with the great awakening of the medical mind, it is probable that the true and reliable sources of vaccine lymph will be more closely defined than ever before. Questions of preference as to methods and of the significance of lesions or changes wrought by the lymph, and of the conditions which limit or secure permanency of protection, will be examined with eager skill. If for the sake of brevity we may commend to others what we would say to ourselves, it is thus:

Do not forsake the Jenner lymph, on the ground that it has lost protective power.

Do not discredit bovine lymph because there has been occasional over-production and fraud.

In our zeal for the old or the new, let us not create a public feeling of distrust in this protection. Remember that there are enough reliable producers to make it competent for you to assure yourself of the reliability of your lymph. Do not let its supply take the form of a mercantile drug, since it is a commodity so special in its character as to need to be supplied more directly.

Watch closely the course of your vaccinations, and, to some extent, depend upon yourself for supply by using lymph that you procure after having obtained your original lymph from a reliable source, inserting it in a healthy child and having been satisfied with its mode of action. Do not use crusts, except in a most pressing emergency.

During an epidemic, with persons who have been directly exposed to small-pox, use, if you can, at first Jenner lymph, on the ground of its greater rapidity of action, even if soon after, at some other point, you introduce the bovine lymph in order to test or intensify the effect.

Let us not allow the mere incidents or accidents connected with the use of either Jenner or bovine lymph to obscure the indispensable importance of vaccination or of protection from small-pox, the hazard from which is actually so great, while that from vaccination is infinitesimally small.

As a summary of the views submitted as a whole in this paper, we may add as follows:

SUMMARY AS TO SMALL-POX AND VACCINATION.

I. Small-pox, after complete vaccination, is as rare a disease as is a second attack of small-pox in the same person.

II. Where a vaccination has not afforded protection it may be owing

(a) to the lymph being spurious, or (b) deteriorated in quality, or (c) insufficient in the degree of saturation of the system, or (d) owing to some idiosyncrasy in the person. If owing to any of these causes, these cannot be said to establish any rule that limits the effects of proper and complete vaccination, since such causes admit of elimination or limitation to a minimum.

III. The protection afforded by vaccination depends much upon the fact that at the time of its performance it has been done so exhaustively as that weekly or bi-weekly repetitions with genuine lymph would not produce any effect.

IV. Revaccination at adult life is often but the supplementing of partial or inadequate vaccination in youth. The chief argument for it is the fact that present methods of first vaccination do not encourage repetition at the time. Revaccination is a wise precaution.

V. So long as there is no compulsory law of vaccination, and no system of certificate as to the perfection of primary vaccinations, revaccination is all the more important.

VI. Lymph from spontaneous cow-pox is, probably, not deteriorated from the mere fact of human transmission, and, therefore, that usually known as the Jenner lymph is still valuable.

VII. Lymph from more recent spontaneous cow-pox, transmitted through successive calves instead of through successive infants, is also a valuable source of supply. This may be used after transmission through persons who have not been previously vaccinated.

VIII. The risk of transmitting other diseases through vaccination is excessively small-is even considered impossible by many of the best authorities. Yet the time will never come when dirty methods of collecting or inserting lymph, or when the careless introduction of other material into the original sore may not transmit septic or irritating material, or when any scratch may not, in a very small fraction of exceptional cases, cause inflammatory or septic results. Such rare and avoidable accidents or neglect furnish no reason for neglect of a process which, for every risk it has occasioned, has saved tens of thousands of lives. The expectation of life to each individual is therefore increased by vaccination.

IX. The security against small-pox consists in the exact knowledge and care of medical men, in the performance of the operation only by competent persons, and in such general laws as favor or secure the purity of lymph and the prevalence of vaccination among children.

X. The only reason why small-pox ever becomes an endemic or an epidemic, is the neglect of complete vaccination.

ANSWER III.

E. L. GRIFFIN, M. D., PRESIDENT OF WISCONSIN BOARD OF HEALTH.

I. "Should the use of bovine lymph supersede the use of humanized lymph ?"

Not necessarily so; perhaps not wisely so. Both are protective, indispensable, and, with wise safeguards in their selection and use, safe.

We would urgently recommend the use of humanized lymph of only a few removes from the heifer, when that form is used. When such a selection is made, the relative merits of animal and humanized lymph cannot be fully determined by any data we have at command.

We regard bovine lymph as possessing all the qualities of safety and protection which could be desired. The essential requisite in the use of either is a conscientious and intelligent care in their selection and use.

II. "What phenomena, if any, have occurred in the use of bovine lymph, as distinct from what has been heretofore noted as to the humanized Jenner lymph ?"

(a) As to variation in time of evolutions and maturity. The period of incubation is from one to three days, generally, longer in the use of bovine lymph than where humanized lymph is used.

A relatively long period is generally observed before the vesicle reaches its several stages of development and maturity.

Retardation in the course of the vaccination is a matter of common observation. This peculiarity is generally thought to be caused by the insoluble quality of bovine albumen in the serum of the blood, and hence the slow action of the absorbents on the vaccinal granule. This delay is so marked in some cases as to cause great surprise, but I have never known any untoward results to follow. The same phenomena and from the same cause are sometimes observed where humanized crust is used. Generally, in the end the vesicle matures fairly, and we may reasonably infer that a protective influence has been secured.

The phenomena of successful vaccinations will present marked deviations in degree when observed in different individuals. The cause of this is to be looked for in the variations in the quality and vigor of the lymph used; in the varying conditions of health in the persons vaccinated; in their unsanitary surroundings and in mechanical interference with the normal development of the vesicle.

(b) Degree of sickness. The constitutional symptoms following the use of pure bovine lymph, and those induced by lymph humanized by a few removes from the heifer, are generally of a like character and degree. In the case of both, these symptoms are sometimes quite severe. The cause is quite often found in the condition of the patient himself. It must be admitted that during the past year an unusual amount of severe constitutional symptoms and local complications have followed the use of bovine lymph. Undoubtedly several causes have combined to produce these results

1. A marked susceptibility, during a portion of the year, in the human subject, to the vaccinal disease, as well as to the variolous poison.

2. The use of bovine lymph of questionable purity.

3. The use of points which were packed and sent out for use, possibly before they were thoroughly dried. In such cases, some vital degenerative change might take place in the albuminous coating of the point, so that when such lymph was planted in the human arm a degree of septic action might be set up. Where orders were in advance of the crop, and impatiently waited for, such an accident is by no means impossible. All these evils are accidental and almost inseparable from a great pressure, such as was brought to bear upon all vaccine establishments during the winter of '81 and '82.

4. Faulty and unskillful methods of vaccinating, especially the one of scarifying too deep.

Simple as is the operation of vaccination, yet it requires a degree of technical skill rarely appreciated in or out of the profession. It is to be deplored that an operation so inseparably connected with the safety of human life should be entrusted to any but skilled hands.

(c) As showing abnormal results. The frequency of vaccinal erythema following the use of bovine lymph is a noticeable phenomenon. This constitutional manifestation of the vaccinal disease is seldom observed in the use of humanized lymph of distant removes from the It is a harmless affair, and only indicates a thorough saturation of the system with the vaccinal disease.

heifer.

E

The phenomena of so-called spurious vaccinations are sometimes very annoying. The prevalent notion that these irregularities appear only after the use of bovine lymph is incorrect, for they were observed years before the introduction of animal vaccination.

While an apparently large number of spurious vaccinations were observed during the winter of '81 and '82, it must be remembered that the ratio was small, since the number vaccinated was simply immense, and this without regard to physical condition or sanitary surroundings, and that the service was rendered in many cases without skill or intelligence such as the importance of the operation demands.

A recent writer has grouped together what may be called the accidents sometimes noticed to follow the use of bovine lymph, having their cause, as we have before stated, sometimes in the patient and his surroundings, and sometimes in the bad quality of the lymph used.

1. Red tubercles, the size of peas, appear at the seat of vaccination. These tubercles sometimes suppurate.

2. The vesicle commences with much itching and irritation. It is not umbilicated, but acuminated or conoidal, and contains strawcolored or opaque, instead of clear lymph. The areola is completed by the fifth or sixth day, and begins to decline on the eighth day, the scab falling off by the tenth day.

3. Instead of the usual papule or vesicle, a bulla containing a transparent fluid, and having a reddened margin, may develop. Troublesome ulceration sometimes arises beneath the crust, which is formed after the rupture of the blebs.

4. A crop of herpetic vesicles, preceded by shivering, may appear about the third day after vaccination. These soon burst, and the exuded fluid gives rise to an eczematous eruption, the skin becoming hard and oedematous. Intolerable itching accompanies the vesicle, and the axillary glands become enlarged.

5. Occasionally vesicles which have apparently run a normal course up to the eighth or tenth day, suddenly rupture, and ulcers, that spread both superficially and deeply, make their appearance. They cause pain or itching, and are accompanied by much constitutional disturbance.

These manifestations are always benign in character, and always end in complete recovery.

(d) As to period of protection. This cannot be definitely settled by *Hardaway on Vaccination and Small-pox.