A Statistical Record of Five 
Thousand Cases of Small-pox. 
BY 
WILLIAM M. WELCH, M. D., 
Physician In charge of the Municipal Hospital for In- 
fectious Diseases, Philadelphia. 
REPRINTED FROM THE 
Neto York fHeHical journal 
for March 17 and 2^ 1894- Reprinted from the Neto York Medical Journal 
for March 17 and 2^ 189Jf.. 
A STATISTICAL RECORD OF 
FIVE THOUSAND CASES OF SMALL-POX* 
By WILLIAM M. WELCH, M. D., 
PHYSICIAN IN CHARGE OF THE MUNICIPAL HOSPITAL FOR INFECTIOUS DISEASES, 
PHILADELPHIA. 
Recognizing the difficulty of interesting an audience 
by the narration of statistics simply, I have concluded to 
present the facts which I have to offer somewhat after the 
style of an object lesson. I shall mention but few facts 
that can not be seen clearly illustrated in the tables hang- 
ing before you. 
Before calling your attention to these tables I should 
say that the opportunity to study and classify these five 
thousand cases of small-pox was afforded me in the Munici- 
pal Hospital for Infectious Diseases of Philadelphia dur- 
ing the period from 1870 until the early part of the pres- 
ent year. This period includes several epidemics of the 
disease, some of which were of considerable magnitude 
and great virulence, notably the epidemic of 1871-'72, 
which was almost world-wide and everywhere marked by 
* Read before the First Pan-American Medical Congress, Septem 
ber, 1892. 
Copyright, 1894 by D. Appleton and Company. 2 
A STATISTICAL RECORD OF 
unusual malignancy. During such visitations of the disease 
a very large proportion of the more severe and malignant 
cases were found among the admissions to the hospital. 
This is owing to two facts: first, since removal of patients 
to the hospital was not compulsory, most of the milder 
cases were treated at their homes; and, secondly, that a 
very large proportion of the patients were received from 
the lower class of society with constitutions exhausted or 
depraved by intemperance and other depressing habits. 
Even many of these were not received until all hope of re- 
covery had passed. During the epidemic of 1871-'72 as 
many as a hundred and twenty-eight patients died in less 
than forty-eight hours after admission, while, indeed, a few 
others died in the ambulance on their way to the hospital, 
and all such are, of course, included in the statistics to be 
submitted. 
I mention these facts in explanation of the unusually 
high death-rates to be seen in the tables. But while the 
death-rates are unusually high there is no disproportion in 
this respect between the vaccinated and the unvaccinated 
cases. That is to say-if the death-rate is excessively 
high in the one, it is to an equal degree excessively high in 
the other. There will therefore be no difficulty in meas- 
uring by these statistics the value of vaccination as a pro- 
tective or modifying agent in small-pox. 
This first table to which I shall call attention is one 
showing the cases classified accordingly as the disease was 
unmodified or modified. The former type, of course, is 
designated variola, and the latter varioloid, while the term 
small-pox, whenever used, must be understood as including 
both. 
All unvaccinated cases, all malignant cases, and all 
vaccinated cases in which the eruption advanced to the 
pustular stage and was attended by well-marked secondary FIVE THOUSAND CASES OF SMALL-POX. 
3 
Table I.-Shoiving the Cases divided into Variola and 
Varioloid. 
Disease. 
Admitted. 
Died. 
Per cent, 
of deaths. 
V ariola 
2,831 
1,534 
54-18 
Varioloid 
2,169 
28 
1-29 
Total 
5,000 
1,562 
31'24 
or suppurative fever have been classified in this table as 
variola, while all the vaccinated cases in which the erup- 
tion was markedly abridged in its course and in which 
there was little or no secondary rise of temperature have 
been classified as varioloid. Under such a classification, a 
fatal result never occurs from the latter, except in greatly 
enfeebled constitutions or when some complication arises. 
While the death rate was 54T8 per cent, from variola, it 
was only 1'29 per cent, from varioloid. 
Table II.-Showing the Cases classified according to the 
Sex of the Patients. 
Sex. 
Admitted. 
Died. 
Per cent, 
of deaths. 
Male 
3,261 
1,031 
31'61 
Female 
1'739 
531 
30-54 
Total 
5,000 
1,562 
31-24 
The table shows that a considerably larger number of 
males than females was admitted to the hospital; and 
also that there is practically no difference between the 
death-rates of the two sexes. 
Although the preponderance of cases is on the side of 
males, yet it can not be said that sex exerts any influence 
whatsoever over susceptibility to small-pox, nor that the dis- 4 
A STATISTICAL RECORD OF 
ease, all things being equal, is more fatal among one than the 
other. It is true that men are more frequently addicted to 
intemperance, and that this habit predisposes to malignan- 
cy of the disease ; but, on the other hand, pregnancy in 
women is very liable to be followed by abortion, and when 
this accident occurs it always proves to be a very serious 
complication. 
Table III.-Showing all the Cases classified according to 
the Color of the Patients. 
Color. 
Admitted. 
Died. 
Per cent, 
of deaths. 
White 
4,200 
1,221 
29'07 
Black 
800 
841 
42'62 
Total 
5,000 
1,562 
31'24 
It is generally believed that small-pox is more fatal 
among colored persons than among whites, and the above 
table seems really to support such a belief ; but before a 
reliable conclusion can be arrived at it is necessary that the 
patients of both colors should be observed under precisely 
the same circumstances-that is to say, comparison should 
be made between the unvaccinated of each color. Such a 
comparison may be seen in the following table : 
Table IV.-Showing the Unvaccinated Cases of Small-pox, 
classified according to the Color of the Patients. 
Unvaccinated. 
Admitted. 
Died. 
Per cent, 
of deaths. 
White 
1,173 
681 
58-05 
Black 
439 
257 
58-54 
Total 
1,612 
938 
58-18 
Reference to the last two tables shows that of the two 
classes of patients-white and black-a very much larger FIVE THOUSAND CASES OF SMALL-POX. 
5 
proportion of the blacks were unvaccinated; of course, 
that accounts for the greater percentage of deaths among 
this class in the former table. In the latter table, however, 
where a comparison can be made between the unvaccinated 
of each color, it is seen that there is practically no differ- 
ence in the death-rates, the deaths among the whites be- 
ing at the rate of 58'05 per cent, and among the blacks 
58'54 per cent. 
I would not presume to say that all authors who con- 
tend that small-pox is more fatal among negroes than 
whites are mistaken in regard to their observations, but I 
wish to emphasize what I have already said-that no con- 
clusion on this point is reliable unless both of these classes 
of patients have been observed under precisely the same 
circumstances. 
Table V.-Showing the Cases classified according to the 
Vaccine Condition of the Patients. 
Admitted. 
Died. 
Per cent, 
of deaths. 
Vaccinated in infancy, good cicatrices.,. 
" " " fair cicatrices ... 
" " " poor cicatrices... 
1,412 
666 
1,070 
124 
98 
290 
8'78 
14'71 
27-10 
Post-vaccinal cases 
Unvaccinated eases 
Unclassified cases 
3.148 
1,759 
93 
512 
1,027 
23 
16-26 
58-38 
24'73 
Total 
5,000 
1,562 
31-24 
In this table a comparison may be made between the 
vaccinated and the unvaccinated cases. For reasons al- 
ready stated, the proportion of deaths in both is excessive- 
ly high. Among the unvaccinated the death-rate is as high 
as 58'38 per cent., and among the vaccinated, as a whole, 
16'26 per cent. Although high in both cases, the difference 
between the death-rates is very striking. If the 1,759 un- 6 
A STATISTfCAL RECORD OF 
vaccinated persons had been vaccinated in infancy, like the 
others, instead of 1,027 deaths among this class, there 
would have been only 286, a saving of 738 lives. Vaccina- 
tion would have accomplished even more than this for 
these patients: it would have so modified the disease in a 
large proportion of those that recovered as to prevent much 
suffering and save them from disfigurement for life. 
In examining the vaccine cicatrices of a large number 
of persons it is found that these scars differ considerably 
in appearance, and the question naturally arises, Can pro- 
tection be measured to any degree by the different charac- 
teristics which they present ? There is no doubt that 
many persons with quite inferior vaccine marks are fairly 
well protected, or even enjoy immunity from small-pox, 
while many with typical marks prove to be susceptible to 
the disease, and indeed often perish from it. But such 
results must, I feel sure, be regarded as exceptions to the 
rule. When a large number of patients are examined and 
the results tabulated, as the above table shows, the degree 
of protection, as indicated by the death-rates, is found to 
bear a very close and direct relation to the character of the 
vaccine cicatrices. 
All of the patients represented in the tables were care- 
fully examined on their admission to the hospital, and the 
number and character of their vaccine scars at once re- 
corded. At this time it was, of course, generally impossible 
to foretell the final result. The scars were divided, accord- 
ing to their quality, into three grades, which are designated 
in the tables by the terms good, fair, and poor. Under 
the first head 1 have classified all cases presenting typical 
vaccine cicatrices-that is to say, cicatrices which are 
distinctly excavated, with well-defined margins, reticulated 
or foveolated, and altogether presenting the appearance of 
having been stamped into the skin by a sharply cut die. FIVE THOUSAND CASES OF SMALL-POX. 
7 
Under the second head T have classified all cases with scars 
having the same general characteristics, though much less 
distinctly marked. Under the third head have been classi- 
fied all cases having scars which were said to have been the 
result of vaccination, but which in very many instances 
were so indistinct or uncharacteristic as to make it difficult, 
and sometimes even impossible, to recognize them as vac- 
cine scars. 
The cases classified under the heads of both good and 
fair marks had all, doubtless, passed through a well- 
marked, or reasonably well marked, course of vaccina in in- 
fancy. Tbe death rates are respectively 8'78 and 14'71 
per cent. But I am strongly of the opinion that very many 
of the cases classified under the head of " poor cicatrices " 
were never successfully vaccinated. Very often I felt fully 
convinced at the time of making the examination and re- 
cording the vaccine condition that such was the case, but, 
as the patients insisted that they had been vaccinated, I 
could not reject their testimony without being considered, 
especially by the enemies of vaccination, a partial judge. 
It certainly does not detract from the reputation of vacci- 
nation to know that when the vaccine process is irregular, 
imperfect, or spurious the protection is diminished or ab- 
sent. As the mean death-rate of the cases showing good 
and fair cicatrices is 10'68 per cent., and the death-rate of 
those showing poor scars is 27T0 per cent., it is evident 
that not only very many of the latter had been imperfectly 
vaccinated, but that a large number had never been sub- 
jected at all to the vaccine process. 
It is impossible to illustrate in this table the very 
striking and conclusive evidence of the protective power of 
vaccination that frequently came under my notice while ob- 
serving these five thousand cases of small-pox-such, for 
instance, as witnessing, on the one hand, an unvaccinated 8 
A STATISTICAL RECORD OF 
person suffering from the confluent form of the disease, 
loathsome and offensive, with the final issue for several 
days uncertain, and on the other hand a vaccinated person 
undergoing a modified form of the disease, so mild and in- 
nocent in its character as not to excite any apprehension 
for the safety of the patient. In the former case, if re- 
covery took place, the individual was left disfigured for 
life, wfliile in the latter, after a few months had passed, 
there was but little, if anything, in the appearance of the 
individual to indicate that he had ever suffered from the 
disease at all. 
Also, I have seen over and over again entire families 
brought into the hospital when all the unvaccinated chil- 
dren have been suffering from small-pox and the vacci- 
nated children unaffected; have seen the former perish and 
the latter remain exempt from the disease, although living, 
eating, and sleeping in the infected atmosphere for several 
weeks. But I have yet to see a single unvaccinated child 
escape the disease under similar circumstances. Further- 
more, I have more than once seen a vaccinated infant draw 
its daily supply of nourishment from a mother suffering 
from varioloid, and the infant remain as free from any 
symptom of the disease as if the infection were a thousand 
miles away and the food were received from a most whole- 
some source. All this is evidence of the prophylactic 
power of vaccination that can not be shown in mortality 
tables. 
Under the head of "unclassified cases" in the last 
table are included quite a large number of patients who 
were vaccinated after exposure to the variolous infection, 
and also a few patients who died and were buried before an 
examination as to their vaccine condition could be made. 
The next table to which I shall direct attention is one 
illustrating the comparative efficacy of vaccination as per- FIVE THOUSAND CASES OF SMALL-POX. 
9 
formed in various countries, especially in the United States, 
Germany, and Ireland. 
Table VI.-Showing the Cases classified as to Nationality 
of the Patients and their Vaccine Condition. 
Admitted. 
Died. 
Per cent, 
of deaths. 
United States : 
Not vaccinated 
1,457 
831 
57'03 
Vaccinated in infancy, good mark.... 
686 
53 
7-72 
" " " fair mark 
375 
53 
14-13 
" " " poor mark.... 
594 
168 
28-52 
Post-vaccinal cases 
1,655 
274 
16-49 
Germany: 
Not vaccinated 
59 
34 
57-62 
Vaccinated in infancy, good mark.... 
345 
33 
9-56 
" " " fair mark 
157 
19 
12-10 
" " " poor mark.... 
250 
47 
18-80 
Post-vaccinal cases 
752 
99 
13-16 
Ireland: 
Not vaccinated 
168 
112 
66-66 
Vaccinated in infancy, good mark.... 
212 
18 
8-49 
" " " fair mark 
57 
15 
26-31 
" " " poor mark.... 
130 
53 
40-76 
Post-vaccinal cases 
399 
86 
21-55 
Other Nativity : 
Not vaccinated 
64 
41 
64'06 
Vaccinated in infancy, good mark... . 
164 
18 
10-97 
" " " fair mark 
75 
10 
13-33 
" " " poor mark.... 
95 
21 
22-10 
Post-vaccinal cases 
334 
49 
14-67 
Unknown: 
Not vaccinated 
11 
9 
81-81 
Vaccinated in infancy, good mark.... 
5 
2 
40-00 
" " " fair mark 
2 
1 
50-00 
" " " poor mark.... 
1 
1 
100-00 
Post-vaccinal cases 
8 
4 
50-00 10 
A STATISTICAL RECORD OF 
Perhaps I should explain, in the first place, that the 
high rate of mortality exhibited under the head of " un- 
known " nativity is owing to the fact that many of the pa- 
tients therein represented were foreigners apparently, and 
were received into the hospital in a moribund state, so that 
it was impossible to learn their nationality. I may add 
also that under the head of " other nativity " are included 
the patients who were natives of the various countries of 
the globe not designated in the table, excepting China and 
Japan, which countries furnished no patients. 
Referring to the table, it is seen that under the three 
nationalities therein given the death-rates of the unvacci- 
nated cases of the United States and Germany do not differ 
materially, but the death-rate of the unvaccinated cases of 
Ireland is very much the highest. A comparison of the 
post-vaccinal cases also shows that the vaccinated patients 
of Irish birth have perished in the largest proportion. This 
seems to indicate that small-pox is most fatal among the 
Irish-a fact which, I believe, I have noticed in every epi- 
demic of the disease that I have witnessed. 
The difference between the rates of mortality among 
the cases showing "good" marks, as is seen under the 
three nationalities mentioned, is not great, and the slight 
difference that does exist may be entirely accidental. But 
the difference between the death-rates of those showing 
" poor " marks is very great and decidedly in favor of the 
patients of German birth. The vaccinations performed in 
Germany prove to be more uniformly protective, and hence 
the death-rate among the post-vaccinal cases under this head 
is the lowest of any of the nationalities. All this seems to 
prove that vaccination is most efficaciously performed in Ger- 
many. The comparative exemption of Germany and the 
German army from small pox is simply a striking example 
of the brilliant result of careful and efficient vaccination. FIVE THOUSAND CASES OF SMALL-POX. 
11 
When most of the vaccinations represented in the table 
were performed it was customary in the United States, 
and in Ireland also, I believe, to use humanized crusts ; 
but in Germany fresh eighth-day lymph or arm-to- 
arm vaccination was the means or method employed, 
and this method has always given the very best results. 
Hence I think it is not improbable that the German 
patients owe their better protection to the superior 
quality of the vaccine lymph generally employed in their 
country. 
There is another explanation that might be offered to 
account for the superior protection enjoyed by the German 
patients-namely, that it is the practice in Germany in per- 
forming vaccination to make numerous insertions of the 
vaccine virus. In examining the arms of patients, of Ger- 
man birth it is quite common to find three distinct scars on 
each arm, and even a greater number is frequently met with. 
I have seen as many as twenty typical vaccine marks on the 
arms of a German patient. If multiple insertions of the 
vaccine lymph increase the protection against small-pox- 
and statistics are not wanting to show that such is the case 
-surely German subjects should be well protected. But, 
in view of the facts which will appear in the following table, 
I am inclined to believe that the Germans owe their superior 
protection from small-pox more to the quality of the vac- 
cine virus they use than to the number of insertions they 
make. 
The first thing to be seen in this table is that there is 
practically no difference between the death-rates of the 
unvaccinated patients and those professing to have been 
vaccinated but showing no visible mark. This proves that 
there was either a mistake as to the alleged fact or that a 
vaccination which is followed by no mark is devoid of pro- 
tective power, most probably the former. 12 
A STATISTICAL RECOHD OF 
Table VII.-Showing the Cases classified as to the Numbei 
and Character of the Vaccine Scars borne by each Patient. 
Admitted. 
Died. 
Per cent, 
of deaths. 
Unvaccinated 
1,512 
881 
58'26 
Professing to have been vaccinated, but 
no visible mark * 
247 
146 
59-10 
Vaccinated seven days and less prior to the 
appearance of the variolous eruption.. 
57 
25 
43-86 
Vaccinated longer than seven days prior 
to the appeal ance of the variolous 
eruption 
74 
15 
20-27 
Vaccinated in infancy, one good mark .. 
787 
70 
8'89 
" " " " fair mark ... 
430 
67 
15'58 
" " " " poor mark... 
850 
252 
29-64. 
Total number showing one mark... 
2,067 
389 
18-81 
Vaccinated in infancy, two good marks.. 
" " " " fair marks... 
265 
20 
7-54 
105 
14 
13-33 
" " " " poor marks.. 
94 
22 
23-40 
Total number showing two marks.. 
464 
56 
12-06 
Vacciuated in infancy, three good marks. 
119 
10 
8-40 
" " " " fair marks. 
45 
4 
8-88 
" " " " poor marks. 
49 
13 
26-53 
Total number showing three marks. 
213 
27 
12-67 
Vaccinated in infancy, four or more good 
marks 
247 
24 
9-74 
Vaccinated in infancy, four or more fair 
marks 
80 
10 
12-50 
Vaccinated in infancy, four or more poor 
marks 
97 
11 
11-34 
Total number showing four or more 
marks 
424 
45 
10'61 
* The cases classified in this table as claiming to have been vac- 
cinated, but showing no visible mark, are included in the other tables 
among the unvaccinated. So, also, quite a number of those classified 
in this table as having been vaccinated during the incubation period of 
small-pox are included among the vaccinated or unvaccinated in some 
other tables, which fact will explain some discrepancies in numbers. FIVE THOUSAND CASES OF SMALL-POX. 
13 
The table also shows that vaccination practiced after 
exposure to the infection of small-pox may afford consid- 
erable protection against the disease. If it be performed 
within two or three days after the infection has been re- 
ceived into the system it is possible for the protectio ton 
be absolute. I have seen as many as twenty-eight chil- 
dren perfectly protected from small-pox by vaccination dur- 
ing the incubation period.* But if the vaccination be per- 
formed much less than seven days before the eruption of 
small-pox appears, no modifying influence will be exerted. 
In a considerable number of the cases included in the table 
under the head of " vaccinated seven days and less prior to 
the appearance of the variolous eruption " the patients had 
been vaccinated no longer than from two to four days be- 
fore the eruption appeared, while a somewhat larger num- 
ber had been vaccinated as long as from four to seven days 
before it appeared. Taking the whole number of cases 
under this head, it is seen that the death-rate is 43'86 per 
cent., while among the unvaccinated it is as high as 58T8 
per cent. This shows that considerable protective influ- 
ence must have been exerted by vaccination performed 
during that period. But a still greater influence was ex- 
erted among the cases included under the succeeding head, 
where vaccination is represented as having been performed 
longer than seven days before the small-pox eruption ap- 
peared. The death-rate here is only 20'27 per cent. 
In regard to the matter of estimating the efficacy of vac- 
cination by the number of vaccine cicatrices borne by each 
person, the table can not be said to support the views of 
most authors, nor does it accord with the experience of 
some other observers. It is, indeed, in striking contrast with 
the evidence on this point collected by Mr. Marson and 
* For further information on this subject see my paper on Vaccina- 
tion during the Incubation Period of Variola, published in the Transac- 
tions of the Ninth International Medical Congress, vol. iv, p. 160. 14 
A STATISTICAL RECORD OF 
tabulated by Mr. Simon. According to these authors, who 
derived their data from six thousand post-vaccinal cases of 
small-pox, the mortality-rate among patients having one 
vaccine scar was 7*5 per cent.; having two, 4'125 per cent.; 
having three, 1'75 per cent. ; having four or more, 0'75 
per cent. Where the vaccine scars were all well marked or 
typical, the loss by death is said to have been even less 
than is here indicated. 
The table shows, it is true, that the highest death-rate 
is among the patients having but one vaccine mark, but 
unquestionably this is owing to the fact that a very much 
larger proportion of the patients under this head than 
under any other showed " poor " marks, and, as already 
pointed out, very many of these patients would be more 
correctly classified if counted among the unvaccinated cases. 
Those having four or more " poor " marks are in a much 
smaller ratio to the total number of post-vaccinal cases un- 
der that head than under any other, and the death rate, to 
be sure, is remarkably low. It is, indeed, almost as low as 
among those showing four or more "good " marks. The 
explanation of the low death-rate here is that nearly all the 
patients classified under this head were natives of Germany, 
where, as already shown, vaccination is so efficiently per- 
formed that if the scars are not in every respect typical 
there is, nevertheless, well-marked protection. 
Referring again to the table, it is seen that, where the 
vaccine scars are typical, there is no relation between the 
number of such scars and the degree of protection con- 
ferred against small-pox. Indeed, it so happens in the table 
that the death-rate among the patients having but one 
" good " mark is a little lower than among those having 
four or more " good " marks. There is no doubt that vac- 
cina characterized by a single typical vesicle destroys in 
the individual all susceptibility to small-pox, and it would FIVE THOUSAND CASES OF SMALL-POX. 
15 
be impossible for multiple vesicles to do more than that. 
As a safeguard against failure, however, or when using 
long-humanized virus, it is advisable to make several inser- 
tions ; but I must repeat that it is my positive conviction 
that quality of vaccine lymph has far more to do with se- 
curing efficient vaccination than multiple insertions have. 
In the next table is illustrated, first, the efficacy of re- 
cent. vaccination as performed in infancy, and, secondly, 
the gradual loss of vaccine protection as the individual 
grows older : 
Table VIII.-Showing the Cases classified as to Age Periods 
of the Patients, and also as to their Vaccine Condition in 
each of these Periods. 
Admitted. 
Died. 
Per cent, 
of deaths. 
Under One Year : 
Unvaccinated 
78 
57 
73-07 
Vaccinated 
2 
One to Seven Years : 
Unvaccinated 
404 
208 
51-48 
Vaccinated in infancy, good mark.... 
10 
" " " fair mark 
10 
i 
10-0 
" " " poor mark.... 
15 
i 
6-66 
Total number vaccinated 
35 
2 
5'70 
Seven to Fourteen Years: 
Unvaccinated 
222 
71 
31-98 
Vaccinated in infancy, good mark.... 
55 
2 
3-63 
" " " fair mark 
23 
2 
8-69 
" " " poor mark.... 
59 
9 
15-25 
Total number vaccinated 
137 
13 
9-48 
Fourteen Years and Upward : 
Unvaccinated 
1,038 
681 
65-60 
Vaccinated in infancy, good mark. .. . 
1,344 
122 
9-07 
" " " fair mark 
629 
93 
14-78 
" " " poor mark.... 
994 
280 
28-16 
Total number vaccinated 
2,967 
495 
16-68 16 
A STATISTICAL RECORD OF 
It can not be questioned that, in a large city like Phila- 
delphia, where gratuitous vaccination is provided for the 
poor and improvident class of the community, there must 
be a very much larger number of children under one year 
old vaccinated than unvaccinated, and yet it is seen by the 
table that seventy-eight of the latter were admitted to the 
hospital, and only two of the former. The unvaccinated 
perished in the proportion of 73'07 per cent., while both 
of the vaccinated of course recovered. One of the vac- 
cinated children was eleven months old ; had been vacci- 
nated two months previously ; showed a good cicatrix ; had 
varioloid in an exceedingly mild form, the eruption consist- 
ing of only six small vesicles; and the child was at no time 
scarcely ill at all. The other vaccinated case had the dis- 
ease so indistinctly marked that, following the diagnosis of 
varioloid as recorded in the Record Book, I find a mark of 
interrogation, which, interpreted, means that the diagnosis 
was somewhat doubtful. These facts show that small-pox 
among unvaccinated children under one year old is very 
common and fatal; also that among vaccinated children at 
this age the disease is very rare, and, when it occurs at all, 
it is no more to be feared, so far as danger to life is con- 
cerned, than ordinary vaccina. 
In children between the ages of one and seven years 
small pox is, of course, very common among the unvacci- 
nated, and occasionally it is seen in a very mild form among 
the vaccinated ; but death never results where there is evi- 
dence of thorough vaccination, except from some serious 
complication. It is seen in the table that one death oc- 
curred under the head of-"fair" vaccine mark. In this 
case the child was about a year old, a foundling, badly 
nourished, having disordered digestion, and was very feeble. 
The eruption consisted of only a very fewr small vesicles. 
Death resulted from sheer debility. Very little need be FIVE THOUSAND CASES OF SMALL-POX. 
17 
said of those classified under the head of " poor " vaccine 
scars, as the vaccination in all such cases was either imper- 
fect or spurious. 
In the next age period-seven to fourteen years-it is 
worthy of note that the death-rate among the unvaccinated 
cases is very much lower than at any of the other age peri- 
ods. Possibly the explanation of this is that the recupera- 
tive powers of life are most active at that age, or that some 
of the depressing habits common in later life, such as in- 
temperance and the like, have not yet been formed. At 
this period of life post-vaccinal cases of small-pox increase 
considerably, and occasionally death occurs from the dis- 
ease, even after quite thorough infantile vaccination. These 
facts clearly indicate that the vaccination of infancy is apt 
to lose at this period more or less of its protective power. 
The last age period noted in the table-fourteen years 
and upward-illustrates, in the first place, how large is the 
number of youths and adults who have never enjoyed the 
prophylactic power of vaccination. Among this class, too, 
the death-rate is seen to be considerably higher than that 
of the corresponding class in either of the two preceding 
age periods. The table also proves in a very indubitable 
manner, by the great increase of post-vaccinal cases of 
small pox at this age period, that vaccination in infancy 
can not be depended upon to confer protection against the 
disease in the later life of the individual. There are there- 
fore two important facts prominently brought forward in 
this table: First, that recent vaccination confers absolute, 
or almost absolute, protection against small-pox, and, sec- 
ondly, that when vaccination has been performed in in- 
fancy revaccination is required at, if not before, the age of 
puberty. 
My experience leads me to place implicit confidence in 
the efficacy of revaccination, although the statistics pre- 18 
A STATISTICAL RECORD OF 
sented in Table IX are somewhat vague and indefinite, 
and do not therefore fully or clearly demonstrate the real 
merits of the measure. The table simply contains the 
relevant data as obtained from the patients who claimed 
to have been vaccinated in infancy and subsequently revac- 
cinated, together with the general results. 
In tabulating the cases represented in Table IX I have 
been obliged to accept the statements of the patients, first, 
as to the fact of revaccination, and, secondly, as to the time 
when it was performed. Their testimony as to whether or 
not it was successful I have found very unreliable. To use 
their own language, they often said "it took a little" or 
" the arm was very sore," and frequently they did not re- 
member whether it " took " at all, but would point to a 
mark which they said they had always believed was the result 
of revaccination. Not infrequently marks were pointed out 
as the result of revaccination which were an exact counter- 
part of one or more other marks present on the arm, and 
which were known to have resulted from the primary vac- 
cination. It is evident, therefore, that it would be very 
difficult to say how many of the cases recorded in the table 
should be regarded as authentic examples of small-pox oc- 
curring after successful revaccination. Some, I think, should 
be so regarded. 
The more positive evidence of the efficacy of revaccina- 
tion is to be found in the fact that persons recently revac- 
cinated with effect do not take small-pox when freely exposed 
to the infection. During my service of twenty-three years 
no resident physician of the hospital, no nurse, laundress, 
cook, or any other employee who was properly revaccinated 
before entering on duty has taken small pox. Perhaps I 
should except a female nurse who was revaccinated on the 
first day of her residence in the hospital with almost typi- 
cal result. In the course of about two weeks I noticed on FIVE THOUSAND CASES OF SMALL-POX. 
19 
the forehead of this nurse, near the edge of her hair, one 
or two variolous vesicles, which were preceded by but little 
if any febrile disturbance. At any rate, she was at no time 
disabled from performing her usual duties. 
What vaccination has done for these employees, whose 
duties have necessarily brought them in the closest possible 
contact with the infection of small-pox, it will do for any 
or all who fully avail themselves of its protective influence. 
I am firmly of the opinion that if all persons were properly 
vaccinated in infancy and again at the age of puberty 
Jenner's prediction as to the power of this agent to extir- 
pate small-pox from the globe would soon be realized. 
In Table X, the last table which I shall present, are 
contained the principal data at hand in regard to the cases 
or alleged cases of second attacks of small-pox. There is 
found in it also the same element of uncertainty as to the 
authenticity of many of the cases as existed in the preced- 
ing table, though perhaps to a less degree, and this uncer- 
tainty is owing to the same cause-namely, the unreliability 
of evidence furnished by the patients. 
It is certain that very many of the cases recorded in 
Table X should not be regarded as true cases of recurrent 
small-pox. For instance, where it is seen that a small- 
pox patient has never been vaccinated, shows little or no 
pitting, and is suffering from an unmodified form of the 
disease, it is more than probable that there has been no 
previous attack. Slight pitting, when present, is not neces- 
sarily proof of such an attack having existed, for the pit- 
ting may have resulted from chicken-pox, which disease, I 
well know, is often mistaken for small-pox. So also all 
those cases having a history of thorough vaccination in in- 
fancy, if characteristic pitting of the alleged previous at- 
tack is absent, should be regarded as very doubtful cases 
of recurrent small-pox. It would be very exceptional in- 20 
FIVE THOUSAND CASES OF SMALL-POX. 
deed for a person first to take vaccina, then small-pox, and 
subsequently a second attack of the disease. 
There is no doubt that a few of the cases recorded in 
the table should be regarded as genuine second attacks of 
small-pox, but in most such cases the disease was exceed- 
ingly mild-so mild, indeed, in some instances as scarcely 
to be recognizable. 1 have never yet seen an unmodified, 
or even a severe, case of small-pox occur in a person who 
was deeply and characteristically pitted from a previous 
attack. Such cases I know may be found on record, but 
it has not been my fortune to meet with them. I might 
say, furthermore, that during my many years of service 
no person has been admitted to the hospital twice suf- 
fering from any form of the variolous disease. In 
view of all these facts, I can not help believing that sec- 
ond attacks of small-pox are much rarer than is generally 
supposed. 
821 North Broad Street. No. 
Character of 
Character of marks 
Length of time 
No. of 
Age. 
vaccination 
from the alleged 
since the alleged 
Disease. 
Result. 
days in 
Remarks. 
in infancy. 
revaccination. 
revaccination. 
hospital. 
1 
45 
Poor. 
Doubtful. 
31 years. 
V arioloid. 
Recovery. 
23 
2 
23 
Fair. 
6 to 8 years. 
G 
G 
7 
Eruption very light, mostly papular; pa- 
65 
Poor. 
tient not confined to bed. 
3 
24 years. 
G 
G 
8 
Disease very mild. 
4 
34 
Fair. 
Doubtful. 
9 years. 
Confluent 
G 
77 
variola. 
5 
23 
Poor. 
Il 
13 years. 
Varioloid. 
G 
7 
6 
20 
ll 
4 weeks. 
Variola. 
Death. 
14 
7 
21 
ll 
11 years. 
Varioloid. 
Recoverv. 
19 
8 
27 
Fair. 
Fair. 
8 years. 
Variola. 
G 
28 
9 
20 
Good. 
Good. 
10 years. 
Varioloid. 
G 
6 
Disease very mild. 
10 
23 
Poor. 
Since puberty. 
G 
G 
19 
Eruption consists of about six vesicles. 
11 
24 
Fair. 
Doubtful. 
3 months. 
V ariola. 
G 
19 
12 
19 
Poor. 
Very poor. 
4 weeks. 
Varioloid ? 
G 
4 
Eruption only papular, disappearing in 
Good. 
two or three days. 
13 
20 
Invisible. 
2| years. 
Variola. 
Death. 
4 
Does not give a very intelligent account 
Good. 
of revaccination; case haemorrhagic. 
Eruption very light; only slightly 
14 
26 
14 years. 
Varioloid. 
Recovery. 
7 
vesicular. 
15 
23 
Poor. 
Invisible. 
10 years. 
G 
G 
24 
16 
26 
Good. 
Good. 
2 months. 
V arioloid ? 
G 
2 
The variolous eruption so mild as to be 
Poor. 
Fair. 
of a doubtful character. 
17 
22 
7 years. 
V arioloid. 
G 
7 
Eruption very mild; three months preg- 
nant. Abortion threatened, but did 
Good. 
Poor. 
not occur while in hospital. 
18 
19 
24 
35 
9 years. 
V arioloid ? 
G 
21 
Eruption so mild as to be of doubtful 
character. 
Poor. 
Invisible. 
21 years. 
Varioloid. 
G 
11 
20 
37 
Fair. 
Fair. 
21 years. 
G 
G 
21 
21 
22 
20 
44 
Good. 
g 
Poor. 
ll 
1 month. 
6 years. 
G 
G 
G 
G 
9 
14 
Eruption very light. 
23 
24 
Fair. 
ll 
6 weeks. 
G 
G 
11 
24 
17 
Good. 
ll 
4 months. 
G 
G 
15 
25 
24 
g 
ll 
2 months. 
G 
G 
11 
26 
17 
Fair. 
Fair. 
3 months. 
G 
G 
9 
27 
28 
29 
g 
Good. 
Fair. 
6 months. 
G 
G 
26 
Eruption consists of only a few papules, 
which did not become vesicles. 
18 
Scarcely visible. 
6 months. 
Variola. 
G 
33 
29 
35 
52 
Poor. 
Fair. 
Uncertain. 
16 years. 
V arioloid. 
G 
26 
All marks have the appearance as if 
from primary vaccination. 
30 
Invisible. 
5 years. 
Variola. 
« 
51 
31 
35 
Good. 
Fair. 
2| years. 
Varioloid. 
« 
18 
Says was exposed to the infection of 
Invisible. 
small-pox shortly after revaccination, 
but did not take the disease then. 
32 
24 
7 years. 
V ariola. 
Death. 
4 
Claims to have been revaccinated at 
Fair. 
seventeen years of age, but no scar 
resulted. 
33 
24 
8 years. 
Varioloid. 
Recoverv. 
10 
Disease very mild. 
34 
26 
Poor. 
4 years. 
G 
20 
35 
48 
Poor. 
g 
14 years. 
G 
G 
23 
36 
30 
Fair. 
Fair. 
14 years. 
Variola. 
u 
64 
37 
19 
Good. 
Poor. 
5 years. 
Varioloid. 
ll 
19 
38 
40 
g 
13 vears. 
ll 
G 
7 
39 
44 
Poor. 
a 
15 years. 
G 
ll 
11 
40 
36 
Good. 
Good. 
14 years. 
ll 
G 
19 
41 
42 
34 
36 
Poor. 
Good. 
Poor. 
Fair. 
18 months. 
3| years. 
G 
G 
G 
G 
19 
19 
Eruption very light. 
Eruption very light. 
43 
58 
Poor. 
Not characteristic. 
16 years. 
G 
G 
16 
44 
24 
Fair. 
Poor. 
14 years. 
G 
G 
14 
45 
16 
Very poor. 
Very poor. 
1 year. 
G 
G 
14 
Eruption very light. 
46 
57 
Fair. 
Poor. 
37 years. 
G 
G 
12 
Eruption very light. 
47 
19 
Poor. 
Not characteristic. 
2 years. 
G 
G 
10 
48 
23 
Good. 
ll G 
17 years. 
V ariola. 
Death. 
18 
Case haemorrhagic; complicated also by 
49 
50 
Poor. 
Invisible. 
disease of the brain. 
25 
40 
Poor. 
ll 
9 years. 
17 years. 
G 
G 
G 
8 
15 
Eruption confluent. 
Eruption confluent; gangrenous inflam- 
Poor. 
mation of right arm. 
51 
33 
Invisible. 
9 years. 
V arioloid. 
Recovery. 
16 
Eruption very light. 
52 
19 
Good. 
9 vears. 
Variola. 
« 
69 
53 
23 
Good. 
Fair. 
10 months. 
Varioloid. 
G 
9 
Very mild case. 
54 
35 
Very poor. 
Very poor. 
6 years. 
V ariola. 
Death. 
6 
Eruption confluent and flat. 
55 
46 
Good. 
Fair. 
19 years. 
V arioloid. 
Recovery. 
21 
56 
46 
Very poor. 
Very poor. 
18 years. 
G 
Death. 
3 
Suffering also from chancre. 
57 
56 
Poor. 
Poor. 
4 years. 
G 
Recovery. 
22 
58 
27 
Invisible. 
Good. 
12 years. 
G 
20 
• 
59 
54 
Very poor. 
Doubtful. 
32 years. 
G 
ll 
38 
60 
25 
Fair. 
Poor. 
13 years. 
ll 
G 
13 
61 
35 
Good. 
Very poor. 
10 years. 
G 
G 
18 
62 
38 
Very poor. 
Poor. 
8 years. 
G 
G 
26 
63 
26 
Good. 
Not recorded. 
16 years. 
ll 
G 
11 
Eruption consists of about twelve vesi- 
64 
Fair. 
cles, which are scarcely characteristic. 
35 
Not characteristic. 
19 years. 
Variola. 
Death. 
6 
Haemorrhagic tendency. 
65 
40 
Indistinct. 
Indistinct. 
9 years. 
Varioloid. 
Recovery. 
17 
Disease very mild. 
Eruption intensely confluent. 
66 
36 
Good. 
Poor. 
18 years. 
Variola. 
Death. 
11 
67 
38 
Fair. 
Very poor. 
10 years. 
Varioloid. 
Recoverv. 
42 
Two months pregnant. 
68 
30 
Poor. 
Poor. 
2 years. 
G 
G 
12 
69 
48 
Good. 
Good. 
22 years. 
G 
G 
32 
70 
40 
g 
Fair. 
31 vears. 
G 
G 
26 
71 
22 
Poor. 
g 
4 years. 
G 
ll 
15 
72 
26 
Good. 
Poor. 
9 years. 
ll 
G 
7 
Disease very mild. 
73 
45 
Poor. 
g 
5 or 6 years. 
G 
ll 
41 
Says was vaccinated when an infant and 
again at five or six years of age, but 
does not know which scar belongs to 
Good. 
Cl 
Very poor. 
Good. 
the former or which to the latter. 
74 
75 
29 
40 
5 or 6 years. 
4 years. 
ll 
ll 
ll 
G 
19 
92 
Says the revaccination took only slightly. 
76 
53 
Fair. 
Poor. 
7 years. 
ll 
G 
22 
77 
24 
Good. 
Good. 
10 or 11 years. 
ll 
ll 
36 
78 
40 
Fair. 
Poor. 
17 years. 
ll 
G 
27 
Disease very mild. 
Table IX.-Showing the Cases occurring in Patients after alleged Revaccination. No. 
Present 
age of 
patient. 
Age at which 
the alleged pre- 
vious attack 
occurred. 
Whether or not 
vaccinated prior 
to the alleged 
previous attack. 
Character of 
the vaccine 
mark. 
Extent of 
pitting. 
Type of pres- 
ent attack. 
Result. 
Remarks. 
1 
35 
6 years. 
Not vaccinated. 
Very little. 
Greatly 
modified. 
Recovery. 
Was confined to bed only during the 
initial stage. 
2 
31 
Childhood. 
Vaccinated. 
Poor. 
44 44 
Very mild. 
44 
Was confined to bed only during the 
initial stage. 
3 
22 
44 
44 
44 
44 44 
4 4 4 4 
44 
So mild as to be a doubtful case of 
varioloid. 
4 
49 
44 
Not vaccinated. 
No pitting. 
Doubtful. 
Unmodified. 
5 
49 
10 years. 
Vaccinated. 
Poor. 
Modified. 
44 
6 
24 
Childhood. 
Not vaccinated. 
No pitting. 
Two or three 
Unmodified. 
44 
7 
45 
19 years. 
V accinated. 
Not noted. 
Very mild. 
44 
Eruption consisted of only a few papules 
doubtful 
which never became vesicular. 
scars. 
8 
28 
2 years. 
Not vaccinated. 
Well marked. 
Greatly 
modified. 
Vesicles few in number and dried up 
quickly; was ill only during the initial 
fever. 
9 
34 
15 years. 
V accinated. 
Poor. 
No pitting. 
Unmodified. 
Death. 
10 
31 
Childhood. 
Not vaccinated. 
Some pitting. 
Very mild. 
Recovery. 
Presents only three or four variolous 
vesicles. 
11 
20 
44 
Vaccinated. 
Good. 
No pitting. 
Modified. 
44 
12 
20 
10 years. 
8 years. 
Not vaccinated. 
Doubtful. 
Unmodified. 
44 
Death. 
44 
13 
27 
V accinated. 
Poor. 
No pitting. 
Three months pregnant; aborted on the 
first day of the eruption. 
14 
22 
18 years. 
Good. 
44 44 
44 
44 
Confluent. 
15 
22 
18 years. 
44 
Two good. 
Very little. 
Modified. 
Recovery. 
Shows about half a dozen small scars, 
said to be the result of a previous 
attack; disease at present mild ; onlv 
seven days in the hospital. 
16 
13 
3 years. 
44 
44 44 
Slight pitting. 
44 
44 
17 
17 
Childhood. 
44 
No visible 
Some pitting. 
Greatly 
44 
Eruption not even vesicular. 
mark. 
modified. 
18 
18 
14 years. 
44 
Poor. 
Very little. 
Greatly 
44 
Eruption so mild as scarcely to be char- 
modified. 
acteristic; four days in hospital. 
19 
18 
6 years. 
Not vaccinated. 
Some pitting. 
Greatly 
modified. 
44 
Eruption very light. 
20 
28 
10 years. 
Vaccinated. 
Poor. 
Deeply pitted. 
Greatly 
modified. 
44 
Eruption very light. 
21 
15 
Childhood. 
a 
Good. 
No pitting. 
Unmodified. 
44 
Thinks he had small-pox when a 
child. 
22 
30 
25 years. 
44 
44 
44 44 
Modified. 
44 
Says his doctor called the alleged pre- 
vious attack small-pox. 
23 
23 
6 months. 
44 
44 
Doubtful. 
44 
44 
Savs she was vaccinated when four 
weeks old. 
24 
14 
3 years. 
Not vaccinated. 
No pitting. 
Unmodified. 
44 
Says her mother tells her she had small- 
pox when three years of age. 
25 
35 
Childhood. 
V accinated. 
Three good. 
Very little. 
Modified. 
44 
26 
31 
6 years. 
44 
Two poor. 
Doubtful. 
44 
44 
27 
24 
18 months. 
Not vaccinated. 
Deeply pitted. 
Greatly 
modified. 
44 
Eruption only papular. 
28 
25 
10 years. 
V accinated. 
Good. 
Some pitting. 
Modified. 
44 
Three months pregnant; aborted the 
first day of eruption. Eruption very 
mild. 
29 
19 
7 years. 
44 
Poor. 
Two small 
Unmodified. 
Death. 
pits. 
30 
12 
3 years. 
44 
No visible 
One or two 
Modified. 
Recovery. 
marks. 
pits. 
31 
21 
Childhood. 
Not vaccinated. 
No pitting. 
44 44 
Unmodified. 
44 
32 
24 
16 years. 
7 years. 
13 years. 
44 44 
44 
Death. 
33 
16 
44 44 
44 44 
44 
Recovery. 
44 
34 
21 
V accinated. 
Good. 
One pit. 
Modified. 
35 
22 
8 years. 
44 
Two good. 
No pitting. 
44 
44 
Two months pregnant. 
36 
38 
Childhood. 
44 
Fair. 
4 4 44 
44 
44 
37 
44 
44 
44 
Poor. 
44 44 
44 
44 
Only a few variolous vesicles. 
38 
41 
31 years. 
44 
44 
44 44 
44 
39 
31 
11 years. 
44 
Very poor. 
Doubtful. 
Greatly 
modified. 
« 
Eruption barely vesicular. 
40 
17 
2 months. 
Not vaccinated. 
44 
Unmodified. 
41 
21 
6 months. 
V accinated. 
Poor. 
No pitting. 
42 
23 
6 years. 
44 
44 
44 44 
Modified. 
44 
43 
24 
7 years. 
Not vaccinated. 
Some pitting. 
Unmodified. 
Death. 
About eighteen pits on face. It is pos- 
sible for these to have resulted from 
chicken-pox. 
44 
41 
18 years. 
Not noted. 
Well marked. 
Greatly 
modified. 
Recovery. 
Eruption only papular. 
45 
50 
2 weeks. 
Vaccinated. 
No visible 
No pitting. 
Modified. 
44 
Says the alleged previous attack of 
marks. 
small-pox occurred about the time she 
was vaccinated, and that two of her 
sisters had small pox at the same 
time and are pitted. 
Table X.-Showing the alleged Cases of Second Attacks of Small-pox. The New York Medical Journal. 
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