had not already had the inoculated form, you might be surprised by the distemper whilst staying in the house of great families, and so endanger them." The actual operation was very simple. About five or six drops of pus, taken from the pustule of some young person who had small-pox of a mild type, were procured. Two small wounds were made, generally one in the arm and one in the opposite leg of the person to be inoculated, and little pieces of lint soaked in the pus were applied to the wounds, and a bandage placed over them. The actual operation, however, was but a very small part of the affair; the preparatory treatment lasted commonly a month, and medical attendance was frequently necessary for five or six weeks longer. The expense in one way and another was great, and consequently the practice of inoculation was very largely confined to the well-to-do classes. It was impossible also to conceal the fact that many deaths had occurred, and therefore timid people hesitated to undergo themselves, or subject their children to the risk, and the poor were unable to bear the cost. The inoculated attack of small-pox ran a course in every way much resembling that of a very mild attack contracted in the ordinary way. 66 I will read you the notes of two cases, which will bring before you far more vividly than any words of my own can do, what people were willing to undergo a hundred and eighty years ago to endeavour to escape the mere chance of this disease. They are taken from a work on eruptive fevers, called Exanthematologia," written by Dr. Thomas Fuller, and first published in 1730. Fuller was born in 1654, and died in 1734, and practised nearly the whole of his life in a small country village in Kent. He had a most original mind, and this book would well repay an idle hour or two spent over it. He was an enthusiastic advocate of inoculation, and practised it with very great success, many people travelling from London to be under his care. The first case is that of E. C., a maid of 21 years old 1st Day. Inoculated. In the Morning the Orifices a little grayish. Blackish. Blackish, and the Lips of the Incisions inflamed. The Blackness went off; the Lips were more inflamed; towards evening she shivered a little. The Inflammations were quite gone; the Orifices were pretty well; her Head and Back ached; she was sick at times. Sickness at times, and Pain in her Head and Back continued. In the Morning the Incisions had discharged much; but towards Night again, very little. In the Morning the Incisions had run well, and she was not so sick as before; but in the Evening she had two Vomits, and two loose Stools; one Pock then appeared on her Throat. The Incisions discharged plentifully; her Sickness abated; she had troublesome 10th Day. The Heat of her Soles went off. Now she was much better. The Pustles continued coming out, but looked pale. She slept badly. 11th 12th 13th 14th 15th 16th 17th 18th 19th The Pustles grew redder, and she slept better. The Pustles rose well. She had a Sore Her Throat grew sorer, and Salivation in- The Soreness of her Throat grew something She found herself perfectly well. This was a perfectly normal case, and is typical of almost all those described. In each there were the same symptoms-the septic condition of the incision, the pain in the back, the sickness and the eruption. The temperature, of course, is not recorded. In many salivation and sore throat were present, and in all, the patients were ill for about three weeks. The other case I will read to you is of moral as well as medical interest : W. Jeffrey, of Sevenoak, in Kent, was about 25 years of age, naturally of a good constitution, but had broken it by giving himself up to drinking strong beer, and, as I think, common spirits, which occasioned frequently pimples in his face, and rendered him subject to a cough, shortness of breath, and inflammatory distempers in his breast, stitches, and rheumatic pains. Add to all this, I have heard, that never any of his blood that had the Small pox recovered He came from London thirteen days before his inoculation; and it's very likely, had both heated his blood by drinking, and also taken infection. For some days before the operation he felt aguish shiverings, much uneasiness, and shootings in his limbs, which he would not make known, as he afterwards confessed, for fear inoculation should be refused him. Ist Day, Oct. 28. Towards Night (having not been let Blood, Vomited, nor Purg'd), he was inoculated. He walked four miles to an Ale-house to drink strong Beer, and Back again in the Evening. That Night he felt Shiverings and Anguish. He was not very well, and in the Night had some Gripes, and two loose Stools, but 4th Day. Being some little matter better, he walked to the same Ale-house and back again, on the same Errand. 5th 6th 7th 8th 9th 10th 11th He was very much out of order all Day. He grew downright sick; vomited, but not They broke out in great Numbers, with He began to spit a little, but that continued but a Day or two, and then went entirely off again, and came no more. During the whole Sickness he seemed not perfectly sensible, and had very little Sleep. 12th,, A Fever (which had not shew'd itself before) rose a little, but came to no great Height. His Urine flow'd away involuntarily and insensibly. 13th 14th This is the only Case that ever I have myself seen of one that dy'd under Inoculation, and I must think that no one who reads this account can possibly have so much partiality and perverseness as to say he dy'd by inoculation. The date of these cases was about 1725. The first actual inoculation in England was in 1721, and during the next eight years the number of persons inoculated was 845. Of this number 17 died of the disease, roughly about 1 in 50, a much lessened mortality when compared to the 1 in 5 of ordinary small-pox, but a sufficiently high death rate to impede the progress of the discovery. For the first twenty it had almost fallen into disuse. At this time very favourable accounts of the benefits conferred by inoculation were brought from America and the West Indies. The practice revived and spread quickly, and in 1746 the Small-Pox Hospital of London was founded for the purpose of inoculating the poor, and keeping the patients distinct from the general population. In 1754 the College of Physicians declared their approbation of the practice, but the subsequent popularity of it was much more due to the work of the Suttons and others who introduced a greatly improved method of treating their patients. The Suttons, two brothers, Robert and Daniel, were not qualified men, but their method of treatment was very good, avowedly modelled on that of Sydenham, and they claimed to have inoculated 20,000 people without a single death. This was doubtless, an exaggeration ; probably the average general mortality from inoculation was about one death in 500 cases, and that of the Suttons may have been a little less. It was now, when the benefits to be gained from it were getting known, that the one fatal objection to it became apparent. The wise regulation of the Small-Pox Hospital to keep all patients apart from the healthy population was very soon departed from-all who applied at the gate were inoculated, and suffered to wander through the streets covered with pustules, and diffusing infection to all around. The disease was carried through the land, and the chances of catching it were greatly increased. It was produced artificially in many more than would probably have caught it naturally, and therefore became much more common. In other words, although the relative mortality was lessened, the absolute mortality from Small-Pox was fearfully increased. In 1752 there were 3,538 deaths from Small-Pox-a number exceeding that of any former year. During the first thirty years of the 18th century, out of every 1,000 deaths the number attributed to small-pox was 74. During the last thirty years, when the effect of inoculation was making itself felt, the number had increased to 95. Thus we see that at the end of the 18th century, in spite of all medical exertion, the mortality from small-pox had progressively increased, and the disease was a more terrible scourge than it had ever been before, when in June, 1798, Jenner published his "Inquiry into the Causes and Effects of Variola Vaccinee." Jenner was born in 1749, and was therefore nearly fifty years of age when his Inquiry was published, but there is clear evidence that the idea of the possibility of preventing small-pox by the inoculation of a different disease had been in his mind from the time he was very little more than twenty. During the intervening thirty years he was observing and recording facts, and making experiments to prove the truth of the ideas he deduced from his observations. Jenner was above all things an observer. Others, before his time, had noted that small-pox did not attack those who had previously been affected with cow-pox; but he was the first to realise what would be the result of a general application of this fact. This protective influence of cow-pox had long been recognised in dairy farming districts both in England published about it in a German paper. In 1791 a village schoolmaster in Kiel inoculated three children from a cow, and these children were afterwards found to be proof against small-pox. In 1774 a farmer in Dorsetshire, named Jesty, purposely introduced cowpox matter into his wife and sons to protect them from small-pox. Jenner's original work consisted in formulating the theory that the "protective influence of vaccine lymph might be continued for ever by inoculation from one human being to another," and proving this theory by direct experiment. Jenner was apprenticed to a country practitioner at Sodbury ; and it was whilst working with him that the popular idea about cow-pox was first brought to his notice. On leaving here in 1770 he went to London to continue his medical studies, and lived and worked for three years with the great John Hunter. With him Jenner was on the most intimate terms; for many years they kept up a frequent correspondence, and it is an interesting speculation as to how much Hunter's enthusiasm and insistence on original observation influenced Jenner in working out vaccination. Jenner's first recorded communication on the subject was made in 1780, in the course of a conversation with a friend, and from this time onward he was engaged in making experiments, learning and investigating the nature of cow-pox and allied diseases in animals, and trying to interest his friends in the same research. In 1789 he inoculated his eldest son, aged about eighteen months, with swine-pox matter, and the child was afterwards twice inoculated with variola; the symptoms as described on the second occasion rather resembling a very mild attack of small-pox. For some years afterwards his work seems to have been directed to trying to demonstrate a conection between "Grease" in horses and cowpox, without succeeding; and it was not until 1796 that an opportunity occurred of proving whether it was possible to propagate the affection (cow-pox) by direct inoculation from one human being to another. On May 14th, 1796, matter was taken from the hand of a dairymaid who had been accidentally infected by her mistress's cows, and was inserted into the arms of James Phipps, a healthy boy of about eight. The boy had cow-pox, and Jenner, who had never before seen the disease except when casually contracted from cows, was astonished at the close resemblance of the pustules thus artificially produced to the natural disease. The most anxious part of the experiment, however, still remained to be performed. In the following July the boy was inoculated with small-pox, and Jenner's prediction that this would have no effect was triumphantly fulfilled. Jenner's experiments were interrupted after this by the disappearance of cowpox from the dairies, but an outbreak occurred again early in 1798. The work was resumed, and in June of this year he published his results in the book to which I have already referred. The reception that this book met with, and the enthusiasm it created were extraordinary. Within a very few years of its appearance it had been translated into many languages, and a knowledge of Jenner's method of preventing smallpox had spread to every civilised country. duction of vaccination. If, eighty years before, variolous inoculation, which had stood the test of years in other countries, could not be brought here without exciting objections, vaccination, a new thing, could not expect to be received by the ignorant without much doubt and misgiving. The opposition, however, was not very scientific, and most of the objections brought forward were more comic than serious. A child at Peckham became quite brutal after vaccination, ran on all fours, and bellowed like a bull. A woman's face was distorted and resembled a cow. A boy turned into an ox. One girl coughed like a cow, and another grew hair all over her body. Many people grew horns, and the moral effects were even more terrible than the physical. Curiously enough the medical profession was by no means unanimously in favour of Jenner's discovery, and many pamphlets and articles were written against it by doctors. The proof, however, of the truth was too easy, for any but the most prejudiced to remain long in doubt. Minute enquiry was made into individual cases. In those days the original observer was more happily situated than we are now, so far, at all events, as small-pox was concerned, and did not have to depend on guinea pigs for his experimental material. In thousands of instances, the patient, after being vaccinated was deliberately tested by inoculation with smallpox, and the results of these experiments were sufficiently uniform to convince public judgment. In 1807 the College of Physicians, after a long and careful enquiry, reported strongly in favour of Vaccination, and the practice became firmly established. From that time, to the present day, Vaccination has been the subject of much legislation, many enquiries and commissions, and an enormous amount of controversy. The first vaccination law was passed in 1840. It provided gratuitous vaccination, and by one of its clauses made small-pox inoculation penal. In 1854, Vaccination was made compulsory, but was not enforced. From 1872 it was more rigidly enforced till recent years, when it generally became relaxed-and the last act is of course familiar to us all. I do not intend to weary you by going into statistics, and I have no wish to send you all to sleep by reading even a thousandth part of the mass of figures, official and otherwise, that have been published on the subject of vaccination-a few facts are, however, both necessary and interesting. Śmail-Pox reached its highest point in 1796, two years before the publication of the "Inquiry," when 18 out of every 100 deaths were caused by it. From 1770 to 1880 small-pox caused 9.5 per cent. of the total deaths; during the next 30 years the average was 4.5 per cent. In 1871, the year of the great epidemic, the deaths from small-pox were 9.8 of the total deaths-a number very little in excess of the average yearly number in the thirty years preceding vaccination. The death rate from small-pox per million inhabitants since 1847 has varied from one in 1889-90 to 1,012 in 1871. In 1896 there were 541 deaths from small-pox in England and Wales, of which 443 occurred in Gloucester alone-during the first half of 1896, the total mortality of that city was cent. In 1898, the deaths from small-pox numbered 258, and were equal to a rate of eight per million of the population. Between the passing of the two first Acts, the practice of vaccination grew gradually but slowly, especially among the infantile population. In the five years from 1848 to 1852, the average births in England were 568,000, and the infantile vaccination only 180,000. In 1854, the first year after the compulsory Act, the number of infant vaccinations was more than double, and the total vaccinations at all ages exceeded the births by 75,000. Vaccination, though compulsory, was not enforced, and the result was a steady decline in the number of children vaccinated in the following years. In 1857 the whole subject was carefully reviewed in a report to the Board of Health by Sir John Simon, a report containing a complete history of small-pox and vaccination up to that time, and one to which most subsequent writers are much indebted. In this report several suggestions were made, and as a result various Acts were passed at different times, intended to enforce vaccination, but without any great effect. I can only briefly refer to the epidemic of 1871, which has been frequently quoted by anti-vaccinators to show the inutility of vaccination. It is usual to compare this year with the preceding thirty during which vaccination had been in operation, and to argue that the practice had failed. It is forgotten that it had not been properly enforced during those thirty years. If we define an epidemic" as an outbreak causing one-tenth or more of the total deaths from all causes in any given year, then we find that in London, in the last half of the seventeenth century, there were ten epidemics of small-pox, twenty-nine in the eighteenth, and none at all in the nineteenth. If we take the lower number of 75 per cent., then in the eighteenth century there were sixty such outbreaks, and in the nineteenth only four. The worst year under vaccination in London was 1871 (7,912 deaths), when barely 4 per cent. of the total deaths were due to small-pox, a proportion which exceeded in the eighteenth century-before vaccination-ninety-three times. was I do not want to introduce any controversial matter into any paper, and time would not permit us this evening to go into the various arguments for and against vaccination. A Royal Commission was appointed in 1891 to finally settle the matter, and I would advise all who are interested in the subject to read its final report, published in August, 1896, not the previous ones (there are altogether fifteen volumes and life is short). The Commission failed to find anything or any means to take the place of vaccination. Referring to the plan generally known as the Leicester system, or immediate isolation of suspected cases, the Commissioners say: "We can see nothing then to warrant the conclusion that in this country vaccination might safely be abandoned and replaced by a system of isolation. . . We are very far from underrating the value of a system of isolation . . but is one thing; whether it can be relied on in its stead is quite another thing" (final report, par. 503, p. 131). The Australian system, which includes the compulsory removal to quarantine for 21 days of all contacts, in addition to the transfer of the patient himself to a hospital, is no doubt theoreticaly excellent -for Australia-but as the Commissioners say (paragraph 500)" It is obvious that in this country the practical difficulties of working such a scheme in the large towns would be really insuperable." The recommendations of the Commission were embodied in the Vaccination Act of 1898, an Act which for all practical purposes removed every trace of compulsion, and left every child at the mercy of its ignorant or fanatical parent. It is a question, of course, amongst thinking people whether it would not have been better to adopt the recommendation dealing with the method of vaccinating infants without removing the obligation to have it done. More especially as to the substitution of calf lymph in place of arm to arm vaccination, and the attendance of public vaccinators at the homes of the children. Two members of the Commission, one of whom was Jonathan Hutchinson, advised this, and in addition, were of the opinion that re-vaccination at the age of twelve ought to be made compulsory; an important recommendation that I venture to think most of you will agree with. The preparation of the lymph is, I think, a specially important point, and if it was generally known with what care it was prepared in the Government establishments, many of the objections to vaccination among the more ignorant classes would very likely disappear. Special laboratories are maintained, and a competent staff of bacteriologists employed for the purpose. The calves used are carefully selected-generally males of from three to six months. The animals are kept in quarantine for a week, and then used if their health is satisfactory. They are vaccinated with the most elaborate antiseptic precaution, and then after another interval of five days, the vaccinated surface is scraped, after being cleansed and sterilized, and the vesicular pulp collected. The calf is then slaughtered, and a complete post-mortem examination is made of all its viscera. No lymph is used until the report of this examination is received, and the animal certified healthy. The vaccine pulp is then taken to the laboratory and mixed in a triturating machine with six times its weight of a sterilized mixture of 50 per cent. pure glycerine in distilled water. The resulting emulsion is stored in test tubes, each containing from four to ten c.c. Every week agar-agar plates are made from the emulsion, and the number of colonies shows successive diminution. At the end of four weeks the plates rarely show any colonies. When a stage is reached when agar plates show no growth after inoculation with the emulsion, samples are used for vaccinating children, and the results recorded a week later; and when the lymph of a given calf is then shown to be satisfactory, the bulk of it is transferred to capillary tubes, and distributed for use. A detailed account of the preparation of lymph will be found in the report of the Medical Officer to the Local As you know, the Act was a provisional one-it came into force five years as an experiment, and is therefore still on its trial, and so not yet to be judged. Two important facts have already been brought out -the "conscientious objector," who was so fashionable about two years ago, has proved rather an unsubstantial person. For the first few months after the passing of the Act he occupied a very prominent position, and took up much of the magistrate's time-now he is so scarce that his appearance forms a pleasant break in the monotony of ordinary police court procedure. Even in his palmy days he frequently applied for a certificate, and forgot to fetch it the next day, his objection not extending so far as paying the shilling demanded for it. Between August 12th, 1898, and December 31st, 1898, a period of about four months, the total number of certificates received was 203,413, relating to 230,147 children. In the whole of the year 1899 the total number of certificates was 32,341, relating to 32,357 children. The number of births in the same period was 928,640. These figures refer to England and Wales only. The second fact is brought out in a Local Government Board memorandum, presented to the House of Commons in August, 1900, and goes a long way towards diminishing the fears entertained that under the new Act England would become an unvaccinated country. Without going into details of figures, it is enough to state that the return shows that the increases in the numbers of vaccinations for the half-years of 1899 as compared with the corresponding half-years of 1898 were 77,713 and 91,322 respectively, a total increase for the year of 169,035, or 33.8 per cent. The number of births registered in England and Wales during 1898 was 923,265, and during 1899 was 928,640. The ratios per cent. of successful primary vaccinations to births registered were 54'2 in 1898, and 721 in 1899, an increase in ratio of 33 per cent. in 1899 as compared with 1898. Such a good result was unexpected, even by the most ardent supporters of the new Act, and it is greatly to be hoped that the figures for 1900 will be equally satisfactory. St. Mary's Hospital Medical Society. The last meeting of the above Society for this year took place on March 6th, when Mr. Keeling read a most interesting paper on "Retinal Detachment." At the close of the meeting the officers for the ensuing year were elected, and votes of thanks were passed to the retiring officers. Messrs. Keeling and A. G. Wilson proposed and seconded a vote of thanks to the retiring President, Mr. Collier, to whose enthusiasm much of the success of the Society during the past year has been due. Mr. Collier, replying, said that it had always been a pleasure to him to look after the interests of the Society, and that although for next year he was taking no active part in the management, his interest During this year there have been many excellent papers read before the Society, and it would be difficult to select out of the many interesting papers any for special mention. Drs. Paine and Poynton's paper on "The Causal [Ed. please note!] Relation of Micro-organisms to Rheumatic Fever" excited a large amount of interest, and also a record attendance, over 90 members being present. The meetings have been on the whole very well attended, and the papers well discussed; but some of the deep technical papers rather frightened off some of the junior members. The meeting at which Mr. Silcock was to have read a paper on "Tetanus" was omitted, owing to the death of Her Majesty Queen Victoria. List of officers elected for the ensuing year :President-A. P. Luff, M.D., F.R.C.P. Vice-Presidents-M. Mitchell Bird, M.D., J. F. H. Broadbent, M.D., W. H. Willcox, M.B., V. W. Low, M.D., B.S., F.R.C.S. Hon. Treasurer-J. E. Lane, F.R.C.S. Hon. Secs.-A. E. Hodder, B.A., M. F. Kelly. M.B., S. E. Dore, B.A., M.B., A. G. Bate, B.A., Auditors-H. E. Corbin, B.Sc., H. M. Raven. Diploma in Public Health. The arrangements for this course have recently been carefully re-constructed, with a view to making it more serviceable to St. Mary's men who intend to take the Diploma. For the benefit of such, we think it may be useful to give the arrangements as they now stand. I. -Two Courses are held in each year, commencing p.m. III.-The Class in Bacteriology is held in the Bacteriological Laboratory on Mondays and Wednesdays at 2.0 p.m. IV. In addition to Laboratory work, arrangements are made by which gentlemen can take a Course in Sanitary Inspection under a Medical Officer of Health. The fee for the course is 15 Guineas, or, including Sanitary Inspection, 20 Guineas. Gentlemen can enter their names at any time at the office of the Medical School. Correspondence. NOTICE TO CORRESPONDENTS.-No anonymous communications can be inserted. All communications must therefore be accompanied by the name and address of the sender, not, however, necessarily for |