22,535 cases in the United States, or 520 cases in our own Statean aggregate amount of human suffering, distress and pecuniary luss, at which every thoughtful mind is appalled, when we consider at what a trifling cost of money or time each and every person can be absolutely protected against the approach of this disease.

No fact within the range of human observation is more thoroughly established than that vaccination, thoroughly and properly performed, secures the individual against an attack of small-pox. The exceptions are so few as to render the rule almost absolute. Over against this fact, let there be placed the other one, that there is no disease known in ancient or modern times, more contagious -more loathsome and more to be dreaded-than this, and the thoughtful mind becomes excited with amazement at the prevalent indifference, not to say criminal neglect, everywhere discovered.

If it be true, as has been said, that "man in the exercise of a wise forethought and of his best intelligence can protect his health and control the ravages and mortality from specific and preventable diseases which overtake the ignorant and the careless," it is clearly the duty of the intelligent people of the State and the custodians of public welfare, to see that all available means are used looking to so beneficent an end.

HISTORY.

The history of small-pox is clothed in much obscurity. The question of its origin, antiquity and spread has been a matter of careful and laborious research, but has not elicited an answer definite and satisfactory. Its highly infectious and contagious nature was early recognized, while at the same time it was believed to arise spontaneously under certain circumstances of climate and soil, such as heat, moisture, filth and decaying organic matter. This false theory of its multiple origin has long since been exploded, and the fact established that small-pox spreads exclusively by contagion. It is always disseminated by means of a specific virus which is begotten in the bodies of small-pox patients, which specific virus being applied to a second party through the skin or through the lungs, reproduces itself. It is never spontaneously developed under any circumstances whatever.

This disease does not appear to have been indigenous in Europe, but to have been introduced there at a relatively late period from other lands, "no one of which," says Curschman, can with certainty be alleged to have been its cradle."

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Ambiguous accounts of it have come down to us from China and Hindoostan, where it is thought to have existed long before the Christian era. The first accurate and satisfactory description of it seems to have been given by an Arabian physician, who lived in the early part of the tenth century. It was known throughout England in the latter part of the ninth century, and, after the Crusades, it prevailed in most parts of Europe. All dreaded its presence, and there seemed to be no power to stay its ravages. After the discovery of the Western Continent, it passed

hither with the tide of emigration, and, in 1517, was carried into St. Domingo, and from thence, in 1520, into Mexico, from whence it spread throughout the Western Continent. On its introduction into the city of Mexico, according to Robertson, it destroyed, in a brief space of time three and one half millions of people. Being introduced into Iceland (1707), it swept away one quarter of the entire population. It reached Greenland in 1733, and very nearly depopulated the country. During the eighteenth century, one tenth of the population of the globe died with this disease, while many more were disfigured by it. In Europe, 400,000 persons died annually from this disease alone. From historical accounts the first visits of small-pox into any country or section of the globe, has always been followed by the most fearful devastation. It has very strikingly illustrated the law that seems universally true, that "a contagious disease is always most virulent on its first introduction into a new scene of actiou." As far back as we have any knowledge of the disease, it has been the scourge of all countries where it has existed. Up to the commencement of the present century, it was by far the most formidable and fatal disease that afflicted mankind.

The eloquent English historian Macaulay, in speaking of the ravages of the plague during the seventeenth century, assigned to small-pox the foremost place as "the most terrible of all the ministries of death."

Very few at that time escaped an attack of the disease, and most of those who survived an attack were left with impaired health or serious disfigurement. The average annual deaths in England from this cause were about three thousand to every million of inhabitants, a death rate, says Seaton, which with the present population would give a loss to the kingdom of more than sixty thousand of its citizens. The bills of mortality in London show that during the last half of the eighteenth century, the population was decimated every year by this terrible scourge.

It is well to refresh our minds by these facts in the history of this disease that we may the more fully appreciate the great blessing of vaccination to mankind, for since its discovery, small-pox, in civilized countries, has ceased to be so general or to manifest itself in such wide-spread destruction. And yet, if it were possible at once to remove the protection which mankind now enjoy by this practice, no one can doubt but that the horrors of the last century would return upon us.

It is without doubt true that neither lapse of time nor any improved mode of treatment have served to materially change its malignancy or fatality. Dr. Jurin, as quoted by Seaton, writing early in the last century, laid it down as the result of his investigations, that of persons of all ages taken ill of natural small-pox, there will die one in five or six. Statistics of hospital reports gathered up during the first quarter of the last century show that from twentyfive to thirty-three per cent. of all cases die. We have only to study the disease as it has appeared from time to time in the large cities of our own country in an epidemic form, to be convinced

of the fact that the fatality of the disease has undergone up to the present time little or no essential change.

During the epidemic which prevailed in the city of Mobile in the winter of 1874-75, the percentage of deaths to cases was 26.46, while in 1873, in the same city, when yellow fever was epidemic, the death rate for that disease was only 15 per cent., showing a fatality of the former disease of nearly double that of the latter.

In 1865, during an epidemic of sinall-pox in London, in the small-pox hospital 47 per cent. of the unvaccinated died. In the same year, in Berlin, the percentage of deaths was 42, including hospital and private practice. During the years 1873-74 and 1875, in the city of New Orleans, there were 3,149 cases of small-pox with 1,307 deaths, a per cent. of 41.29. In 1868-9 it was epidemic in San Francisco, Cincinnati, and many other cities, but in these two places especially it claimed a large tribute of human life. At these points its manifestations were as malignant and the mortality among those attacked as great as at any period before the discovery of vaccination. It is reported to have been if possible more severe in private than in hospital practice. Dr. F. W. Hatch, the present secretary of the California State Board of Health, reported, in both private and hospital practice an average death-rate of one in three cases. Dr. Logan, in his report of cases in San Francisco and Sacramento, gives even a larger per cent. of mortality, and he justly remarks, "this fatality is almost unprecedented in the annals of this disease."

During this same season many of the Indian tribes were visited by this disease, and the ravages were said to be fearful. Whole encampments were attacked and large numbers swept off.* In Cincinnati the deaths were one in every five and a fraction. During the winter of 1876, this same city has been visited with as extensive an epidemic and nearly if not quite as fatal a ratio. At the present writing, August, 1876, San Francisco is again paying the fearful penalty, in human lives, for great neglect of preventable measures, while passing through another epidemic as malignant and fatal as that of 1868-9.

These facts are grouped together to impress the mind with the fact that this loathsome disease has lost nothing of its virulence and fatality, but that, given as favorable soil in which to work, it goes abroad among the cities of the land now, as a century or more ago, "the most terrible of all the ministries of death." They forcibly impress the mind with the criminal neglect of the people, that while it is so preventable a disease, and the means of prevention are so ample and reliable, it is permitted to stalk abroad, destroying one in every three or five it attacks, "blasting the beauty of the rest, and bringing distress and desolation into thousands of homes and human hearts.

The mortuary tables of nearly all our large cities duplicate the above facts, showing that everywhere among the unvaccinated and unprotected, this disease is as fearful in its harvest of death as in olden times.

* Sre W. B. Davis' report on vaccination.

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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 city 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.'

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.'

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