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The disease is not confined to the herds of this country, but has long been known on the Continent, in Asia Minor, and in many other remote parts of the world. England, possessing the honour of the discovery of the immortal Jenner, continues to diffuse its benefit to all countries, as appears by the numerous foreign applications to the National Establishment.
It is a curious fact, that the lymph still employed was taken from the cow in the year 1799, by the late Dr. George Pearson, founder of the Original Vaceine Pock Institution, which, in the infancy of vaccination, rapidly afforded means of disseminating this inestimable blessing to the poorer classes of society, and thereby of gratifying the anxious importunities of the faculty. The navy and army were also supplied by an order from Government. At this early period the benefits of the Institution were not confined to our own country; from the same source its advantages were extended to France, Germany, Russia, Portugal, Italy, different parts of Asia, Africa, America, and the West Indies. To corroborate the principle laid down, as regards the original source of the lymph, I may here be permitted to make an extract from the first Report of the Cow Pock Inoculation, written by the Physicians to the Institution, and published in 1803. “In 1798, after Jenner's publication, no one was in possession of vaccine matter during the remainder of the year 1798, except Mr. Cline, who inoculated one patient, but he did not avail himself of the oportunity of re-collecting' it. Inquiries being made among the farmers and others concerning the history of the cow pock, matter was in consequence obtained in January 1799, on the appearance of disease amongst the cows of Mr. Harrison, in Gray's Inn Lane, and those of Mr. Willan's, in Marylebone-fields. From these sources only the vaccine inoculation was begun and carried on in London, and in several provincial towns, with great zeal by many practitioners, so that, by the termination of the year 1799, four thousand persons at least had been inoculated principally in London and its neighbourhood.”
Having been from the year 1800 a Governor of the original Institution, and joint Treasurer for some years, it has enabled me to add my testimony of the vaccine vesicle not having undergone a perceptible change in any of its original characters, as exemplified on reference to the coloured engraving prefixed to the first report of the Vaccine Pock Institution, published in the year 1803, that beautifully exhibits progressive specimens of the vesicle in all its important stages, and exactly accords with the graphical representations of Dr. Jenner. These valuable documents prove that the vesicle has neither been vitiated, nor suffered in its efficacy, by passing through so many thousand persons during the period of thirty years. My appointment of District Vaccinator to the National Vaccine Establishment has offered the additional opportunity of minutely observing the repetition in every essential point in nearly two thousand cases. In the last annual Report, dated March the 2d, 1829, these remarks are most satisfactorily confirmed, “ for it does not appear to us to be weakened or deteriorated by transmission through any number of subjects in the course of any number of years."
Some practitioners entertain an opinion that the security from small-pox, derived from vaccination, is only temporary, and that it loses its conservative power after four or seven years. From what false pathological reasoning so prejudicial an idea has arisen, it is not easy to conjecture; nosology does not sanction any such argument. The vaccine disease is surely worthy of being classed with those which are generally found to afflict the constitution but once during life, such as sinall-pox, measles, and hoopingcough. In what manner the human frame is ever afterwards rendered unsusceptible of their recurrence is truly surprising, and must ever remain a problem too difficult for the comprehension of man. Had our species been exposed to the unceasing repetition of such contagious diseases, population -might have been swept from the surface of the globe: the child could scarcely have attained the period of manhood, the mighty object of the creation would have been lost, and the earth restricted to its primeval inhabitants the beasts, birds, and fishes.
In my public and private practice, upwards of a hundred patients have been re-vaccinated; in almost every instance producing premature irregular vesicles, accompanied by incessant itching and dying off in a few days. These have been also tested at almost every variety of years subsequent to the original vaccination. They have, however, chiefly consisted of the mothers of poor children, who, whenever they have expressed a doubt of their security, have been re-vaccinated from their own babes, thus proving to demonstration (as they were, in all probability, vaccinated during their infancy,) that the prior operation had not failed to extend its protecting influence throughout their lives. Among these cases four occurred in private practice, in which regular vesicles were the result as they passed through all the gradations and terminated in the mahogany-coloured crust. The patients were under nine years of age, and had been vaccinated in the country. On inquiry, the progress of the former vesicles was deficient, and the cicatrix could not be discovered; the children were, therefore, in all probability, insecure until after the second operation.
Cases of small-pox after vaccination have recently occurred in some families of rank, which have caused a considerable panic and corresponding loss of confidence. Now, although the theory of insecurity after an indefinite period has been strongly opposed in this paper, yet no possible harm can arise by even an annual repetition of vaccination ; since, by this means, the apprehensions of the timid may be allayed, and persons possessing any peculiarity of constitution which might render them liable to secondary smallpox, will thus continue in safety.
If an accurate history could have been handed down, of all the cases of secondary small-pox from the time of Charles the First to the present period, it would no doubt appear that such cases were at least as numerous in proportion to the number of infected persons, as those instances of smallpox which have of late years occurred after vaccination. But in such secondary cases of small-pox, it is a singular and well-known fact, that the last attack was invariably more severe than the first, and usually fatal. Whereas it may be contended on the clearest evidence, that the disease, when preceded by vaccination, is safe, mild, and usually denominated by practitioners a mitigated case of small-pox, turning on the fifth or sixth day, resembling rather a slight case of chicken-pox, and scarcely exciting alarm. Few instances of death have supervened ; and, although in some rarer cases, a violent eruption of the confluent type has been observed, yet the protective inAuence afforded by vaccination has been singularly manifested by preventing the recurrence of the secondary fever: if, therefore, vaccination does not in every case afford absolute security, it protects the person from the fatal effects to which he might otherwise be exposed.
It is readily admitted, that many persons have had small-pox after vacci. nation; but, upon investigation, such patients are generally found to be deficient in those signs which denote the former to have been perfected ; the abuse, therefore, to which vaccination is still exposed in this capital, cannot be considered as unworthy of notice. The following case, selected from many others, may serve for illustration. An infant nine months old was brought for re-vaccination, only a fortnight after it had undergone the operation. The mother, not feeling satisfied, wished it to be repeated; on examining the arms, there were three rose-coloured spots of an oval form, about the size of a split horse-bean, no elevation of the cuticle had ever taken place, or any surrounding inflammation ; the lancet had actually been armed after tearing off the black scab from another child, which readily accounted for the failure. The infant was re-vaccinated from an eighth day case by five punctures in each arm; on the fourth day nine had taken effect, on the eighth day each vesicle was regularly formed with incipient indications of the areola, on the twelfth day they had passed the height, and the concentric circles were well defined. From some of these vesicles several children were vaccinated, and the board of the N. V. E. supplied with one hundred and twenty-five double-armed ivory points.
of infinite importance, and the regulations regarding it cannot be too deeply impressed on the attention of practitioners; indeed, the neglect of this circumstance alone has been the real cause of bringing the cow-pock into disrepute. It cannot be used too early ; as soon as the vesicle, even as early as on the fourth or fifth day, yields sufficient lymph to arm the lancet, it may be done with the surest effect: the usual time and the latest recommended is on the eighth day, prior to the full developement of the areola. If taken too late, it produces an irregular vesicle, destitute of the true characters: in stead of being circular, the edge of the pock elevated, and its centre depressed, the form is reversed, rising in the middle like a cone, or pimple, by the projection of which the vesicle is more exposed to friction and likely
lymph, instead of being absorbed into the circulation, and thereby affording future protection, is constantly exuding, as from an ill-conditioned ulcer; the concentric circles are not palpable, the texture is soft and flabby instead of being compact, and it fails to leave the proper test, viz. a permanent cicatrix. It is unreasonable to expect that such a marked deviation from the regular form and progress of vaccination can offer security against variolous contagion. The period, therefore, of employing the lymph is diametrically opposed to the former practice of inoculation for small-pox; the matter in that case was never taken until the pock had turned, as recommended by Baron Dimsdale, under the impression that, the matter having undergone this change, its virulence was modified. An allusion to this eircumstance is here made under the apprehension that some gentlemen in the profession may still labour under a similar impression with regard to the vaccine vesicle: the remarkable case of failure above related seems to have arisen in consequence of such an opinion. To produce the effect of genuine cow.pock, it becomes indispensably necessary to employ the lymph from a well-formed vesicle while in its most active state, not exceeding the eighth day. The late Mr. Rush followed this practice, terming it “the golden rule of vaccina
A curious anomaly with respect to the complete vesicle deserves notice in this place : the black scab, or crust of a well-formed pock, after having been kept for months, is sometimes found effective. For which purpose the crust must be reduced to a fine powder in a mortar, and mixed with cold water to the consistence of a mucilage, when vaccination may be performed with this liquid in the usual manner. This paradox future physiologists may perhaps explain ; at present it is not easy of solution. It is singular that, after a certain time, as already exemplified, it withholds or ceases to generate the genuine pock, but by undergoing all the regular changes, it would seem that the original property is actually restored to the crust. Why the matter of the vaccine pock becomes less and less capable of producing the perfect vesicle after the ninth or tenth day, the following suppositions are submitted for consideration. We may suppose that vaccine lymph, in the first place, produces its own peculiar excitement, in consequence of which a transparent lymph is secreted in a vesicular eruption, impregnated with the vaccine poison; and that this secretion continues till a portion is absorbed, and an alteration thereby effected in the constitution, by which the system is rendered incapable of being acted upon in future either by the vaccine or variolous poison. After this constitutional change, the peculiar vaccine secretion ceases, and an ichorous serum, imperfectly vaccine, continues from the irritation of the fluid collected. The black scab being divested of the superfluous ichor becomes concentrated, and thereby re-assumes its original pro
its efficacy, the specific action and true secretion being exhausted.
A difference of opinion prevails among the faculty with regard to the necessary number of punctures, some preferring one, others two, three, four, and even fire in each arm. It is readily admitted that one vesicle, if well preserved, or allowed to remain entire, affords sufficient protection. All appre,
July. VOL. XXVI. NO. CIT.
hension, however, of overdoing this mild disease is groundless, and is opposed in an inverse ratio to the introduction of small-pox matter. But the more freely the vaccine lymph is inserted, the greater perhaps will be the security effected; by affording a larger surface for absorption, the more complete may be the saturation of the system. The unpleasant casualty of one or two being broken or disturbed by accident, is effectually guarded against by increasing the number of vesicles. The Original Vaccine Pock Institution, from the beginning to its dissolution, uniformly set the example of forming three vesicles in each arm, in the figure of an equilateral triangle, each pustule making a triple apex, distinctly about an inch apart. The last year the number was augmented from three to five, six, or more, in each arm. It is not unlikely that the poor, by undergoing vaccination more freely, are better off than the opulent; the former, indeed, require greater protection, because they are much more liable to be exposed to the contagion of smallpox: many of their associates being yet insensible of the advantage of the preventive process, carelessly forego “ the resource which the charity of Parliament most humanely and generously provides for its safety." This quotation is from the last annual Report (1829), and the following will equally add strength to the argument: * We have the satisfaction, however, of finding that more than 10,000 of the poor have been vaccinated in London and its neighbourhood since our last Report ; and it is particularly gratifying to learn, from the records of the last year's experience of the Small-pox Hospital, that no patient admitted there under small-pox, after vaccination, had been vaccinated by any officer of this establishment: whence it is fair to presume, that when the operation has been performed with due care and intelligence, it is much less liable to be followed by small-pox; and that such care and circumspection are absolutely necessary to a just and confident expectation that complete protection will be afforded by it." In accordance with the foregoing sentiments, I have always in my public, and generally, if possible, in my private practice, made five punctures in each arm, about threequarters of an inch apart, a distance sufficient to preserve each vesicle distinct ; the areola a little exceeds in diameter two pustules an inch separate.
Only a single case has occurred of erysipelatous inflammation extending from the shoulder to the elbow after the twelfth day, which readily yielded to a saturnine lotion; the arm thus affected had four vesicles, the other three, with the areola of the usual character and dimensions, marked by the concentric circles. Whence an inference was drawn, that the inflammation had been caused either by accidental pressure, or external injury.
A practitioner having a number of patients to vaccinate from an eighth day case, a good sprinkling of vesicles allows him to do so with additional confidence, by enabling him to leave two or more untouched. When one or two pustules only are produced, the faculty are frequently requested to vaccinate the family of a relative or friend ; and having no alternative, they are compelled to act contrary to their real wishes or approval.
When a vesicle is damaged during the most active period of secretion, from the fourth to the eighth day, it becomes materially deficient in the quantity of lymph, and deceives the observer by insidiously undergoing the relative vicissitudes of areola, concentric circles, to the black crust, and even cicatrix. By such a reduction of lymph, the chances are that an adequate degree of absorption, necessary to protect the constitution, is either greatly diminished or wholly defeated, and if only a single pock, a failure ought to be anticipated, and re-vaccination strongly recommended. This fact has been frequently recognised, while puncturing the vesicles for drawing lymph to doubly arm the ivory points for the Board. Out of four or five pustules in the same arm, the one that has been injured, although corresponding in size with the rest, but a shade darker, by repeatedly puncturing the cellular structure, so completely refuses to yield a discharge of lymph, that a single point or glass cannot even be moistened.
Should these remarks be honoured by the perusal of the fair sex, whose sympathising affection, anxious and maternal solicitude, are so invariably exemplified on all occasions for the welfare of their tender offspring, “the mother's hope, the father's joy,” it is confidently expected that all intelligent mothers will cheerfully become converts to the plans here suggested, and permit the surgeon to exercise his discretional judgment. What can be the cruelty of a few punctures from the lancet, to that of leaving the child exposed to the ravages of a loathsome disease ?
Lest, however, these observations may excite unnecessary alarm in the minds of the timid or nervous, on retrospection, if only one or two vesicles should have gone through the necessary changes unmolested, they may cheerfully conclude that all is right; but, if otherwise, the simple operation of re-vaccination becomes absolutely necessary. When inoculation was first introduced, an incision was made in the arm, deep and long enough to deposit a bit of thread from a quarter to half an inch in length, stiff, and saturated with the matter of small-pox.**
Burke has observed, that “ early and prudent care is the nurse of safety;"> let the parent cherish this maxim in his recollection, and in every doubtful case re-vaccinate the subject. As the vaccine lymph only contains its specific poison, no other disease can be communicated along with it; the thousands it has already passed through with impunity, readily satisfies the mind upon that point.
Casualties arising from the manner of vaccinating.-When blood flows too freely from the puncture, it may defeat the operation by washing off the lymph; on which account the most uncertain subjects are those under a fortnight old, when the muscles are flabby by reason of the cellular membrane not being filled up, and the cuticle so thin in its texture that the lancet, even with the greatest caution, wounds the vessels of the cutis; and the operation is generally required to be repeated. This early vaccination can only be justified under circumstances of small-pox breaking out in the same habitation or immediate neighbourhood. It has been generally remarked, that in almost all cases where blood issues too quickly it is more liable to fail. The variety in the texture of the cuticle of different subjects is very remarkable, and requires attention on the part of the surgeon, to adapt the puncture so as to avoid the casualty here alluded to with consequent failure. When the skin is thus delicate, success is better effected by arming the lancet with a full charge of lymph every second touch, holding the instrument in a slanting direction downwards, slightly pricking the skin, and wiping the lymph into the orifice. Another mode is by making as superficial a puncture as possible in the usual manner, and applying more lymph, after it has ceased to bleed, with the flat surface of the lancet.
Children ought to be vaccinated from six weeks to two months old, previously to the irritation of teething, in good health, and free from eruption.
Lymph should be taken from those cases only in which three or four vesicles have formed ; and one or two, at least, should always be permitted to go through the regular course, without being punctured or otherwise disturbed ; the variola vaccinæ then may be considered complete.
Recent lymph, not exceeding the eighth day, should be preferred, whenever it can be procured.
If the Jennerian practice could be effectually and universally enforced, small-pox must altogether cease. The freedom, however, enjoyed by the people of the British empire precludes the Government from passing a bill to enforce vaccination. A proposal to legislate in this particular case was made, in the year 1813, by Lord Boringdon, for that express purpose, but rejected. The following extract from a popular periodical workt, proves the successful results of enforcing the anti-variolous influence in foreign countries.
• It may, perhaps, not generally be known that the constitution can be equally as well put to the proof by vaccine lymph as by small-pox matter; therefore, re-vaccination ought always to have the preference, because life is not endangered. . t Quarterly Review, No. 66.-1825.