pleto on several interesting points, but so far as vaccination is cjncemed, they give full and abundant information. All tho cases except seven (entered because of their relation to others), were seen by myself. Nothing but the final result has been recorded at second hand, and I havo preferred leaving some points unnoticed to subjecting my conclusions to the suspicion of being based on uncertain data. I am solely responsible for the figures, and take this opportunity of saying that if on some points my conclusions?as derived from these figures?differ from those ordinarily received, it is on a posteriori grounds, tho questions having been forced upon me by the figures, which were
not in tho first instance collected with any reference to As I said before, it was to test the goodness or otherwise
them.
Bhurtpoor vaccinations that the observations were made, they were simply recorded from day to day with no view to their future use as bearing on controverted questions. Tho conclusions have been gradually formed in analysing the returns long after small-pox had ceased, and I had no pre-conceived opinions to support. Besides a sketch of tho progress of the epidemic, the returns give room for an enquiry into the value of vaccination in India; the alleged deterioration of the protective power of vaccination from change of climate; and the supposed greater prevalance, severity, and fatality of small-pox in hot countries, and among the dark-skinned races. On each of these points some light will be thrown, which, it is hoped, may help to reconcile conflicting statements and beliefs. As preliminary to these, however, and as tending to the better appreciation of results, I shall give a brief outline of the progress of vaccination in Bhurtpoor, from its first introduction, up to the time of of tho
and
the recent outbreak. Seventeen years ago tho Maharaja was vaccinated with a few other children, by the present head of tho Medical Department, Dr. Murray, then Civil Surgeon of Agra; and a few cases wero afterwards operated on each year; but no record has been kept of these, nor wero any regular vaccinators employed, and tho little work which was done can have had no effect in bringing the prophylactic to tho notice of tho public. So far as can bo discovered, no systematic attempt to introduco it appears to havo been made till tho season of 1861-62. Up to that time the
Agency Surgeon's operations seem isolated cases, vaccine work forming tho operations wero probably too few differenco in the IN BHURTPOOR. SMALL-POX AND VACCINATION By Robert
Surgeon
to
Harvey, M. B., &c.,
the Eastern Rajpootana To/itical
Agency.
I rtTRi'OSE to record briefly the late epidemic of small-pox in Bhurtpoor, in its relation to the progress of vaccination in the state, and as bearing on some undecided points concerning smallin India generally. The observations and pox and vaccination conclusions which follow are based on analyses of eight hundred cases of small-pox seen and noted by myself during last cold ; and on the daily returns of cases and deaths made to tho Magistrate. The latter returns are exceptionally accurate and were tested over and over again in all
season
City trustworthy.
They
of ways, while the epidemic lasted, and an additional proof of their accuracy is found in the fact that the results deduced from them tally in a great degree with those derived from my own figures. These, so far as they go, may be relied to watch the course of the upon. It was of course manner
impossible
disease in all cases, and, indeed, the majority were seen only once or twice, while a few of exceptional interest, and tho postvaccinal series frere noted throughout. The original object of
the investigation was to test previous vaccine work, and the great point being to see as many cases as possible, it was difficult to pay second visits to ordinary cases as tho now ones wero so numerous. On this account my notes are somewhat iucom-
vast
number of
to havo been limited to part of his duty, and
no
to make any
appreciable
unprotected
persons. Tho late Dr. Stewart was tho first to endeavour to remedy this unsatisfactory state of things, but there was a good deal of
opposition; his cases were not numerous, and when Dr. Mott was appointed to succeed him in 1861, it may fairly bo said that vaccination was only beginning, and that, practically, its introduction dates from that timo. Dr. Mott took up the,subject with energy ; taught the Native Doctors and Compounders attached to the different dispensaries, and mado them expert and by securing the operators under his own supervision, services of two good vaccinators from Agra, and instituting a in infusing a measuro series of rewards for good work, succeeded
of his own zeal into his subordinates. Ilis exertions met with from tho first, large numbers of cases being operated less than appears to bo on each year, and the opposition being bo ascribed in part to the moral generally the case. This may effect of the Maharaja's having been vaccinated in infancy, to tho comparative freedom from prejudice which in success
and part characterises
the Jats. Thero was much apathy, and little apof tho value of tho boon at first, with occasional active resistance to tho vaccinators; but year by year it becamo cases, active opposition declined into apathy, and to
preciation
easier
get
some extent changed into appreciation. It will be seen that the system which Dr. Mott introduced is in the main the old dispensary system of vaccination, and it has many of the disadvantages of that system. In un unhealthy season, for instance, tho Native Doctors and Compounders being
apathy to
THE INDIAN MEDICAL GAZETTE.
258
otherwise fully occupied, vaccination suffers; and at all times
it is
impossible for them to vaccinate villages at any distance frum their dispensaries; such villages having to be left to a chance visit from a peripatetic vaccinator, whose work cannot he properly overlooked. The chief recommendation of the plan is its cheapness, no special vaccine establishment being necessary.
The
circumstances in which the agency surgeon is the objection which has been fatal to the dis-
placed,, remove
pensary system as formerly practised under the nominal superintendence of civil surgeons in British territory. Their efficient supervision was almost impossible, the civil surgeon as a rule being tied to the station, and unable to visit his district more than two or three times a year. In Bhurtpoor, on the other
hand, the medical officer is constantly in camp during the cold season; and visiting the different centres frequently,?is able, to a considerable extent, though by no means perfectly, to
superintend the work. spite of this imperfect agency great progress was made during five seasons under Dr. Mott's care, and when he left in 1866, all preliminary difficulties had been to a great extent' overcome, and it remained only to push on the operations, and increase, if possible, the percentage of success. This in 1865-66 had been only 71*80, a considerable decrease on previous seasons, and it seemed evident that, unless it could be raised, great disIn
credit must be thrown
small-pox,
the
people,
on as
a
vaccination
rule, being
between successful and unsuccessful
on
the next outbreak of
little able to discriminate "With this view, and
work, and each season a3 many men as could be temporarily withdrawn from all other duty and put under his orders, the Native Doctors continuing to vaccinate in the immediate neighbourhood of their dispensaries. In this way great improvement was hoped for, without trespassing too far on the liberality of a State which had already done so much for its sick poor. The following medical institutions are kept up by the Durbar, which last year spent nearly fourteen thoustion of the
spared
were
and rupees on "Medical services:"? A general hospital, with a daily average this year of 92 in-
patients. A jail hospital. A sudder dispensary in the city of Bhurtpoor. Nine branch dispensaries. The use of crusts has been gradually abolished, fresh lymph being substituted. Each vaccine centre has been frequently visited, and in distributing the rewards, regard has been had solely to the character of the work produced for inspection, numbers being looked upon as subsidiary to success. Attempts have also been made to impress upon the people the objects and advantages of vaccination. The result of these measures has been a steady increase in the percentage of successful cases, which rose to 80-04 in 1867-68, and to 8653 during last season. While I believe these figures to be fairly correct I will not vouch for them, but there can be no doubt that each year has shewn a considerable improvement on its predecessor; and it frequently happened to me last cold weather to go over a day's work?numbering thirty, forty, or even fifty cases?without meeting with a single child in whose arm the virus had failed to take.
The increased success is due to many concurrent causes, undoubtedly the use of fresh lymph ; but more careful selection of in the
the chief of which is
prolonged experience
operators,
of a cases, and the abandonment in great measure by parents practice of washing off the virus, or opening and applying drugs to the vesicles, have all helped to swell the return of that has successful cases. As an illustration of the
progress
been made, I may mention that when small-pox was last prevalent in 1864-65, Dr. Mott reported (annual report 1864-65), that
"the epidemic caused greater doubts than
ever
concerning the
1869.
during the recent outbreak, the by the more intelligent of the people; and I personally vaccinated nearly two hundred and fifty children at the special request of their parents, and might have done many more had I always had fresh lymph by me. It is much to be regretted that no exact estimate can be formed of the number of persons protected by vaccination iu the city of Bhurtpoor at the beginning of the recent epidemic. Yet as the whole significance of the succeeding figures depends on the relative proportion of protected to unprotected persons, it is necessary to have some idea of what that proportion was. The vaccination returns cannot be made use of, as they do not discriminate sufficiently between cases in the city itself, and those in the villages around, and even if they did, they are not such evidence as would command respect. The following table gives the result of the examination of nearly four hundred children early in the epidemic. It would have been more conclusive had the numbers been greater, but existing small-pox and vaccination complicated further enquries, and introduced sources of fallacy: utility
of vaccination," whereas
vaccinators
were
eagerly sought
after
?
Children under
eight years
Bore marks of previous Had vaccine cicatrices
of age.
small-pox
...
Unprotected
...
...
Total
cases.
in order to assimilate the Bhurtpoor system to the more perfect one obtaining in our own provinces, a native superintendent of vaccination was engaged to assist in the inspection and verifica-
[Decembek 1,
This
examined.
Percentage.
...
103
34-44 39-07 26-49
...
389
100-00
...
134
...
152
gives 59-61 children protected by vaccination to 40'39 protected, in every hundred who had not gone through small-pox; or as nearly as possible three to two. In my last annual report I stated that I thought this proportion too high, and that unprotected were probably as numerous as vaccinated children, but I now believe that the percentage indicated was not excessive. The numbers are small it is true, and, taken by themselves, would be of little value one way or other, but they are more than borne out by others, as will appear when we come to enquire into the number of cases of small-pox, and their proportion to population at different ages. This will, however, more properly fall to be discussed in connection with the influence of vaccination on the epidemic, when I hope to be able to shew, not only that the work done in past years has been good, but that vaccination has been sufficiently accepted by the people to have had a very marked effect in diminishing the number of cases and deaths which, without vaccination, were to have been expected. (To be continued.) not
so
not in tho first instance collected with any reference to As I said before, it was to test the goodness or otherwise
them.
Bhurtpoor vaccinations that the observations were made, they were simply recorded from day to day with no view to their future use as bearing on controverted questions. Tho conclusions have been gradually formed in analysing the returns long after small-pox had ceased, and I had no pre-conceived opinions to support. Besides a sketch of tho progress of the epidemic, the returns give room for an enquiry into the value of vaccination in India; the alleged deterioration of the protective power of vaccination from change of climate; and the supposed greater prevalance, severity, and fatality of small-pox in hot countries, and among the dark-skinned races. On each of these points some light will be thrown, which, it is hoped, may help to reconcile conflicting statements and beliefs. As preliminary to these, however, and as tending to the better appreciation of results, I shall give a brief outline of the progress of vaccination in Bhurtpoor, from its first introduction, up to the time of of tho
and
the recent outbreak. Seventeen years ago tho Maharaja was vaccinated with a few other children, by the present head of tho Medical Department, Dr. Murray, then Civil Surgeon of Agra; and a few cases wero afterwards operated on each year; but no record has been kept of these, nor wero any regular vaccinators employed, and tho little work which was done can have had no effect in bringing the prophylactic to tho notice of tho public. So far as can bo discovered, no systematic attempt to introduco it appears to havo been made till tho season of 1861-62. Up to that time the
Agency Surgeon's operations seem isolated cases, vaccine work forming tho operations wero probably too few differenco in the IN BHURTPOOR. SMALL-POX AND VACCINATION By Robert
Surgeon
to
Harvey, M. B., &c.,
the Eastern Rajpootana To/itical
Agency.
I rtTRi'OSE to record briefly the late epidemic of small-pox in Bhurtpoor, in its relation to the progress of vaccination in the state, and as bearing on some undecided points concerning smallin India generally. The observations and pox and vaccination conclusions which follow are based on analyses of eight hundred cases of small-pox seen and noted by myself during last cold ; and on the daily returns of cases and deaths made to tho Magistrate. The latter returns are exceptionally accurate and were tested over and over again in all
season
City trustworthy.
They
of ways, while the epidemic lasted, and an additional proof of their accuracy is found in the fact that the results deduced from them tally in a great degree with those derived from my own figures. These, so far as they go, may be relied to watch the course of the upon. It was of course manner
impossible
disease in all cases, and, indeed, the majority were seen only once or twice, while a few of exceptional interest, and tho postvaccinal series frere noted throughout. The original object of
the investigation was to test previous vaccine work, and the great point being to see as many cases as possible, it was difficult to pay second visits to ordinary cases as tho now ones wero so numerous. On this account my notes are somewhat iucom-
vast
number of
to havo been limited to part of his duty, and
no
to make any
appreciable
unprotected
persons. Tho late Dr. Stewart was tho first to endeavour to remedy this unsatisfactory state of things, but there was a good deal of
opposition; his cases were not numerous, and when Dr. Mott was appointed to succeed him in 1861, it may fairly bo said that vaccination was only beginning, and that, practically, its introduction dates from that timo. Dr. Mott took up the,subject with energy ; taught the Native Doctors and Compounders attached to the different dispensaries, and mado them expert and by securing the operators under his own supervision, services of two good vaccinators from Agra, and instituting a in infusing a measuro series of rewards for good work, succeeded
of his own zeal into his subordinates. Ilis exertions met with from tho first, large numbers of cases being operated less than appears to bo on each year, and the opposition being bo ascribed in part to the moral generally the case. This may effect of the Maharaja's having been vaccinated in infancy, to tho comparative freedom from prejudice which in success
and part characterises
the Jats. Thero was much apathy, and little apof tho value of tho boon at first, with occasional active resistance to tho vaccinators; but year by year it becamo cases, active opposition declined into apathy, and to
preciation
easier
get
some extent changed into appreciation. It will be seen that the system which Dr. Mott introduced is in the main the old dispensary system of vaccination, and it has many of the disadvantages of that system. In un unhealthy season, for instance, tho Native Doctors and Compounders being
apathy to
THE INDIAN MEDICAL GAZETTE.
258
otherwise fully occupied, vaccination suffers; and at all times
it is
impossible for them to vaccinate villages at any distance frum their dispensaries; such villages having to be left to a chance visit from a peripatetic vaccinator, whose work cannot he properly overlooked. The chief recommendation of the plan is its cheapness, no special vaccine establishment being necessary.
The
circumstances in which the agency surgeon is the objection which has been fatal to the dis-
placed,, remove
pensary system as formerly practised under the nominal superintendence of civil surgeons in British territory. Their efficient supervision was almost impossible, the civil surgeon as a rule being tied to the station, and unable to visit his district more than two or three times a year. In Bhurtpoor, on the other
hand, the medical officer is constantly in camp during the cold season; and visiting the different centres frequently,?is able, to a considerable extent, though by no means perfectly, to
superintend the work. spite of this imperfect agency great progress was made during five seasons under Dr. Mott's care, and when he left in 1866, all preliminary difficulties had been to a great extent' overcome, and it remained only to push on the operations, and increase, if possible, the percentage of success. This in 1865-66 had been only 71*80, a considerable decrease on previous seasons, and it seemed evident that, unless it could be raised, great disIn
credit must be thrown
small-pox,
the
people,
on as
a
vaccination
rule, being
between successful and unsuccessful
on
the next outbreak of
little able to discriminate "With this view, and
work, and each season a3 many men as could be temporarily withdrawn from all other duty and put under his orders, the Native Doctors continuing to vaccinate in the immediate neighbourhood of their dispensaries. In this way great improvement was hoped for, without trespassing too far on the liberality of a State which had already done so much for its sick poor. The following medical institutions are kept up by the Durbar, which last year spent nearly fourteen thoustion of the
spared
were
and rupees on "Medical services:"? A general hospital, with a daily average this year of 92 in-
patients. A jail hospital. A sudder dispensary in the city of Bhurtpoor. Nine branch dispensaries. The use of crusts has been gradually abolished, fresh lymph being substituted. Each vaccine centre has been frequently visited, and in distributing the rewards, regard has been had solely to the character of the work produced for inspection, numbers being looked upon as subsidiary to success. Attempts have also been made to impress upon the people the objects and advantages of vaccination. The result of these measures has been a steady increase in the percentage of successful cases, which rose to 80-04 in 1867-68, and to 8653 during last season. While I believe these figures to be fairly correct I will not vouch for them, but there can be no doubt that each year has shewn a considerable improvement on its predecessor; and it frequently happened to me last cold weather to go over a day's work?numbering thirty, forty, or even fifty cases?without meeting with a single child in whose arm the virus had failed to take.
The increased success is due to many concurrent causes, undoubtedly the use of fresh lymph ; but more careful selection of in the
the chief of which is
prolonged experience
operators,
of a cases, and the abandonment in great measure by parents practice of washing off the virus, or opening and applying drugs to the vesicles, have all helped to swell the return of that has successful cases. As an illustration of the
progress
been made, I may mention that when small-pox was last prevalent in 1864-65, Dr. Mott reported (annual report 1864-65), that
"the epidemic caused greater doubts than
ever
concerning the
1869.
during the recent outbreak, the by the more intelligent of the people; and I personally vaccinated nearly two hundred and fifty children at the special request of their parents, and might have done many more had I always had fresh lymph by me. It is much to be regretted that no exact estimate can be formed of the number of persons protected by vaccination iu the city of Bhurtpoor at the beginning of the recent epidemic. Yet as the whole significance of the succeeding figures depends on the relative proportion of protected to unprotected persons, it is necessary to have some idea of what that proportion was. The vaccination returns cannot be made use of, as they do not discriminate sufficiently between cases in the city itself, and those in the villages around, and even if they did, they are not such evidence as would command respect. The following table gives the result of the examination of nearly four hundred children early in the epidemic. It would have been more conclusive had the numbers been greater, but existing small-pox and vaccination complicated further enquries, and introduced sources of fallacy: utility
of vaccination," whereas
vaccinators
were
eagerly sought
after
?
Children under
eight years
Bore marks of previous Had vaccine cicatrices
of age.
small-pox
...
Unprotected
...
...
Total
cases.
in order to assimilate the Bhurtpoor system to the more perfect one obtaining in our own provinces, a native superintendent of vaccination was engaged to assist in the inspection and verifica-
[Decembek 1,
This
examined.
Percentage.
...
103
34-44 39-07 26-49
...
389
100-00
...
134
...
152
gives 59-61 children protected by vaccination to 40'39 protected, in every hundred who had not gone through small-pox; or as nearly as possible three to two. In my last annual report I stated that I thought this proportion too high, and that unprotected were probably as numerous as vaccinated children, but I now believe that the percentage indicated was not excessive. The numbers are small it is true, and, taken by themselves, would be of little value one way or other, but they are more than borne out by others, as will appear when we come to enquire into the number of cases of small-pox, and their proportion to population at different ages. This will, however, more properly fall to be discussed in connection with the influence of vaccination on the epidemic, when I hope to be able to shew, not only that the work done in past years has been good, but that vaccination has been sufficiently accepted by the people to have had a very marked effect in diminishing the number of cases and deaths which, without vaccination, were to have been expected. (To be continued.) not
so
