THE valuable experience we gained in our fight with smallpox should not be lost to posterity. Our final success in exterminating the disease demonstrated, beyond doubt, the feasibily and immense value of formaldehyd disinfection on a large scale. It has also shown that thorough investigation, strict quarantine, and sanitary measures are most powerful weapons against the disease. It has further brought to light that vaccination with the commercial bovine. virus, which is now generally used, has its shortcomings and even its dangers. As a prophylactic measure to immunize mankind against the dreaded scourge its value is indisputable, but let it be done by the family physician in time of peace, with plenty of leisure and with humanized virus. Then a vaccination will usually last a lifetime. To overcome an epidemic it is too slow a means; it is too ineffective and unreliable.

Vaccination will frequently not take. It will fail in cases in which prompt action would be most desirable. That has its several reasons.

1. Vaccine is a very delicate product. Exposure to a high temperature will quickly destroy it. I am told that a whole batch was made inert by being placed on a radiator in a postoffice, but scores of points had been used before it was found out. That loses time. It ought to be placed in a cool dark place in order to keep. The druggist usually keeps it on a shelf, the doctor in his satchel or pocket, where it may be dark enough, but what about coolness?

2. It may not be properly applied. The physician in his eagerness to avoid sepsis employs an antiseptic solution on the arm. That is sufficient, the virus will not take. Or he wants to be very careful not to draw blood and does not denude enough. He is in a hurry and does not take time to rub the

* Abridged from the Cleveland Medical Journal.

vaccine in, or does not take time to let it dry before he lets go of the arm, which is very likely to occur when you have a school of from 1,000 to 2,000 chindren in front of you and would like to get through.

3. People submit to vaccination, but afterwards employ a means to destroy its effects. In 1900 Dr. Stotter and I vaccinated the employees of a manufacturing plant, some 300. A smallpox scare was on and the manufacturers had brought pressure upon their employees to get vaccinated, offering to pay for it. The men heroically bared their arms and stepped up defiantly to be vaccinated, but I saw a good many afterwards go to the hydrant and wash off the vaccine! Last June I was out in Newburg on a trip of investigation. Walking up the street I met a crowd of children calling to each other: "Are you vaccinated? Are you vaccinated?" I knew then that the vaccinators were in the school-house, and I slackened my pace to hear the comments. Pretty soon I knew what they were up to. The grocery-man on the corner had told some of them that they must wash their arms to prevent them from getting sore. They communicated it to each other in a most lively manner, and all hurried as fast as they could to the grocery-store to wash their arms.

Two years ago there was a general complaint among medical men that the virus did not take, and a clamor was raised by the profession for points that would take. The manufacturers seem to have yielded to this pressure, and send out points which are active. Last year I was offered samples of points with a verbal guarantee that every one would work. I tried one of them. It "took," but oh, what an arm! I had to console the poor mother with the usual subterfuge that it was a splendid "take," that her boy surely would have had smallpox if he had come in contact with it, and that he would have had it very badly. The next point I tried on a man who was broken out with smallpox. I told him that it would modify the disease, and that he would not have it so severely. He had only a few

pimples on him. His arm also became very sore. I had to tell him that the vaccination drew all the poison to that arm, and that he would have had a terrible eruption if I had not vaccinated him. Still I was not satisfied. I wanted to vaccinate someone who had just recovered from smallpox, to see whether it would take. For quite a while I could not find anyone foolish enough to let me try the experiment; but, as luck would have it, I was sent to a boardinghouse to vaccinate all the inmates, for they had all been exposed. The first one who came up to me had had smallpox about six months before. He was a little gay from drink, and swaggeringly bared his arm, saying: "You may vaccinate me all you please." I knew him, and I used the point which I wanted to try. After I had vaccinated him he began to make fun of me, saying that it would never "take" on him, that it had been I who had sent him to the hospital, This man developed such a horribly sore arm that I had to dress it daily for five weeks, and I did it willingly and thank my lucky star to-day that I got out of it so easily.

Last year the virus took altogether too well.

Fully one-fourth developed sepsis. The arms swelled clear to the elbow; yes, clear to the wrist-joint, with high fever and enlargement of the axillary glands; pieces of flesh as big as a dollar and twice as thick would drop right out, leaving ugly suppurating wounds, which to heal took from six weeks to three months. I had to dress a little girl's arm for fifteen weeks before it got well. This is not vaccina, it is sepsis pure and simple, and such a vaccination does not protect against smallpox; as I have found out at 60 Louis street, where three children developed smallpox 19 days after a seemingly successful vaccination, when they ought to have been so immune that inoculation with variolus pus itself should not have produced the disease.

To top the climax four fatal cases of tetanus developed after vaccination. No one has ever demonstrated the presence of tetanus bacilli in any virus of any make.

It

seems to be a secondary infection. But no one can doubt that there is some connection between tetanus and vaccination. The vaccination seems to prepare the soil for the tetanus bacilli by causing suppuration.

Taking all the facts together we can readily see that the virus at my disposal was not a certain means to check the spread of smallpox; that it could not be relied upon; that by its frequent failure to "take," or by causing sepsis, most valuable time. was lost; and that the people became disgusted and grew suspicious of the Health Department, so that they became antagonistic instead of working in harmony with us, and hid cases and helped their neighbors hide them, jumped quarantine whenever there was a chance, refused information, etc. From the score of letters I have received from all over the country I find that others are having exactly the same experience that we have had here.

I came to the conclusion that the lymph we used contained more than vaccine, and that vaccination had become a drawback in the fight with smallpox, so I dropped it. I had been studying the last epidemic since 1899. I had seen it from a small beginning spread all over the city. I had watched the way it traveled and the means it employed in its progress, and had ofted reflected upon. the circumstances which favored its development and hastened it on in its triumphant march. But there I had also learned which weapons were effective and could be relied upon with safety. The only means to strike it a death-blow is disinfection with formaldehyd. I am firmly convinced that it will do it every time, for it has done it here in Cleveland in every instance in which we have tried it. In 1899, and the beginning of 1900, all the smallpox patients were treated in their homes. Usually some of the family got it. After all were through desquamating, the scabs used to lie thick on the floor. The poison must have been concentrated in these rooms, but after a formaldehyd generator was put there and set going, and the house was thoroughly disinfected, all the poison was killed. Not a

single case could be traced to a disinfected house, no matter how many cases had occurred there. Based upon these facts I proposed to the Mayor a house-to-house disinfection. I felt unspeakably relieved when he kindly told me: "Go ahead, Doctor, and I will uphold you." This was on Saturday, July 27. Next Monday, July 29, we began disinfection and continued until November 9. I applied to three medical colleges for all their available men, and put them on as fast as we could get machines.

Each man had to serve a day's apprenticeship. Finally I had a squad of forty men. Thus we disinfected every section of the city where smallpox had been, and every house of the section, no matter whether the disease had been there or not, and every room, nook and corner of a house, paying special attention to the winter clothing which had been stored away, presumably full of germs. And I always enjoined the sanitary policemen to see that no watercloset was forgotten. The boys did their work faithfully and conscientiously.

Along with disinfection went the sanitary measures. I called all the sanitary patrolmen into the office and instructed them to begin a house-to-house crusade against dirt of any description, to enjoin people to clean their yards and barns, drain all puddles or fill them in, abate all nuisances, clean all closets that needed cleaning, and enforce sewer-connection wherever there was a sewer in the street, and also to look over dumps, and vacant lots, and compel the owners to keep them in a sanitary condition.

The cleaning of the streets is one of the most important sanitary measures. What the people of Cleveland spend in cleaning their streets they save in doctor's bills. Besides there will be a saving of human lives and of much unnecessary suffering, to say nothing of the comfort and satisfaction clean streets afford.

Smallpox is on the increase all over the United States according to the last report from Washington. We have extirpated the. loathsome scourage from our midst, but I am fully aware of the fact that we have made no immunes, and that there is danger

for Cleveland as long as the disease surrounds us. We cannot descend from the watch-tower as long as there is a case in the country, nor lay down our arms before the enemy has been exterminated throughout the land.

Cats and dogs must be treated like persons. This was most forcibly brought home to me down in the flats, near the river. There we had a boy sick with the smallpox. One day when I came there I found the dog in bed with the boy, under the cover, both the boy's arms around it. It seemed that I had surprised them, and the mother made quite a fuss about the dog being in bed. She chased it out of bed, opened the door, and before I could interfere the dog was outside. Now I could not catch that dog, nor could the guard. There were any number of dogs in the neighborhood, and in due time we had smallpox all over the neighborhood, and peculiarly enough it invariably began with the children and in families that had a dog.

I have to speak a word yet on investigation and the way we carried it on. It is a most arduous task, and no one who has not done the work can imagine what a tremendous job it is. Since the fight against smallpox has begun in earnest last May, we investigated everything that was at all suspicious, e. g. we investigated every case of measles, as malignant smallpox has a great similarity to measles and mistakes have been made. Also warty pox (Variola verrucosa) has in the beginning a resemblance to smallpox. Then all cases of chickenpox, anything that was telephoned to the office as suspicious, even though we found nothing but mosquito-bites when we came there. Whenever we found a case of smallpox we asked the patient, besides the usual questions about name, age, whether vaccinated and how many in the family, the following:

1. Who has visited you during the last two or three weeks? The difference in time depends upon the state of development of the eruption.

2. Whom have you visited during the last three weeks?

3. Have you been at any public meeting

during that time, where and who was present to your knowledge?

4. Where do you work?

5. Where do the children go to school? 6. Where does the family attend divine worship?

This information obtained, the trotting commenced. All the given addresses had to be visited. Besides we asked the foreman, preacher, and teacher for all sick or absentees from shop, church or school during the last month, and they were seen. It made an almost endless chain, and the work connected with it was immense.

Looking back over our smallpox history we find that in 1898 we had 48 cases, the next year 475, the following 993, and from January 1 to August 23, 1901, 1,230. On this last date the last case developed in Cleveland.

Almost six months have elapsed since the Scourge has been exterminated from our midst. When we consider all the means employed and measures taken during our struggle with the hydra-headed monster, when we sum up and try to reach a conclusion, in my opinion investigation, strict quarantine and sanitary measures come in for a great share in our victory, but the death-blow was dealt by formaldehyd.

AIR and water, says the Medical Brief, are two remedies apt to be overlooked by the profession in the search for cures, yet as all progress is constantly bringing us back to, and accentuating the value of, first principles, we occasionally find cases on whom all medicines have lost effect, and who yet can be restored by the intelligent use of these two natural agencies.

We have a case in mind at this writing. The patient had been an invalid for years. She had been the round of doctors and pathies. Had experimented with all the fads at home and abroad, with only temporary benefit. At length, she fell into the hands.

of a common-sense doctor in a little country town where she was passing the summer.

He regulated her diet and established her habits on a sound hygienic basis. Then he taught her how to breathe (something which many people do not know), and insisted that she drop everything and devote a few minutes several times a day to proper breathing. Also, and most important of all, that she drink a glass of water every hour of the day while awake.

She followed his directions to the letter, principally out of curiosity at first, and later because she began to see the good effects of the treatment. Her color improved, flesh became firm and bowels regular. In six months she was perfectly well.

The tissues of this woman were full of impurities, which the increased supply of oxygen and water either burned up or flushed out into the proper channels of elimination. The circulation and excretory organs felt the stimulus of the additional fluid and increased their work. When the autotoxemia was relieved, all the unpleasant symptoms subsided.

The good effects which follow a sojourn at the various mineral springs are due chiefly to the large amount of water drunk, and the moderate, but regular, amount of exercise involved in getting it.

Consumption is a house-air disease; probably catarrh is also. In all chronic diseases there is a condition of self-poisoning. Here the remedial value of air and water is not half appreciated. Give your patients a tablet, to be dissolved in a glass of water, or a small vial from which a few drops may be added, to insure that they drink the full amount. Insist upon their going outside, warmly wrapped in cold or inclement weather, and breathing deeply, slowly, regularly, at certain intervals during the day.

At the end of a few weeks or months, you will be perfectly astounded at the alteration for the better effected in apparently desperate cases, without a drop of medicine. Try it.

FECTION.

WITHIN the past few years, says the Medical Record, the belief has been steadily gaining ground that insects are important factors in the dissemination of various diseases. With regard to the propagation of malaria by the agency of a species of mosquito, the theory to that effect has received striking and conclusive confirmation, and is now accepted almost universally. The statement made some considerable time ago, that yellow fever is spread in a similar manner by another species of the same gnat tribe, which would appear to have been further strengthened by the result of the recent experiments in Manila of Drs. Reed, Carroll, and others, may perhaps soon be also accepted as proven. Flies-even before the Spanish-American war-had been under suspicion as carriers of infection, and especially as conveyers of the germs of typhoid fever. Dr. George M. Sternberg had, as early as 1885, drawn attention to the necessity of isolating and disinfecting excrement. Many investigators have shown clearly that Asiatic cholera is often transmitted by the agency of flies. Dr. George M. Kober, of Washington, D. C., declared it to be his opinion some years ago that flies played a prominent rôle in transmitting typhoid fever. After the outbreak of the SpanishAmerican war the opportunities for closely investigating the subject were numerous, and in 1898 Dr. H. A. Veeder published in the Medical Record of September 17th an exceptionally able article, entitled "Flies as Spreaders of Disease in Camps," adducing a number of strong arguments in support of his contention, that flies are prolific conveyers of typhoid fever when the sanitary arrangements of camps are not properly. supervised. These views were practically established by the investigations of the army medical commission, appointed to inquire into the origin and spread of typhoid fever in the United States military camps during the Spanish War, and to the findings of which commission reference has been fre

medical journals, both American and foreign. The fact may be taken, therefore, as definitely decided, that flies are responsible for much of the spread of typhoid fever which occurs in military camps and other places where good sanitary arrangements are not sufficiently regarded. Dr. L. O. Howard, of the United States Board of Agriculture, who has just published a paper on the subject, pertinently points out that, in all the literature dealing with the question, there has been no discrimination made between the different varieties of insects concerned. The word flies is used indifferently by writers, as if all flies were guilty, or as if there was but one kind of fly-presumably the house fly. Dr. Howard accordingly has undertaken a careful investigation of the insect fauna of human excrement, especially of the flies which breed in human feces or are attracted to them. The result of these researches was exceedingly instructive. It was discovered that the number of species of insects found breeding in or frequenting human excrement was very large, of which the Diptera alone were of significance from the disease-transfer standpoint. The conclusions reached were that it appears plainly that the most abundant species breeding in or attracted to human excrement do not occur in kitchens and dining-rooms; but it is none the less obvious that while the musca domestica (house fly) under ordinary city and town conditions, as they exist at the present day, and more especially in such cities and towns or in such portions of cities as are well cared for and inhabited by a cleanly, respectable population, may not be considered as an imminent source of danger, it is nevertheless under other conditions a factor of the greatest importance in the spread of intestinal disease. It is shown that the house fly prefers horse manure as a breeding-place, but it is also shown that in army camps, where human excrement is left exposed, it will and does breed in this substance in large numbers and may be attracted to it without necessary oviposition. The use of box privies should, for similar