Three-page article printed in section “Medical Missionary Department”, WA Ruble, MD (General Secretary), LA Hansen (Assistant Secretary), HW Miller, MD (N. Am. Div Secretary)

Vaccination a Prevention of Smallpox and Typhoid Fever: Sanitation Not Dependable Protection’

FOR many years it has been generally held that smallpox and typhoid fever might largely be controlled through quarantine and disinfecting measures properly carried into effect. But we have reason to believe that this result will never be obtained in such a manner, since with our sanitation, improved as it has been during the past two decades, we have had a tremendous amount of smallpox in the United States.

In 1902 there were 54,014 cases, with 2,083 deaths; in 1910 there were reported 30,352 cases of smallpox. Something, it is true, has been done in protecting communities from this disease; but once let smallpox enter a community and it finds plenty of susceptible persons who readily came down with it, and the death rate is very high.

Statistics gathered by the board of vaccination show that only five per cent of the population in prevaccination thing, it is true, has been done in pro-ease. In the eighteenth century in Europe only one in twenty escaped the disease. Since so few have natural immunity, immunity must be produced artificially; and we are compelled to look to vaccination to secure this, and not depend on sanitation to protect against smallpox. In districts in which vaccination has not been enforced, it is shown that there has been but a very slight decrease in the death rate of smallpox as a result of quarantine and ordinary sanitary measures. In the early part of the nineteenth century the annual toll of death in France from smallpox was thirty thousand, while in England and Wales statistics gathered in 1796 show that out of every million, three thousand died annually of this disease.

A Disease That Affects All Classes

Furthermore it is a disease that attacks the rich as well as the poor, the educated and well-kept as well as the ignorant and often less well-cared-for persons. Among the royalty who succumbed to smallpox were William II of Orange, Emperor Joseph of Austria, Louis II of France, Peter II of Russia, Queen Mary and her uncle, the Duke of Gloucester, and many others. It is recorded of George Washington that he was suddenly taken ill with smallpox during his early manhood, when on a visit to the West Indies.

Too much dependence should not be put on what the municipal boards of health will be able to do in protecting any one from this dread malady through quarantine precautions. Any one who depends upon careful diet, healthful surroundings, plenty of exercise, and general hygienic precautions for protection, and at the same ‘time neglects vaccination against smallpox, is taking a tremendous risk. Many instances might he shown of the results to only partially vaccinated communities that were kept in good sanitary condition, many persons being infected through exposure to his disease.

I will note only one illustration, which was recorded by William Osler: On Feb. 28, 1885, a Pullman car conductor, who had traveled from Chicago on the Grand Trunk Railway to Montreal, through a district in which the government officials had been slack regarding the enforcement of vaccination for a number of years, left in his trail along the line of the railway and in the city of Montreal an epidemic of smallpox, there being reported, in the nine months following, the death of 3,164 persons, the disease having started from this single infection.

Vaccination Applied to Other Diseases

‘That today which affords the greatest protection to the unvaccinated is the fact that epidemics are to a certain extent checked, compared to what they were a century ago, by reason of the proportionate number of persons in every community who have been vaccinated. The greater the proportion that are vaccinated, the greater the community immunity. For years there has bern more or less prejudice on the part of a certain class of educators, as well as among a large mass of the laity, against the use of vaccine from cattle. Confidence in vaccination depended for years upon experience and the showing of statistics; and the laity’s lack of knowledge concerning the methods of preparing vaccine led to some suspicion in reference to its utility in the production of immunity. But today the same principles of vaccination are being applied in other diseases, as typhoid, diphtheria, and cholera, with gratifying results in the reduction of mortality; and this has yearly strengthened confidence in the use of vaccination to secure immunity.

History of Vaccination

Vaccination against smallpox has an interesting history. During the eighteenth century the mild epidemics of smallpox were taken advantage of by inoculating from the pustule of one suffering with that disease to an abrasion made in the skin of another susceptible individual. This method of inoculation had been used for a number of centuries as a means of contracting the disease at a time when the epidemic was of least severity, rather than to take chances on the more virulent types that swept off a large number of the inhabitants; and it was recognized that one attack of smallpox, though it be a mild one, prevented a second attack. On the same principle some today take a vantage of childhood in exposing their children to measles, since it is known that the disease is more mild in childhood.

During the latter part of the eighteenth century it became known that cattle had a type of smallpox very similar to the human, and that occasionally persons would contract smallpox from a cow. This type of the disease was called cowpox. On May 14, 1796, a milkmaid of Sodbury, England, made the statement in the presence of a young physician by the name of Edward Jenner: “I cannot take that disease. I have had the cowpox.” This led Jenner to study carefully the nature of transmission of cowpox to the human, and to adopt artificial inoculation from the cow, and his system of vaccination against the disease proved a great blessing to humanity in the century past.

The disease that cattle have is produced by the same virus as that which human beings have, except that this virus in passing through the body of a cow has its infectious character and virulence greatly diminished, so that when transplanted again to an individual the disease is greatly modified, and in some cases produces scarcely any reaction. Nevertheless, immunity is just as truly and just as fully established in those individuals in which the reaction from smallpox vaccination is light as in those in whom it is exceedingly severe.


Since today we are vaccinating against not only one disease, but numerous diseases, a great abundance of knowledge has come to us through methods of producing immunity against infectious diseases. The general principle of immunity is that in some way or other the violence of the toxin, or active poison, of any infectious disease-producing organism is so diminished that its introduction into the susceptible individual is not attended with serious results. We have known in the past the body’s ability to resist poisons to a wonderful extent, and in excessively large doses, provided those poisons were first introduced into the body by gradually increased doses. For example, every one is aware of the ability of the drunkard to drink large quantities of alcohol, while only one fourth of the same quantity would intoxicate a person not accustomed to the use of this beverage. Again, not infrequently patients have been admitted to institutions for the cure of the morphine habit, who were daily consuming fifteen to twenty grains of morphine; whereas, if those same individuals had been given one grain hypodermically when they had just begun the use of the drug, it might have resulted fatally. This adaptability of the body to resist poisons comes about through the development within the blood of an antitoxin, or fighting toxin, which neutralizes and destroys the active drug poisons injected. These drugs — morphine, strychnine, and a number of other deadly narcotics — belong to the group of medicines known as alkaloids. They are derived from plants. They are very similar in their action upon the body to the poisons produced within the bodies of bacteria and eliminated by them. These germs are miniature one-celled plants, and certain types are poisonous, the same as some kinds of larger plants are poisonous. In the same way that opium can by certain methods of preparation be given in large doses and prove less toxic to the body, so it is that these bacteria can be modified through the kind of cultural media that they grow upon, or by passing them through the body of an animal, or by an unfavorable environment, such as being subjected to extremes of heat and cold, so that they become very mild in their toxic effect, and then are useful for producing immunity without harm.

Whenever it is possible to reduce the virulence of these disease-producing bacteria, it enables us to use, by a process of vaccination, these poisonous germs which we can control, to educate the tissues of the body to produce in a larger quantity an antitoxin for the purpose of destroying or neutralizing the large doses of the virulent type of bacterial poison of accidental infection which we otherwise could not control. This process of developing within the body substances which have a destroying and resisting influence upon any particular kind of disease-producing organisms is what we understand by the production of immunity.

Diphtheria Antitoxin Different

In some cases, for example diphtheria, the antitoxin is produced by the oft-repeated inoculation of an animal, such as the horse, with increasing doses of the organism and its poison until the animal has developed within its blood large quantities of the antitoxin. The persons suffering with this disease take into their bodies the antitoxin made by the horse’s blood, and in that way obtain immediate immunity. This is called passive immunity, as the horse produces the antidotal vaccine, and man borrows it from the horse. The other class is called active immunity, which is the immunity resulting from the production of antitoxin within the human body.

Thus we depend for immunity upon producing in the individual a resistance against these infections, knowing that at some period in life the individual is sure to meet with this or that infection, which if he is in a susceptible condition might result fatally. We consider it vastly more important to be able to control individual resistance against disease than to be able to control environment and circumstances which prevent simply direct contact with disease, as the latter is not yet entirely possible.

Sanitation endeavors to control disease by keeping it away from people, whereas vaccination fortifies the individual against the disease; and, as before stated, the results show that vaccination is very much more to be depended upon than sanitation, in respect to both smallpox and typhoid fever, the diseases we are especially considering in this article.

Vaccination Statistics

Authentic statistics show that the results of vaccination are superior to those of sanitation. Most of the figures that I shall give, cover a period of time when quarantine regulations and sanitary precautions were about as rigorously enforced as at the present time; and yet a neglect of vaccination showed that among the unvaccinated, smallpox was just about as prevalent as it ever was, and just as destructive. To illustrate: we have been using quarantine measures against measles, scarlet fever, and whooping cough for nearly a century past, and yet these diseases, which are of the same contagious character as smallpox, have decreased during the past century only about five per cent in frequency in proportion to the population, whereas, in the case of smallpox, the decrease has been seventy-two per cent. This tremendous decrease in the attacks of smallpox over those of measles is certainly due to the practice of vaccination as a protection against disease.

Statistics collected in Sweden between 1774 and 18o1, a period of twenty-seven years, show an average of 2,050 people infected with smallpox out of every 1,000,000 inhabitants; whereas, the forty years following the introduction of vaccination, from 1801 to 1840, the statistics of that country show only 158 cases of smallpox out of every x,000,000 inhabitants.

During the great pandemic of smallpox in Europe, between the years 1870 and 1874, there were found in Germany, as a result of vaccination, only 160 cases out of every x,000,000 inhabitants. Copenhagen, a city which in the prevaccination period had at times suffered terribly from this disease, during the years 1811 to 5823, a period of thirteen years, after the introduction of vaccination, did not have a single death from smallpox.

The British Royal Commission on Vaccination reports six epidemics in the early nineties of the nineteenth century, in which 11,965 attacks of smallpox resulted in 1,283 deaths. This report is of interest as showing a very small number of fatalities among those who had been previously vaccinated. Of those having the disease, 5.2 per cent of the previously vaccinated died, whereas among those who had not been vaccinated the death rate was 35.4 per cent. Another important consideration of the report of the commission is the fact that nearly all the cases of smallpox that did occur among those who had been vaccinated were among those who had been vaccinated but once, and that in childhood; and further, the vaccinated cases showed very few complications, whereas among the unvaccinated there were many cases of abscesses, bedsores, blindness, deafness, joint disease, insanity, paralysis, and subsequent pneumonia.

This same commission, in reporting upon another epidemic, showed that out of 286,397 previously vaccinated persons, there were only 4,151 attacks, or 1.55 per cent of occurrence; whereas, among 5,715 of the unvaccinated population, there occurred 552 attacks, or 9.7 per cent. Especially important in the statistics of this epidemic is the fact that 65,000 of the vaccinated were children, and there were but 353 attacks among them, amounting to .5 per cent; whereas of the unvaccinated there were 2,259 children, with 228 attacks, the death rate amounting to 10.5 per cent. This would show that in recently vaccinated persons, as was the case with those children, there is almost 100 per cent of immunity insured.

The Franco-Prussian War furnishes an important chapter in the history of vaccination. Before the time of this war, vaccination was compulsory in the German army, whereas little attention had been paid to it among the French. Statistics of this kind are entirely reliable, and show that the Germans lost during the war only 297 men from smallpox, while the French paid the terrible toll of 23,469 men. This was not altogether due to the lack of vaccination in the French army, but to the poor methods of using the vaccine.

An Immune Nation

Possibly no other country in the world has attained such general immunity to smallpox as has the German Empire, where there is enforced vaccination. The rule is that every child must be vaccinated at the expiration of the first year of its life unless it has been previously vaccinated or has had the disease. In case it is necessary to delay vaccination on account of some physical disability, the child is vaccinated within one year after the removal of the disability. Every pupil of a public or private educational institution must be vaccinated between the ages of thirteen and fourteen years, unless there is medical proof that he has had an attack of smallpox within five years, or has been successfully vaccinated within that time. A vaccination must in every case be performed by a physician, for failure or neglect of which a fine is imposed. The results of this compulsory vaccination prove its value, since in 1899 among a population of 54,000,000 there were only twenty-eight deaths from this disease. In 1897 there were only five deaths, most of these were recorded among those living in the outlying districts of the German Empire.

In our own country we have some very important records of the value of vaccination. In Philadelphia there were entered into the Municipal Hospital during a period of thirty-four years 9,00o cases of smallpox, which were cared for by the physicians and nurses of that institution. During that entire time, no physician or nurse was permitted to come in contact with these patients unless he had been vaccinated; and although the physicians and nurses are in constant association with these patients, the Municipal Hospital has never had a physician, a nurse, or an attendant attacked by smallpox. This is not true of scarlet fever or of measles, the record showing a large number of persons on the hospital staff who not only contracted these diseases, but succumbed to them; and it is not believed that scarlet fever and measles are any more contagious than smallpox. This certainly affords very strong proof in behalf of immunity due to vaccination.

How Vaccine Is Prepared

It is now customary everywhere to employ calf vaccine; that is, to use lymph obtained from calves which have previously been inoculated with the resulting characteristic pustular lesions.  Before these calves are vaccinated, they are carefully examined and tested for tuberculosis.  The lymph taken from the calves is first diluted with glycerin.  The glycerin, besides destroying any extraneous germs which may happen to be present, increases the quantity of the vaccine so that it can be used for a greater number of cases.  It can be truly said that no harm can follow the vaccination of normally healthy children when a carefully prepared vaccine is used with antiseptic precautions.

Method of Vaccination

It is very important that the proper method in every case be used.  The arm is generally the best part of the body to select. The skin about three inches below the shoulder joint is scrubbed with soap and water, then washed with alcohol, after which it is rubbed dry with a sterilized piece of gauze or cotton.  It is then scarified to the extent of the appearance of blood, but with no flowing of blood.  A small drop of the vaccine is laid upon this scarified area and is slowly brushed in by the same scarifier. The vaccine should then be allowed to dry, and a vaccination shield with a felt margin and celluloid cover should be placed over the arm, and the arm carefully protected from injury and dirt. Usually on the third or fourth day some soreness will develop, and a small papule will begin to show, which in two or three days becomes very sore. The glands under the arm swell and become sore. In a short time this papule breaks and forms a scab, which after a few days falls off, leaving a scar. In some cases the amount of reaction is very slight indeed, no marked scar being left; yet these cases have been known to show as great an immunity against the disease as some of the more marked reactions.

The general rule to follow as to the time to be vaccinated is, first of all, during the first or second year of child life, and then again at the occurrence of every epidemic. No vaccination should be depended upon longer than three years, especially if one is residing in a territory where smallpox is raging at all times. Those who travel into a distant country where they are almost certain at some time or other to come in contact with those infected with this disease, should be protected by vaccination.

We are not living today in the experimental stages of vaccination, but should open our eyes to the clear and very definite evidences which show that it affords almost perfect immunity, when properly carried out, against this dread disease, smallpox.

Immunity in Typhoid

The results thus far in vaccination for typhoid fever show that the per cent of prevention is even greater than in the case of vaccination for smallpox.  Sanitation has done and is doing much to limit this disease; and since we know the specific organism that causes typhoid fever, we can deal with it by sanitation better than with the unknown infectious virus of smallpox. Yet, with all modern methods in sanitation, we find that through accident or carelessness thousands of people annually pay a terrible penalty in sickness and death from typhoid bacilli. There is no absolute security afforded in the supervision of food and water supplies against typhoid. Some communities and cities have suffered terrible epidemics from this disease without its source being detected. It has become proverbial around hospitals that if a nurse or a doctor contracts typhoid from a patient, he will surely die of it; for the germ gains in virulence every time it passes through the human host.

From a recent statement of the United States War Department, which has made vaccination in the army and navy compulsory, the following is taken: “It has now been clearly demonstrated that immunization against typhoid fever by the use of typhoid prophylactic is a thoroughly practical measure for the prevention of the disease, that it is unattended by bad results, and that is protective value is very probably equal to that afforded against smallpox by vaccination.”

The annual death rate of typhoid today in the United States is 400,000, or 46 for every 100,000 of population. During the Boer War there were 31,000 cases among the British troops, and 5,877 deaths from this disease. In 1906 in the Spanish-American War, among 10,759 troops stationed at Jacksonville, Fla., there were 2,000 cases and 248 deaths in four months, and among one regiment of 1,300 soldiers there were 400 cases of typhoid. The story among soldier camps today is entirely different. The United States in 1911 sent 20,000 troops to Texas, all of whom had been vaccinated, and in four months there were but two cases of smallpox in the army. Both recovered. The record of this army for one year, according to the surgeon-general’s report, was a total of eight cases and two deaths as against 2,000 cases in Florida with only one half the number of men in the camp.

No country has seemed more reluctant to use typhoid vaccine on its troops than England. That country experimented long and carefully before making it of general adoption. A commission of English army surgeons in India vaccinated 10,378 soldiers, the larger portion of a division of the army. The other portion of this army, amounting to 8,936, were not vaccinated. They all lived in the same camp and were subjected to the same conditions. There wee 56 cases of typhoid and 5 deaths among the 10,000 vaccinated, and 272 cases and 46 deaths among the 8,936 non-vaccinated. Today typhoid vaccination is very popular among the laity in India.

Physicians, nurses, and attendants today feel a great degree of safety when among the typhoid patients, because of the immunity assured them by vaccination. Medical journals now rarely record the death of a doctor or a nurse from typhoid fever.

What Is the Vaccine Used?

The germs of typhoid fever are dependent upon soluble albumin, moisture, and warmth for growth. A solution of beef bouillon is a splendid culture media for these bacilli, and when incubated they grow rapidly. It has been found that the poisonous powers of these germs are chemical components residing in their bodies; that these germs, when they enter the body of an individual, excite the blood cells to activity in the production of a neutralizing substance called the “antibody ” (a chemical antidote), rendering the germs inactive an easily killed and digested by the phagocytes (white corpuscles).

If it were not for this power possessed by the human body of producing an antidote to the poison of the germ, the germs would continue to grow, and would increase until no one would ever recover from typhoid. When typhoid germs grown outside of the body are mixed with the blood drawn from an individual convalescing from the fever, it is noted that the germs are paralyzed and soon die, and this ability of the blood to kill germs insures persons against the second attack of typhoid fever, and is the state we call immunity.

Since that poison which incites the production of these antibodies within the blood is found in the bodies of the typhoid fever germs, and its poisonous character is not affected by sterilization, a given quantity of these germs grown in bouillon are sterilized to prevent their increase in number, and immunity is gradually induced by the injection of all doses of these dead bacilli. It has been found that immunity is just as complete to when established by repeated injections of the dead germs which are incapable of harm beyond the local reaction, as when produced by their multiplication in the tissues during an attack of the fever. Once immunity is established by the development of the antibody, within the blood, typhoid fever germs may be drunk in liquids, or even injected, if in not too great numbers, and there is no reaction noticed at all, the body having been fortified to take care of them. Antityphoid vaccination is simple, easy, and safe of execution, and affords protection when all else fails.

By methods known to the bacteriologist, the number of typhoid germs are counted, and a certain number constitutes a dose. For example, 500,000,000 of these dead germs held in suspension by a salt solution and bouillon, are put up in a little sealed glass vial. The second dose is double this amount, and the third dose is the same as the second dose, or even larger. A certain non-virulent strain of the germ is selected for the culture. It is grown in an incubator for three weeks, and then heated to 6o°C or 140°F to kill the germs. It is then divided into doses of sufficient ‘strength to kill a guinea pig, which is just a sufficient amount to produce a good reaction in man.

Method of Use

Three doses are considered necessary to establish immunity. They are given ten days apart by injecting about one cc. (one quarter teaspoonful) of a diluted culture under the skin of the arm with a hypodermic needle. Four o’clock in the afternoon is the best hour to select for the injections, as the reaction follows in from three to six hours, and will occur during the hours of sleep. There is usually some redness around the area of injection, some soreness in the arm, and occasionally in the axilla, but no scar is left. In some of the severe cases there is headache, fever (102° to 105°), and nausea; but the cases of severe symptoms are very rare indeed. The Germans have divided the types of reactions into three classes: —

1. Those of no reaction.

2. Those of moderate reaction (temperature, 101° to 102°).

3. Those of severe reaction (temperature, 102° to 104°).

About two thirds of the persons inoculated fall in the first class, one fourth in the second class, and about one in twenty in the third class. The immunity in all three classes of reactions is considered equally protective. No vaccine should be used that is more than three months old. The immunity resulting is quite permanent, with no apparent necessity for revaccination. It is important that this technic be carried out by a physician or one trained in antiseptic procedure. Thus far in its use by the United States government not one case of fatality has occurred, nor any accident serious to the future health of the person vaccinated. So carefully and well has the work been accomplished that not one case of abscess has followed the thousands of injections. Neither is it shown that the body loses its natural protective immunity to other diseases by typhoid protective inoculation.

Who Should Be Vaccinated

I would say in regard to typhoid, the same as in smallpox, that every one ought to be vaccinated, unless it be those above sixty years of age. Typhoid is not a disease of old age, rarely attacking those of over fifty years, and is not frequent in childhood; but those of late childhood and middle age, in view of the frequent occurrence of this disease in every community, its high mortality, and its serious effects on the future health of those that survive an attach, should most certainly be vaccinated at their earliest convenience.

All the vaccine used thus far for purposes of vaccination in the United States Army and Navy has been prepared in the laboratories of the Army and Navy, Medical School at Washington. Every batch that is made up has, before being sent out, been tested by injecting some of it into guinea pigs and mice, these animals being most susceptible to tetanus and other forms of infections, and not one contamination has yet occurred, according to the government report. Certainly in these enlightened times such wonderfully protective measures should be made use of, which, if generally adopted, would almost stamp out of existence two of the most dreaded diseases; and the possibility of attaining such immunity is readily within the reach of every American citizen.

Objections, we know, are offered even at this late date, but they are growing fainter and less founded as our knowledge of diseases and their causes is increasing through scientific research. We can often well afford to wait for good evidence and confirmation before subjecting our bodies to any questionable test, but there is very little that we are more sure of concerning the prophylaxis and rational treatment of disease than the use of vaccination in typhoid fever and smallpox, and there need no longer be hesitation or delay in making use of this safeguard.