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Unity of Zymotic Persons.

is no reason, that I know of, for believing that what happens in insects may not take place in the highest animals. Indeed, there is already strong evidence that some diseases of an extremely malignant and fatal character to which man is subject are as much the work of minute organisms as is the Pebrine. I refer for this evidence to the very striking facts adduced by Professor Lister in his various well-known publications on the antiseptic method of treatment. It seems to me impossible to rise from the perusal of those publications without a strong conviction that the lamentable mortality which so frequently dogs the footsteps of the most skilful operator, and those deadly consequences of wounds and injuries which seem to haunt the very walls of great hospitals, and are, even now, destroying more men than die of bullet or bayonet, are due to the importation of minute organisms into the wounds, and their increase and multiplication; and that the surgeon who save most lives will be he who best works out the practical consequences of the hypothesis of Redi.

Dr. Bastian has laboriously endeavoured to prove that low forms of animal life originate during the decomposition of organic matter; but a careful study of the evidence which he has published in support of his views has not convinced me that organisms originate spontaneously under the circumstances which he mentions. If Dr. Bastian subjected the organic matter operated upon by him to a sufficiently high and prolonged temperature, I believe no forms of life would appear in it if air were excluded.

Mr. A. Wolff, F.R. C.S., expresses his dissatisfaction with the existing theories in relation to the intimate nature of contagious diseases. He contends that there is not a multiplicity of zymotic poisons, but that all diseases are molecular motions of varying degrees of intensity. A dissection wound is one of the best illustrations of zymotic action in its simplest form, "there being no question of a special germ or vitiated secretion; so also it is observed when particles of textures which are themselves inflamed become capable of secreting inflammation in particles with which they have contact." Dr. Wolff is of opinion that all the phenomena of the zymotic diseases are under the control of the ordinary physical laws which govern growth and decomposition. He arranges the zymotics into groups, the diseases in which are connected by points of resemblance-for example, variola, vaccine, and varicella, measles and scarlatina, and so on. A number of persons placed together under insanitary conditions, and exposed to the influence of decomposing animal matter, will not always become affected with the same zymotic; for the precise form which the disease may assume does not depend upon the presence of a specific germ, or entity, but upon a variety of causes, such as, for example, the channel through which the materies morbi comes in contact with the healthy subject.

Notwithstanding the very ingenious reasoning of Dr. Wolff, he has not satisfied me that the cause of cholera is to be found in the catalysis of ordinary animal matter. As truly might it be said

Zymotic Diseases; their Correlation and Causation. London: J. and A. Churchill, 1872.

that all the parasitic maladies which affect animals are referable to the attacks of a single creature as to assert that cholera and small-pox have a common origin. When a zymotic disease is prevalent, who can doubt but that it is produced by a special and not by a general cause? Simple decomposing animal matter may produce some form of disease, but could it, under any circumstances, develope syphilis, or small-pox, or rabies?

There is no doubt as to the epidemic nature of typhoid fever, and its contagious character is unquestionable; but the cases where it is directly through air or touch communicated from the sick to the healthy are rare, Perhaps this zymotic is one which does not admit of being extirpated by human agency. When our knowledge of the etiology of zymotic diseases is more perfect than it is, we shall probably distribute these maladies into two groupsnamely, one to include all diseases which are only directly or indirectly communicated from individual to individual-syphilis and small-pox, for example; another in which to place those diseases which, though contagious, are sporadic under certain conditions of soil, climate, vegetation, &c. Miasmatic fevers, enteric fever, and cholera morbus are diseases which, possibly, originate from time to time spontaneously.

I have often entertained a doubt as to the zymotic nature of diarrhoea, or at least as to the propriety of placing it in the same category of diseases which include smail-pox, typhoid, and scarlatina. It is not probable that the poison of this malady is a specific entity like the virus of measles or cholera. As bronchitis prevails

in

very cold weather, for an obvious reason, so diarrhoea prevails in summer, when fruit is abundant. Dr. J. Wyatt Crane, of Leicester, contends 'that diarrhoea is not a true zymotic, and is not, therefore, in the ordinary sense of the word, a preventable disease. Of course, so far as private hygiene is concerned, there are many means of lessening the amount of diarrhoea; for example, by paying attention to diet, so as to avoid using foods which are likely to produce diarrhoea. Public hygiene may also do something in the direction of lessening the amount of diarrhoea, by preventing the sale of unsound food, and taking care that the milk which is so largely used by children is supplied to them in a pure condition. Still, I think that some distinction should be made between diarrhoea and the undoubtedly contagious diseases.

Report of the Sanitary Condition of Leicester for 1869, by J. Wyatt Crane, M.D., Medical Officer of Health. Leicester; J. and T. Spencer. 1870.

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First Appearance of Small-pox.

CHAPTER XV.

VACCINATION AND RE-VACCINATION.

Small-pox has been termed the type of zymotic diseases. It is one of the most fatal, and is certainly the most loathsome of the contagious maladies. Since its first recognised appearance amongst mankind, its victims have numbered many millions. No mention of it is made in the writings of the Greeks or Romans; and the first account which we have of this frightful disease is that given by an Arabian medical writer of the tenth century, named Rhazes. Small-pox, however, was probably known in Europe about the eighth century, and there is reason to believe that it was known in England towards the latter part of the ninth century. One result of the Crusades was to spread the contagium of this disease over the greater part of Europe. Early in the sixteenth century it was imported by the Spaniards into the New World; and, according to Robertson, so dreadful were its ravages in Mexico, that in a short time three and a-half millions of the inhabitants of that country were carried off. The isolated position of Iceland long secured for that remote island immunity from small-pox; but when, in 1707, the disease did effect an entrance, it speedily destroyed one-fourth of the inhabitants. Some years later it reached Greenland, which, subsequently, it all but depopulated.

The United Kingdom has suffered severely from small-pox. In 1838 no fewer than 16,268 persons succumbed to this disease in England alone; and although, owing to vaccination and to a general improvement in the hygienic condition of the country, the mortality from small-pox is greatly lessened, it still annually carries off a large number of victims. Occasionally, too, it becomes epidemic, as in 1871-2, and slays many thousands.

In the year 1796 an English physician, Dr. Jenner, proved the great fact by which he has immortalized his name and earned for himself the lasting gratitude of man-namely, that by inducing in the human subject an attack of the mild disease termed cowpock, immunity might be secured against the far more deadly malady, small-pox. The practice of vaccination thus introduced by Jenner has since been adopted, more or less generally, by all civilized and some semi-civilized peoples, and it has superseded the older, but inefficacious, plan of lessening small-pox mortalitynamely, inoculation.

In Ireland the deaths from small-pox have steadily declined since the practice of vaccination has become general amongst all classes, and especially since the passing of the statutes rendering inoculation illegal and vaccination compulsory. During the decade ended in the year 1841, the deaths from small-pox numbered,

Ravages of Small-pox.

147

in Ireland, 58,006 persons, whilst an immense number of persons must have been blinded and seriously disfigured. During the next ten years the deaths numbered 38,275, from which time the disease became less prevalent, until, in 1870, it seemed to be utterly extinct in Ireland. In 1871 it became epidemic in France, England, and other places, and broke out with great virulence in Ireland, and, during two years, destroyed several thousand lives. It has now almost disappeared from the country, and, no doubt, the last outbreak was due to the importation of abundance of smallpox contagion from England and Scotland,

It is generally supposed, before the late outbreak, that the disappearance of small-pox from Ireland was due to the admirable manner in which the dispensary physicians have carried out the instructions under the Vaccination Acts, and also to the readiness which the whole population exhibited in consenting to have their children vaccinated. In the year 1870 it was a general belief that small-pox would not again appear in Ireland; that it had been eradicated, and that even if a fresh supply of small-pox poison were introduced into the country, the disease would not spread, so well protected was the population by vaccination. The small-pox epidemic of 1870-71 gave a rude shock to the belief of many persons in the prophylactic virtues of vaccination, and even led a few persons to deny that the operation was at all serviceable. In England the latter belief was far more generally entertained, and even a few physicians were to be found amongst the antivaccinators.

It might reasonably have been expected that our knowledge of the etiology of small-pox and of the advantages of prophylaxis in connexion with it would have been greatly increased during the recent epidemic. This expectation has not been fully realized. The published statistics showing the mortality amongst vaccinated as against unvaccinated patients are by no means so abundant as we could have hoped for. This disappointment in the result of the general negligence of the great body of practitioners is not stating in their certificates of death from small-pox whether the deceased had or had not been vaccinated; and if the former was the case, whether or not the vaccine scars were imperfect. The only statistics relative to this point are those furnished by the hospital authorities. From these it appears that a large majority of smallpox patients admitted into hospital had been vaccinated. In order to draw a correct conclusion from this fact, we should know the relative numbers of the vaccinated and unvaccinated amongst the population. There are no reliable statistics in reference to this point. Probably 10 per cent. of the people of England are unvaccinated; and if this estimate be admitted, it must be conceded that the protective influence of vaccination (as at present practised) is by no means so great as we have long been led to believe. This fact should be met fairly and fully by sanitarians, and, if possible, clearly accounted for. If we believe in the protective influence of

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Instructions for Vaccinators.

vaccination, there is indeed but one way to explain the anomaly of so large a proportion of small-pox cases being post-vaccinalnamely, that vaccination is frequently not properly performed.

The authorities of the small-pox hospitals, who so candidly admit that even so many as 87 per cent. of their patients had been vaccinated, yet show that the mortality from the disease is only from 5 to 9 per 100 amongst the vaccinated; whilst it rises to 49 per cent. amongst the unvaccinated. We further learn from this source that the mortality amongst the vaccinated who exhibit marks of perfect vaccination is so low as from 0.5 to 2 per cent. It would appear, then, that the reason why vaccination fails so frequently as a preventive of small-pox is simply because the operation is generally so imperfectly performed. It is therefore a matter of great importance that vaccinators should pay the strictest attention to the performance of this operation, and to neglect no precaution likely to ensure its success. The medical authorities in England appear to believe that there is great carelessness in vaccination, for they have issued the following code of instructions to the medical men who perform the operation by contract :—

INSTRUCTIONS FOR VACCINATORS UNDER CONTRACT.

1. Except so far as any immediate danger of small-pox may require, vaccinate only subjects who are in good health. As regards infants, ascertain that there is not any febrile state, nor any irritation of the bowels, nor any unhealthy state of skin; especially no chafing or eczema behind the ears, or in the groin, or elsewhere in folds of skin. Do not, except of necessity, vaccinate in cases where there has been recent exposure to the infection of measles or scarlatina, nor where erysipelas is prevailing in or about the place of residence.

2. In all ordinary cases of primary vaccination, if you vaccinate by separate punctures, make such punctures as will produce at least four separate goodsized vesicles, not less than half an inch from one another; or, if you vaccinate otherwise than by separate punctures, take care to produce local effects equal to these just mentioned.

3. Direct care to be taken for keeping the vesicles uninjured during their progress, and for avoiding afterwards the premature removal of the crusts. 4. Enter all cases in your register on the day when you vaccinate them, and with all particulars required in the register up to column nine inclusive. Enter the results on the day of inspection. Never enter any results which have not been inspected by yourself or your legally qualified deputy. In cases of primary vaccination, register as "successful" only those cases in which the normal vaccine vesicle has been produced; in cases of re-vaccination, register as "successful” only those cases in which either vesicles, normal or modified, or papules surrounded by areolae have resulted. When the vaccination of an unsuccessful case is repeated, it should be entered as a fresh case in the register.

5. Endeavour to maintain in your district such a succession of cases as will enable you uniformly to vaccinate with liquid lymph directly from arm to arm; and do not, under ordinary circumstances, adopt any other method of vaccinating. To provide against emergencies, always have in reserve some stored lymph-either dry, as on thickly-charged ivory points, constantly well protected from damp; or liquid, according to the method of Dr. Husband, of Edinburgh, in fine, short, uniformly capillary (not bulbed) tubes, hermeti cally sealed at both extremities. Lymph, successfully preserved by either of these methods, may be used without definite restriction as to time; but with all stored lymph caution is necessary, lest in time it have become inert,