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afdc4551-a788-4db7-af6e-dc329ddb3027 | We think those who have denied the efficacy of vaccination have often lost sight of the circumstance that investigations, which have followed so many different roads, have all led to the same end. We have not disregarded the arguments adduced for the purpose of showing that a belief in vaccination is unsupported by a just view of the facts. We have endeavoured to give full weight to them. Having done so, it has appeared to us impossible to resist the conclusion that vaccination has a protective effect in relation to Small-Pox. We think— 1. That it diminishes the liability to be attacked by the disease. 140 2 That it modifies the character of the disease, and renders it (a) less fatal, and (b) of a milder or less severe type. 3. That the protection it affords against attacks of the disease is greatest during the years immediately succeeding the operation of vaccination. It is impossible to fix with precision the length of this period of highest protection. |
eb12db56-8905-4d9d-98c7-aeff86cc4430 | Though not in all cases the same, if a period is to be fixed, it might, we think, fairly be said to cover in general a period of nine or ten years. 4 That after the lapse of the period of highest protective potency, the efficacy of vaccination to protect against attack rapidly diminishes, but that it is still considerable in the next quinquennium, and possibly never altogether ceases. 5. That its power to modify the character of the disease is also greatest in the period in which its power to protect from attack is greatest, but that its power thus to modify the disease does not diminish as rapidly as its protective influence against attacks, and its efficacy during the latter periods of life to modify the disease is still very considerable. 6. That re-vaccination restores the protection which lapse of time has diminished, but the evidence shows that this protection again diminishes, and that, to ensure the highest degree of protection which vaccination can give, the operation should be at intervals repeated. 7. |
64827b1d-9123-4783-9a56-2d2158052c00 | That the beneficial effects of vaccination are most experienced by those in whose case it has been most thorough. We think it may fairly be concluded that where the vaccine matter is inserted in three or four places, it is more effectual than when introduced into one or two places only—and that if the vaccination marks are of an area of half a square inch, they indicate a better state of protection than if their area be at all considerably below this. 141 (B.) As to the objections made to vaccination on the ground of injurious effects alleged to result therefrom; and the nature and extent of any injurions effects which do, in fact, so result. We proceed to address ourselves now to another subject submitted to us, viz., "the objections made to vaccination on the ground of injurious effects alleged to result therefrom; and the nature and extent of any injurious effects which do, in fact, so result." This is obviously a matter of great importance. |
c8f9eb8e-0087-4661-bbdb-de25e404508b | Not only has the utility of vaccination been denied, but it has been asserted that mischievous effects have been due to it, resulting in personal injury and in the loss of life. If the practice has been productive of substantial benefit in limiting the ravages of Small-Pox, and mitigating the severity of the disease, the fact that vaccination may lead in certain cases to personal injury or death, would, of course, not be a conclusive argument against its use. Danger of personal injury, and even of death, attends many of the most common incidents of life, but experience has shown the risk to be so small that it is every day disregarded. A railway journey or a walk in the streets of any large town certainly involves such risks, but they are not deemed serious enough to induce anyone to refrain from that mode of travelling or from frequenting the public streets. |
e6f75bb9-e7a6-4fdc-8fd7-7d22767c8c0a | And to come within the region of therapeutics, it cannot be denied that a risk attaches in every case where chloroform is administered; it is nevertheless constantly resorted to, where the only object is to escape temporary pain. The admission, therefore, that some risk attaches to the operation of vaccination, an admission which must without hesitation be made, does not necessarily afford an argument of any cogency against the practice, if its consequences be on the whole beneficial and important, the risk may be so small that it is reasonable to disregard it. Everything depends, then, upon the extent and character of the risk. Those who have assailed vaccination on the ground of the 142 evil consequences which are said to flow from it, have adopted two lines of attack. They have asserted that evidence of its mischievous influence is to be traced in an increase in the number of deaths from certain specified diseases, corresponding with a spread of the practice of vaccination, of which increase vaccination was, they alleged, really the cause. |
199a6805-6029-47c5-be7c-e3b41c86aae1 | They have further insisted that evidence of the evil effects it produces is furnished by an examination of particular cases in which it has been found that injury or death has resulted from the operation. We shall examine in the first place the contention, that the records of mortality, show an increase in the deaths from certain diseases during periods of extensive vaccination, when compared with those when the practice was less in use, and that it may be fairly inferred, from this comparison, that vaccination was the cause of that increase. It is to be observed, that the diseases selected for such a comparison by the opponents of vaccination have not always been the same. In 1877, a return was obtained by an Order of the House of Commons, showing the deaths from 14 diseases at three periods, viz., 1847-1853, 1864-1867, 1868 to 1875; these periods having been regarded as distinguished from one another by a progressive advance in the number of vaccinated persons, especially children. |
4a3a1102-2246-4b28-b935-7987f7adb5ac | The diseases were, Tabes Mesenterica, Diarrhoea, Bronchitis, Pyaemia, Skin Disease, Syphilis, Convulsions, Cholera, Diphtheria, Pneumonia, Atrophy and Debility, Whooping Cough, Erysipelas, Scrofula. The first six of theses diseases showed an increasing, the next four a decreasing, mortality, whilst the remaining four exhibited an irregular mortality, there being in three cases an increase in the second period, and a decrease in the third, and in another case a decrease in the second, but a slight increase in the third, when, however, the mortality was not so high as in the first period. When all the diseases were taken together, there 143 appeared to be in the aggregate an increasing mortality. Some found in this circumstance, evidence of the malign influence of vaccination. Such a conclusion is manifestly untenable. |
1dd1cd7f-a984-4d6f-a224-d2877fa6058e | There was no more reason for attributing to vaccination the increase of mortality in the case of those diseases where the mortality had grown, than there was for asserting that to its beneficent influence was due the decrease of mortality in those cases in which the mortality had become less. The hypothesis that it caused the mortality in some instances to grow, and in other instances to decrease, and that it was responsible for the balance of increase shown on an aggregation of the two, does not merit serious attention. It is not as if all the diseases in the class showing an increasing mortality were such as could be deemed capable of being affected by vaccination, whilst those included in the class with a decreasing mortality, were in a different category. Two of the diseases included in this latter class, viz., Convulsions and Pneumonia, have been regarded in particular cases, even on recent occasions, as having had their origin in vaccination. Dr. |
76763654-459d-4e73-9d48-8980b1525dcd | Ogle, in statistics drawn from the Reports of the Registrar-General for England and Wales, points out that the line of reasoning which had been considered by some sufficient to show that vaccination has produced in those who have been subject to it, serious diseases, would equally serve to show that it has rendered them largely exempt from other diseases no less serious. He gives, as an example, the mortality from Phthisis, Pneumonia, Convulsions, and from causes not ascertained or stated too vaguely for classification, and shows that, in each case, there has been a large decrease of mortality during the period from 1874 to 1891. He does not, of course, suggest that vaccination has been the cause of this decrease, but he asks, and we think the question a pertinent one, why it should be credited with the increase of diseases which have increased, and not equally be credited with the decrease where the mortality has diminished. |
70cc12bf-73ef-4f0b-99bf-11e74406ac06 | We will refer now specifically to the principal diseases, an 144 increase in the mortality from which is at the present day charged against vaccination. Before doing so, it will be well to enquire whether infant mortality has shown an increase during the period into which we are enquiring. Vaccination is, in the vast majority of cases co-incident in point of time with this stage of life. If, then, it is the parent of other diseases, and has substantially augmented the number of deaths due to them, we should expect to see some effect produced on infant mortality as a whole, yet it is clear that the mortality of infants in the first year of life, as measured by the proportion of their deaths to births, has not increased at all during the times when infant vaccination has been increasing. |
cc5cdd7f-3c23-4043-836e-c7593f3dee32 | The figures show that from 1838 to 1842 the annual infantile death-rate to one thousand births was 152; from 1847 to 1850 it was 154 ; in the million births in Leicester on the one hand, and in England and Wales on the other. The Registrar-General has supplied us with the means of comparing the deaths in the period 1863-1867 with those in the period 18831887. We have already seen that the latter years were marked by a great decrease in the practice of vaccination amounting at last to a practical disuse of it. If vaccination were, to any serious extent, a cause of syphilis, we should have expected to see some evidence of it in these comparative records of the mortality of infants under one year of age. |
c30b83d9-84c5-4d33-a155-0c9758e2d748 | Yet we find that whereas in England and Wales there was as between the former period and the latter an increase in the infant mortality from syphilis in England and Wales of 24.7 per cent, only, the increase between the same periods in Leicester was no less than 69.3 per cent. This does not, of course, imply any connection between the disuse of vaccination and the increase of infantile syphilis. It does, however, conclusively rebut the argument of those who seek to connect the increase of mortality from syphilis with the practice of vaccination. It has been observed that the comparison is made between Leicester, which is an urban population, and the whole of England and Wales, which would comprise a large rural population. This 145 is no doubt true, but it is true for both periods alike. |
f25f95e8-2f24-456f-974b-d85c2549b29b | It does not appear to us materially to vitiate the comparison for the purpose of disproving the allegation that the great increase of syphilis during the last twenty years is due to vaccination. Even if it can be shown that in some instances syphilis has been inoculated by vaccination, the conclusion would still remain that this cannot have been so to any substantial extent. We take next Cancer. There can be no doubt that the mortality from Cancer shown by the registered causes of deaths has considerably increased in recent years. This disease is, it must be remembered, one to which persons of advanced years are specially subject. The young are seldom its victims. And the increase of mortality from it has, for the most part, affected adults and principally old people. There has been an actual decrease in the mortality from the disease of those under five years of age. |
843d3a0c-6115-47aa-9c2a-f3bdb1ad93a6 | It may well be that in some cases vaccinated children have suffered fatally from Erysipelas who, but for the operation of vaccination, would not have been attacked by the disease. This is a point we shall have to consider presently. But the evidence is, in our opinion, conclusive to show that there has not been during the last forty years any material increase of deaths from Erysipelas owing to vaccination. Passing on to tabes mesenterica and scrofula, we find that the mortality from these diseases, as returned to the RegistrarGeneral, shows an increase during the last forty years. On the other hand, the mortality from allied diseases, such as Hydrocephalus and Phthisis shows a decrease. |
9209ebd3-5217-4213-9681-cdfe99a22675 | Some part, and it is impossible to say how much, of this increased mortality in the case of the two first-named diseases, and of the decrease in the two last-named, is apparent only and not real, and results no doubt from better diagnosis leading to a transfer of cases from one class to another. On this point again it is useful to resort to the experience of Leicester. The increase of deaths under one year J 146 from tabes mesenterica and scrofula per million births in Leicester during the years 1883-87, as compared with the years 1863-67, was 25.8 per cent. A similar comparison for England and Wales shows a per-centage of 26.8 per cent. We do not find any facts to warrant the assertion that the increased mortality from tabes mesenterica and scrofula, or any part of it, was due to vaccination. |
0e22c12b-74d0-4bbb-aa1f-f63f8e77736a | Without encumbering our report with the details relating to Pyaemia, Bronchitis, Diarrhoea, and Skin Diseases, which are all said to have increased owing to the mischievous influence of vaccination, we may confidently say that there is no evidence to justify the statement. It is, however, worth while pointing out that comparing, as before, the period of 1883-87 with the period of 1863.67, the increase of deaths under one year of age from Diarrhœa and Dysentery in Leicester was 4.2 per cent., whereas in England and Wales it was 0.5 per cent. A similar comparison in respect of Bronchitis shows the increase in Leicester to be 112.8 per cent., in England and Wales 73.3 per cent. It seems clear that as regards general infantile mortality Leicester has not gained by its avoidance of vaccination. |
e33213ca-10f5-48ee-b12a-dfc193943e5c | Whilst in England and Wales the mortality of children under one year of age had between the periods selected for comparison decreased 7.5 per cent., in Leicester the decrease was only 2.8 per cent. Upon the whole, then, we think that the evidence is overwhelming to show that, in the case of some of the diseases referred to, vaccination cannot have produced any effect upon the mortality from them, and that it has not in the case of any one of them increased the mortality to a substantial, we might even say an appreciable, extent. When we pass to a consideration of the evidence that personal injury or death has resulted from vaccination, the questions which present themselves do not admit of the same simple solution as those with which we have just been dealing. The cause of death, 147 or the nature of an illness, is sometimes obscure, and even if its nature be known, it may be difficult to ascertain with certainty what has been its origin. |
df0bc5c4-983c-4e25-b1c1-c8dda454bec1 | We shall have to make further reference presently to the difficulties which must needs be encountered in the investigation upon which we are engaged. As we have already stated, it is not open to doubt that there have been cases in which injury and death have resulted from vaccination. In the years 1859-67 the deaths returned as due to erysipelas after vaccination varied from 2 to 13; the annual average being 6.8. From 1868-71 inclusive they varied from 9 to 24; the annual average being 18.0. From 1859-71 the population of England and Wales had increased from 19 to 22 millions. Inaddition to this there can be no doubt that the number of children vaccinated increased very much between 1868 and 1871, as compared with the previous period, owing to the legislation of 1867. |
b5480616-375e-4853-815e-1f1792670d12 | Of course, the greater the number of the vaccinated amongst the children born in any given period the greater, cateris paribus, would be the number of cases of erysipelas after vaccination, without any necessary connection between the two. The same remark applies to the period between 1872 and 1880, when the cases returned as erysipelas after vaccination varied from 16 to 39 ; the annual average being 28.5. The Act of 1871 undoubtedly increased largely the number of infantile vaccinations in this period as compared with that which preceded it. In subsequent years erysipelas after vaccination was not separately recorded, being included under the heading "cow-pox and other effects of vaccination." There were 283 such cases in the years 1881-1885. During the years 1886 to 1891 the cause of death was in 279 cases certified as connected with vaccination. Many of these cases were the subject of special inquiry by the Local Government Board. |
b5bdf25e-c6e3-4e17-8e99-f14bf1ca0f49 | We have had before us a summary of the reports made to the Board of the results of such inquiries, prepared for us by Dr. Acland and Dr. Coupland. The reports referred to cover the period from the 1st of November, 1888, to the 30th of November, 148 1891. We have ourselves, in many instances, instituted independent inquiry. The cases in which the death has been certified as connected with vaccination cannot all be regarded as cases in which there was the link of causation between them. Indeed, the medical men whose certificates associated the two did not always intend to indicate that the disease which ended in death had its origin in vaccination. There have, no doubt, been other cases in which, although the illness which ended fatally was engendered by vaccination, there has been no mention of it in the certificate of death. |
5cfcd2cc-d709-4a68-90d5-7bf855ccb204 | Whether these are sufficient in number to counterbalance, or more than counterbalance those in the other category, the evidence does not enable us to say. Taking for the moment the 279 deaths during the years 1886 to 1891, certified as connected with vaccination, to have been really so connected, how does this figure compare with the number of vaccinations effected during the same period. The number of primary vaccinations during the years 1890 and 1891 were not put before us by Dr. Ogle; they had not then been published. He stated, however, that in the years 1881 to 1889, inclusive, the number of deaths certified as connected with vaccination was 476. During those years there were 6,739,902 primary vaccinations, showing the proportion of one death to 14,159 primary vaccinations. There is, no doubt, that for the years 1886-91, it was not substantially different. |
25222c12-3ac3-44c7-aa3f-f395c4a15069 | For the reasons stated in the preceding paragraph it is not possible to fix with absolute certainty the number of deaths connected with vaccination. Since the first of June, 1889, we have, from time to time, been informed from various sources of cases in which death or non-fatal injury has been alleged or suggested to have been caused by, or otherwise connected with vaccination with a view to their investigation, and since the 14th of February, 1891, the Local Government Board have immediately informed us of all such cases brought to their notice. In March, 1892, the Home Office addressed a circular 149 letter to coroners throughout England and Wales, requesting that in all cases where they received information that the death of any person, on whose body they proposed to hold an inquest, had been alleged to have been caused by, or to have had any connection with, vaccination they would communicate immediately with the Commission. |
51ba49ab-0517-4ca1-bce1-327bde3beb50 | From all sources 421 cases in which death or non-fatal injury has been alleged or suggested to have been connected with vaccination, have been brought to our notice, from 1st June, 1889, to 1st July, 1896. These 421 cases, however, include 19 groups of connected cases, each of which has only been counted as one in arriving at that number. The individual cases included in these groups amount to about 150. Some of these 421 cases were investigated and made the subject of reports by medical inspectors of the Local Government Board. We received reports with reference to a large number of them from medical men appointed by ourselves. In a few cases the nature of the allegation or suggestion rendered it unnecessary, in our opinion, to make any inquiry into the case. |
4fbbe9ed-440e-4941-85c6-be70f96d5fe1 | In a considerable number we sought for further information, and after we had considered the further facts thus acquired there appeared to be no necessity for an investigation by the medical men who assisted us by personally inquiring into cases of alleged injury from vaccination. We have not any means of ascertaining in what number of cases some other disease has supervened on vaccination as a consequence of it, without producing a fatal result. We are able, however, to form some judgment upon this point by observing the number of non-fatal cases to which our attention has been called. We do not mean to suggest that we have been informed of all cases of this nature which have occurred during the last six years. There have very likely been many cases which have not come to our knowledge, where the Inflammation set up has been more than usual, and some where a slight attack of Erysipelas has resulted. |
f0204d06-7b90-4a0e-ba7f-d82c05520cc3 | But when we consider that the fact that we were engaged upon 150 this inquiry has been thoroughly well known, and that active organisations and zealous individuals were at work, searching out cases in which the results of vaccination have been abnormal, with a view to bring them under our notice, and that some of those which we were asked to investigate turned out to be of a trifling or unsubstantial nature, we think we are able to form a fairly accurate estimate of the amount of injury which can be plausibly attributed to vaccination. A consideration of all the circumstances has led us to the conclusion that, as regards the non-fatal cases with which we are now dealing, serious injury cannot have resulted in any considerable number of cases. An examination of the analysis of the fatal maladies connected with vaccination during the period 1886 to 1891, made by Dr. Ogle, shows that Erysipelas is credited with almost onehalf of the total number of deaths. |
4e9ba733-7763-4814-9a9d-b9ed7a00d1ba | To these a considerable number is to be added, where inflamed arms occurred, but in which the disease did not receive the name of Erysipelas, though it was probably allied to it. Next in number comes the class, which includes Pyaemia, Septicaemia, and Blood Poisoning. If this class be added to cases of Erysipelas, and maladies allied to it, they account altogether for two-thirds of the cases in which the cause of death has been connected with vaccination. An examination of the particulars of the cases of alleged deaths and injury from vaccination, to which our attention has been called during the last six years, shows that the death or injury has been attributed in the great majority of cases to one or other of these diseases, and chiefly to Erysipelas. It must not be forgotten that the introduction into the system of even a mild virus, however carefully performed, is necessarily attended by the production of local inflammation and of febrile llness. |
a78f0b64-6bd6-4dc8-b8ab-f79fa78b1f7a | If these results did not in some measure follow, the practice would probably fail in its protective influence. As a rule, the inflammation and illness are of a trifling character; in exceptional cases, however, they may exhibit more severity, and, 151 as certain facts submitted to us in evidence have shown, there are cases, though these are rare, where a general eruption may follow vaccination. In order to determine how far the risk of Erysipelas is a necessary incident of vaccination, what is the extent of that risk, and how it may best be avoided, it is necessary to consider the various circumstances which may occasion Erysipelas and allied diseases in the case of vaccinated children. It is established that lymph contains organisms, and may contain those which, under certain circumstances, would be productive of Erysipelas. |
6f8173ea-9b86-4db1-89bf-3e5314273cb2 | It is, therefore, possible that some contagious material (the specific virus of erysipelas, for instance) may be conveyed at the time of vaccination, owing either to its presence in the lymph employed, or to its being conveyed by the vaccinator himself, or by those with whom the child comes in contact at the time of vaccination. We believe that the cases in which the virus is conveyed at the time of vaccination are rare. It has, however, in some instances, been clearly established, the immediate occurrence of Erysipelas in several co-vaccinees making it practically certain that some virus was conveyed at the time of the operation. In some instances, where this has been the case, and there is every reason for believing that the contagion was conveyed through the medium of the lymph; it is, nevertheless, in evidence that the vaccinifer did not display anything more than a slightly inflamed arm. |
c20a162e-9ee3-4950-9f25-e6226df3bdfa | The scrupulous avoidance of inflamed arms in vaccinifers will do much to reduce the risk of conveying erysipelas, in the act of vaccination (a risk which, as we have seen, has been proved to be a very slight one), but it is possible it would not wholly remove it. Where the contagious matter which produces Erysipelas, or blood poisoning, has not been conveyed at the time of vaccination, the disease must have resulted, when it afterwards displays itself, from a subsequent introduction or development of the poison. It is not always easy to determine whether vaccination has been the cause of, or has contributed to, subsequent 152 Erysipelas or blood poisoning. Erysipelas is a common disease in infancy, and not unfrequently leads to death. The evidence of Dr. Ogle shows that nearly two thousand per million die of Erysipelas during the first three months of life, and that the mortality rapidly declines as the age advances. |
eb5c95e3-59c6-4c31-ae80-27fb468c7592 | Quite apart, then, from vaccination there is nothing remarkable in the occurrence of Erysipelas in the case of an infant. The disease is obviously contracted in the majority of cases from some other source. Where a child has been in good health prior to vaccination, and is seized with any malady after it, it is not unnatural that the two occurrences should be connected together, as cause and effect by those who have not a wide experience of the liability to be attacked by the disease independently of vaccination. It is a common fault too readily to connect together, as cause and effect, occurences which follow one another in point of time. There can be no doubt that this tendency has sometimes been the reason why, without any real connexion between the two, subsequent illness has been believed to have its origin in vaccination. The apparent connexion of the two may be a mere chance coincidence. Illustrations of this have not been wanting. |
8e5c2c04-2401-409b-81db-544a2820900e | It has sometimes happened that circumstances have led to the vaccination being, on the day appointed for the operation, postponed to a later date. A troublesome skin disease has shortly afterwards manifested itself, which would certainly have been believed to have been caused by the vaccination if it had taken place at the appointed time. In many of the cases which we have had to investigate, where vaccination has been followed by Erysipelas, the disease has been present in the immediate vicinity, it cannot therefore be asserted with certainty that in such cases the child would have escaped Erysipelas if it had not been vaccinated. Erysipelas may be acquired without any lesion. |
00aa3787-64c9-4370-8bae-3ec9be15ca8f | We do not intend to represent that the wound made in vaccination may not cause an attack of Erysipelas, where, if there were no lesion, there would be no such 153 attack, but only to suggest that caution is necessary, and that it would be an error to refer all cases of Erysipelas, or allied diseases, occurring after vaccination to that operation as their cause. There can be no doubt that even very slight wounds may lead to Erysipelas. It has been induced by scratches from pins, abrasions from the dress and other injuries, in themselves most trivial. We propose to call attention to some of the features which have been observed in the cases we have investigated where Erysipelas has ensued upon, and in all probability been connected with, the act of vaccination. We have already said that in some of these cases, erysipelas was prevailing in the neighbourhood, and sometimes even in the immediate vicinity of the vaccinated child. |
66e23ea9-83e3-4ad3-8002-5fdc77f045c3 | In a considerable number it was reported that the condition of the premises in which the child was living was extremely insanitary. In some it was manifest that there had been a lack of care and attention on the part' of the mother or other person in charge of the child. Not unfrequently the wound was in contact with and rubbed by articles of dress very likely to cause inflammation, and cream and other substances were applied to the wounds under circumstances which made the process a source of danger. There were instances in which persons in the habit of nursing a vaccinated child were suffering themselves at the time from running sores, which were very likely the source of contagion. In some cases, too, where the vaccinated vesicles had been opened on the eighth day, Erysipelas manifested itself at a time which suggested that it had been acquired at a date subsequent to this opening of the vesicles. |
1c52ef67-0a54-4c31-8437-e5d306801f51 | A priori, this would appear to be a source of danger by rendering an attack of erysipelas more probable if the child came within the reach of contagion. The evidence, however, is not conclusive that Erysipelas has, owing to this cause, appeared more often than it would have done if the vesicles had remained unopened. There is an opinion abroad 154 that the taking away of lymph on the eighth day of itself causes some risk of inflammation of the arm. This, however, has not been confirmed by any evidence before us, and it is probable that it is almost wholly an imaginary danger. The evidence given in reference to cases in which one or other of the maladies classed as Scrofula has been supposed to have had its origin in vaccination, has usually been of a very vague and inconclusive character. |
77a9e190-1d73-4b5d-ab6e-21635e6b84c5 | Scrofula is a disease chiefly of childhood; and, being very common, there is nothing to cause surprise in the fact that occasionally children may show its presence in a manner likely to excite suspicion that it was due to vaccination. It may, indeed, easily be the fact that, vaccination, in common with Chicken-Pox, Measles, Small-Pox, and other specific Fevers, does occasionally serve as an exciting cause of a scrofulous outbreak. It may, however, not unreasonably be suspected that in all such cases a latent predisposition was already present. The chain of causation is so complicated that it is impossible in isolated cases to arrive at any satisfactory conclusions. To attempt any analysis of the evidence on this subject comprised in Appendix IX. and the various Reports which we have already issued would serve no useful purpose. |
cfc5bbd3-ffa6-44fb-a2b0-2b9a51e499b0 | It must be sufficient to say that after careful consideration of the whole evidence there appears to be no reason whatever to believe that the practice of vaccination tends in any material degree to increase the prevalence of this class of disorders. Precisely the same arguments as those just used are applicable to the chronic skin diseases, chiefly of the type of Eczema, which are so often, by the public, attributed to vaccination. Of these numerous supposed instances have been brought before us and the medical men whose assistance we have had. It is to be freely admitted that vaccinia, like varicella, does occasionally cause an irritable condition of the skin which may last long, but it is exceedingly improbable that it is responsible for any substantial increase in the number of chronic skin diseases in children. 155 No sufficient evidence whatever in support of such a conclusion has been brought before us. |
77fb5dc3-2031-46cc-9000-2fe6762f844e | Amongst the inconveniences connected with vaccination is the production of contagious forms of eruption, such as have been classed under the names of porrigo and impetigo contagiosa. These eruptions are not attended with any risk to life, nor by any permanent injury to health, and they are usually curable by simple measures. References to these eruptions have been made by many witnesses. Their occurrence has no doubt not unfrequently caused prejudice to the practice of vaccination. As has been already stated, the occurrence of a febrile illness is the desired result of vaccination. To that illness the term vaccinia is applicable, and it may sometimes be attended by an eruption. It is in evidence that vaccinators in the early years after the introduction of the practice, were familiar, not only with severely inflamed arms, but with the frequent occurrence of general eruptions. |
1bab6b29-8da8-459f-b6e7-8b12fccbf08f | Familiar as they, were with the horrors of Small-Pox itself, they thought very lightly of events which in the present day would cause much complaint and would excite opposition. The greater care now exercised in vaccination, and possibly above all, the much diminished risk of variolation at the same time, have reduced to a very small number indeed the occurrences referred to. Still it has not been found possible wholly to prevent them, and not only do vaccinators still meet occasionly with inflamed arms and Erysipelas, but now and then a case occurs of severe eruption attended by Fever, which may end in death. These cases occur exclusively in primary vaccinations and in young infants. They are so infrequent that no well-characterised examples have been brought under the notice of the medical men who have assisted us. A few which had occurred in former years have, however, been the subjects of evidence. |
3ff94837-a4f9-44bc-8de5-eb78b2a78371 | These cases may be placed in two groups, one in which the vaccination sores proceed normally, but a general eruption, possibly gangrenous, occurs and a second in which the pocks 156 inflame, and are attended by satellites, and a more limited eruption, possibly due only to external contagion, is produced. Of the first, only a single example is to be found in the reports (Case 31 : not fatal) before us, but of the second there have been several. One of the most definite of these latter is the case ably and fully reported in the evidence of Dr. Fyson and Dr. Frederick Taylor. In that instance a child previously in good health, and vaccinated with calf-lymph by means of a needle which had never been used before, died about six weeks afterwards with severely ulcerated arms, and ulcers in several parts of the body and limbs. |
5732c127-81f5-4d20-96d8-086e38fe8a2d | No precaution had been neglected, and the event could only, as in other similar cases, be attributed to what is known as idiosyncrasy on the part of the child, a peculiarity of health attended by exceptional susceptibility to the specific virus of vaccinia. Nothing has produced so deep an impression hostile to vaccination as the apprehension that syphilis may be communicated by it. It was at one time doubted whether syphilis could result, and it was even confidentially asserted that it could not. The fact that this was possible had been fully established, and was generally acknowledged by the medical profession before we commenced our enquiries. Our work has, therefore, chiefly been to ascertain the extent and character of the risk and the means of its prevention. As a general summary of the evidence on this matter, it may be stated that nothing in the least novel has been elicited, and that no hint has been given of the occurrence of any recent series of vaccination-spyhilis cases in British practice. |
86228572-c284-4848-8c2c-856ba022335a | In 1856, an extensive investigation undertaken by the Board of Health, under the direction of its Medical Adviser, resulted in the expression of an opinion that there was no proof that syphilis could be communicated in the practice of vaccination. Mr. Simon had issued circular letters of enquiry very widely, and although a few of his respondents had answered cautiously, none had been able to produce convincing facts, and a large majority had expressed entire credulity. Amongst the latter were Sir Thomas 157 Watson, Sir Charles Locock, Sir Benjamin Brodie, Mr. Acton, Mr. Marson, Mr. Ceely and Sir William Jenner. Facts which were, not long after the issue of Mr. |
7df7d6a2-9eab-492e-8ebb-cd4bc026c05f | Simon's report, brought before the profession, and which were carefully investigated, made it certain that the negative conclusion which had been arrived at was a mistaken one, and from that time no doubt can have been entertained by any that it is possible to convey syphilis in the act of vaccination. In reference to the frequency of this, the report just referred to is still, however, of high importance. It is impossible to believe that an event concerning the possibility of which almost the leaders of the profession were in 1856 incredulous can be otherwise than extremely rare. Before proceeding to speak of the facts, or supposed facts, as to syphilis due to vaccination, which have been brought before the Commission, it is necessary to advert to the difficulties of the inquiry. |
a56ee40f-de97-4cc4-a0c6-668e76115bd3 | The phenomena of syphilis may be closely approached by those of other disorders, and even when the nature of the malady is evident beyond doubt, there remain numerous sources of fallacy which have to be cleared away before the conclusion can be accepted that the disease has been caused by vaccination. The very close resemblance in certain very rare cases of the results of vaccination, whether with calf-lymph or humanized lymph, to those attributed to syphilis (a resemblance so close that it has caused in a few cases a difference of opinion whether the disease was syphilis or vaccinia) has led to the expression by Dr. Creighton of the opinion that there is some essential relationship between the two diseases. This, however, is a point of speculative, almost it might be said of transcendental pathology, upon which for practical purposes it is useless to enter. |
9a9eb6d2-d0ac-42c6-91bc-727d7a62e048 | It must be sufficient to remark that, whatever may be the relationship alluded to, it exists, if it exists at all, equally between Small-Pox and syphilis as between vaccination and syphilis. For all practical purposes variola and vaccinia are both wholly distinct from syphilis, and their differences are, with the rarest exceptions, 158 easily recognised. They are alike in being attended by affections of the skin and mucous membranes, and exceptionally by disease of the bones, eyes, and other parts, but in all these it is a question of resemblance and not of identity with which we have to deal. Among the 279 deaths referred to vaccination as a cause during the period 1886-1891, five were attributed to Syphilis. Except in cases where an inquest is held, these records are based simply on the certificate given by the medical attendant who certified the cause of death, but who had not necessarily attended the patient during the course of illness which terminated fatally. |
a31b2fac-628b-4d82-9d76-b28be96e206d | Practically all the deaths referred to vaccination as a cause during the years 1889, 1890, and 1891, and some of those so referred during the last two months of the year 1888, have been investigated and reported upon by Medical Inspectors of the Local Government Board. It appears that all the five cases attributed to Syphilis after vaccination, during the longer period 1886-1891, were among the cases so reported upon. We have studied these reports and we are satisfied that in none of the five cases is there sufficient evidence to show that the death resulted from Syphilis caused by vaccination. One of them was the Leeds case, to which we shall refer immediately. As regards the others, with perhaps one exception, there is abundant reason for believing that they were not cases of Syphilis at all. |
e86180f3-802a-4135-bc63-cfc495ddcf6b | But besides these five deaths, there were amongst those alleged or suggested to have been connected with vaccination, which were investigated and reported upon by Medical Inspectors of the Local Government Board, eight cases in which, in the course of the investigation, some suspicion of Syphilis was raised in connexion with the illness which terminated fatally. In none of these eight cases, however, is there evidence of any value to show that Syphilis was communicated by vaccination. Two or three other isolated cases have been brought to our notice which witnesses believed to be examples of this occurrence, but in none of them were the facts such as in our opinion to 159 justify us in concluding with any degree of confidence that the belief expressed had been sustained. On the other hand, a large amount of negative evidence had been offered. |
d84c564e-c4c9-41c5-9747-e6538d4d7c22 | Witnesses who had been engaged through long series of years in the very extensive practice of vaccination, bore testimony to their never in their own sphere of observation having witnessed or heard of any case in which the suspicion of Vaccination-Syphilis had occurred. At the same time it is not to be forgotten that a natural reluctance to register deaths as due to Syphilis may have prevented some cases where recently vaccinated persons have died from that disease from being made public. Only a few items of the evidence produced before us appear to require special notice; among these, the most prominent is what has been known as the "Leeds case," upon which we have heard the evidence of Mr. Ward, Mr. Littlewood, and Dr. Barrs. The witnesses named regarded it as a case of Syphilis, conveyed by vaccination, but all of them admitted that the course of events was most unusual. |
41f86100-8e58-4d9e-bd32-e337eb5e64ef | We have carefully investigated this case, and notwithstanding the opinion formed by the witnesses, there appears good reason to doubt whether it was one of Syphilis. The case was made the subject of careful inquiry by Dr. Barlow on our behalf, who shared the doubt we have expressed. The view taken by the Medical Inspector of the Local Government Board who in the first instance investigated the case was that it was a case of hereditary Syphilis. It seems certain, however, that the parents of the child whose death was in question were not in any way affected by Syphilis. The vaccinifer also appeared to be free from any taint of that disease, and its family history confirmed this view. The co-vaccinees from the same lymph also exhibited no trace of Syphilis. These facts of themselves make out a strong case against that having been the nature of the disease. |
a0f748b7-5fd7-42a5-92eb-85b68e18b260 | Coupled with the fact that it could not have been communicated by the vaccinator himself, they seem to render it practically impossible that Syphilis was the cause of death. If 160 the symptons exhibited had in all respects corresponded with those which are known to characterise Syphilis, the proper inference might have been that there was some error in ascertaining the facts of the case. But it is beyond question that the course of events was very different in some respects from that experienced in undoubted cases of syphilis, and we think the true conclusion is that it was not a case of that disease. It may probably be classed with a few others as examples of gangrene and blood poisoning, the direct result of vaccination, which are not to be explained by supposing the introduction of any Syphilitic or other poison. Fortunately, such cases are extremely rare, so much so that the witnesses concerned knew of no case precisely parallel. The evidence given by Dr. |
a6898698-86db-48c2-b182-cf80c62d9714 | Robert Lee and Dr. Coutts, the former, physician of the Ormond Street Hospital for Children, and the latter, formerly a resident medical officer to the same institution, may be taken as relating to one and the same case. Both these witnesses testify to the abundant occurrence of the ordinary forms of congenital Syphilis in the practice of that institution. Each of them mentions one single case in which it was believed that Syphilis was communicated in vaccination and that the vaccination sore became a chancre. Although it is not established in evidence that these witnesses were speaking of the same case, it is almost certain that they were, as Dr. Coutts expressly states that the child was Dr. Lee's patient. Neither of the witnesses knew more of the case than its earliest stages, and both were subjected to questions the answers to which left much doubt as to the correctness of the diagnosis. |
57c2fe09-d1b5-4c43-a917-1535747938ad | Whilst, however, Syphilis cannot by any means be said to have been proved, the case must stand as one of reasonable suspicion, and Dr. Coutts' statement that another infant (not seen) vaccinated from the same source was said to have suffered in a similar way gives some support to Dr. Lee's opinion. It is of much importance to note that out of an experience of 30,000 children, at an institution beyond all others likely to attract cases of this kind, this was the 161 only example of supposed transmission of Syphilis in vaccination which Dr. Lee had ever known. In considering those cases specially investigated by medical men on our behalf, we have as a rule the advantage of definite and adequate information. We have already mentioned that in the Leeds case, upon which we heard evidence, we had the benefit of Dr. Barlow's assistance; and we need not further discuss that case. |
4c94b179-bbf2-4614-a082-69bad2c0dbf0 | Amongst the others investigated by medical men on our behalf were two cases in which death was apparently certified as from Vaccino-Syphilis. The first of these two deaths was registered, in 1892, as due to " Vaccinia Syphilitica; Marasmus," but it subsequently appeared that the medical man who certified the death had not intended to state that it resulted from Syphilis caused by vaccination. In explanation of his certificate, he said: " . . . . the meaning I intended to convey was 'vaccinia,' i.e., a general eruption over the body exactly like the vaccination pocks occurring in an infant the subject of congenital syphilis"; and a careful inquiry by Dr. Acland elicited overwhelming evidence in support of the view that the case was one of inherited Syphilis. The second of the two deaths was registered, in the present year, as due to "vaccination of Syphilis." |
d8e585e0-6f0a-474a-a2ec-4b47efb5359d | A thorough investigation showed that the case was certainly not one of Syphilis caused by vaccination, and in all probability not one of Syphilis at all. Two other cases, both fatal, were reported to us in which children whose vaccination had undoubtedly been followed by serious illness were believed to have been subjects of inherited Syphilis. Both cases were very carefully investigated by Dr. Acland on our behalf. In neither of them is there any evidence that Syphilis was communicated by vaccination. Probably both children were, as at first surmised, subjects of inherited syphilis. Besides these deaths, there were amongst those alleged or suggested to have been connected with vaccination, which were investigated and reported upon by medical men on our behalf, ten 162 cases in which, in the course of the investigation, some suspicion of Syphilis was raised in connexion with the illness which terminated fatally. |
15d1f2aa-a43c-4a2c-a095-f1ff62418bd6 | In none of these ten cases, however, is there evidence of any value to show that Syphilis was communicated by vaccination; possibly five of them were cases of inherited syphilis. The other five were certainly not cases of Syphilis at all. Turning now to the non-fatal cases investigated by medical men on our behalf, we have had brought to our knowledge with a view to such investigation twenty-six non-fatal cases where Syphilis was alleged to have been, or as to some few of the cases possibly to have been, communicated by vaccination. One of these twenty-six cases could not be traced by the medical men whom we asked to investigate it. It had been reported to us, with twenty-one of the other twenty-five cases, by a gentleman whose only information as to the case, obtained from a relative of the child's, was that "the child had a frightful arm, and broke out badly everywhere, and was a very long time of getting better." |
19f604a9-4a41-48ba-a4c0-f442afaf1b7e | The remaining twenty-five cases were, however, carefully investigated on our behalf, some by Dr. Barlow, some by Dr. Acland, and fifteen of them by those gentlemen jointly. In twenty-four of the twenty-five there is no evidence that Syphilis was communicated by vaccination ; indeed, none of the twenty-four were cases of Syphilis at all. In the remaining case it appears that there was some ground for the allegation, though it is by no means proved that syphilis was communicated by vaccination, or even that the case was one of syphilis at all. The case, brought to our notice in 1892, was that of a boy born in 1880 and vaccinated in the following year. When examined on our behalf in September, 1892, he presented no unmistakable signs of having suffered from syphilis, either inoculated or inherited. |
9ab09b92-e62d-434d-89c4-53546e77bbdb | The length of time which had elapsed, and the absence of any record, made it impossible to trace the source of lymph. The history of the boy's illness is extremely uncertain, but upon the whole, if it can be relied upon at all, it tends to render some support to the view that Syphilis was communicated by vaccination or by contamination of the vaccination wounds. 163 Besides the non-fatal cases to which we have just referred, there were amongst those investigated by medical men on our behalf, in which non-fatal injury had been alleged or suggested to have been caused by vaccination, 13 cases in which in the course of the investigation some suspicion of Syphilis was raised in connexion with the illness which followed vaccination. In none of these 13 cases, however, is there evidence of any value to show that Syphilis was communicated by vaccination; one was a case of inherited Syphilis, and the other 12 were not cases of Syphilis at all. |
c917a872-fe87-418d-8f33-764246f267c3 | The evidence offered to us would lead to the belief that whilst with ordinary care the risk of communication of Syphilis in the practice of arm-to-arm vaccination can for the most part be avoided, no degree of caution can confer an absolute security. The rejection as vaccinifers of young infants, say below four months of age (in whom Congenital Syphilis may be as yet undeclared), and of adults (in whom the disease may possibly have been recently acquired) are precautions which would probably shut out almost the whole of the risk. The outbreaks of Syphilis in connexion with vaccination which have been mentioned to the Commission (all of which had been previously published) have occurred chiefly in arm-to-arm vaccination amongst soldiers, or from the use as vaccinifers of young infants the offspring of parents whose history was not known to the vaccinator. |
d6a55dcf-37e2-481d-9934-5ec90260cdce | It must, however, be admitted that neither the examination of the vaccinifer if taken alone, and without a knowledge also of the parents, nor the most scrupulous avoidance of any visible admixture of blood with the lymph, are in themselves, however valuable, sufficient absolutely to exclude risk. The evidence given by Dr. Husband, of the Vaccine Institution of Edinburgh, established the fact that all lymph, however pellucid, does really contain blood cells. Absolute freedom from risk of Syphilis can be had only when calf-lymph is used, though where the antecedents of the vaccinifer are fully ascertained, and due care is used, the risk may for practical purposes be regarded as absent. 164 It is obvious that the employment of calf-lymph only would wholly exclude the risks as regards both Syphilis and Leprosy. |
6d109a74-2982-45ce-b47c-6253a3a7f1ed | Respecting the latter disease, however, there appears to be reason to doubt whether any risk exists, and at any rate it does not concern the British population. Even in Leprosy districts the employment of English human lymph would be, so far as Leprosy is concerned, as safe as that from the calf. The risk of Syphilis, although real, is an exceedingly small one, even when humanized lymph is employed, and may probably be wholly avoided by care in the selection of the vaccinifer. As regards all the other dangers, whether of severe illness or temporary inconvenience, the two forms of lymph appear to stand on the same level. The instances of inflamed arms, of Erysipelas, of Vaccinia Maligna, and Eczematous eruptions are not more common after the use of human lymph than after that from the calf. |
a0efe6dd-2f42-4f9c-b89a-a67ee4c3bb31 | Some of the best qualified witnesses who have afforded us their assistance have expressed a deliberate preference for arm-to-arm vaccination, believing that the advantages of calf-lymph are more imaginary than real. A careful examination of the facts which have been brought under our notice has enabled us to arrive at the conclusion that, although some of the dangers said to attend vaccination are undoubtedly real and not inconsiderable in gross amount, yet when considered in relation to the extent of vaccination work done they are insignificant. There is reason further to believe that they are diminishing under the better precautions of the present day, and with the addition of the further precautions which experience suggests will do so still more in the future. We put the use of calf-lymph in the forefront because, as we have said, this would afford an absolute security against the communication of Syphilis. |
c4b124a6-2111-456a-b22c-9f28012bdcfe | Though we believe the risk of such communication to be extremely small where humanized lymph is employed, we cannot but recognise the fact that however slight the risk, the idea of encountering even such a risk is naturally 165 regarded by a parent with abhorrence. We think, therefore, that parents should not be required to submit their children to vaccination by means of any but calf-lymph, but this should not preclude the use of humanized lymph in case they so desire. So long as the State, with a view to the public interest, compels the vaccination of children, so long even as it employs public money in promoting and encouraging the practice, we think it is under an obligation to provide that the means of obtaining calf-lymph for the purpose of vaccination should be within reach of all. We have no hesitation, therefore, in recommending that steps should be taken to secure this result. |
ee9def2f-f0eb-4cfd-95a1-d976faa54966 | Whether the duty of providing calf-lymph should be undertaken by the Local Goverment Boards in the several parts of the United Kingdom, or whether some other method would be more advantageous, can be better determined by those who have had practical acquaintance with the working of the vaccination laws. In connexion with this subject, our attention has been drawn to the experiments recently made by Dr. Copeman as to the effect of the storage of vaccine lymph in glycerine. The conclusions at which he arrives are that the addition of glycerine, whilst it leaves the efficacy of the lymph undiminished or even increases it, tends to destroy other organisms. If it be the fact that the efficacy of the lymph remains unimpaired, its storage in glycerine would largely diminish the difficulties connected with the use of calflymph, which are inseparable from calf to arm vaccination. The investigation has not yet reached a point at which it is possible to pronounce with certainty whether the anticipated results would be obtained. |
d0ff0ed1-a0f9-4045-bcf3-635a67d61e3a | And it was at one time suggested that the introduction of glycerine was likely to be mischievous. The question is one a further investigation of which is obviously desirable. If lymph is to be preserved in glycerine, due care would be requisite to ensure its purity and the absence of contamination in its introduction. We think that, whether mixed with glycerine or not, each tube should contain only sufficient lymph for the vaccination of one person. 166 (D.) As to what means, other than vaccination, can be used for diminishing the prevalence of Small-Pox; and how far such means could be relied on in place of vaccination. Another question upon which we are asked to report is, what means, other than vaccination, can be used for diminishing the prevalence of Small-pox; and how far such means could be relied on in place of vaccination. |
ca578a8a-b5b4-49af-a4eb-16d992de2ec6 | The means other than the inoculation of Small-Pox and CowPox, which have been referred to by witnesses as being capable of diminishing the prevalence of Small-Pox, are such means as have been employed against infectious diseases generally; they may be summarised as—i. Measures directed against infection, e.g., prompt notification, isolation of the infected, disinfection, &c., 2. Measures calculated to promote the public health, the prevention of overcrowding in dwellings or on areas, cleanliness, the removal of definite insanitary conditions, &c. It will be well to commence with a brief statement of the growth of our knowledge on the subject of isolation as a means of dealing with infectious or contagious diseases. We have already adverted to the fact that Small-Pox is highly contagious, and that contagion from those suffering from it is the means by which the disease is propagated. |
bcb034c1-1f71-409a-8581-f2b838a99049 | Although reference to infection appears in some of the Arabian writers, the contagiousness of Small-Pox attracted little attention in this country and in Western Europe until the 18th century. Sydenham (1624-1689), though he refers to the contagiousness of Small-Pox, did not dwell upon the matter, and did not regard it as so important an element in the spread of the disease as some peculiar constitution of the atmosphere to which he attributed epidemics. Boerhaave was the first at the commencement of the 18th century distinctly to formulate the now generally accepted doctrine that Small-Pox arises only from contagion. In 1720, Mead drew up an elaborate system of notification, isolation, disinfection, &c., in view of a threatened invasion of the 167 plague, but no attempt to deal with Small-Pox in a similar fashion appears to have been made until the last quarter of the 18th century. |
28c905c8-8cf4-4b1f-8a1f-6ecb9b3a4447 | This was in all probability largely due to the adoption of inoculation as the recognised defence against Small-Pox, and the acceptance of Sydenham's doctrine of epidemic causation may have exercised an influence in the same direction. Prior to the year 1866 there was no provision made by law for enabling sanitary authorities to establish hospitals for infectious diseases and thus to promote the isolation of such cases. The only institutions of that description then existing were the result of private effort. So far as regards Small-Pox there was, practically speaking, no provision for its treatment by means of isolation. The Sanitary Act of 1866 empowered, though it did not compel, local authorities throughout England and Wales, Scotland, and Ireland, to provide or to join in providing isolation hospitals for the use of the inhabitants of their districts. |
0e9fedbc-91a6-4f33-9e6b-58bfc167698e | There was further legislation on the subject by the Public Health Act, 1875; the Public Health (London) Act, 1891; the Public Health (Scotland) Act, 1867; and the Public Health (Ireland) Act, 1878, into the details of which it is not necessary to enter. The most recent Act relating to the matter is the Isolation Hospitals Act of 1893, which applies to the small towns and rural districts of England and Wales. In London, the local authorities to whom the power to provide isolation hospitals was given by the Sanitary Act of 1866 were, in the City, the Commissioners of Sewers, and in other metropolitan districts the Vestriesor District Boards. With few exceptions, these authorities did not exercise the powers conferred on them, and, speaking generally, it may be said that the Sanitary Act of 1866 had practically no effect in London as regards the provision of hospital accommodation for Small-Pox. |
0e26dec0-6fd1-4f6f-ad2d-6e292f18c990 | Some few of the metropolitan workhouses, however, had infectious wards attached in which cases of Small-Pox were treated, and the guardians of 168 some of the Unions sent cases by arrangement to the Small-Pox Hospital at Highgate. This institution, which had been established in 1746, was extended in 1850 so as to provide accommodation for about 100 Small-Pox patients. It remained down to the year 1870 the only Small-Pox Hospital in London. The obvious difficulty and danger attending the treatment of persons suffering from Small-Pox in the same institutions in which other destitute persons are practically forced to reside led to the enactment of certain provisions of the Metropolitan Poor Act of 1867, and to the issue under that Act of an order of the Poor Law Board virtually uniting the whole metropolis into one district for the purpose, amongst others, of providing hospital accommotion for paupers suffering from Small-Pox. |
120da4ca-9e8a-4b72-9e96-d77f1aa50b74 | Although the Metropolitan Asylums Board had power to provide hospital accommodation for paupers only, they found it practically impossible to confine the inmates of their hospital to this class, owing to the epidemic which prevailed at and after the time when their first hospital was opened in December, 1870. In 1879, by the Poor Law Act of that year, power was given to the Metropolitan Asylums Board to contract with the local authorities for the reception into the Board's hospitals of any persons suffering from Small-Pox or other dangerous infectious disorder within their districts, but it was not until 1889 that express power was given to the Asylums Board by the Poor Law Act of that year to admit persons reasonably believed to be suffering from Small-Pox who were not paupers. It will thus be seen that the hospitals of the Asylums Board have been practically the only isolation hospitals available for London, though to some extent the Highgate Hospital has served the same purpose. |
57c7fa14-58a3-4ff3-ad29-16857fca871c | After the hospitals established by the Metropolitan Asylums Board had been employed for some time for the reception of 169 persons suffering from Small-Pox, attention was called to the fact that the number of cases of the disease in the neighbourhood of the hospitals was apparently in excess of the number found in streets further removed from them, and a suspicion was aroused that the hospitals were themselves causing a spread of the disease. There had appeared, according to Dr. Thorne, to be ground for believing that in the case of two provincial hospitals, one at Maidstone and the other at Stockton, the inhabitants of dwelling-houses in their neighbourhood had suffered owing to proximity to these institutions. In consequence of the suspicion which existed as to the influence of London hospitals in spreading the disease, a careful investigation was made for the Local Government Board by Mr. Power of the circumstances relating to the Fulham Small-Pox Hospital. |
9db42a00-3d9d-4fdc-a2dd-f86dcb0e0f4a | In the result, he came to the conclusion that the Fulham Hospital, with all its advantages of site and construction, and with the many excellences of its administration, had, by dissemination of Small-Pox material through the atmosphere, given rise to an exceptional prevalence of Small-Pox in its neighbourhood. The matter was felt to be of so much importance that a Royal Commission was appointed to consider the prevention and control of epidemic infectious diseases in London and its neighbourhood. The Commission arrived at the conclusion that it "appeared clearly established," by the experience of the five hospitals maintained by the Asylums Board for small-pox patients, that "by some means or other the asylum hospitals in their present shape, cause an increase of Small-Pox in their neighbourhoods." |
13870bc5-7bf0-4a71-a4a8-22cbb8337c70 | They accordingly recommended that these hospitals, which, in their judgement, should be no longer used to anything like the extent they then were for cases of Small-Pox, should become, in the main, Fever Hospitals, and that mild and convalescent cases of Small-Pox should be provided for in two or three more country hospitals, it being apparently thought impracticable to remove acute cases to such hospitals. 170 Towards the end of the year 1883 the Metropolitan Asylums Board, who had already made some use of a hospital camp at Darenth, and a hospital ship, the "Atlas," moored at Greenwich, for the treatment of Small-Pox patients, decided to make important changes in its method of dealing with London Small-Pox. The "Atlas" hospital ship was moved to Long Reach, about 20 miles below London Bridge, and well without the metropolitan area, and re-opened in February 1884; the hospital camp at Darenth was re-opened early in the following month; |
0f399319-8850-48cb-acfd-cf230870d4cd | in June of the same year a second hospital ship, the "Castalia," was opened alongside the "Atlas," and a second hospital camp opened at Darenth; and from February to October, 1884, the cases of SmallPox received by the Board were dealt with in the following manner:—Cases of Small-Pox were received at first at three, and afterwards at six, intra-urban hospitals and there treated—(in May the hospitals at Hampstead and Fulham had been re-opened for this purpose, and a sixth hospital hired at Plaistow, just beyond the metropolitan boundary, but in a populous district)— but the number of cases under treatment in each intra-urban hospital at any one time was not allowed to exceed 50, mild and convalescent cases being thence transferred from time to time to the hospital ships and camps, where their treatment was continued; after the middle of June mild cases of Small-Pox were also received on the hospital ships directly from their homes. |
ae129825-db37-4aed-acb6-b0bd6082f9e3 | Complaints, however, again arose that some of the six intra-urban hospitals, and even that the hospital camps at Darenth, were spreading Small-Pox in their vicinity, legal proceedings being instituted with reference to the use of the latter; and from October, 1884, though the Board continued for a time to follow the same method of dealing with cases of Small-Pox, but the number of cases under treatment in each intra-urban hospital at any one time was not allowed, as a rule, to exceed 25. Finally, in July, 1885, the Metropolitan Asylums Board decided thenceforward to treat, in the first instance, on the 171 hospital ships, all cases of Small-Pox received by the Board, unless the condition of the patients made their removal to the ships dangerous; and the Boards arrangements, well designed and well carried out, for the conveyance of patients thereto, have since been found to admit of practically the whole of the cases being taken to the ships. |
6bb3adaf-15df-49c2-82bd-e5d56965ecf7 | As a relief to the hospital ships in times of Small-Pox epidemics, the Board erected in 1888-9, and extended in 1893-94, at Darenth, on a site near that before used for the hospital camps, a hospital primarily intended for cases convalescent after Small-Pox, which was so used during the later part of the Small-Pox outbreak of 1892-94. The Metropolitan Asylums Board have also provided, since 1881 a partial, and since 1889 a complete, ambulance service for London Small-Pox; and so well has the service, which formerly was an undoubted means of infection, been carried on by the Board that it may, in this connexion at least, be taken that no spread of infection has occurred from the Board's ambulances. |
c401cdbf-b5c1-45b0-beec-eb65cb83f6cc | We have already directed attention to the fact that it was, practically speaking, not until 1871 that hospital accommodation was provided in London, which rendered possible the removal from their home of persons suffering from Small-Pox, and we have detailed the measures adopted from time to time for that purpose. As these facilities were augmented, the proportion of cases treated in the Metropolitan Asylums Board's hospitals steadily increased:— Years. Number of Deaths from SmallPox registered in London, or (of London Residents) in the Metropolitan Asylums Board's Hospitals situated outside London. Number of Deaths from Small-Pox in the Metropolitan Asylums Board's Hospitals. Deaths in Metropolitan Asylums Board's Hospitals—Per Cent. of Total Deaths. |
bab27fa2-dad1-453a-88cb-decd31141f0f | 1871-2 9.643 3,020 31 1881 2,373 1.431 60 1893 206 180 87 172 The deaths shown by the table in the last of these years are not those which occurred in the hospitals during that year, but the deaths of patients who, during that year, were admitted to the hospitals. This does not, however, detract from the importance of the figures as evidence of the great increase in the proportion of Small-Pox cases treated in the hospitals. The Royal Commission, to which we have referred, in their Report made in July, 1882, contrasted the amount of Small-Pox in London with that which had occurred in England generally. It will be well to bring such a comparison down to the present time and to notice the features which it presents. |
3992befd-4aef-4240-96bb-03fc0ba51c87 | The following table affords a comparison between the mortality in London and that in England and Wales with the metropolis excluded, the deaths being those from Small-Pox to every 100,000 living. The figures are taken for the five years 1838-2, and from 1847 onwards in decennial periods, the figures for the years 1843-6 not being procurable. - Mean annual Deaths from SmallPox to every 100,000 living. England & Wales, excluding London. London. |
2edbd375-85a1-4964-88d6-8d7c2ca5c215 | 1838-42 545 77.1 1847-56 236 34.6 1857-66 200 26.8 1867-76 22.5 41.9 1877-86 3.3 274 It will be seen that during the second and third periods, there was a great reduction of mortality both in England, excluding the metropolis, and in London; though it must be remembered that 1838-42 includes 1838, in which there was a considerable epidemic. The great epidemic wave of Small-Pox which swept over the 173 country in 1870-1, and which made itself felt in almost every part of Europe, naturally produced a sensible effect on the mortality of the next decenium, but it is to be noted that its effect was much more serious in London than outside the metropolis. |
fc8e13f7-6a1d-4324-8b94-6336fc20a3ce | The mortality there, though raised higher than in the previous decennium, did not reach the point at which it stood in the decennium before that. In London, on the other hand, the mortality largely exceeded that of the two previous decennia. Again it is to be observed that though in the next decennium the mortality fell, both in England generally and in the metropolis, the fall was very different in its extent; outside the metropolis it was vastly greater than within it. It is only since the year 1885 that the condition of London has been at all comparable as regards the amount of Small-Pox mortality with the rest of the country. The corresponding figures for the years 1887-94 to those given above are as follows :— England & Wales, excludingLondon. London. |
e84e9481-9b56-46b3-9161-b941a41274f1 | 1887-94 2.0 1.0 In the Report of the Royal Commission of 1881, already alluded to, suggestions were made with regard to notificatian and isolation which have since been largely carried into effect. As we have said, it was considered proved that the existing Small-Pox Hospitals had caused a spread of the disease in their neighbourhood. We cannot but think that this may in some measure account for the greatly increased mortality from Small-Pox in London during the 1871-72 epidemic as compared with the rest of the country. It is true that the statistics relating to England and Wales outside the metropolis include those of other large towns where the same evil was present, but it probably did not exist then in so aggravated a form, and the effect may be neutralised by the statistics relating to smaller towns and rural 174 districts with which they are combined. |
85cbe5e9-11c1-42c3-9645-f84b82439e2d | This idea has been suggested to us, as the result of the inquiry, how it has come about that whilst the metropolis, in the decennium 1867-1876 and again down to 1885, compared so unfavourably with the rest of the country, the condition has since that date become so entirely changed? We think it is impossible to attribute this change to vaccination. There is no reason to suppose that the position of the metropolis in respect to vaccination has, since the year 1885, become superior to the rest of England and Wales; rather the other way, as the decrease in infantile vaccination has been greater during the last few years than in the rest of England and Wales. The change, therefore, must be due to some other cause. We have no difficulty in answering the question, what means other than vaccination can be used for diminishing the prevalence of Small-Pox? |
0257928d-eead-4ba8-99da-e1b68d20cf2b | We think that a complete system of notification of the disease, accompanied by an immediate hospital isolation of the persons attacked, together with a careful supervision, or, if possible, isolation for sixteen days of those who had been in immediate contact with them, could not but be of very high value in diminishing the prevalence of Small-Pox. It would be necessary, however, to bear constantly in mind as two conditions of success, first, that no considerable number of Small-Pox patients should ever be kept together in a hospital situate in a populous neighbourhood, and secondly, that the ambulance arrangement should be organised with scrupulous care. If these conditions were not fulfilled, the effect might be to neutralise or even do more than counteract the benefits otherwise flowing from a scheme of isolation. The question we are now discussing must, of course, be argued on the hypothesis that vaccination affords protection against Small-Pox. |
df3745e8-62ec-4c40-8b3e-3c2755c07171 | Who can possibly say that if the disease once entered a town, the population of which was entirely or almost entirely unprotected, it would not spread with a rapidity of which we have in recent times had no experience, or who can 175 foretell what call might then be made on hospital accomodation if all those attacked by the disease were to be isolated? A priori reasoning on such a question is of little or no value. We can see nothing, then, to warrant the conclusion that in this country vaccination might safely be abandoned, and replaced by a system of isolation. If such a change were made in our method of dealing with Small-Pox, and that which had been substituted for vaccination proved ineffectual to prevent the spread of the disease (it is not suggested that it could diminish its severity in those attacked), it is impossible to contemplate the consequences without dismay. To avoid misunderstanding, it may be well to repeat that we are very far from underating the value of a system of isolation. |
9d21950e-ead6-420d-80b8-e8a563469bec | We have already dwelt upon its importance. But what it can accomplish as an auxiliary to vaccination is one thing, whether it can be relied on in its stead is quite another thing. Our attention has been drawn to the circumstance that outbreaks of Small-Pox have not unfrequently had their origin in the introduction of the disease to common lodging-houses by tramps wandering from place to place. In view of this we make the following recommendations:— (i.) That common shelters which are not now subject to the law relating to common lodging-houses should be made subject to such law. (ii.) That there shall be power to the local authority to require medical examination of all persons entering common lodging-houses and casual wards to see if they are suffering from Small-Pox, and to offer a reward for prompt information of the presence of the disease. (iii.) |
48847afe-e3cf-4e76-800d-77654951fda6 | That the local authority shall have power to order the keeper of a common lodging-house in which there has been Small-Pox to refuse fresh admissions for such time as may be required by the authority. 176 (iv.) That the local authority should be empowered to require the temporary closing of any common lodginghouse in which Small-Pox has occurred. (v.) That the local authority shall have power to offer free lodgings to any inmate of a common lodging-house or casual ward who may reasonably be suspected of being liable to convey Small-Pox. (vi.) That the Sanitary Authority should give notice to all adjoining Sanitary Authorities of the occurrence of Small-Pox in common lodging-houses or casual wards. (vii.) That where the disease occurs the Public Vaccinator or the Medical Officer of Health should attend and vaccinate the inmates of such lodging-houses or wards, except such as should be unwilling to submit themselves to the operation. |
3c61ec0d-e158-4972-8ae4-87a0493b19bd | In connection with the subject with which we have been dealing we may advert to the suggestion that the vaccination and the Sanitary Authority should in all cases be identical. It has been pointed out that whilst the isolation of patients in hospitals and otherwise is provided for by the Sanitary Authority the extent of the provision requsite to deal with an outbreak of an epidemic of Small-Pox may depend upon the degree in which the vaccination laws have been enforced. More hospital accommodation may be required where vaccination has been neglected than where the vaccination laws have been complied with. It is contended that sanitation and vaccination, concerning as they both do the health of the people, should be under the jurisdiction of a single authority, and that the Sanitary Authority is the appropriate one for that purpose. Indeed, the advantage of placing in the same hands the supervision of vaccination and of the other measures designed to prevent the spread of disease are so great and obvious that the proposal to do so deserves most serious consideration. |
d3070a07-a412-4cf9-9883-9beeebf93896 | 177 At the same time, we fully recognise the importance of achieving it as far as possible, and we should regard with favour such changes as would render the amalgamation of the vaccination and sanitary authorities feasible, or indeed any steps taken in that direction, even although they should only partially effect the object in view. (E.) As to whether any alterations should be made in the arrangements and proceedings for securing the performance of vaccinations, and, in particular, in those provisions of the Vaccination Acts with respect to prosecutions for non-compliance with the Law. From the views which we have expressed on the subject of vaccination, and on the absence of proof that any practical alternative exists which could be relied on to accomplish the same results if vaccination fell into disuse, it follows that we are of opinion that the State ought to continue to promote the vaccination of the people. Nor are we prepared to recommend that the State should cease to require vaccination, and trust entirely to a voluntary adoption of the practice. |
2b5515bc-f1a3-48f9-a442-dafbe0959723 | It will be well at the outset of our discussion of this subject to advert to the nature of the compulsion at present employed, to secure compliance with the law requiring that children should be vaccinated within a limited time after their birth. When vaccination is spoken of as "compulsory," it is only meant that, in case a child is not vaccinated as prescribed by law, a pecuniary penalty is imposed which may be followed by distress and imprisonment. The liability to this penalty no doubt in many cases leads to vaccination, where it would otherwise be neglected ; but, whether the penalty be enforced once or repeatedly it does not compel vaccination in all cases. If a parent is content to pay the penalty, his child remains unvaccinated; there have been not a few cases in which repeated penalities have been thus paid. Vaccination could be made really compulsory only by taking the child from the parent and vaccinating it against his L 178 will, if he would not himself procure or consent to its vaccination. |
6b13b76b-3090-40a7-8016-a783754f789e | It is necessary to bear this distinctly in mind in considering the modifications of the present law which have been proposed. There may be some who would consider it both justifiable and expedient for the State thus to take the matter into its own hands, and effectually ensure the vaccination of the entire population. We do not stop to inquire whether it would be justified in adopt ing such a method, for we are satisfied that no such measure, if proposed, would have any chance of acceptance; indeed, few even of the most ardent advocates of vaccination have hitherto made such a proposal. Nor, again, do we think that a proposal to substitute for the pecuniary penalty now imposed a more stringent form of punishment, such as imprisonment, would have any greater chance of acceptance. |
6f2ee6b3-3e27-43f6-9c0e-68bc11ba808d | If, then, the only kind of compulsion available is to attach some pecuniary penalty to the neglect of vaccination, the question to be determined is what form of law, based on penal provisions of this description, will secure the largest number of vaccinated persons. That this is the question to be solved has, we think, sometimes been lost sight of. In our Fifth Report we recommended that repeated penalties should no longer be enforced. Our proposal has been subjected to criticism, on the ground that it would enable a person to break the law, and to purchase immunity by the payment of a single penalty. But there is no difference in principle, whether immunity can be purchased by the payment of one or of several penalties. If the cases in which vaccination was omitted would be less in number, supposing one penalty only were enforced instead of many, the end which the Legislature sought to accomplish in enacting the compulsory vaccination law would be better attained. |
0b236f25-1a55-4ab5-af84-ebf1e00abf94 | To secure that vaccination should be as widespread as possible is, we think, the object to be kept primarily in view. When an answer has been found to the question, what scheme which is within practicable limits would best conduce to that end, the form which legislation should take will, in our opinion, have been ascertained. 179 We have alluded to the mode in which pressure is at present exerted to secure vaccination; we must now direct attention to the machinery by which the law is enforced. It is for the local authorities to put the law in motion. In England and Wales the guardians have been in the main an elected body, necessarily reflecting the views of those by whose votes they obtain their office. In some districts, guardians have been elected from time to time, solely because they have pledged themselves not to prosecute those who fail to have their children vaccinated. |
0fadd2d4-660c-4233-a93c-3dd86c4ab9bc | The enactments under which the guardians are the authority to enforce the vaccination laws contain no provision dealing with the case in which they neglect or refuse to do so. By a Statutory Order, made by the Local Government Board, the duty of enforcing these laws has been cast upon the Guardians, and in the case of the Guardians of the Keighley Union a mandamus was issued by the Court of Queen's Bench commanding them to perform this duty. In default of obedience, they were committed to prison. After a short incarceration, they were let out on bail. When subsequently brought before the Court to answer for their contempt, they were released on entering into their own recognizances to come up for judgment when called upon. By the terms of the recognizance they were bound while guardians to do nothing in disobedience to the Vaccination Acts, or to cause their operation to be in any way disturbed. The proceeding proved, however, quite ineffectual so far as vaccination was concerned. |
25a9c7a7-0f9f-41b9-bfd2-8d354b68c064 | The same course was pursued afterwards as before. There is no process open for constraining guardians to enforce the vaccination law except a mandamus resulting in their committal to prison in case they refuse to obey the command of the court. Experience has shown that when the guardians represent a local community opposed to vaccination, this method of putting pressure upon them is inoperative to promote it. The necessity of proceeding to enforce a penalty, or at all events repeated penalties, arises for the most part in cases where the parent objects to have his child vaccinated, and not in cases 180 of mere neglect or indifference. It is important to consider how it has come about that whereas in many parts of the country there is no serious objection to vaccination, in other places the objection is so acute and widespread that the opponents of the practice are enabled to elect gaurdians pledged to abstain from enforcing it. |
1fe38ac3-28d6-44fb-bd94-9b223d8b11a5 | We believe that it has largely arisen from the attempt to compel parents to vaccinate their children who conscientiously believe that vaccination is of little or no advantage as a protection against Small-Pox, and that it involves a serious risk of injury to the health of the vaccinated child. Symptoms of injury following vaccination, and really or apparently connected with it, have occurred in the case, it may be, of an elder child of the same parent, or in the case of a neighbour's child; this immediately arouses hostility to vaccination, and induces the parent to resolve that his child shall remain unvaccinated. If the attempt be made to compel a parent, in this attitude of mind, to have his child vaccinated, it meets with determined opposition, and, where the penalty is repeated, the hostility is often intensified without any progress being made towards the vaccination of the child. |
e224cb10-ffec-4bd6-8523-575291741c35 | Such a parent has often become a focus of hostility to the vaccination laws; his neighbours and friends take his side; he is regarded as a martyr; and he and they frequently become active agitators against the vaccination laws. There are, indeed, a central association and local associations which advocate the abolition of compulsory vaccination, and denounce the practice altogether; but it is local circumstances, such as we have described, which stimulate the creation of these local associations and give them their vitality, and which add to the force of the central association. It is often said that the opposition to vaccination is the work of agitators. This may be true; but the agitation, though it may be afterwards intensified from without, in our belief, has its origin, almost invariably, in a particular locality. It is this, we think, which accounts for the phenomena to which we have called attention that the acute opposition to vaccination is confined to a limited number of localities, and that it seems usually tospread from a local centre. |
35af08bf-a62c-4ffd-98a3-416308a8aeb0 | 181 "We are now in a position to state the reasons which led us to recommend that repeated penalties should no longer be enforced; indeed they will be apparent from what we have already said. "We do not doubt that the fact that penalties may be repeated secures in some cases the vaccination of children who would otherwise remain unvaccinated; but we believe that the irritation which these repeated prosecutions create, when applied in the case of those who honestly object to have their children vaccinated, and the agitation and active propaganda of antivaccination views which they foster in such cases, tend so greatly to a disuse of the practice, in the district where such occurrences take place, that in the result the number of children vaccinated is less than it would have been had the power of repeated prosecution never existed or been exercised. This seems to us to be the crucial question. |
e4c8a2c2-27ce-4af8-b70c-e49d5b9c5535 | A law severe in its terms, and enforced with great stringency, may be less effectual for its purpose than one of less severity and which is put in force less uncompromisingly. When this is the case it cannot be doubted that the law which appears less severe is really the more effective. The ultimate object of the law must be kept in view. The penalty was not designed to punish a parent who may be considered misguided in his views and unwise in his action, but to secure the vaccination of the people. If a law less severe, or administered with less stringency, would better secure this end, that seems to us conclusive in its favour. " |
dd90d5e6-12d6-4cfd-b3bf-3818cf86edae | If, then, we cannot look with any certainty to a change of the authority whose duty it is to enforce the law as a means of securing vaccination in those districts where it has already fallen into disuse, it obviously follows that every endeavour should be made so to frame and to administer the law that opposition to vaccination should not spread to other districts, and that it should cease or diminish in those parts of the country where it at present prevails. 182 "It is to be hoped that our Report will stimulate belief in the efficacy of vaccination, that it will remove some misapprehensions and reassure some who take an exaggerated view of the risks connected with the operation, as well as lead to a more ready enforcement of the law by local authorities. We desire to call attention again to the recommendation, which we made in our fifth interim report, that persons committed to prison by reason of the non-payment of penalties imposed under the vaccination laws, should no longer be treated as criminals. |
600fd19c-4887-40db-886e-59ac24a1109e | We stated in that report our reasons for this recommendation, to which we still adhere. If, however, the changes in the compulsory provisions of the vaccination laws which we have suggested were adopted, the matter would lose much of its importance. We have had the misfortune to lose by death several of our colleagues. Mr. Bradlaugh died at an early stage in the inquiry, and was replaced as a member of the Commission by Mr. Bright. Sir William Savory and Dr. Bristowe died at a later period, and their places have not been filled. We are deeply sensible of the valuable assistance in the preparation of this Report of which death has thus deprived us. All which we humbly submit for Your Majesty's gracious consideration. (Signed) HERSCHELL. JAMES PAGET. CHARLES DALRYMPLE. W. GUYER HUNTER. EDWIN H. GALSWORTHY. |
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