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inoculation still being permitted, it appears that the deaths from various diseases amounted to ten thousand seven hundred and fortyfour, of which number, four hundred and twenty-nine were from small-pox. This affords the evidence of a considerable reduction in the proportional mortality from this disease, it being as forty in the thousand; during a period when vaccination had been practised and institutions established for its dissemination.
Since 1811, variolous inoculation has been prohibited by law. During the four succeeding years, not a death from small-pox was recorded. In 1816, there was a great influx of foreigners, particularly from the British dominions in Europe ; by these persons the disease was introduced into this city, and proved fatal in that year to no less than ninety-seven persons. It was accompanied with a papular eruption, resembling, in many particulars, mild variola-affecting some of those who were believed to have been protected from smallpox by having previously undergone what was supposed to be successful vaccination; of these, no death is recorded that has come to our knowledge. In 1820, 21, 22, the city again enjoyed an exemption from this malady. This assertion is founded on the fact of no deaths from small-pox, in these years, having been reported to the Board of Health. In 1823, 24, the pestilence again afflicted our city, and the mortality from this source amounted to four hundred and eighty-four.* The fact that a large number of those who had been previously vaccinated with the greatest care, as well as many of those who had previously passed through small-pox by inoculation or otherwise, were attacked during this epidemic with a modified form of small-pox, created considerable alarm in the public mind, and directed anew the attention of the profession to an investigation of the amount of protection afforded by the vaccine disease. Upon the recurrence of sınall-pox in 1827, the Medical Society of Philadelphia appointed a committee to collect and report to the society all the facts within their reach, in relation to this important subject. The committee immediately addressed a circular to the physicians of the city and county, containing a series of interrogatories calculated to elicit information in relation to the protective powers of vaccination. The report of this committee, embracing the facts collected by them, was made to the society in 1828, and was of such a character as to renew the confidence of the profession in the protective powers of the vaccine infection. Notwithstanding, it was admitted that in many instances, those who had been previously vaccinated would be liable to become affected, during the prevalence of variola, with a modified, and, usually, mild form of small-pox, yet it was shown that the public are highly benefiited by the practice of vaccination, which
*For an account of the epidemic of 1823, 24, we refer to a very able paper by Drs. Mitchell and Bell, in the North American Medical and Surgical Journ. vol. ii. p. 27 et seq.
For a copy of this report, see North American Medical and Surgical Journal, vol. v. page 400.
was, in every sense, to be preferred to inoculation, and hence, that humanity and sound policy imperiously demanded its continuance.
In succeeding years, with occasional mitigations, Philadelphia has suffered more or less from the disease. Taking the whole period since variolous inoculation was prohibited, the mortality from all sources has amounted to one hundred and forty-three thousand and seventeen, of this number, two thousand four hundred and ninetyseven are referred to small-pox; by which it will be perceived that the proportional mortality has been reduced to eighteen in the thousand.
We have thus endeavoured to exhibit the degree of protection against small-pox afforded by the process of vaccination. The evidence adduced does not depend on individual experience, but rests on the broad basis of the public records, into which no undue bias can have entered.
It must be conceded, that the anticipations of the warm friends for vaccination, that this process would lead to the extirpation of the small-pox, have not been accomplished. In making this concession, the question necessarily arises, whether the requisite precaution, for preventing the intercourse of those affected with small-pox, and those still susceptible of the disease have been duly enforced. The remarks of one who took a lively interest in arresting the progress of this loathsome malady, appear to be particulary pertinent, and to deserve the earnest consideration of every individual desirous of removing from the community this dreadful scourge. The words of Dr. Haygarth are," the discovery of vaccine inoculation by Dr. Jenner is the most fortunate and beneficent improvement that medical science ever accomplished. It does not, however, preclude the necessity of investigating the nature of the variolous poison, and of considering by what regulations its propagation may be prevented. In order to secure the unthinking multitude from this destructive pestilence, measures to prevent the casual small-pou should every where accompany vaccine inoculation ; without such protecting care by the wise and homane part of society, this mortal malady would, for ages, lurk unheard of and unsuspected, to the annual destruction of many thousands. No town, no village, not even a single solitary house would enjoy perfect safety from danger."
The foregoing, your committee beg leave to present, as a solution of the first question submitted to them by the College.
The occurrence, year after year, of the small-pox in the city of Philadelphia, and in other communities, and the frequency with which those who had been vaccinated were attacked with a more or less severe, though generally modified form of the disease, induced many to suppose that the protective power of the vaccine infection was only temporary. The question as to the necessity of re-vaccination now arose, but whilst few practised it, many condemned it as useless, and calculated to weaken public confidence in the protective powers of vaccination. Others, however, maintained that, as there was no certain criterion by which the protective powers of the primary infection
could be established with absolute certainty, re-vaccination was necetsary in all cases in order to test the efficacy of the first operation. This opinion very naturally obtained importance from the fact, that few cases of modified small-pox were known to have occurred after a second vaccination, provided the insertion of the vaccine virus produced an action sufficient to prove that it had been taken up by the absorbents; also, from the disease being observed, in numerous inslances, to be arrested in families, and in neighbourhoods, where those already reputed to be vaccinated were again subjected to the operation.
When vaccination has been repeated in those who have been previously subjected to the disease, it is found to produce a local affection, marked by very different degrees of intensity. In some, slight inflammation occurs on the second or third day, and then fades away. In others, various degrees of inflammation manifest themselves, followed by a pock or pustule, terminating in a brown or yellow crust, whilst, very rarely, a distinct, regular areola is produced, or the other phenomena of the genuine disease, as will fully appear from the table here annexed.
The subject of repeated vaccination has engaged a large feld of inquiry in different parts of Europe ; a very full abstract of the results of which, will be found in the work of Dr. Condie on the Diseases of Children, page 458.
The second question, therefore, submitted to your committee, was to determine the phenomena resulting when those who have been already vaccinated are again subjected to the disease, and the necessity and policy of re-vaccination. It is to the first portion of this question that the committee have been obliged, necessarily, to confine their attention. It must be very evident that to test fully the necessity or propriety of re-vaccination, would either require that after large communities shall have been a second time subjected to vaccination, time be allowed in order that they may be repeatedly subjected to the influence of variolous contagion, during the epidemical visitations of small-pox, or that the direct test be resorted to of inoculating with small-pox those who have been successfully vaccinated, at different periods subsequent to the primary operation, as well as after a secondary operation, and carefully noting the comparative immunity from the impression of the variolous poison exhibited by each class of patients.
In order to obtain as wide a field of observation as was in the power of your committee they applied to the comptrollers of the public schools, soon after their appointment, for the privilege of vaccinating the scholars whose parents would consent to the operation being performed; whether they had been previously vaccinated or not; in order to accertain the degree of impression that would be made in each case by a repetition of the operation, and with a view of watching hereafter the effect or influence it may have in preventing the occurrence of small-pox in the subject of our experiments, should an epidemic of that disease again appear amongst us. But the comptrollers did not at that time consent to our request, and the investigation of the subject had to be postponed. In the early part of the present year, small-pox again made its appearance and excited considerable uneasiness in the minds of the public. Your committee entertaining the opinion that the period was propitious for a renewal of their application to the comptrollers, accordingly did so, and their consent was promptly given. Circulars were then sent to the pa. rents of the children, attending several of the schools, requesting their permission, which was in most cases readily granted, and every facility was offered to carry into effect the object your committee had in view.
The operation was performed in nine hundred and thirty-one cases; six hundred and thirty-five of whom took on various grades of action; many of these had been vaccinated three, four, and five times before, and stood in relation to small-pox, chicken-pox, and varioloid as stated in the following account:
Nine hundred and thirty-five persons reputed to have been protect. ed by previous vaccination, having distinct cicatrices on the arm, or by having passed through the small-pox, were subjected to the action of the vaccine virus.
50 did not appear on the days appointed for examination. 294 exhibited no signs of inflammation from the process. 52 of these were reputed to have been previously vaccinated twice. 6
three times. 1
four times. 14
to have had the small-pox. 36
chicken-pox. 76 had various degrees of inflammation on the fourth day, which
had faded before the eighth day 15 of these were reported to have been previously vaccinated twice. 2
to have had the small-pox. 5
chicken-pox. 181 had inflammation more or less severe, accompanied by a yellow
or purulent crust, on the eighth day. 30 of these were reported to have been previously vaccinated twice. 11
three times. 2
four times. 1
seven times, 9
to have had the small-pox. 7
chicken-pox. 95 had very diffusive inflammation, the pustule still moist on the 10 of these were reported to have been previously vaccinated twice. 1
three times. 1
four times. 2
to have had the small-pox. 4
23 of these were reported to have had the chicken-pox. 179 exhibited more or less inflammation and a brown crust on the
10 of these were reported to have been previously vaccinated twice. 4
three times. 1
seven times. 8
to have had the small-pox. 7
chicken-pox. 57 had a pock with various degrees of inflammation ; diffused and
irregular in its margin on the 8th day. 2 of these were reported to have had the small-pox.
chicken-pox. 3, viz. a boy and two girls, exhibited a well defined pock and the
areola characteristic of the perfect vaccine impression as observed on the 8th day. They are stated not to have been
affected with the small-pox, varioloid, or chicken-pox. From the foregoing observations, as well as from those derived from previous practice, your committee are justified in the conclusion, Ist, that vaccination is the best preservative of human life now known against the contagion of small-pox; and although it has not answered the full expectations of its more sanguine advocates by protecting the system in all instances against at least a modified form of variola, which is the case with the small-pox itself, nevertheless, life is very generally protected by it, and humanity and sound practice imperiously call for its continuance.
2ndly. Patients who have been once fully subjected to the influence of the vaccine infection, lose, in a great degree, their susceptibility to a second infection ; the susceptibility diminishing still more at every subsequent vaccination.
3rdly. That portion of the community who have been once successfully vaccinated are in the great majority of cases fully protected from small-pox or varioloid.
4thly. A second vaccination does not insure the system in every instance against an attack of varioloid ; neither does second vaccination prevent an impression being made on the system by a subsequent operation.
5thly. Upon the recurrence of small-pox in a family or neighbor. bood, it is all important that ail individuals in regard to whom there is any doubt or uncertainty as to the fact of their having been successfully vaccinated, should be subjected immediately to the operation, this being the most certain means of preventing the spread of the variolous contagion.
Your committee have not heard of a single instance of varioloid having occurred in any of the children of the public schools vaccina
ed by them, notwithstanding the epidemic was prevailing at the time and subsequently.
D. Francis CONDIE,