Small=pox and Vaccination

Kai Tiaki : the journal of the nurses of New Zealand, Volume II, Issue 4, 1 October 1909, Page 139

Small=pox and Vaccination

Lecture delivered by Dr. Wiujam Irving to the Canterbury Branch of the X.Z. Trained Nurses' Association

The subject upon which I intend lecturing to-night: " Small-Pox and Vaccination," may seem to you a peculiar one, and one in which you are not, for various reasons, particularly interested. This is partly the reason why I have chosen it. In this country small-pox, I am glad to say, and vaccination, I am sorry to say, do not come much in our way. Many of you probably have never seen anyone vaccinated, and still fewer have seen a case of small-pox, and I think the object of having lectures at all in this Trained Nurses' Association should be to bring before you as post-graduates, subjects of scientific and practical interest to you as nurses, which you have very little or no opportunity of learning much about during your training. DESCRIPTION Small-pox is an acute infectious disease with definite symptoms, and a characteristic eruption of spots, which pass through the various stages of papule, versicle, and pustule. HISTORY It is a disease of great antiquity, and one only has to refer to ancient history to realise its appalling ravages in its unfettered state. In 1518, for instance, it helped to complete the depopulation of St. Domingo, which fire, sword, and famine had begun. Soon afterwards, in Mexico, it even surpassed the cruelties of conquest, suddenly smiting down three and a-half millions of the population. Prescott, in his " Conquest of Mexico/' describes the epidemic as " sweeping over the land like fire over the prairies ; smiting down prince and peasant, and leaving its path strewn with the dead bodies of the natives, who perished in heaps, like cattle stricken with a murrain." In Siberia, and Kanschatka ; in Greenland and Iceland ; in Brazil ; in Borneo ; on the Gold Coast, and in Madagascar, its devastations were similar, and striking accounts of its ravages among the North American Indians may be gathered from the following passage in a work by one Caslin, published in 1811 :— " Thirty millions of white men are now scuffling for the goods and luxuries of life over the bones and

ashes of twelve millions of red men, six millions of whom have fallen victims to the small-pox, and the remainder to the sword, the bayonet, or whisky/' To turn to European figures : We find that fully two-thirds of all children born were sooner or later attacked by small-pox, and that on an average one-twelfth of all children born succumbed to the disease. In England in those days, that is, in the latter part of the 18th century, and the early part of the last century, smallpox was responsible for about 3,000 deaths out of every million of population ; a deathrate which, with the present population of England, would give an average of 80,000 deaths annually from small-pox. It was not only the number of deaths which made smallpox such a frightful scourge in those days. PVom the earliest records of the disease, there is constant mention of the tax which it levied on survivors, and Macaulay, who gives small-pox the foremost place as, " the most terrible of all the ministers of death/ 1 exclaims in an eloquent passage : ' ' The havoc of the plague had been far more rapid, but the plague had only visited our shores once or twice within living memory. The small-pox was always present, filling the churchyard with corpses, tormenting with constant fears all whom it had not yet stricken, leaving on those whose lives it spared the hideous traces of its power, turning the babe into a changeling at which the mother shuddered, and making the eyes and cheeks of the betrothed maiden objects of horror to the lover/' Another writer tells us that among those who outlive an attack, many either totally or partly lost their sight or hearing, many are left consumptive, sickly, weak, or maimed ; many are disfigured for life by hideous scars, and become shocking objects to those who approach them. No wonder the old-time proverb says : " From small-pox and love few remain free." This will give you some idea of the state of things which existed until the middle of the 18th century, when inoculation was introduced into England, and later, vaccination was discovered by Jenner towards the end of the century.

In pre-vaccinatiou days few people escaped small-pox ; the insusceptibility has been variously estimated as from one to five per cent, probably it is not more than one or two per cent., and most susceptible persons contract it on first exposure to infection. In countries where it had been widely prevalent for generations, it was, prior to the introduction of vaccination, a disease mainly of children, as are measles, scarletina, whoopingcough, and diphtheria at the present day ; nearly all individuals contracted it in infancy or early childhood, and the majority of survivors were thereby protected against it for life. But when it attacks an unvaccinated population, or after a long period of immunity, all ages are affected alike. It has at one time or another, prevailed in every quarter of the globe, with the exception of Australia and New Zealand, and although isolated cases have been introduced, they have been, as a rule, promptly recognised and isolated, and no further cases have occurred. The worst outbreak there has been took place in Christchurch as you may remember, a few years ago, when several cases occurred. The ignorant and know-all public scoff at this outbreak, and say that it was not small-pox at all ; but all the same they made indecent haste to get themselves revaccinated, and their neglected children were done probably for the first time. I was fortunate enough myself to discover one of the cases. Although there were only a few pocks, they were absolutely typical, and only the other day I saw the first patient attacked — a woman — and she has a typical pockmarked face. vShe told me her mother had inoculated her in her infancy. CONTAGION Small-pox is very contagious ; the contagion may be direct or indirect, and it is now well known that the virus may be carried from a small-pox hospital some distance in the air without losing its infectivity. The virus enters the human body by the mucous membrane of the nose, mouth, or respiratory tract ; some believe also by the mucous membrane of the stomach. It may be communicated from the sick to the healthy by (1), persons suffering from small-pox ; (2) bodies of persons who have died of smallpox ; (3) neglected articles ; (4) healthy third persons ; (5) by the air, to persons living at some distance ; (6) inoculation. I have seen one example of its extreme con-

tagiousness : While I was doing hospital work in London, a case came into the outpatient department. It was the only case I ever saw at the hospital, and being so rare, all the students came in to see it. One of them, who was only in the room a minute or two, contracted small-pox, and all his family caught it from him ; all of his brothers died, and he himself was badly pitted. INOCULATION The incubation period is almost always twelve days. It varies a little, but it is one of the most definite of all the incubation periods. The onset is sudden backache, headache, and pyrexia being the first symptoms. Then one gets the ordinary symptoms of all acute fevers, rigors, vomiting, anorexia, thirst, etc. The temperature ranges high, till the appearance of the rash on the third day, then it falls a little, to rise again in the pustular stage — the so-called secondary fe.ver of S.P. ERUPTION The specific eruption of S.P., from which, of course, it takes its name, begins on the third day of the illness, by the formation of small, red papules or pimples, on the face, forehead, and scalp. They appear subsequently on the wrists, arms, and feet, and finally on the legs and trunk. These papules soon become prominent ; they are firm, and feel solid to the finger, a condition described as " shotty." On the third day of their appearance a small vesicle or bladder, appears in the centre, which is at first clear and transparent. The next two days it gets larger, the centre becomes depressed, and the surrounding part forms a prominent ring round it. Theyare then said to be (( umbilicated." About this time the contents of the vesicle become opaque, and finally about the sixth day (that is, the eighth of the disease they become purulent. During this change the surrounding skin becomes pink, an inflammatory ring, and if there are many pustules on the face, for instance — this leads to a great deal of swelling, which is often so considerable as to make the features quite unrecognisable. The stage of suppuration lasts about two days, then the pustules gradually dry up, beginning at the centre and forming a brown scab which adheres for several days then it falls off, leaving first a raised, deep red spot, which becomes ultimately the depressed white scar so typical of small-pox The mucous membrane of the mouth and

throat may also be attacked, the tongue may become covered with pustules, and breathing may be obstructed by the swelling and crusts of the nasal mucous membrane. VARIETIES There are several varieties of small-pox. Many authors have described many varieties. The simplest arrangement is to divide the varieties into thiee : discrete, confluent, and hoetnorrhagic. The description I have given you applies to an ordinary discrete attack in a person who has not been recently vaccinated. In one who has been vaccinated, we get, as a rule, what is known as modified small-pox. The protection is incomplete and so the individual falls a victim. I say, ' as a rule n we get modified small-pox, but this is not always the case. Where the immunity afforded by vaccination has ceased, we may get an attack of " natural smallpox/* la modified discrete forms the rash, as a rule, is not abundant, the vesicles may not exceed half a dozen ; much of the eruption is vesicular within twelve or twenty-four hours of its appearance. The course of the disease is short. The temperature falls to normal with the appearance of the rash, and in tn any cases does not rise again. In the mildest attacks the patient feels quite well after the initial symptoms have subsided, the disease, as regards subjective symptoms, is at an end. In more severe cases the temperature rises to 99 or 100 degrees during the pustular stage, the pulse is slightly actelerated, but the constitutional symptoms are very slight, and the patient is convalescent within a week or ten days after the onset of the illness. The symptoms of Natural Confluent small-pox are much more severe than those of discrete. In most cases the whole of the skin is covered by vesicles, which soon becomes confluent. The initial fever is high, and falls not at all, or very little, with the appearance of the rash. During the period of vesicular growth in milder cases the patient is free from restlessness, and but for the itching and discomfort of the eruption, feels fairly well ; in severer cases, especially those in which the eruption is completely confluent on the face and extremities, there is intense irritation and discomfort towards the end of the vesicular period. So acute is it, that patients sometimes tear the epidermis completely off, and I have seen one patient who had torn off all the skin of one side of his leg, leaving a raw, oozing surface. In

these cases, of course, the constitutional symptoms are correspondingly severe ; there is extreme restlessness, much delirium, rapid pulse, and the patient succumbs about the ninth to the eleventh day of the disease. Mr. McCombie describes a bad case of confluent small-pox thus: "At the height of the vesicular period, and in the pustular stage, the eyelids are often intensely oedematous, the upper eyelid overlapping the lower. The patient is quite unable to open his eyes, and the lids can with difficulty be separated. The nose, cheeks, and lips swell enormously, the neck even in a greater degree. The hands and feet are swelled and acutely tender to the touch, the fingers being partially fixed. There is copious eruption on the nasal mucous membrane, fauces, and phaynx, saliva trickles incessantly from the open mouth. A day or two later pus oozes from freshly ruptured pustules, and from under the freshly-formed scabs, and the patient presents a picture of hideous disfigurement, and helpless bodily discomfort without a parallel in acute infectious diseases." In unfavourable cases — 50 per cent. — the constitutional symptoms gets worse and worse, and the patient dies. In favourable cases the temperature falls gradually, the pustules dry up, the ctdema subsides, and the patient eventually creeps back to convalescence. In Confluent modified small-pox, the course of the disease is the same as in natural small-pox until the third or fourth day of the eruption, when, instead of going on.to the pustular stage the rash, to put it shortly, shrinks up, the constitutional symptoms subside, and the patient recovers. All the stages are shortened and less severe. Hj^morrhaGIC small-pox is mostly fatal. One gets cutaneous and subcutaneous haemorrhages with or without the presence of the characteristic eruption on the skin ; also bleeding from the nose, lungs, kidney, rectum, or uterus. But it is not necessary to go any further into a description of the symptoms. I have gone into them at some length, as I want you to realise the difference between natural and modified small-pox. A large proportion of the cases that occur now-a-days in a well-vaccinated communityj are of the modified form. In many instances, so completely is the course of the eruption altered, and the symptoms, after the initial stage is over, are so modified, that it is often difficult to realise the identity of the ordinary and modified forms of the disease. What

has brought about this change ? Is it chance ? Is it impro ved sanitary arrangements ? Is it because the disease is naturally dying out ? It is due to none of these. VACCINATION It is due to vaccination, and impartial students of the history of medical progress admit that vaccination, which has now stood the test of practice for over a century, remains to-day one of the greatest medical prophylactics the world has ever seen. The history of vaccination dates back to the end of the 18th century. In 1796 Jenner performed his first vaccination. But vaccination was not the first attempt to grapple with the small-pox scourge. For some time previous to Jenner 's discovery the practice of inoculation had been in vogue in England. INOCULATION Inoculation is the actual insertion into the skin of matter from a small-pox pustule. The origin of this practice is unknown. The Chinese claim to have been in the habit for many centuries of (( sowing the disorder/' by putting some of the crusts into the nostrils ; but this is a different thing to inoculation, as in these cases the injection would enter by the air passages. The Brahmins in India are said to have practised inoculation for centuries back, and it was certainly practised in Turkey in the beginning of the 18th century, and probably earlier. In 1713 Dr. Iyimoin, an Oxford graduate, who had settled in Constantinople, wrote to a doctor in London giving him an account of the new process, and testifying as to its success. The account was sent up to the Royal Society, and published in its transactions the following year. Other accounts were sent home from Turkey, but they do not seem to have been much noticed. " We owe the actual introduction of the practice of inoculation into Great Britain to the good sense and courage of an English lady, whose lively epistles have taken their place in our current literature (I quote from some very old clinical lectures delivered at Kings College Hospital). Lady Mary Wortley Montague, the wife of our Ambassador at the Ottoman Court, writes thus from Constantinople in the year 1718 ; ' The small-pox so fatal and so general among us, is here entirely harmless by the invention of engrafting, which is the term they give it. Every year thousands undergo the operation, and the French Ambassador says, pleasantly, that they have

the small-pox here by way of diversion, as they take the waters in other countries. There is no example of anyone having died in it, and you may believe l" am well satisfied of the safety of this experiment since I intend to try it on my dear little son. I am patriotic enough to take pains to bring this useful invention into fashion in England/ In fact, she recommended it by her own example. The first person inoculated with the small-pox in England was her daughter ; then a child of a physician who had visited Miss Wortley ; afterwards, some condemned felons, who were pardoned on their submitting to the experiment, and at length, some of the Royal family." So about the middle of the 18th century, inoculation was fairly common in England. It was satisfactory, in that it mitigated the severity of the disease, prevented deformity, and saved life ; but it was just as harmful in another way, as inoculated small-pox was just as infectious as natural small-pox. An example of its practical use is given by a naval surgeon : " The small-pox was introduced among the crew of a man-o'-war, in a tropical climate, where no vaccine was procurable. The men were almost all unprotected. Sixteen of them took the disease in a natural way, and of these nine, or more than half, died, of 363 who were inoculated under the disadvantages of a hot climate, and no preparation, not one perished." To show how times have changed the practice of inoculation is thus tersely dealt with in Clifford Aubut's latest " System of Medicine : ' " Inoculation is not practised in civilised countries, it is illegal, and has only a historical interest." Inoculation has therefore (( gone out," and rightly so. It has given place to vaccination, and for this wonderful discovery we are indebted to Edward Jenner, a surgeon practising near Gloucester, and whose name can be coupled with such great men as Pasteur and I v ister, for the enormous benefits they have bestowed on the human race. HISTORY Dr. Jenner found, among the great dairy farms of Gloucestershire, a popular belief that anyone who had had the cow-pox could not take the small-pox. Cow-pox is a disease characterised by a vesicular eruption, communicated to the milker from the udder of the cow suffering from the complaint. Jenner inoculated several persons who believed themselves immune, and satisfied himself that it was as they said, " and at length conceived

the great and happy idea of propagating the cow-pox from one human being to another, and so preventing in all cases the perilous and disfiguring distemper of smallpox, which he hoped might finally be expelled from the earth." It was enough to make poor Jenner turn in his grave, could he have known that his own city of Gloucester was a hot-bed of anti- vaccination in 1895, in which year, just about a century after his discovery, the city was visited by one of the worst epidemics of modern times. His first experiment took place on 14th May, 1796, and is thus chronicled : " On that day matter was taken from the hand of Sarah Netmes, who had been infected by her master's cows, and inserted by two superficial insertions into the arm of James Shipps, a healthy boy of about eight years old. He went through the disease apparently in a regular and satisfactory manner, but the most agitating part of the trial still remained to be performed. It was needful to ascertain whether he was secure from the contagion of small-pox. This point, so full of anxiety to Dr. Jenner, was fairly put to issue on the Ist of July following. Variolous matter, immediately taken from a pustule, was carefully inserted by several incisions, but no disease followed." This, then, was the first practical and successful demonstration of a practice which is now in vogue the world over, but which, strange as it may seem, has always had its opponents, and bitter opponents at that ; for there has never been a more rabid anti-anything than an antivaccinator. EFFECTS OF VACCINATION DEATHS DUE TO SMALT-POX IN LONDON FIFTY YEARS BEFORE AND FIFTY YEARS AFTER THE INTRODUCTION OF VACCINATION. Deaths due to Small-pox in every Decades. 10,000 deaths due to all causes in London. 1 750-00 . . 8.30 —60-70 . . 946 —70-80 . . 826 —80-90 .. 891 -90-1800.. 787 Vaccination introduced 1798. 1800-10 .. 580 — 10-20 .. 342 —20-30 . . 237 --30-40 .. 144 Statistics imperfect. —40 50 .. 114 I now hope to be able to show you the effect of vaccination on small-pox. This is a chart representing the deaths that occurred from small-pox, in 1,000 deaths from all causes in London, for the 50 years immediately pre-

ceding and immediately after the introduction of vaccination. You will notice what a marked decline there is, and this decline we believe to be due to vaccination. To what else could it be due ? The opponents of vaccination have various ways of explaining it, of which improved sanitation and natural decrease are the chief. To take the latter first we find that small-pox still flares up from time to time in towns in which vaccination is not efficiently carried out, and that its virulence has not diminished but rather increased of late years. With regard to improved sanitation : Small-pox is not a disease such as typhoid, which is contracted from defective drains, etc. In 1886 the Gloucester Anti- Vaccination Society took shape, and they presented their- city to the Royal Commission on vaccination as a sample of how a healthy and well-ordered town could defy small-pox unaided by vaccination. Alas ! in 1895 small-pox came with a vengeance. The population of Gloucester was roughly 4-0,000, and there were 1,979 cases of small-pox, and 4-31 deaths. The neglect of vaccination cost the Guardians over /1 5,000. The Anti- Vaccination Society sought to demonstrate to the citizens of Gloucester and the public generally, that the epidemic was not due to neglect of vaccination, as the Press so generally asserted, but to defects in the sanitary arrangements of the city itself. Gloucester is like many other cathedral cities ; a beautiful cathedral, standing in a beautiful close, and nestling around it quaint old streets and houses hundreds of years old ; very pretty and interesting to look at, but not a bit sanitary, and many of them slums A the worst type. Oddly enough there were here, where one would have expected the contrary, fewer cases of smallpox than anywhere else, and the greatest number took place in the new part of the city where everything sanitary was found to be in perfect order. There are other cities and towns in England in which the anti-vac-cinator nourishes, and in these cities and towns, partly due to the apathy of the public and partly to the baneful influence of antivaccination literature. The number of vaccinations performed are very few, and they are from time to time visited by epidemics of small-pox, which do occasionally attain alarming dimensions, and would do so much more frequently were it not for the vigilance and promptness of the health authorities. Even in the days of inoculation there were

those who could say nothing bad enough for it and for those who practised it. Objection on religious grounds was pretty strong, and on Bth July, 1722, a sermon was preached in St. Andrew's. Holborn, by the Rev. Edmund Massey, who took for his text the words : l< vSo went Satan forth from the presence of the Iyord and smote Job with sore boils from the sole of his foot, unto his crown." He argued that Job's disease was small-pox, that Satan was the first inoculator, and that therefore inoculation is a diabolical operation tending to anticipate and banish Providence out of the world, and to promote the increase of vice and immorality. The reply to this of a great inoculator is worth reading : " from useful discoveries," he says " there can always be drawn important conclusions. First, here learn we that sniall-pox is an ancient disease, for if it was conveyed to Job by inoculation it must have been taken from some other body infected with the distemper ; secondly, that Sydenham was not the first that began the cool regimen, for Job sat down upon the ashes in the open air ; his friends saw him afar off ; thirdly, that his friends were tardy, above three weeks before the3 T came to see him ; for in the general confluent kind of small-pox it would be that time before they can bear scraping with a potsherd ; fourthly, beloved, this confluent kind of small-pox were more gentle, to be sure, than the common, natural ones ; for he seems neither to have had delirum, sore throat, nor shortness of breath ; he talked distinctly, and good sense." Since vaccination came in there have also been and always will be, I suppose, those who are strongly opposed to it. The religious objection still persists to a certain extent, though one would hardly credit it. Another objection is, that it is a disgusting and filthy operation, viz., the taking of diseased matter from animals, and inserting it into healthy human beings. Another, that it may cause a healthy person to become infected with other diseases, and of course, the statement of the anti-vaccina-tors that they can prove by statistics that vaccination does not afford the protection against small-pox which is claimed by its supporters. The pitch to which the antivaccinator can be wound up to is seen in the following extract from a pamphlet written by a Mr. J. Pickering, of I.eeds, a great antivaccinator: — "Vaccination is little better, than cool and deliberate murder. The immortal Jenner was a poor, ignorant, super-

stitious, hair-brained fanatic, a small country apothecary, a man who was totally destitute of any scientific accuracy ; a man who adopted a craze that immediately turned itself into a curse, and whose followers to this day, are making as great a blunder as he by perpetuating a rite whose unaltered venom is destroying the best blood of the nations. Was Jenner sane ? I think not. His greed for gold had obscured his judgment. Better for him had he never been born. If I could believe in vaccination I would argue thus : ' There is no God, and if there be no God then vaccination may be true.' How the King of Terrors must revel as he follows the wake of the public blood-poisoner ! How he gloats over his annual Herodian massacre, which is perpetrated for the sake of two shillings a life." It is not easy to reason with people who take such extreme views as this. COMPLICATIONS There is no doubt that the idea of diseased matter being inserted into the healthy body of their children accounts for a great number of vaccination opponents, and many people would rather run the risk of their children contracting it than have them vaccinated. Then again, there is the fear that some other disease may be contracted. It is well known that certain rashes may be produced by vaccination. They are as a rule harmless, and of simple, well-known forms, such us occur iu all persons, especially in the young, from irritants of different kinds. The rashes produced by bell., pot., iod., shell-fish, hydatids, antitoxin, etc. are familiar to all of us, and it is probable that the rash is of the same kind and due to the same cause. But all kinds of rashes which appear about the same time as the vaccination are attributed to that cause by many ignorant people, and not only rashes, but all kinds of children's ailments, and it is quite common to hear, " he has never been right since he was vaccinated." But more serious allegations have been made against vaccination. It is claimed that by indergoing vaccination other diseases have been inoculated at the same time ; these are syphilis, tuberculosis, leprosy, lupus, and cancer. It is doubtful whether any really genuine case of these different diseases having been in- vaccinated has been demonstrated. Syphilis and tubercle have not infrequently been inoculated in the rite of circumcision, in tattooing, and in accidental ways. It would seem, therefore, probable that in vaccination there is a real danger to

be apprehended from these causes. Most thorough and exhaustive inquiries and researches have been made, and these showthat though these complications do exist they are of extreme rarity. In 30,000 patients, seen at the Great Orinond Street Hospital for Sick Children, Dr Robert I,ee only saw one case of supposed vaccinal syphilis, and at the East London Hospital for Children, Dr. RadclifFe Crocker lias not seen or heard of one such case, although for many years he has been making special inquiries for their occurrence. Since the use of calf-lymph has become universal these dangers are much less than formerly, and the report of the Royal Commission on this subject is as follows : — " Although some of the dangers attending vaccination are undoubtedly real and not inconsiderable, in gross amount they are insignificant, and there is reason to believe they are diminishing under the better precautions of the present day, and with the addition of the further precautions which experience suggests will do so still more in the future." In former days it was the custom to take matter from a vaccination pustule of a healthy child, and vaccinate other children with the vaccine so obtained This practice is now illegal, and all vaccinations have to be performed with fresh calflymph. Briefly, the method of preparing calf-lymph is as follows : — Calves from three to six months old are chosen for the purpose. They are all picked animals, and should be kept under observation under model conditions for at least a week before they are used. Then if they seem satisfactory they are placed on a tilting table, so constructed that everything can be kept absolutely clean upon it ; their limbs are fixed, and the abdomen shaved from the navel to the thighs. The skin is thoroughly sterilised, and parallel linear incisions are then made with a scapel through the outer layers of skin only, care being taken not to draw blood. Glycerinated calf-lymph is then run into the incisions and the calf is put back into its stall. At the end of four or five days the calf is again put on the table. The incisions now should show a line of continuous vesiculation. These vesicles and their contents are then collected by means of a sterilised Volchmann's scoop, and placed in a sterile bottle. The calf is then killed and examined carefully by an expert, and if there is anything at all wrong with it, nothing more is done' with the lymph. If, however, all is right, and there is no sign of tuberculosis

(very rare in calves of that age), or any other disease, the scrapings are ground down into a pulp, and rinsed with four times their weight of pun.' glycerine and distilled water. The object of adding glycerine is to destroy other organisms which arc at first present in the lymph, and it is found that if this is done, and the lymph stored away in a cool place for some weeks all other organisms are destroyed. This is proved by inoculating ordinary culture media with the glycerinated lymph, no growth takes place, not even when tubercle bacilli and strepococi have been purposely added. The lymph is then ready for use, and is stored in a cool place till required. This is the way the lymph we use here is prepared at the Government Vaccine Station, and I have to thank Dr. Makgill, of the Health Department, for literature on the subject. The vaccine does not keep its potency for ever, and instructions are issued that if it is not used it should be returned in two months. The actual operation of vaccination consists in inserting into the superfical layers of the skin, under strict antiseptic precautions, this glycerinated calf-lymph, which is supplied us in capillary tubes, one tube to be used for each operation. There have been many instruments devised for this simple operation, but as sterility is the chief thing to be aimed at the simpler the instrument the better, and a plain needle makes about the best and simplest thing to use. After thoroughly sterilising the skin, little spots of vaccine are placed on the arm, or the leg as the case may be, a spot for each mark it is intended to make, then the skin is scratched with the needle, care being taken to draw no blood, and the vaccine allowed to dry. As we shall see later on, four places give the best protection. On the third or fourth da} 7 , pale red papules develop at the points of inoculation which, in the course of the next five days develop into vesicles with clear contents, and later, about the tenth day, into puspules. The vesicles are at first fully distended and plump, then they gradually dry up, and a scab is formed. Between the 1 lth and 20th days the scab falls off leaving a scar which, dusky red at first, gradually after some months, becomes white and pitted. The general symptoms are commonly unimportant, sometimes a slight rise of temperature is noted about the third day, which reaches its maximum about the eighth day. Then, as we have seen, there may be various rashes, which accom-

pany even the mildest and most favourable cases of vaccination. Also, one may get the usual symptoms common to any acute fever, such as headache, lassitude, irritability, sleeplessness, and a disturbance of the digestive organs. A re-vaccination in an adult generally leads to more disturbance than a primary in an infant ; the reaction to calf -lymph is also apt to be more severe, with more local swelling, cudema of the arm, swollen glands and radiating pain. IMMUNITY We now come to the last and most important part of our subject, viz., the immunity against small-pox derived from vaccination. The best way to learn this and the only way for those who have not seen for themselves, is by studying the various tables and statistics compiled from the small-pox hospitals and epidemics of recent years. During the sitting of the Royal Commission on vaccination which lasted some years, there were several most instructive outbreaks of small-pox in England and these were most carefully and thoroughly investigated by doctors of the highest standing sent out by the Commission. Every one of these inquiries prove to the hilt that vaccination protects from and modifies small-pox to a reasonable extent. Jenner's hope that small-pox would be expelled from the earth will probably never be realised for we know now that vaccination is not an absolute protection against small-pox, however efficiently it is carried out. It is not necessary to weary you witli long columns of figures. I have drawn up one or two, just to show you as examples, but they are all more or \ less * alike.

Tn evidence— children. — Without going too much into details, what strikes one first is the fact that the vaccinated children under ten years of age who have contracted smallpox have been almost immune from death —

I have chosen Gloucester because I saw almost every case of small -pox which occurred there. When they have contracted the disease it has been its mildest form. At Gloucester, as I told you before, the vaccination laws were practically in abeyance between the years 1886 and 1895, so that about 80 per cent, of the children born during that time were unvaccinated. When the day of reckoning came the results w r ere dire in the extreme. Of the children under ten there were attacked 26 vaccinated., of whom one died, equivalent to 3.8 per cent. ; 680 unvaccinated, of whom 279 died, equivalent to 41 per cent., nearly half. Of persons over ten there were attacked 1,185 vaccinated, of whom 119, or ten per cent, died and 88 unvaccinated, of whom 35, or 39.7 per cent, died. At Halifax, in 1892, there were 513 cases, and 44 died ; of these 425 were vaccinated and only eight died (1.8 per cent). The remaining 88 were unvaccinated, and of these 36. or -10*9 per cent. died. There were no vaccinated cases under five, but of 50 unvaccinated children of that age period, 20 or 40 per cent. died. One could go on giving these illustrations for long enough, they all show the same thing. The Blackburn visitation in 1893 shows the protection afforded by re-vaccination after exposure to infection ; 243 persons were detained in quarantine for 11 days; 211 of these were re-vaccinated, 15 were already re-vaccinated or had had previous attack, 17 were not re-vaccinated. Of the re- vaccinated 211, two caught the disease, one having been exposed to infection

four days, the other five days before the operation ; of the 17 who were not vaccinated 5 caught the disease, equivalent to about one per cent, in one case and 30 per cent, in the other. Another example of how vaccination protects even after exposure to infection is given by Dr. Gale: <( (hie of four children got small-pox, the mother immediately brought the other three to be vaccinated, and although they remained in the same house as their sister they did not get the disease. Two constables had occasion to visit a house where there was an unrecognised case of small-pox, as soon as it was found o.:t re- vaccination was offered to them, one accepted and escaped, the other refused, and a fortnight later was admitted into the hospital with a bad attack of confluent small- pox which nearly cost him his life. " Hospital Officials. — The immunity of smallpox hospital doctors, nurses, and attendants is one of the strongest arguments in favour of vaccination and re- vaccination. Dr. Collie, for many years a superintendent of one of the hospitals of the Metropolitan Asylums Board says: " During the epidemic of 1871, 110 persons were engaged in the Hoverton Fever Hospital in attendance upon the small-pox sick, all these, with two exceptions, were re-vac-cinated, and all but these exceptions escaped small-pox. The experience of the epidemic of 1876-7 was of the same kind, all re-vac-cinated attendants having escaped, while the only one who had not been vaccinated took the disease and died of it. So in the epidemic of 1881 ; of 90 nurses and other attendants of the Atlas Hospital, Miss , the only person who contracted small-pox, was a housemaid who had not been re-vaccinated. The anti-vaccinators say that doctors and nurses should escape the infection of smallpox, just as for the most part they do other fevers for which no vaccination is prescribed. But do they escape other fevers ? We knowthat they do not. In 1893 we find that of 2,484 persons employed in the nine Metropolitan fever hospitals, 130 became infected, and 2 died ; 4 assistant medical officers, 10 nurses, 43 assistant nurses, and 16 ward servants were attacked by scarlet-fever ; 2 assistant medical officers, 6 nurses, and 15 assistant nurses by diphtheria, and so forth. Again, the deaths of medical men from smallpox are but 13 per million as against 73 per million of the general population, whereas in scarlet fever against which doctors have

no special protection, there is the remarkable fact thai 59 medical men per million die from this cause, as against 16 per million of the public. With regard to the efficiency of vaccination it has been proved that the patient showing the best scars is the best protected. Here again, one can get any number of figures to prove this. This table shows the classification of cases according to their marks, four being, as you will see, the most satisfactory number : — ■

I will not weary you with any more figures or statistics. Rfficient vaccination has been shown to confer on children under ten years of age an immunity from death by small-pox which is almost absolute, and that this immunity thus acquired extends in the vast majority of cases for a much longer period ; that in children both over as well as under ten,, the more efficient the vaccination the milder the disease ; that in unvaccinated children the virulence of the disease and its mortality are as in pre-vaccinatiou times, so that children, to be efficiently protected, should be re-vaccinated about puberty. With regard to compulsory vaccination, Dr. Ernest Hart writes thus : " It is urged by some people with a show of plausibility that however beneficial vaccination may be, to have it generally compulsory is an intolerable infringement of the liberty of the subject. Such people, however, overlook the fact that the proved benefits of vaccination afreet especially the juvenile portion of the community, which has as } r et no voice in the matter, and that the person who neglects to avail himself of the means of protecting himself against small-pox, is a serious menace, nuisance, and indirect cause of expense to the community in which he resides. Others again, think that the Leicester system of compulsory quarantine for ten or twelve days is the proper substitute for vaccination, forgetting apparently, that even Leicester, the parent of this system, finds it absolutely necessary, not only to protect its small-pox hospital staff by vaccination, but also to enforce, as far as possible, the vaccination or re-vaccination of all persons who may have

been exposed to the infection. Most people, after looking seriously at the question, will agree that a quarantine of ten or twelve days is a form of compulsion vastly more costly, dangerous, leaky, and individually irksome than that of vaccination." In conclusion : I know it is difficult to realise things that 3^011 only read about, or hear of second-hand, but it is the only way you can learn about it at present, and if you will only believe one who has seen you cannot be of two opinions as to the efficacy of vaccination in mitigating small-pox. When I was a student I used to take it for granted that vaccination was all right, and the proper thing to do, but when once one has seen its effect on small-pox one cannot have two opinions, nor should one hesitate to speak firmly on the subject if the occasion arises. Go into a house where several members of the family are attacked with small-pox. The parents and older children are probably vaccinated and protected to a certain ext nt, but from some cause or other the younger ones have been neglected, as was the case in so many families at Gloucester. What do we find ? The previously vaccinated either escaping altogether, or only with a mild attack, the little ones black with confluent small-pox, and dying at the rate of over 40 per cent. Again, go down the wards of the small-pox hospital and note the difference in cases. Here is a man who hardly seems ill, he has a few spots about him, and he will soon be convalescent ; in the next bed is a black, stinking mass of humanity, truly a dreadful and never-to-be-forgotten sight. Many converts were made in the small-pox hospital in Gloucester. The patients themselves saw what a difference vaccination made and sent word to the rest of the family to get done at once. It is our duty to reason with and instruct the public who are always listening to the anti-vaccinator, because the anti-vaccinator is always talking. We do

not talk enough, doctors do not talk enough, for several reasons ; it is often distasteful to argue with people, and as I said before, some of them are very bigoted, and absolutely refuse to be reasoned with. But often it is sheer ignorance. Patients have several times come to me and said, " I don't believe in vaccination." I say, " don't you, you wait till you see a little small-pox," and by talking a little they generally come round, and when it is all over they wonder why they made such a fuss. One thing they are very fond of saying is that small-pox is never likely to come to New Zealand, that they wo -Id wait to get vaccinated till it did. Those of you who saw the mad rush to get vaccinated at the outbreak here some time ago know the utter worthlessness of that argument. I must say I don't think small-pox could ever get much hold here, our Health Department is too much alive, but then the good people of Gloucester thought they were safe. Only last Monday you may have noticed that the Health authorities in Auckland are taking special precautions for fear any small-pox should get in from West Australia, and if it once got a footing in New Zealand and got into our large schools we should be as badly off as Gloucester was. The vaccination laws in New Zealand, as in Great Britain, permit of a so-called conscience clause, and owing to this and other causes, over nine per cent, of children born are unvaccinated. There is a great deal more one might have said, and many more points one might have touched in dealing with the subject of smallpox and vaccination. I trust there are no anti-vaccinators present, if there are, I hope I have given them something to ponder over. What I set out with the purpose of doing was to show you as nurses that vaccination is a very real and important thing, and if I have made this any clearer to you I have not spoken in vain.

METROPOLITAN FEVER HOSPITAL

SHEFFIELD OUTBREAK

GLOUCESTER -1895

METROPOLITAN FEVER HOSPITAL