cinated in Philadelphia, Dr. Welsh does not give the number of successful re-vaccinations, but judging from the experience of local physicians, not more than twenty-five per cent. were successful, and yet, Dr. Welsh says not one of these found his way to the small-pox hospital. This certainly is strong presumptive evidence in favor of protection without apparent successful vaccination. Of course, temporary insusceptibility must always be reckoned with in such cases.

During the prevelance of small-pox my advice to persons who have not been successfully vaccinated since childhood is: Unless a successful result is obtained, be vaccinated every two weeks while the danger lasts. My reasons for this are: First, the virus may be inert; second, temporary insusceptibility may be present; third, the small-pox virus when taken into the system through the respiratory mucous membrane is so much more virulent than when introduced by inoculation, that there is danger of taking the disease in a mild form, even though the system seems to be immune to vaccination. Frequent vaccinations, although no apparent effect is produced, will, I believe, prevent this, or at least place us on the safe side. If we can in this way exhaust the susceptibility to vaccine, small-pox cannot occur except under a renewal of such susceptibility.

I am indebted to Dr. Edwards of Edwardsville and Dr. McKee of Plymouth, for tabulated statements, of which the following is a summar: Of 132 cases treated by Dr. Edwards, five had small-pox. All of those recovered. Of 52, from 25 to 50 years of age, twenty-nine were not vaccinated, eight of whom died; twenty-one were vaccinated in childhood, and these recovered. Of 30, from 15 to 25 years of age, 12 had not been vaccinated, two of whom died; four had been vacIcinated in childhood, these recovered; four were vaccinated at periods of from two to fifteen days before small-pox appeared and all recovered. Of 14, from 10 to 15 years of age, two were not vaccinated, but recovered, twelve were vaccinated at periods varying from five to thirty days before being taken by small-pox and all recovered. Of 35, from 1 to 10 years of age, sixteen were not vaccinated, of whom five died; nineteen were

vaccinated at periods varying from eight to sixty days prior to attack, one of whom died. Of the whole number reported, you will notice that of those who died, none had ever been vaccinated, except one child, eight days previously, and of course was not protected. None of those taken ill of the disease had ever been successfully re-vaccinated in adult life. Thirty-five were vaccinated many days after exposure in infected homes, but took the disease at periods varying from five to thirty days following vaccination, as follows: I in 34 days, 3 in 30 days, 3 in 26 days, 4 in 20 days, 3 in 18 days, 2 in 16 days, I in 15 days, 2 in 14 days. The remainder were vaccinated within the incubating stage of small-pox and were not supposed to be protected by vaccination, but out of the nineteen just cited, all should have been protected, and there would seem to be but one explanation and that is: the susceptibility to vaccine was not exhausted by the operation. If it was, then recent successful vaccination does not give complete immunity from small-pox. The former, in my opinion, is the correct conclusion.

Of 76 families infected, 463 persons were exposed to the infection, 183 took the disease and 280 escaped. Some of these who took the disease had never been vaccinated, and none had been successfully re-vaccinated until after exposure to infection. Out of 16 confined in one infected house only one escaped, and he was a Polander who had been several times vaccinated in his native country. Thirteen Polanders were confined in infected houses and all but one escaped the infection. They were vaccinated in infancy in their own country, but not during their period of quarantine.

One nurse, a medical student, had never been successfully vaccinated. He served as a nurse in the hospital for two months and failed to take the diesase, even by inoculation with the fresh virus of small-pox. Dr. Edwards was vaccinated in childhood and had good marks. During his first few weeks of attendance upon small-pox patients he was re-vaccinated five times, but without effect. He was about to give up the attempt at successful re-vaccination, believing that he was

immune. Dr. McKee vaccinated him on the arm and leg and got a typical vaccine vesicle in each instance. This was in all probability a case of temporary insusceptibility and had he not been vaccinated might, under favorable conditions, have taken small-pox.

Dr. McKee, who had attended a large number of small-pox patients had not been successfully vaccinated since childhood. Many attempts had been made, but none within six months of his taking small-pox. He, however, took the disease in a mild form. Had he continued vaccination at short intervals up to this time, and thus exhausted his susceptibility to vaccine, he, in all probability, would have escaped the disease even by inoculation. I believe, too, that it is fair to assume that he might have been successfully vaccinated at the time he took smallpox, by inoculation.

This brings us to the consideration of the technique of vaccination. Perhaps the greatest objection to vaccination on the part of the laity comes from the dread of the very sore arm which it sometimes produces. That this may be avoided by the use of a puncturing instrument is the chief object of my paper. By a severe sore arm, I mean the sloughing sore which not infrequently follows vaccination by scarification. They are frequently as large as a nickel and I have seen several as large as a half dollar. These excavated sores, as you know, are sometimes a week in healing and all the time, unless an antiseptic dressing is applied and frequently changed, there is danger of infection from any infectious germs that the clothin g may contain or that may be floating in the atmosphere.

It is true that nature sets up a barrier against infection in most of these cases, but the instances in which tetanus has followed vaccination emphasize the importance of adopting any method by which this condition may be eliminated. Vaccination by puncture is perhaps as nearly ideal as it is possible to make this operation, while from two to five per cent. will represent the failures of first trials in primary vaccinations. A tube of virus is placed on the arm and the point of the puncturing instrument is dipped into it each time a puncture is made.

The excess of virus left on the surface is then rubbed into the puncture. In a few minutes it is dry and the patient may leave the office. By this procedure the virus cannot be rubbed off and no dressing at this time is necessary. The puncture is made with a blunt cup-shaped instrument and no blood is drawn, thus avoiding the chief danger of transmitting syphilis. After a few minutes the puncture closes, and instead of an abraded, absorbing surface, such as we have after scarification, there is only a small puncture, so nearly closed as to lessen greatly the danger of the absorption of any infectious material.

The number of vesicles usually produced is four. Any number of punctures necessary to exhaust the susceptibility of the patient may be made without any local effect more than is natural to the developing and drying of the vescicles. As the pock appears and the vesicle forms, there is no destruction of skin surrounding it. The pock goes through its stages, dries, and falls off, leaving, not an ugly scar, but only a few pits to mark the site of the inoculation.

Perhaps you may regard my statements as too positive. However, they are substantiated by at least one thousand vaccinations by this method, without, so far as we have knowledge, a single sloughing sore. Dr. Weida and Dr. Marvin have been my associates in this work and will, I believe, roborate this statement.

cor

This instrument is not new. Its introduction to the profession dates back over twenty years. Dr. Weida first called my attention to its advantages and he learned its use from his preceptor. Soon after it was brought into notice, the vaccine points were used almost exclusively, which, of course, precluded the use of this method of vaccination. Those who formerly used this instrument laid it aside for the ivory points. The plates were destroyed, and, so far as I know, Dr. Knapp, Dr. Weida and myself are the only physicians of this locality who possess an instrument of this kind. Codman & Shurtliff of Boston are the makers, but in reply to a letter from Dr. Marvin, say the plates have been lost, and unless a demand is

created it would not pay them to make new plates. The instrument, I think, might be improved upon. One objection urged against instruments of this kind is that they are difficult to sterilize. But the chances of infection by this method is so slight, compared to vaccination by scarification, and its results are so overwhelmingly in the favor of this instrument, notwithstanding the theoretical objections to it, that I cannot refrain from saying that I believe the time will come when vaccination by puncture will receive the unqualified and universal endorsement of the profession.

Recent bacteriological investigation by Schamberg of Philadelphia shows that "the streptococcus and the staphylococcus are the principal bacteria found in the variolous and vaccine pustules and is the result not of secondary infection, but in all probability of the action of the micro-organism which produces the disease," This would account for the slough surrounding the vaccine sore after scarification. The resisting power of the skin is destroyed by scarification, which leaves the surface surrounding the vesicle open to attack by the streptococcus contained in the pustule. So it makes no difference what kind of a dressing is applied, the skin will become infected from the vesicle after scarification unless something is done to destroy the pus-producing organism which it contains.

Dr. Lowe of Edinburgh, in a recent article, asks the question: "Is the suppuration and its attendant blood poisoning a necessary part of vaccination?" To this he gives an emphatic negative reply. He then says: "The insertion of vaccine lymph into the system produces certain changes of which the outcome is the vaccine vesicle. When this is fully formed and filled with the colorless liquid, the process, I take it, is complete, and it is difficult to believe that the subsequent change of this liquid into pus and the absorption of septic matter can add anything to the protective influence of the vaccine."

In order to prevent this pus formation he applied pure carbolic acid to the vescicle on the seventh day, the surrounding skin having been previously oild with salad oil. In a few sec