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.
H. W. MILLER, M. D.