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Since then there is prevalent so large an amount of small-pox, so severe and so fatal, it becomes imperative that we should extend our inquiries in order to ascertain what defects exist in the machinery of prevention, which are capable of improvement. It has been said that deaths from small-pox should be among the rarest entries in the register.

There can be but one answer to our inquiries-namely-neglect of thorough and complete vaccination.

After more than three-quarters of a century of accumulating evidence of the almost absolute protection which may be secured by vaccination, argument in support of this fact seems hardly

necessary.

Dr. Logan, physician to the small-pox hospital in Sacramento, in his account of the epidemics of 1868-9, says: "The primary and chief cause is inattention to vaccination. That the extreme prevalence of the disease is not due to failure of the antivariolous power claimed for vaccination, but to the neglect or absence of its protecting influence." Dr. Gibbons, in writing upon the same epidemic, says: "Let me state a fact of immense magnitude in its bearing on this question. During the prevalence of small-pox in San Francisco, covering the greater part of the year, not a physician contracted the disease, nor a professional nurse, nor a solitary member of the families of physicians or nurses. * * * Those persons who armed themselves properly with the shield of the immortal Jenner, walked unscathed amid the rankling pestilence while ministering to its victims." During the same year the Health Officer of Cincinnati writes that full ninety per cent. of those who died of small-pox in that eity were unvaccinated, and that no death occurred in which there was unmistakable evidence that the individual had been previously properly vaccinated. He further says: "We are driven to the conclusion that the lives of 580 persons who died during the year 1869, in Cincinnati, might have been saved by vaccination alone. This is certainly a very remarkable instance," he observes, "of criminal neglect of duty, or of ignorant bigoted prejudice.'

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It is a question of vital importance in our inquiry, What are the conditions precedent upon which an individual or a community may receive perfect protection against small-pox by vaccination? It may be premised as a settled fact that a true and perfect vaccination is a sure preventive of this disease, and that an outbreak of it can occur only as the result of neglected or imperfect vaccination. This proposition is accepted by every medical man of education and experience, as well as by every intelligent citizen. We submit the three following points:

1. THE OPERATION SHOULD BE SKILLFULLY AND SUCCESSFULLY PERFORMED.

It does not follow because a person has been vaccinated that he has been properly vaccinated, and is in consequence protected. Undoubtedly there are unfavorable conditions under which it is

often necessary to perform the operation, and which are difficult to eliminate from it. But the mere manipulation of the vaccinating instrument is a matter of more importance than is generally attached to it. "It is not merely a trick of the fingers."

It is to be feared that ordinary vacinnations as practiced by the average physician throughout the country are too often defective. If the operation is followed by a sore, while the characteristics which denote a protective result are nearly all absent, the case passes from observation, the dupe of a false security and a dangerous delusion. The unkindest fraud which can be practiced is to impose a false security in this regard. Where health and life are at stake, and such grave issues may result, ignorance and stupidity should give place to conscientious care and skillful manipulations. "If," says Marson, "a little operation-little important in practice, but very important in its results-well performed can save many lives, as most certainly it can, and prevent much suffering and sorrow, it should surely always be done with the greatest care and in the best known way. The success of all operations depends upon nice care and management.

After a most thorough and painstaking observation upon many thousand cases in children, so thoroughly convinced were Drs. Seaton and Buchanan, experts in this department of study, of the faulty and imperfect operations so generally practiced, that they felt compelled to strongly recommend that this operation should be committed to a few thoroughly trained vaccinators, who should devote themselves exclusively to this work. Hence, in many places in Europe the matter is held to be of so much importance that instructions are issued yearly from a central vaccine board to all vaccinators throughout the country, instructing them upon the points essential to success in this process. [Toner.]

The mere introduction of the virus into the arm is an operation so simple that it has led to a promiscuous domestic practice wherein many cases are assumed to have "taken," when the conditions essential to a complete protection have never been present.

No other duty is fraught with more responsibility than that of affording immunity from small-pox. This service has a special claim upon the candid and careful attention of every physician who stands as the true remedial guardian of the people among whom he resides.

However trifling it may seem as a surgical operation, there is nothing more certain than this, that careful observation, practical experience and painstaking accuracy are indispensable for securing its most perfect results.

All great masters of this practice, from Jenner to the present time, have taught that the merits of vaccination will always appear in proportion to the merits of the operator. "If sickly children are vaccinated without regard to their actual condition-children breeding other disorders or having skin diseases, the result will be very likely to be unsatisfactory."

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Not only is it necessary that the operation itself should be perfect, but it is equally essential that the subsequent evolutions of

the case should be normal and typical. Hence every case should be held under observation by the operator to that extent which will allow him to recognize all the processes of maturity and note any deviation from a typical standard. The physician who renders this service acts under an implied and recognized duty to confer upon the patient, by the operation, the most complete and perfect protection against small-pox, which vaccination is capable of doing. To do less than this is a violaation of an assumed obligation and a stigma upon his noble and beneficent calling. It is obvious that this demand cannot be conscientiously met without much careful study and patient observation. There should be no uncertain guess-work, but knowledge based upon the study of the best approved methods and careful personal observation. This being so, the folly of confiding this operation to nurses, midwives, barbers or any other party excepting the intelligent physician, becomes apparent. He alone is capable of appreciating any significant or important deviation in the progressive evolutions of the pock, which should cast suspicion or distrust upon the operation. Any such deviation demands a renewal of the operation, under conditions which shall be, if possible, more favorable to success. The failure to do this gives false security which raises questions of doubt in the minds of many as to the prophylactic value of vaccination. A failure to appreciate a perfect operation costs a large annual tribute of human life. Until the consequences that may result, indeed are almost sure at some time or other to result, from the bad and unskillful performance of this operation have taken thorough possession of the public mind, these faulty operations will continue to be found.

2-THE VIRUS USED MUST BE VIGOROUS AND OF UNDOUBTED PURITY OF STOCK.

This is a matter of the utmost importance. This condition of success needs no argument. When enfeebled or deteriorated lymph is used, a limited modification of the susceptibility of the system to the vaccinal and variolous disease is produced. Under this condition a subsequent vaccination, even with the most active and vigorous lymph, results in only a modified expression of the vaccinal disease. As a rule, it is not possible to secure a typical vaccinal expression when once the system has been brought under the partial influence of vaccinia by enfeebled or deteriorated lymph; hence the great necessity that in all cases vigorous and active lymph should be used so that the system shall be thoroughly saturated and hence thoroughly protected by its influence.

The lymph should be taken only from perfectly healthy subjects and from thoroughly characteristic pocks,

Previous to the introduction into this country, in the autumn of 1870, of animal vaccine, and its propagation for general or commercial use, the supply of good reliable lymph of the humanized form was very limited and inadequate to meet a sudden demand. Upon the appearance of small pox in a community, it was often

difficult to secure from any known source that of undoubted purity and vigor. The urgent necessities of such outbreaks have been met by such material as was available, and hence a large amount of vaccination has been performed which was undeniably spurious and unprotective. Furunculous sores have been produced in infinite numbers, which by the ignorant and uninstructed have been accepted as the genuine protective vesicle of vaccinia. The very miscellaneous way in which physicians have so often been compelled to procure lymph has served to greatly increase the number of those who are resting in a false security. A great error also prevails in the community even among those who entertain no doubt as to the necessity and propriety of this operation, in that so many neglect this simple duty until prompted to it by an outbreak of small pox, and the presence of real danger. At such times there is great danger that the operation may be hastily and imperfectly performed, and with carelessly selected lymph, for there is generally a pressure upon the operator for virus which he is not able at once to meet, and the temptation is great, and probably not always resisted; to use material which in times of less excitement and pressure would be rejected. This operation should never be left to a season of panic.

It is the opinion of careful observers of the vaccinal disease that the character of the vescile is an index to the protection produced. As a general rule it may be said also that the results obtained by the use of virus are a good indication of the strength and perfection of the stock from which it come.

Liquid lymph taken upon a surface-an ivory point or quill slip at the period of its greatest activity, a period just anterior to the full pronouncement of the areola, is without doubt the very best form in which vaccine virus can be used. In this form it possesses all the possible vigor inherent in the stock and at the same time has little or no animal matter mixed with it. In this form there is little danger of transmitting in the subject diseased, germs, which it is possible may exist in the decomposing animal matter always found in the crust.

It is confidently believed that a large amount of spurious, enfeebled and not wholly protective virus has been used through these many years past in this country.* That such has also been the case in England appears evident from the recent report of Registrar General, wherein he shows that the deaths among those who had been vaccinated were 13.5 in each hundred cases, a rate only to be accounted for by reason mainly of the too general use of humanized virus which has failed to give the maximum of protection.

It is not within the purpose of this report to discuss, at length, the relative merits of animal virus as compared with humanized. We give it as our opinion that properly selected humanized virus of the first remove from the heifer, by human transmission, will afford as perfect a protection as is possible to besecured. But the humanized virus is so very generally procured and used under such

*See report on vaccination by the writer in Transactions of Wisconsin State Medical Society, 1874.

varied vicissitudes and with such an imperfectly understood history, that a conscientious operator must often entertain doubt as to its vigor and the certainty that it will give the maximum of protection. It is a question whether there is any vaccine in use in this country whose pedigree is known and which is worthy of confidence, excepting that which is produced from the calf or can be traced to that source through a few near removes by human transmissions.

Every operator is held by public sentiment and considerations of professional honor to the exercise of the greatest vigilance and care in the selection of humanized virus. Experience has demonstrated that the vaccinal disease, when imparted to certain subjects, produces in them an imperfect or modified development, and that lymph taken from such subjects has so far lost its character, when perpetuated through other subjects, as to give rise to an imperfect vaccinal disease. There is then under certain circumstances, a degeneration of virus taking place; once we can readily understand that when virus is carelessly selected, this may seriously damage the degree of protection. Hence in the choice of virus, special reference should be had to its quality. This will lead to a knowledge of its origin. If it is animal virus, it should have an accredited pedigree-and must be propagated under the direction and by the hands of a thoroughly competent person. If of human origin we should know its remove from the heifer, and that it has been propagated through healthy and vigorous persons, and those_vaccinated for the first time. I think nearly all operators who have carefully studied this subject advise the use of heifer lymph when it can be obtained. When this is not accessible, that which is only a few removes from it. The nearer the better.

The use of heifer lymph not only ensures the maximum of productive influence, but removes all possible objection on the part of any who are unwilling to subject themselves or their families to the operation through fear of the introduction into the system of some associated disease. While it is found that the possibility of transmitting diseases by vaccination is far less than is generally supposed, and that this possibility can be asserted positively only of syphilis, nevertheless in a procedure which so many contend against, and which, especially in the minds of the laity, is so objectionable, even the appearance of error must be most scrupulously avoided, not only for the personal interests of the physician, the interest, especially of good cause," [Curschman.]

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