Vaccination has now been in use for 60 years. It was hoped by the founder of the practice, and by its early advocates that it would in time eradicate smallpox from the list of human maladies. This consummation devoutly to be wished for has not taken place. Deaths from smallpox are still frequent, and number in this city alone several hundred each year. During the seven years ending 1855, 3,327 deaths from smallpox, and 178 deaths from varioloid, occurred in New York city.
From the frequency of variolous diseases within a few years past, a growing want of confidence has been experienced in regard to the protecting powers of vaccination. There are comparatively few at the present day who are wholly opposed to the practice of vaccination, but in relation to the degree in which it protects, and in regard to the length of time during which the individual is rendered safe, and the necessity for revaccination, we find quite diverse views held.
There are quite a number of physicians of good standing in the profession, who still hold that one good vaccination should be sufficient, and they infer the vaccination to have been imperfect if a second vaccination be successful, or the patient have variola in any degree. Others consider a single vaccination to be sufficient for a certain period, some say seven, other ten or twelve years. Many authorities assert that vaccination performed in infancy is a complete protection against smallpox to the period of puberty. A number of physicians have serious doubts as to the propriety of revaccination. In the proceedings of a very respectable medical society in Boston Mass., (Society for Medical Improvement,) no longer ago than 1854 we find the propriety of revaccination discussed; the following is an extract:
“Most of the gentlemen would revaccinate if requested to do so; several would certainly do the operation if persons were much exposed. Certain members declared themselves nonrevaccinators”*[American Journal of Medical Science, Oct. 1854]
Thus it will be seen that the most confident made the revaccination to depend on being requested to do so, or upon the individual being much exposed. At a meeting of the Homoeopathic Society of the County of New York, within a few months past, the subject of vaccination was discussed, and exceedingly various views elicited in regard to it, some advocating revaccination until no effect could be produced, others recommending one vaccination in infancy and another after the period of puberty, believing this to be a complete protection against variolous diseases.
Thus it will be seen that the medical profession are by no means agreed on the subjects of vaccination and revaccination I will briefly remark upon these opinions held, that there is sufficient evidence that one vaccination is not always sufficient, and in regard to the length of time during which vaccination will protect, that there is very little evidence to indicate the existence of any definite period of immunity, the weight of evidence being in my opinion opposed to this view.
Different individuals differ very greatly in regard to their susceptibility to variola, as they do unquestionably to many and most other diseases. A certain but very limited number of persons are not susceptible of it at any period of their lives. Another more numerous class can have the disease but once. A third class, which I believe to comprise more than any other, can have the disease twice. Instances are not uncommon of persons who can have the disease three times, and the susceptibility to a greater number of attacks in not unheard of though rare.
I believe that with very rare exceptions the susceptibility to variola and to vaccination is similar, and that those who are liable to the one are to the other also; that one vaccination protects against one attack of variola; If the individual is only liable to one attack he is protected for life. If he is liable to more than one he requires as many vaccinations as lie is liable to attacks of variolous disease; the only way to ascertain how far the susceptibility extends being to repeat the vaccination until no effect can be produced. Then the individual is safe for life. There is an apparent exception to these rules, which is more apparent than real. At certain times variolous disease prevails epidemically; which can only be accounted for by supposing some special predisposing cause acting at such times. At these periods some persons who had been vaccinated unsuccessfully in ordinary times can be vaccinated with perfect success, and, as follows from the foregoing rules, persons who would not have taken variolous disease if exposed in ordinary times are then liable. These epidemics arc exceedingly favorable times to carry out the plan of repeated vaccinations, as it is probable that persons vaccinated during one of them until no effect is produced, possess an immunity for life.
There is no want of proof to show that vaccination exerts a protecting power against smallpox, nearly or quite equal to the smallpox itself. We have every reason to believe that those who have varioloid after vaccination would be liable to it after an attack of the smallpox.
These assertions, however, are of little value as the results of individual experience. If the profession are ever to agree on the disputed points of this subject, it must be in consequence of the testimony of experiments on a large scale, conducted by those in official positions.
From a paper “on the protection against smallpox afforded by Vaccination, illustrated by the returns of Army, Navy, and Royal Military Asylum, by J. Graham Balfour, M. D., surgeon to Royal Military Asylum Chelsea, England,” I glean the following valuable statistical results:
“Among the boys in the Military Asylum, who are all vaccinated, or have had smallpox, there have been only 39 cases and 4 deaths among 31,705 boys. All the 4 deaths were in boys who had had smallpox.“* [Medico Chir. Review, April, 1853.]
“Out of every 1000 boys admitted protected by smallpox 6.15 and out of every 1000 protected by vaccination 7.06 were attacked subsequently by smallpox.“† [American Journal of Medical Science, Jan., 1857.]
“These statistics were further of great value in showing that smallpox after smallpox was by no means the rare occurrence it was sometimes represented to be, a point which must always be borne well in mind in any attempt to estimate the value of vaccination.”
It would appear from the results of Dr. Balfour, that the probability of fatal attack of smallpox was less after vaccination than after smallpox, but that the liability to an attack was slightly greater after vaccination.
It was at first supposed by Jenner, that one vaccination afforded complete protection to the individual. It was ascertained, within a few years, that many of those vaccinated had the smallpox, but in a modified form. This naturally attracted much attention and furnished the opponents of vaccination with arguments, but failed in general to shake the confidence of its friends. Many interesting points in this early discussion could be adduced were space allowed, but I shall only quote from a work published in 1818, written by Alex. Monro, Prof, in the “University of Edinburgh, on the “Smallpox which follows vaccination, illustrated by a number of cases,” among which were three of his children. He seems to have been a most enthusiastic advocate of vaccination; nor does his faith appear to be the least shaken by the sickness of his family.
“For, those that have been vaccinated, (living in the same house-sleeping in the same apartment, and even in the same bed-using the same spoon, and eating from the same dish with others who had not had Cow pox, and who were within a few days or even within a few hours of death from malignant smallpox,) have either escaped the smallpox or have been afflicted with a form of that disease which though at first severe, has, after the sixth or seventh day of the eruption, almost invariably disappeared, with a rapidity which perhaps forms the most striking feature of the disease.
The events therefore of the above period, so far from militating against Dr. Jenner's discovery have proved in the clearest manner, its incalculable value, and may be said to have confirmed the triumph of vaccination.”
This extract is of interest in several points: thus the occurrence of numerous cases, of what we now call varioloid, is shown to have been well known at that comparatively early period in the history of vaccination, and affords proof against the assertions of some at the present day, that the vaccine has deteriorated, because we occasionally have epidemics of varioloid. But no suggestion of revaccination is contained in the work above quoted. I am not aware who first proposed revaccination for the purpose of exhausting the susceptibility of the individual. A form of revaccination, called Bryce's test, was early used, which consisted in revaccinating two or three days after the 1st; it was considered a test of the constitution being affected if the 2d vaccination ran a more rapid course than the 1st, so as come to its period of full development at the same time, but if on the contrary the 2d vaccination ran a regular course, the 1st vaccination was regarded as imperfect and the test repeated with a 3d vaccination. This process however is quite different from the revaccination of the present day, in which one vaccination is allowed to run its course before the system is again subjected to the influence of another.
It is in Continental Europe, especially in Prussia and Wurtemburgh, that revaccination seems to have been first practiced, and it is in those countries that it has been most thoroughly carried out, and where we must look for statistics of its results.
It seems scarcely necessary to offer proof that persons vaccinated only once, have frequently been the subjects of severe varioloid. It was known in the time of Jenner, and has been the common experience of mankind since. I will however quote from the Report of the Commission of the French Academy on vaccination of 1845.
“An official document published by the government of Wurtemburgh, wherein it is set forth that out of 1677 cases of smallpox which occurred from the year 1831 to 1836, no fewer that 1055 were in vaccinated persons.
“The reports too of various epidemics in this country (France) clearly show that the proportion of vaccinated persons, who have become affected with the disease, is more than one third of the entire number attacked.”
To illustrate the advantages to be derived from revaccination, I shall have to introduce statistical results. Figures have a somewhat dry and uninteresting aspect, but I trust that the importance of the conclusions to be deduced will be sufficient to secure attention to the dry but necessary detail.
If I were to state that of some hundred cases, in which I had performed revaccination, no case of smallpox even in its most modified form had occurred to my knowledge: it would be evident that the information was not of great value, as many sources of fallacy might arise. Every physician is aware that he frequently has little knowledge of the subsequent history of his patients, and that many, might have had the disease without my knowledge. Various other objections will be thought of, which apply to individual experience as connected with statistical results.
The French Academy of Medicine, in 1844, offered a prize for essays on the subject of vaccination; a large number of communications were received, and a commission appointed to examine them. I have already extracted from the report of the commission, and shall offer some further extracts on the present subject. A portion of the report reads as follows:
“It is to the Continental states, especially Prussia and Wurtemburgh, that we are indebted for carrying on the experiment of revaccination on a large scale. In the former country, of 216,289 revaccinations, from 1833 to '37, (inclusive) there were 84,516 successful, and of 44,000 in the latter country, 20,000 succeeded.” “The precise proportion of successful cases has varied from 31 to 45 or 46 percent-the period between the ages of 10 and 30 being found the most certain of success.”*[ Medico Chir. Review, Oct., 1845.]
The portion just quoted illustrates the successful revaccination of a large proportion of those on whom it was practised; another extract will show the beneficial effects experienced by the individuals and the community:
“The effects of revaccination in the Prussian Army, since the year 1833, have almost completely extripated smallpox from its ranks. In the kingdom of Wurtemburgh also, it has been found that out of 14,384 soldiers, and 19,864 civilians, who were revaccinated, only one case of varioloid has occurred among the former and only three among the latter, during the period of five years. Since the year 1830, when the practice of revaccination became general, no epidemic of smallpox has been experienced in that kingdom. The good effects of this practice have been not less striking in some of the Italian states.”
“Among the many thousands who have undergone revaccination in Prussia and Wurtemburgh, an example of the occurrence of smallpox has only here and there been observed Moreover, in the case of an epidemic breaking out, it has been found in various localities that immediate revaccination has arrested its course-individuals in whom the operation proved successful and those in whom it failed equally resisting the disease.”
-“We have good reason for believing not only that multitudes have been preserved from variolous contagion by having recourse to this measure, but also that the disease has thus been actually arrested in its progress by, as it were, a barrier which it could not overleap.”*[Medico Chir. Review, July, 1845.]
In addition to the above allusions to the Prussian Army statistics, I have been enabled to compile the following tabular statement of revaccinations in that army during the years 1845, 1847, 1848, and 1849. It gives some particulars of interest in this investigation.
It will be observed that cases of varicella are included in the Prussian returns. There is some difference of opinion among physicians as to the propriety of including varicella as among the effects of the smallpox poison. Wilson considers it as modified smallpox, but scarcely protective against the subsequent occurrence of variola. Watson says “it must, therefore, be admitted that there is a separate disease called chicken pox which springs from a specific poison.” West (Diseases of children, Am. Ed., p. 463) says “The weight of evidence, however, is decidedly in favor of the opinion that varicella is an affection distinct from, and wholly independent of smallpox, not being produced by any modification of the poison of that disease, nor affording any kind of protection from its attacks.” It is not my intention to enter into the discussion of this subject, but merely to express a doubt as to the propriety of including the cases of varicella in the consideration of the effects of revaccination. Wilson who adheres to the theory of a common origin, admits that its occurrence is not so protective as vaccination. It is possible that we shall sometime discover the existence of two forms of the disease, one produced by the modified effects of smallpox, and the other by a specific poison.
I beg leave to introduce in this place the results of the revaccination of the Protestant Half Orphan Asylum in this city. It was performed about a year and a half since when variola was prevalent in the Asylum. Those already attacked were not vaccinated.
Thus in more than one half the vaccination ran nearly a regular course, and in full 3-4 produced decided effect. The examination of the arms was made on the 9th day. Two of those who took fully also contracted varioloid, each disease running a pretty regular course, but neither of those in whom the vaccination produced no effect had varioloid. Almost all of the inmates of the Asylum were under the age of puberty as the rules do not permit of their being retained longer. The vaccinations were all performed with one scab so that any difference in effect produced must be attributed to difference of susceptibility to variola or constitutional peculiarities. In the classification I have divided them into those which took fully and those which took slightly, but in reality every degree of effect was observed from a slight flush of inflammation to a perfect vesicle, and well marked surrounding areola. In some the local inflammation and constitutional symptoms were severe, and in others these were very slight, some were so irregular in their course that they would have been called spurious, yet they were produced by the same matter with the most perfect vesicles.
I have shown that in a large proportion of instances, one vaccination does not exhaust the susceptibility to variola, but that in the early days of vaccination as well as at the present day, numerous cases have occurred in those vaccinated. In one instance cited, no less than two-thirds of those having smallpox had been vaccinated.
Also, that revaccination will succeed in from 30 to 75 percent at different times. This variation appears large but is a valuable fact, showing the susceptibility of vaccination to vary. I believe the susceptibility to variola will be found to be subject to similar and simultaneous variations.
I regard it as proved, that the repetition of vaccination prevents the occurrence of variolous diseases. Thus it has been shown that in the kingdom of Wurtemburgh, of 34,148 persons revaccinated, only 4 cases of varioloid occurred. And that in the Prussian Army only 16 cases of variola, 48 of varioloid, and 26 of varicella. It may be remarked that these numbers include some not yet revaccinated.
Revaccination not only protects those on whom it is performed, but it adds to the safety of others; diminishing the probability of their being exposed to the influence of the contagion, by lessening the number of fit subjects. It may be compared to interspersing fire-proof buildings through a city, which would obviously tend to prevent an extensive conflagration. If we suppose one half of a population to possess an immunity to variolous disease, it seems to me evident that the remainder who are liable to the disease, if exposed, are not more than half as likely to take it-if this be true, we should diminish the number of cases 75 percent by rendering 50 percent perfectly safe. That this statement is not a purely hypothetical one may be shown by statistics. One item from the letter of Dr. Edward Seaton to viscount Palmerston, which was published by order of Parliament, May 3d, 1853, will illustrate my position:
“In various German states, sufficient evidence can be obtained to show that, before vaccination was used, out of every 1000 deaths there occurred from smallpox 66.5, after vaccination there occurred 7.26.“* [Medico Chir. Review, Oct., 1853]
These figures, it will be observed, are very greatly in advance of the hypothetical case stated. Some may assert that where vaccination has been so thoroughly performed as it has been in most of the German states, scarcely any are liable to variolous diseases even on exposure. But if we recur to the statistics of revaccinations in the Prussian Army, we shall observe that regular vesicles were produced in about 60 percent, irregular in 15 or 20 percent, leaving only 20 or 25 percent in whom no effect was produced by revaccination, and in about 1-5 of these a second trial produced some effect, so that previous to the revaccination not more than 15 or 20 percent were to be considered as perfectly secure. There are two considerations which might be brought forward to invalidate the accuracy of my statement:
“The result of revaccination does not afford a certain proof that those vaccinated persons in whom it takes effect were destined to contract smallpox: but only a high probability that it is especially among such individuals that the disease is likely to occur.”
This very guarded statement is probably as near the truth as we can arrive. Revaccination may succeed in 100 individuals, yet of this number probably not one half would ever be exposed to variola, consequently, even if they had been proper subjects they would not have had the disease.
It has been asserted that, because vaccination succeeded after smallpox in a larger proportion of instances than a 2d attack of smallpox had been known to occur, therefore vaccination was not a test of the susceptibility of the individual to variola. The probability of a certain number escaping exposure to the contagion is, I think, a sufficient explanation. It must be remembered that we have no statistics of inoculation after the occurrence of smallpox, with which to compare the results of vaccination after smallpox. This would be the true manner of testing the question.
In 1848 9 were revaccinated without success, and subsequently had some form of variolous disease. Including die the cases of varicella. “One death occurred in the person of a soldier, who had been revaccinated 3 times without effect.” The whole number revaccinated in 1848 was 28,839.
Thus we find that in these two years, 80,496 persons were revaccinated, and among those revaccinated without success, 34 cases of variolous disease (including varicella,) and one instance of death from variola.
From the statistics it would appear that a certain number of persons exist, on whom vaccination produces no effect, but are yet liable to contract variolous disease. The fact of only one death being recorded in such persons would seem to indicate that these exceptionable individuals were not liable to the disease as a general rule in its severer forms, and renders it probable that a peculiar conjunction of circumstances is required to have them take it in any form.
As I have before stated, I believe that the susceptibility to variola and vaccination varies at different times from some unknown predisposing causes. It is only in this way that the occurrence of epidemics can be satisfactorily explained. The same principle is recognized in regard to scarlatina and other diseases.
Now we can Conceive of a person being vaccinated unsuccessfully at a time when little of this predisposing cause existed, who nevertheless could be vaccinated successfully or might have varioloid when the predisposing cause “Was fully in force. A case which occurred in my own practice last winter, I believe to be one of this character. A lady had been vaccinated with success in early life; a year ago it was attempted to vaccinate her with lymph, taken directly from the arm of a child; no effect was produced. This was when variola was not prevalent. I vaccinated her last winter with perfect success, the vesicle running nearly a regular course, and a 2d vaccination which I performed, subsequently, produced some effect At this time variola was quite prevalent.
As a general rule we must receive with very great caution the statement of individuals having been vaccinated without success, and subsequently having been attacked with variola. All physicians are aware, that they frequently fail to produce effects, simply on account of the virus having lost its power from age.
Since this article was written, I find in the Medical News of Philadelphia, copied from Medical Times and Gazette (London) of June 12th, 1858, the following paragraph, containing several points of interest, among others the occurrence of variola in some unsuccessfully vaccinated.
“Epidemic variola in Berlin. During the month of March the epidemic increased in virulence. The police had notice of 805 cases, and these 60 died. Of the 805, 659 cases had been vaccinated, 105 had not been vaccinated, and 41 unsuccessfully vaccinated. Of the fatal cases 16 hed been vaccinated, 39 were unvaccinated, ane in 5 the vaccination was uncertain. Thus 7.48 per cent of all the cases proved fatal. Among the vaccinated the proportion was 2.42 percent, among the non-vaccinated 37.14. and of the uncertainly vaccinated 12.19 percent.”
It appears probable that the vaccinations had, as a general rule, been performed at some period previous to the occurrence of the epidemic, as no mention is made of its having been performed recently.
Although I do not consider the experience of one or two individuals, in private practice, as sufficient to establish a theory; still, such evidence may be admitted in coroboration, and when multiplied to a sufficient extent becomes valuable. It has been my custom for some years past, to revaccinate more extensively than has been usual with physicians: it is an invariable rule with me to repeat the vaccination of the infant either at the 8th day from the lymph or when the crust came off. The only exceptions being when the parents would not consent to the operation; the reason most commonly alleged being, that the infant had suffered enough from the first. When taking the lymph on the 8th day or when the crust conies off, I vaccinate such members of the family as will submit to it, using all my influence in favor of the trial. There are several advantages in this plan. The matter being fresh is likely to take effect if the subject possesses sufficient susceptibility, and coming from a member of their own family they will not attribute any slight inconvenience consequent on the vaccination, to the influence of the poisonous matter. When persons apply to me to be vaccinated, I not only vaccinate them then, but recommend them to come back and have the operation repeated at intervals of two or three weeks, until no perceptible effect is produced. To secure their return I sometimes make only one charge for the complete course. In some instances I have revaccinated persons 4 or 5 times with success; the vesicle not running a regular course perhaps in either. The greater the number of times vaccination is repeated, the more slight are its effects and the more rapid its course; the symptoms appear earlier and terminate sooner. The periods when variola is epidemic are the times when persons are most likely to desire vaccination, and as I have before stated, those which afford the best opportunity for testing the susceptibility of the system, by repeated vaccinations. At these periods I am accustomed to revaccinate every one I can conveniently, even if I had vaccinated them previously with or without success.
It may be of interest to state that neither in the practice of Dr. Joslin, Sen., nor in my own practice, have any cases of varioloid, even of the most mild description, occurred in persons revaccinated. This result of the experience of some years during which several epidemics of variola have occurred can scarcely be the result of chance alone.
In this country, where vaccination is purely voluntary, it is no very uncommon occurrence to find children, and even adults, who have never been vaccinated. Such instances have come under my own observation, not only among ignorant emigrants, but in native born persons. I have witnessed the occurrence of variola in such families; and the loathsome character of the disease and its fatal termination, in a large proportion of cases, have impressed on my mind the great importance of calling the attention of the profession to the importance of vaccination and revaccination. I am convinced that if the profession felt the importance of the subject, and as individuals threw the weight of their influence into the scale, that variolous diseases would be almost unheard of, and that the occurrence of death from variola absolutely prevented. The real obstacles in the way of the extermination of the disease have been found in the apathy of the profession, and in some instances in their want of confidence in vaccination. Physicians rarely think of recommending vaccination excepting the primary one of an infant; this fortunately has become a general custom.
The plan of general compulsory revaccination is undoubtedly the most perfect method of eradicating variolous disease from the community, but it is opposed to the spirit of our institutions. Moreover, it would be found impracticable at the present day, in consequence of the want of knowledge of the beneficial effects of revaccination among a large proportion of medical practitioners. The fear which some have of communicating thereby other diseases, would also strongly operate against it.
The attention of the profession and the public should be particularly called to the consideration of the subject, both with a view of advancing human knowledge in this direction as well as to remove many of the absurd opinions which prevail in regard to the subject. There is much room for investigation yet, and if every member of the profession were to contribute his quota, the doubtful points would in a reasonable time be cleared up, and we should have reliable statistics with which to convince the public of the great advantage and safety of revaccination. Now, although I consider the practice of general compulsory vaccination and revaccination to be impracticable in this country, I still advocate its introduction in all institutions depending on public support.
The disease is kept up in this country, in a great measure, by emigrants from Ireland and England, a very large portion of whom have never been vaccinated. To obviate this evil, I would advocate the thorough vaccination and revaccination of every emigrant before he is admitted into the country. This we have a perfect right to require. The expense Would be very slight, and could well be afforded, for a reason similar to that which induced certain Poor House Commissioners in England to adopt vaccination, viz: to save the expense of coffins. Next I would extend the advantages to every child in our public schools, and make it a prerequisite of admission that the vaccination had been repeated until it produced no appreciable effect.
I would also advise the vaccination of the convalescent inmates of Hospitals, and the inmates of Alms Houses, and Prisons. The various Orphan Asylums being mostly under private management, could not so well be reached by law, but a law could be passed, that no institution should receive pecuniary assistance from the State unless the regulations included a complete system of revaccination.
Though these propositions may appear to some extreme and difficult of execution, I am confident that, could the machinery be once put in operation, it would not be long before the advantages would be apparent to every one. Smallpox as a disease involving loss of life, would disappear from our midst.
|Source:||The AMERICAN HOMOEOPATHIC REVIEW Vol. 01 No. 05, 1859, pages 214-230|
|Author:||Joslin, B.F. Jr.|
|Editing:||errors only; interlinks; formatting|