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29c9ddcb-fd80-436c-89f3-016bd1bb78a6 | JOHN S. DUGDALE. M. FOSTER. JONATHAN HUTCHINSON. FREDERICK MEADOWS WHITE. SAM. WHITBREAD. JOHN A. BRIGHT. Bret Ince, August 1896. Secretary. 183 The undersigned do not find themselves able to go so far in recommending relaxation of the law as is suggested. We think that in all cases in which a parent or guardian refuses to allow vaccination, the person so refusing should be summoned before a magistrate, as at present, and that the only change made should be to permit the magistrate to accept a sworn deposition of conscientious objection, and to abstain from the infliction of a fine. We are also of opinion that, in spite of the difficulties as set forth, a second vaccination at the age of twelve ought to be made compulsory. W. GUYER HUNTER. |
43e5b15c-a1f5-45c0-a7ac-3f29c3830ba8 | JONATHAN HUTCHINSON. We, the undersigned, desire to express our dissent from the proposal to retain in any form compulsory vaccination. We cordially concur in the recommendation that conscientious objection to vaccination should be respected. The objection that mere negligence or unwillingness on the part of parents to take trouble might keep many children from being vaccinated would be largely, if not wholly, removed by the adoption of the Scotch system of offering vaccination at the home of the child, and by providing for medical treatment of any untoward results which may arise. We therefore think that the modified form of compulsion recommended by our colleagues is unnecessary and that in practice it could not be carried out. The hostility which compulsion has evoked in the past toward the practice of vaccination is fully acknowledged in the Report. In our opinion the retention of compulsion in any form will, in the future, cause irritation and hostility of the same kind. |
3f3d2d8e-b2b0-4666-9248-5dc712a261b2 | The right of the parent on grounds of conscience to refuse vaccination for his child being conceded, and the offer of vaccination under improved conditions being made at the home of the 184 child, it would in our opinion be best to leave the parent free to accept or reject this offer. SAM. WHITBREAD. JOHN A. BRIGHT. W. J. COLLINS.* J. ALLANSON PICTON.* * Note.—Dr. Collins and Mr. Picton sign the above note of reservation, though they have not signed the Reports. An abridged statement of their grounds of dissent from the Report follows:— Statement by Dr. Collins and Mr.Picton of the Grounds of their Dissent from the Commission's Report. |
722e1371-a4ce-471b-a7ad-687d3f02cea7 | We entirely agree with the Report of our colleagues in so far as it shows the great change of professional and scientific opinion since vaccination first engaged the attention of the Legislature, and since the passing of the first compulsory Act, in 1853. We hold with them that the prophylactic power of vaccination has been at least exaggerated, and that dangers incidental to the practice, though at one time denied, "are undoubtedly real and not inconsiderable in gross amount." We gladly added our signatures to theirs in support of the Commission's interim report recommending the abolition of repeated prosecutions, and also that recalcitrants against the vaccination laws should no longer be subjected to the same treatment as criminals. We now desire, also, if compulsion in any form is to be maintained, to support their final recommendations for the relief of conscientious nonconformity with the law. We also gladly endorse the precautions they recommend with the object of preventing avoidable dangers in connexion with the operation. |
a02a337b-8cd2-4008-b109-d834215ccbc9 | There is no difference among us on these points; so far as these recommendations go the Commission is absolutely unanimous. We feel, however, that the evidence not only justifies but requires a more complete reconsideration of the present state of the law, as well as of the methods adopted in dealing with Small-Pox. For this purpose it 185 is necessary to review in some detail the history of Small-Pox and the various preventive measures which have at different times been in vogue, and to scrutinise the grounds on which one alone of these preventive measures has been relied upon to the exclusion of others. We desire also to give reasons for thinking that other more effective and practicable (as well as less objectionable) modes of stamping out Small-Pox, or protecting communities from its introduction, are available. |
0409e753-3a5a-4e59-85ad-98d4817c29e8 | We venture to think that the report of our colleagues, in the preparation of many portions of which we have borne our part, has approached the consideration of the behaviour of Small-Pox, and the means of preventing it, too exclusively from the standpoint of vaccination, and that too little attention has consequently been accorded to sanitary organisation, prompt notification and isolation, measures of disinfection and cleanliness, and healthy conditions of living, whjch we believe to be of the first importance in preventing and controlling outbreaks of Small-Pox. In 1710, for the first time since the Bills of Mortality had been compiled, more than 3,000 deaths were ascribed to SmallPox in London, or 127 per 1,000 deaths from all causes. The prevalence of the disease led to many speculations as to possible means of deliverance from it. The orthodox teaching of propagation by "epidemic constitution of the atmosphere" was not calculated to inspire sanitary precautions, or the separation of the sick from the whole. |
146e1d58-0dd0-4e43-a759-c309a8318001 | Mead's work on the prevention of contagions, primarily directed against a threatened invasion of plague, was not written until 1720. On the other hand there were reports from the Levant, where Small-Pox had been long endemic, that by a method of "engrafting" the disease artificially it might be robbed of its terrors. As far as the epidemiological history of Small-Pox can be followed back in Asia and Africa, we find records of the popular practice, in some form or other, and often with religious associations, of the artificial induction of the disease. Even in Wales and Scotland, and in Western Europe, some kind of popular tradition of a similar practice has been traced by some authorities. 186 Whatever credit may attach to the introduction of the practice of inoculation into this country is, however, due to Lady Mary Wortley Montague. |
9f627ab1-fa8d-4e8c-b2df-54f04e161466 | During her residence at Pera, while her husband was Ambassador to the Porte, Lady Mary learnt that it was there the fashion "to take Small-Pox by way of diversion as they take the waters in other countries." In a letter, dated 1717, she announced her attention of submitting her son, aged five, to the operation, and added, "I am patriot enough to take pains to bring this useful invention into fashion in England." Her son was accordingly inoculated by a Greek woman, under the supervision of Mr. Charles Maitland, Surgeon to the Embassy, and he passed favourably through the disease. Lady Mary returned to London, and in the spring of 1721 had her younger child inoculated by Maitland. The operation, which was satisfactory, was witnessed by three physicians, as well as several ladies and persons of distinction. |
4752453d-02df-49e6-957a-2c60f793e989 | In August, 1721, inoculation was tried experimentally on six criminals at Newgate, and the practice was encouraged by the Court. While the effects in most of the early cases appear to have been mild, a few terminated fatally, and the practice became for a while less popular. After 1740, however, inoculation was revived, and, in the modified form of Dimsdale and Sutton, was widely adopted in many parts of the United Kingdom. In 1746 an inoculation hospital was started in London, and in most of the large provincial towns the new practice was encouraged by the clergy, as well as the leading medical practitioners, "and in 1754 the Royal College of Physicians of London pronounced its authoritative sanction of what was no longer a speculative novelty." The resolution of the College was: —"The college having been informed that false reports concerning the success of inoculation in England have been published in foreign countries, think proper to declare their sentiments in the following manner, viz. |
2cf9df4c-8fee-4939-a8e6-272c4090da7b | :—That the arguments which at the commencement of this practice were urged against it have been refuted by experience; that it is now held by the English in greater esteem, and 187 practised among them more extensively than ever it was before; and that the College thinks it to be highly salutory to the human race." From this date to the end of the century inoculation was widely diffused, though to varying degrees, in different districts; the practice doubtless paved the way for the later acceptance of vaccination. The latter came to replace the former method, and by the Act of 1840, sec.8, the practice of inoculation became a penal offence. Now the practice of inoculation was based on the belief that one attack of Small-Pox protected from subsequent attack those who recovered. And it was argued that the artificially-inoculated disease, though usually far less severe than the natural disease, yet afforded a similar immunity. |
db85f9bb-3616-4cdf-bb24-2f49dd5726f5 | It is neither necessary nor profitable to discuss at any length the various theories that have been advanced to account for such immunity; suffice it to say there exists, and has always existed, a belief, shared by medical writers, that in the case of many infectious diseases one survived attack affords a certain amount of protection against a second attack. The earlier writers on Small-Pox appear to have held that second attacks of the disease undoubtedly, occurred and not unfrequently. The view that second attacks of Small-Pox occurred was held by Sydenham, also by Diemerbroek, who observed that the eruption was more severe in second attacks than the first. The case of Louis XV. has been often quoted; he had a first attack at fourteen, and died of a second at sixtyfour. During the inoculation period the possibility of second Small-Pox was emphatically denied by several writers. |
7afeb7c7-c1a4-44a5-b558-1108047b914f | After the introduction of vaccination the controversy which took place over its relative merits when compared with those of inoculation brought to light numerous instances of second Small-Pox in the same individual. Jenner collected more than a thousand cases of the kind. Moore says, " For some years the periodical and other medical publications teemed with cases of Small-Pox occurring 188 twice." At the present time cases of second attacks of the disease are usually met with in every outbreak of any extent, and it would seem reasonable to conclude that the protection afforded by a previous attack, though considerable, is by no means absolute. Moreover, experience, though of limited amount, appears to show that no mitigating influence is exerted by the first upon a second attack, should it occur. |
2cf68b83-1fde-4e2d-92ed-a1f7929d5585 | Notwithstanding the extensive practice of inoculation, or, as has been alleged, in consequence of it, Small-Pox continued throughout the eighteenth century to be endemic in London, and severely epidemic, often at frequent interval in many towns and villages in this country and abroad. During the latter half of the century attention was called by many writers to the serious evil to society of partial and indiscriminate inoculation. It was shown that, whatever advantages might result to the inoculated by way of protection from attack, the practice had frequently been the means of introducing the disease into towns and villages that were previously free from it, and that it could only be worked at an intolerable cost of life. Attention was also, about this time, called to the restrictive influence which might be exerted upon outbreaks of SmallPox by separating the sick from the healthy. |
2b036ee4-7a11-453f-bc90-5333b5b22cf2 | The part played by contagion in the propagation of epidemics had, since the adoption of inoculation, come to be clearly recognised, and measures were suggested for stamping out Small-Pox on the lines of methods employed against the plague. Some, like Haygarth, suggested the combination of general and systematic inoculation at stated intervals with measures of isolation. Others, like Rast, Faust, and Cappel, advocated hospital isolation of the infected, and regarded inoculation as not only superfluous, but dangerous, and opposed in principle to the proper method of exterminating the infectious poison. It was at this juncture that the value of the Cow-Pox as a 189 protection against small-Pox attracted attention. It could be inoculated, like the Small-Pox, from one person to another, but unlike the latter it was stated to be not communicable by infection. |
2ba1fd26-0586-41ca-967a-be4e07a34ecc | If it afforded protection against Small-Pox without spreading the disease, opinion was evidently ripe for the substitution of the one practice for the other, for inoculation had come to be regarded about this time, not merely as a troublesome affair to those who submitted to it, but as a serious evil, to society. Henceforth, the controversy over the Cow-Pox absorbed almost exclusively the attention of those concerned for the prevention of Small-Pox, and for a long while little was heard of any means other than vaccination, such as isolation, &c., for the suppression or restriction of the disease. From such records and statistics as are available it would appear that Small-Pox was more prevalent and the mortality from it was greater, especially in large towns, during the 18th century than it had been in the 17th. It is also true that, speaking broadly, the present century compares favourably with the last; the disease has not been the scourge that it then was. |
cdd78e29-fee4-44c0-a97c-cf0ee6b16526 | Prior to 1838, when official registration of the causes of death in this country began, the longest series of figures, and those which have been most often quoted, are the London Bills of Mortality. The following figures are taken from a table put in by Sir J. Simon, which was compiled by Dr. Farr, with due regard to the many sources of error which these Bills admittedly contain:— Annual Death Rates in London per 100,000 living at Seven different Periods during the Years 1629-1835, from— - All Causes. Small-Pox. Fever. |
482084a8-00b4-4051-8cc5-efee552bc382 | 1629-35 5.000 180 636 1660-79 8,000 417 785 1728-57 5,200 426 785 1771-80 5,000 502 621 1801-10 2,920 204 264 1831-35 3,200 83 111 190 There was evidently a great improvement in the health of London, as measured by the fall of the death-rate from all causes, from its highest point in the Plague period, to a rate of about onehalf or one-third of what it had been. A great improvement took place between the middle of last century and the earlier years of the present. Dr. |
db08fe4c-f057-4e2b-9db8-68de12e9b4f6 | Farr, remarking on these figures, says:— "The diseases of London in the 16th century still prevail in unhealthy climates; not only the diseases and the manner of death have changed in this metropolis, but the frequency and fatality of the principal diseases have diminished. "Small-Pox attained its maximum mortality after inoculation was introduced. The annual deaths of Small-Pox registered 1760-79 were 2,323; in the next 20 years, 1780-99, they declined to 1,740; this disease, therefore, began to grow less fatal before vaccination was discovered; indicating, together with the diminution of fever, the general improvement of health then taking place. In 1771-80 not less than 5 in 1,000 died annually of Small-Pox; in 1801-10 the mortality sank to 2, and in 1831-5 to 0.83. |
ebe5fa96-3ad9-4694-8408-25b057430fc5 | "Fever, exclusively of the Plague, has progressively subsided since 1771; Fever has declined nearly in the same ratio as Small-Pox. In the three latter periods of the table the deaths from fever decreased as 621 : 264 : 111; from Small-Pox as 502 : 204 : 83." We think these figures suggest that the fall of the death rates from Fever and Small-Pox were associated in cause as well as in time with the improvement in the public health which the fall in general mortality indicates. It is possible that inoculation as practised in London in the latter part of last century, prevented an earlier or greater reduction in Small-Pox than actually took place. |
c06c669d-ddea-433a-b157-bf5ef1bf1e89 | Among the influences at work in the last quarter of the 18th century which would tend to counteract any injurious influence of inoculation were the progressive rooting out of SmallPox from our prisons, the sanitary improvements in our towns, 191 the growth of what has been termed the "new humanity," which made the care of the sick and the protection of the public health against noxious agencies matters of public concern and active philanthropy, influences for good with which the names of Howard and of Cook and of Haygarth are honourably and eternally associated. Since Dr. Farr compiled the figures which we have quoted above, we have five completed decades of registration statistics, and extracting for London the death rates to the same scale from all causes, from Small-Pox, and from Fever, we obtain the following :— Annual Death Rates in London per 100,000 living from:— - All Causes. Small-Pox. Fever. |
a7d7d21c-1374-41bf-89e9-a9c5ec376a52 | 1841-50 2,500 40 97 1851-60 2,400 28 88 1861-70 2,400 27 90 1871-80 2,240 45 37 1881-90 2,037 14 21 We are, therefore, led to the conclusion that the great fall in the Fever death rate since the middle of last cnntury in London is a real and substantial one, that it is in all probability due to greater sanitary activity, and that a fall of about the same amount has, during the same period, taken place in Small-Pox mortality, and we are unable to agree that it is not largely due to similar causes. This is, in fact, what we find when we examine such figures as are available for determining the influence of inoculation on the prevalence of and mortality from small-pox, as, for instance, the London Bills of Mortality. |
24efe7cd-baad-4736-89e4-a4f4caa94179 | Whether we consider the horribly insanitary conditions with the attendant overcrowding, or the disregard of precautions against contagion, it would probably be difficult to conceive conditions more favourable to the spread and 192 fatality of small-pox than those which obtained in London in the first three quarters of last century. In this respect, it is probable London was as bad, or even worse, than other large European towns. Small-pox and other infectious Fevers were allowed to run riot, and Bernouilli's calculation, derived from the experience of such places at such times, to the effect that 60 per cent. of those born took small-pox was probably not far wrong. The introduction of even partial and indiscriminate inoculation was not likely to, and in fact did not, increase to the extent which might otherwise have been expected the heavy toll that small-pox already exacted. |
a4237b9f-eccb-4cb8-bc16-ffebae96a869 | Thus, the figures from the London Bills show that in the first quarter of the 18th century, when inoculation had scarcely begun to be practised in London, the deaths from smallpox were 44,306 out of 586,270 total deaths, or 7.6 per cent. In the following quarter, when a certain amount of inoculation was carried on, especially towards its close, small-pox was responsible for 49,941 deaths out of 660,800, or again 7.6 per cent. In the third quarter, when inoculation had become an established custom, 56,690 out of 549,891 deaths, or 10.3 per cent., were ascribed to small-pox. In the last quarter of the 18th century, although the total deaths had greatly fallen, under the influences to which we have already alluded, the deaths from small-pox still constituted 9.2 per cent. |
e07b0d9e-8516-4aec-a718-b44dfb8ed68b | of the whole (45,428 out of 493,309). It cannot be denied that the proportion of small-pox deaths to deaths from all causes was greater last century in London after the introduction of inoculation than it was before, though it is also true that the death-rate in proportion to the estimated population from all causes and from small-pox showed signs of improvement during the last quarter of the 18th century, that any changes which would have the effect of reducing the chances of infection would diminish for the susceptible the prospects of attack and death by small-pox; while those who had acquired natural or artificial immunity would constitute to that extent a protected class. In so far as vaccination substituted a non-infectious procedure for the old inoculation, to that extent, and apart from any question of its affording any immunity, it should by checking 193 a fertile cause of the diffusion of small-pox bring about indirectly a reduction of mortality from that disease. |
804d1f09-241a-4139-a03e-eb514aab8431 | Great as such influence must have been, and great as were the efforts which were now for the first time made to restrict the spread of smallpox—by efforts directed against contagion—there were, in addition, those other influences at work during the last quarter of the 18th century to which we have already alluded, influences which have been continued and intensified during the present century, and which, in our opinion, must be credited with a considerable share in the reduction of small-pox. We agree with those witnesses who are of opinion that inoculation, as practised in this country and many parts of Europe last century, did tend to increase the prevalence and mortality from small-pox, that it introduced the disease into places that, in all probability, would have remained exempt from it, and in some large towns like London it tended to keep the contagion alive and make the disease endemic. |
f73befff-ef16-4f99-a5c8-a36e367224af | It appears, however, from the Bills that its introduction did not at once or very materially increase the mortality from small-pox in London. This was, doubtless, owing to the fact that it was scarcely possible to make matters much worse then than they were before in regard to the number of small-pox deaths. We are led to believe that but for the disease being kept alive by inoculation, the improvement of the public health which set in towards the end of the 18th century, in obedience to the causes to which we have alluded, would have brought about an earlier and greater decline of small-pox mortality. The mere substitution of a non-contagious process like vaccination for the old inoculation in a population of whom some 80 per cent. or more had acquired naturally or artifically such protection as previous small-pox affords would have a striking effect upon the small-pox death-rate by reducing the liability to infection of the remaining susceptible. |
9b84abc4-df01-431b-a746-30757d8ae288 | We think there can be no doubt that, speaking generally, in m 194 London last century, whether from the indiscriminate practice of inoculation or from habitual indifference which permitted smallpox to run riot with little, if any, restriction, the great bulk of persons suffered from small-pox in childhood, and acquired such protection as an attack of small-pox affords. The deaths from small-pox each year were chiefly those of young children or new comers, who were exposed to the constant sources of infection always kept going, and to the effects of which they had not been rendered immune. Thus the matter stood, when in January, 1799, cow-pox was discovered in a dairy in the Gray's Inn Lane, London, and attracted the attention of the leading medical men in town, and became the subject of experiments on a large scale by Drs. Woodville and Pearson at the small-pox Hospital. |
224ce65e-7917-4fce-b532-d0a3b79566bc | Woodville published the results of his experiments in May, 1799, and Pearson in March of the same year distributed the hospital lymph to some 200 practitioners at home and abroad. This was the starting point of the practice of "vaccination"; for Jenner had lost his strain of lymph. Woodville's cases merit careful attention, as from their number and detail, and from the fact that he had submitted nearly all of them to the variolous test within three months of their "vaccination," and found they resisted it, they produced a profound impression on the mind of the public and the profession. In July, 1800, thirty-three of the most eminent physicians and forty distinguished surgeons of the metropolis signed a declaration to the effect that "those persons who have had the cow-pox are perfectly secure from the future infection of the small-pox, and that the inoculated cow-pox is a much milder and safer disease than the inoculated small-pox." |
1ed04a60-c526-4076-bdb2-38b171a9f980 | (Morning Herald, July 19th, 1800.) Thus, Mr. Marson records 3,094 cases of post-vaccinal smallpox treated by him at the Highgate Hospital between 1836 and 195 1851, and a further series of 10,661 such cases between the years 1852 and 1867. Dr. Gayton during the years 1870 to 1883 treated 8,234 cases of small-pox in vaccinated persons in the hospitals of the Metropolitan Asylums Board. At Sheffield, in 1887-8, 5,035 vaccinated persons were attacked by small-pox. It is, however, superfluous to cite further evidence at this stage to prove what is no longer denied by anybody, that smallpox attacks the vaccinated. |
4ee2dbe7-f4cd-470b-83db-0125bf11bec2 | No witness who has appeared before us has maintained the original contention of Jenner and the earlier vaccinators, and the protection now claimed by those who assert such protection is relative, not absolute; temporary, and not permanent. It was at one time alleged that even if vaccination did not invariably prevent attack by small-pox, yet such attack was modified, and never severe or fatal. There can, however, be no doubt that fatal small-pox and cases of the disease in all its various types of severity occur in persons who have been successfully vaccinated. Dr. Gayton's tables include fatal cases, not only in those stated to be vaccinated but without visible marks, nor only in those whose marks were considered to be imperfect, but also amongst those who exhibited at the time of their attack one, two, three, and four good marks of vaccination. |
4beaf830-2123-4fca-9039-690892028a68 | We are not now concerned with the question of relative mortality in the various classes, to which we shall return, but these and numerous other examples suffice to prove what we believe is no longer disputed by anyone, that severe and fatal small-pox occurs in those who have been successfully vaccinated. As affecting the kind of attack, as well as liability to attack, the influence now claimed for vaccination is a relative one; that is to say, the contention is that, admitting to the full the occurrence of small-pox, and even 196 death from small-pox in the vaccinated, yet the vaccinated are relatively to the unvaccinated in a superior position both as regards the liability to be attacked and the chance of the disease assuming a severe or fatal form. |
b7067a47-5762-4239-85be-86ede980fc2d | Restricting our attention, in the first instance, to the question of liability to attack, it is right to state that in the earlier part of the century, when cases of the failure of vaccination began to multiply, it was urged that, inasmuch as small-pox itself did not invariably prevent a second attack, it was unreasonable to expect that vaccination could accomplish more. The view appeared to receive support when experiments seemed to show that the cowpox was merely the small-pox of the cow, and it was said the vaccinated are protected against small-pox because they have in fact had it. Indeed, the Select Committee of the House of Commons, which inquired into the operation of the Vaccination Act in 1871 reported that they had no doubt "that the almost universal opinion of medical science and authority is, in accordance with Dr. Gull, when he states that vaccination is as protective against small-pox as small-pox itself. |
0092ff82-ec03-4242-adb2-8a66b229cb0d | We have already shown that such protection is by no means absolute, but we cannot recall a single witness who has been examined by us on this question who has not admitted that whatever may be the amount of protection afforded by vaccination, it is at any rate less than that conferred by a previous attack of small-pox. The Registrar-General, in his 43rd Annual Report, thus states the view of "the best authorities" on this point; he says, "it is pretty generally recognised, and this on good grounds, that the immunity derived from vaccination is both less perfect and less permanent than that conferred by small-pox itself; its efficacy diminishing with the lapse of time, while the protective influence of small-pox remains practically unaltered." Dr. Ogle thinks there is no doubt that the protection by previous small-pox is greater than that of vaccination. 197 Dr. |
bddf986c-367c-4e34-9161-c5c7674c12c2 | Gayton, after quoting a later opinion of Jenner's to the effect that the protection by vaccination was tantamount to that of an attack of small-pox, says, "Proofs are abundant already, and will continue to accumulate, to disprove these statements." Mr. Marson, in the 16 years following 1836, and when he estimated the number of persons who had been inoculated or had Small-pox to be probably about equal to the number of those who had been vaccinated, found that only 47 persons were admitted to the hospital suffering from small-pox after the natural or inoculated disease, whereas there were 3,094 cases of small-pox after vaccination. Mr. Sweeting is of opinion that vaccination is decidedly less protective than a previous attack of small-pox. At Sheffield, in the 1887-88 epidemic, Dr. |
5b2946e3-4567-46de-87a5-9518dd717b5e | Barry found, as the result of his census, that 18,292 persons, or 6.6 of the enumerated population of the borough of Sheffield, had had small-pox prior to 1887. Of these, 23 were attacked again in 1887-88, and five died. This gives an attack-rate of 13 per 10,000 against an attack-rate of 155 per 10,000 in the vaccinated. The evidence leads us to the conclusion recorded by Dr. Gregory, the Physician to the Small-Pox Hospital, in 1843, viz., " that any attempt to institute a parallel between cases of small-pox after vaccination, and cases of secondary or recurrent small-pox, must fail." No hospital supplies so large an experience, extending over a long series of years, as the London Small-Pox Hospital. We learn from the figures recorded by Mr. Marson and Dr. |
f49761d0-9707-486c-83e2-7ff85c2a0f56 | Munk, and the reports of the hospital, that the percentage of cases of vaccinated small-pox patients to the total admissions has progressively increased with the increase of vaccination among the general population, if not in exact ratio, at any rate in a ratio approximating closely to it. 198 Years. Post-vaccinal Small-Pox per Cent. of Total. 1826 38 1835-45 - 44 1845-55 - 64 1855-65 - 78 1863 - - 83 1864 - - 84 1878 - 79 - 93 1885 - - 93 1888-91 - (14 cases only) 100 We are not aware of any grounds for thinking that at any time more than 90 per cent. of Londoners have been vaccinated. Judging from the vaccination returns the proportion would seem to be less than this, and the evidence derived from local investigations supports the latter view. |
09a36592-ad19-40a6-ad84-efde5754fd0d | The per centage of children not finally accounted for as regards vaccination in London is given as follows, by the Local Government Board, for the years since 1872:— 1872 8.8 1883 65 1873 8.7 1884 6.8 1874 8.8 1885 7.0 1875 9.3 1886 7.8 1876 6.5 1887 9.0 1877 7.1 1888 10.3 1878 7.1 1889 11.6 1879 7.8 1890 13.9 1880 7.0 1891 16.4 1881 5.7 1892 18.4 1882 6.6 Annual Small-Pox Death Rates per 100,000 at different Ages in London. - 0-5 Years. |
71e6dc80-fe60-4cdf-880d-6850f9cca71c | 5 years and upwards. 1851-60 130 13 1861-70 116 14 1871-80 113 34 1881-88 37 16 199 Thus we see that, except in the last period (which has been one of increasing default in regard to vaccination), and then only in the case of those under five years of age, there has been no substantial reduction of small-pox mortality, while at all ages over five the mortality from small-pox has been actually greater in the last three periods than in the first. Such saving of life as there has been in London in the period 1851-88 was most noticeable in the period 1881-88, and was confined to children under five years of age. |
73347677-6718-4659-b37e-4cbbe427fb99 | It has been urged that the observed changes in age incidence of small-pox mortality point to vaccination rather than sanitary reforms as the cause of the difference, since sanitary reforms should operate equally upon all ages, while vaccination might be expected to effect especially the young. There are, however, some considerations which prevent the acceptance of this explanation, at any rate for the whole of the facts. The increased death-rate from small-pox in persons above the age of childhood might, with equal reason, be ascribed to vaccination, or at least seems incompatible with the belief that the influence of vaccination against fatal small-pox is of an abiding character. Moreover, it has been pointed out by the Registrar-General in his report for the year 1879 that sanitation operates differently upon the general mortality of persons at different age periods. He calls attention to the fact that " while the mortality in early life has been very notably diminished, the mortality of persons in middle or advanced life has been steadily rising for a long period of years." |
ebd26c81-39c8-48d6-8ef3-c2996dadd325 | He adds, "That the sanitary efforts made of late years should have more distinctly affected the mortality of the young is only what might be naturally anticipated; for it is against noxious influences to which the young are more especially sensitive that the weapons of sanitary reformers have been chiefly directed." He further suggests that the enhanced mortality at later ages may in part be due to the indirect influence of sanitation by preserving from early death a vast number of children of permanently unsound constitution who so diminish the healthiness and add to 200 the death-rates of later ages. At any rate there is evidence to disprove the assertion that sanitation in the wider sense must affect mortality at all ages equally. |
d2e44d10-8af8-4eba-90f1-4ff62c986fc2 | Again, it has been fairly urged that, in order to ascertain whether the shifting of the age incidence of fatal small-pox can be fairly attributed to vaccination rather than to sanitary reforms, it is desirable to institute a comparison between small-pox deaths or death-rates at different ages and other comparable diseases rather than with the deaths or death-rates from all diseases. Dr. Ogle thinks that the zymotic diseases would be the better ones to compare small-pox with, but he truly observes: "It is impossible to make similar comparisons in the case of Scarlet Fever or Measles, and diseases that only affect children. Fever is the only one of the zymotic headings that you can take, because it is the only one that affects all ages to any extent. Fever is, therefore, the only one which it is possible to subject to this kind of investigation." |
8d01f669-d384-4339-a187-f353a0bd8f71 | Now, in regard to Typhus, which is not at the present time responsible for many deaths under five years of age, we learn that, comparing the earliest quinquennium which the RegistrarGeneral's figures enable us to use with the quinquennium 1886-90, a fall of 46.9 per cent. in the children's share, i.e., from 6.4 per cent. to 3.4 per cent. For the same period in the case of Typhoid Fever (even when the necessary correction for varying classification in regard to remittent fever has been made) there is a fall of 51.7 per cent, in the children's share, i.e., from 17.4 per cent. to 8.4 per cent. |
25bafaf2-cdc9-4d9a-bb7a-687327554ab2 | For small-pox (even without any correction for chicken-pox) there is a fall during the same period of the children's share equal to 36.9 per cent., i.e., from 31.1 per cent. to 19.6 per cent. Not only then do we find that in certain other zymotic diseases comparable with Small-Pox a shifting of age incidence of the deaths so that the children's share is less and the adults' share 201 greater than was formerly the case, but the shifting would appear to be somewhat greater in the case of Typhus and Typhoid Fevers than in the case of small-pox. The diminution of mortality of infants side by side with increase of mortality of older persons, which has been claimed to specially indicate the influence of vaccination upon small-pox mortality, seems to be also true in a remarkable manner of Influenza. |
c2652a1f-eb21-4e23-b144-657fd6544623 | The Register-General, in his Fifty-fourth Report, institutes a comparison between the great Influenza epidemics of 1847-48 and 1890-91, and calls attention to the fact that "the epidemic of 1890-91 was distinguished from the equally fatal epidemic of 1847-48 by the greater comparative severity with which it attacked persons of middle age," and the table he gives shows that, while at ages under fifteen there was a lower rate in the last epidemic, at ages from fifteen to fifty-five there was an enhanced mortality, while above sixty-five there was again a reduction. We find in these facts evidence that in diseases other than Small-Pox, and against which no artificial protective is invoked, there has been a change in the age-incidence of deaths and deathrates in the same direction as, and not very dissimilar in amount from, that which has been asserted to be distinctive of small-pox in consequence of the special influence of vaccination upon it. |
95001ffc-5907-47a2-9645-a2d84e7ec1cb | We are bound to conclude that a theory of causation, which takes no account of these phenomena, is unequal to an adequate explanation of the whole case. If we are right in our conclusion that causes other than vaccination are operative upon the age-incidence of fatal smallpox, and if, as we hold, sanitary measures are influential upon small-pox mortality, and if it be true that "it is against noxious influences to which the young are especially sensitive that the weapons of sanitary reformers have been chiefly directed," we should naturally expect to find that in sanitary or healthy districts 202 as compared with less sanitary or unhealthy districts the reduction of small-pox mortality would be greater among the young than among the adult population. That this is actually the case has been shown in section 198 of our colleagues' report. It is true that the admitted fact is there referred to the greater opportunity afforded to town dwellers of catching small-pox and catching it early. |
8ec31898-f5e3-4ad9-b629-889072a28ba4 | We are, however, quite unable to agree with our colleagues that overcrowding upon area or within dwellings ought not to be regarded as an insanitary circumstance, and the fact remains that sanitation or environment, or at any rate means other than vaccination, exert a profound influence, not only upon the amount of small-pox mortality, but also upon its age distribution. That vaccination cannot be accepted as an adequate explanation of the shifting of age incidence of fatal small-pox, or at any rate as the sole explanation of the phenomenon, is proved by the fact that a very considerable shifting has been observed in the case of deaths from small-pox of those certified to have been unvaccinated. Now it is only since the year 1881 that the Registrar-General has classified the deaths from small-pox into three groups—the vaccinated, the unvaccinated, and the "not stated." |
be804ac9-deea-4647-995b-23b3c3049eee | Confining our attention to the unvaccinated, we learn that of 3,746 deaths in the years 1881-93, 1,483 were under five years of age, or 39.5 per cent. Now it has been repeatedly stated that the normal proportion of deaths from small-pox under five to the total Small-Pox deaths last century (and vaccination apart) may be taken as 80 per cent. What, then, is the explanation of the reduction of the proportion by one-half? It has indeed been alleged that vaccination may indirectly have produced the effect by reducing the amount of small-pox or controlling its virulence. If this explanation be regarded as satisfactory, it may equally be urged that any measures, such as isolation and more efficient precautions against contagion, may also exert a powerful influence, not only upon the amount of small-pox, but also upon its age distribution amongst the unvaccinated. |
d036a72a-179e-4121-9b74-9993e62dc3e1 | 203 With a view to prove the truth of the theory that cow-pox is the small-pox of the cow—Variolæ Vacciniæ—and also to establish fresh lymph supplies, numerous attempts have been made by several observers in various ways to infect bovine animals with the virus of human small-pox. In the majority of the experiments the results have been negative. In a few, when the Small-Pox matter has been diligently rubbed into scarifications, or denuded surfaces, or punctures, certain results have been obtained which have been variously interpreted. The positive results have generally been redness, tumidity, or papules at the points of insertion. In some of the successful cases, appearances approaching what may be described as vesicular have been obtained, a few, indeed, have exhibited the physical appearances of vaccine inoculated on the calf; such vaccine results have sometimes appeared not at the points of insertion but at some distance from them. |
2d14b91b-42d7-411b-a066-eb0ab9baf822 | In none of the experiments have the usual signs of natural cow-pox been found to result. Some of the cases in which vesicular results were obtained are certainly open to the objection that under the circumstances under which the experiments were made, there was the possibility, and even the probability, that vaccine virus (accidentally communicated) accounted for these results. Matter obtained from the local products of such variolations of animals, when inoculated on human beings, in the hands of Chauveau and others, gave rise to small-pox, which proved to be infectious. In the hands of others, matter taken from the local results, even when these bore no resemblance to vaccine vesicles, after serial inoculations on animals and human beings, approximated so closely to the Vesicles of ordinary vaccination as to be indistinguishable from them; in such cases there does not appear to be any ground for believing that the communicated disease, whatever its nature, is any longer infectious. |
6cf6b0ac-194c-436e-b153-295a44c0e40e | In order to obtain local results on human beings similar to those of ordinary vaccination, by the application of matter derived 204 from human small-pox, it does not appear necessary to resort to the cow as an intermediary. One of the earliest experimenters who succeeded in variolating the cow, Dr. Thiele, of Kasan, described a method of storage and dilution of small-pox virus whereby he was enabled to cultivate lymph giving results indistinguishable from vaccine. Dr. Walker, who carried on a large vaccination practice in London, in the beginning of the century, appears to have entertained similar views, and practised the dilution with water of the small-pox virus.—(Memoirs of Lettsom, Vol. iii., p. 351.) Adams, in 1805, had already succeeded in obtaining perfect vaccine results, without rash, with small-pox lymph taken from a mild variety of that disease. |
c0db92b9-6f2c-4791-81a4-34be4157d5bc | Guillou, in 1826, again records the fact that all the local appearances of vaccination could be obtained with lymph of undoubted variolous origin. Indeed, results approximating to these appear to have been arrived at by some inoculators in the previous century, who claimed to give small-pox without Fever or eruption, and with no other symptoms than those occurring on the inoculated arm; it was, however, pointed out that such modified variolation did not give the same immunity as that which usually occasioned an eruption. While it is probable, then, that the insertion of small-pox matter into the skin of a calf can produce vesicles similar in some cases to those obtained by the inoculation of cow-pox matter, we are not aware of any evidence to show that the inoculation of the Pox of the cow on the human skin has ever produced small-pox. |
d66fd472-5d40-4870-bd8b-1f5256358c8f | In this sense then cow-pox and small-pox are not convertible, and we think it is incorrect to speak of cow-pox as the small-pox of the cow. It is impossible now to distinguish the various stocks of vaccine in use, it is, however, clear that much of that now current in this country and abroad is not derived from cow-pox at all, and probably still less is derived from that special variety of cow-pox which Jenner regarded as the true or protective 205 variety. It is scarcely probable, unless indeed it be held that all viruses that will give rise to the physical appearances of a vaccine vesicle when inoculated, are identical, that one and all should be endowed with precisely the same effects qua immunity towards small-pox. If we had to express a preference for lymph derived from any of the sources described we should give it to that of variolous origin, provided always it has been rendered incapable of giving rise to infection. |
2fe53e48-70f7-4c52-8021-463012b4aa47 | Reference III.—The objections made to vaccination on the ground of injurious effects alleged to result therefrom. It was at one time officially maintained that against "the vast gain" by vaccination there is no loss to count. Of the various alleged drawbacks to such great advantages the present state of medical knowledge recognises no single trace. The Select Committee of 1871 reported "that if the operation be performed with due regard to the health of the person vaccinated, and with proper precautions in obtaining and using the vaccine lymph, there need be no apprehension that vaccination will injure health or communicate any disease." Even more recently this view has been re-affirmed in a pamphlet, entitled "Facts concerning vaccination for heads of families," "revised by the Local Government Board, and issued with their sanction"; which states that "as to the alleged injury from vaccination, all competent authorities are agreed that, with due care in the performance of the operation, no risk of any injurious effects from it need be feared." |
01e9d4eb-9f29-4a67-afdf-ba8bdcf915ba | We agree with our colleages that, notwithstanding repeated and emphatic assertions to the contrary, the admission must without hesitation be made that risk attaches to the operation of vaccination. The statements contained in sections 399-421 of the Report appear to us to give ample reason at least for hesitation in 206 retaining compulsory vaccination in any form. We allude especially to the following statements, in which we generally concur:— Section 399.—"It is not open to doubt that there have been cases in which injury and death have resulted from vaccination." Section 409.—"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 illness." Section 410.—"It is established that lymph contains organisms, and may contain those which, under certain circumstances, would be productive of erysipelas." |
fa5a08fe-60ca-4c60-9ba7-69ed04a1bd2b | In section 413 we are told that vaccination may become exceptionally risky, through special circumstances over which, in our opinion, the parents can have little or no control, such as the prevalence of disease in the neighbourhood. Section 417.—"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.' Section 418.—"It is freely to be admitted that vaccinia, like varicella, does occasionally cause an irritable condition of 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." And again, "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. |
15ec73f9-6a6a-4b1a-a44d-8eea9c27f6de | 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. 207 Their occurrence has no doubt not unfrequently caused prejudice to the practice of vaccination."And in section 419 is recited the case of "a child previously in good health, and vaccinated with calf-lymph by means of a needle which had never been used before, who died about six weeks afterwards, with severely ulcerated arms and ulcers in several parts of the body and limbs. 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." |
48fc7096-898a-425b-82f8-c4728f78c59c | In sections 420 and 421 it is pointed out that " It was at one time doubted whether syphilis could result (from vaccination), and it was even confidently asserted that it could not," but that " Facts which were, not long after the issue of Mr. 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." Putting together all these admitted elements of danger, though each may be slight in itself, we think that the sum of them constitutes a very serious objection even to the modified form of compulsion favoured by our colleagues. |
904920d2-72cf-4ac2-81b6-a3de1270606b | It appears to us that the case for even this modified compulsion is practically surrendered in section 437, where our colleagues insist on the right of parental option as to the lymph to be used, on the ground that the risk of syphilis from arm-toarm vaccination, however slight, is "naturally regarded by a parent with abhorrence." We cannot understand on what principle a parent is entitled to refuse arm-to-arm vaccination, because he regards its risks with abhorrence, but is not entitled also to refuse the not unreal risks of calf-lymph, though he also regards these with abhorrence. 208 Reference II.—Means other than Vaccination for diminishing the prevalence of Small-Pox. We are quite unable to agree with those who have maintained that sanitary measures have little or no influence upon Small-Pox. |
f59b0e93-4b5d-4363-af39-1ce8c5ce2db1 | We have already given our reasons for thinking that the teaching of the early sanitarians, like Howard and Haygarth towards the close of last century, initiated a new line of thought in the prevention of disease, and we believe the general improvement of the public health, which then set in, was due, in a large measure, to a greater sanitary activity, and that the falling off in the death rates of fevers and small-pox, as well as in the general death rate, is confirmatory of this view. In speaking of sanitation we use the word in its widest sense; we are not speaking merely of drainage improvements, but we include the prevention of overcrowding on areas, or within houses and rooms, the proper constructions of dwellings, so as to permit thorough ventilation; the promotion of cleanliness by adequate water supply and the prompt removal of filth accumulations. |
a81494ad-12c8-43a3-a83b-6b91f87439de | Related to these measures, but in a somewhat different category, are means directed against contagion, the speedy separation (in suitable hospitals) of the infected from the healthy, the disinfection of persons and things, and the prevention of the propagation of the disease by inadvertent carelessness or by intentional inoculation. If the view that attributes small-pox exclusively to contagion be well founded, it might indeed be possible to keep out the disease, even from insanitary places, by rigid isolation; but experience shows that some, even of the contagious diseases, are dependent for their extension and severity upon influences other than contagion. The Royal Commission on Infectious Hospitals in 1882, in their report, called attention to the fact that the opportunity for contagion which the presence of a small-pox hospital might afford to a particular neighbourhood, is insignificant as compared with other deleterious influences from which London suffers. |
8d975c20-e4a5-45b1-8efb-40cb07b6b510 | The 209 returns and maps showed that a healthy neighbourhood in which a hospital has been planted, though to a certain extent injured, may yet be favourably compared as regards prevalence of small-pox with those localities in which, from over-population and neglect of sanitary precautions, the predisposing causes of disease are more deeply seated. In 1885 the Metropolitan Asylums Board began to convey small-pox patients by steamer to the floating hospitals on the Thames at Long Reach. In 1889 notification became compulsory in London, and nearly all the reported cases of small-pox have been promptly isolated in such a manner as not to occasion infection from hospitals in crowded neighbourhoods. The comparative immunity that London has enjoyed of recent years is no doubt due to this policy which has been so vigilantly carried out by the managers of the Asylums Board. There are 400 beds in constant readiness at the ships, and additional accommodation is available at short notice at Gore Farm. |
6c1a3bef-f2da-493f-8a7a-88837059670f | On receiving telephonic or other communication at headquarters an ambulance proceeds with a nurse to where the patient is, and on receiving the certificate that the case is one of smallpox, and without any compulsion, the patient is conveyed to the wharf where the ambulance steamboat is in readiness. Here the patient is seen by a medical officer of the Board, to confirm the diagnosis or otherwise. There are three ambulance steamers comfortably fitted up so as to carry 100 acute cases at a time. It is a matter of experience that it is easier to secure notification and isolation in the case of small-pox than in the case of any other infectious disease. The promptness and ease with which an outbreak of small-pox in Marylebone was dealt with successfully by the Board, in 1894, afforded a striking illustration. The Asylums Board has no jurisdiction in regard to disinfection or vaccination, nor is there in London any machinery for quarantining the inmates of infected households. |
0f45dc59-2a06-48c6-a51a-320f98c0a2ee | Investigations n 210 which have been made in London and elsewhere have emphasized the local and personal infectiveness of small-pox, and the pedigrees of localised outbreaks have been definitely traced to single importations. Attention has been of late drawn to the part played by tramps in the spread of small-pox. Mr. Scovell, of the Metropolitan Asylums Board, pointed out the need for greater supervision of "shelters," and for the enforcement of greater cleanliness on the part of the vagrant population who use them. "small-pox," he says, "is usually found to be rife among the lower and more uncleanly portion of the population." Dr. |
54bcfb46-9bf9-4dfb-9699-b7a78f126cee | Birdwood, who speaks from the experience of some 12,000 cases of small-pox, believes that attention to cleanliness and frequent ablutions prevent the spread of small-pox and dimish the amount of eruption ;he cites the successful precautions taken against the infection of visitors to the small-pox ships, and the occurrence of discrete small-pox in babies, who are frequently washed, as evidence of the truth of his views. In the last report of the Metropolitan Asylums Board we read, in reference to the recrudescence of cases of small-pox in June, 1895, that "the causes which produced this sudden spread of the disease were not far to seek. Of the 35 patients admitted during June, only six possessed a fixed home. |
0e9149ed-a809-48af-afb7-665e889b6faf | Of the remaining 29, three were infected in a London infirmary where small-pox had been introduced by some undiscovered means in May, and seven were infected in another infirmary by the agency of a vagrant who developed small-pox shortly after his admission there. The remaining 19 were vagrants who possessed no lodging or no fixed lodging, or other persons of the lowest class of society, all of them sleeping, when they slept under a roof at all, in common lodging-houses, Salvation Army shelters, or the like." Those who trust to vaccination say :—Vaccinate your child before it is three months old, and so render it less liable to have 211 small-pox badly if it should happen at some future date to come in the way of it. Those who trust to isolation say :—Small-pox is notified to be here, now. |
b582ed7f-0dac-4b0c-b6ee-6233f9819543 | Let the healthy be separated from the sick, let the latter be isolated at home, or, if they cannot be properly attended to there, let them be removed to a suitably isolated hospital. There can be no doubt that the latter is the stronger position of the two; and in practice it has been found to secure the intelligent co-operation of the public. In accordance with the sub-head No. 2 of the reference to the Commission, we would suggest the following as the means other than vaccination which should be employed for protection of a community from small-pox :— 1. Prompt notification of any illness suspected to be smallpox. Improved instruction in the diagnosis of small-pox. 2. A hospital, suitably isolated, of adequate accommodation, in permanent readiness, and capable of extension if required. No other disaese to be treated at the same time in the same place. 3. |
df205b30-2aa9-4f4e-b2e0-ed95595790e4 | A vigilant sanitary staff, ready to deal promptly with first cases, and, if necessary to make a house-to-house inspection. The medical officer of health to receive such remuneration as to render him independent of private practice. 4. Prompt removal to hospital by special ambulance of all cases which cannot be properly isolated at home. Telephonic communication between Health Office and Hospital. 5. Destruction of infected clothing and bedding, and thorough disinfection of room or house immediately after removal of the patient. 6. Daily observation (including, where possible, taking the temperature and inspection for rash) of all persons who have been in close contact with the patient during his 212 illness; such supervision to be carried out either in quarantine stations (away from the hospital) or at their own homes. 7. Closure of schools on the occasion of the occurrence of small-pox among the scholars or teachers. 8. |
de370d1a-cc30-46d4-8ea3-dafb0546df46 | Hospitals and quarantine stations to be comfortable and attractive, and so administered as to secure the confidence of the public. Hospital treatment to be free to all classes, and compensation to be paid to those detained or otherwise inconvenienced in the public interest, at the public expense. 9. Tramps entering casual wards to be medically inspected, their clothing disinfected, and bath provided. The measures for detection and isolation of small-pox in common lodging-houses suggested in a previous section of the report to be carried out. 10. International notification of the presence of small-pox, and special vigilance at sea-ports in communication with infected places, after the plan adopted in the case of cholera. 11. Attention to general sanitation—prevention of overcrowding, abundant water supply, and frequent removal of refuse. Reference V.—Alterations in the provisions of the Vaccination Acts with respect to Prosecutions for non-compliance with the Law. |
0c30d84c-dde9-4122-afba-3404cc14700a | It must be obvious from what has been already said that we necessarily consider the legal enforcement of vaccination as inexpedient and unjust. We see no sufficient reason for withdrawing this particular medical prescription from the personal option which attaches to all other medical prescriptions or surgical operations; we do not think that medical authority or advice is 213 likely to gain in confidence or respect, by the adventitious aid of the police, and fine and imprisonment. But even if vaccination were a more effective and trustworthy prophylactic than we hold it to be, we should still think the continuance of compulsion at the present time to be an anachronism. The Final Report of the majority of our colleagues appears to show us this conclusively. The view there expressed of the value of vaccination differs very considerably from the opinion prevalent in and before 1853, the date of the first compulsory law. |
18a6845e-7276-4b28-acc1-e2c6b75111e8 | Whether such limited and conditional confidence in vaccination as is expressed in the report of the majority would have been held by the Parliament of 1853 to justify compulsion, is,of course, a matter of opinion; but when we recall the unqualified assurances then given that universal efficient vaccination would secure universal immunity from smallpox, we must say, in our opinion, it would not. Our inquiry has shown that medical opinion as to the degree of immunity afforded by efficient primary vaccination has been modified since 1853, the date of the first compulsory Vaccination Act. At that time the Epedemiological Society used its influence to get the Act passed on the ground that the whole medical profession was agreed on the certain efficacy of vaccination as a preventative. The evidence we have received shows that this agreement no longer exists. Amongst the professional witnesses who have favoured us with their views there are marked differences of opinion as to the length of the period during which primary vaccination is effective. |
2bff9bbf-0b2b-44af-b9cd-c3a23c220a22 | But not one of them has maintained Jenner's first claim that vaccination conferred a lifelong protection. It is apparent from the history of legislation on this subject that the assumption underlying every amendment of the law was a strong and general belief that, if only the absolute universality of efficient primary vaccination could be secured, epidemics would be prevented, and practical immunity would be secured for the whole population throughout life. On the other hand we have it 214 in evidence that the epidemic of 1871-73 was as severe and widespread as any experienced during this century, and that in the course of this epidemic " a very large proportion of the total smallpox deaths of adults was amongst people who had at some time or another been vaccinated." It would seem, therefore, that there is a certain amount of discrepancy at the present day between the theory on which the compulsory law is based and the actual state both of fact and opinion. |
befe4eb3-3683-4e86-937e-8a20be95b15e | Under these circumstances it has been suggested to us that the obvious remedy is to amend the law by making re-vaccination compulsory. But though such a course might receive a good deal of support from medical opinion, the evidence we have as to the condition of public feeling shows that it would be impracticable. This condition of things can hardly be considered satisfacfactory. The law, as it stands, enforces, under penalty of fine or imprisonment, a practice once thought to be an effectual preventive of epidemics, and a practical safeguard for every individual vaccinated. But this prescription of the law is now generally recognised as insufficient, unless primary vaccination be supplemented by secondary or repeated vaccination. The question thus arises whether it is just or expedient to enforce at the cost of much local discontent a preventive which does not secure the end proposed, and which confessedly cannot now be supplemented by the only measures which, according to the medical opinions quoted, could make it effective. |
10414935-ff2f-498b-90e1-87b2ee8fb6fe | In support of a continuance and reinforcement of the present law it is urged that if primary vaccination be not an infallible preventive, at least it always lessens the severity of the disease, if caught, and diminishes the mortality. It is, however, doubtful whether such results as these would have been held to justify compulsion when it was first proposed. And we cannot shut our eyes to the fact that this shifting of the ground of compulsion has 215 re-opened the whole question in the minds of many who accept this modified view of the Jennerian practice. As Commissioners commanded to consider and report on " provisions of the Vaccination Acts with respect to prosecutions for non-compliance with the law," we cannot avoid a reconsideration of this issue, which has very much to do with the unsettlement of public opinion on the Acts in question. It cannot be denied that the law, as it stands, is of a very exceptional character. |
5e15f69f-7ad9-4f53-a170-036e4a4e5bf1 | It is the only instance under our Constitution of the universal enforcement by fine and imprisonment of a surgical operation. In all other cases preventive sanitary law affects only outward circumstances, such as light and air, sewerage, overcrowding, public exposure of infected persons, and the like. In all such cases the social interests are so direct and predominant, and the individual claims affected are so slight, or so merely mercenary—as in the case of owners of insanitary premises—that the reasons for compulsion are simple and uncomplicated by any delicate question of personal rights. But compulsory vaccination goes beyond outward circumstances, and invades the integrity of the healthy body. It requires a wound, however slight, to be inflicted on every healthy infant born, and the contraction of a disease, however slight, of the successful cultivation of which the vaccinating surgeon must satisfy himself. The law gives the parent or guardian no option as to incurring the possible dangers of the operation. |
db7af826-64f1-48d7-937b-a694e5d854d7 | In all other cases he is allowed to decide on his own responsibility whether he will follow a particular medical prescription or not. But in this he must accept the operation with all its dangers, real or imaginary, at the dictation of the law. He may believe that he has lost previous children through the effects of vaccination. But nevertheless he must run the risk again, or be treated as a criminal. It may fairly be conceded that a compulsory law of this nature requires justification different both in kind and degree from that of laws affecting ordinary nuisances. The case, as put before Parliament in 1853, seemed 2l6 ingly strong. But, unfortunately, it did not receive much discussion. It rested, as we have seen, on the practical unanimity of the medical profession in the opinion that universal primary vaccination would extinguish small-pox. It was argued that the plague of small-pox was such as to justify exceptional measures. |
ac942580-298f-421f-af6a-7dd6cd1c0e67 | It was believed that vaccination had already come into such general vogue that only carelessness accounted for occasional neglect. And, finally, it was assumed that there were no dangers to be feared such as might perplex the consciences of parents. The law is also in abeyance by resolution of the guardians, in the following Metropolitan Unions, viz., Camberwell, Hackney, Islington, Lambeth, Mile End, St. Olave's, St. Saviour's, and Shoreditch. Making allowance for the fact that in about 46 of the 122 unions the suspension of the compulsory law is professedly only temporary until this Commission shall have reported, we cannot regard without anxiety and fear the painful conflict that would be inevitable if an attempt were made to revive and re-enforce the compulsory law in these localities against the prevalent opinion of the inhabitants. Indeed, even to make the attempt would be impossible without a considerable change in the law. |
f58b13b2-f3fc-446f-83df-925b508dadff | For at present the duty of enforcement lies with the guardians, and it is made a test question in their election. If we could suppose that the evidence laid before us would have the effect of changing local opinion, we might count on the future election of guardians willing to carry out the law. But a large part of that evidence has been published already, and there is hitherto no appearance whatever of any change in the local opinion of the unions above mentioned, except in the rare cases in which epidemic has occasioned panic. Each year of our labours has witnessed not an increase, but a decrease in the number of guardians elected in these unions by the supporters of compulsion. It appears, therefore, that, if the present law is to be made really effective, this can only be secured by imposing the duty of 217 its enforcement on the police under the direction of inspectors of the Local Government Board. |
0c2d9edd-dc5c-4074-8830-c33698a3ed0b | There is too much reason, however, to fear that even this would not be sufficient without a material increase in the severity of the law. The evidence received as to the prevalence and strength of conscientious objections on the part of parents convinces us that a considerable number could not be compelled by any penalties of fine or imprisonment to bring their children for vaccination or to allow the operation at their own homes. People who show this spirit are considered martyrs by their neighbours, and a few such cases soon create a local agitation against the law. The only way of enforcing the law without prosecution of parents would be to empower public vaccinators to seize children by the aid of the police and vaccinate them by force. But the attempt would probably create an agitation such as no Government could withstand. The difficulty of compulsion is greatly enhanced by the undeniable fact that vaccination is attended by an appreciable amount of danger. |
f66f5f2a-7fc9-485e-ba0d-22c9aed9237c | The constitution of a child is always more or less disturbed by it; and though the number of cases in which this disturbance assumes a painful or fatal form bears small proportion to the number f infants vaccinated, yet a certain amount of risk remains undeniable: and the question whether this risk should be encountered or not is naturally regarded as a matter of parental responsibility. We are unable to report that this risk is infinitesimal or unimportant. The degree of risk which parental feeling may justly be compelled to encounter is scarcely susceptible of statistical statement. If we were in a position to affirm that there is absolutely no danger, our task might be simplified. But when once the reality of appreciable danger is proved, as we hold it to be, it becomes a very delicate question how far the law is morally justified in interfering with the discretion of parents. It may be urged that a very great danger to the community might justify the enforcement of a proved and indispensable safeguard even at 2l8 some risk to individuals. |
3389d0d9-8977-4867-9f8a-d3df7b29aaa2 | But the danger from small-pox to any community using such precautions as we have recommended is not now great enough, nor is the safeguard of sufficient certainty to fulfil these conditions. It is true that in a considerable number of the cases examined for us the injury or death is reported to have been only indirectly due to vaccination. Insanitary surroundings and parental ignorance or even parental neglect are assigned in some cases as the causes of complications. But even in such cases it is clear that, apart from the vaccination, the contributory causes alone would not have produced the results admitted. An operation which for its safety requires complete sanitation, with care and skill on the part of every mother, would seem to be scarcely a fit matter for universal compulsion. On the whole, then, we are of opinion that a resolute and universal enforcement of vaccination is neither possible, nor expedient, nor just. |
9aad446a-bd9b-4c83-aa9d-afe3c8996052 | It is not possible, because there exists a sufficient amount of conscientious opinion opposed to give it to recalcitrants the credit of martyrdom, and because in great centres, such as Leicestershire, it is questionable whether even the police could carry out compulsion without the aid of the army. It is inexpedient, because it concentrates attention on a safeguard proved to be insufficient in itself, and leads to the neglect of sanitation and isolation, which our evidence shows to be more effective. It is unjust, because to meet a danger often remote by a defence at best uncertain, it overrides parental responsibility and disregards parental feeling. The proposal of our colleagues is, that while abandoning the attempt to enforce vaccination upon those who honestly object to it, we should continue to press it by force of law upon the indifferent and negligent. |
baa5018b-96c3-4b94-bad9-2f108e2cc008 | In the matter of re-vaccination, however, their proposal is different; they are impressed with the transient influence of vaccination, and recognise the need of revaccination as early as nine or ten years of age, and advise its 219 repetition at intervals, but they do not suggest that the repeated operation, which they regard as essential, should be pressed upon the indifferent and negligent as in the case of the primary operation. Now, the whole principle of securing the protection of a community from small-pox by the artificial production of a mild disease (whether it be inoculation or vaccination) is based upon the thoroughness of the procedure in two directions:—1. In applying the inoculatory process to every individual; 2. In securing to each individual operated upon the maximum of protection the process is capable of securing. The proposals of our colleagues appear to us to fail upon their own showing in both directions. |
5f412888-16eb-4474-9b53-e62094c2dd67 | They recognise the impossibility of securing the primary vaccination of every person, and open a means of escape for objectors. They are also not prepared to recommend that re-vaccination should be pressed in the same manner as the primary operation at a time when the vaccinated have lapsed into susceptibility to small-pox. This serves to prove that any such system must at best be a broken reed on which to rely for the protection of a community from small-pox epidemics. We believe the methods of isolation of the infected, disinfection, and the observation of strict cleanliness are both more successful and more legitimate methods for the State to encourage. They have the advantage of applying the preventive only where it is required: and they do not necessitate an operation upon the person of every healthy individual. We, therefore, recommend that the law be amended by the repeal of the compulsory clauses of the Vaccination Acts. |
609ba635-0e36-4870-a48d-83a45ecaad2b | But in consideration of the prevalent belief in the value of vaccination as a prophylactic for an indefinite period, and we suggest that in other respects the law should be left as it is, subject, however, to 220 such modifications as are recommended for the diminution of attendant risks. The precedent established in the case of the abolition of compulsory church rates might be followed with advantage. In that case all machinery for laying and collecting the rate was left intact though the power of enforcement was taken away. The effect of our recommendation, if adopted, would be that vaccination would continue to be provided as at present for those who desire to avail themselves of it, but efforts to secure vaccination would be limited to moral influence—in a word, the whole country would be in the position of those unions in which the guardians have abandoned compulsion. The grounds on which we object to the enforcement of vaccination by penalties necessarily lead us also to object to any method of indirect compulsion. |
658d89b1-8a95-4406-91ef-1f942476698a | We regard as both expedient and unjust exclusion from any branch of public service because of the refusal to submit to vaccination or re-vaccination. The injustice is perhaps most severely felt in the case of candidates for employment as pupil-teachers in public elementary schools. There are now districts in which, owing to the general opposition to vaccination, scarcely a girl or boy can be found who is legally eligible, and candidates have to be brought in at great inconvenience from surrounding districts. The existence of an exceptional case or cases in which such rejected candidates have, at some time afterwards, taken small-pox is, in our view, no justification for the continuation of this grievance. Statistics furnished to the Commission prove that large numbers of vaccinated or re-vaccinated persons have taken the disease; and we are not aware of any evidence to show that vaccinated pupilteachers have any special immunity. If our recommendations were carried out the danger of contagion would be greatly diminished in schools, as elsewhere. |
31db9faa-667e-46e7-9261-e580c0882e97 | On the whole, then, while there is much in the report of our colleagues from which we dissent, and we have accordingly abstained with reluctance from adding our signatures to theirs, 221 we are at one with them in holding that it is unwise to attempt to enforce vaccination on those who regard it as useless and dangerous. We, however, go further, and agree with our colleagues, Mr. Whitebread and Mr. Bright, that it would be simpler and more logical to abolish compulsory vaccination altogether. W. J. COLLINS. J. ALLANSON PICTON. The methods recommended by the dissentient commissioners, Dr. Collins and Mr. Picton, on page 211, have been carried out in London for some time past, long before the issue of the reports, with the exception that tramps entering a casual ward are not examined unless they complain of, or exhibit symptoms of illness. All the other points recommended are carefully carried out in this parish. |
a6c13e94-885c-4dd8-a3c4-c5e8a02d55c3 | No personal opinion has been given in this resume by myself except that on page 91, a paragraph on the inapplicability of the Scottish method of carrying out public vaccination to large English cities is inserted. There is the further consideration that all control of public vaccination by the Inspectors of the Locol Government Board, which now takes place at uncertain intervals with no previous notice to the Public Vaccinator, who is therefore liable to inspection at any moment, which would, by the adoption of the Scottish system of the Public Vaccinator going from house to house, become absolutely impossible. A statement as to personal experiences as Public Vaccinator for some thirty years in Battersea may not be out of place here. |
ac050f02-d32b-4d37-bd3c-e6c441a7871f | During that period no case of syphilis contracted as the result of public vaccination was seen by me, no deaths directly attributable to the operation came to my notice and, further, during several epidemics of small-pox, as the result of enquiries in every case by the Sanitary Inspectors, no child vaccinated at the vaccination station by the Public Vaccinator was the subject of small-pox in this parish. 222 Summary The great amount of work done by the Sanitary of Sanitary Operations staff is shewn in Table XVI. The work done was of during 1895 a very thorough character and reflects great credit on the Chief and District Sanitary Inspectors. The house to house inspections, the means by which most sanitary defects are detected, were up to the average number and would, if other duties did not make more urgent calls upon the staff, enable them to inspect every house in the parish during the year, a result which has been aimed at for some years. |
3e92c1f7-597a-4a27-8654-e6d720d53e20 | The great number of complaints received from the public, notifications of the existence of infectious disease, with removal to hospital in many cases and inspection and disinfection in all, together with the more systematic testing and re-organisation of defective drains and other urgent matters, render the inspectors unable to give more than a comparatively small portion of their time to this important work. Some premises require and obtain several inspections during the year from the constantly recurring defects found therein. It will be seen that the total number of houses inspected is greater than in former years, notwithstanding that such inspections formerly were in the majority of cases from house to house, when, of course, they can be more readily inspected than when from the prevalence of infectious disease or other causes each sanitary inspector has to traverse the whole area of his district daily. Inspections under the Factory and Workshops Act also add much to the duties of the staff. |
6a52a20b-bbba-411c-a598-17b3df766661 | It will be observed by reference to Table XVI., that sixtynine thousand, four hundred and thirty two Sanitary operations were carried out during 1896, the largest number yet returned. The numbers for the years 1892, 1983, 1894 and 1895 are also given as a means of comparison, the Sanitary Staff having been augmented in the earlier of these years. The number of house inspections during 1896 was the largest yet recorded, thirty-eight thousand seven hundred and 223 eighty-one. Although so great a number of houses have been inspected, many of them several times during the year, the great and most important work of all, house to house inspection, has not been universal in the parish; the ideal, towards which we should aim, being the inspection of every house each year. I have reason to anticipate that this matter will receive the earnest attention of all concerned and steps be taken to carry it out. |
45426bec-3141-4305-92d1-800005d10f1c | There were three thousand four hundred and sixty-one intimations served under Sec. 3, Public Health (London) Act, 1891. Nine hundred and nine of these cases required statutory notices under Sec. 4, &c., by order of the Health Committee and the Vestry, in addition to which one thousand nine hundred and fifty-two notices were served under Secs. 62 and 65, In nine hundred and fifty-nine cases proceedings were ordered, sixty-five summonses were issued, the other orders having been complied with and Magisterial orders were obtained and enforced in fiftyfive instances. Three thousand three hundred and two complaints were received during 1896 and attended to. One thousand six hundred and ninety-eight houses were disinfected for sanitary reasons, one thousand seven hundred and forty certificates of disinfection issued, and disinfectants were distributed free of charge in six thousand seven hundred and forty-eight instances. |
e3a8ef0b-9d28-44a0-9fe5-530b0aa4ba4a | Overcrowding was abated in sixty instances, but this is an evil not at all so frequent in this parish as compared with those of central London. Two hundred and thirty-five premises were cleansed or repaired. Drains were tested by smoke in one thousand one hundred and eighty-eight cases, the majority of cases being found defective. Two thousand eight hundred and twenty-nine new or reconstructed drains were subjected to the hydraulic test and found sound. The large number of nine hundred and forty-one drains were cleansed and repaired. The water supply apparatus to w.c.'s were newly provided or repaired in nine hundred and eleven instances, six hundred and eighty-seven cisterns were cleansed or repaired. Two hundred and eighty-eight certificates of water supply to new houses were issued. TABLE XVII. Summary of Sanitary Operations during 1896. |
cb52f493-8ccc-4cde-8fbe-7ed53a3b1fac | 1892 1893 1894 1895 1896 Total Sanitary operations 38,779 54,577 53,791 55,806 69,432 Number of House Inspections 23,587 25,091 24,747 30,051 38,781 Bakehouses Inspections 215 296 313 460 532 Bakehouses Nuisances abated ... 18 19 49 57 Urinals—Inspections 251 260 318 483 468 Do. altered, repaired, or water laid on ... 120 119 31 40 Intimations Served, 54 & 55 Vic. cap. 76 (3) 3,691 4,420 4,289 4,256 3,461 Notices Served under Sec. 4 921 1,211 1,076 1,198 909 Notices Served under Sec. 62 and 65 1,588 2, |
49ac7f26-1ce5-43c2-91ef-975dc6535764 | 572 1,605 1,709 1,952 Complaints Received and attended to . 4,089 3,253 3,877 3,302 Number of Houses Disinfected 1,227 2,069 1,449 1,454 1,698 Houses Supplied with Disinfectants 3,026 5,275 3,175 3,616 6,748 Overcrowding Abated 34 38 56 33 60 Premises Cleansed and Repaired 189 280 328 138 235 Drains Tested By Smoke 700 1,491 1,272 1,331 1,188 Water 178 491 794 997 2,829 Drains Cleansed and Repaired 1,107 1,564 1,106 1,205 941 Drains Relaid 220 917 742 742 762 Soil Pipes ventilated . . |
c57efff0-8b7b-4933-89b6-589cc2940fbe | 135 796 846 Sink and Rain Water Pipes disconnected 1,360 562 1,012 634 565 Water Closets Cleansed and Repaired 237 314 426 236 282 Cesspools Abolished 1 4 6 8 . Mews and Stables Drained and Paved 86 30 11 8 17 Yards Drained and Paved 161 253 938 555 735 Accumulations of Manure Removed or proper receptacles provided 41 70 56 61 56 Dust Receptacles Provided 738 772 1,221 688 587 Dust Complaints forwarded to the Surveyor . 271 214 377 209 Leaky House-roofs and Gutters Repaired 185 84 24O 134 180 Houses Supplied with Water 151 130 93 252 121 Water Closets Supplied with Water, |
24b9f9b4-cd05-4398-b8b9-cb944e9feefb | or supply disconnected from drinking water cistern 860 731 1,113 1,054 911 Cisterns Covered, Cleansed and Repaired 409 469 624 816 687 Keeping of Animals in unfit state discontinued 5 16 11 16 25 Smoke Nuisances dealt with 10 26 21 11 12 Certificates of Disinfection Granted 1,044 1,659 1,55I 1,538 1,740 Water Supply Certificate Granted (Sec. 48) 16 118 141 282 288 Proceedings Ordered by Vestry and Sanitary Committee 444 1,211 1,100 1,243 959 Summonses Issued 14 73 52 63 65 Magisterial Orders Obtained and Enforced 14 70 42 59 55 Sanitary Conveniences provided or improvements affected to Factories and Workshops, Sec. |
25fcbcdb-3ec0-4e58-9ffd-c7a04c495605 | 38 4 8 19 14 38 Underground sleeping rooms disused ... ... ... 12 19 Gipsy vans inspected ... ... ... 64 56 Drains laid to New Houses ... ... ... ... 266 Samples taken under the Sale of Food and Drugs Act 101 103 101 227 294* *This is for the Sanitary year, 1896—the Analytical year ends March, 1897. 225 DETAILS OF POLICE COURT PROCEEDINGS. Summonses issued. Withdrawn or dismissed. Magisterial Orders obtained. |
45f88fbb-c583-47f8-806e-a40ab3c7acfa | Under the Sale of Food and Drugs Act 45 9 36 Under Public Health (London) Act, 1891— Non-compliance with Notices or Contravention of Byelaws 15 - 15 Exposure of Unwholesome Food 5 1 4 65 10 55 Under the Sale of Food and Drugs Act, seven cases were withdrawn for the following reasons :— 1 Refusal to serve Inspector—article proved to have already been sold. 4 Analyst's certificates not being in accordance with the decision of Fortune v. Hanson. 1 A second defendant had already been convicted for the same offence. 1 Defendant dead. Total 7 And in two instances the summonses were dismissed, one on account of the article being duly labelled, and the other owing to conflicting evidence, the defendant being afforded the benefit of the doubt. The case withdrawn under the Public Health Act was due to the fact that the defendant gave a wrong address, and could not be traced. |
df004a3e-8d6d-42a1-9d1f-f138d337eb55 | In the case of exposure of bacon in a condition unfit for human food, the defendant, in default of payment of a fine of £20, was committed to prison for two months. Two hundred and ninety-three bodies were received in the Public Mortuary during the year 1896, seventeen of which were for sanitary reasons. A prominent feature in the work of the Public Health Department is the largely increased number of special inspect ions made by the Chief Sanitary Inspector and the District Sanitary Inspectors the results of which are reported to the Health Committee at the next subsequent meeting. In order to facilitate reference to the minutes if necessary the dates upon which such reports have been made during the year 1896 are appended. |
657f31d8-60ca-42c4-82a9-e6741bea9b13 | o 226 January 14th.—In consequence of a magistrate attached to the South-Western Police Court having been attacked by Typhoid Fever, the Chief Sanitary Inspector submitted a report at this Meeting relative to the sanitary condition of the Court in question, which was alleged to have probably been the cause of the illness. It stated that from a structural point of view the sanitary condition was good, that the various sanitary conveniences were properly trapped, ventilated, and supplied with water. The water supply was also examined, and found to be satisfactory, the cistern properly covered, and no defects in the sanitary arrangements of the premises could be discovered as likely to cause the illness. He also submitted report relative to the sanitary conveniences provided at the Essex Paper Mills, Lavender Hill, to the effect that the water closet accommodation was not in a sanitary condition, and that no urinal accommodation was provided. |
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