DANGERS AND COMPLICATIONS

The alleged danger from vaccination has been greatly magnified by the antivaccinationists. However, vaccination is not always a harmless procedure; it must be looked upon as the production of an acute infectious disease, and, although the disease is always mild and trivial, it must not be treated as trifling. The chief danger lies in the fact that we have produced an open wound, which is subject to the complications of any wound. Even a pin prick or a razor scratch may result in death. While the aggregate number of deaths resulting from the complications of vaccination may be considerable, the aggregate of the individual risk is so small as to be disregarded, especially when proper precautions are taken. Many of the infections after vaccination occur in those in whom the regard for cleanliness is slight, and who neglect the site of the wound. In recent years, owing to the improved quality of the vaccine virus and the introduction of aseptic methods, a bad sore arm is a rare occurrence, and serious complications still rarer. In any case, the danger connected with vaccination is infinitesimal when compared with the benefit conferred. The important complications are:

Auto Vaccination. This is usually due to scratching the virus into the finger, the nose, the mouth, the mucous membranes, or any part of the skin. When carried into the eye it may cause blindness. Physicians sometimes vaccinate their lips by blowing into vaccine tubes. In vaccine establishments accidental vaccination of the hand is common.

Generalized Vaccination.-This is sometimes reported, but is usually a mistaken diagnosis. A generalized eruption of cowpox is exceedingly rare, if it ever occurs. I have seen it in the calf after intravenous injection of a large amount of the virus, in which case there is a prolonged period of incubation.

Wound infections, such as ulcers, gangrene, erysipelas, abscesses, lymphangitis, suppuration of the axillary glands, and other septic infections are now exceedingly rare, and should be treated with the usual measures to prevent their occurrence.

Impetigo contagiosa occasionally occurs and may be a serious complication of vaccination, especially the bullous impetigo or pemphigoid forms, which presumably have their origin in cattle.

Syphilis, tuberculosis, and leprosy are sometimes feared, but these are practically impossible with the use of bovine virus. In any case it is doubtful whether tuberculosis or leprosy could be so transferred.

Tetanus deserves a special word. Several outbreaks have been reported in this country after the use of certain viruses. Willson in 1902 found tetanus spores in the vaccine virus used in a New Jersey outbreak. Glycerin does not destroy the tetanus spore. Many hundreds of

examinations made in the Hygienic Laboratory at Washington have failed to discover a tetanus spore in a single vaccine point or tube. The occasional danger cannot be denied. It is probable, however, that the infection in some of these cases comes from outside sources.

The occurrence of occasional stray spores in vaccine virus was demonstrated by Carini. Such vaccine, however, had proved entirely harmless in thousands of cases. It is more than probable that the actual danger would begin if such occasional stray spores were allowed to germinate in the vaccine pulp through some serious fault in manipulation. It is conceivable that the vaccine pulp after removal from the calf or heifer, if not at once chilled, or if not at once mixed with glycerin, may form a very rich medium for anaerobic bacteria. Some carelessness or neglect just at this stage might prove disastrous if tetanus spores accidentally present should multiply. The epidemic in this country in 1902 reported by Willson and MacFarland may have been the result of some such occurrence. On the other hand, neglected vaccination wounds or those in which proper bandages or shields favor anaerobiosis may stimulate the germination of spores coming from without and lead to the occasional reported sporadic cases following vaccination.

To prevent tetanus complications it is important to avoid scarification and irritation, also to avoid the use of shields and bandages which favor anaerobic conditions; to practice strict cleanliness, and to use vaccine virus that has been properly prepared and tested. Special tests for tetanus are now required by federal regulations of every lot of vaccine virus before it is placed upon the market.

Foot and Mouth Disease.-The infection of foot and mouth disease has in one instance been demonstrated as a contamination of vaccine virus. It is, however, impossible to convey foot and mouth disease to man through cutaneous inoculation. While no harm has been done to man, the contamination is undesirable, and special federal regulations now require vaccine virus to be tested from time to time to assure its freedom from this infection.

As an illustration of how seldom complications are caused by vaccination we have the results of Germany, where in thirteen years (18851893) 32,166,619 children were vaccinated. Of these 115 died within a few weeks or months after the operation, presumably of injuries incidental thereto. Of these at least 48 probably did not die as a direct result of the vaccination.

The figures of recent years are still better, for it is now exceedingly rare for a death to be recorded as directly due to vaccination. For

1Centralbl. f. Bakt., Orig. 1904, XXXVII, p. 1147.

"Jour. A. M. A., 1902, XXXVIII, p. 1147.

Jour. Med. Research, 1902, n. s. II, p. 474.

* Mohler and Rosenau, U. S. Dept. of Agriculture, B. A. I. Circular 147, June 16, 1909.

example, in the Philippine Islands in the past few years the United States authorities vaccinated 3,515,000 persons without a single death or any serious post-vaccinal complications.

THE GOVERNMENT CONTROL OF VACCINE VIRUS

By the law of July 1, 1902, the vaccine virus sold in interstate traffic in the United States must come from a licensed manufacturer. These licenses are issued by the Secretary of the Treasury only after a careful inspection of the plant, personnel, and product by a competent government officer. The licenses are good for one year only, and are reissued only after reinspection. The government regulations require each lot of vaccine virus to be examined carefully by modern bacteriological methods to determine the number of bacteria, and special tests must be made to determine the absence of pathogenic microorganisms. These tests include animal inoculations, as well as cultural methods. Special tests for each lot of vaccine must be made to determine the presence or absence of streptococci, tetanus spores, foot and mouth infections, etc. The government does not guarantee the purity and potency of each package of vaccine virus, but through its inspections and frequent examinations of the virus on the market every confidence may now be had in the vaccine virus propagated by licensed manufacturers in this country.

THE UNITY OF COWPOX AND SMALLPOX

The unity or duality of these two diseases has been the subject of much contention. Jenner originally considered cowpox to be a modified smallpox. The successful experiments in Germany, England, and this country, in which smallpox has actually been modified by passing variolous matter through calves has proved positively that we are dealing with two forms of one disease. Much of the vaccine virus used during the past hundred years was originally obtained from cases of casual cowpox. This virus has been shown by experience and experiments to protect against smallpox, which makes it highly probable that we are dealing with one disease. The parasite Cytorrhyctes variola, discovered by Councilman, Brinckerhoff, and Tyzzer, gives a probable explanation of how smallpox may, under certain circumstances, become attenuated. The life cycle of this parasite interpreted by Calkins indicates that the mild disease, cowpox or vaccinia, is due to the asexual phase in the life cycle of the parasite which lives and multiplies in the cytoplasm of the epithelial cell; smallpox is caused by the combined asexual and sexual cycle of the same parasite, the latter phase occurring in the nucleus of the epithelial cell. When the Cytorrhyctes variola loses its power to generate by sexual division it never again regains it; that is, while small

pox may be modified into cowpox, cowpox has never been returned to smallpox.

It seems plain that much of the so-called casual cowpox probably has its origin from smallpox through accidental inoculation in milking or handling these animals by persons having or recovering from variola. Once started, the propagation of the modified virus from cow to cow would be comparatively simple.

COMPULSORY VACCINATION

Vaccination affords a high degree of immunity to the individual, and a well-nigh perfect protection to the community. To remain unvaccinated is selfish in that such persons steal a certain measure of protection from the community on account of the barrier of vaccinated persons around them.

1

The laws and regulations relating to vaccination in the several states of the United States show marked lack of uniformity. Compulsory general vaccination can be said to exist by law only in Kentucky, Rhode Island, and Porto Rico. Arizona, Hawaii, Maryland, New Mexico, North Dakota have laws requiring vaccination of children. In recent years smallpox has been so mild in the United States that the case death rate has been as low as 0.2 per cent., or 1 death in 500 cases.

Decisions in the various courts in the United States have held compulsory vaccination to be legal. A decision of the Supreme Court of the United States (Henning Jacobson vs. The Commonwealth of Massachusetts, April 1, 1905) upheld in every respect the statute, the validity of which was questioned under the Constitution.

The liberty secured by the Constitution of the United States does not impart an absolute right in each person to be, at all times, and in all circumstances, wholly freed from restraint. Real liberty for all could not exist under the operation of a principle which recognizes the right of each individual person to use his own, whether in respect to his person or his property, regardless of the injury that may be done to others.

Theoretically it would be ideal if all persons submitted to vaccination and revaccination voluntarily. But experience has shown that this is impractical, and, wherever tried, has failed. The best results have always been obtained where vaccination has been compulsory, and, in my judgment, this is the only present means by which smallpox may be eliminated. The world may learn a valuable lesson from the splendid results obtained in Germany through compulsory vaccination and revaccina1 Kerr, J. W., “Vaccination, and Analysis of the Laws and Regulations Relating Thereto in Force in the United States," Public Health Bull. 52.

2 Massachusetts, in 1809, was the first state to enact legislation relative to vaccination.

tion. In England the "conscience clause" allows many persons to remain unvaccinated and thereby seriously diminishes the effects of the vaccination laws of that land. In Minnesota the state health authorities became weary of the clamor against compulsory vaccination and assisted in having the law repealed. They said, in substance, to the people of the state: "Take your choice. Be vaccinated and protect yourself, or run the risk of contracting smallpox; if you get it, it is your own fault."

TABLE 1.-DEATHS FROM SMALLPOX IN COUNTRIES WITH COMPULSORY VACCINATION AND THOSE WITHOUT COMPULSORY VACCINATION

The practice of inoculation must be carefully distinguished from that of vaccination. By inoculation we mean the introduction of smallpox matter into the skin of man. The disease thus produced is usually very mild, but is nevertheless true smallpox, and just as contagious as smallpox.

This phase of the subject may be made clearer by considering smallpox as existing in three forms: (1) variola vera or true smallpox; (2) variola inoculata or inoculated smallpox; (3) vaccinia, cowpox, or modified smallpox. The differences between these affections are shown in the table on the following page.

Emphasis must be placed on the fact that variola inoculata, while usually a mild disease, is just as communicable as true smallpox, and those who contract the disease in this way get true smallpox, often in serious or fatal form. Inoculation, therefore, protects the individual but endangers the community.