses which are possible in compulsory vaccination are forcibly illustrated in a pathetic instance which has come under our notice during the past week. An Irish servant girl in the city has been for a long time saving up her earnings that she might be able to pay the passage of her brother to this country, and by economy and persist- ence she at length accomplished her object. Last week the lad arrived, but he had, with others, been compelled to submit to vaccination on shipboard, and he now lies at death's door from the effect of the use of im- pure virus. The surgeon of the ship in a case like this ought to be brought to strict account. Steerage passengers 168 vaccination of immigrants. are at least human, and their lives should not be left at the mercy of every careless practitioner who prefers to risk their health rather than to take the trouble of ascertaining the safety of his materials. The case of which we speak seems especially cruel, as the poor girl is nearly heart-broken that her labor has re- sulted only in bringing her brother to die in a strange land; but as a matter of fact, it is only one instance among many. The matter is one that needs looking to closely; since even the most determined opponents of immigration can hardly be prepared to go to the length of legal murder as a means of preventing it.—Boston Courier, May 3, 1883. APPENDIX B. Infection and Disinfection. The following passages of an article in the Wiener Medi- cinische Wochenschrift, of June 3, 1882, may enlighten the ignorant and reassure the timid. Dr. Lorinser, one of the leading physicians of Vienna, writes as follows: "A great deal of printer's ink has of late been wasted in discussions on the spread of the so-called ' infectious' dis- eases, and on the best means of preventing it. In all these discussions public attention is more particularly drawn to smallpox. It is easy to describe the dangers and the con- tagiousness of such a disease, and when this has been done, it requires but little pleading to obtain the public sanction for a series of defensive or preventive measures apparently as efficacious as they are vexatious and tyrannical. The first cry is for a more vigorous enforcement of vaccination, then schools and markets are to be closed, fairs to be pro- hibited, and as cabs cannot be prevented from conveying variolous patients and convalescents, and as the dangerous contact with members and frequenters of infected house- holds cannot altogether be avoided, a universal disinfection with the irrepressible carbolic acid becomes a matter of urgent and obvious necessity. The measures recommended by the sanitary authorities which might have reassured the public are then emphasized and gloated over by newspaper writers in such a silly manner, that the public, instead of being reassured, is frightened and alarmed without any necessity. " The doctors, who are in a great measure responsible for this state of public feeling, ought to remember that the shafts they have caused to be directed against the public may at any (169) 170 infection and disinfection. moment be turned against themselves. Already there are people who dread their doctor's visit, not knowing whether he might not come fresh from a smallpox patient, convey- ing the dreaded poison in his clothes and in his very breath. "Under these circumstances it would seem opportune to inquire, for once, how much of these opinions concerning variolous infection has been scientifically ascertained. What has been proved is only this—by subcutaneous inoc- ulation of liquid variolous lymph we can produce either a local crop of pustules or general variola. We also know from the Chinese, that the same disease can be induced through the inhaling of the dust of dried variolous scabs into the cavities of the nose. Consequently variola can be propagated by the contact of variolous matter either with the broken skin or with the mucous membrane. But it is not this fixed contagion which is dreaded so much, and which is to be disinfected; such a substance (whether fluid or solid) being hardly liable to be altered by the fumes of carbolic acid. That which is most dreaded and most eagerly combated is a 'volatile gaseous' substance, which, fortunately, thus far has not been proved to exist outside the imagination of the learned. If we take for granted that such a volatile contagion fixes itself on the skin or the hair, on clothes and utensils, and that it can remain there for days or weeks without losing its efficacy, it becomes easy enough to explain the spread of the disease. But when we ask whether there is a single fact that could prove the ex- istence of such a contagion, and its power of conveying the disease, we are bound to reply in the negative. We know, as a matter of fact, that thousands of persons, though living in daily contact with variolous patients, have not caught the disease; but that one single person has ever caught it by inhaling the "volatile contagion" can never be proved, con- INFECTION and disinfection. 171 sidering that variola, like all other diseases, can also break out spontaneously. Nevertheless, both doctors and patients cling fondly to this belief in a volatile contagion: the doc- tors because it frees them from the necessity of investigating the genuine causes of the disease; the patients because indi- viduals (like nations) prefer to seek the causes of their suf- ferings in their neighbors, their owTn sweet body being quite incapable of generating such loathsome disease. "Thus indolence and amourpropre are the chief support of this popular belief. Unfortunately, this dogma can neither be disproved nor proved; but if it were true, if such a thing as volatile contagion really existed, it would be found in its greatest concentration and virulence in small- pox hospitals, and nothing would be more natural than that the attending doctors and nurses should be those most fre- quently affected by it. Yet such is not the case. Neither in the terrible epidemic of 1871, nor in any subsequent epi- demic, have I heard of a single case of a doctor or a nurse catching the disease in the Vienna smallpox hospital. . . . "The remarkable immunity of hospital attendants, what- ever it may prove concerning the volatile contagion, proves clearly that even the fixed contagion cannot possibly be considered as a very formidable agent. And this being so, the question arises, What is it we want to disinfect? What is it we dread ? In truth we do not know. That is the only answer we can give or we ought to give. The belief in in- fection has no scientific basis, and the efficacy of disinfection is on a par with that of vaccination and re-vaccination, which even credulous physicians are beginning to doubt. "There is no royal road to health, and preservatives like these can only act where they are not wanted—in persons who know how to keep their skins clean and their blood pure, and by leading a proper life." APPENDIX C. What to do about Animal Disease. The following editorial from the New York Tribune, March 18, 1884, will apply just as well to smallpox, and will be instructive reading during the next smallpox scare. There has not been before in many years such general health among American cattle and hogs as there is now. The late Swine Commissioners—one of whom visited twenty six States—found practically no disease. There is, and probably always will be, occasional trichinae, a very small percentage, but the "experts" know little or nothing of its cause; it effects our pork, perhaps, no more than that of other countries; and the one and easy safety is in thorough cooking. The " cholera," which has been made excuse for selfish sensationalism so costly to producers, had "dis- appeared" last fall, according to official admission. But how about pleuro-pneumonia? Not an item of proof has been brought against the many competent witnesses who testify that there is very little of that. Whence, then, all this noisy affirmation? It emanates from a few persons already in Government employ and naturally anxious to enlarge and perpetuate their easy places. Every slight local sickness is magnified and tele- graphed over the whole land, as was the case the other day in Columbia County, N. Y. The alarmists are thoroughly organized; they have been working toward this one end half a dozen years, and it is proverbial that Plea is much more active than Protest. But we are not saying—and (172) WHAT TO DO ABOUT ANIMAL DISEASE. 173 have never said—that there is no pleuro-pneumonia in the Atlantic States. It would be strange, if there were not, with our frequent cattle importations from the infected fields of Europe. Let what there may be " stamped out," but do it in a sensible, business-like way. If the few States, claimed to be infected, are not deemed capable of dealing with the disease, as in Massachusetts and elsewhere, then let Government put the whole matter into the hands of some one practical, honest business man, with authority to quarantine, to buy, to kill and bury or burn, calling to his aid all necessary assistants and co-operation; and then let him present the bill, with vouchers for every item of expense. But to organize for this simple work the proposed new " Bureau of Animal Industry," and that, too, in connection with the not highly esteemed " Agricultural De- partment," at Washington, and equip it with a quarter of a million dollars, and twenty men appointed by political intrigue, is to repeat on a mammoth scale the " hog cholera " disgrace and the "grasshopper" folly of past years. So of "foot-and-mouth disease," of which we have lately heard in Maine and Kansas. That, too, if it is here at all, was also imported. Get rid of it at once, in the same simple way above suggested; and our coasts once clear of these much-talked-of sources of danger, let us see that we stop bringing any more of either infection across the Atlantic— since quarantine restrictions seem to prove ineffectual. For why should the whole vast cattle interests of America be put in jeopardy for the profit of the few who ship cattle here for speculative purpose? We have a good plant of all the leading thoroughbreeds of Europe; let us make the best of them, and likewise of our own hardy, healthy natives which contain elements capable of unsurpassed de- velopment. 174 WHAT TO DO ABOUT ANIMAL DISEASE. But, after all, it is one comfort to reflect that this costly sensationalism, which has characterized the agitation of " contagion," will not be wholly without compensating re- sults, if it serve indirectly to draw attention to the impor- tant truth that health in domestic animals, as in human creatures, can only result from wholesome food, pure air, comfortable quarters and general provision for maintenance of strength. Western hogs cannot keep well, nested in mud and cold, or in sties reeking with filth, and eating frozen, mouldy corn; nor Eastern cows in crowded, unventilated stables, with fermenting brewers' grains, glucose meal and half-decayed ensilage as insufficient feed. When all stock- keepers humanely regard the comfort of their animals, there will not be a hook left for hungry alarmists to lay hold upon. INDEX. Adams, Dr., of Waltham, small- poxes a cow, 38. Amateur vaccinists, 24. American statistics unreliable, 66. An appeal for justice, 147. Animal disease, what to do about, 172. — virus, 141. Annual vaccination, 45. Appendices, 161. Arm-to-arm vaccination, 51. Army of vaccinators, an, 100. Austria, smallpox after vaccina- tion in, 89. Badcock's experiments with smallpoxing the cow, 38. Bakewell, leprosy and syphi- lis communicated by vacci- nation, 122. Ballard, Edward, on the dan- gers of vaccination, 35. —, the epidemic of 1871, 109. —, vaccinal-syphilis, 121. Baltimore, smallpox after vacci- nation in, 73. Bavaria, smallpox after vaccina- tion in, 72. Bayard on smallpox after vac- nation, 74. Beaugency vaccine stock, the, 39. Berlin, smallpox after vaccina- tion in, 92 —, deaths in, 1746 and 1871, 91. Bibliography, 151-159. Birch on deaths from vaccina- tion, 116. Birkenhead, smallpox after vac- cination in, 81. Birmingham, the smallpox epi- demic of 1874 in, 95. Blane, Sir Gilbert, on eight- eenth century smallpox, 59. Boeing, PL, vaccination a delu- sion, 78. Boston, Mass., experience with smallpox, 61. —, inoculation introduced, 16. Bovine tuberculosis, 143. Boylston, Dr., introduces inoc- ulation at Boston, Mass., 16. Braxendell, Joseph, on small- pox mortality statistics, 98. Brereton on invaccinated lep- rosy, 128. British army, smallpox after vaccination in, 74. (17-: 176 INDEX. Browning on smallpox after vaccination, 75. Buchanan, George, on inef- ficient vaccination, 100. Lalf-lymph, 39. Cameron, Charles, smallpox deaths among the vacci- nated, 99. —, on vaccinal virus, 42. Carpenter, W. B., on post- vaccinal smallpox mortal- ity, 110. Carter, Brundenell, on vac- cinal-syphilis, 125. Ceely's experiments, 38, 142. Chambers, Sir Thomas, vac- cination has not reduced death-rate, 107. Chauveau on smallpoxing the cow, 41. Chicago, smallpox after vaccina- tion in, 73. Cholera replaces fever (1832), 104. Cicatrices, numerous, 83. Colin, Leon, on what consti- tutes vaccination, 88. Collins, W. B., on vaccinal- syphilis, 120. Compensatory death-rate, law of, 102. Compulsory vaccination, 145. — a monstrous tyranny, 147. Cornell, B. F., on vaccinal- syphilis, 121. Cory, Doctor, invaccinates him- self with syphilis, 148. Cow-pox derived from horse- grease, 21. —, origin of, 20. — prevents smallpox, origin of the belief that, 22. —, spontaneous, 21. Dangers from vaccination,l 15. — of vaccination, 35, 144. Daremberg on inoculation, 17. Death-certificates, false, defend- ed, 116. Death-rate of smallpox, 60. — not mitigated by vaccination, 110. — and fever, 64. Delusion, vaccination a, 78. Depaul on vaccinal-syphilis, 120. Desjardins on vaccinal-syphi- lis, 128. Does vaccination prevent small- pox in the vaccinated? 55. Dogma, a curious, 146. Ducharme on smallpox after vaccination, 71. Duisburg, smallpox after vacci- nation in, 92. Eadon, Samuel, on vaccinal- syphilis, 127. Early devotees of vaccination, 24. Eczema pustulosum, 22. England, 122,000 cases of small- pox after vaccination in six months (1871), 75. Epidemic smallpox varies in in- tensity and fatality, 18. INDEX. 177 Equination, 37. Equine analogue of scrofula, the, 136. Erysipelas from vaccination, 34. — necessary to vaccination, 40. Essex Market Dispensary vac- cine, 52. Evil results of vaccination, 47, 51. False death-certificates defend- ed, 116. Farcy, 136, 141. Farr on the decline of small- pox, 62. — on eighteenth century statis- tics, 59. — on the relativity of zymoses to sanitation, 109. Fatality of hospital smallpox be- fore vaccination, 60. " Fifteen-marks" vaccination, 45. First vaccination, the, 23. French army, smallpox after vaccination in, 74. Gassner's experiments, 37. Germann on vaccinal- syphilis, 125. Glanders, 136. — conveyed by vaccination, 142. Glasgow mortuary statistics, 104. —, smallpox after vaccination in, 82. Goat-pox, children vaccinated with, 36. Graunt, John, on vital statistics (1604-1664),'105. 9 Grease, 21. — the product of scrofula, 22. Gregory on inoculation, 17. Gull, Sir William, on vaccinal- syphilis, 122. Gunn, Kobert A., on vaccinal- syphilis, 126. Hamburg, smallpox after vacci- nation in, 92. Heim on vaccinal-syphilis, 121. Henderson on smallpox after vaccination, 72. Hering, Constantine, on vac- cinal-syphilis, 126. —, M., on grease, 22. Hill, Alfred, on smallpox after vaccination, 95. Hitchman, William, on vacci- nal-syphilis, 124. Holland's, Sir Henry, opin- ion, 76. Homerton Fever Hospital statis- tics, 87. Hopkins, T. S., on vaccine acci- dents, 51. Horse-pox, 37. — virus, evil results from, 142. Hunter, J., on vaccination, 23. Hutchinson, Jonathan, on vaccinal-syphilis, 123, 124. Immigrants, vaccination of, 146, 161, 163, 167. Impure vaccine, 51. India, smallpox in, 111. Indians, vaccinated, die of small- pox, 97. 178 INDEX. Infants, vaccinated, die of small- pox, 85. Infantile mortality, 113. — from syphilis, 131. Infection and disinfection, 169. Inoculability of tubercle, 136. Inoculable diseases, 138. Inoculation an exploded medical dogma, 19. — by the Suttons, 16. — in Boston, Mass., 16. — in second century, 17. — introduced by Lady Mary Wortley Montagu, 15. — made criminal, 19. —, phenomena of, 17. — spreads smallpox, 18. —, vaccination substituted for, 15. Insusceptibility to vaccination, 30. Introduction, 9. Invaccinated leprosy, 122, 128. — syphilis, 119. Is it vaccinia? 43. Jenner guarantees absolute im- munity (1798), 56. — hears of cow-pox, 22. — re vaccinates every year (1820), 56. — rewarded, 25. — spontaneous cow-pox, 39. — vs Jenner, 56. — Sir William, on vaccinal- syphilis, 122. Jones, Joseph, on vaccinal- syphilis, 120. Jurin on deaths from natural smallpox, 60. Keller, L. J., on smallpox after vaccination, 89. Kirby on grease, 22. Knight's experiments, 38. Kolb, G. F., on smallpox after vaccination, 73. —, vaccination a delusion, 78. Kratz, O., on vaccinal-syphilis, 120. Leacroft, John, on vaccinal accidents, 75. — vs. Browning, 75. Lettsom on smallpox prior to vaccination, 59. London hospital experience, 80. — statistics, 67. —, smallpox after vaccination in, 74. —, deaths among the vaccinated in, (1870-9), 99. Lyttleton, Lord, on the ratio of vaccinated to birth-rate, 100. Maclean on inefficient vacci- nation, 70. Manchester, smallpox after vacci- nation in, 96. Marseilles, smallpox after vacci- nation in, 70. Marson, J. F., comparative death-rate among vaccinated and unvaccinated, 79. —, death-rate from smallpox, 82. INDEX. 179 Marson, J. F., inoculation, 18. —, "Jenner's estimate", 57. —, on vaccinal-syphilis, 122. Martin, Sir Konald, on invac- cinated leprosy, 122. May, Henry, on death-certifi- cates, 116. Meric, M. de, on vaccinal-syphi- lis, 122. Method of vaccinating, 44, 53. Milan, smallpox after vaccination in, 74. Mild epidemic smallpox (1872), 93. — Jenner's experience (1791), 94. — Isaac Massey's account (1723), 94. Montague, Lady Mary Wort- ley, brings inoculation to England, 15, Monteith, on inoculation, 19. — smallpox mortality, 61. Mortality from plague, 106. — from smallpox, 59. — 1700 to 1880, 62. Moseley on vaccinal-syphilis, 119. Mueller on smallpox after vac- cination, 93. Muller's Orphan Home, smallpox after vaccination in, 93. Multiple "marks", value of, 83. — vaccination, 45. Munn, S. B., on vaccinal-syphi- lis, 128. Newcastle Dispensary report, 140. Newton, J. E., on vaccinal- syphilis, 126. New York, smallpox after vacci- nation in, 73. — in, 1804-1810, 69. Niemeyer on vaccinal-syphilis, 127. Nightingale's, Florence, opinion, 58, 110. Odier the father of the words "vaccine" and "vaccinia," 50. Oidtmann on smallpox deaths among the vaccinated, 97. Origin of cow-pox, 20. — grease, 22. — the words "vaccine" and "vaccinia," 50. — vaccine, 37. Paget, Sir James, on vaccina- tion, 46. Parliamentary grant to Jenner, 25. Pearce, Charles T., on vacci- nal-syphilis, 121. Pearson on the origin of the words "vaccine" and "vac- cinia," 50. Personal susceptibility to vacci- nation, 30. Phenomena of vaccination, 27. Phipps, James, vaccinated, 23. Phthisis caused by vaccination, 135. 180 INDEX. Pigeon, Charles, on vaccinal- syphilis, 128. Plague statistics, 105. Playfair, Sir Lyon, on small- pox mortality, 63. Preface, 5. Progressive infantile mortality, 139. Protection through vaccination, 57. Prussian army, smallpox after vaccination in, 71. Putnam's experiments, 38. Registrar-General Farr on eighteenth century statis- tics, 59. — on the relativity of zymoses to sanitation, 109. Eelative mortality, 104. Eelativity of zymoses to sanita- tion, 109. Eetarded vaccinal phenomena, 32. Ee-vaccinations, 83. Eicord on vaccinal-syphilis, 119. Einger, Sidney, on vaccine phenomena, 30. Eobinson's, Enoch, observa- tion, 109. Eollet on vaccinal-syphilis, 122. Eowley, William, on deaths from vaccination, 115. Eussell on smallpox after vac- cination, 82. Sanitation the preventive of smallpox, 114. Sarcoptes hippopodus, 22. Schools, vaccination in the pub- lic, 146. Schuppert's experience, 85. Scrofula, the equine analogue of, 136. — and tubercle, 137, Seaton, Edward C, on efficient vaccination, 56. —, inefficient vaccination, 100. —, smallpoxing the cow, 37. —, vaccinal-syphilis, 123. Shaftesbury, Lord, on sanita- tion as a preventive of smallpox, 112. Shorthouse, John, on animal virus, 142. Silly charges against vaccina- tion, 117. Simon, John, on bovine tubercu- losis, 143. —, contagiousness of smallpox, 59. —, vaccinal-syphilis. 121, 127. Simonds on bovine pox, 141. Skin disorders modify vaccinia, 48. Smallpox a filth-disease, 58. — after cowpox, 68, 70. — less frequent since 1770, 62. — mocks at vaccination, 109. — not vaccinia, 41. — obliterates vaccination marks, 81. — prior to vaccination, 90. — spread by inoculation, 18. INDEX. 181 Smallpox and Inoculation Hos- pital, London, founded, 16. — and syphilis, deaths from, 132. Smallpoxed five times, 56. Smallpoxing the cow, 37. Smith, Thomas, on vaccinal- syphilis, 124. Sonderland's experiments, 37. Sources of vaccine, 52. Spencer, Herbert, on vaccinal- syphilis, 118. Spontaneous cow-pox of Beau- gency, 39, 42. Springsteen, A. G., on vaccinal- syphilis, 127. Spurious vaccination, 33. Susceptibility, personal, to vac- cination, 30. Sutton, Daniel and Eobert, apply inoculation, 16. Sweden, smallpox after vaccina- nation in, 70. Swine-pox, Jenner uses, 36. Switzerland and compulsory vac- cination, 149. Sydenham on alterations in dis- eases, 106. — suggestions applied to inocu- lation, 16. Symptoms of vaccination, 29. Syphilis as a cause of infantile mortality, 131. — through vaccination, a case of, 129. Thiele's experiments, 38. Tompkins, .Henry, on smallpox after vaccina- tion, 95. Touissaint on bovine tubercu- losis, 143. Trousseau, A., on vaccinal- syphilis, 125. Tuberculosis from vaccination, 135. — in the cow, 141. Tuberculous lymph, 137. Two centuries of smallpox, 63. United States Navy, smallpox after vaccination in, 71. Vaccinal-phthisis, 135. Vaccinal-syphilis, 119. —, a case of, 129, 148. —, opinions and experiences of Surg. Genl. Bakewell, Drs. Edward Ballard, Brunde- nell Carter, W. B. Collins, B. F. Cornell, M. Depau^ M. Desjardins, Saml. Eadon, Profs. Germann, Eobt. A. Gunn, Sir William Gull, Drs. Heim, Constantine Hering, William Hitch- man, Jonathan Hutchinson, Sir William Jenner, Joseph Jones, O. Kratz, J. F. Mar- son, M. de Meric, Mosely, S. B. Munn, J. E. Newton, Prof.Niemeyer, Drs. Charles T. Pearce, Ch. Pigeon, Prof. Eicord, M. Eollet, Drs. Ed- ward C Seaton, John Simon, Thomas Smith, Herbert 182 INDEX. Spencer, A. G. Springsteen, Prof. A. Trousseau, Sir Thomas Watson, Drs. West, Whitehead, Prof. Alexander Wilder, 118-128. Vaccinal virus, 36. Vaccination a substitute for in- oculation, 15. —, early devotees of, 24. — of immigrants, 146, 161, 163, 167. — in the public schools, 146. — laws, 146. —, personal susceptibility to, 30. —, phenomena of, 27. —, smallpox after, 68, 70-78. —, symptoms of, 29. Vaccine accidents, 51. — a menace to health, 144. — should be untainted, 50. — vesicle, the, 28. Vaccinia a disease, 35, 145. — a zymosis, 49. — and latent germs, 47. Vaccinisation, 88. Vacher, smallpox after vacci- nation, 81. Value of multiple "marks," 83. Van Bibber's experiments, 38. Variation in vaccine phenomena, 31. Vesicle, the vaccine, 28. Viborg on smallpoxing the cow, 37. Vicarious mortality, law of, 101. Virus, vaccinal, 36. Vital statistics in United States, 65. Warlomont on vaccinisation, 88. Watson, Sir Thomas, on small- poxing the calf, 141. — vaccinal syphilis, 127. Watt, Eobert, on proportionate mortalities, 102. Weakens the constitution, vacci- nation, 117. Wells, Sir Spencer, on the sav- ing of life by vaccination, 105. West on vaccinal-syphilis, 122. What to do about animal disease, 172. Wheeler, Alex., on smallpox after vaccination, 86. Whelan, on smallpox after vac- cination, 71. Whitehead on vaccinal-syphi- lis, 121. Wilder, Alexander, on vacci- nal-syphilis, 127. Wirtemberg, smallpox after vac- cination in, 70. With what shall we vaccinate, 147. Wood on vaccinal-syphilis, 122. Wyld, Geo., on smallpoxing the cow, 41. Zymosis a constant quality, 101. — and cleanliness, 108. i5 ks NLM001236460