The testimony of the recent epidemic in Illinois is fully corroborative of every claim thus made. Small-pox proved to be as destructive as in any epidemic of the pre-vaccination period wherever its contagion was introduced among the unvaccinated-the mortality rising, in this class, to over fifty per cent. On the other hand, just in proportion as vaccination and revaccination had been efficiently performed, that mortality was diminished-falling from a death-rate of over forty-four in every one hundred attacked who had been unsuccessfully vaccinated, to absolutely no deaths among the few who, having been previously efficiently vaccinated, were still attacked with the disease, but were again successfully vaccinated after exposure. The duration of the disease, its severity, and its results were all found to bear a direct relation to the vaccinal history of the patient; where this was nil, there was the longest duration (except where terminated by death) the greatest severity, and the most disastrous sequela; where the vaccinal history was good, the disease was mild, often of only a few days' duration, and never followed by disfigurement, loss of sight or hearing, or by other disability. And, lastly, it was found that, after the contagion had obtained a foothold in a community where vaccination had been neglected, no enforcement of sanitary measures, nor isolation of cases, then availed to restrict the epidemic influence or tendency until vaccination and revaccination had been made general.

The preceding pages contain in fullest detail, and from a variety of sources, the abundant proof of these assertions. In the Tables, Notes and Comments, in the Details of Local Outbreaks, in the Tabular Statement of 1100 Cases, with its rich and copious Notes, in the Statistical Results of the School Vaccination Order, and in the Vaccination Records and Experience of Physicians, there is a mass of facts presented which amounts to a demonstration of the value of vaccination, and of its entire adequacy, when universally and properly performed, to positively make small-pox of as little effect, among the evils besetting the life and health of the citizen of the State, as any extinct epidemic of the middle ages. A brief consideration of the causes which have led to the apparent comparative failure of this absolutely certain preventive of small-pox, and some indications for the removal or correction of these causes, seem to be a fitting conclusion to this report on the Small-Pox Epidemic of 1880-82.

THE NEGLECT OF VACCINATION AND ITS REMEDY.

Even in those countries of the Old World where vaccination is more or less rigidly enforced by law, a very considerable proportion of the population, varying from three to more than fifteen per cent., is found to be unvaccinated. In this country, except in Massachusetts, there has never been any successful attempt to legally enforce the operation by State law, although such laws have been enacted from time to time. In Illinois, the subject had heretofore been relegated to the municipal authorities; and, except in Chicago, and a few other of the larger cities and towns, no effort had ever been made to secure the general vaccination, even of school-childrenthe result being that, as elsewhere shown in these pages, fully onethird of the population of the State was unprotected and susceptible to small-pox at the beginning of the recent epidemic.

When, at its special meeting in November, 1881, the STATE BOARD OF HEALTH decided to secure the vaccinal protection of schoolchildren, it was confronted with certain considerations which, for a time, caused some hesitation. To what extent was it justifiable to compel vaccination when the supply and quality of vaccine material could not be controled? When even many physicians, to say nothing of the laity, looked upon the operation as a mere scratching of the skin? When the majority of medical colleges regarded it as too insignificant to devote a single lecture to, and conferred degrees upon men who had never seen a vaccine vesicle?

An eminent sanitary authority, Dr. Elisha Harris, of New York, has laid down the following, as essential conditions which the State should secure before attempting to enforce compulsory vaccination:

I. That the quality of the vaccine lymph shall be absolutely perfect, and that the insuring of this uniform excellence shall not be permitted to be subject to uncertainty or any kind of capricious. judgment [or commercial exigencies.]

II. That no barriers of poverty, ignorance, or the inaccessibility of means, shall prevent the administration of the vaccination which each child needs.

III. That every parent and custodian of children, and every other person susceptible to small-pox, and every medical practitioner, shall, by timely and adequate provision of the State and local sanitary authorities, be wholly without excuse for failing to have conveniently accessible the needed supply of perfect vaccine virus, and whatever is needed in the nature of information, instruction and a personal record.

IV. That whatever is ordered or required by the public authorities to be performed in respect of vaccination, the laws should enable and require the same authorities to insure being performed, and should give to the people, as well as to the authorities, such necessary means of information and instruction as shall suitably prepare them to understand and perform their duties.

The wisdom and the justice of these propositions are fully admitted; but, on the other hand, there was an imminent public calamity which it was believed possible to avert, in large measure, by promptly securing thorough vaccination and revaccination to as great a degree as possible. In this dilemma, the BOARD adopted that middle course in which the Latin poet says lies safety; and, while not making the vaccination of school-children absolutely compulsory, ordered that no scholar should be admitted to school "without presenting satisfactory evidence of proper and successful vaccination." By enforcing this rule the safety and welfare of the schools, as a whole, as well as the personal rights of those scholars who, notwithstanding their vaccination, still remained susceptible to smallpox, would be secured, without interfering with the individual rights of those opposed to vaccination, except to the extent of abridging their school facilities. It was a question of the greatest good to the greatest number, with the least evil to any; and upon this basis. the question was disposed of, for the time being. Supplementing this school order, effort was made in various other directions to

secure the vaccination and revaccination of as many others as could be reached, by circulars, letters and other means, which were mandatory, instructional, or advisory, as the case seemed to require.

The situation was gravely complicated by the difficulty of procuring pure vaccine material-sometimes of procuring any; by the results of the operation improperly performed; and, in not a few instances, by the pecuniary question. Compulsory vaccination by State law was demonstrated to be impracticable under existing conditions; and the conclusions finally arrived at may be thus formulated on the lines already laid down by Dr. Harris:

First-The practice of vaccination has fallen into neglect through the failure of medical colleges to impart, and of the medical profession to acquire, a thorough knowledge of the essentials of vaccination; through a frequent belittling of the operation, a slurring of details, and a reprehensible carelessness on the part of those who possess the necessary knowledge; through the use of imperfect or improper vaccine material; and through the want of such secular knowledge, concerning its value and importance, as it is clearly the duty of the family physician and of sanitary authorities to disseminate.

Second-The most scrupulous care in the selection of vaccine material; the greatest skill in vaccination; the faithful observation and record of result; the exercise of good judgment concerning the quality and perfectness of the operation and its results; the faithful testing (by Bryce's method, or a revaccination,) in every case in which the sufficiency of the primary vaccinal operation may be reasonably doubted; the revaccination of every child after the period of puberty; the exercise of tact and patience in the persuasion of the ignorant and prejudiced; and, finally, the systematic registration of vaccinated infants and all older children in our country, are essential requisites in the system for securing a trustworthy and universal protection against small-pox.

Third-That, inasmuch as even these protective measures cannot be secured in any city or State without the accessory facilities which only a State system of registration of births can afford, all experience shows that a judicious system of medical and official notification and instruction to parents, when supervised by competent minds, becomes one of the most effective agencies in securing the timely and cheerful compliance with the duty of vaccinating every infant. The Scottish, English, French and German laws and official methods for securing vaccination of infants are complete examples as respects the system of procedure in providing for public vaccination; but the faultiness in the qualities of the vaccinal virus employed, the frequent carelessness of vaccinators, and the want of adequate instruction to parents and care-takers of children are great drawbacks upon the success and popularity or acceptableness of obligatory vaccination. These circumstances need not be drawbacks in this country, if we infuse and vitalize the vaccinal system which shall be adopted with the instruction, and the inquisitive criticism which Americans are wont to give to matters of public sanitary duty.

Fourth-The encouragement of official supervision of the supply of vaccine material, which shall be kept continually under a system of registered observation and testing for the maintenance of the perfection of its attributes, is plainly a duty of the first importance; and wherever a State Board of Health is formed, or a municipal sanitary board is endowed with sufficient authority and means, it should maintain, or at least supervise, such a system of vaccinal supply. It is by no means necessary to wait for the organization and development of a complete sanitary system, nor for the perfecting of birth registry, before providing a perfect standard and a public supply of vaccinal lymph.

Fifth-No code of obligatory laws or regulations for general vaccination should be framed which does not provide for adequate instruction and the best safeguards to secure perfect vaccination. The laws for the purpose, the rules and methods of administration under the laws, even when compulsory, can and should be so ordered as to avoid the needless incitement of ignorant prejudice and wanton opposition.

Sixth-State boards of health and the sanitary authorities in each city and town of the respective States may greatly expedite the securing of general vaccination, by uniting in efforts to secure ample diffusion of correct knowledge concerning the merits and duty of vaccination among all classes of people, and providing methods for supplying perfect vaccine virus and an effective system of practical instruction in vaccinating.

Seventh-In large cities and populous districts regular vaccinating days, at intervals of one week, are established by all experienced public vaccinators and by the best family physicians, for the duty of inspecting every vesicle and vaccine at the expiration of about seven days; the importance of facilities on particular days for fresh lymph and arm-to-arm vaccination with it, as well as the practical relation of habit and regularity in any duty or service which is liable to procrastination or neglect, require that in every city and large town the public health authorities, or the medical profession, shall see to it, that on a designated day and hour and in suitable places, the public vaccination shall be offered. In like manner, medical practitioners-especially when serving the poor-may greatly facilitate and insure the best results of the duty they owe to families, by designating one day in the week for replenishing their own stock of vaccinal virus, inspecting every vaccinated person of the previous week, and vaccinating others then requiring it. Vaccinating days and the seventh or eighth day inspection must be regarded as essential to the success as well as to the general popularity and universal application of vaccination. In sparsely-settled communities and in country practice, the difficulties in the way of arm-to-arm vaccination will often be found insuperable; and recourse must be had, in such cases, to the stored lymph, the crust, or the bovine. point. This, however, should not be held to absolve the physician from the imperative duty of examining the vesicle, and the resulting cicatrix, at the proper times, and of certifying to the character of the vaccinal protection secured.

Eighth.-Vaccination is so truly within the domain of medical science and practice, that no official and public system, however compulsory it may be, can wholly supersede the duty of family physicians in the vaccination of families of the more intelligent classes; and for this reason, and for awakening the scrupulous concern of physicians for the maintenance of perfect means and efficacy in private, as well as public, vaccination, the official method relating to the subject needs to be adopted to secure mutual efforts on the part of the family practitioners and the sanitary authorities, and so to render the protection against small-pox universal and perfect.

Ninth. Experience in various countries, as well as in our own State, now proves that a State or a nation may justifiably require that in all departments of public employment in which there is such liability to the contagion and dissemination of small-pox as would embarrass the public service or injure the people, it should be an established rule of all official and subordinate service in that department, that each individual shall present certified testimony of vaccination, or other protection against small-pox.

Tenth. In all schools, colleges, universities, penal and reformatory institutions, asylums, and factories, there should be an established rule, requiring that every individual therein shall present certified evidence of vaccination, or other protection against smallpox.

Eleventh.-Experience in the best governed States and cities altogether confirms the correctness of the principle and practicability of the laws which require that such rules as are specified under the last two preceding conclusions should be supervised by sanitary authority.

Twelfth.-Obligatory vaccination is not in danger of becoming odious to the people, if the law, and the practice under it, provide for perfect accuracy in the operation itself; for the maintenance and care of a perfect standard vaccinal supply; for the critical observation of results in its application; and for maintaining a system which, as Mr. Simon truly says, "from beginning to end, and from center to circumference, requires, in all its parts, to be vitalized by the science of medicine." In maintaining such a system of obligatory vaccination, the conclusion of John Stuart Mill, in regard to "the limits of the province of government," aptly applies: that when a government provides means for fulfilling a certain end, leaving individuals free to avail themselves of different means, there is no infringement of liberty, no irksome or degrading restraint. One of the principal objections to government restraint is then absent." The means, the motives, and all needed instructions can so prepare the way for the duty of vaccination that universal obedience to the public laws concerning it will be promptly rendered.

Until, however, these means are provided; until medical instructors include the practice of vaccination among the subjects of importance in the lecture-room and dispensary; until physicians and the public are impressed with the value and the dignity of the operation; the enforcement of compulsory vaccination must, necessarily, be more or less unsatisfactory and defective. But with these