Selected Papers.

From the Lancet for July, 1858.

NECESSITY OF EFFICIENT VACCINATION.

THE student of the writings of Jenner cannot be more struck with the perfect confidence he expressed in the power of successful vaccination to guard the human constitution against small-pox, than with the great stress he invariably laid on the precise and very definite character of the affection of the system, resulting from the introduction of vaccine lymph, from which alone that protection could be derived. His belief and teaching were, that it was impossible to be too cautious in the selection of lymph, too watchful in regard to the state of the health of the child to be operated on, or too attentive to the local action induced by the vaccination. He held that lymph taken from a vesicle which deviated from the normal type, or from a genuine vesicle at too late a period, might afford an insufficient protection, and that all so vaccinated might be more or less liable to small-pox. Even when genuine lymph had been used, there might be circumstances which would interfere with the progress of the vaccine affection, and it was therefore necessary to watch in every case, and none were to be held safe who had not been so watched, and, when necessary, tested by re-vaccination.

Within a year, indeed, of the publication of his first treatise on vaccination, serious errors had begun to creep in, and he felt it necessary, in a second tract, "to point out the fallacious sources from whence a disease imitative of the true variola vaccinæ might arise, with a view of preventing those who may inoculate from producing a spurious disease.' A few years later, (in 1804,) in a letter to Lord Berkeley, he mentioned his expectation that cases of failure would occur in considerable numbers, for want of that accurate discrimination between "the perfect and imperfect pustule," without which, he says, "to inoculate the cow-pox is folly and presumption." Writing to Mr. Dunning in the same year, he says, "You will have enough of small-pox after cow-pox. It must be so. Every bungling vaccinist who excites a pustule on the arm will swear it was correct, without knowing that nicety of distinction which every man ought to know before he takes up the vaccine lancet." In other letters he condemns the use of lymph taken at too late a period,

and speaks of the modification which its quality may undergo in passing through the skins of those affected with various cutaneous diseases, as herpes, etc., so that "it will produce pustules of a diminutive size, with a faint, or even without any areola, and finishing its course prematurely." And in 1817, he relates to Moore the fact of a parish vaccination by contract, conducted by a medical man, the lymph taken from two very imperfect vesicles on the arms of a scabby child, which he had condemned as deceptions. In regard to his own vaccinations, it was a circumstance which teased and annoyed him considerably, that in numerous instances those vaccinated by him did not give him an opportunity of judging of their security by ever returning to show him their arms.

Such were the obstacles to correct vaccination pointed out by Jenner, and there is not one of them which does not exist at the present day. The discrimination between the perfect and imperfect vesicle is often not correctly made, and lymph is taken from vesicles which deviate from the normal standard. Even from a normal vesicle it is frequently taken at too late a period. Before inserting it, due inquiry is not made into the existence of those affections, as herpes and intertrigo, which, without inquiry, would often escape notice altogether, but yet which seriously interfere with the due course of vaccine affection; sometimes, indeed, there is an absence of knowledge that such diseases are of any consequence at all. The most correct and scrupulous vaccinator meets with many difficulties in ascertaining by inspection the success of the operation he has performed, and is, indeed, often deprived of the opportunity of doing so altogether.

It would be easy to produce illustrations of every one of these sources of failure, but it is not needed; for so numerous are they, that we are convinced there are few of our readers who have paid much attention to this subject, whose experience will not supply them with such. The result is truly lamentable. Many persons are reported vaccinated in whom the operation has produced no effect at all; others go through a disease which they are either told or imagine to be the vaccine affection, but which is in reality a spurious disease. If these persons become at any time exposed to the contagion of small-pox, they contract the disease, and perhaps they die; and not only is life thus sacrificed, but the greatest discredit is brought on vaccination itself.

To the extent to which the vaccinations of this country are tainted with these sources of error, the attention of Parliament was called some years ago by the Epidemiological Society. Instances were given especially of that error which Mr. Marson believes causes more mischief than all other causes put together-the taking of lymph at too advanced a period of the vesicle. It was shown that in many instances children were reported and registered as vaccinated, whose arms presented not the least marks of cicatrix, and in whom the insertion of vaccine lymph was found to develop the genuine disease. The elaborate inquiry undertaken by Mr. Simon confirmed these statements, and justified the conclusion at which he arrived, "that there is current in England and Wales, not only an appreciable amount of utterly incompetent vaccination, but a very considerable amount of second-rate vaccination." Mr.

Marson, indeed, had stated to the same effect some years before, and his statement has the more value because it was part of a purely scientific inquiry, undertaken without any relation whatever to the laws regulating vaccination. While his ample opportunities at the Small-pox Hospital had proved to him that the Danes, Swedes, Norwegians, and Germans are better vaccinated than any other people, they also showed that England and France are at the bottom of the scale.

And really this is not to be wondered at, as regards England, when we think of what the system in this country has been; or, rather, how entirely vaccination has been left to take its chance without any system or organization whatever. Till the Act of 1853, there was nothing in the law to prevent any amateur from trying his hand at vaccination: chemists and druggists, midwives, old women with stocking-needlesany one might "cut for the cow-pox," and any one so cut looked on himself, of course, as vaccinated. The Act of 1853 required that, as regards all children born after its passing, the operation should be performed and its success ascertained by inspection by a duly qualified medical man; but in respect of this, as of its other provisions, there is no one to see that they are carried out. So the so-called vaccination of chemists and druggists may flourish still, and the duly-qualified medical man may be represented, if he will-nay, is represented sometimes-by his unqualified assistant. Indeed, so utterly defective are all the provisions with regard to vaccination in this country, that even a legally qualified medical practitioner may be without the requisite knowledge of vaccination, and the very errors to which we have called attention have occurred in the practice of such. Though it depends on the correct or incorrect performance of this operation whether a person has real immunity from a hideous and fatal disease, or only a false sense of security which may lure him into danger, but cannot save him from destruction, our Legislature has never thought that any care need be taken that vaccinators really know their work, nor even that it was needful to make any provision for instruction in vaccination at all. All is left to chance. If a medical man has been the pupil of a careful vaccinator, he will have acquired a competent knowledge of vaccination, and it will be well for him and his patients; but what if he have been a pupil of a careless and incompetent man-of such a one as he of whom Jenner speaks in his letter to Moore? Or if, as is not uncommon now-a-days, he have not resided with a medical man at all? The whole thing is too bad to last. It must be corrected, and that speedily, unless this country is willing to remain under the stigma of being the worst vaccinated country in Europe. And none are more interested in having it corrected than the great body of public vaccinators-men who thoroughly know their work, and take pride in it, and to whom it must be a source of constant annoyance to be confounded with the comparatively few amongst them whose misdoings have brought such discredit on the vaccinations of England.

From the North American Medico-Chirurgical Review for July, 1858.

REMOVAL OF AN OVARIAN TUMOR, IN WHICH THE ÉCRASEUR

WAS USED.

BY JOHN L. ATLEE, M.D., of Lancaster, Pa.

On the 29th of January, 1858, I was called to see Mrs. E. E., of this city, in consultation with Dr. James Rodgers. She was then in her sixtyfirst year; commenced menstruation at seventeen; married at the age of twenty-three, and had never conceived. Her menses continued until the age of fifty-two, with occasional slight intervening leucorrhoea, and had always been more or less painful, and somewhat profuse. On one occasion, about two years after her marriage, she had uterine hemorrhage, which weakened her and kept her confined to bed for a few days. Soon after the cessation of the menses, she had an attack of erysipelatous inflammation of the face; since which time, until the winter of 1856-7, her health had been very good. Her husband died four years ago. Some time in January or February, 1857, she became troubled with flatulent distension, as she supposed, of the lower portion of the bowels, and a frequent inclination to pass urine, although the quantity discharged was trifling. She had also occasional pain on each side, just above the groins, which resembled the pains of menstruation. On the 5th of August, finding her symptoms increase, she consulted Dr. Rodgers, who, upon examination, discovered a tumor occupying the whole lower portion of the abdomen, with evident fluctuation. A course of diuretic and hydragogue cathartic treatment, combined with mercurials, was instituted, and perseveringly carried out by him, alone, and subsequently in consultation with a highly respectable and experienced physician, with no other effect than to debilitate the patient. The size of the abdomen gradually increased; and on two occasions Dr. Rodgers was of the opinion, from the severity of the pain, that peritoneal inflammation existed in the left iliac region. The patient now complained so much of the discomfort arising from the distension, that, on the 17th of December, her physicians removed eight pounds of a highly albuminous fluid by tapping. A tumor of considerable size remained. occupying the left hypogastric, iliac, and lumbar regions. The character of the disease being now understood, all active treatment was suspended, and the patient placed upon a more generous diet. The only medicine given was a mild saline aperient, to regulate the bowels. Four and a half weeks after the first tapping, a similar amount of fluid was drawn off by Dr. Rodgers. Two weeks after this, I was requested to see her. I found the abdomen as large as at the full period of pregnancy. There was evident fluctuation over the whole of the right side of the abdomen, extending to the left hypochondriac and upper portion of the lumbar regions. A very hard tumor occupied the lower portion of the left lumbar and iliac regions, pressure over which occasioned severe pain. Upon examination, à, per vaginam, I found the neck of the uterus occupying a

central position in the pelvis; the left side presenting a tumor without fluctuation. On the right side a tumor could be felt, covering the brim, with evident fluctuation when the tumor was percussed from above. I diagnosed a multilocular tumor of the left ovary. Owing to the great oppression and pain arising from the pressure of the cyst, we tapped her again on the 3d of February, less than three weeks from the last operation, and eight and a half pounds of fluid were removed, containing so much albumen that it coagulated perfectly by heat. This rapid filling of the cyst had caused great emaciation, and it was evident that unless resort was had to the removal of the cyst she could not long survive. Her pulse ranged from 90 to 100, and, occasionally, was above that; it was small and irritable, and quickened by mental emotion and exercise.

Three days after the last tapping a careful examination of the tumor was made, with reference to the practicability of an operation. The large remaining tumor, now that the abdomen was relaxed, could readily be moved to the opposite side; and inasmuch as the severe local pains, which existed when the abdomen was distended, were immediately relieved after tapping, I had reason to doubt the existence of much previous peritoneal inflammation, and consequent adhesion. After representing fairly and candidly all the dangers of the operation, in the presence of her attending physician and immediate friends, she was left to decide for herself-my opinion having been given that it was practicable, and would be successful. At all events, should dangerous adhesions exist, the operation would be abandoned, and the wound closed; as had occurred to me in a previous case, with a favorable result. After various delays, and another tapping on the 3d of March, at which ten pounds of albuminous fluid were removed, she finally demanded the operation; being sensible, from the rapidity of the filling of the cyst, and her increasing debility and emaciation, that it could no longer be delayed. The day previous the bowels were freely evacuated, the patient restricted to cold water, and in the evening twenty drops of elixir of opium administered, to keep the bowels quiet. At midnight she took a second dose. Thirty drops were given on the following morning, the 23d of March, on which day, at noon, I proceeded to the operation, in the presence of Drs. Rodgers, Parker, Perry, Ehler, M. M. Nithens, and John L. Atlee, Jr., and Messrs. Weiger, Brensman, and Frick, medical students. The temperature of the room had been elevated to 80° F., and it was steadily maintained at that for several subsequent days. The bladder having been evacuated before placing her on the table, she was put under the influence of ether and chloroform, and an incision was made through the skin, cellular and adipose tissues, to the fascia, from one inch below the umbilicus to two inches above the pubis. The fascia and peritoneum were then successively divided upon the director to the extent of the external wound. The large cyst was now exposed, occupying the upper, lower, and right side of the abdomen, presenting, on its left aspect, a deep sulcus between it and a second cyst, which filled a large portion of the left lumbar and iliac regions. The hand was then introduced, and the adhesions caused by the previous tappings separated,