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Provincial Medical &Surgical JournalSource: Provincial Medical and Surgical Journal (1840-1842), Vol. 1, No. 24 (Mar. 13, 1841), pp.393-395Published by: BMJStable URL: http://www.jstor.org/stable/25490187 .

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SIMAIL-POX ;AND- VACCINATION.

tlleir power-over this portion of the bone, which, on the continuance of -traction, smnks doivn, and assumes-its natural position, in relstios to the tlong axis of the bone. - If by this means the broken ends of the bone are brought into nice apposition, (more particularly if the fracture is iU a transverse direction,) and so retained by Boyer's, or any other extending apparatus, an excurvation of the fractured part will generally etitue. Why this takes place it is ditl cult to say; probably it is in consequience of the naturally ourved shape: of the healthy, bone giving it this tendency when broken.

To..prevent this I have been induced to adopt the appa ratus I am about to describe.- It. at least, has the merit of being very simple, and may, perhaps, answer otlier indica tions in the treatment of these accidents.' - I generally use

awplint- bout five feet long, on. the principle of -Bdwer's, hlving attached near its-extretnity a leatbr shoe: working on an endless screw, by wlich the exteniinw ip,rqgul*t#t. It differs from it, however, in being somewhat brosder and tlhicker, to prevent the lateral thllgli splint Wfien tapplied, pressing it-outwards, and so ultimately warping it. -t has,' in,additioTn a softy-padded crutchl-banid, with a sstrj atid buckle, admitting-of more easy 'and gradutita-d rkgftln thIan the padded. handkerchief commonly in. use. -Tal9ing a plint made, in this manner, I ascertaiu as nearly as pos sible what part of it would lie along the outside of the tlhigh in a number of different individuals. To this part of the long splint the miner thiglh splint it attached in the following mannPer:-.four lrass nuts with female screws are let in-, aleng- the central.axis- of the long splint, situated about two inxches and a hialf apart, and extendilig though its whole thickness. -In these nuts are made to work four thum'b screws, the tuir,ed ends of which project when

wvorking through - the long splint, and are received into ftor holes drilled- in bras", awni fixed on the outer side of the shoil spluit to be -ued for thie irtward pressure. Thlis inner splt' is abou*t .eleven .inchs ioig,and slightly-hol lowed on its ininer side. ;The nmsnwx ef -its applicaion is as 4)lewts .exteonsn having bowproduced- by: means of the lcing extnding screw acting upon the fdot, secured to the'shopipce- the short spliit is'praced on the outside of the thigh between it- an* A6e l6&g splint; the thumb srws are then worked, and their ends are received into the brass holes in. tle back of the slort splint, and thus, by 'coutinuing the screwing, this splint is pressed iniwards towards the thigh, until the requisite degree of pressure is produted. It is generally necessary to use two of tjie screws only. - Should it 4e necessary -to 61ift the sJOrt splint uipwards or dow'nwards -along the 'lhih, the sciws are made to work inr-the two upper or lower holes, as Xy be required, and in -wsay, a ranige of sevren inches at each en4 y; e,pbtaind5 j.and - u4ua it;iZym . *ayajy be ada'p dp_,,-oqeractureat' 'anyA:' -IX, pyt {of the v > bio t adaplaWo'n, de. lon 'I tslnt soud be so finnt1y fiS1dto tbe tkjgll, ate'and b7elom tlae ~fracture, as to prevent its teing t:o Much.preised out - by the actions of ilte thumb

-194 Vwr: it isv.pce4ingly difficult to. give an-y thing tlR,e au iut -litil; dscriptiqn of o,ny kind of sur

gi0 I rine4hau owi, owerer simple. i aybe. n Ad therefore beg t fstitfe, thiat the apparats ncireat is intended to pieAuoe.lateral pressiure on the outsife - of the thigh, and tb4tJustaL1n_smuLawa_r that-any similars apparatus has ever b,ef ex es4. .I believe it to be well calculated to a ger tug, cL i -tendod wxd as I am not able at present to prnocure a dparxin of it, -I hae requested Mr. Lasdy,

who whasiiuch 0leaae1 Ihen he saw i, to show it to any gne 'man wtho may wish to see it

fj - * - -

CQU41. AP?V#NTu6XT..T-Rabert Keate, Esq. has been appointed SeieanDt-Surgeon in ordinary to her Majesty, in the room of the late Sir-Astley Pastoll Cooper, Bat.

PROVINCIAL

MEDICAL & SURGICAL JOURNAL.

SATURDAY, MARCH 13, 1841.

AT the present juncture, when small-pox is so widely spread, and once again inflicting its ravages in many parts of the country, any authentic information respecting its progress becomes doubly worthy of attentioni. In the brie report of the Small-pox and Vaccination Hospital for the year 1840, drawvn up by Dr. Gregory, we find matter for serious reflection; and although we do not altoager coin cide witlh the author in some of the inferences which he seems disposed to draw, the questions to which the report gives rise are of such, rdal importance, that the most-care ful consideration should be given to any auithentic state

ments which may-bear upon them. Dr. Gregory embodies some of the' resulis observed in the lhospital in the tabular forisnd inirtiin the report their tables; the first show ing the lntQle of p1atients admitted in to the hospital dt4ng the yf %r,itli e deatlhs and recov-rhs' - Oe second showitig tile ages of the patients having sin-pox, the deathis and recoveries being also indicated; aiiA Ie third, the number of vaccinations performed at the Iictal, and of those who have been gratuitously supplied ;W vaccine lympb.;

The two first of these tables we insert here, as we shiall lhave occasion to refer to them

Admlitted. Died. Recovered.

Patient whlolly -unprotected 194- 87 107 previoustly vaccinated...... .. 120 8 112 suppose to have pro'

viously undergoie 2 0 3

not havinglpx..:?.. 11

. -

TOTAL ...4. ''_,*.... 327 95 232

PateI :t. Admitted. | Iied. Recovered.

Patienitsunder tlve years of age 48 28 20 ` .bt*esfive-af tifteeR

, years of age iniclu- 44 9 35 dive .

Adults .. f + # ; .......... 224 58 160

TOTAL ... . 316 95 221

D'ductlng the eleven cases which proved not to be small-pox, we l,ave 316 patients admitted labouring uuder that disease; of which number 120 had been vaccinated, 2 are supposed to lave previously gone through small-pox, and 194 were altogether unprotected. The proportion, tberefore, of the previously vaccinated to the uniprotected

was about three to iv e, or 38 per cenit. of the total nunmber of small-pox cases. Dr. Gregory expresses the opinion that this prpoportion (tlhe same which has existed for many, years at the hospital) has probably some reference to the actual nuimber raccinated anid unvaceinated now living in this country. If, by this statement, it is meant to be iu ferred that the proportion of the vaccinated in London, or throughout England, is that wMhich is here indicated, namely, 38 per cent. of the wlhole populationi, it would fol low tlhat5 in respect of conft,rring actual immniii1ity from thle

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- SM4 PX 4AVp V4CCIVWTlN.

attacks of small-pox, the powers of yaccination are abso lutely null. We presumne, however, that it is intended that, of a trtain relative proportion of raccinatec and' 0

vaccinatel persons, suclh as now obtains in this country, whatever that proportion may be, the sufferers from small pox are in thte ratio of three of the fornmer to five of the later. This st4tement, even suppQ?ing it to be correct, conveys po. acoual inforn0jtjon is thte relative liability of tlw one or otlher plos Qf persons to the disease. If "Pe proportior of the vaccinated to the iinv#ccinated be three to five, and the proportion of those attacked with smnall pov be the same, tt4e influence of vaccination on the lia bility to tJe dis4ae, as wq h4ve before remarked, is null; if the prpportion of the vaccirtated to the iinvaccinated he veater Pian three to five, a degree of ivrmmnity cor respondirg to She actual excess of the vaccinated over the ratio jndicated by Dr. Gregory it conferred. In any case the ingtrenc may be drawn, on the supppsition that Dr. (6re,nry's :atio is AmTrect, that at least 38 per cent. of the

popplati o? Lon1pp are vaccinated, siacp nwqs, we be lipre, will be fpwus to ponten4 that vaccination develops an inerepsed. liability to Oma11-pox. It is pufliciently .obvioigs, however, that the data collected by Dr. Gregory c4R Pord only very imperfect tneans for the determina. tiou of the protacting powers of vaccination. Tley are

n,kher so4ffcienOy extensive, por do they include thoso elements wlicil are indispensably. necessary to render thelA of v4,ue for statistical purposes. We cannot, there fore, regard the assumption-that the relative numbers of the cases of variola occurring after vacciniation, and in the

wlholly unprotected, treated in the Small-pox Hospital, bear any reference tq the actual numbers of the vaccinated and uinvaccinated now living in this country, as being fouinded upon sufficient grounds' In the absence of de finite information, it would be impossible to assign the actual cause of the large proportion of cases After vacci nation amoing thte smal-pox prtieats received into the hos pital, though it will be seen in the sequel that, this fact, taken by itself, affords no ground for questioning the

general efficacy of vaccitiation as a protective power. It shlould, however, be here stated that this high proportion of sinall-pox after vaccinationi is scarcely in accordance with the experience of most of tho*e who have hag tlh opportunity of forming a correct opinion. But, whatever may be the degree of immunity afforded by vaccination against thle attacks of small-pox, the protective power of this process iu modifying the severity and 4imninishing tlhe danger of the disease is very apparenit. Of the 120 cases occurring after vaccination, the greater numnber, we are inforined, w.ere mild, atnd assurned the modified or variotoid form. Some, however, were severe, and eiliht terminated fatally. Of the eight fatal caMes, one was from erysipe?a and seven were froin the acknowledged efects of sm^a;pox, aftbrding the proportion of one in seventeen, or not quite siX per cent. Of the wholly unprotected cases, elgtit-seven out of 194, that is, forty-five per cent. OF neatly one-half, terminated fatally. 'The total number oV'atiehts with small-pox amounted to 316, of whom 95 died, being, 's Drt.Gregory states, in the proportion of thirty out of every hbndred, the averan,e mortality of smn&i-#Pdi in this and mbst other coun'tries. But this averae includes tie vaecinated as well as the wholly un protected, and consequently, however the severity and danger of the disease may have been lessened in the

former cla, t4ie geqeral rests poq the law of mor t4!ity wo04d aPt see to be afifcted This is a gQaqlWsion

which, taken in coanexion with the idea thrown out by Dr. Gtegory, that the records of the hospital may probably afford an indication of what occurs in the coantry gene rally; requires careful investigation. For our owni part, we are by no mgans inclined to take so ulnfavourable a view as those records would sgem to ji4rstify, and we much question whethler the general experience of the profession will bear out the statement either in respect of the pro portionate prevalence of the small-pox in the vaccinated and the unvaccinated, or of its relative mortality in the cases belonging to the former class. Of 310 cases of var4o loi4 diease, or mqdified small-pox, occurring in the vacci nated, and cominig within the knowledge of Dr. John

Thoinson, of Edinburgh, in one only did the disease prove fatal. The testimopy of other observers during the same epidemic quoted by this writer is to the sname effect, while, of 71 pernons attacked who had previousy passed tlrough smll-x, three died of the secondary disease.

We could refer to numerous resent instances of the occurrence of small-pox, amongst wiich the cases after vaccination are rare, certainly by no means in the propor tion of two to five; and no authentic fata4 case of this de scription froul the actual effects of small-pox has comc to our knowledge. Still the facts brought forward by Dr. Gregory demaind the closest scrutiny, and it is much to be desired that some means were devised to procure data upon wlhich to found definite conclusions of a more extenisire and less partial clpaacter. Amonig the points *risiirg out of the repot Whicl require elt;cidation are, first, the num ber of the vaccinated and unvaccinated in a givent extent of population; secondly, the number of cases of small-pox occturring in both classes within a certain period in the same population; tbirdly, the number of deaths from the die, distinguisl4jg in like iannar ho owcurring in the vaccinated and in the un-vaneinated. T'hese data

might be obtained witholt much difficulty in any distriet of limited extent in which small-pox has been recently prevalent, at least so as to arrive at such an approximation to the truth as would eiable us to form a morw correct estinmate of the protective powers of the vaccine than we at present possess. Another view of a more encouraging character may, however, be taken of' the proposition brought forard4 by Dr. Gregory. Admpitting hi prin ciple of the relation borne between the Snlahl-pox Jqspal and the country generally, in reference Ip thp prpportions of the vaccipatld nd thte unvaecinated whoi become the subjects of small-pox, the high proportion of the vaccinated cases may be owing, as a necessary consequence, to the great extent of vaccination. Were every incdivi4a to go through the cow-pock, it is obv!ous that the smrlt-pox, if it prevailed at all, copld only appear in tq vacwciated the greater ?hR propption, tl)erefore, that the vacoinated bear to tlh unvaecinated, whatever may he the absoluto ratio of prevalence of small-pox after *accinatlon, the higher Will be the a pparent proportion in tlle vweiated class in kelation to tte urtynccinatpd- ? q o l if pf every hundred persons ninety are raccinated, and one in ten of the vacciniated are liable to become the subjects of small-pox, wlhile one in ten of the unprotected sball resist the disease, the actul numbers of each category ittacked during 4 goneral small-pox epidemtIc would be tfisame.-a nine of the vaccinated and ine of the unvaccinated in

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. MEDICAL CONFERENCE. 39g every hundred of the population exposed to the influerice. Undttr such circumstances it might be presumed that the vaccination had been kept up with some degree of regu larity, and that, consequently, the unvaccinated indiv'iduals wotild be found cihiefly among the chiildren, and the case.s of small-pox after vaccination in those of more advanced age. This supposition agrees with what is actually ob scrved in the Small-pox Hospital, as the followiug state

ment, expl4natory of the secornd table, tends to show: "The number of children admitted into the hospital has been larger, in 1840, thian usual, amouinting, as will be seeni in table 2, to nearly one sixfh of the whole. The mor tality at this early age is always very, large; more than half the number perished. Between the ages of five and fifteen, the number of admissions was nearly the same, but the mortality was here reduced from 56 per cent. to 20 per cent. Adults formed, as they have ever done, the bulk of the patients admitted into the hospital. Out of 316 ad

miissions, 224 were adults, of whom 58 died, being in the proportion of 26 per cent. Thiis very moderate rate of mortality must be attributed, in a great degree, to the cir cumstance that the largest proportion of those who took small-pox after vaccination were adults between the ages of 16 and 32."

'TIe relativelv high proportipn of small-pox cases after vaccination, therefore, taken as an isolated fact, if it proves anything, would seem to favour the idea that the spread of vaccination lhas beeni probably more extensive than had been previousjy supposed. In the absence, however, of nore definite informationi, great uncertainty must prevail ou this point, and on many otllers of equatl importance to the attaiuing of correct views; and the necessity of insti tuting such inquiries as may tend to clhar up the difficul ties in wlichl these points are at present involved is clearly inidicated. An active medical commission, appointed to investigate this question in different parts of the metropolis and in some of our larger towns, would be enabled, -in the

coutse of a short time) end at no great cost to the public,

to obtain facts from which definite infonnation as to the real value of vaccination might be obtained; and as pro

vision is now made for the performance 'of the operation at the public expense, it is but fitting, even in. an economical

Wansit of view, that the amount of prttection afforded

slhould be correctly ascertained. It-is a subject in, which the wlhole community is deeply interested, and one upon which the government ought to take every practicable

neans to arrive at correct knowledge. Madny foreigrn states

liave instituted searching inquiries into the whole subject of vaccination; and it is a disgrace to the country to whieh

it owes its origin, that so much apathy should prevail, and that so little should be sttemnpted on the part of those in authority to ascertain the actual value of a process which they h4ye legally recognized.

- THE MEDICAL CONFERENCE.

Tijs letter of Mr- Carter, whiclh we publislhed in the last wmner of the PROVINCIAL JOURNAL, and the comiiiu ication fr!p Mr. Wickham, in our present number, re

quhire fr9m ts a few words of explanation. The difireiice of opini9n betwjpea ourselves and our colleagues in the Cont'ereuce cai be reconciled in the most simple manner. Our remarks applied to the constitution and acts of the Conference, dturing the firstfour days of ih existence; the

observations of Mr. Carter and Mr. Wickham refer to the composition and proceedings of the Conference subse quently to that period, when tbe arrival of the Irish dole gates, the persevering watclhfulness of Mr. Carter, and the retiremnent of some of the Provincial delegates, had very materially altered the tone of certain parties, and led to the adoption of priniciples which we shall willingly sus tain witlh whatever influence we may possess. The me,ical profession is already so muz1 divided against itself, tha3 any disunion amongst those wlho profess to regenerate us by a general fusion into one faculty should be carefully avoided; but,,called upon as we are by the remnarks of' Mlr. Carter and Mr. Wickhatn, gentlemen for wlhom we entertain the highest respect, we feel compelled Xo state a few facts in our own justification.

We lhave stated that, in constituitioni, the Conference was faulty, because an undue preponderance was given to one association. We have now before Its the names of the gentlemen who attended durinig the/irstfour days, and we find tlhat, at the first meeting, of thirteeni memJners, nine were from the Council of the Britisl Medical Association; at the second imeeting, of fourteen members, eight were trom the same council; at the third meeting, of fourtee

members, nine were from Dr. Webster's council; and at the fourth meeting, of thirteen memnbers, nine were from the saine council. We lhere state simple facts, without inquliring into causes.

Wl'e also lhave objected to certain proceedings of the Conference during the first four meetiags. The grounds of our objection are readily stated and can be as readily appreciated. A laudable qualm of conscience induced one of the members, at the first meeting, to propose that no question whiich might come before the Coniference slhould be decided by individual voting, but thiat every gentlem-an should deliver his opinion, anid that dissentients might eniter protests. The reasoni for making this proposal waa obvious enough, and it was adopted, althiough it led to. the manifest absurdity of incapacitating the Conference from coming to a decision upon aiy single point submitted to it. The general principles of Medical Reform having been discussed, Dr. Heninis Green, in conformity with -an in struction forwarded from the Proxincial Medical Associa tion, proposed the following resolution, which was seconded by Mr. Carter, viz. "'TIhat, in the opinion of this meeting, it is expedient that existing institutiots be respected, pro vided their existence can be rendered compatible with uniformity of qualificationi, equality of privilege to praeti.s ne(licine, and a fair system of representativegovernment."

Trhis very conciliatory proposition was opposed, and anl amiendment tlaereuuto mioved by Dr. Marshall Hall. We do not complain of this; but wlhat we then objected toj and lhave subsequently condemned, was the violatioi ot the fiundamental rule laid down by the Conference at its first mneetitg. The amrzendment of Dr. Hall wes put to the

vote; the tiaines of those wlho voted for it were takeit

down, and it wns found that the original proposition was rejected by a majority of six to three. T'lhat there nmay be iio possible mnistake upon this point, we here -give the

namles of the voters as they were taken do& n at the timiie. For Dr. Green's.resolution, Dr. Macartniey, Mr. Carter, Dr. Green: for Dr. Ilall's amendment,- Dr. Webster, Dr. R. D. Thomson, Dr. M. Hall, Mr. Farr, Mr. Evans, Mr. Davidson. We have since been gravely assured, that this was not roting; but if the carrying an amend

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