Popular Science Monthly/Volume 16/January 1880/Vaccination in New York
By R. OSGOOD MASON, M. D.
THE question of the usefulness and safety of vaccination as practiced in the principal cities of the United States is fairly settled. The general voice pronounces it both safe and useful. A small minority only of the intelligent refuse to acquiesce in the verdict, and comparatively few among the ignorant now refuse to test its benefits. In Europe, notably in England and Germany, the same can not be said. It is among the German population that even here the greatest prejudice exists, and in England there is at the present time a controversy going on, growing out of efforts to extend and enforce a compulsory vaccination law, which opens up all the old issues and affords opportunity for sending broadcast statements of the most sensational and mischievous character. These have recently been collected by a well-known littérateur and forwarded as a newspaper letter to this country, where, on account of their startling and sensational character, they have been somewhat widely copied.
It is charged in these statements—
1. That several terrible diseases, such as syphilis, cancer, consumption, and scrofulous diseases generally are widely scattered and communicated by vaccination. One vaccinator of twelve years' experience is made to say, "If I had the desire to describe one third of the victims ruined by vaccination, the blood would stand still in your veins." Another, "I have seen hundreds of children killed by it." A medical journal is quoted as saying that consumption has widely spread since the introduction of vaccination; which is very likely also true as regards lawn-mowers and pedestrian matches. A physician to the London Cancer Hospital declares that many of the cases of cancer treated at that institution originated with vaccination! A physician testifies before a Parliamentary committee that eleven out of thirteen children whom he vaccinated became syphilitic. Another declares that a large proportion of apparently inherited syphilis is really imparted through vaccination. A large number of cases of various kinds are cited with full and harrowing details, some of which have been subjects of discussion in medical circles during the past twelve or fourteen years.
2. It is charged that vaccination does not protect its subjects from small-pox. It is pronounced "not only an illusion but a curse to humanity"; "The greatest mistake and delusion in the science of medicine"; "A fanciful illusion in the mind of the discoverer, devoid of scientific foundation." It states that, out of 22,000 cases of smallpox treated in five London hospitals in five years, 17,000 had been vaccinated; and, furthermore, that, since compulsory vaccination had been established, the death-rate from small-pox had more than doubled. Such, in brief, according to these very remarkable statements, have been the results of vaccination in England, and it is in contrast with these statements that the results of vaccination as practiced in the city of New York are here presented.
Previous to the epidemic of small-pox in 1874-'75, vaccination had been fairly practiced, but in the same loose and unsystematic manner as was formerly the custom everywhere. Some physicians vaccinated the children of the families in which they were medical attendants and some did not. Vaccination was performed free to those who desired it at all the dispensaries, but no special care was taken to see that all the children in the several districts were vaccinated. Some physicians exercised skill and judgment in collecting the virus and doing the work of vaccination, while others were careless and slovenly. There was no uniformity, no general supervision, and no responsibility.
In the autumn of 1874, notwithstanding some special attention was given to the matter, the number of cases of small-pox increased so rapidly, and the number of unvaccinated persons was found to be so great, that it was evident some more effective means must be adopted to meet the danger of a great epidemic. It was at this time that a permanent corps of vaccinators was organized under the charge of Dr. James B. Taylor, "Inspector of Vaccination," and under the general management of the Board of Health. The object of this corps was to visit systematically throughout the city, especially among the tenement-house population, offering free vaccination to all, and urging its advantages and even its necessity, in view of the epidemic character of the disease then prevailing.
During the following fifteen months ending in December, 1875, fifty-eight different physicians were connected with the corps, and an average of seventeen were constantly employed during that whole time. During this period, over 126,000 vaccinations were performed, all of which, so far as possible, were carefully watched and studied by competent medical men, not only for immediate practical results but also for the purpose of scientific deductions.
The method of procedure was as follows: It was important to commence the work with pure virus. Among those who had been interested in the careful study of vaccination here in New York was the late Dr. Jonas P. Loines, for many years house physician to the Eastern Dispensary. Twenty years earlier he had secured from abroad what was considered the best and purest virus to be obtained in any country. The use of this virus he personally superintended, and its results were carefully watched. It was kept separate from all other, and had proved protective and thoroughly satisfactory. This was the virus first used by the newly organized Vaccinating Corps.
At first no separate districts were assigned, but those localities most threatened with small-pox were sought out, and particular streets, blocks, or houses were designated for special attention. Later the city was districted and thoroughly canvassed. Each vaccinator made semi-weekly returns of his work to the inspector. These returns were on printed forms which required the name and address of the patient, whether front or rear house, number of room, age, nationality, parentage, and whether a primary or revaccination. At the inspector's office all these reports were carefully classified and recorded for future reference, primaries being kept separate from all others.
On the eighth day every case of primary vaccination was visited by a member of the corps specially qualified for the work, to observe the character and condition of the vesicle, whether perfect or in any way deficient, to revaccinate any cases of failure and to collect virus from perfectly healthy infants presenting perfect vesicles. All vaccinations not considered perfect, even though they had to a certain extent "taken," were either immediately revaccinated or the parents informed that the protection was not perfect; and advised to have the operation repeated at an early date. This work was also reported to the inspector, and the revaccinated cases again visited on the eighth day.
Between the twentieth and thirtieth days each case of primary vaccination was visited a second time to make sure that all was right, and deliver certificates of vaccination. If any unusual symptoms had occurred or the sore was tardy in healing, the case was taken in charge and treated until well. But even here the care did not cease. In each family where vaccination was performed a circular was left, printed in English and German, giving directions for the care of the vesicle, and directing parents to bring their children to the inspector's office at any time afterward, should any unpleasant effects appear which they might attribute to the vaccination—a privilege which they were not backward in claiming.
All the schools, institutions, asylums, workshops and factories were visited and vaccination offered. Two physicians were assigned specially to the public schools and the same care regarding reports, records, and revisiting was observed. Certificates were also given to those thoroughly protected in order to avoid the annoyance and labor of unnecessary examinations.
Thus the work of vaccination was for the first time carried on in a thorough and systematic manner, and thus it has been kept up ever since. Twice a year the tour of inspection and vaccination is made throughout the tenement-house region, factories, and all places where people are habitually brought together in large numbers in a more or less confined atmosphere. The schools are thoroughly canvassed about once in three years. Five years of such extensive, systematic and thoroughly studied work could scarcely fail of results of some kind either for good or for evil. During that time 270,970 vaccinations were performed by the Vaccinating Corps alone, independent of the great number performed at the dispensaries, and by physicians in their private practice. It remains to examine these results as regards the protection which vaccination affords against small-pox, and as regards the transmission of disease, which has constituted the great ground of prejudice against the practice of vaccination. Regarding the advantages or disadvantages of vaccination two main points present themselves:
1. Is vaccination a protection against small-pox?
2. Is it a vehicle for the communication of other diseases? Let the facts themselves speak; and the facts here presented, all of which occurred during the epidemic of 1874-'75, are drawn from the published reports of the Board of Health and from personal conversations with Dr. Taylor, the very efficient Inspector of Vaccination, whose excellent judgment and ample experience entitle both his facts and opinions to great weight.
1. Concerning protection. 1. In a large tenement-house in East Third Street were nine German families. An unvaccinated child was taken sick with small-pox, and the case was kept secret until the child died. All the other people in the house were vaccinated except one family consisting of parents and three children. The parents did not believe in vaccination and persistently refused it for their children. All three children had small-pox and two died. No other cases occurred in the house.
2. The inmates of No.—East Eleventh Street were exposed to small-pox. The vaccinators found three babies whose parents refused to have them vaccinated. Within three weeks all three children died of the disease. There were no other cases in the house.
3. No.—St. Mark's Place. Three cases of small-pox had already occurred in the house. The inspectors found three unvaccinated children, but vaccination was refused. The two eldest children took the disease; the youngest was already dying of marasmus. No other cases occurred.
4. At No.—Tenth Avenue was a concealed case of small-pox already of twenty-one days' duration. He had been vaccinated in infancy, but not since. He died before he could be removed. His wife and four children had been successfully vaccinated just before the husband took sick, and, though they had all slept in the same room with this fatal case of small-pox twenty-one nights, not one of them took the disease.
Cases of this character, where the unvaccinated were selected and attacked by the disease, while the vaccinated, though equally exposed escaped, could be multiplied almost without limit. Here is one from the inspector's own experience:
Small-pox was in a tenement-house of eighteen families. Most of the inmates submitted to vaccination, but two children were found upon one floor and three upon another whose parents refused to allow it, though repeatedly urged. Within a short time all five of these children had the disease and three died. The parents of the three unvaccinated children had a fourth child who had been successfully vaccinated at school, and for which she received a severe beating at the hands of her father. This child, although sleeping in the same room with those who were sick and dying of the disease, entirely escaped.
No more striking examples of protection afforded by vaccination could exist than that furnished by placing infants on the first day of their vaccination in a small-pox hospital, filled with patients in every stage of the disease. This was frequently necessary during the epidemic, where the mother was attacked, and the infant must accompany her to the hospital; and, says the inspector, "not a single instance has occurred where the infant so exposed has contracted the disease," even though the infant nursed the mother throughout the illness.
Experience has abundantly proved that, when babies not vaccinated, are so exposed, the result has invariably been directly the opposite. In fact, the evidence in this matter is so abundant and of so conclusive a character that all who have taken the trouble to observe or study it during the past five years must be convinced that perfectly vaccinated persons are absolutely protected from small-pox, at least to the same extent as if they had already experienced the disease.
Why, then, it may be asked, do vaccinated persons have the disease at all? Simply because, in order to have the protection perfect, the vaccination must be perfect; and to this end two things are absolutely necessary: 1. The primary vaccine vesicle must be of proper size and character, and must run its proper and normal course. 2. Revaccination must be performed at proper intervals, namely, within five years after the primary, and again soon after puberty in those who are vaccinated in infancy, and at least one revaccination in those whose first vaccination was after maturity.
It is here that the great fallacy of statistics upon this subject is found; and this is why the English statistics before quoted show that, out of 22,000 cases of small-pox treated in the hospitals, 17,000 had been vaccinated. They had been vaccinated in infancy—perhaps properly, perhaps improperly—but in all probability had never been revaccinated. It should be once for all understood that, in order to have full protection, revaccination at the proper periods is just as necessary as the original vaccination.
It should be understood that a primary vaccination is not expected to protect for a long series of years, but only for a few years; and that after a limited time, although it may modify more or less the severity of the disease, it ceases to be absolutely protective, and must be renewed.
Statistics, however, show that, of persons attacked with small-pox, from three to four times as many deaths occur among those who have not been vaccinated at all as among those who are reckoned as vaccinated, though it may have been only in infancy. They also show that such vaccinations are nearly worthless as protection against smallpox after several years have elapsed, and very uncertain even in their power to modify the disease.
II. Concerning the transmission of other diseases by means of vaccination.
It may be presumed that if bad results of any kind were to follow vaccination, it would happen in primary cases, where the virus exerts its full influence of every kind. It has been seen with what care all these primary vaccinations have been watched during the past few years, the oversight extending even beyond the perfect healing of the arm. A circular was left in each family, requesting that any unfavorable symptoms which might subsequently arise, apparently as the result of vaccination, should immediately be reported to the inspector at his office. As a consequence of this invitation quite a number of complaints were received, every one of which was thoroughly investigated. It is fair, therefore, to suppose that every case of importance thus came under the observation of the inspector. Out of 24,395 primary vaccinations, 145 complaints were entered—scarcely more than one in 150 cases. On examination these were divided into four classes:
1. Ulceration and sloughing of the arm about the sore.
Two deaths occurred, both from erysipelas. Both these cases were in bad subjects, one being complicated with meningitis, the other being in a poor anæmic child with "such miserable surroundings as to preclude the possibility of recovery." In such subjects any operation, even the slightest, or any accident, an ordinary cut or bruise, without inoculation of any kind, is liable to be followed by most serious results. The vaccine virus can not be held responsible for the mischief in these nor any of the cases complained of, since in the same streets, even in the same houses, many other children were vaccinated with the same virus with perfect results. The fault was in the children themselves, their parentage, their constitutions, their habits and surroundings. So true is this that, if vaccinators could choose their cases, avoiding all bad or doubtful subjects for the sake of avoiding the prejudice aroused by a single unfavorable result, seldom indeed would a complaint be entered; but, on the other hand, many a child fairly entitled to the benefits of vaccination might be left unprotected. These results are mentioned, however, that nothing may be covered up which was actually found as a sequel even if not a result of vaccination.
Looking for statistics or even single cases of disease actually transmitted from one person to another by means of vaccination, no such cases exist. Concerning syphilis the inspector says, "Among all the cases of bad results which we have seen, we have failed to find a single one showing any indications of syphilitic inoculation, nor have we ever met a case of this kind in all our experience." Only a very few such cases have been brought to notice as even suspected, and none which would bear investigation. They were either not syphilis at all, the most usual result of examination, or else showed some other and more probable way of receiving the infection.
But what of other terrible diseases—cancer, consumption, and all the other forms of scrofula—for which vaccination has been blamed? No such cases have ever been brought to the notice of the inspector. The idea that such diseases can be so transmitted is absurd on its face, since it is certainly most difficult, if not utterly impossible, to reproduce any of them by any process analogous to that employed for vaccination.
All these reports and facts relate to vaccinations performed with humanized lymph, and previous to 1876. The most careful examination of every reported or suspected case among the 126,000 vaccinations performed up to that time failed to furnish a single case of the transmission of disease of any kind whatsoever from one person to another by means of vaccination.
In order, however, to avoid as far as possible the prejudice which was at one time so widespread in this matter, no humanized lymph has been used by the Vaccinating Corps for nearly three years. All the virus now used is eighth-day lymph taken from healthy calves carefully selected and kept in the country under the supervision of the inspector, exclusively for this purpose.
No very special advantage is claimed at present for this over properly selected humanized lymph; if, however, any difference is observable in the results, it is in favor of the bovine lymph, as affording fewer cases of troublesome inflammation.
One advantage is decided: it has tended to diminish a prejudice, and so remove in some degree an objection to vaccination.
It is in the face of an abundance of facts such as these, instead of the badly observed and badly studied facts of fifteen years ago, that intelligent people now must doubt the safety and utility of vaccination.