SANDS, Dr. H. B., New York. SIMMONS, Dr. DUANE B., Yokohama, Japan. TAIT, LAWSON, F.R.C.S., Birmingham, Eng. VALENTINE, Dr. FERDINAND C., New York. VANCE, Dr. AP MORGAN, Louisville, Ky. VOL. XXI. JANUARY 7, 1882. Original Communications. A PLEA FOR IMPROVED VACCINATION. BY S. BARUCH, M.D., HONORARY MEMBER AND EX-PRESIDENT SOUTH CAROLINA MEDICAL A RECENT editorial in this journal presents a succinct It is gratifying to note that an influential journal calls attention to the importance of heeding the influence of these people upon the public, who are so readily entrapped by pseudophilanthropists of all stripes. The busy practitioner is too prone to believe that he has done his whole duty when he has obtained pure (?) bovine virus and inserted it into the arms of all the babies in his clientele. He regards with contempt the anti-vaccination agitation, characterizing it as the offspring of ignorance and fanaticism, and refrains from studying their arguments and statistics because he is satisfied that the experience of the profession sustains him in continuing the much-abused practice. In the course of a thorough study of the subject of vaccination, undertaken while Chairman of the State Board of Health of South Carolina, I had occasion to canvass the arguments of the anti-vaccinationists, and I confess that some of their claims are not without substantial basis. It can, for example, not be denied that a very large proportion of admissions-a large majority in some small-pox hospitals-are cases bearing vaccine-marks upon their arms, and that many of these cases succumb to the disease. Like all extremists, the anti-vaccination people claim to receive from such statistics confirmation of their assertion that Jenner's grand discovery has proved unavailing. But they ignore the fact that Jenner claimed only the same immunity for the vaccinated which was possessed by those who had passed through small-pox. There is, however, much food for reflection in statistical tables. My recent investigation of this subject demonstrated clearly to my mind not only the protective influence of vaccination against small-pox invasions, but also its ameliorating effect upon the type of the disease when contracted, and the diminution of the mortality thus wrought by it. No fair-minded person could deny the latter especially. But I was also surprised to discover unsought evidence upon another point. A critical examination of all the records of small-pox from 1818 to 1880 brought out the fact that, in the epidemics (of which we have reliable data) from 1818 to 1870, the No. 1. average mortality among vaccinated patients was 4.32 During Jenner's active work, and in the years immediately succeeding, the "golden rules" of the illustrious discoverer were scrupulously followed. His influence swayed the medical mind long after his labors were brought to a close. Filled with the recollection of the dread scourge from which he was liberating the world, medical men regarded his every rule as imperative. Arm-to-arm vaccination, with lymph carefully chosen from eighth-day pustules, was the rule, and, without questioning its infallibility, it was obeyed. As the terrific nightmare, which had brooded over the profession until Jenner dispelled it and infused hope in its stead, faded from their recollection, and when the enemy seemed bereft of his power, their vigilance relaxed. Modifications were introduced, various methods of obtaining, preserving, and propagating lymph were adopted; mothers and nurses regarded themselves competent to perform this operation seemingly so trifling. It was not long ere the consequences of neglect and indifference made themselves felt. Holding the view that the inadequacy of vaccination in recent years is the cause of the imperfect protection afforded, I will enforce it by reference to several recent reports of committees. In 1860 to 1864, Drs. Stevens, Buchanan, and Sanderson reported to the British Government ("Reynolds' System of Medicine," vol. i., 171, Seaton), that an examination of half a million vaccinated children revealed the startling fact that not mere than one child in eight was found to be so vaccinated as to have the highest degree of protection that vaccination is capable of affording; not one in three could, on the most indulgent estimate, be considered well protected. On page 151, Dr. Marson says: Cases of small-pox have kept gradually increasing in numbers until they now amount to four-fifths (!) of the admissions into small-pox hospitals." On page 152, Dr. Marson also demonstrates that, out of 544 cases having four or more vaccine-marks, only one-half of one per cent. died of small-pox, and that the mortality increased in an inverse ratio to the number and quality of the scars. In the "Report of the British Army Medical De partment for 1877" (p. 229), Surgeon-Major Archer, who took great pains to investigate and note the marks of all recruits examined by him, proves that "a large proportion of adults of the present generation are imperfectly vaccinated. Forty per cent. of the young recruits were insufficiently protected. He also shows that the liability to small-pox bears a distinct relation to the quality of the vaccination. The same result has been shown by the "Report of the Hampstead and Homerton Small-Pox Hospital." Dr. Bridges, in his report to the Local Government Board, divides the cases registered into four classes. Hampstead Hospital, from 1876 to 1878. CLASS I.-Patients bearing marks of good vaccination. The death-rate was 57 per 1,000; ranging, however, from 31 per 1,000 in patients with four marks or more, to 95 per 1,000 in patients with one mark or more. CLASS II.-Patients bearing marks of indifferent quality. The death-rate in this class was 113 per 1,000; ranging from 58 per 1,000 in patients with four or more such marks, to 143 per 1,000 in patients with one or more such marks. CLASS III.-Patients stated to have been vaccinated, but showing no evidence. The death-rate was 320 per 1,000. CLASS IV.-Unvaccinated patients. 468 per 1,000. Death-rate Homerton Hospital, from 1871 to 1878, same classifi cation. CLASS I. showed a death-rate of 33 per 1,000; ranging from 15 per 1,000 in patients with four good marks, to 39 per 1,000 with one mark. CLASS II. showed a death-rate of 111 per 1,000; ranging from 55 per 1,000 to patients with four marks, to 158 per 1,000 in those with one mark. CLASS III. gave a death-rate of 272 per 1,000. CLASS IV. gave a death-rate of 452 per 1,000. Here we have carefully collated data, which prove conclusively that the influence of vaccination upon the mortality of, and pari passu upon the liability to small-por, is in an unmistakably direct ratio to the quality of the vaccination, diminishing with the imperfect and increasing with the perfect manner in which this operation has been done. It behooves every physician to ask himself what share he bears in the perpetuation of the imperfect vaccination which has evidently been practised during the past twenty or thirty years. How many medical men do now devote the time and attention necessary to the selection of the lymph, the examination of the vaccinee, the proper inoculation of the lymph, the inquiry regarding the result, and the revaccination of imperfectly matured cases and cases whose protection is rendered doubtful by complicating inflammatory conditions? I do not know a single physician who is a true disciple of Jenner in this respect, or who carefully follows Marson's and Seaton's directions, so ably and earnestly inculcated in their works on this subject. Glaring deviations from health in the infant are not overlooked, but there are some obscure ailments which should be inquired after. So trifling a trouble, for instance, as intertrigo, is regarded by Seaton as a bar to vaccination (unless in the presence of small-pox exposure). Many infants presenting a robust appearance are affected by this ailment in the lower part of the body, where it is hidden from the eye of the physician. To the careful physician's inquiry regarding the health of the babe, the mother points with pride to its well-developed limbs and rounded outlines, deeming the intertrigo a matter of no consequence-a trouble which is "natural to fat babies." I do not propose to enter into this subject as fully as its importance demands, because the literature of vaccination abounds with precise,[minute, and reliable data. Regarding the selection of lymph, sufficient care is not exercised. Scabs are frequently used. These not rarely contain pus or blood, or are obtained from inflamed surfaces, all of which not only offer serious impediments to successful vaccination, but may also, as is well known, excite constitutional or local disturbance of grave character. In these days of mercenary traffic in all things, human life is but too often regarded as naught when placed in the scale against profit. The tottering tenements, the rotten ships, the rusty boilers and frail bridges which have sent their victims into eternity, bear witness to this fact. Is it not possible-yes, probable--that this mercenary spirit has touched the dealers in "vaccine virus" and rendered them careless regarding the maintenance of its purity and efficiency? When we remember the extreme care necessary for the preservation of the human and the cultivation of the animal "virus," the skill and familiarity with the entire subject demanded of those who are engaged in this work, we cannot be too careful with reference to the source of our supply. In this matter we are at the mercy of the dealers, among whom there are doubtless many who realize its importance, and who are scrupulously honest in the recommendation of their wares; and yet I have observed that, out of thirtyfive vaccinations made by myself last winter, with bovine "virus" purchased from one of the most reliable drug-houses in this city, I had no less than ten "irregular" vesicles, which took on an inflammatory action, resulting in fibrinous deposits and extensive erysipeloid blush over arm and shoulder. I have a vivid recollection of two babes whose arms and shoulders were enormously swollen, brawny, tense, and in one of whom constitutional disturbance was alarming. These children, who had been in perfect health up to the time of vaccination, were vaccinated by experienced and justly distinguished physicians, who would neglect no precaution with reference to the purity of the "virus" or its careful insertion. In the majority of cases referred to there was no other cause to which the systemic and local disturbances could be charged but some defect in the "virus." All physicians will readily recall similar instances in their own experience. According to Seaton, “a vaccination presenting any deviation from the perfect character of the vesicle and the regular development of the areola is not to be relied on as protectire against small-pox." "A spoiled and broken appearance of the vesicle, which is frequently on the eighth day ascribed to rubbing or mechanical irritation, is often really an irregularity arising from one or other of these causes (either the use of lymph not well chosen, or to something amiss in the state of the child vaccinated)." How many of our vaccinations approach in their results the standard of this authority? And yet, his large experience, sustained by others of equal eminence, induces him to lay down the above "one important, practical fact." How many physicians resort to revaccination in cases of inflamed or otherwise irregular vesicles? I know not one who would have the hardihood to propose revaccination to the mother of a child which has recently passed through illness of three or four weeks, produced by vaccination of "pure (?) virus.” The mother having a fear of the repetition of sleepless nights and anxious days with her fretting babe before her, will almost surely decline. I have heard mothers say they would risk a liability to small-pox rather than expose their children to a repetition of the ordeal. With regard to the method of operating, I need not dwell upon the well-known fact that mothers and nurses often take upon themselves this work, deeming it only necessary to scratch the surface and apply the "virus," and regarding the efficiency of the procedure in exact proportions to the amount of irritation and the size of the vesicle they have produced. Nor are physicians as careful with this seemingly trifling procedure as its real importance demands. We are too prone to lose sight of the fact that the imperfect execution of this operation may at some future time result in loss of life and destruction of happiness, which the imperfect performance of any one of the capital operations could not approach in direness. Jenner, Seaton, and others devote page upon page to the description of this seemingly slight operation, to pointing out the causes of failure and modes of avoiding the latter. And yet how many students are taught these invaluable lessons? Marson says with much feeling: "Great care is given to teaching and learning the capital operations, as they are called, which not one practitioner in twenty through the whole country ever performs; no care, or next to none, to teaching and learning the other (vaccination), which nearly all, when in practice, will have to perform frequently. As medical and surgical practitioners, our object should be to save all the lives we can by our art, no matter by what means; and if a little operation-little, apparently, 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 on nice care and management. Operations for hernia and for stone, for instance, if roughly, carelessly, and badly done, end badly; so it is with vaccination; and, so far as the public are concerned, it is quite as objectionable to them, no doubt, to die of small-pox, because they have been carelessly and badly vaccinated, as it would be to them to die of hernia or stone, because the operations for these complaints respectively had been badly performed. In the latter case the day of retribution would come immediately; in the former, unfortunately for its correction, it is delayed perhaps for twenty years or more; otherwise it would soon be set right." I have quoted somewhat at length from this excellent writer, because his life has been spent in the effort to counteract the evils of bad vaccination. It would appear from the writings of Seaton that the degeneration which has been attributed to the "virus," on account of its long descent through the human body, is really a myth, and that this charge of degeneration belongs more justly to the technique of vaccination. Marson and Seaton affirm that they have found virus of undoubted Jennerian descent, successful in the production of true Jennerian vesicles after transmission through a period of fifty years. I do not propose to enter the lists against the advocates of bovine virus. Far be it from me, for this substitute for the humanized lymph is extremely useful for preservation and transportation, and affords good protection when genuine and carefully guarded and inoculated. But I do hold that the good old Jennerian plan of arm-to-arm vaccination should be resorted to whenever practicable. That it is often practicable to the painstaking physician no one will doubt. The remedies for the existing imperfect protection against small-pox would, in my judgment, be found: Each First. In renewed attention to the, selection of proper eighth-day lymph, more careful cultivation of bovine "virus," greater care in both cases to scrutinizing and tracing it to a pure source. supply should be tested on one healthy vaccinee before it is extensively inoculated. Especially is this precaution needed in the use of bovine "virus," which not rarely produces local irritation, whose effect is pernicious upon the protective influence afforded by it. Second. Too much attention cannot be given to the methods of vaccination now in vogue-the technique of this simple procedure. Those who are not familiar with the writings upon this subject by Marson and Seaton, would do well to study their valuable suggestions and elaborate directions, especially with reference to the watchfulness necessary when the vesicle is maturing or matured. The care precision, and attentive regard for minutiæ which the men of Jenner's day and the time immediately succeeding bestowed upon this seemingly trivial work, may be profitably emulated by the present generation of medical men, if they would protect their fellow-men against the terrible scourge which now and then invades our cities and populous country districts. Third. A more thorough instruction of medical students in the details of obtaining supplies of vaccine material, in the methods of its propagation, in the technique of vaccination, in the diagnosis of the true from the spurious vaccine vesicle, is imperatively demanded. The medical student cannot be too deeply impressed with the idea that this operation, slight as it may seem, will confer greater benefits to the people under his care than all the skill he may acquire in surgery. The admirable instructions on vaccination, written by Mr. Simon, for guidance of "vaccinators under contract," by order of the Privy Council, July 29, 1871, are a model upon which teachers may successfully construct their lectures on this subject. No medical student should be allowed to graduate who does not exhibit a full appreciation of the importance of vaccination and a thorough knowledge of all its details. Fourth. I would suggest the inauguration of a new specialty. The "vaccinator" would in our large cities (which are the habitat of most specialists) prove far more useful to the public than many of the specialists who now minister to its numerous special ills." A vast deal of good would be accomplished by men who, like Marson and Seaton, have studied the subject of vaccination in all its details, and who would relieve the general practitioner of all care in this important matter. A large number of educated physicians may devote themselves to this branch of study and practice with credit and profit to themselves and to the profession. As it now stands, the general practitioner obtains but little thanks, frequently not even compensation (for it seems to be by many regarded as a complement to the labor case), for this work. The opprobrium, on the contrary, resulting from the insufficient protection due to various causes over which the busy doctor has but little control, is unstinting. The greatest bene fit, however, would accrue from this departure. Just as in other departments vast results have been achieved by special study, so will in time be accumulated large stores of statistical information and practical improvements in the methods of cultivating the vaccine-lymph and transmitting the vaccine disease in its purity and genuine type. Let it be borne in mind that the grand aim of medicine, the "stamping out" of small-pox, has thus far not been reached. On the contrary, we are confronted daily by failures, and taunted by the frequent recurrence of small-pox epidemics. This failure of vaccination to accomplish its alleged mission is converting a credulous public to the doctrines of the anti-vaccinationists, and thus adding fuel to the disease. I have attempted to demonstrate the cause of failure and to point out the remedy. The immeasurable importance of this subject demands earnest and immediate action on the part of the medical profession. 144 WEST FORTY-THIRD STREET, NEW YORK. } REPORT OF CASES OF PHTHISIS TREATED DURING 1880-1881. AIKEN, S. C. (Continued from THE MEDICAL RECORD, November 15, 1879, October 30 and November 6, 1880.) Or the cases described in my report for 1878–79, and 1879-80, a few returned to Aiken, and thus afforded me the opportunity of presenting the continuation of their case histories. CASE II. Succumbed to his disease after having passed seven seasons at Aiken with more or less improvement. CASE V. The improvement noted in this case has continued, but, being of a rather nervous temperament, could not be induced to submit to an examination. He has now enjoyed good health since May, 1879. CASE VI. This patient returned to Aiken, but did not consult me. She presents the appearance of a girl in perfect health, and her mother reports that she is doing well. CASE XV.-Continues to enjoy perfect health. CASE XVII.-November 15th, pulse 92,temperature 99.4. Cough slight, with a small amount of expectoration. There is still diminished resonance over the upper portion of the left chest, extending from clavicle to third rib. Respiration somewhat feeble, with an occasional squeak, the result of an acute bronchial catarrh contracted during the journey South. Posteriorly, there is dulness over suprascapular region, the respiration being roughened, with prolonged expirium. May 4th.-Has passed the winter without any relapse. Her color is fresh and ruddy; her flesh is firm, and her weight 130 pounds, which is more than she ever weighed in perfect health. The only reminder of her former disease is an occasional hack. The old area of dulness over the left apex is still present, but the more recent one to the outer side of the heart has entirely disappeared. No change in the condition of the lung posteriorly. This patient has purchased a residence at Aiken, and intends making it her future home. CASE XXIII.-Wintered in Aiken, but did so well that he did not require the advice of a physician. He looked quite robust, and appeared to be in perfect health. CASE XXIX.-Went to Colorado, expecting to establish himself in business there; but, finding that the climate disagreed with him, returned to Aiken, where he passed the winter. April 28th.-Pulse, 88; temperature, 98°; weight, 134. Has had no relapse, goes about without regard to weather, and has the appearance of a perfectly healthy man. On the right side there is still dulness over the upper third of the scapula and over the corresponding interscapular space. Respiration somewhat jerking, but in other respects normal. CASE XLI.-Passed the summer in West Virginia, where she was exposed to intense heat, combined with a high degree of relative humidity, which caused her to lose much of what she had gained at Aiken. On her arrival (November 19th) she was pale, thin, and decidedly cachectic in appearance. Pulse, 102; temperature ranging from 99 in the morning to 101° in the evening. Over the upper portion of the right lung there is diminished resonance in front, with dulness behind over the upper two-thirds of the scapula. Respiration bronchial, with prolonged expirium. May 13th.-Patient had a slight hemorrhage in February, and in April an attack of diarrhoea. In every other respect she has done well and is much improved. Pulse, 96; temperature ranges from 98.50° to 99.2°. Cough is slight, and the expectora tion does not exceed one ounce in twenty-four hours. Over the right front there is dulness above and under the clavicle, with harsh respiration, but without râles. Behind there is diminished resonance half down the scapula, with feeble respiration. Result. It will be observed that this patient regained much of what she had lost during the summer, increasing in weight and improving in strength, together with diminution in the extent of the dis ease. CASE XLIII.-This patient, in whom the disease has remained quiescent for years, had some little twinging of sputa in February, but remains quite well and pursues her accustomed avocations. CASE XLIV.-Passed the winter in Aiken, but did not report until January 7th. His temperature was normal, and his weight had increased to 135 pounds, a gain of 9 pounds. His face had the ruddy hue of health, and, with the exception of a limited area of dulness, there were no evidences of disease. In a letter from him, dated October 23, 1881, he states that during the last three months he has filled the arduous duties of cashier in a large mercantile establishment in Massachusetts, without losing a single day through sickness. He still remains free from cough. This patient was sent to Aiken as a dernier ressort, his physician stating that he might possibly improve, but intimating that his case was a desperate one. CASE XLVII.-Returned to Aiken, but failed to present himself for examination. His appearance was that of a well man, and his physician informs me that, with the exception of one hemorrhage, he has had no trouble since his departure from Aiken the previous spring. CASE LI-Passed the summer at Bethlehem. N. H., where he remained quite well, and returned to Aiken in November. His color was good, his pulse and temperature normal, and his weight 142 pounds. Cough very slight, with a trifling amount of expectoration in the early morning. Physical examination revealed no symptoms of disease other than a limited amount of dulness over the right supraclavicular region. May 1st. Has gone through the winter without |