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SMALLPOX and 
 
 VACCINATION 
 
 JAY F. SCHAMBERG, M. D. 
 
 PHILADELPHIA, PA. 
 
 )JC 
 
 PRESS OF 
 
 American Medical Association 
 
 Five Hundred and Thirty-Five North Dearborn Street 
 
 CHICAGO 
 
,<s£" 
 
 'f 
 
 A. Journal of Individual and Community Health 
 
 The publication through 
 which the medical profes- 
 sion of the United States 
 presents to the public 
 interesting, instructive 
 and authoritative articles 
 about health 
 
 Published Monthly 
 $3.00 the year — 25 cents the copy 
 
 American Medical Association 
 
 535 North Dearborn Street - CHICAGO 
 
SMALLPOX * 
 
 JAY F. SCHAMBERG, M.D. 
 
 PHILADELPHIA 
 
 Smallpox, perhaps more than any other disease, has 
 inspired fear and terror in the popular mind because 
 of its loathsome appearance, its extreme contagious- 
 ness and its disfiguring consequences. 
 
 Lord Macauley's Description of Smallpox. — Lord 
 Macauley, writing of the untimely death from small- 
 pox in 1694 of the young and beautiful Queen Mary 
 of England, gives us a powerful pen picture of the 
 ravages of this pestilence : 
 
 That disease, over which science has since achieved a 
 succession of glorious and beneficient victories, was then 
 the most terrible of all the ministers of death. The havoc 
 of the plague has been far more rapid, but the plague has 
 visited our shores only once or twice within living memory; 
 and the smallpox was always present, filling the church- 
 yards with corpses, tormenting with constant fears all whom 
 it had no, v yet stricken, leaving on those whose lives it spared 
 the hideous traces of its power, turning the babe into a 
 changeling at which the mother shuddered, and making the 
 eyes and cheeks of the betrothed maiden objects of horror 
 to the lover. 
 
 Blindness from Smallpox. — During certain periods 
 in England, a very large percentage of the people were 
 pockmarked. Ben Jonson, the Elizabethan dramatist, 
 wrote : 
 
 Envious and foule disease, could there not be, 
 One beautie in an age and free from thee. 
 
 Not only did the disease destroy life, disfigure and 
 maim, but it was at one time the most common cause 
 of blindness. The early records of the London Asy- 
 lum for the Indigent Blind showed that two thirds of 
 the inmates had lost their sight as a result of 
 smallpox. 
 
 Smallpox Adages. — Smallpox was a great scourge 
 before the introduction of vaccination. In London 
 during the eighteenth century it caused one twelfth 
 of all deaths. Every one felt that he had to pass 
 through an attack of smallpox at some period of his 
 
 * This pamphlet is one of a series on public health, prepared by the 
 Council on Health and Public Instruction of the American Medical 
 Association [1914]. Other pamphlets can be secured from the American 
 Medical Association, S'3S North Dearborn Street, Chicago. 
 
life. One of Horace Walpole's correspondents 
 (Walpole's Letters) wrote: "Poetry is as universally 
 contagious as smallpox: everyone catches it once in 
 a lifetime at least, and the sooner the better." The 
 Germans had a proverb which expressed the same 
 thought : "From love and smallpox but few remain 
 free." Most children in London contracted smallpox 
 before the aee of 7. 
 
 Fig. 1. — Normal appearance of site of vaccination, first day. 
 
 Extent of Smallpox. — In the City of London, from 
 1700 to 1800, in a population varying approximately 
 from 600,000 to 750,000, there were only nine 
 years throughout the century when the deaths from 
 smallpox declined below 1,000; taking the entire cen- 
 tury the deaths averaged almost 2,000 per annum. This 
 would represent more than 10,000 attacks of small- 
 pox annually, as less than one in five victims died. 
 Smallpox did not occur in epidemics, as at present, for 
 it was present continuously. 
 
EXPOSURE TO SMALLPOX 
 
 Smallpox Infection in Clothing. — Smallpox is one 
 of the most contagious of diseases. The infection is 
 usually transferred directly from one individual to 
 
 Fig- 2. — Normal appearance of vaccination site, fifth day. 
 
 another through the atmosphere, but it may be trans- 
 mitted through infected clothing and other objects 
 In the smallpox epidemic of 1901-1904, in Philadel- 
 
phia, a number of cases of smallpox broke out among 
 the salesmen in a large clothing store ; the infection 
 was traced to a window-dresser whose daughter was 
 suffering from smallpox at home, and the contagion 
 was, beyond reasonable doubt, carried to the store in 
 the infected garments of the father. 
 
 Fig. 3. — Normal appearance of vaccination site, seventh day. 
 
 Smallpox Sufferers Traveling on Trains. — Persons 
 suffering from smallpox in the early stages some- 
 times travel long distances on railroad trains. On 
 one occasion a young woman heavily veiled, and suf- 
 fering from what later proved to be a very severe 
 attack of smallpox, traveled in a day coach from 
 
Atlantic City to Philadelphia in order to enter a hos- 
 pital in the latter city. A large number of people were 
 exposed to the infection of the disease without sus- 
 pecting their danger. I have personal knowledge of 
 other patients traveling hundreds of miles on railroads, 
 while in an actively contagious stage of the disease. 
 Such experiences are a sufficient answer to those per- 
 
 
 4 
 
 Fig. 4. — Normal appearance of vaccination site, ninth day. 
 
 sons who lull themselves into the false security that 
 they can avoid exposure to smallpox. 
 
 THE MILD TYPE OF SMALLPOX 
 
 Different Types of Smallpox. — Since 1896, there 
 has been widely prevalent in the United States, a pecu- 
 liarly mild type of smallpox which kills only a very 
 small proportion of those attacked. Hundreds of 
 thousands of such cases have occurred throughout the 
 country. This mild type is doubtless due to the weak- 
 ness of the infecting germ. Two entirely different 
 
types of smallpox have prevailed in this country — one 
 the virulent imported variety, which destroys the lives 
 of one-quarter of those whom it attacks, and the other 
 the mild type above referred to. An interesting feature 
 of the latter type is that it is not only mild as to mor- 
 tality but also as to its contagiousness; practically it 
 
 Fig. 5. — Normal appearance of vaccination site, fifteenth day. 
 
 attacks only the unvaccinated, and vaccinated persons, 
 even if the vaccination dates back thirty or more years, 
 are, as a rule, protected against it. The opponents of 
 vaccination point to this mild type of smallpox and 
 say that the disease has lost its terrors. Those who are 
 thoroughly familiar with the subject, however, know 
 
that neglect of vaccination may prepare a community 
 for a death-dealing epidemic of the classic type of the 
 disease. 
 
 SMALLPOX A CRUEL DISEASE 
 
 Early Symptoms. — -The patient, during the early 
 stages of a classic attack of smallpox, suffers from a 
 pronounced chill, followed by sudden fever and severe 
 headache and backache : nausea and vomiting occur 
 with great frequency and the latter may persist for 
 several days. Dizziness and general aches and pains 
 are common. In severe cases, there is great weakness 
 
 Fig. 6. — Infant born in _ the smallpox wards of the Philadelphia 
 Municipal Hospital. Vaccinated immediately and protected against 
 small-pox. (From Acute Contagious Diseases, Welch and Schamberg; 
 published by Lea Bros., Philadelphia.) 
 
 and prostration. During this stage, while the symp- 
 toms may be most suggestive of smallpox, no positive 
 diagnosis can be made as the "grip" and certain other 
 infections may imitate the early symptoms of small- 
 pox. Not until the eruption appears can one be abso- 
 lutely sure of the nature of the disease. Many persons 
 are commonly exposed to smallpox before the diag- 
 nosis can be definitely established. 
 
 Eruptive Stage. — About the third day of the illness, 
 the fever abates, the pains subside and the patient 
 begins to feel that his illness is at an end. But he is 
 
8 
 
 woefully mistaken, for it has barely begun. At this 
 time the eruption makes its appearance ; it is not for- 
 midable at first sight and looks not unlike a multitude 
 of flea-bites on the face, hands and elsewhere. Soon it 
 spreads over the greater part of the body. From day to 
 day the eruption undergoes a change (see Figs. 1-7), 
 soon the face is covered with numerous pustules, the 
 
 Fig. 7. — Typical "take" of vaccination showing necessity of revacci- 
 nation at intervals. Patient relied on previous scar as showing immunity. 
 
 features are swollen beyond their normal proportions 
 and the patient disfigured beyond recognition. The 
 fever again rises and acquires the characteristics of 
 blood-poison fever. The patient suffers greatly from 
 the soreness occasioned by the multitude of pustules 
 present, particularly those on the hands and feet. In 
 severe cases the pustules may reach the enormous 
 number of 30,000 to 40,000. The presence of small- 
 
pox sores in the nose and mouth cause great difficulty 
 in breathing and great distress in swallowing. 
 
 The Plague of Boils. — At about the end of a fort- 
 night, the patient if he recovers, has passed through 
 the height of the eruptive process, and is led to believe 
 that he is on the road to convalescence. Now a new 
 plague attacks the unfortunate victim, for he begins to 
 be the subject of boils and abscesses which may num- 
 ber but a half-dozen or may reach a hundred or more. 
 In a proportion of smallpox cases, which varies with 
 the severity of the attack, one or both eyes may be lost, 
 with consequent impairment or loss of vision. 
 
 An attack of unmodified smallpox runs its course in 
 about five or six weeks. At its conclusion, the patient 
 exhibits on his countenance numerous disfiguring pits 
 and scars which remain throughout his life as a sad 
 reminder of the cruel malady through which he has 
 passed. 
 
 Smallpox, in its usual form, is a terrible disease and 
 there is an almost universal susceptibility of the human 
 family to its infection, but there is no malady against 
 which science possesses a surer and more complete 
 safeguard. For that great discovery, the world is 
 indebted to Edward Jenner. 
 
 DR. EDWARD JENNER, WHO INTRODUCED VACCINATION 
 
 Honors Conferred on Jenner. — Dr. Edward Jenner, 
 of Berkeley, England, announced to the world in 1798 
 what was later generally regarded as the "greatest dis- 
 covery ever made for the preservation of the human 
 species." Jenner proclaimed his discovery in a modest 
 pamphlet which excited the attention of the entire civ- 
 ilized world. When the truth of his conclusions was 
 established, honors fell fast on him. The British par- 
 liament voted him $50,000 in 1802, and five years later 
 a second grant of $100,000. He was made physician 
 extraordinary to the king of Great Britain. The most 
 distinguished scientific bodies throughout the world 
 vied with each other in conferring degrees on the illus- 
 trious but modest physician. Within twenty-one years, 
 Jenner received no fewer than 28 diplomas from insti- 
 tutions of learning, and within a period of six years, 
 eight medals were struck in Europe in honor of the 
 great discovery, one of these being the most beautiful 
 of the Napoleonic series. Many of the crowned heads 
 
10 
 
 of Europe addressed complimentary epistles to Jenner. 
 and a letter from the discoverer constituted the best 
 passport through foreign countries in time of war. 
 
 Fig. 8. — Two children in the Municipal Hospital of Philadelphia, in 
 1913. One unvaccinated, the other vaccinated on the day of admis- 
 sion. Crust of vaccination still seen on leg. This child's mother had 
 smallpox and child remained with her in the hospital for three weeks: 
 was discharged perfectly well. The unvaccinated child, admitted with 
 smallpox, died. (From Acute Contagious Diseases, Welch and 
 Schamberg. ) 
 
 THE CLAIMS FOR VACCINATION 
 
 Duration of Protection After Vaccination. — A recent 
 successful vaccination will confer protection against 
 
.5 <o 3 
 
 ^_ »« 2 
 ■a « 5 
 
12 
 
 smallpox in at least ninety-nine out of one hundred 
 individuals. An infant successfully vaccinated can not 
 contract smallpox even though it be placed in bed 
 with a person suffering from this disease. This has 
 been abundantly proved in every smallpox epidemic 
 in every country. After a lapse of five or ten years, 
 the susceptibility to smallpox may in part return, and 
 the individual may require revaccination to reestablish 
 immunity against smallpox. An attack of smallpox, 
 scarlet fever, measles or chickenpox leaves in the sys- 
 tem a protective substance, which, in the vast majority 
 of instances, safeguards the individual against a second 
 attack. There are, to be sure, some highly susceptible 
 subjects in whom the immunity is not permanent and 
 who may, on future exposure, contract a second attack 
 of the disease. Second attacks of smallpox are rare. 
 
 Hozv Vaccination Protects. — Vaccination, which is 
 the result of the inoculation of a virus closely related 
 to smallpox, protects against the latter disease much 
 in the same manner as one attack of smallpox confers 
 protection against a second, save for the fact that the 
 immunity is not, as a rule, of so long duration and 
 requires renewal. It is not claimed at present that a 
 single vaccination will invariably protect against small- 
 pox for life. Such lifelong protection is sometimes 
 conferred, but in most instances the protection wears 
 out in the course of years and requires to be renewed. 
 The period of protection after the primary vaccination 
 is scarcely ever less than five years and not infre- 
 quently covers a period of from ten to twenty years. 
 After a second successful vaccination, the individual 
 is in the majority of instances protected against small- 
 pox for life. 
 
 When the term "vaccination" is employed, a success- 
 ful vaccination is of course referred to. The mere 
 production of a sore arm without the typical course 
 of the vaccine affection gives no protection whatsoever. 
 There are doubtless many persons who rest under the 
 false security of immunity against smallpox in whom 
 genuine vaccination has never resulted, and who, on 
 exposure to smallpox, would take the disease. 
 
 Unsuccessful Vaccinations. — Occasionally instances 
 are encountered of persons who have been vaccinated 
 a number of times, but never successfully. Sometimes 
 these persons contract severe and even fatal smallpox. 
 
Fisr. 10.— Father and child. Child, vaccinated, escaped the disease. 
 
14 
 
 One such case was a physician who had been vaccin- 
 ated seven times but without result. Such persons 
 have a low susceptibility to vaccinia but not neces- 
 sarily to smallpox. Commonly a good active vaccine 
 virus will "take" after weaker lymphs have failed. 
 
 Fig. 11. — Mother and daughter. The daughter, through vaccination, 
 although exposed, did not contract the disease. 
 
 PROOF OF THE EFFICACY OF VACCINATION 
 
 Unanimity of Opinion on Vaccination. — Proof of 
 the efficacy of vaccination as a safeguard against small- 
 pox is based on more than a century's experience with 
 this measure. There is no one fact in medicine which 
 
15 
 
 is more conclusively demonstrated. Doctors disagree 
 on many things, but there is practical unanimity of 
 opinion on the value of vaccination. There are a few 
 physicians who are opposed to vaccination, but they 
 
 Fig. 12. — Mother seen in Figure 11, front view. Typical distribution 
 of eruption. 
 
 constitute but a minute fraction of 1 per cent, of the 
 profession. There is no medical scientist of promi- 
 nence in the United States who is not an ardent advo- 
 cate of this protective measure. 
 
17 
 
 Well Protected Countries. — Convincing proof of the 
 life-saving power of vaccination is furnished by mas- 
 sive statistics gathered from Germany, Cuba, Porto 
 Rico, Philippine Islands and other countries where 
 vaccination has been thoroughly carried out. The 
 statistical evidence of the efficacy of vaccination is 
 overwhelming, but space will not permit its inclusion 
 in this pamphlet. 
 
 Crucial Experiments on Monkeys. — Scientific proof 
 of the protective power of vaccination is definitely 
 established by tests on the monkey, the only animal 
 besides man that can be given generalized smallpox by 
 inoculation. If the monkey is inoculated with small- 
 pox virus, he acquires a mild form of smallpox of the 
 type purposely produced in the eighteenth century to 
 protect people against the more severe natural small- 
 pox. If, however, the monkey is first vaccinated, it is 
 utterly impossible to give him smallpox. This is a 
 complete confirmation of the tests carried out by 
 Jenner and others on human subjects more than a 
 century ago, and constitutes evidence of the most irre- 
 futable character of the protective value of vaccination 
 against smallpox. 
 
 IMMUNITY OF VACCINATED PHYSICIANS, NURSES, AND 
 ATTENDANTS IN SMALLPOX HOSPITALS 
 
 If it can be demonstrated that physicians, nurses and 
 attendants in smallpox hospitals can be perfectly pro- 
 tected by vaccination, then this must be regarded as a 
 crucial test of its protective influence ; for if these per- 
 sons, living in the same atmosphere with scores or hun- 
 dreds of smallpox patients, breathing their very exha- 
 lations, are enabled to escape the infection, it certainly 
 should be possible for others much less exposed to 
 acquire similar immunity. 
 
 Protection of Persons in Smallpox Hospitals. — 
 Experience shows that physicians, nurses and attend- 
 ants, if recently successfully vaccinated or revacci- 
 nated, may live in smallpox hospitals in perfect safety. 
 Dr. Marson, physician to the Smallpox Hospital of 
 London for many years, giving evidence in 1871, stated 
 that during the preceding thirty-five years no nurse or 
 servant at the hospital had been attacked with small- 
 pox. Dr. Marson took the precaution of revaccinating 
 all attendants before permitting them to go on duty. 
 
19 
 
 Dr. Collie, whose experience is also large, says : "Dur- 
 ing the epidemic of 1871, out of one hundred smallpox 
 attendants at Homerton (England) all but two were 
 revaccinated, and these two took smallpox." Dr. 
 T. F. Ricketts, medical superintendent of the smallpox 
 hospital ships on the Thames, states that out of 1,201 
 persons in attendance on board the smallpox ships, 
 only six contracted the disease, all of them recovering. 
 None of these six persons had been successfully revac- 
 cinated before going on duty. According to Dr. Hill, 
 of Birmingham (England), during the epidemic of 
 1893, over one hundred persons were employed at the 
 city smallpox hospital, all of whom had been recently 
 revaccinated; not one of them contracted smallpox. 
 
 Dr. William M. Welch, of Philadelphia, states that 
 in the Municipal Hospital of Philadelphia during a 
 period of thirty-four years, in which time almost 
 10,000 cases of smallpox were treated, there was no 
 instance of a physician, nurse or attendant, who had 
 been successfully vaccinated or revaccinated prior to 
 going on duty, contracting the disease. 
 
 IMMUNITY OF MEDICAL STUDENTS VISITING 
 SMALLPOX HOSPITALS 
 
 Medical Students in Chicago and Philadelphia. — In 
 the city of Chicago, Dr. Heman Spalding has, since 
 1899, taken thousands of medical students into the 
 wards of the smallpox hospitals for instruction in 
 diagnosis. All of the students were previously vaccin- 
 ated. Of this large number not a single student con- 
 tracted the disease. From 1901 to 1904, during an 
 epidemic of smallpox in Philadelphia, about 700 med- 
 ical students were taken in small classes through the 
 smallpox wards of the Municipal Hospital. But one 
 student contracted smallpox and he had evaded vac- 
 cination and, indeed, came of an antivaccination 
 family. 
 
 ALLEGED DANGERS OF VACCINATION 
 
 Some Risk in All Human Acts. — F-ery human act 
 is accompanied by some measure of danger. When 
 one rides in an elevator, in a railroad car, or even 
 promenades on the sidewalk, he takes a certain definite 
 risk which can be mathematically calculated. While 
 in the aggregate, the number of accidents and deaths 
 from each of these causes may be considerable, yet the 
 
21 
 
 individual risk is so small that it may be disregarded. 
 It is the same with reference to vaccination. Inasmuch 
 as this procedure necessitates the production of an 
 abrasion or wound, it naturally is liable to infections to 
 which wounds from other causes are subject. Most 
 
 Fig. _ 16. — Severe smallpox, showing large pustules. (From Acute 
 Contagious Diseases, Welch and Schamberg.) 
 
 of these infections occur in persons in whom regard 
 for cleanliness and for the subsequent care of the vac- 
 cination are neglected. 
 
 Physicians Well Vaccinated Class.— -If there is any 
 class of men in the community who should be familiar 
 
22 
 
 with the accidents and complications of vaccination, it 
 should certainly be the physicians. With this knowl- 
 edge in their possession, medical men regard vaccina- 
 tion as so safe a procedure that they almost universally 
 employ this measure on themselves, their wives and 
 
 Fig. 17. — An unvaccinated man, exhibiting the development of a 
 moderately severe attack of smallpox. Third day of eruption. (From 
 Acute Contagious Diseases, Welch and Schamberg.) 
 
 their children. Indeed, physicians and their families 
 constitute the best vaccinated class in the community. 
 English statistics show that only thirteen medical men 
 per million die of smallpox as against seventy-three 
 
23 
 
 per million of the general population. The contrast is 
 all the more striking in view of the fact that physicians 
 are more exposed to smallpox than the average citizen. 
 U. S. Public Health Service Supervision. — Prac- 
 tically all of the accidents of vaccination are prevent- 
 
 Fig. 18. — Fourth day of eruption. 
 Welch and Schamberg.) 
 
 (From Acute Contagious Diseases, 
 
 able by the selection of the proper virus and care of 
 the arm during and after vaccination. The United 
 States Public Health Service has supervision over the 
 products of vaccine establishments and has the power 
 
24 
 
 to revoke the license of a firm placing impure virus 
 on the market. Frequent examinations of virus for 
 purity are made by government experts. 
 
 The danger from vaccination has been enormously 
 exaggerated by the opponents of this measure. When 
 we consider the thousands on thousands of vaccina- 
 
 Fig. 19. — Sixth day of eruption. 
 Welch and Schamberg.) 
 
 (From Acute Contagious Diseases, 
 
 tions performed, even on the unclean and under unfa- 
 vorable circumstances, and note how rare it is for any 
 serious complication to develop, we are justified in 
 concluding that the risk attending vaccination in any 
 individual case is practically a negligible quantity. The 
 danger connected with vaccination is slight compared 
 with the peril of remaining unvaccinated. 
 
25 
 
 Remarkable Results of Vaccination in the Philip- 
 pines. — Dr. Victor G. Heiser, Sanitary Director of the 
 Philippine Islands (Report of the Philippine Commis- 
 sion, and of the Secretary of the Interior, part 2 
 1907), states that, up to 1907, over 2,000,000 humar 
 beings in the Philippines had been vaccinated by the 
 
 .,?&' 20 - — Eighth day of eruption. (From Acute Contagious Diseases, 
 Welch and Schamberg.) 
 
 United States authorities without the loss of a single 
 life or limb and without any serious case of infection. 
 This_ remarkable record shows what a safe procedure 
 vaccination is. 
 
 OPPOSITION TO VACCINATION 
 
 Opponents of Vaccination Not Technically Quali- 
 fied. — The reader might pertinently ask, If vaccina- 
 
26 
 
 tion is such a wonderful preventive against a loath- 
 some, pestilential disease, why should there be any 
 opposition to it? People have a natural antipathy to 
 coercive measures ; this applies not exclusively to vac- 
 cination but also to quarantine and forcible removal 
 to the hospital. All of these are measures designed 
 for the public welfare and come within the exercise of 
 
 Fig. 21. — Twelfth day of eruption. (From Acute Contagious Dis- 
 eaeses, Welch and Schamberg.) 
 
 police power. As a matter of fact, there is very little 
 opposition to vaccination except in localities where 
 there is much agitation against the procedure. If some 
 unfortunate complication follows a vaccination, no 
 matter whether or not it be due to neglect on the part 
 of the patient, the antivaccinationists place the blame 
 on the vaccine virus. The opponents of vaccination in 
 
27 
 
 this country are made up of perfectly sincere but woe- 
 fully misguided laymen, who are not qualified by tech- 
 nical training to pass judgment on a medical question, 
 and a sprinkling of physicians who have no scientific 
 sense of proportion. The great physicians and the 
 eminent medical scientists of the country are as a unit 
 in favor of vaccination. 
 
 Fig. 22. — Fourteenth day of eruption. 
 eases, Welch and Schamberg.) 
 
 (From Acute Contagious Dis- 
 
 Vaccination Compulsory in All Armies and Navies. 
 — All of the civilized countries of the world have 
 found it desirable to make vaccination compulsory in 
 their armies and navies and, in most instances, oblig- 
 atory in one form or another for the civil population. 
 Government Commissions in England, Denmark, Ger- 
 many and the United States which were appointed to 
 investigate vaccination, have unqualifiedly approved 
 this measure as a safeguard against smallpox. 
 
28 
 
 HOW TO AVOID VERY SORE ARMS 
 
 Improper Care of Vaccinated Arms. — Nearly all 
 very sore arms and the vast majority of the complica- 
 tions of vaccination are due to maltreatment of the 
 
 Fig. 23. — Sixteenth day of eruption, 
 eases, Welch and Schamberg.) 
 
 (From Acute Contagious Dis- 
 
 arm after vaccination. Many children injure the vac- 
 cination through rubbing, scratching or other violence 
 resulting in tearing off of the scab or having it become 
 adherent to the underclothing. Such a state of affairs 
 
29 
 
 favors increased inflammation and infection with 
 various germs, and is the most fertile cause of com- 
 plications. These cases bring vaccination into disre- 
 pute; the cause of the trouble is, in ninety-nine out of 
 one hundred cases, not the vaccine virus, but the 
 improper care of the arm afterward. Physicians 
 should therefore give more detailed information to 
 
 Fig. 24. — Appearance of patient after recovery. Scarring present 
 but not deep. (From Acute Contagious Diseases, Welch and 
 Schamberg.) 
 
 parents concerning the care of the arm after vaccina 
 tion. Furthermore, parents should be told what symp- 
 toms to expect after vaccination and when the vaccin- 
 ated subject cannot be kept under observation by the 
 physician, they should report to him any undue devel- 
 opment in the vaccination. 
 
30 
 
 COURSE OF VACCINATION 
 
 1. After a child is vaccinated a small reddish blood- 
 crust forms at the site of the abrasion. 
 
 2. About the fourth day the inoculated area becomes 
 reddened and is slightly raised above the surface. 
 
 3. About the sixth day a pearl-colored flat blister or 
 vesicle is formed, containing a clear fluid. 
 
 4. The vaccination reaches its height about thj 
 eighth or ninth day ; there is a flat blister with a dark 
 central caving in; around the blister there is a zone of 
 redness with some swelling. 
 
 5. The contents of the vesicle is now changed to a 
 creamy or purulent fluid; the glands in the armpit 
 become tender and slightly enlarged, and a slight 
 elevation of temperature may be present for a day 
 or two. 
 
 6. The vesicle now becomes darker in color and drier 
 and is gradually converted into a hard mahogany- 
 colored crust, which remains attached for at least three 
 weeks. The retention of this crust on the arm until 
 healing has taken place beneath is the best protection 
 to the vaccination site. 
 
 CARE OF THE ARM AFTER VACCINATION 
 
 1. Vaccination, of necessity, produces a wound on 
 .he skin ; this wound may, like other wounds, become 
 infected with various germs if cleanliness is not 
 )bserved. 
 
 2. Nearly all of the injuries after vaccination are 
 due to neglect of the vaccination. Germs of blood- 
 poisoning, and even those of lockjaw may get into the 
 wound if the vaccination is left unprotected, scratched 
 or comes into contact with dirty clothes and the like. 
 
 3. Shields should not be allowed to remain on the 
 vaccination, as undue inflammation and infection may 
 result. A small, perforated, linen shield may be placed 
 over the vaccination for a few hours until it dries. It 
 should then be removed. 
 
 4. The best protection to a vaccination is given by 
 the application of a half-dozen layers of sterile gauze 
 (cheese-cloth, 3 by 4 inches, wrapped in unprinted 
 paper and baked in a stove oven for about a half-hour, 
 will suffice). The gauze should be held on the arm by 
 a gauze bandage or strips of adhesive plaster. 
 
31 
 
 _ 5. The gauze should be applied shortly after vac- 
 cination and should be kept on constantly. 
 
 6. Clean gauze should be applied every few days, 
 according to circumstances. The person changing the 
 dressing should thoroughly scrub the hands with soap 
 and hot water beforehand. 
 
 Fig. 25. — Severe scarring and loss of hair following smallpox 
 Patient unvaccinated. This patient also lost an eye from the disease. 
 (From Acute Contagious Diseases, Welch and Schamberg.) 
 
 7. Care should be taken by the vaccinated person to 
 avoid having the arm bruised or injured in any way. 
 
 8. If the gauze sticks to the vaccination, and is not 
 easily removed, a hot 2 per cent, solution of carbolic 
 acid in water or similar antiseptic should be poured on 
 the gauze to loosen it. 
 
32 
 
 9. In the event of any undue inflammation or of any 
 illness of the patient, a physician should be consulted. 
 
 10. Patients may take baths in a tub in a sitting 
 position, but the gauze dressing should not be allowed 
 to get wet. 
 
 11. An excellent method of treating the vaccination 
 site and one which increases the comfort of the sub- 
 
 Fig. 26. — Destruction of eyeball due to smallpox. Patient unvac- 
 cinated. (From Acute Contagious Diseases, Welch and Schamberg.) 
 
 ject and lessens inflammation and liability of infection, 
 is to paint over and around the vaccination each day 
 (beginning forty-eight hours after vaccination) a 2 
 per cent, solution of picric acid in 70 per cent, alcohol. 
 This should be continued daily until the crust has 
 become nuite hard, which it will under this treatment 
 
33 
 
 from the tenth to the fifteenth day. Later, carbolized 
 vaseline may be applied. After painting, the arm 
 should be covered with gauze and a bandage. 
 
 HOW TO CONTROL AND PREVENT SMALLPOX 
 
 1. Any person suspected of having smallpox should 
 be isolated in an appropriate apartment and no one 
 permitted to see him except those in medical 
 attendance. 
 
 2. The proper health authorities should be immedi- 
 ately informed, by telephone if possible, of the exist- 
 ence of a smallpox suspect. 
 
 Fig. 27. — Destruction of eyeball due to smallpox. Patient u 
 cinated. (From Acute Contagious Diseases, Welch and Schamberg,. - 
 
 s 
 
 3. If the case proves to be smallpox, the patieni & 
 should, impossible, be immediately removed to an isola- 
 tion hospital. 
 
 4. When smallpox is first suspected, all who reside 
 in the domicile and all who have been in contact with 
 the patient, should be vaccinated or revaccinated. 
 
 5. Careful inquiry should be made to ascertain the 
 names and residence of all "contacts," in order that 
 
34 
 
 they may be located and vaccinated Otherwise 
 numerous foci of infection may be established and lead 
 to a widespread epidemic. 
 
 6 In vaccinating "contacts" it is well to make at 
 least two insertions of the lymph, in order to lessen the 
 chances of failure. 
 
 7 If the smallpox patient is sent to a hospital, the 
 house should be thoroughly disinfected, and if the con- 
 ditions warrant the inmates, if vaccinated may be 
 allowed their freedom under surveillance They si hould 
 be most carefully examined between the eighth and 
 eighteenth days after the first exposure Most per- 
 sons who fall ill, exhibit symptoms about eleven days 
 after exposure, although with the prevailing mild 
 type" the incubation may be longer than eighteen days^ 
 
 8 If the patient is treated at home, the house, with 
 all of the inmates, must be strictly quarantined until 
 the termination of the case and disinfection of the 
 premises. 
 
 9 After the recovery or death of the patient the 
 house with all of its contents should be disinfected by 
 formaldehyd. The mattress on which the patient has 
 lain had better be burned if facilities are not at hand 
 to disinfect by superheated steam. 
 
 10 School children residing in a house visited by 
 smalipox should not return to school without author- 
 ization from the school or health authorities. School 
 or library books should not be returned until after 
 special disinfection. 
 
 11 In case of death, the body should be wrapped in 
 trife: saturated with 1 : 500 mercuric chlorid solution, 
 
 in a sealed coffin and buried within twenty-four 
 . according to regulations of the Board of Health 
 fe district. Of course, no public funeral services 
 5 be held in the home of the patient. 
 
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